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Wanner Core Messages ✔ Spinal fractures are frequently located at the thoracolumbar junction for biomechanical rea- sons ✔ The AO classification has gained widespread acceptance in Europe for the grading of thora- columbar fractures: Type A: vertebral compres- sion fractures; Type B: anterior and posterior column injuries with distraction; Type C: ante- rior and posterior element injury with rotation ✔ The initial focus of the physical examination of a patient with a spinal injury is on the vital and neurological functions, because effective resus- citation is critical to the management of poly- traumatized patients and patients with spinal cord injury ✔ The imaging modalities of choice are standard radiographs and CT scans. A CT scan should routinely be made to visualize bony injury. MRI is helpful to diagnose discoligamentous injuries and to identify a possible cord lesion ✔ Primary goals of treatment are prevention and limitation of neurological injury as well as res- toration of spinal stability, regardless of whether operative or non-operative therapy is chosen ✔ Secondary goals consist of correction of defor- mities, minimizing the loss of motion, and facili- tating rapid rehabilitation ✔ Early stabilization and fusion is generally accepted for patients with unstable fractures and neurological deficits ✔ The optimal treatment for patients with less instability, moderate deformity and absence of neurological compromise is not based on scientific evidence and remains a matter of debate. ✔ Good clinical outcome can be achieved with non-operative as well as operative treatment Epidemiology Fractures most frequently affect the thoracolumbar junction Systematic epidemiologic data on traumatic thoracolumbar fractures are rare and differ depending on the area studied and on the treating center. The studies avail- able from western countries reveal typical and comparable data on incidence, local- ization, and mechanisms of injury. Thoracolumbar fractures are more frequent in men (2/3) than in women (1/3) and peak between the ages of 20 and 40 years [30, 47, 65, 81, 94]. Approximately, 160000 patients/year sustain an injury of the spinal col- umn in the United States. The majority of these injuries comprise cervical and lum- bar (L3–L5) spine fractures. However, between 15% and 20% of traumatic fractures occur at the thoracolumbar junction (T11–L2), whereas 9–16% occur in the tho- racic spine (T1–T10) [36, 46]. Hu and coworkers [56] studied the total population of a Canadian province over a period of 3 years. The incidence of spine injuries was 64/ 100000 inhabitants per year, predominantly younger men and older women. A total of 2063 patients were registered and 944 patients were treated in hospital: 182 patients (20%) with a cervical spine injury, 286 patients (30%) with a thoracic spine injury and 403 patients (50%) with an injury of the lumbosacral spine. Traumatic cross-section spinal cord injury occurred in 40 out of 1 million inhabitants. About Fractures Section 883 a bc d ef gh ijkl Case Introduction This 23-year-old female sustained a motor vehicle accident as an unrestrained passenger. Clinically, she presented with an incomplete paraplegia (ASIA C) and an incomplete conus-cauda syndrome. The initial CT ( a–d) scan demonstrates an unstable complete burst fracture of L1 (Type A3.3). The 3D reconstruction ( a, b)givesagoodoverviewofthedegreeof comminution and the deformity; the posterior fragment is best visualized in the lateral 2D reconstruction ( c)andthe axial view ( d). In an emergency procedure, the myelon was decompressed by laminectomy and the fracture was reduced andstabilizedwithaninternalfixator( e–h). Interestingly, the prone position alone (e) reduced the fracture to a certain degree when compared to the CT scan taken with the patient in a supine position. With the internal fixator (RecoFix), the anatomical height and physiological alignment was restored ( f) and the posterior fragment was partially reduced (g, h). This indirect reduction of bony fragments, called ligamentotaxis, is possible if the posterior ligaments and the attach- ment to the anulus fibrosus are intact. We performed a complete clearance of the spinal canal by an anterior approach 5dayslater( i–l). In this minimally invasive technique, the spine is approached by a small thoracotomy from the left, the ruptured disc and bony fragments are removed, and an expandable cage is inserted. One of the first steps in this tech- nique is the positioning of a K-wire in the upper disc space of the fractured vertebra ( i). In this figure, the four retractors of the Synframe and the endoscopic light source are seen. The final result after 9 months ( j–l) demonstrates the cage (Synex), the physiological alignment without signs of implant failure or kyphosis, a good clearance of the spinal canal from anterior and the laminectomy from posterior ( k), and a bony healing of the local bone transplant of the lateral side of the cage ( l). Fortunately, the patient completely recovered from her neurological deficit (ASIA E). 