Thoracolumbar fractures classification

1. Thoracolumbar
Fractures Classification
Dr.YousefT. Khoja

2. ?? Classification ??
• Indications for surgery
• Optimal time for surgery
• Best approach for surgery
• Should be:
• Comprehensive
• Reproducible
• Usable
• Accurate

3. Classification
Morphologic
Classification
1930 ‘40 ‘50 ‘60 ‘70 ‘80 ‘90 2000 ‘10
CT evolved MRI evolved
*
Post elements
important
2 column
3 column Load
Sharing
AO
TLICS

4. Holdsworth’62
Kelley &Whitesides ’68
Denis ‘83
McAfee ‘83
Ferguson & Allen’84
Anatomic Classification

5. Anatomic Classification
• 2 ColumnTheory: Holdsworth 1962
• Reviewed 1,000 patients: Separated spine into
anterior weight-bearing column (a) and
posterior tension-bearing column (b)
• Six types: simple wedge, dislocation, rotational
fracture-dislocation, extension, burst, and
shear.
• Stressed importance of posterior elements
• If destabilized, must consider surgery

6. Anatomic Classification
• 3 ColumnTheory: Denis 1983
• Based on radiographic review of 412 cases
• Anterior: ALL , anterior 2/3 body
• Middle: post 1/3 body, PLL
• Posterior: all structures posterior to PLL
• Middle column Injury was necessary & create instability.
• Posterior injury not sufficient to cause instability

7. Denis Classification
• Divides spinal fractures into minor and major injuries
• Minor injuries: fractures ofTransverse Process, Pars Interarticularis,
Spinous Process.
• Major injuries: Wedge Compression, Burst, Seat-belt type & Fracture-
Dislocation.

8. Denis Classification
• Wedge Compression Fracture:
• Isolated failure of the anterior column
• Result from forward flexion
• Rarely are associated with neurological deficit except in multiple adjacent
vertebral fracture
• PLC may be disrupted in tension if there is loss ofVB height >50%

10. Denis Classification
• Burst Fracture:
• The anterior and middle columns fail from axial load
• In stable Burst  PLC intact. In Unstable burst  PLC disrupted
• No relation between canal compromised & neurological defecit.
• Early Stabilization in:
• Neurologic Deficits
• InjuryToThe Posterior Ligament Complex
• > 30°kyphosis
• > 50% loss of vertebral body height
• > 50% canal compromise

12. Denis Classification
• Flexion-distraction injury (Chance, seat belt injury)
• 3-columns injury
• Anterior: Compression
• Middle & Posterior: Tension
• Abdominal visceral injuries are commonly associated ~ 50%
• Bony vs Ligamentous

14. Denis Classification
• Fracture-dislocations
• All three columns have failed in compression, tension, rotation, shear
with translation deformity.
• At the affected level, one part of the spinal canal has been displaced in
the transverse plane

16. Load-Sharing Classification
• McCormack Classification:
• Designed specifically for thoracolumbar burst fracture (1994)
• Devised method of predicting posterior failure
• 1-3 points assigned grades to amount ofVB comminution, displacement
of fracture fragments, degree of kyphosis
• Sum the points for a 3-9 scale
• < 6 points posterior only
• > 6 points anterior
<30% 30-60%
>60%
0-1mm 1-2mm >2mm
Comminution
Fragment Displacement
Kyphosis
Correction
<3° 4-9°
>10°

17. AO Classification
• Review of 1445 cases (Magerl,Gertzbein et al. European Spine Journal 1994)
• Based on direction of injury force
• 3 types, 53 injury patterns

19. Thoracolumbar Injury Classification & Severity Score
(TLICS orTLISS)
• Introduced by the SpineTrauma Study
Group in 2005.
• Three major injury characteristics:
1. Injury morphology
2. Neurologic status
3. Integrity of the PLC

21. TLICS
• The total score used to guide treatment:
• ≤ 3 points  non-operatively
• ≥ 5 points  surgical intervention
• = 4 points  w/ or w/o surgery

22. Example (1)
• Dx: Compression Fx
• TLICS
• Morphology: Compression
• Neurology: Intact
• PLC: Intact
• 1 + 0 + 0 = 1 point  Non-OP

23. Example (2)
• Dx: Stable Burst Fracture
• TLICS
• Morphology: Burst
• Neurology: Intact
• PLC: Intact
• 2 + 0 + 0 = 2 points  Non-OP

24. Example (3)
• Dx: Unstable Burst-Complete Neuro Injury
• TLICS
• Morphology: Burst
• Neurology: Complete
• PLC: Injury
• 2 + 2 + 3 = 7 points  OP

25. Example (4)
• Dx: Stable Burst-Complete injury
• TLICS
• Morphology: Burst
• Neurology: Complete
• PLC: Intact
• 2 + 2 + 0 = 4 points  Non-OP vs OP

26. Example (5)
• Dx: Fracture-Dislocation
• TLICS
• Morphology: Distraction
• Neurology: Complete
• PLC: Injury
• 4 + 2 + 3 = 9 points  OP

27. Example (6)
• 18-year-old woman presented with severe mid back pain following a
rollover motor vehicle collision. Patient assessment revealed a normal
neurologic examination with a palpable, tender gap in the
thoracolumbar region.

28. Example (6)
• Dx:T11-12 fracture-
dislocation with a Chance
fracture atT12
• TLICS
• Morphology:Translation
• Neurology: Intact
• PLC: Injury
• 3 + 0 + 3 = 6 points  OP

29. Example (7)
• A 63-year-old man sustained a 15- foot fall at work and reported
severe back pain. Assessment revealed a normal neurologic
examination with no posterior tenderness, gap, or step-off.

