thoracolumbar fracture classification system a new approach spine trauma study group alexander r...

Thoracolumbar FractureClassification System

A New ApproachSpine Trauma Study Group

Alexander R Vaccaro M.D.Professor

Thomas Jefferson UniversityDepartment of Orthopaedics

and the Rothman Institute

Thoracolumbar FractureClassification System

A New ApproachSpine Trauma Study Group

Alexander R Vaccaro M.D.Professor

Thomas Jefferson UniversityDepartment of Orthopaedics

and the Rothman Institute

Spine Trauma Study Group Thoracolumbar

Classification SystemThree Part Description

Spine Trauma Study Group Thoracolumbar

Classification SystemThree Part Description

Fracture Description (Morphometric)

Neurologic Status

Integrity of PLC

Fracture Description (Morphology)

Fracture Description (Morphology)

•Compression-axial, flexion,distraction,translation/rotation

•Distraction- extension,flexion,translation/rotation, compression

•Translation/Rotation-flexion, distraction

•Compression-axial, flexion,distraction,translation/rotation

•Distraction- extension,flexion,translation/rotation, compression

•Translation/Rotation-flexion, distraction

•Intact•Nerve Root Injury•Cauda Equina Injury•Cord Injury-Incomplete, Complete

•Intact•Nerve Root Injury•Cauda Equina Injury•Cord Injury-Incomplete, Complete

Neurologic StatusNeurologic Status

Posterior Ligamentous Complex Posterior Ligamentous Complex

•Intact

•Disrupted In Tension

•Intact

•Disrupted In Tension

•Mechanism

•Neurology

•Ligament/ bone Integrity

•Mechanism

•Neurology

•Ligament/ bone Integrity

TreatmentDetermined by:TreatmentDetermined by:

Mechanism-Point SystemMechanism-Point System

Compression1

Distraction3

Translation /Rotation

3

Two Component Mechanistic Description

Neurology-Point SystemNeurology-Point System

Cauda equina

Cord

Incomplete Complete

Nerve root3

3 2

1

Intact0

Stability-Soft Tissue Point System

Stability-Soft Tissue Point System

Ligaments

PLC

Evaluated by MRI

Intact 0

Injured 3

Stability Spinal Column Point SystemStability Spinal Column Point System

Spinal Column

Anterior

Middle

Posterior1

1

1

Next Step - Direct TXNext Step - Direct TX

Assign Points

Conservative

Surgery

Point SystemPoint System

Neurology

Root - 1Complete - 2Incomplete - 3

Cauda equina - 3

LigamentPLC - 3

Spinal ColumnAnterior - 1

Middle - 1

Posterior - 1

Mechanism

Translation/Rotation - 3Distraction - 3

Compression - 1

TreatmentTreatment

•Fractures with 4 points or less = non operative

•Fractures with 5 points=Nonop vs Op

•Fractures with 6 points or more = surgery

•Fractures with 4 points or less = non operative

•Fractures with 5 points=Nonop vs Op

•Fractures with 6 points or more = surgery

•Compression ( mechanism) - 1

•Intact (neurology) - 0

•PLC (ligament) no injury - 0

•Anterior Column - 1

•Compression ( mechanism) - 1

•Intact (neurology) - 0

•PLC (ligament) no injury - 0

•Anterior Column - 1

ExamplesAnterior Compression Fx

ExamplesAnterior Compression Fx

Total 2 points- Non Op

•Compression (mechanism) - 1•Intact ( neurology) - 0•PLC (ligament) no injury (0)•Ant/Middle column 1+1

•Compression (mechanism) - 1•Intact ( neurology) - 0•PLC (ligament) no injury (0)•Ant/Middle column 1+1

ExampleStable Burst Fracture

ExampleStable Burst Fracture

Total 3 points-Non Op

•Compression (mechanism) -1

•Complete (neurology) - 2

•PLC (ligament) injury - 3

•Ant/Middle column -1+1

•Compression (mechanism) -1

•Complete (neurology) - 2

•PLC (ligament) injury - 3

•Ant/Middle column -1+1

Example

Unstable Burst-Complete Neuro Injury

Example

Unstable Burst-Complete Neuro Injury

Total 8 points-Surgery

ExampleStable Burst-Complete injury

ExampleStable Burst-Complete injury

• Compression-1

• Complete neurology-2

• PLC Intact-0

• Anterior, Middle Column disruption- 1+1

Points 5-Non Op vs Op

• Compression-1

• Complete neurology-2

• PLC Intact-0

• Anterior, Middle Column disruption- 1+1

Points 5-Non Op vs Op

•Translation/rotation - distraction (mechanism) - 3 + 3

•Complete (neurology) - 2

•PLC (ligament) injury - 3

•Anterior column - 1

•Translation/rotation - distraction (mechanism) - 3 + 3

•Complete (neurology) - 2

•PLC (ligament) injury - 3

•Anterior column - 1

ExampleFx Dislocation

ExampleFx Dislocation

Total 12 points-Surgery

Surgically Indicated Patients

Approach SelectionSurgically Indicated Patients

Approach SelectionNeurologyNeurology

Ligament StatusLigament Status

ModifiersModifiers

Approach SelectionApproach Selection

Neurologically IntactNeurologically Intact

Ligament Injury presentLigament Injury present

Posterior alone vs.Anterior alone vs.Combined

Posterior alone vs.Anterior alone vs.Combined

Approach SelectionApproach SelectionNeurologically IncompleteNeurologically Incomplete

Ligament InjuryLigament InjuryNoNo YesYes

AnteriorAnterior Combined vsAnteriorCombined vsAnterior

Modifier – Osteoporosis CombinedModifier – Osteoporosis Combined

Approach SelectionApproach Selection

Neurologically Complete InjuryNeurologically Complete Injury

Posterior Posterior

Thoracolumbar Fracture Classification System

Thoracolumbar Fracture Classification System

•Point system to determine nonoperative vs operative treatment

•Neurology, ligamentous status helps determine surgical approach

•Validation necessary

•Point system to determine nonoperative vs operative treatment

•Neurology, ligamentous status helps determine surgical approach

•Validation necessary

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