This document discusses the anatomy of the thoracic and lumbar spine and various classification systems that have been developed over time to describe fractures and dislocations in this region. It describes early morphologic classifications, followed by anatomic classifications like the 2-column and 3-column systems. Later, mechanistic classifications like the AO system and the Load Sharing Classification were introduced. The Thoracolumbar Injury Classification and Severity Scale (TLICS) is presented as a comprehensive, reproducible system that considers injury morphology, neurologic status, and integrity of the posterior ligamentous complex to determine treatment. However, some studies have found low reliability between observers in applying some aspects of these classification systems.
This document provides an overview of different classification systems for thoracolumbar fractures. It discusses early anatomic classifications including the 2-column theory and 3-column theory. It then summarizes the Denis classification and Load-Sharing classification. The AO classification and Thoracolumbar Injury Classification and Severity Score (TLICS) are also described. The document concludes by outlining a new AOSpine Classification and Injury Severity System for Traumatic Fractures of the Thoracolumbar Spine which is based on the morphological classification of the fracture, neurologic injury status, and clinical modifiers.
- Thoracolumbar injuries can cause neurological injury and long-term pain. They require assessment of fracture classification and the integrity of the posterior ligamentous complex to determine appropriate management as surgical or nonsurgical.
- Surgical approaches include posterior, anterior, or combined based on the fracture type and neurological status. Proper classification guides treatment to decompress the spine and restore stability.
- Complications include problems from immobilization as well as implant failure and infection. Careful consideration of fracture morphology, neurological findings, and ligamentous integrity directs optimal treatment.
The document summarizes thoracolumbar spine injuries, including:
- Anatomy of the thoracic and lumbar spine regions which predispose the thoracolumbar junction to injury.
- Epidemiology showing these injuries most commonly affect segments T11-L2 and have bimodal age distribution.
- Classification systems including Denis, McCormack, and TLICS which evaluate morphology, neurology, and ligamentous integrity to determine treatment.
- Treatment principles aim to preserve neurology, minimize compression, stabilize the spine, and rehabilitate the patient either via non-operative or operative means.
This document discusses the treatment of cervical facet injuries. It begins by presenting the case of a 55-year-old male who fell and is experiencing neck pain. The document then discusses goals of treatment, appropriate imaging studies, considerations for closed reduction versus surgery, and classifications of cervical spine injuries. Key points emphasized include the importance of MRI before reduction to check for disc herniations, the safety and benefits of immediate closed reduction if the patient can be monitored neurologically, and classification systems like AO, Allen-Ferguson, and SLIC.
This document discusses the treatment of complex fractures of the elbow. It begins by outlining the pathoanatomy and mechanisms of injury, including the terrible triad injury and Essex-Lopresti injury. It then details the surgical approach and treatment of specific components, including repair or replacement of the radial head, repair of the coronoid process, reattachment of the lateral collateral ligament, and repair of the medial collateral ligament. Post-operative management involves early range of motion exercises while maintaining stability through the use of external fixation or hinged braces if needed. Poor long-term outcomes were historically reported but modern treatment protocols show more encouraging short-term results, though long-term outcomes remain unknown.
The document summarizes information about spine injuries, including:
- Spine injuries can be stable or unstable depending on the risk of displacement. Primary injuries involve damage to vertebral structures while secondary changes hours later involve neurological damage.
- Common mechanisms of injury include traction, direct impact, and indirect injuries. The 3 column theory states that injury to more than 1 column results in instability.
- Cervical spine injuries require careful examination and imaging like X-rays from multiple angles to identify fractures or dislocations. Thoracolumbar injuries include compression fractures which can be wedge-shaped or burst fractures.
- Initial management focuses on immobilization and ruling out injuries before clearing the spine. Diagnosis involves
This document discusses thoracolumbar fractures of the spine. It begins by describing the anatomy of the spine and functional spinal units. It then discusses the physiological anatomy of the thoracic and lumbar spine. It describes the etiology, classifications including the Denis three-column theory and AO/MAGREL classification, clinical presentations, investigations including x-rays, CT and MRI, and classifications of spinal instability for thoracolumbar fractures.
