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1. THREE COLUMNS OF DENIS

2. DENIS’ CLASSIFICATION
• Denis’ Type I : Compression fractures
– A : Fracture in the frontal plane
– B : Fracture of the anterior upper endplante
– C : Fracture of the anterior inferior endplante
– D : Failure of both endplate
• Denis’ Type II : “ Burst fractures
– A : Fracture of both endplates
– B : Fracture of superior endplate
– C : Fracture of inferior endplate
– D : Burst / rotation fracture
– E : Burst / lateral flexion fracture

3. CLASSIFICATION’ DENIS
• Denis’ Type III : “ Seat belt “ fracture
– A : Once level “ Chance “ fracture with bone disruption
– B : Once level discoligamentous disruption
– C : Two level fracture with bone and ligamentous disdruption
– D : Two level ligamentous disruption
• Denis’ Type IV : Fracture / dislocation
– A : Flexion / Rotation fracture, through bone
– B : Flexion / Rotation fracture, through disc
– C : Shear fracture, posteroanterior
– D : Shear fracture, anteroposterior
– E : Flexion / distraction fracture

4. Denis’ Type I : Compression fractures
A : Fracture in the frontal plane
B : Fracture of the anterior upper endplante
C : Fracture of the anterior inferior endplante D : Failure of both endplate

5. Denis’ Type II : “ Burst fractures
A : Fracture of both endplates B : Fracture of superior endplate C : Fracture of the anterior inferior endplante
D : Burst / rotation fracture E : Burst / lateral flexion fracture

6. Denis’ Type III : “ Seat belt “ fracture
A : Once level “ Chance “ fracture with bone
disruption
B : Once level discoligamentous disruption
C : Two level fracture with bone and ligamentous
disdruption
D : Two level ligamentous disruption

7. Denis’ Type IV : Fracture / dislocation
A : Flexion / Rotation fracture, through bone B : Flexion / Rotation fracture, through disc
D : Shear fracture, anteroposterior E : Flexion / distraction fracture
C : Shear fracture, posteroanterior

8. McAFEE’S CLASSIFICATION
• The individual components of a
complex spinal injury can be
analyzed with reference to the X,Y
and Z axes. Along the X axis there
are three mechanisms of injury :
flexion, extention, and left and
right lateral translation. Along the
Y axial, there are axis
compression, axial distraction and
clockwise and counterclockwise
rotation. Along the Z axis, there
are lateral flexion to either side
and anterior or posterior
translation. Axis compression, axis
distraction, and translation are of
prognostic significance and
correlate with specific patterns of
injury.
Y
McAfee et al

9. SIX TYPES INJURIES
1. Wedge compression fracture results from forward flexion and
cause an isolated failure of the anterior column. It is rarely
associated with neuro compromise, except when it occurs on
multiple adjacent vertebral levels.
2. Stable burst fracture is described as a failure in compression of
both the anterior and middle columns ; the posterior column is
unaffected.
3. Unstable burst fracture is described as failed in compression ,
lateral flexion, or rotation. It frequently results in late kyphosis with
progressive neurologic impairment.

10. SIX TYPES INJURIES
4. Chance fracture, as decribed elsewhere, is due to the application of
strong tensile forces with the axis of rotation in front of the
anterior longitudinal ligament , creating a horizontal transection of
the vertebral body.
5. Flexion / distraction injuries occur when the axis of rotation is
posterior to the anterior longitudinal ligament . The flexion /
distraction results in failure in compression of the anterior column
and failure in tension of the posterior and middle columns.
Subluxation and/or dislocation of the facets may be associated.
6. Translation injuries occur when shear forces cause failure of all three
column, resulting in displacement of all structures in the harizontal
plane.

11. 1. Wedge compression fracture

12. 2. Stable burst fracture

13. 3. Unstable burst fracture

14. 4. Chance fracture

15. 5. Flexion / distraction injuries

16. 6.Translation injuries

19. EVALUATION OF INSTABILITY
• Evaluation of instability: each of the
columns of the spine ( anterior, middle,
psterior ) includes a bony (B) and a
ligamentous (L) component – a total of
six element. Injury to any three or
more of these elements results in
instability.
– A burst fracture generally invoves
injury to the B and L of the anterior and
middle column, resulting in a grade 4
instability ( two B + two L ).
– A Compression fracture general
invoves the B and L of the anterior
column ( B + L ) and results in the
grade 2 instability.
– A chance injury includes any three of
the components ( grade 3 ) : three L,
three B, two L + B, or two B + L. A
fracture / dislocation involves all six
element ( grade 6 )
Total= 6 elements
Farcy et al

20. INDICATION SURGERY
• Denis
– Type II : Neurologic deficit or instability
– Type III
– Type IV

21. THORACOLUMBAR INJURY
CLASSIFICATION AND SEVERITY
SCORES (TLICS)
≤ 3 nonoperative candidates
4
≥ 5 Surgical candidates

22. CHOICE OF SURGERY
APPROACH
• Denis’ type II : Anterior or posterior or both
approach
• Denis’ type III, IV : posterior approach
• Thoracolumbar (D11–L2) : posterior
approach

23. SURGICAL TREATMENT
POSTERIOR APROACH
• Decompression of the neural elements
• Reduction of deformities
• Fixation in the reduced position

24. PEDICLE SCREW TECHNIQUE
Straight ahead technique

27. HOW MANY LEVELS FIXED ?
1. Eccentric flexion injuries, if unstable ( 50% loss
of vertebral height or 30° local kyphosis ) : Two
levels above and below the injury level.
2. Ligamentous flexion/distraction injuries : one
above, one below with transverse connection
3. Fracture/dislocation ( thoracic spine and
thoracalumbar junction ) : two to three levels
above and two levels below.

28. FUSION ?