Spine fractures: Anatomy, pathology & treatment options Gautam Das MD, FIPP President Elect: Indian Society for Study of Pain Editor-in-chief: Journal on Recent Advances in Pain Ex-chairman: WIP-India, Pakistan, Iran & Sri Lanka section Examiner: FIPP exam by WIP at USA & Netherlands Author of 4 Books: 1. Clinical Methods In Pain Medicine-2nd Ed 2. How To Start & Run A Pain Clinic 3. Basics Of Pain Management 4. Common Pain Management Procedures

references Basics of Pain Management: Gautam Das The Biomechanics of Back Pain: Adams, Bogduk, Burton & Dolan Recent Advances in Spinal Surgery: Vaccro, Koerner & Kim Spine Surgery: Garg & Malhotra Basic Science of Spinal Diseases: Sharan, Tang & Vaccro https://radiopaedia.org/ last seen on 5th April 2017

Discussion points Anatomy & Physiology of bone Structure & innervation of vertebral body Types of spine fractures Treatment outline

OSTEOBLASTS OSTEOCYTES OSTEOCLASTS OSTEON CENTRAL CANAL LACUNAE CANALICULI MATRIX

Serum Calcium CALCITONIN Vit D PTH PTH Increased Osteoclastic activity Immobilization PTH Gucocorticoids Steroids Less dietary Ca Vit D deficiency Osteolytic tumors Decreased Osteoclastic activity Calcitonin Estrogen Bisphosphonates PTH Increased Osteoblastic activity Children & adolescent Exercise Fracture Osteoblastic tumors Teriparatide Anabolic Steroids Serum Calcium PTH

Bone remodeling: wolf’s law

Loading of vertebral body Weight of upper limbs & head Contraction of paraspinal muscles to keep us erect

Innervation of vertebral body

Three column concept of Denis anterior column anterior longitudinal ligament (ALL) anterior two-thirds of the vertebral body anterior two-thirds of the intervertebral disc (annulus fibrosus) middle column posterior one-third of the vertebral body posterior one-third of the intervertebral disc (annulus fibrosus) posterior longitudinal ligament (PLL) posterior column everything posterior to the PLL pedicles facet joints and articular processes ligamentum flavum neural arch and interconnecting ligaments

Denis classification: in 1976 type A: fracture of both endplates without kyphosis. mechanism of injury: pure axial load. predilection site: lumbar region type B: fracture of the superior endplate (CT may also demonstrate a sagittal split of the lower endplate). most frequent burst fracture. mechanism of injury: axial load and flexion. predilection site: thoracolumbar junction type C: fracture of the inferior endplate. Rare. mechanism of injury: probably axial load and flexion. no particular site pattern could be identified type D: burst rotation fracture. burst fracture with comminution of the vertebral body, large central defect on CT, loss of posterior height, increase of the interpedicular distance, vertical fracture of the lamina, bone retropulsed into the spinal canal. mechanism of injury: axial load and rotation. predilection site: mid lumbar region type E: burst lateral flexion fracture. fractured posterior wall of the vertebral body with fragment extrusion towards the side of the flexion. mechanism of injury: axial load and lateral flexion

Magerl classification A: compression injuries A1: impaction fractures A1.1: endplate impaction A1.2: wedge impaction A1.3: vertebral body collapse A2: split fractures A2.1: frontal split fracture A2.2: sagittal split fracture A2.3: pincer fracture A3: burst fractures A3.1: incomplete burst fracture A3.2: burst split fracture A3.3: complete burst fracture A3.3.1: pincer A3.3.2: flexion A3.3.3: axial B: distraction injuries B1: predominantly transligamentous flexion- distraction injury B1.1: with transverse disc disruption B1.1.1: flexion subluxation B1.1.2: anterior dislocation B1.1.3: B1.1.1 or B1.1.2 the with fractures of the articular processes B1.2: with type A vertebral body fracture B2: predominantly osseous flexion-distraction injury B2.1: transverse bi column fracture B2.2: posterior osseous disruption with transverse disc disruption B2.2.1: through the pedicles B2.2.2: through the interarticular portions (flexion spondylolysis) B2.3: with type A vertebral body fracture B2.3.1: through the pedicles B2.3.2: through the isthmus B3: anterior disruption through the disc B3.1: hyperextension-subluxation B3.2: hyperextension-spondylolysis B3.3: posterior dislocation C: torsion injuries C1: rotation-compression injury C1.1: impaction C1.2: split C1.3: burst C2: rotation-distraction injury C2.1: with transligamentous flexion-distraction C2.2: with transosseous flexion-distraction C2.3: with hyperextension- distraction C3: rotational shear injury