This document provides an overview of different classification systems for thoracolumbar fractures. It discusses early anatomic classifications including the 2-column theory and 3-column theory. It then summarizes the Denis classification and Load-Sharing classification. The AO classification and Thoracolumbar Injury Classification and Severity Score (TLICS) are also described. The document concludes by outlining a new AOSpine Classification and Injury Severity System for Traumatic Fractures of the Thoracolumbar Spine which is based on the morphological classification of the fracture, neurologic injury status, and clinical modifiers.
- Thoracolumbar injuries can cause neurological injury and long-term pain. They require assessment of fracture classification and the integrity of the posterior ligamentous complex to determine appropriate management as surgical or nonsurgical.
- Surgical approaches include posterior, anterior, or combined based on the fracture type and neurological status. Proper classification guides treatment to decompress the spine and restore stability.
- Complications include problems from immobilization as well as implant failure and infection. Careful consideration of fracture morphology, neurological findings, and ligamentous integrity directs optimal treatment.
The document summarizes thoracolumbar spine injuries, including:
- Anatomy of the thoracic and lumbar spine regions which predispose the thoracolumbar junction to injury.
- Epidemiology showing these injuries most commonly affect segments T11-L2 and have bimodal age distribution.
- Classification systems including Denis, McCormack, and TLICS which evaluate morphology, neurology, and ligamentous integrity to determine treatment.
- Treatment principles aim to preserve neurology, minimize compression, stabilize the spine, and rehabilitate the patient either via non-operative or operative means.
This document discusses the treatment of cervical facet injuries. It begins by presenting the case of a 55-year-old male who fell and is experiencing neck pain. The document then discusses goals of treatment, appropriate imaging studies, considerations for closed reduction versus surgery, and classifications of cervical spine injuries. Key points emphasized include the importance of MRI before reduction to check for disc herniations, the safety and benefits of immediate closed reduction if the patient can be monitored neurologically, and classification systems like AO, Allen-Ferguson, and SLIC.
This document discusses the treatment of complex fractures of the elbow. It begins by outlining the pathoanatomy and mechanisms of injury, including the terrible triad injury and Essex-Lopresti injury. It then details the surgical approach and treatment of specific components, including repair or replacement of the radial head, repair of the coronoid process, reattachment of the lateral collateral ligament, and repair of the medial collateral ligament. Post-operative management involves early range of motion exercises while maintaining stability through the use of external fixation or hinged braces if needed. Poor long-term outcomes were historically reported but modern treatment protocols show more encouraging short-term results, though long-term outcomes remain unknown.
The document summarizes information about spine injuries, including:
- Spine injuries can be stable or unstable depending on the risk of displacement. Primary injuries involve damage to vertebral structures while secondary changes hours later involve neurological damage.
- Common mechanisms of injury include traction, direct impact, and indirect injuries. The 3 column theory states that injury to more than 1 column results in instability.
- Cervical spine injuries require careful examination and imaging like X-rays from multiple angles to identify fractures or dislocations. Thoracolumbar injuries include compression fractures which can be wedge-shaped or burst fractures.
- Initial management focuses on immobilization and ruling out injuries before clearing the spine. Diagnosis involves
This document discusses thoracolumbar fractures of the spine. It begins by describing the anatomy of the spine and functional spinal units. It then discusses the physiological anatomy of the thoracic and lumbar spine. It describes the etiology, classifications including the Denis three-column theory and AO/MAGREL classification, clinical presentations, investigations including x-rays, CT and MRI, and classifications of spinal instability for thoracolumbar fractures.
1. Immobilize the cervical spine and obtain imaging of the full spine including CT scan of the cervical spine to evaluate for fractures or ligamentous injuries.
2. Perform neurological examination and assess for signs of spinal cord injury such as motor and sensory deficits.
3. Maintain adequate perfusion with intravenous fluids to achieve a mean arterial pressure of 85 mmHg to support cord perfusion.
4. Administer steroids such as methylprednisolone if spinal cord injury is present based on imaging and neurological exam findings.
