Thoracic and Lumbar Spine

Fractures and Dislocations:

Assessment and Classification
Jim A. Youssef, M.D.

Original Authors: Christopher Bono, MD and Mitch Harris, MD; March 2004
Jim A. Youssef, MD; Revised January 2006 and May 2011
 Anatomy of Thoracic Spine
• Kyphosis is natural
alignment
• Narrow spinal canal
• Facet orientation
• Rib factor on stability
• Conus at T12-L1
 Anatomy of Lumbar Spine

• Lordosis is natural
alignment
• Larger vertebral bodies
• Facet orientation
• Cauda equina
Thoracolumbar Junction
Transition Zone

Kyphosis Lordosis

Mechanical Difference:
Lumbar spine less stiff in
flexion
 Transition Zone:
Predisposed to Failure
Little opportunity for
force dispersion

Central loading
of T-L junction

Not anatomically
disposed to transfer force
 Patient Evaluation

• Pre-hospital care

• EMT personnel
– Initial assessment
– Transport and immobilization
 Patient Evaluation

• ABC’s of Trauma
• History
• Physical Examination
• Neurological Classification
 Clinical Assessment
• Inspection
• Palpation
• Neurological Evaluation
– ASIA Impairment Scale
• Sensory Evaluation
• Motor Evaluation
• Reflex Evaluation
– Bulbocavernosus, Babinski
 Clinical Assessment
• Associated Injuries
– Meyer, 1984 – 28% have other major organ
system injuries
– Noncontiguous spine fractures 3-56%
– Always monitor Hematocrit
– GU: Foley recommended, check post-void
residuals, if abnormal get cystometrogram
– GI: prepare for ileus.
 Radiographic Evaluation
• Trauma series includes: lateral cervical,
chest, lateral thoracic, A/P and lateral
lumbar and A/P pelvis

• Obtunded patients require further skeletal

survey
– Mackersie et al J Trauma 1988
 Additional Imaging

• CT scan – bony injuries

• MRI – images spinal cord, intervertebral

discs, ligamentous structures
 CT Scan

• L3 unstable
burst fracture
 MRI Scan

• Thoracic fracture
subluxation with
increased signal in
conus medullaris
Thoracolumbar Fractures
Controversies

CLASSIFICATION!!!!!
Indications for surgery
Optimal time for surgery
Best approach for surgery
 Classifications Necessary for……

• Uniform method of description

• Directing treatment ***
• Facilitating outcome analysis
• Should be:
Comprehensive
Reproducible
Usable
Accurate
 Böhler 1930
• Importance of injury mechanism
• Determines proper reduction maneuver
• Evaluated fractures using:
• Plain roentgenograms, anatomic dissection of fatalities
• 6 types of spinal fractures included in system
• Compression
• Flexion
• Extension
• Lateral flexion
• Shear
• Torsional
Böhler, Verlag von Wilhem Maudrich 1930
Böhler, Fractures and Dislocation of the Spine, 1956
 Morphologic Classification
Watson-Jones 38

• Descriptive terms based on 252 films

– 7 types
Examples:
– Wedge fracture (compression fx)
– Comminuted fracture (burst fx)
– Fracture dislocation

CT evolved MRI evolved

1930 ‘40 ‘50 ‘60 ‘70 ‘80 ‘90 *

2000 ‘10
Morphologic
Classification
 Morphologic Classification
Stable vs. Unstable
Nicoll 49
• Based on review of 152 coal miners
• Recognized importance of posterior ligaments
• 4 fracture types:
– Stable = post ligaments intact
– Unstable = post elements disrupted

CT evolved MRI evolved

1930 ‘40 ‘50 ‘60 ‘70 ‘80 ‘90 *

2000 ‘10
Morphologic Post elements
Classification important
 Anatomic
Classification

2 or 3
Columns Denis ‘83
McAfee ‘83
Ferguson &
Allen’84

Holdsworth’62
Kelley &
Whitesides ’68
 Anatomic Classification
2 Column Theory
Holdsworth 62
Posterior Anterior
Six types- Nicols +2
– Reviewed 1,000 patients 2 1

–1 Anterior- vertebral body, ALL, PLL

• Supports compressive loads
–2 Posterior- facets, arch,
Inter-spinous ligamentous complex
• Resists tensile stresses
• Stressed importance of posterior elements
– If destabilized, must consider surgery
Anatomic Classification
3 Column Theory
Denis 83
Posterior Middle Anterior

