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

2. 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

3. Know the source for recommendations

4. 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

6. Seat belt-type injuries

7. 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

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

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

12. ASIA Scale
Poor prognosis
Good prognosis

13. 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

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

15. 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

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

17. Case files

18. 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

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

21. Two-stage procedure
Stage 2
Lateral corpectomy
Interbody cage

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

23. 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

24. 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

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

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

27. 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 ?

28. 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

29. 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…

30. 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

31. 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)

32. 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

33. 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

34. References
Denis F. The Three Column Spine. Spine 1983; Vol. 8, No 8:
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
Pocket cards and protocols