5. Determine need for surgical stabilization and decompression depending on fracture pattern and presence
The document discusses classification systems for thoracolumbar spine injuries including the Denis three-column classification, AO classification, and TLICS classification. The TLICS classification scores injuries based on morphology, posterior ligament integrity, and neurologic status to determine treatment. It provides examples of clinical cases and reviews imaging findings to assess injuries like burst fractures, Chance fractures, and neurologic status to guide clinical decision making.
The document discusses classification systems for thoracolumbar spine injuries including the Denis three-column classification, AO classification, and TLICS classification. The TLICS classification scores injuries based on morphology, posterior ligament integrity, and neurologic status to determine treatment. It provides examples of clinical cases and reviews imaging findings to assess injuries like burst fractures, Chance fractures, and neurologic status to guide clinical decision making.
MCL. LCL.ALL injuries
To understand the relevant anatomy of the side ligaments of the knee
To study the mechanism of injury of each ligament and how to diagnose such injury
To highlight the different treatment options in acute or chronic situations
This document provides an overview of traumatic thoracolumbar fractures. It discusses the themes of the lecture (three column injury, neurological deficit/ongoing compression, ligamentous injury involving 2-3 columns), biomechanics of spinal fractures, definitions of various fracture types, grading systems including Denis three-column model, and treatment considerations. The document covers the history, evaluation according to ATLS protocol, and classifications of thoracolumbar fractures in detail over several pages.
Thoracolumbar fractures account for 50% of spinal fractures and often occur between the T9 and L2 vertebrae. They are commonly caused by high-energy trauma like motor vehicle accidents or falls. Assessment involves neurological examination, imaging like x-rays and CT scans to evaluate bone injury and MRI to assess soft tissues. Treatment depends on factors like degree of vertebral compression and kyphosis, with non-operative options for mild cases and surgical stabilization and fusion for more severe injuries or neurological compromise. Rehabilitation focuses on restoring function, preventing complications, and bracing to solidify healing.
Pelvic injuries for MBBS (undergraduate medical education)Siddhartha Sinha
The document discusses pelvis fractures, including the anatomy of the pelvis, mechanisms of injury, classification systems, clinical evaluation, management, and treatment options. It describes the ligamentous structures that provide stability to the pelvis, different injury patterns based on the mechanism of force, methods to control hemorrhage, associated injuries, radiographic evaluation methods, and classifications used including the Tiles and Young-Burgess systems. Surgical and non-surgical treatment approaches are outlined depending on the stability and displacement of the fracture.
Tile classification system categorizes pelvic fractures into three main types (A, B, C) based on the integrity of the posterior pelvic ring and stability. Type A fractures have an intact posterior ring and are stable. Type B fractures have a partially disrupted posterior ring and are rotationally unstable but vertically stable. Type C fractures have a completely disrupted posterior ring and are both rotationally and vertically unstable. The Young-Burgess classification system categorizes fractures based on the direction of forces (lateral compression, anteroposterior compression, vertical shear, combined mechanisms) and predicts prognosis and treatment. Both systems have moderate to substantial inter-observer reliability, with the Young-Burgess system potentially being more reproducible for learning
Thoracic and lumbar fractures account for 30-50% of all spinal injuries. The majority occur between T11-L1 (thoracolumbar junction). They account for 50% of all spinal fractures, with an incidence of 4-5 per 100,000 people aged 18-35 years and occurring more in males. Neurological injuries occur in 25% of cases. Operative treatment is indicated for vertebral height loss over 40%, canal compromise over 40%, or kyphosis over 25 degrees. The goals of treatment are maximizing neurological recovery, maintaining spinal alignment, obtaining a healed and stable spine, and preventing deformity.
Intertrochanteric fractures are fractures of the proximal femur that occur between the greater and lesser trochanters. They are most common in elderly patients following a fall and can be classified using systems like the Evans or AO classifications to determine stability. Treatment involves early surgery with internal fixation using devices like the dynamic hip screw or intramedullary nails. Precise reduction and implant positioning are important for optimal healing and outcomes. Non-operative management is reserved for patients who are poor surgical candidates.
1. Thoracolumbar spinal injuries most commonly occur in the T11-L2 region due to the anatomical transition from the rigid thoracic spine to the more mobile lumbar spine.