30. Example (6)
• Dx: L2 burst fracture
• TLICS
• Morphology: Burst
• Neurology: Intact
• PLC: Intact
• 3 + 0 + 0 = 3 points  Non-OP

31. AOSpine Classification and Injury Severity System for
Traumatic Fractures of theThoracolumbar Spine
• This system is being subjected to a rigorous scientific assessment.
• Based on the evaluation of three basic parameters:
1. Morphologic classification of the fracture
2. Neurologic injury
3. Clinical modifiers

32. AOSpine Classification and Injury Severity System for
Traumatic Fractures of theThoracolumbar Spine
1. Morphologic classification
• Type A: Compression injuries. Failure of anterior structures under
compression
• Type B: Failure of the posterior or anterior tension band
• Type C: Failure of all elements leading to dislocation or displacement.

33. Morphologic classification
• Type A: Compression injuries.
• Five subtypes and no further sub-classification.
• A0 / minor, nonstructural fractures
• A1 /Wedge-compression
• A2 / Split
• A3 / Incomplete burst
• A4 / Complete burst

34. A0 / minor, nonstructural fractures
• Do not compromise the structural integrity of the spinal column

35. A1 /Wedge-compression
• Fracture of a single endplate without involvement
of the posterior wall of the vertebral body.

36. A2 / Split
• Fracture of both endplates without involvement of
the posterior wall of the vertebral body.

37. A3 / Incomplete burst
• Fracture with any involvement of the posterior wall; only a single
endplate fractured.

38. A4 / Complete burst
• Fracture with any involvement of the posterior wall and both
endplates.

39. AOSpine Classification and Injury Severity System for
Traumatic Fractures of theThoracolumbar Spine
1. Morphologic classification
• Type A: Compression injuries. Failure of anterior structures under
compression
• Type B: Failure of the posterior or anterior tension band
• Type C: Failure of all elements leading to dislocation or displacement.

40. Morphologic classification
• Type B: Failure of the posterior or anterior tension band
• There are three subtypes:
• B1 /Transosseous tension band disruption / Chance fracture
• B2 / Posterior tension band disruption
• B3 / Hyperextension

41. B1 /Transosseous tension band disruption / Chance fracture
• Axial plane horizontal fracture of the anterior and posterior
elements goes through the bone of a single vertebra before
exiting into the soft tissues posteriorly.

42. B1 /Transosseous tension band disruption / Chance fracture

43. B2 / Posterior tension band disruption
• Bony and/or ligamentary failure of the posterior tension band
together with aType A fracture.

44. B3 / Hyperextension
• Injury through the disk or vertebral body leading to a
hyperextended position of the spinal column. Anterior structures,
especially the ALL are ruptured but there is a posterior hinge
preventing further displacement.

45. AOSpine Classification and Injury Severity System for
Traumatic Fractures of theThoracolumbar Spine
1. Morphologic classification
• Type A: Compression injuries. Failure of anterior structures under
compression
• Type B: Failure of the posterior or anterior tension band
• Type C: Failure of all elements leading to dislocation or displacement.

46. Morphologic classification
• Type C: Failure of all elements leading to dislocation or displacement.
• There are no subtypes
• The pattern of the failure of the tension band can be also specified using
theType B subclassification like B2-flexion distraction or B3
hyperextension.

47. Type C: Failure of all elements

48. Algorithm for Morphologic Classification

49. AOSpine Classification and Injury Severity System for
Traumatic Fractures of theThoracolumbar Spine
• This system is being subjected to a rigorous scientific assessment.
• Based on the evaluation of three basic parameters:
1. Morphologic classification of the fracture
2. Neurologic injury
3. Clinical modifiers

50. AOSpine Classification and Injury Severity System for
Traumatic Fractures of theThoracolumbar Spine
2. Neurologic injury
• Neurologic status at the moment of admission should be scored
• N0: Neurologically intact
• N1:Transient neurologic deficit, which is no longer present
• N2: Radicular symptoms
• N3: Incomplete spinal cord injury or any degree of cauda equina injury
• N4: Complete spinal cord injury
• NX: Neurologic status is unknown due to sedation or head injury

51. AOSpine Classification and Injury Severity System for
Traumatic Fractures of theThoracolumbar Spine
• This system is being subjected to a rigorous scientific assessment.
• Based on the evaluation of three basic parameters:
1. Morphologic classification of the fracture
2. Neurologic injury
3. Clinical modifiers

52. AOSpine Classification and Injury Severity System for
Traumatic Fractures of theThoracolumbar Spine
3. Clinical modifiers
• There are two modifiers
• M1: is used to designate fractures with an indeterminate injury to the tension band
based on spinal imaging with or without MRI.This modifier is important for
designating those injuries with stable injuries from a bony standpoint for which
ligamentous insufficiency may help determine whether operative stabilization is a
consideration.
• M2: is used to designate a patient-specific comorbidity, which might argue either
for or against surgery for patients with relative surgical indications. Examples of an
M2 modifier include ankylosing spondylitis or burns affecting the skin overlying
the injured spine.

54. References
• Thoracolumbar SpineTrauma Classification; J Am Acad Orthop Surg
2010;18:63-71
• A Review ofThoracolumbar Spine Fracture Classifications: Journal of
Orthopaedics andTraumaVol. 1 (2011),Article ID 235406, 5 pages.
• Thoracolumbar Spinal Injuries: http://www.springer.com/978-3-540-
40511-5
• Thoracic and Lumbar Spine Fractures and Dislocations: Assessment
and Classification: Christopher Bono, MD and Mitch Harris, MD; March
2004: Jim A.Youssef, MD; Revised January 2006 and May 2011; OTA