Thoraco-lumbar fractures are common injuries that occur primarily from motor vehicle accidents. Several classification systems exist to characterize the injuries including the commonly used Denis classification, Load Sharing classification, and AO classification system. The Thoracolumbar Injury Classification and Severity Score (TLICS) system incorporates injury morphology, neurological status, and posterior ligamentous complex integrity to determine a score to guide treatment decisions. A score of 4 or less generally indicates non-surgical management while a score of 5 or more indicates surgery is needed. The timing of surgery remains unclear but early decompression may improve outcomes in neurologically incomplete injuries. Treatment is based on fracture stability, deformity, and neurological status.

1. Thoraco-lumbar Fractures
Sami Al Eissa, MD
Consultant Orthopedic & Spine Surgery

2. Epidemiology
• United State
– 150000 to 160000 vertebral column fracture/ year.
• 10000 -12000 spine cord injury
– 15000 major thoraco-lumbar fracture/ year
• 4700 – 5000 significant neurological deficit
• Saudi Arabia
– No national statistic exist
– In one trauma center in Riyadh;
• Over 100 patients admitted yearly with major T/L fracture
from MVA only

3. Biomechanics

4. T2 – T9
• Shielded by;
– Paraspinal musculature
– Sternum & Rigid thoracic rib stiffness
– Coronal alignment of facet joint
» Resist flexion / Extension
» Minimal resistance to torsion
– Physiological kyphosis
compression/ flexion injuries
Biomechanics

5. • T11 – L1; Transition zone between
Kyphotic immobile segment &
Lordotic mobile segment
–Predispose to injury by rotational and shearing
forces
• Rib are not present
• Facet have not re-oriented completely
60% of TL fractures occur at this junction
Biomechanics

6. • Upper thoracic spine:
Center of gravity is anterior to the
spine. Axial loading will result
in compressive forces
anteriorly, tensile forces
posteriorly. This will result in
flexion-type of injuries.
• lumbar spine:
Center of gravity is posteriorly.
Flexion type of injuries will
straigthen the lumbar spine
and result in axial loading. In
this area we will see many
burst fractures.
Biomechanics

7. Three column model of Denis

8. Three column model of Denis

9. Thoracolumbar fractures
• 75% to 90% of spinal fractures occur in the thoracic and
lumbar spine
• Most of these occurring at thoracolumbar junction (T10-
L2).
• Little consensus regarding injury classification and
management.
• Treatment varies widely, from bracing to
circumferential fusion, based on geographical,
institutional, and surgeon preferences rather than on
scientific evidence.

10. General guidelines
• Stability
• Neurological compromise
• Deformity

11. How can we decide?

12. How
can not
decide?
Surgery
Brace or
no brace
Anterior approach
Posterior approach
Conservative
Bed rest
How many levels?

13. General guidelines
Spine structure Neurologic Treatment
stable Normal Non surgical
stable Complete Non surgical
stable Incomplete Decompression &
stabilization
Unstable complete stabilization
Unstable incomplete Decompression &
stabilization
Adopted by Capen DA, Spine, 2003

14. Classification
• Many systems are convoluted, with an
impractical number of variables. Others
are too simple, lacking sufficient detail to
provide clinically relevant information.
lack of a widely accepted classification
system

15. Data Supporting the Common Classification Schemes

16. • Several classification systems
• Most commonly used are
– Denis classification system
– Load sharing classification described by
McComack
– AO classification system
Classification

17. Denis classification system

18. Denis classification system
Compression
Fracture
dislocation
Burst
Flexion
destraction

19. • Not sufficiently detailed to account for all
fracture types
• Does not provide prognostic information
for the neurological status of
does not adequately aid surgical decision
making.
Denis classification system

20. AO classification
• Simple Morphology
• Neurological Injury
• Modefiers

21. AO Classification

22. AO Classification

23. AO Classification

24. AO Classification

25. AO Classification

26. AO classification

27. Algorithm for AO fracture type
classification

28. Thoracolumbar Injury Classification and
Severity Score
• Introduced by the Spine Trauma Study Group in 2005
• The TLICS is the first system to incorporate the
neurologic status of the patient

29. Injury
Morphology
Neurological
status
Posterior
ligamentous
complex
3 factors determine the decision !

30. TLICS system
• Thoracolumbar Injury
Classification and Severity
Score.*
• Scoliosis Research Society
Injury Severity Score.
* Rihn JA, Anderson DT, Harris E, Lawrence J, Jonsson H, Wilsey J, Hurlbert
RJ, Vaccaro AR.