McAfee classification wedge compression: isolated anterior column compression  stable burst: anterior and middle column compression but posterior column is normal unstable burst: anterior and middle column compression with disrupted posterior column flexion-distraction  anterior column compression middle and posterior column: tensile failure axis of flexion: posterior to anterior longitudinal ligament chance fractures pure bony injuries that extend all the way through the spinal column: from posterior to anterior through the spinous process, pedicles, and vertebral body, respectively axis of flexion: anterior to anterior longitudinal ligament translational fractures ​shear force to all the 3 columns

Modified denis classification Anterior wedge/compression fracture Burst fracture Flexion-distraction fracture or seat-belt injury Fracture dislocation

Anterior wedge/compression fracture Most common Axial loading with flexion In young & middle aged: motor vehicle injury or fall from height/ In elderly minor trauma in osteoporotic bone Middle column normally remains intact

Axial loading End plate injury Compression fractures

Management of wedge/compression fracture 3 months conservative management with rigid arthrosis Surgical fixation if more than 40% height loss Vertebroplasty/ kyphoplasty Rami communicantes fibre block Epidurals

Burst fracture Severe axial compression with middle column injury stable burst: anterior and middle column compression but posterior column is normal unstable burst: anterior and middle column compression with disrupted posterior column Neurodeficits in 50-60% situations

No Deficits: Conservative Consider VP/ KP Unstable Controversial Burst fracture Stable Deficits: Surgery No Deficits: Conservative Consider VP/ KP Unstable Controversial Management Image Neurological examination

Flexion-distraction fracture Originally described by Chance in 1948 Seat-belt injury when lap type belt is used Always unstable even anterior column is preserved Mostly surgical fixation

Fracture-dislocation Significant high force is needed Neuro-deficits are very common Surgical treatment is needed in most situation

Thoracolumbar injury classification and severity score (TLICS) Patsy Robertson et al. Recommended by spine trauma group Lee JY, Vaccaro AR, Lim MR et-al. Thoracolumbar injury classification and severity score: a new paradigm for the treatment of thoracolumbar spine trauma. J Orthop Sci. 2005;10 (6): 

Thoracolumbar injury classification and severity score (TLICS) Classification score is based on three major categories, known as parameters: injury morphology posterior ligamentous complex integrity patient neurology

Morphology - CT compression fracture - 1 point burst fracture - 2 points translational or rotational injury - 3 points distraction injury - 4 points

Posterior ligamentous complex-mri intact - 0 points suspected injury or indeterminate - 2 points injured - 3 points

Neurologic status intact - 0 points nerve root injury- 2 points cord injury(complete) - 2 points cord (incomplete) - 3 points cauda equina - 3 points

Treatment and prognosis Total number of points helps guide managing surgeons and physicians determine a management plan depending on the presence of other co-morbidities and injuries. Patient with a score of: <4 - treated non-operatively 4 - may be treated operatively or non-operatively >4 - considered for operative management

Summary Osteoporotic wedge/compression fracture is the commonest type of spine fracture Immobilization & rest increases osteoporosis & softens bone, early mobilization is key for long term management VP/KP is an important component of non-operative management Operative management is needed in unstable fracture with neuro-deficits TLICS score may be helpful in decision making