Thoracolumbar spine fractures

1. THORACOLUMBAR
SPINE INJURIES
Dr.Rohan Dhotre
Dr.SSM Unit
KEM Hospital
Mumbai

2. EPIDEMIOLOGY
• Thoracolumbar junction - most common injury
site for thoracic and lumbar trauma
• More than 50% fractures occur at T11-L1 level
and 30 % occur between L2-L5
• Bimodal age distribution – peaks males < 40yrs
& again in 50-70 elderly age group

3. PHYSIOLOGICAL ANATOMY OF
THORACIC SPINE
• Facets lie in the coronal plane – allows more
axial rotation
• It is kyphotic and has greater instrinsic stability
due to the attachment to rib cage
• Lower 2 vertebra have floating ribs and no
costotransverse articulations
• Canal size is relatively narrow

4. PHYSIOLOGICAL ANATOMY OF
LUMBAR SPINE
• Lordotic
• More mobile
• Facets resist rotation as they are arranged in
sagittal plane
• Relatively wide spinal canal

5. THORACOLUMBAR JUNCTION
• It is more susceptible to injury mainly due to
the following reasons :
• Transition from relatively rigid, kyphotic
thoracic vertebra to more mobile, lordotic
lumbar vertebrae
• The T11-T12 provide less stability at the
thoracolumbar region compared to the upper
thoracic region as they do not connect to the
sternum

6. • The facets joints of the thoracic vertebrae are
oriented in coronal plane, limiting flexion and
extension
• In lumbosacral region, facets are oriented in
sagittal plane hence increasing the degrees of
flexion and extension

8. ETIOLOGY
• Usually high energy trauma such as Motor
vehicular accidents
• Fall from height
• Sports accident
• Gun shot injuries
• Osteoporosis
• Tumours etc.

9. INITIAL ASSESSMENT
• Adequate history
• Mode of injury – trivial
trauma or high velocity
• Fall from height or RTA
• ATLS protocol

10. SECONDARY SURVEY &
NEUROLOGICAL EXAMINATION
• Note facial injuries for occult cervical spine
fractures
• Other concomitant spine injuries (20%)
• Check for extremities and pelvis injuries in
polytrauma scenario
• Chest & abdominal injuries commonly
associated -pneumothorax /
pneumoperitoneum / haemoperitoneum
• Detailed neurological assessment

11. CLINICAL PRESENTATION
• History – high energy mechanism – RTA / fall
from height
• Cardinal symptoms –
Pain
Inability to move
Sensorimotor neurodeficit
Bowel bladder dysfunction
• Concomitant spinal and non spinal injuries

12. PHYSICAL EXAMINATION
• Vital signs-
• Hypotension is common
• Neurogenic shock - Hypotension with
associated bradycardia
• suggests spinal cord injury leading to loss of
autonomic regulation
• Hypovolemic shock - hypotension with
compensatory tachycardia
• suggests massive hemorrhage from major
vessel injury

13. EXAMINATION
• Inspection -
• Log roll patient during initial assessment to avoid
iatrogenic spinal cord injury in the setting of an
unstable fracture pattern
• skin abrasions and ecchymosis
• open spinal fractures are uncommon
• Palpation –
• spinous processes
• fluid collection
• crepitus
• increased interspinous distance
• suggests injury to the posterior elements
• localized tenderness

14. NEUROLOGICAL EXAMINATION
I. Motor examination
II. Sensory examination
III. Reflexes examination

15. MOTOR EXAMINATION
• Lumbar and sacral motor root examination

16. SENSORY EXAMINATION

17. EXAMINATION OF REFLEXES

18. NEUROLOGICAL EXAMINATION
• American Spine Injury Association (ASIA) scale is used for
neurological findings

19. • ASIA Impairment scale classifies cord injuries into
complete and incomplete
• A complete spinal cord injury is defined as the absence
of all motor and sensory functions, including sacral
roots, distal to the site of injury.
• Incomplete injuries are defined as those with some
degree of retained motor or sensory function below the
site of injury
• The determination of a complete or incomplete spinal
cord injury requires resolution of spinal shock.