2. They present with pain, loss of function, and potentially neurological deficits depending on the severity of the injury. Common causes are axial compression, flexion/distraction, or rotation.
3. Treatment depends on the fracture classification (AO/Denis), stability, and presence of neurological deficits. Unstable or injuries with deficits generally require surgical stabilization to restore alignment and prevent further injury, while stable injuries may be treated non-operatively with bracing or casting.
Spinal Cord Injurises presentation from orhtopedics, neurology, neurosurgery....agungtk456
Spinal cord injuries from orthopedics. Epidemiology and management. Type of spinal cord injury. Diagnosis of spinal cord injury. Management of spinal cord injury. Neurolgy, neurosurgery, orthopedics
This document provides information on shoulder anatomy and pathology examination using ultrasound and MRI. It discusses the normal anatomy of the shoulder including the layers of the rotator cuff. Examination procedures for ultrasound and MRI are described. Various pathologies are then summarized such as rotator cuff tears, calcific tendinopathy, and grading systems for muscle atrophy. Measurement accuracy for different imaging modalities in detecting tears is also presented.
Trauma classification systems aim to improve communication, guide medical decisions, determine injury prognosis, and allow for standardized research. An ideal system provides both descriptive and prognostic information. Descriptively, it relays details of the traumatic condition based on consistent imaging and clinical findings. Prognostically, it accounts for injury outcomes to guide treatment. There are several classification systems for cervical spine trauma, including Holdsworth, Allen, Harris, Cervical Spine Injury Severity Score, Subaxial Cervical Spine Injury Classification, and AO Classification. They characterize injuries based on mechanism, morphology, neurologic status, and other factors. Anterior column injuries often result from hyperflexion and are identifiable on imaging as compression fractures or
This document provides an overview of spinal trauma. It begins with relevant spinal anatomy and the epidemiology of spinal injuries. The most common mechanisms of injury are motor vehicle accidents and falls. Clinical signs include neurological deficits that correspond to the level and completeness of injury. Radiological imaging such as X-rays, CT, and MRI are used to identify fractures and spinal instability. Early management focuses on immobilization, corticosteroids, and treating associated conditions like neurogenic shock. Surgical stabilization is indicated for incomplete injuries with neural compression or unstable fractures with neurological deficits. The goals of treatment are to preserve neurological function, minimize compression, stabilize the spine, and rehabilitate the patient.
In the elderly osteoporotic fractures although the principles are the same but some special considerations in management of the soft tissues and the bony injuries are considered.
1) The document discusses the anatomy, definition, classification, treatment, and prognosis of the "terrible triad of the elbow" injury, which involves concurrent fractures of the radial head and coronoid process along with elbow dislocation.
2) The terrible triad injury commonly results from high-energy trauma and causes damage to multiple ligaments and bone structures in the elbow. Proper management focuses on repairing the coronoid process, radial head, and lateral collateral ligaments.
3) With recent advances, outcomes of treated terrible triad injuries have significantly improved, with most patients regaining over 100 degrees of flexion. However, the authors argue that the term "terrible triad" is no longer accurate
ortho journal club by Dr. Amit MotwaniAmit Motwani
The document describes a study evaluating a prone posterior surgical approach for treating fractures of the posterior tibial plateau. 16 patients with isolated posterior medial or posterior lateral fractures, or combinations, were treated with this approach. It allowed direct visualization and anatomic reduction of the fragments using buttress plates. Outcomes were good, with most patients achieving anatomic reduction and healing without complications. The approach provides improved access compared to conventional techniques for these fracture patterns.
1. Immobilize the cervical spine and obtain imaging of the full spine including CT scan of the cervical spine to evaluate for fractures or ligamentous injuries.
2. Perform neurological examination and assess for signs of spinal cord injury such as motor and sensory deficits.
3. Maintain adequate perfusion with intravenous fluids to achieve a mean arterial pressure of 85 mmHg to support cord perfusion.
4. Administer steroids such as methylprednisolone if spinal cord injury is present based on imaging and neurological exam findings.
