Thoracic and Lumbar Spine

Fractures and Dislocations:

Assessment and Classification

Jim A. Youssef, MD
Durango Orthopedic Association

Mitch Harris, MD
Wake Forest University
 Introduction
 Anatomy
 Incidence of thoracic and lumbar injuries
 Approach to patient
 Radiographic examination
 Classification of thoracolumbar fractures
 Introduction
 Mechanism of injuries to the
thoracolumbar spine
 Assessment of spinal stability
 Treatment
– Non-surgical
– Surgical
 Anatomy of Thoracic Spine

 Normal kyphotic
alignment
 Narrow spinal canal
 Transverse facet
orientation
 Rib and sternum
increase stability
 Conus at T12-L1
 Anatomy of Lumbar Spine
 Normal lordotic
alignment
 Larger vertebral
bodies
 Biplanar facet
orientation
 Cauda equina
 Thoracolumbar Junction
Major Transition Zone

Kyphosis to lordosis

Stiff thoracic to mobile

lumbar

Spinal cord to conus to cauda

 Patient Evaluation

 Pre-hospital care

 EMT personnel
– Initial Assessment
– Transport and immobilization
 Patient Evaluation

 ABC’s of ATLS
 History
 Physical Examination
 Neurological Classification
 Clinical Assessment
 Inspection
 Palpation
 Neurological Evaluation
– ASIA Impairment Scale
 Sensory Evaluation
 Motor Evaluation
 Reflex Evaluation
– Bulbocavernosus
 Clinical Assessment
 Associated Injuries
– 28% have other major organ system injuries
– Noncontiguous spine fractures 3-17%
– Always monitor hematocrit and urine output
– Urinary – Foley recommended,
– GI – prepare for ileus
» Retroperitoneal bleeding from fracture
» Gastroparesis from trauma
Meyer ‘85
 Radiographic Evaluation
 Initial Trauma Series: (Classic ATLS)
Lateral cervical, chest, AP pelvis
Secondary spine films determined by individual condition
and MOI

 Trauma protocols with CT scans of chest, abd. and

pelvis provide much more information;
Challenges necessity for plain films

 Obtunded patients require further skeletal survey,

secondary survey essential
 Additional Imaging

 CT scan – bony injuries

 MRI – soft tissue imaging:

Spinal cord, intervertebral discs, ligamentous
structures
 Classification of Thoracic and
Lumbar Fractures

 Which injuries are stable ??

 Which injuries benefit from spinal cord
decompression ??
 Which injuries require surgical
stabilization ??
 Classification of Thoracic and
Lumbar Fractures
 ‘Founding Fathers’ of Classification
– Nicoll – stable vs. unstable
– Holdsworth–2 column theory
– Denis – 3 column injury
– Ferguson and Allen – mechanistic
classification
– McAfee- Identified the stable burst fracture
 Denis Classification of
Compression Fractures

Four types A-D

 Denis Classification of Burst
Fractures
 A – axial load, involves
both endplates
 B – superior endplate
burst
 C – inferior endplate
burst
 D – combination of
type A with rotation
 E –lateral burst fracture
 Wedge Compression Fractures

 Hyper flexion or
compressive failure
 Anterior column
 Stable injury
 Stable Burst Fracture
 Failure of anterior and
‘middle’ columns
 Predominantly axial
load
 No posterior column
disruption
 Stable injuries
– < 50% retropulsion
– <20 degrees kyphosis
 Unstable Burst Fracture

 Posterior column
involvement !!!
 Distraction or
translation/rotation
injury mechanisms
 Flexion-Distraction Injury
 Due to distraction
forces of middle and
posterior columns
 Usually secondary
to seat belt injuries
 Boney, purely soft
tissue, mixed
 Visceral injuries
common
 Translational/ Rotational Injury
 Results from
shearing failure of
middle column
 Holdsworth coined
“slice” fracture
 Most unstable !!!
 Highest incidence
of neurologic
deficit
 Biomechanics of Thoracic
Injuries
Center of Gravity:
– Anterior to the
vertebral body with
axial load
- Posterior ligamentous
tension band

Potential for KYPHOTIC

deformity
 Biomechanics of Lumbar Injuries

Center of Gravity:
– Posterior ½
vertebral body
– Lordotic alignment
“protective”
– Potential for 20
flexion moment (seat
belt)
 Biomechanical Studies
 Roaf, 1960 – pure axial load or pure flexion
leads to little posterior ligamentous injury

 Nagel, 1981 – 20 degrees of kyphosis or 10

degrees lateral angulation implies incompetence
of PLL and posterior elements, thus inferring
instability
 Biomechanical Studies
 Panjabi, 1981 – it takes sectioning of PLL
and posterior annulus to destabilize a
motion segment with the addition of facet
capsule and interspinous ligament
disruption

 James et al, ’94 – middle column offers

little additional resistance to kyphosis with
increasing axial load
Management of Thoracic and
Lumbar Injuries

CONTROVERSIAL!!!!
Non-Operative Treatment of
Thoracic Spine Injuries

Brace or Cast Treatment

– Compression Fractures
– Stable Burst Fractures
– Pure Bony Flexion-Distraction Injury
 Surgical Management of
Thoracolumbar Injuries

 Unstable burst fractures

 Purely ligamentous
 Facet dislocations
 Translational/rotational
injuries
 Neurologic deficits ????
 Results of Treatment
 Neurologic

– Denis, 1984 – 17% neuro deterioration in

patients treated nonoperatively. Most authors
disagree

– Krompinger, 1986 – neuro deficits persists in

80% treated nonoperatively
 Results of Treatment
 Neurologic

– Weinstein, 1988
– 77% improved with nonoperative means

– SRS, 1992
– 88% improved with anterior decompression
versus 83% with posterior (NSS)
– 60-70% with nonoperative treatment
 Treatment Guidelines
 Incomplete neurological injury:Surgery may
potentiate neural recovery and facilitate earlier
rehabilitation

 Complete neurological deficits: Operative

stabilization will hasten onset of rehabilitation

 Neurologically intact: non-operative treatment

unless significant deformity or posterior complex
injury
 Outcomes of Treatment
 Deformity
– Poor correlation with symptoms
( >300 kyphosis assoc with pain)

 Pain
– SRS Study, 1992 – more pain in nonoperative
group
– Rechtine, 1999 – no significant difference in
operative versus nonoperative groups
 Outcomes of Treatment
 Work Capacity

– Denis, 1984 – 25% of nonoperative group

failed to return to work while all of the
operatively treated patients returned to work

– Conservative case studies have shown return to

work rates of 88-90%. Not heavy labor
 Timing of Surgery
 Emergent:
– Progressive neurological deficit in a unstable
fracture pattern
– Studies have shown no significant increase in
morbidity with early surgery

 Subacute:
– Decreased edema, stable general condition,
decreased blood loss, ‘Spine team’
– Late recovery common
 Surgery:
Anterior versus Posterior
 Anterior  Posterior
– More – More familiar
predictable/safer approach
decompression – Usually requires more
– Saves levels levels
– Avoids posterior – Early indirect
musculature reductions successful
– SRS,1992 – may be – Quicker, often better
indicated for bladder tolerated early
dysfunction
Thank You

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