20. SPINAL SHOCK
• Spinal shock is a physiologic response to trauma that is
marked by initial depolarization of axonal tissue
immediately after injury.
• It lasts for 24 – 48 Hrs after trauma
• During spinal shock, the patient exhibits a transient period
of flaccid paralysis , areflexia and absent Bulbocavernous
reflex
• Appearance of Bulbocavernous reflex marks the end of
spinal shock following which complete vs incomplete cord
injury can be evaluated

21. RADIOLOGICAL EVALUATION
• Plain radiographs – AP & Lateral
• CT scan
• MRI

22. X-RAYS
•AP View –
Fractures of transverse process or isolated
lamina
Loss of vertebral body height
Widening of interpedicular distance
Vertebral translation
 Loss of alignment of spinous processes
Increased interspinous distance
Horizontal split in the body

23. •Lateral view -
Loss of anterior vertebral height
Kyphosis > 30 degrees
Vertebral body collapse >50%
Loss of posterior vertebral body height
Posterior cortical bulging
Loss of spinal alignment
Vertebral translation
Facet joint dislocation
Spinous process fracture

24. CT SCAN
• Required for fracture classification and
morphology
• Surgical planning
• Axial view allows an accurate assessment
of the fractures and dislocation of
fragments into spinal canal
• Sagittal and coronal view are helpful for
determining fracture pattern

25. MRI SCAN
• Neurological deficit – to identify possible cord
lesion or compression that may be due to disc
, fracture fragments or epidural haematoma
• Assessment of integrity of posterior
ligamentous complex and thereby
differentiate into stable or unstable injury
• Mental obtundation
• Whole spine screening should be done to
identify multilevel non contiguous spine
injuries

26. CLASSIFICATION SYSTEMS
1. Bohler
2. Watson-Jones
3. Nicoll
4. Holdsworth
5. Kelly Whitesides
6. Denis
7. McAfee
8. McCormack load sharing classification
9. AO (Magerl) classification
10. Thoracolumbar Injury Classification and Scoring
system (TLICS) – Vaccaro / spine trauma study group

27. • Denis Three Column theory – 1983
• Introduced the concept of middle column
• The vertebral column is divided in 3 columns
I. Anterior column
II. Middle column
III. Posterior column
DENIS CLASSIFICATION

28. THREE COLUMN THEORY

29. • More of a mechanistic classification
• Remains indispensable even today
• Insisted that fractures with middle column injury
are unstable
• Four types of major injuries -
i. Compression
ii. Burst
iii. Flexion distraction (seat belt injuries)
iv. Fracture dislocation

30. • Minor injuries –
I. Transverse process
II. Spinous process
III. Articular process
IV. Pars interarticularis

31. COMPRESSION
FRACTURES
• Failure of anterior
column under
compression
• Usually no
neurological
deficit
• Four subtypes

32. BURST
FRACTURES
• Occurs due to severe
axial compression
resulting in failure of
anterior and middle
column
• If posterior column is
involved -> instabilty
• Most commonly at
thoracolumbar junction
• 5 subtypes

33. BURST
FRACTURE

34. FLEXION DISTRACTION
INJURIES
• Also known as seatbelt type
of injuries or Chance fracture
• Both posterior and middle
column fails due to
hyperextension &
subsequent tension forces
• Chance fracture – a
horizontal fracture extending
through the spinous process,
through the lamina and
pedicles, and into the
vertebral body

35. CHANCE FRACTURE

36. FRACTURE
DISLOCATION
• Results due to failure of all
the columns under
compression, tension,
rotation or shear
• Anterior hinge is also
disrupted and some degree
of dislocation is present

37. DEMERITS OF DENIS CLASSIFICATION
• Does not provide guidance for treatment
decision making
• Labelled two column injuries as operative
• Does not address ligamentous injuries
• Difficult to distinguish stable and unstable
burst fractures ..according to Denis all burst
fractures are unstable

38. AO/MAGERL CLASSIFICATION
SYSTEM
• 1994.
• More comprehensive classification
• Easy for communication
• A progressive alphanumeric scale of
anatomical damage
• Three types : A ,B ,C
• Every type has 3 sub types which are
further classified

40. HOW TO
CLASSIFY ?

41. TLICS CLASSIFICATION
• Thoracolumbar Injury Classification System
• Conceptualised by Spine Trauma Study Group –
VACCARO
• Used for decision making of treatment
• Three variables are evaluated
I. Mechanism of injury
II. Integrity of Posterior ligamentous complex (MRI)
III. Neurological status

42. TLICS
CLASSIFICATION

43. • When there are multilevel vertebral fractures ,
each level has to be scored separately
• The level with the highest TLICS score will
determine the treatment

44. MANAGEMENT

45. A0 – TRANSVERSE /
SPINOUS PROCESS
FRACTURE
• Does not compromise the
structural integrity of the spinal
column
• Treated by conservative
management

46. A1 WEDGE
COMPRESSION
FRACTURES
• Fracture of either
end plate with no
posterior wall of
vertebra injury
• Can be managed
conservatively

47. A2 SPLIT / PINCER
FRACTURE
• Fracture of both the end
plates without
involvement of posterior
wall of vertebral body
• Plan – conservative
management