5. Determine need for surgical stabilization and decompression depending on fracture pattern and presence
The document discusses classification systems for thoracolumbar spine injuries including the Denis three-column classification, AO classification, and TLICS classification. The TLICS classification scores injuries based on morphology, posterior ligament integrity, and neurologic status to determine treatment. It provides examples of clinical cases and reviews imaging findings to assess injuries like burst fractures, Chance fractures, and neurologic status to guide clinical decision making.
The document discusses classification systems for thoracolumbar spine injuries including the Denis three-column classification, AO classification, and TLICS classification. The TLICS classification scores injuries based on morphology, posterior ligament integrity, and neurologic status to determine treatment. It provides examples of clinical cases and reviews imaging findings to assess injuries like burst fractures, Chance fractures, and neurologic status to guide clinical decision making.
MCL. LCL.ALL injuries
To understand the relevant anatomy of the side ligaments of the knee
To study the mechanism of injury of each ligament and how to diagnose such injury
To highlight the different treatment options in acute or chronic situations
This document provides an overview of traumatic thoracolumbar fractures. It discusses the themes of the lecture (three column injury, neurological deficit/ongoing compression, ligamentous injury involving 2-3 columns), biomechanics of spinal fractures, definitions of various fracture types, grading systems including Denis three-column model, and treatment considerations. The document covers the history, evaluation according to ATLS protocol, and classifications of thoracolumbar fractures in detail over several pages.
Thoracolumbar fractures account for 50% of spinal fractures and often occur between the T9 and L2 vertebrae. They are commonly caused by high-energy trauma like motor vehicle accidents or falls. Assessment involves neurological examination, imaging like x-rays and CT scans to evaluate bone injury and MRI to assess soft tissues. Treatment depends on factors like degree of vertebral compression and kyphosis, with non-operative options for mild cases and surgical stabilization and fusion for more severe injuries or neurological compromise. Rehabilitation focuses on restoring function, preventing complications, and bracing to solidify healing.
Pelvic injuries for MBBS (undergraduate medical education)Siddhartha Sinha
The document discusses pelvis fractures, including the anatomy of the pelvis, mechanisms of injury, classification systems, clinical evaluation, management, and treatment options. It describes the ligamentous structures that provide stability to the pelvis, different injury patterns based on the mechanism of force, methods to control hemorrhage, associated injuries, radiographic evaluation methods, and classifications used including the Tiles and Young-Burgess systems. Surgical and non-surgical treatment approaches are outlined depending on the stability and displacement of the fracture.
Tile classification system categorizes pelvic fractures into three main types (A, B, C) based on the integrity of the posterior pelvic ring and stability. Type A fractures have an intact posterior ring and are stable. Type B fractures have a partially disrupted posterior ring and are rotationally unstable but vertically stable. Type C fractures have a completely disrupted posterior ring and are both rotationally and vertically unstable. The Young-Burgess classification system categorizes fractures based on the direction of forces (lateral compression, anteroposterior compression, vertical shear, combined mechanisms) and predicts prognosis and treatment. Both systems have moderate to substantial inter-observer reliability, with the Young-Burgess system potentially being more reproducible for learning
Thoracic and lumbar fractures account for 30-50% of all spinal injuries. The majority occur between T11-L1 (thoracolumbar junction). They account for 50% of all spinal fractures, with an incidence of 4-5 per 100,000 people aged 18-35 years and occurring more in males. Neurological injuries occur in 25% of cases. Operative treatment is indicated for vertebral height loss over 40%, canal compromise over 40%, or kyphosis over 25 degrees. The goals of treatment are maximizing neurological recovery, maintaining spinal alignment, obtaining a healed and stable spine, and preventing deformity.
Intertrochanteric fractures are fractures of the proximal femur that occur between the greater and lesser trochanters. They are most common in elderly patients following a fall and can be classified using systems like the Evans or AO classifications to determine stability. Treatment involves early surgery with internal fixation using devices like the dynamic hip screw or intramedullary nails. Precise reduction and implant positioning are important for optimal healing and outcomes. Non-operative management is reserved for patients who are poor surgical candidates.
1. Thoracolumbar spinal injuries most commonly occur in the T11-L2 region due to the anatomical transition from the rigid thoracic spine to the more mobile lumbar spine.
