1、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
2、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 ZoneKyphosis LordosisMechanical Difference: Lumbar spine less stiff in flexion,Transition Zon
3、e: Predisposed to Failure,Little opportunity for force dispersionCentral loadingof T-L junctionNot anatomically disposed to transfer force,Patient Evaluation,Pre-hospital careEMT personnel Initial assessment Transport and immobilization,Patient Evaluation,ABCs of Trauma History Physical Examination
4、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 Noncontigu
5、ous 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 pelvisObtunded patient
6、s require further skeletal survey Mackersie et al J Trauma 1988,Additional Imaging,CT scan bony injuriesMRI images spinal cord, intervertebral discs, ligamentous structures,CT Scan,L3 unstable burst fracture,MRI Scan,Thoracic fracture subluxation with increased signal in conus medullaris,Thoracolumb
7、ar 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:ComprehensiveReproducibleUsableAccurate,Bhler 1930,Importanc
8、e 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,Bhler, Fractures and Dislocation of the Spine, 19
9、56,Bhler, Verlag von Wilhem Maudrich 1930,Morphologic Classification Watson-Jones 38,Descriptive terms based on 252 films 7 types Examples: Wedge fracture (compression fx) Comminuted fracture (burst fx) Fracture dislocation,Morphologic Classification,1930,40,50,60,70,80,90,2000,10,CT evolved,MRI evo
10、lved,*,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,Morphologic Classification,1930,40,50,60,70,80,90,2000,10,CT evolved,MRI
11、 evolved,*,Post elements important,Holdsworth62 Kelley & Whitesides 68,Denis 83 McAfee 83 Ferguson & Allen84,Anatomic Classification 2 or 3 Columns,Anatomic Classification 2 Column Theory Holdsworth 62,Six types- Nicols +2 Reviewed 1,000 patients Anterior- vertebral body, ALL, PLL Supports compressi
12、ve loads Posterior- facets, arch, Inter-spinous ligamentous complex Resists tensile stresses Stressed importance of posterior elements If destabilized, must consider surgery,Posterior,Anterior,Anatomic Classification 3 Column Theory Denis 83,Based on radiographic review of 412 cases 5 types, 20 subt
13、ypes Anterior- ALL , anterior 2/3 body Middle - post 1/3 body, PLL Posterior- all structures posterior to PLL Same as Holdsworth Posterior injury-not sufficient to cause instability,Anterior,Middle,Posterior,McAfee Classification,Six typesCT based-100 patientsMiddle column most important,Load Sharin
14、g Classification McCormack, Spine 1994,Review of injuries fixed posteriorly (McCormack 94) Which failed? Could they be prevented? Suggests when to go anteriorly,Morphologic Classification,1930,40,50,60,70,80,90,2000,10,CT evolved,MRI evolved,*,Post elements important,2 column,3 column, McAfee,Mechan
15、istic classifications,Load Sharing,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 anterior,Comminution,Fragment Displacement,Kyphosis correction,30%,30-60%,60%,0-1mm,1-2mm,2m
16、m,3,4-9,10,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 Type C - Rotational,Morphologic Classification,1930,40,50,60,70,80,90,2000,10,C
17、T evolved,MRI evolved,*,Post elements important,2 column,3 column, McAfee,Mechanistic classifications,Load Sharing,AO,Increasing severity,AO Mechanistic Classification Complex subdivisions to include most fractures,Classification of thoracic and lumbar spine fractures: problems of reproducibility A
18、study of 53 patients using CT and MRI,Oner, European Spine Journal 200253 PatientsAO & Denis Classifications5 observers Cohen Test0 = No Agreement1.0 = Perfect Agreement,Results,AO Interobserver CT 0.31 MRI 0.28 CT/MRI 0.47Denis Interobserver CT 0.60 MRI 0.52,Vaccaro, A.R. et al, Spine 2005,Spine Tr
19、auma Study Group Thoracolumbar Injury Classification and Severity Scale (TLICS) Three Part Description,Injury Morphology,Neurologic Status,Integrity of PLC,Injury Morphology,Compression: prefix-axial, lateral, flexion,postfix-burstDistraction: prefix-extension, flexionpostfix-compression, burst Tran
20、slation/Rotation: prefix-flexionpostfix-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 Morpholog
21、y Neurology Ligamentous Integrity,Vaccaro, A.R. et al., J. Spinal Disorders & Techniques 2005,Point System,Compression fx Axial, Flexion 1 Burst - add 1,Distraction injury 4,Translation /,Rotation 3,Injury Morphology Select one,Neurology-Point System,Cauda equina,Cord And conus medullaris,Incomplete
22、,Complete,Nerve root,3,3,2,2,Intact 0,Posterior Soft Tissue Point System,PLC(displaced in tension),Evaluated by MRI, CT, Plain X-rays, Exam,Intact 0,Injured 3,Suspected/ Indeterminant 2,MODIFIERS,AS/ DISH/Metabolic bone disease Nonbraceable Sternal fracture Multiple rib fractures at same or adjacent
23、 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 Fle
24、xion 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 Inj
25、ury,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-0Points 4-Non Op vs Op,Translational/Rotati
