Thoracolumbar fractures

Two column concept:

Holdsworth F, 1970

Flexion

Flexion + compression

Torsion

Two column concept:

Holdsworth F, 1970

Flexion-distraction

Two column concept:

Holdsworth F, 1970

Two column concept:

Holdsworth F, 1970

Flexion-distraction

Comprehensive (AO ASIF) classification:

1445 fcs

Two column concept

Three categories –A, B, C (55 individual fracture types)

Magerl F, 1994

Comprehensive (AO ASIF) classification:

A

Comprehensive (AO ASIF) classification:

B

Comprehensive (AO ASIF) classification:

C

Comprehensive (AO ASIF) classification:

Importance of MRI:

Leferink VJM, 2002

30 % of B-type fractures are initially unrecognised

Comprehensive (AO ASIF) classification:

Rupture of the ligaments

B.3.1.1

Signs of rotation

Type B

Type A

Type C

Anterior column

Fracture of the vertebral body

Posterior column

Disruption of the disc

Fracture

T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5

Surgical treatment:

Conservative

Neurol. intact Stable fractures

Operative

Neurol. deficit Unstable fcs Open fcs

Surgical treatment:

Conservative

Neurol. intact Stable fractures

• bed rest for 4-6 weeks + gradual ambulation + Jewet

• early ambulation + Jewet

Operative

Neurol. deficit Unstable fcs Open fcs

Operative

Neurol. deficit Unstable fcs Open fcs

Operative

Neurol. deficit Unstable fcs Open fcs

Operative

Neurol. deficit Unstable fcs Open fcs

Surgical treatment:

Timing:

acute neurol. deficit » urgent surgery (life prior to the spinal cord)

Conservative

Neurol. intact Stable fractures

Conservative

Neurol. intact Stable fractures

Operative treatment:

• posterior (pedicular fixation + augmentation)

• anterior (spacer + fixation)

• combination

Operative treatment:

• posterior (pedicular fixation + augmentation)

Operative treatment:

• posterior (pedicular fixation + augmentation)

lordotisation lordotisation and distraction

pros

• minor surgical trauma

• cosmetic scar

• preservation of mobile segments (?)

• no permanent HW

• urgent stabilization (SCI, concomittant trauma

Operative treatment:

• posterior (pedicular fixation + augmentation)

• screw application

• muscle detachment

• orthosis

• HW removal

cons

• posterior (pedicular fixation + augmentation)

Operative treatment:

Approach technology:

Open - thoracoabdominal

Approach technology:

• better spinal canal decompression

• better long term results (radiological, implant failure)

• single level fusion

• mini-invasive technology

• anterior (spacer + fixation)

pros

Operative treatment:

• day light surgery (team work)

• major surgical trauma (?)

• greater blood loss (?)

• longer hospital stay (?)

• permanent HW

• revision surgery

• anterior (spacer + fixation)

cons

Operative treatment:

endoscopic techniqes

open

less invasive

Approach technology:

Approach technology:

Choice of the approach:

F. Magerl:

anterior approach - fusion

posterior approach - stabilisation

Comined procedure ?

Load-sharing classification:

Three qualities:

1. Amount of damaged vertebral body

2. Spread of fragments

3. Amount of corrected traumatic kyphosis

McCormack T et al., 1994

Load-sharing classification:

Σ: 3 - 9 points

1. amount of damage

2. spread of fragments

3. corrected kyphosis

McCormack T et al., 1994

Typ A

Choice of the approach:

Type B, LSC 7 Choice of the approach:

Type B, LSC 5 Choice of the approach:

Choice of the approach:

Spine vertebroplasty:

Spine vertebroplasty:

Spine vertebroplasty:

Scoliosis (5)

M. Scheuermann (17)

Spondylosis, spondylathrosis (27)

Trauma C1 - 2

subaxial C (51)

T – L

Specific + non-specific inflammation (24, 26)