2. They present with pain, loss of function, and potentially neurological deficits depending on the severity of the injury. Common causes are axial compression, flexion/distraction, or rotation.
3. Treatment depends on the fracture classification (AO/Denis), stability, and presence of neurological deficits. Unstable or injuries with deficits generally require surgical stabilization to restore alignment and prevent further injury, while stable injuries may be treated non-operatively with bracing or casting.
Spinal Cord Injurises presentation from orhtopedics, neurology, neurosurgery....agungtk456
Spinal cord injuries from orthopedics. Epidemiology and management. Type of spinal cord injury. Diagnosis of spinal cord injury. Management of spinal cord injury. Neurolgy, neurosurgery, orthopedics
This document provides information on shoulder anatomy and pathology examination using ultrasound and MRI. It discusses the normal anatomy of the shoulder including the layers of the rotator cuff. Examination procedures for ultrasound and MRI are described. Various pathologies are then summarized such as rotator cuff tears, calcific tendinopathy, and grading systems for muscle atrophy. Measurement accuracy for different imaging modalities in detecting tears is also presented.
Trauma classification systems aim to improve communication, guide medical decisions, determine injury prognosis, and allow for standardized research. An ideal system provides both descriptive and prognostic information. Descriptively, it relays details of the traumatic condition based on consistent imaging and clinical findings. Prognostically, it accounts for injury outcomes to guide treatment. There are several classification systems for cervical spine trauma, including Holdsworth, Allen, Harris, Cervical Spine Injury Severity Score, Subaxial Cervical Spine Injury Classification, and AO Classification. They characterize injuries based on mechanism, morphology, neurologic status, and other factors. Anterior column injuries often result from hyperflexion and are identifiable on imaging as compression fractures or
This document provides an overview of spinal trauma. It begins with relevant spinal anatomy and the epidemiology of spinal injuries. The most common mechanisms of injury are motor vehicle accidents and falls. Clinical signs include neurological deficits that correspond to the level and completeness of injury. Radiological imaging such as X-rays, CT, and MRI are used to identify fractures and spinal instability. Early management focuses on immobilization, corticosteroids, and treating associated conditions like neurogenic shock. Surgical stabilization is indicated for incomplete injuries with neural compression or unstable fractures with neurological deficits. The goals of treatment are to preserve neurological function, minimize compression, stabilize the spine, and rehabilitate the patient.
In the elderly osteoporotic fractures although the principles are the same but some special considerations in management of the soft tissues and the bony injuries are considered.
1) The document discusses the anatomy, definition, classification, treatment, and prognosis of the "terrible triad of the elbow" injury, which involves concurrent fractures of the radial head and coronoid process along with elbow dislocation.
2) The terrible triad injury commonly results from high-energy trauma and causes damage to multiple ligaments and bone structures in the elbow. Proper management focuses on repairing the coronoid process, radial head, and lateral collateral ligaments.
3) With recent advances, outcomes of treated terrible triad injuries have significantly improved, with most patients regaining over 100 degrees of flexion. However, the authors argue that the term "terrible triad" is no longer accurate
ortho journal club by Dr. Amit MotwaniAmit Motwani
The document describes a study evaluating a prone posterior surgical approach for treating fractures of the posterior tibial plateau. 16 patients with isolated posterior medial or posterior lateral fractures, or combinations, were treated with this approach. It allowed direct visualization and anatomic reduction of the fragments using buttress plates. Outcomes were good, with most patients achieving anatomic reduction and healing without complications. The approach provides improved access compared to conventional techniques for these fracture patterns.
