1. 2010.10.1 AOSpine Advance Course Yokohama 2010 Surgical Indication for thoracolumbar injury - Anterior or posterior - Okayama University Masato Tanaka

3. 1. Classification of Thoracolumbar injury London, St. Paul cathedral

4. Various classification of TL fracture Classification Principle Merit Demerit Holdsworth (1970) Two-column Simple Too old Denis (1983) Three-column Simple Instability Ferguson&Allen (1984 ) Mechanical Instability Complicated McComack&Gaines (1994) Point system Clinical results no neurology AO/Magerl (1994) Morphologic Severity&Instability Complicated TLISS/TLICS / Vaccaro (2005) Point system Insta.&Clinical results Liability

6. 1. 胸腰椎圧迫骨折 Anterior (Thoracolumbar Compression Fractures) 2. 胸腰椎破裂骨折 A +M (Thoracolumbar Burst fractures) 3. 胸腰椎屈曲伸延損傷 M+ P (Thoracolumbar Flexion-Distraction Injuries) 4. 胸腰椎脱臼骨折 A + M + P (Thoracolumbar Fracture-Distraction Injuries) (Denis F, 1983, Spine) Denis classification (Three column theory) 利点：分類が簡単 欠点：重症度や不安定性 の詳細な評価が不能

7. McCormack and Gaines classification (Lord shearing classification) A: Comminution/involvement B: Apposition of fragment C: Deformity correction (kyphotic correction) < 30% 30%~60% > 60% minimal At least 2mm displacement < 50% > 50%  3 ° 4 ° ~9 °  10 ° (McCormack and Gaines, Spine, 1994) 6 and less = posterior 圧迫骨折と破裂骨折の重症度のみ

8. 1. Type A 圧迫損傷 66.1 ％ (2/3) (Compression injuries) 1. Impaction Fx , 2. Split Fx, 3. Burst Fx 2. Type B 伸延損傷 14.5 ％ (Distraction injuries) 1. Posterior disruption, 2. Arch Fx, 3. Anterior dis. 3. Type C 多方向性損傷 19.4 ％ (Multidirectional with trans) 1. Anteroposterior, 2. Lateral, 3. Rotational (Magerl, 1994, Eur Spine J) AO classification (Comprehensive classification)

9. AO classification more precise VS more complicated Burst fx A A 3.1.1 Superior incomplete burst A 3.3.3 Complete axial burst Flexion-distraction fx B B 2.1 Transverse bicolumn B 2.2.2 Flexion spondylolysis

10. Impossible to classify by another system Including severity From A to C From 1 to 3 AO classification

11. TLICS classification TLICS scoring Parameter Points 1. Morphology Compression fracture 1 Burst fracture 2 Translational/rotational 3 Distraction 4 2. Neurologic involvement Intact 0 Nerve root 2 Cord, conus medullaris Incomplete 3 Complete 2 Cauda equina 3 3. Posterior ligamentous complex Intact 0 Injury suspected/indeterminate 2 Injured 3 Management as per TLICS score Management Points Nonoperative 0–3 Nonoperative or operative 4 Operative ≥5 (Thoracolumbar Injury Classification and Severity Score) (Vaccaro et.al, 2005, Spine)

12. 2. Principle of selection for anterior or posterior UK, Stonehenge

13. Principle of selection for anterior or posterior (Zdeblick AAOS 2009) 1. 胸腰椎圧迫骨折 Conservative (Thoracolumbar Compression Fractures) 2. 胸腰椎破裂骨折 Anterior or Posterior (Thoracolumbar Burst fractures) A (severe neurologic deficit) 3. 胸腰椎屈曲伸延損傷 Posterior (Thoracolumbar Flexion-Distraction Injuries) 4. 胸腰椎脱臼骨折 Posterior (Thoracolumbar Fracture-Distraction Injuries ) A & P (Severe type)

14. 3. AO type A fractures London, Tower Bridge

15. Denis: TL Compression Fx AO : A 1.1 ～ A 1.3 (Impaction fx) A 1.1 end-plate impaction A 1.2 wedge impaction A 1.3 VB collapse 1. Structural stability Absolutely stable 2. Treatment Basically no surgical intervention Op indication: Young & >50 ％ compression Posterior (Bradford 1977, Denis 1988) >30% compression ？ (Garfin 1998) Conservative

18. A 3.1.1 Superior incomplete burst A 3.3.3 Complete axial burst Gains score Age, BMD Conservative Posterior Tokuhashi Ito Anterior Taneichi apposition 2 Yukawa Denis: Burst fx or AO: A3 Severity is important

19. Gains score 7-8 and less Posterior 8-9 and more Anterior Old Pt Young Pt Denis: TL Burst Fx Our solution AO : A 3.1 ～ A 3.3

20. Post op X-p Preop CT 19 yrs M, L1 Burst fx, AO Type A3.1 （ Gains score 6 ）

21. Pre op X-p Post op X-p Preop CT 21 yrs M, T12 Burst fx, AO Type A3.2 （ Gains score 8 ）

22. 4. AO type B fractures London, Big Ben

26. 5. AO type C fractures London, Buckingham palace

31. 5. Special type fractures Ramses British museum Rosetta stone

32. Character of Fracture in Ankylosed Spine Gap Bamboo spine Basically unstable (Three column injury)

33. Thoracolumbar Flexion-Distraction Injuries AO type B3 ; Anterior disruption through the disc Hyperextension Injuries Character of Fracture in Ankylosed Spine

34. 73 yrs M, DISH + L1 fracture

35. 73 yrs M, DISH + L1 fracture

36. Treatment ( similar to fracture of extremity) Posterior long fusion

37. Of the 122 spine fractures in 112 consecutive patients with ASD, the majority were transdiscal extension injuries, most commonly affecting C6-C7 . Spinal cord injury was present in 58% of the patients. Mortality was 32% over a 7-year period. Surgery was performed on 67% of patients, consisting primarily of multilevel posterior instrumentation 3 levels above and below the injury.

38. 72 yrs M, L4 fracture, AO typeA1.1.3 Pedicle screws are easy to pull-out Severe osteoporotic spine

39. 74 yrs F, T12 fracture, AO typeA1.1.3 If posterior long fusion was performed, adding on phenomina will be ocuured.

40. 44.2° Th12 76 yrs F, T11.12 fracture, AO typeA1.1.3

41. Pedicle subtraction osteotomy (PSO) is one solution for osteoporotic spine. Th12 Th12 44.2° 27.0° 76 yrs F, T11.12 fracture, AO typeA1.1.3

42. New solutions are coming soon! Vertebroplasty Kyphoplasty Perforated screws with dual core & double lead Synthes Medtronic

43. Thank you for your attention