Oliver I. Schmidt, Ralf H. Gahr Pitfalls in Spinal Fracture Classification Oliver I. Schmidt, Ralf H. Gahr Trauma Centre St. Georg Clinic Leipzig, Germany

Magerl, M. Aebi, et al., „A Comprehensive Classification Of Thoracic and Lumbar Injuries“, Eur Spine J (1994) 3: 184 -201 Standardized Nomenclature, Golden Standard CLASSIFICATION Comprehensive Classification for Type of vertebral fracture and injury mechanism Separation into stable and unstable conditions Treatment options can be based on classification result

A B C Three fundamental types of injury Groups Groups Groups Subgroups Compression B Groups Subgroups Disruption C Groups Subgroups Axial torque CLASSIFICATION

Type A – Vertebral Body Compression Pure axial compression force => No Injury to Posterior Column Compression injury of the anterior (and medial) column, only TYPE A PITFALL Osteoporotic fractures: old vs. fresh/active

AVOID PITFALL 1. Check history of point of injury 2. Do check for local pain / association to fracture height 3. X-Ray: Check for sclerosis of fractured vertebra Look for additional fractures in the spinal column TYPE A 4. If available or in doubt, go for MRI (T2-Fat saturated)

Where´s the fresh osteoporotic # ?! TIRM T2w TSE T1w TYPE A ?

Type B1.1: Posterior ligament. Lesion Hyperflexion of the spine => Injury to Posterior Column PITFALL TYPE B Ruptur to PLC presents w/o signs of vertebral fracture

AVOID PITFALL Check history for any distraction/hyperflexion injury 2. Clinical Signs of posterior injury: local tenderness, Hematoma, Proc. Spinosi #, Supraspinous Lig. # TYPE B 3. X-Ray: Check Alignement of all three spinal columns Look for widened interspinous space in PLC Look for facet diastasis/luxation 4. If available or in doubt, go for MRI

Type B1.2: Posterior Distraction – Anterior Compression Hyperflexion of the spine Posterior distraction Posterior Column Injury Anterior Compression vertebral compression fracture TYPE B PITFALL vertebral fracture is recognized but posterior injury overlooked

AVOID PITFALL If Type A injury is diagnosed, always assume injury to posterior column: 1. Check history for any distraction/hyperflexion injury TYPE B 2. Clinical Signs of posterior injury 3. X-Ray: Check Alignement of all three spinal columns Look for widened interspinous space in PLC Look for facet diastasis/luxation Look for pedicle fracture, ? Pedicle Position 4. If available or in doubt, go for MRI

Type B2: Posterior Distraction w. osseous Lesion Hyperflexion of the spine Posterior distraction Injury to Posterior Column Traumatic Spondylosis TYPE B

Type B3: Anterior Distraction Hyperextension of the spine Anterior distraction Anterior Column Injury pure discoligamentous Injury w/o vertebral fracture TYPE B PITFALL Discoligamentous injury w/o signs of vertebral fracture

Type B3: Anterior Distraction => Characteristic injury mechanism

AVOID PITFALL Check history for any hyperextension injury 2. Rule out intraabdominal injury: Hyperextension can lacerate mesenteric trunc or Pancreas => Abdominal Exam, Ultrasound, CT TYPE B 3. If available or in doubt, go for MRI

Type C1: Rotational/Axial Injury with compression Axial Rotation & Type A injury of the spine => Instability TYPE C PITFALL Type A fracture diagnosed, but Signs of Rotational Injury overlooked

AVOID PITFALL Check history for any rotational injury (insufficient data, in most cases) 2. Rule out intraabdominal injury: Rotation can lacerate mesenteric trunc or Pancreas => Abdominal Exam, Ultrasound, CT TYPE C 3. X-Ray: Check for Signs of discoligamentous injury Signs of Rotational Injury: Transverse Proc. #, lateral vertebral bulge Fragment, asymmetrical vertebral # 4. If available or in doubt, go for MRI

Stable Type A Fracture ?! TYPE C

=> Nope ! Unstable Type C1 Stable Type A Fracture ?! Lateral Bulge TYPE C Fracture of Proc. Transv. Exzentric Proc. Spin. => Nope ! Unstable Type C1

Type C2: Rotational/Axial Injury with distraction Axial Rotation & Type B Injury of the spine => Instability TYPE C PITFALL Type B fracture diagnosed, but Signs of Rotational Injury overlooked

Type C3: Pure Rotational/Axial Injury Pure Axial Rotation Injury of the spine => Instability TYPE C

CAVE ! Type B Type A Stable Type C Unstable Smooth transition from Type A to B and C Fractures Always rule out higher grade injury Type B Type A Stable Type C Unstable GUIDELINES

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