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S4_Classification-Thoracolumar-Spine.ppt
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
2. Anatomy of Thoracic Spine
• Kyphosis is natural
alignment
• Narrow spinal canal
• Facet orientation
• Rib factor on stability
• Conus at T12-L1
3. Anatomy of Lumbar Spine
• Lordosis is natural
alignment
• Larger vertebral bodies
• Facet orientation
• Cauda equina
5. Transition Zone:
Predisposed to Failure
Little opportunity for
force dispersion
Central loading
of T-L junction
Not anatomically
disposed to transfer force
20. Anatomic Classification
2 Column Theory
Holdsworth 62
Six types- Nicols +2
– Reviewed 1,000 patients
– Anterior- vertebral body, ALL, PLL
• Supports compressive loads
– Posterior- facets, arch,
Inter-spinous ligamentous complex
• Resists tensile stresses
• Stressed importance of posterior elements
– If destabilized, must consider surgery
Posterior Anterior
1
2
1
2
21. Anatomic Classification
3 Column Theory
Denis 83
• Based on radiographic review of 412 cases
• 5 types, 20 subtypes
– 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
1
2
3
1
2
3
23. Load Sharing 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
Mechanistic classifications
Load
Sharing
24. 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
Comminution Fragment Displacement Kyphosis correction
<30% 30-60%
>60%
0-1mm 1-2mm >2mm <3° 4-9°
>10°
25. 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
CT evolved MRI evolved
*
Post elements
important
2 column
3 column,
McAfee
Mechanistic classifications
Load
Sharing
AO
Increasing severity
26. 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
27. 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
30. Spine Trauma Study Group
Thoracolumbar Injury
Classification and Severity
Scale (TLICS)
Three Part Description
Injury Morphology
Neurologic Status
Integrity of PLC
38. Posterior Soft Tissue Point System
PLC
(displaced in tension)
Evaluated by MRI, CT,
Plain X-rays, Exam
Intact 0
Injured 3
Suspected/
Indeterminant 2
39. 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
40. Next Step - Direct TX
Assign Points
Conservative Surgery
41. Treatment
• Injuries with 3 points or less = non
operative
• Injuries with 4 points=Nonop vs Op
• Injuries with 5 points or more =
surgery
47. • Surgical Decision making based off tenets of
classification system
– Injury morphology
– Neurological status
– PLC integrity/injury stability
Journal of Spinal Disorders & Techniques, 2006
48. • Reliability/treatment validity at single
institution
–Treatment validity exceptional- 96.4%
– Moderate agreement for PLC (66%) and
mechanism (60%)
Spine, 2006
50. 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
51. • Problems
– Inter-rater agreement on sub-scores was:
• Lowest for mechanisms followed by PLC
• Highest for neurological status
• Substantial for the management recommendation
J. Neurosurgery Spine, 2006
52. 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
53. 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
54. • IMPACT OF EXPERIENCE
(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
55. • IMPACT OF TRAINING
• Management component:
reliability rose from κ = 0.46
(r=0.47) on first assessment to κ
= 0.72 (r=0.91) on the 2nd
assessment.
Spine, 2007
Dramatic Reliability Increase in Latest Evaluation:
Inter-rater Reliability as Assessed by Cohen's Kappa
Mech PLC Total Management
0.00
0.25
0.50
0.75
TJU TLISS June
STSG TLISS July
Rothman/TJU Reliability Study, Fall 2005
TJU TLISS Dec
kappa
56. • 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
J Spinal Disorders, 2006
57. • 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
59. Non-Operative Treatment of
Thoracic Spine Injuries
Brace or Cast Treatment
– Compression Fractures
– Stable Burst Fractures
– Pure Bony Flexion-Distraction Injury
60. 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
Folman and Gepstein, J Orthop Trauma, 2003
61. 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
Agus, Eur J Spine, 2005
Evaluated 29 pts with 2- or 3-column-injured thoracolumbar burst
fractures
62. 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
Koller, Eur Spine J, 2008
Evaluated 21 pts; 9.5 yr f/u
64. 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
Dai, J Trauma, 2004
147 pts w/acute thoracolumbar fractures: 1988 to 1997
Min. 3yr f/u; 4 pts died during hospital stay
65. 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
Thomas, J Neurosurg Spine, 2006
Evaluated scientific literature on operative & non-op treatments
66. 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
67. 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
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
68. 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, 2008
69. 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
Whang, J Am Acad Orthop Surg, 2008
70. 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
71. Surgery:
Anterior 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 requires more
levels
– Less blood loss
– Transpedicular anterior
column bone grafting may
protect posterior construct
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74. Thank you
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