26、on Injury,Distraction, Translation/rotational, compression injury - 4 Complete (neurology) 2 PLC injury - 3,Total 9 points-Surgery,Surgical Decision making based off tenets of classification system Injury morphology Neurological status PLC integrity/injury stability,Journal of Spinal Disorders & Tec
27、hniques, 2006,Reliability/treatment validity at single institution Treatment validity exceptional- 96.4% Moderate agreement for PLC (66%) and mechanism (60%),Spine, 2006,Conflict: Mechanism vs Morphology,The Journal of Spinal Disorders and Techniques,Identifying objective findings on imaging studies
28、 and clinical examination instead of guessing injury mechanisms provides more valid understanding of injury classification,Problems Inter-rater agreement on sub-scores was: Lowest for mechanisms followed by PLC Highest for neurological status Substantial for the management recommendation,J. Neurosur
29、gery Spine, 2006,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 L
30、ee, 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,IMPACT OF E
31、XPERIENCE (attending surgeons, fellows, residents, and non-surgeon health care professionals). Most reliable among spine fellows, followed by attending spine surgeons.,Lim, Coluna/Columna Journal, 2006,IMPACT OF TRAINING Management component: reliability rose from = 0.46 (r=0.47) on first assessment
32、 to = 0.72 (r=0.91) on the 2nd assessment.,Spine, 2007,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, differ
33、ences subtle,J Spinal Disorders, 2006,DIFFERENCES IN NATIONALITIES Inter-rater reliability for mechanism higher among non-US surgeons Reliability for PLC, neurological status, management higher among US surgeons,World J Emerg Surg, 2007,Management of Thoracic and Lumbar Injuries,CONTROVERSIAL!,Non-O
34、perative Treatment of Thoracic Spine Injuries,Brace or Cast Treatment Compression Fractures Stable Burst Fractures Pure Bony Flexion-Distraction Injury,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
35、) 48% of subjects filed lawsuits concerning injuryPain intensity correlated with angle of kyphosis But not w/magnitude of anterior column deformityBed rest alone adequately manages traumatic, uncomplicated thoracolumbar wedge fractures,Folman and Gepstein, J Orthop Trauma, 2003,No correlation was fo
36、und between radiological progressive in 3-column Significant remodeling of canal encroachment (CE) proportional to initial amount of CE but not related to age & radiology,Agus, Eur J Spine, 2005,Evaluated 29 pts with 2- or 3-column-injured thoracolumbar burst fractures,62% showing good or excellent
37、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,Koller, Eur Spine J, 2008,Evaluated 21 pts; 9.5 yr f/u,Surgi
38、cal Management of Thoracolumbar Injuries,Unstable burst fractures Purely ligamentous Facet dislocations Translational injuries Neurologic deficit,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 hig
39、hly 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,Dai, J Trauma, 2004,147 pts w/acute thoracolumbar fractures: 1988 to 1997 Min. 3yr f/u; 4 pts died during hospital stay,Lack
40、 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,Thomas, J Neurosurg Spine, 2006,Evaluated scientific literature on ope
41、rative & non-op treatments,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,Dai, Spine, 2008,Extended anterolateral fixation is biomechanically comparable to circumferenti
42、al 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,Acosta, J Neurosurg Spine, 2008,Biomechanical comparison of 3 fixation techniques for unstable thoracolumbar fractures.
43、 Induced at L1:1) Short-segment anterolateral fixation2) Circumferential fixation3) Extended anterolateral fixation,Angular stable plate system showed higher primary and secondary stability In specimens with lower BMD, the use of angular stable systems substantially increased stability,Disch, Spine,
44、 2008,Difficult to establish the ideal surgical approach Anterior decompression assocd w/ recovery of motor strength pain & improve neuro status Stand-alone anterior constructs: complications & likely to have revision More definite evidence required to determine best surgical strategy,Whang, J Am Ac
45、ad Orthop Surg, 2008,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: An
46、terior versus Posterior,Anterior More predictable decompression Saves levels Questionable improved recovery of neuro function Gertzbein,1992 may be indicated in bladder dysfunction McAfee, 1985 neuro recovery in 70 patients,Posterior Less morbidity Failures with short segment constructs Usually requ
47、ires more levels Less blood loss Transpedicular anterior column bone grafting may protect posterior construct,Thank You,Bibliography,Meyer PR Jr, Sullivan DE. Injuries to the spine. Emerg Med Clin North Am. 1984 May;2(2):313-29. Mackersie RC, Shackford SR, Garfin SR, Hoyt DB. Major skeletal injuries
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