Thoracolumbar Fractures Classification Models Fracture Management Case Illustrations Purpose is to talk assessment and management, NOT about specific techniques Kevin Chao, MD Stanford Neurosurgery

Classification Models Denis Three-column ANATOMIC biomechanical model Accounts for mechanism of injury No rigid guidelines for treatment Magerl/ AO Spine MECHANISTIC model Detailed characterization of fracture subtypes Thoracolumbar Injury Classification and Severity Score (TLICS) Accounts for 1) fracture morphology, 2) neurologic deficit, and 3) posterior complex status Point-based system guides intervention (TLICS > 4) Overall just helps you sort out in your mind what to consider

Know the source for recommendations

Denis Three Column Model Anatomic 3 column based classification Anterior ALL Ant annulus Ant wall VB Middle PLL Post annulus Post wall VB Posterior SSL/ISL Posterior arch Facet capsule Ligamentum flavum

Seat belt-type injuries

Denis Series Outcomes (412 pts) Fracture pattern % Acute neuro deficit Compression Burst 48 Seat belt -type Fracture dislocation 75 (52% complete) Denis argues against the contribution of the posterior band to spinal column stability !! Denis gives NO RIGID PARAMETERS for treatment

MECHANISTIC classification system borrowed from orthopedic extremity injury classfication systems 3 groups 3 sub groups 3 sub types

TLICS TOTAL ___ TLICS addresses limitations of current system Reproducible with low interobserver variation Accounts for neurologic deficit Apply this to our cases TOTAL ___

ASIA Scale Poor prognosis Good prognosis

Spine Fracture Approach Assessment Mechanism of injury Neuro exam Imaging Levels Bone vs soft tissue Dynamic vs static Vessels? Degree of instability Management Surgery vs no surgery Goals? Brace? Activity restrictions Follow up Imaging Rehab

Stable or Unstable? Overall degree of instability 1st degree: Mechanical instability 2nd degree: Neurological instability 3rd degree: Both

Stable or Unstable? UNSTABLE > 50% height loss > 20°angulation > 50% canal compromise* Neurologic deficit Progressive kyphosis STABLE Minimal anterior column wedge Above T8 if ribs and sternum intact Seat-belt type injuries without neurologic deficit

Fracture Management Goals: Mechanical stabilization Prevention of secondary neurologic injury [ Decompression, if needed ] !! Instrumentation only serves as a bridge to fusion (or ligament healing)

Case files

35M paragliding accident Motor Right hip flexion pain-limited weakness (otherwise full strength) Normal rectal tone Sensory Right thigh to knee completely numb Left knee and shin partly dumb Saddle anesthesia Reflexes Diminished at knees and ankles No clonus L2 Describe CT Mechanism Stable or unstable? 2 burst fracture 3 cauda equina 0 post intact 3rd degree instability TLICS 5 (2+3+0) ASIA D

Two-stage procedure Stage 1 Segmental instrumentation T12-L4 Decompression Posterolateral fusion

Two-stage procedure Stage 2 Lateral corpectomy Interbody cage

Post op result Motor Improved hip flexion Able to walk Sensory Unchanged Bracing TLSO Follow up - 4 week repeat X rays 

Teaching points Recognize cauda equina syndrome Define surgical goals Many approach options (P, A/P, L/P) Lateral approach technique No abd surgery exposure needed L3-T12 (below L3 often limited by iliac crest) Rib resection +/- chest tube may be needed Lumbar lordotic curve  significant load bearing in middle and posterior columns

1st degree instability TLICS 7 (4+0+3) ASIA E 42M fell from tree Motor Full strength Normal rectal tone Sensory Intact to LT, proprioception, pin prick Reflexes Normal at knees and ankles No clonus T12 Describe CT Mechanism Stable or unstable? 4 distraction 0 intact 3 disrupted posterior ligamentous complex 1st degree instability TLICS 7 (4+0+3) ASIA E

Sag CT recon Facet disruption MR Sag STIR Disc extrusion Ligament disruption MR Axial T2 FS Canal hematoma Facet disruption

Post op result T11-L2 posterolateral fusion Motor Intact Sensory Bracing TLSO Follow up - 6 week repeat X rays pending

Teaching points Look beyond static image: What was the mechanism of injury? Ligamentous injury >> bony injury Ligamentous seat-belt-type fracture management options: Open surgical instrumentation/fusion Internal bracing (i.e. percutaneous instrumentation) Bracing ?

3rd degree instability TLICS 9 (3+3+3) ASIA C 22M motorcycle crash 2/5 hip flexion and knee extension 0/5 below knee diminished rectal tone Sensory Diminished sensation to light touch below knee Reflexes None at knees and patella No clonus Describe image Mechanism Stable or unstable? 3 rotation/translation 3 cauda equina 3 post ligaments disrupted 3rd degree instability TLICS 9 (3+3+3) ASIA C

1st attempt at surgery: Aborted due to sacral hemorrhage Wound packed Pelvic binder placed Sacral vessels embolized Transfused pRBC, FFP, plts Returned to OR 2 days later…

Post op result L1-L5 segmental instrumentation and posterolateral fusion Correction of fracture-dislocation using Wilson frame and reduction screws Motor unchanged Sensory some ROF below knees Bracing TLSO Follow up - 6 week repeat X rays  Not yet

Teaching points Fracture-dislocations lead to majority of neurologic deficits from spine traumas (~50%) Recognize other trauma injuries Many spine fractures are URGENT (treat within 48 hours). Very few are EMERGENT (treat < 12 hours). Wait for hemodynamically stability AMAP Know fracture pattern/ anatomy preop Be prepared for other injuries (thecal sac/ nerve roots, vascular, ureters, bowel, etc)

Teaching points Can reduce some fractures with special OR tables (Wilson frame, Axis tilt, Jackson prone) Reduction screws can be very helpful Reduction screw Wilson frame Axis-Jackson Table

Final point TP fractures are not always benign L4-5 TP fractures associated with lumbosacral plexus injury T1-2 TP fractures associated with brachial plexus injury

References Denis F. The Three Column Spine. Spine 1983; Vol. 8, No 8: 817-831 Classic historic paper with simple classification system No rigid parameters for treatment Patel A, Vaccaro A. Thoracolumbar Spine Trauma Classification. J Am Acad Orthop Surg 2010;18: 63-71 New TLICS classification point system to guide treatment http://www.aospine.org/ Pocket cards and protocols