• Based on radiographic review of 412 cases

• 5 types, 20 subtypes
–1 Anterior- ALL , anterior 2/3 body 3 2 1

–2 Middle - post 1/3 body, PLL

–3 Posterior- all structures posterior to PLL
• Same as Holdsworth
• Posterior injury-not sufficient to cause instability
 McAfee Classification
• Six types
• CT based-100 patients
• Middle column most important
COLUMNS
Type Anterior Middle Posterior Mechanism
Wedge Compression Compression None None Forward Flexion
Stable Burst Compression Compression None Axial Compression
Unstable Burst Compression Compression Comp, Lat Flex, Rot Comp,Lat Flex, Rot
Flexion-Distraction Compression Tension Tension Anterior Fulcrum
Chance Tension Tension Tension Anterior Fulcrum
Translational Shear Shear Shear Shear
 Load Sharing Classification
McCormack, Spine 1994

• Review of injuries fixed posteriorly

(McCormack 94)

– Which failed?
– Could they be prevented?
– Suggests when to go anteriorly

CT evolved MRI evolved

1930 ‘40 ‘50 ‘60 ‘70 ‘80 ‘90 *

2000 ‘10
3 column, Load
Morphologic Post elements 2 column McAfee Sharing
Classification important

Mechanistic classifications
 Load Sharing Classification
(McCormack 94)

• Devised method of predicting posterior failure

– 1-3 points assigned to the variables below
– Sum the points for a 3-9 scale
• <6 points posterior only
• >6 points anterior

0-1mm 1-2mm >2mm <3° 4-9°

<30% 30-60%

>10°
>60%

Comminution Fragment Displacement Kyphosis correction

 Mechanistic Classification
AO
• Review of 1445 cases (Magerl, Gertzbein et al. European
Spine Journal 1994)

• Based on direction of injury force

• 3 types,53 injury patterns
– Type A - Compression
– Type B - Distraction Increasing severity
– Type C - Rotational
CT evolved MRI evolved

1930 ‘40 ‘50 ‘60 ‘70 ‘80 ‘90 *

2000 ‘10
AO
3 column, Load
Morphologic Post elements 2 column McAfee Sharing
Classification important

Mechanistic classifications
 AO Mechanistic Classification
Complex subdivisions to include most fractures
Types Groups Subgroups Specificastions

A1.1
A1 impaction A1.3 A1.2.1, A1.2.2, A1.2.3
A1.3
A2.1
A compression A2 split A2.2
A2.3
A3.1 A3.1.1, A3.1.2, A3.1.3
A3 burst A3.2 A3.2.1, A3.2.2, A3.2.3
A3.3 A3.3.1, A3.3.2, A3.3.3

B1.1 B1.1.1, B1.1.2, B1.1.3

B1 post ligamentous B1.2 B1.2.1, B1.2.2, B1.2.3
B2.1
B distraction B2 post osseous B2.2 B2.2.1, B2.2.2
B2.3 B2.3.1, B2.3.2
B3.1 B3.1.1, B3.1.2
B3 anterior B3.2
B3.3

C1.1
C1 A with rotation C1.2 C1.2.1, C1.2.2, C1.2.3, C1.2.4
C2.1 C2.1.1, C2.1.2, C2.1.3, C2.1.4
B rotation C2 B with rotation C2.2 C2.2.1, C2.2.2, C2.2.3
C2.3 C2.3.1, C2.3.2, C2.3.3
C3 shear C3.1
C3.2
 Classification of thoracic and lumbar spine
fractures: problems of reproducibility
A study of 53 patients using CT and MRI
Oner, European Spine Journal 2002

• 53 Patients
AO & Denis Classifications
5 observers
Cohen Test
0 = No Agreement
1.0 = Perfect Agreement
 Results
• AO Interobserver
– CT 0.31
– MRI 0.28
– CT/MRI 0.47

• Denis Interobserver
– CT 0.60
– MRI 0.52
Vaccaro, A.R. et al, Spine 2005
 Spine Trauma Study Group
Thoracolumbar Injury
Classification and Severity
Scale (TLICS)
Three Part Description
Injury Morphology

Integrity of PLC

Neurologic Status
 Injury Morphology

•Compression: prefix-axial, lateral, flexion,

postfix-burst

•Distraction: prefix-extension, flexion

postfix-compression, burst

•Translation/Rotation: prefix-flexion
postfix-compression, burst
 Neurologic Status

•Intact
•Nerve Root Injury
•Cauda Equina Injury
•Cord Injury-Incomplete, Complete
Posterior Ligamentous Complex

• Not disrupted in tension

• Disrupted in tension
 Treatment
Spine Trauma Severity Score
Determined by:

• Injury Morphology
• Neurology
• Ligamentous Integrity
 Vaccaro, A.R. et al.,
J. Spinal Disorders & Techniques 2005
 Point System
Injury Morphology
Select one
Translation /

Compression fx Rotation
Axial, Flexion 1 3
Burst - add 1

Distraction injury
4
 Neurology-Point System

Intact
0
Cauda equina Nerve root
3 2
Cord
And conus medullaris

Incomplete Complete
3
2
 Posterior Soft Tissue Point System

Intact 0

PLC
Suspected/
(displaced in tension)
Indeterminant 2
Injured 3
Evaluated by MRI, CT,
Plain X-rays, Exam
 MODIFIERS

• AS/ DISH/Metabolic bone disease

• Nonbraceable
• Sternal fracture
• Multiple rib fractures at same or adjacent levels as
fracture
• Multiple trauma
• Coronal plane deformity
• Burns at site of anticipated incision
 Next Step - Direct TX

Assign Points
Conservative Surgery
 Treatment

• Injuries with 3 points or less = non

operative
• Injuries with 4 points=Nonop vs Op
• Injuries with 5 points or more =
surgery
 Examples
Flexion Compression Fx

•Flexion compression (morphology) - 1

•Intact (neurology) - 0
•PLC (ligament) no injury - 0

Total 1 points- Non Op

 Compression
Burst Fracture
•Flexion compression burst - 2
•Intact ( neurology) - 0
•PLC (ligament) no injury (0)

Total 2 points-Non Op
 Compression
Burst-Complete Neuro Injury
•Axial compression burst with distraction
posterior ligamentous complex -4
•Complete (neurology) - 2
•PLC (ligament) injury - 3

Total 9 points-Surgery
 Compression
Burst-Complete injury
• Axial compression burst-2
• Complete (neurology)-2
• PLC (ligament) Intact-0

Points 4-Non Op vs Op
 Translational/Rotation Injury

•Distraction, Translation/rotational,
compression injury - 4
•Complete (neurology) – 2
•PLC injury - 3

Total 9 points-
Surgery
 Journal of Spinal Disorders & Techniques, 2006

• Surgical Decision making based off tenets of

classification system
– Injury morphology
– Neurological status
– PLC integrity/injury stability
 Spine, 2006

• Reliability/treatment validity at single

institution
– Treatment validity exceptional- 96.4%
– Moderate agreement for PLC (66%) and
mechanism (60%)
Conflict: Mechanism vs Morphology
 The Journal of Spinal Disorders
and Techniques

Identifying objective findings on

imaging studies and clinical
examination instead of guessing
injury mechanisms provides more
valid understanding of injury
classification
 J. Neurosurgery Spine, 2006

• Problems
– Inter-rater agreement on sub-scores was:
• Lowest for mechanisms followed by PLC
• Highest for neurological status
• Substantial for the management recommendation
 The Spine Journal, 2006

Status PLC
Most reliable indicators:
• Vertebral body translation on plain
radiographs
• Disrupted PLC components on T1 sagittal
MRI
• Focal kyphosis in absence of vertebral body
injury
Assessment of Injury to the PLC in the
Setting of on Normal Plain Radiographs
Lee, J., Vaccaro, A.R. et al. J Orthopaedic Trauma 2006
Validation Study J. Orthopaedic Research
Submitted 2006

STATUS PLC
- Disrupted PLC components i.e. ISL, SSL, LF;
black stripe on T1 sagittal MRI , most important
factor
- Diastasis of the facet joints on CT
- Fat suppressed T2 sagittal MRI
 Lim, Coluna/Columna Journal, 2006

• IMPACT OF EXPERIENCE
(attending surgeons, fellows,
residents, and non-surgeon health
care professionals).
• Most reliable among spine fellows,
followed by attending spine
surgeons.
 Spine, 2007

Dramatic Reliability Increase in Latest Evaluation:

Inter-rater Reliability as Assessed by Cohen's Kappa
0.75

• IMPACT OF TRAINING
TJU TLISS June
STSG TLISS July
0.50 TJU TLISS Dec

kappa
• Management component: 0.25

reliability rose from κ = 0.46

0.00
Mech PLC Total Management

Rothman/TJU Reliability Study, Fall 2005

(r=0.47) on first assessment to κ

= 0.72 (r=0.91) on the 2nd
assessment.
 J Spinal Disorders, 2006

• DIFFERENCES BETWEEN SPECIALTIES

– Inter-rater reliability: “injury mechanism” higher in
neurosurgeons
– Assessment of PLC, neurological status- higher in
orthopaedic surgeons
– Reliability total score/management recommendations similar
– Overall, differences subtle
 World J Emerg Surg, 2007