48. A3 / INCOMPLETE BURST
FRACTURE
• Fracture of any end
plate with posterior
wall involvement

49. A4 / COMPLETE
BURST FRACTURES
• Fracture of both the
end plates with
posterior wall
involvement

50. A3, A4 WITH INTACT NEUROLOGY +
STABLE BURST FRACTURES

52. A3, A4 STABLE BURST FRACTURES WITH
INTACT NEUROLOGY
• Similar outcomes with surgery and
conservative treatment
• TLICS Score also < 4
• Consecutive >> surgery

53. A3 , A4 WITH INTACT NEUROLOGY +
UNSTABLE BURST FRACTURES
• Again , divided literature on benefits vs no benefit
of surgery
• Needs to be discussed with the patients
• Early mobilisation and prevention of late kyphosis
may favour surgical option
• Surgery >> conservative

54. A3, A4 FRACTURES WITH NEURODEFICIT
• TLICS Score > 4
• Surgical intervention is required
• Incomplete injuries are more aggressively
managed
• Recovery remains unpredictable
• Primary aim of the surgery is stabilisation –
early mobilisation and rehabilitation
• And also to correct deformity – prevent late /
progressive kyphosis

55. • AO B & C types require surgical intervention
• TLICS Score > 4
• Also injury to posterior ligamentous complex

56. TREATMENT OPTIONS
• Nonoperative
• Operative
• Nonoperative treatment –
• Immobilisation can be done in Thoracolumbar Sacral
Orthosis brace or TLSO hyperextension brace
(Jewett) for 10-12 weeks
•

57. THORACOLUMBAR SACRAL ORTHOSIS
BRACE

58. TLSO HYPEREXTENSION BRACE (JEWETT)

59. SURGICAL CONSIDERATIONS
• Timing of the surgery
• Approach
• Posterior short segment vs long segment
• Indirect vs direct decompression
• Role of Minimal invasive surgery

60. TIMING OF THE SURGERY
• Delayed surgery – complete cord injury
To avoid secondary insult due to
surgery
• Early surgery – within 72 hrs – better neurological
outcome in incomplete cord injury patients

61. TIMING OF THE SURGERY
• Controversy
• 28 patients with unstable fractures with neurologic
deficit
• 40% underwent Surgery in < 8hrs and 60% > 8hrs
• Mean improvement was better in the group - <8hrs
• Mainly observed in patients with incomplete cord
injury

62. APPROACHES
• Anterior approach
• Posterior approach

63. ANTERIOR APPROACH
• Canal clearance – Direct and complete
• Kyphosis correction – same as posterior approach
• Reconstruction of anterior column – prevents late
kyphosis

64. DRAWBACKS OF ANTERIOR APPROACH
• Technically demanding – High morbidity
• Should be delayed until the patient is stable
• Usually reserved for lumbar spine or with
severe comminution of the vertebral body

65. POSTERIOR APPROACH
• Canal clearance – indirect and incomplete
• Kyphosis correction – same as anterior approach
• Reconstruction of anterior column – late kyphos
• Technically easier – low morbidity
• Indirect correction of kyphosis & canal
encroachment

66. SURGICAL OPTIONS
1. Posterior stabilization only
2. Posterior stabilization with decompression
3. Posterior stabilization with anterior
reconstruction
4. Anterior reconstruction only

67. POSTERIOR STABILIZATION ONLY
• It is done when there is disruption of posterior
ligamentous complex

68. POSTERIOR STABILISATION WITH
DECOMPRESSION
• Done when there is retropulsed fracture
fragment causing cord compression &
disruption of posterior ligamentous complex
• Type B fractures

69. POSTERIOR STABILISATION WITH
ANTERIOR RECONSTRUCTION
• Distraction —> cage / graft insertion —>
Compression
• Type C injuries

70. ANTERIOR RECONSTRUCTION
• A3 Incomplete burst fracture
• A4 complete burst fracture
• B3 hyperextension injuries
• Can be done by anterior approach or posterior
transpedicular approach

71. ANTERIOR RECONSTRUCTION
• McCormack and Gaines classification
• Score >= 7 : Anterior reconstruction

72. INSTRUMENTATION – SHORT VS
LONG
• Type B fractures
• B1 and B2 fractures – posterior short segment
instrumentation
• B3 fractures – Anterior short segment
instrumentation
• Can be done via anterior approach or posterior
transpedicular approach

73. TYPE C FRACTURES
• Always long instrumentation
• C1 ( A + Rotation ) – Posterior long segment
• C2 ( B + Rotation ) - Posterior long segment
• C3 ( Rotation sheer injury) – Posterior long segment
instrumentation + anterior column reconstruction

74. TREATMENT ALGORITHM

75. TAKE HOME MESSAGE
• Classify – To understand mechanism of injury
• AO Classification – Description of fracture
• TLICS – To Decide the management
• Neurology – prognosis and decide the timing of
surgery
• Principles of management – posterior tension band
restoration & good anterior reconstruction

76. THANK YOU