spinefractures-230515204524-720d473.pptx
- 2. Definition of instability White and Panjabi – “Clinical instability is defined as a loss in the ability of the spine under physiologic loads to maintain relationships between vertebrae in such a way that there is neither damage nor subsequent irritation to the spinal cord or nerve roots. In addition there is no development of incapacitating deformity or pain due to structural changes. ”
- 3. Evaluation of the Thoracolumbar Injury Classification System in Thoracic and Lumbar Spinal Trauma Andrei F. Joaquim, MD,* Yvens B. Fernandes, PhD, MD,*† Rodrigo A. C. Cavalcante, MD,‡ Rodrigo M. Fragoso, MD,† Donizeti C. Honorato, MD, PhD,§ and Alpesh A. Patel, MD¶ A New Classification of Thoracolumbar Injuries The Importance of Injury Morphology, the Integrity of the Posterior Ligamentous Complex, and Neurologic Status Alexander R. Vaccaro, MD,* Ronald A. Lehman, Jr., MD,† R. John Hurlbert, MD, PhD,‡ Paul A. Anderson, MD,§ Mitchel Harris, MD, Rune Hedlund, MD,¶ James Harrop, MD,# Marcel Dvorak, MD,** Kirkham Wood, MD,†† Michael G. Fehlings, MD, PhD,‡‡ Charles Fisher, MD, MHSc,** Steven C. Zeiller, MD,* D. Greg Anderson, MD,* Christopher M. Bono, MD,§§
- 4. Problems with Denis classification • Not detailed enough to account for all fracture types. • No prognostic information • Doesn’t account for the neurologic status and, therefore, does not adequately guide surgical decision making
- 5. AO attempt • AO tried correcting it but has 50 subtypes • Low inter and intraobserver agreement due to the complexity • Doesn’t account for the patients neurologic status
- 6. TLICS CLASSIFICATION • Vaccaro et al proposed a new classification system based on 3 major descriptive categories :- 1. Morphology 2. Integrity of posterior ligamentous complex (PLC) 3. Neurological status
- 7. When there are several fractures, each level has to be scored separately. The level with the highest TLICS score will determine the type of treatment.
- 8. Morphology Compression Translation/Rotation Distraction Axial compression/ axial burst Translation/rotation Flexion distraction Flexion compression, flexion burst, flexion compression or burst with distraction of posterior elements Unilateral or bilateral facet dislocation flexion distraction compression or burst Lateral compression Translation/rotation compression or burst Extension distraction Lateral burst Unilateral or bilateral facet dislocation compression or burs
- 10. Integrity of PLC • PLC consists of Supraspinous ligament, interspinous ligament, ligament flavum and facet joint capsule • Together known as ‘tension band’ of spinal column • A torn PLC has a tendency not to heal and can lead to progressive kyphosis and collapse.
- 11. CT features of PLC pathology are: •Widening of the interspinous space. •Avulsion fractures or transverse fractures of spinous processes or articular facets. •Widening or dislocation of facet joints. •Vertebral body translation or rotation. When the PLC is definitely injured on CT, it can already be scored as 3. MRI features of PLC pathology are: •Definite: 3 points Loss of normal low signal intensity of the ligamenta flava or supraspinous ligaments on T1 and T2. •Indeterminate: 2 points Edema without clear rupture; high signal intensity of the interspinous ligaments or along the facet joints on T2 SPIR or STIR. MRI has a tendency to overdiagnose PLC injury (4).
- 12. Neurological status • The incomplete spinal cord injuries are considered American Spinal Injury Association (ASIA) B, C, and D • The complete injuries are considered ASIA A.
- 13. TLICS guiding surgical approach 1) An incomplete neurologic injury generally requires an anterior procedure if neural compression from the anterior spinal elements is present following attempts at postural or open reduction 2) PLC disruption generally requires a posterior procedure and 3) A combined incomplete neurologic injury and PLC disruption generally requires a combined anterior and posterior procedure.
- 14. Qualifiers • Local - extreme kyphosis or collapse, lateral fracture angulation, open fractures, overlying burns, multiple adjacent rib fractures, or inability to brace. • Comorbidities can also influence treatment such as a sternum fracture, severe closed head injury, limb amputation, and multisystem trauma. • Systemic considerations also play a role in clinical decision-making such as rheumatoid arthritis, ankylosing spondylitis, osteoporosis, obesity, patient age, and even general health.
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