• DIFFERENCES IN
NATIONALITIES
• Inter-rater reliability for mechanism higher
among non-US surgeons
• Reliability for PLC, neurological status,
management higher among US surgeons
Management of Thoracic and
Lumbar Injuries
CONTROVERSIAL!!!!
Non-Operative Treatment of
Thoracic Spine Injuries

Brace or Cast Treatment

– Compression Fractures
– Stable Burst Fractures
– Pure Bony Flexion-Distraction Injury
 Folman and Gepstein, J Orthop Trauma, 2003

 85 pts reviewed to determine late outcome of non-

op management
 Chronic pain predominant in 69.4%
 25% of subjects had changed jobs (most full to part)
 48% of subjects filed lawsuits concerning injury

 Pain intensity correlated with angle of kyphosis

 But not w/magnitude of anterior column deformity

 Bed rest alone adequately manages traumatic,

uncomplicated thoracolumbar wedge fractures
 Agus, Eur J Spine, 2005
 Evaluated 29 pts with 2- or 3-column-injured thoracolumbar burst
fractures

 No correlation was found between radiological

&functional parameters
 Vertebral column deformity that occurred after the
injury was stable in 2-column; progressive in 3-
column
 Significant remodeling of canal encroachment
(CE) proportional to initial amount of CE but not
related to age & radiology
 Koller, Eur Spine J, 2008
 Evaluated 21 pts; 9.5 yr f/u

 62% showing good or excellent outcome

 38% showing moderate or poor outcome
 Significant effects on clinical outcome:
 Load-sharing classification, posttraumatic
kyphosis & overall  lumbopelvic lordosis
 Surgical reconstruction appropriate treatment in
more severe fractures
 Surgical Management of
Thoracolumbar Injuries

• Unstable burst fractures

• Purely ligamentous
• Facet dislocations
• Translational injuries
• Neurologic deficit
 Dai, J Trauma, 2004
 147 pts w/acute thoracolumbar fractures: 1988 to 1997
 Min. 3yr f/u; 4 pts died during hospital stay

 Delayed diagnosis in 28 pts (19%)

 Differences b/w surgical & non:
  in pulmonary complications & length of
hospital stay in non-op pts.
 Surgical pts had highly significantly less pain
 Radiographic studies should be performed
 Choice of treatment in pts with multiple injuries is
not different from that in pts with no asscd
injuries
 Thomas, J Neurosurg Spine, 2006

 Evaluated scientific literature on operative & non-op treatments

 Lack of evidence demonstrating superiority of one

approach over the other
 No evidence linking posttraumatic kyphosis to
clinical outcomes
 Strong need for improved clinical research
methodology to be applied to this patient
population
 Dai, Spine, 2008

 Reviewed 37 pts
 Accuracy of plain radiographs improved
w/experience of observers
 Impact of disagreement on treatment plan was
significant
 Plain radiography alone is not adequate
 Acosta, J Neurosurg Spine, 2008
 Biomechanical comparison of 3 fixation techniques for unstable
thoracolumbar fractures.
 Induced at L1:
1) Short-segment anterolateral fixation
2) Circumferential fixation
3) Extended anterolateral fixation

 Extended anterolateral fixation is biomechanically

comparable to circumferential fusion
 Extension of anterior instrumentation & fusion 1-
level above and below the unstable segment can
result in near equivalent stability to a 2-stage
circumferential procedure
 Disch, Spine, 2008

 Angular stable plate system showed higher

primary and secondary stability
 In specimens with lower BMD, the use of angular
stable systems substantially increased stability
 Whang, J Am Acad Orthop Surg, 2008

 Difficult to establish the ideal surgical approach

 Anterior decompression assocd w/ recovery of motor
strength & bowel/bladder fxn;  pain & improve
neuro status
 Stand-alone anterior constructs:  complications & 
likely to have revision
 More definite evidence required to determine best
surgical strategy
 Conclusions on Treatment
• Surgically treating incomplete neuro
deficits potentiates improvement and
rehabilitation
• Complete neuro deficits may benefit from
operative treatment to allow mobilization
• Little chance of developing neuro deficits
with nonoperative treatment
 Surgery:
Anterior versus Posterior
• Anterior • Posterior
– More predictable – Less morbidity
decompression – Failures with short –
– Saves levels segment constructs
– Questionable improved – Usually requires more
recovery of neuro levels
function – Less blood loss
– Gertzbein,1992 – may be – Transpedicular anterior
indicated in bladder column bone grafting may
dysfunction protect posterior construct
– McAfee, 1985 – neuro
recovery in 70 patients
Thank You
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 Thank you

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