1. 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

2. 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
last seen on 5th April 2017

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

4. OSTEOBLASTS
OSTEOCYTES
OSTEOCLASTS
OSTEON
CENTRAL CANAL
LACUNAE
CANALICULI
MATRIX

5. 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

6. Bone remodeling: wolf’s law

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

8. Innervation of vertebral body

9. 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

10. 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

11. 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

12. 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

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

14. 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

15. Axial loading End plate injury Compression fractures

16. 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

17. 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

18. 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

19. 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

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

21. 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): 

22. 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

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

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

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

26. 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

27. 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