31. Injury Morphology
• Compression injuries:
Loss of height of the vertebral
body or disruption through the
vertebral end plate. This
includes;
– Traditional compression (ie,
anterior column)
– Burst (ie, anterior column,
middle column)

32. Injury Morphology
• Rotation/translation injury
horizontal displacement of one
thoracolumbar vertebral body
with respect to another.
– Unilateral/ bilateral dislocations,
facet fracture-dislocations, as
well as bilateral pedicle or pars
fractures with vertebral
subluxation.

33. • Distraction injury; anatomic
dissociation in the vertical axis,
such as a hyperextension injury
– Disruption of the anterior longitudinal
ligament, with subsequent widening of
the anterior disk space.
– Fractures of the posterior elements (ie,
facet, lamina, spinous process) may
also be present in distraction injury.
– Severe kyphotic deformities caused by
tensile failure of the posterior
ligamentous structures,
Injury Morphology

34. Mechanism-Point
System
Compression
1 point
Distraction
4 points
Translation
Rotation
3 points
Injury Morphology

35. Neurologic status
• Described in increasing order of urgency:
neurologically
– Intact
– Nerve root injury
– Complete (motor and sensory) spinal cord or cauda equina
injury
– Incomplete (motor or sensory) spinal cord or cauda equina
injury.

36. Neurology point
system
cord
complete
2 points
incomplete
3 points
Cauda
equina
3 points
Nerve root
1 point
intact
0 point
Neurological status

37. Posterior Ligamentous
Complex Integrity
• Anatomic structures of the PLC include the supraspinous
ligament, interspinous ligament, ligamentum flavum, and
facet joint capsules.
• plays a critical role in protecting the spine and spinal
cord against excessive flexion, rotation, translation, and
distraction.
Once disrupted, the ligamentous structures
demonstrate poor healing ability

38. • Categorized
– Intact, Indeterminate, and Disrupted.
• Assessment based on
– Clinical exam
– Plain radiographs
– CT scans
– magnetic resonance
Widening of the interspinous space or of the facet
joints, empty facet joints, facet perch or
subluxation, Dislocation of the spine
Posterior Ligamentous
Complex Integrity

39. Posterior
longitudinal
ligament
Not Intact
3 points
intact
0 point
Stability-Soft Tissue Point System

40. Next Step - Direct TX
Assign Points
Conservative Surgery

42. • Fractures with 4 points or less = non
operative.
• Fractures with 5 points or more =
surgery
Treatment

43. Compression ( mechanism) - 1
Intact (neurology) - 0
PLC (ligament) no injury - 0
Anterior Compression Fx
Total 1 points Non Op
Example

44. Compression (mechanism) : 1+ 1
Intact ( neurology) - 0
PLC (ligament) no injury :0
Stable Burst Fracture
Total 2 points Non Op
Example

45. Compression + burst (mechanism): 1 + 1
Complete (neurology) : 2
PLC (ligament) injury : 3
Unstable Burst-Complete Neuro
Injury
Total 7 points Surgery
Example

46. Translation/rotation - distraction
(mechanism): 3
Complete (neurology): 2
PLC (ligament) injury: 3
Fracture Dislocation
Total 8 points Surgery
Example

47. 18 yr-old
MVA
Normal
neurological exam
63 yr-old
Fall from hight
Normal
neurological exam

49. Limitation of TLICS system

50. • Not for pediatric population
• For acute injuries
• cannot be applied to;
– Symptomatic epidural hematoma
– Spinal cord injury without radiographic abnormalities
– posttraumatic deformity
– Iatrogenic spinal instability
– Pathologic fractures associated with tumor or infection.

51. • TLICS is a reliable system for assessing fractures of the
thoracic and lumbar spine when used by experts.
• the posterior ligamentous complex subcomponent score
was the least reliable component.

52. Timing of surgery
• Remain unclear.
• Lack of class one evidence, no standard guidelines.

53. Timing of surgery
• Preclinical studies suggest that early surgical
decompression of the spinal cord is important in
mitigating secondary injury.
• The completeness of SCI injury seems to be the key
prognostic factor
• To date …. there is no robust evidence to suggest that
early surgical intervention in tSCI is superior.
• Surgical decompression performed before 24 h post
injury has the potential to result in superior motor
recovery in comparison with late surgery performed at or
after 24 h post injury

54. General guidelines
Spine structure Neurologic Treatment
stable Normal Non surgical
stable Complete Non surgical
stable Incomplete Decompression &
stabilization
Unstable complete stabilization
Unstable incomplete Decompression &
stabilization
Adopted by Capen DA, Spine, 2003

55. Conclusion
•Have a clear understanding to nature of the fracture
and it’s consequences.
Stability, deformity, and neurological picture will
remain the main factors determining the surgical
decision