50–60% of thoracolumbar fractures affect the transition T11–L2, 25–40% the thoracic spine and 10–14% the lower lumbar spine and sacrum [80, 86]. In a study by Magerl and Engelhardt [81] on 1446 thoracolumbar fractures, most injuries concerned the first lumbar vertebra, i.e., 28% (n=402), followed by T12 (17%, n=246) and L2(14%,n=208). The epidemiologic multicenter study on fractures of the thoracolumbar transition (T10–L2) by the German Trauma Society studied 682 patients and revealed 50% (n =336) L1 fractures, 25% 884 Section Fractures (n=170) T12 fractures, and 21% (n=141) L2 fractures [65].Our own series at the University Hospital in Zürich demonstrated a very similar distribution for oper- ated spine fractures (1992–2004, n=1744): 20% cervical spine (n =350),8%tho- racic spine T1–T10 (n=142), 62% thoracolumbar spine T11–L2 (n=1075), and 10% lumbosacral spine L3-sacrum (n=176). The susceptibility of the thoraco- lumbar transition is attributed mainly to the following anatomical reasons: The transition from a relatively rigid thoracic kyphosis to a more mobile lumbar lordosis occurs at T11–12. Thelowestthoracicribs(T11andT12)providelessstabilityatthethoraco- lumbar junction region compared to the rostral thoracic region, because they do not connect to the sternum and are free floating. The facet joints of the thoracic region are oriented in the coronal (frontal) plane, limiting flexion and extension while providing substantial resistance to anteroposterior translation [36]. In the lumbosacral region, the facet joints are oriented in a more sagittal alignment, which increases the degree of potential flexion and extension at the expense of limiting lateral bending and rotation. Spinal cord injury occurs in about 10– 30 % of traumatic fractures Spinal cord inj ury occurs in about 10–30% of traumatic spinal fractures [37, 56]. In thoracolumbar spine fractures (T1–L5), Magerl et al. [81] and Gertzbein [47] reported 22% and 35.8% neurological deficiencies, respectively. The epidemio- logic multicenter study on fractures of the thoracolumbar transition (T10–L2) by the German Society of Traumatology [65] revealed neurological deficiencies in 22–51%, depending on the fracture type (22% in Type A fractures, 28% in Type B fractures, and 51% in Type C fractures, according to the AO classification). Complete paraplegia was found in 5% of the patients with fractures of the thora- columbar transition. Pathomechanisms At the time of injury, several forces may act together to produce structural dam- age to the spine. However, most frequently, one or two major forces, defining the major injury vector, account for most of the bony and ligamentous damage. The most relevant forces are: axial compression flexion/distraction hyperextension rotation shear Axial Compression Axial load may result in a burst fracture While axial loading of the body results in anterior flexion forces in the kyphotic tho- racic spine, mainly compressive forces occur in the straight thoracolumbar region [64]. Axial loading of a vertebra produces endplate failure followed by vertebral body compression [98]. Depending on the energy, the axial load may result in incomplete or complete bu rst fractures, i.e., vertical fractures with centripetal dis- placement of the fragments [12, 33]. The posterior elements are usually intact; how- ever, with severe compression, significant disruption of these elements may occur. The combination of an axially directed central compressive force with an eccentric compressive force anterior to the axis of rotation (center of nucleus pulposus) typi- cally leads to wedge compression fractures. Herein, the vertebral body fails in (wedge) compression, while the posterior ligamentous and osseous elements may Thoracolumbar Spinal Injuries Chapter 31 885 remain intact or fail in tension, depending on the energy level of the injury. In the latter case, the injury is classified as flexion-distraction injury. Violent trauma is the most common cause of compression fractures in young and middle-aged adults. The most frequent causes are motor vehicle accidents and falls from a height, fol- lowed by sports and recreational activity injuries. In the elderly population, osteo- porotic compression fractures following low-energy trauma are most common. Flexion/Distraction Flexion forces cause eccentric compression of the vertebral bodies and discs and cause tension to the posterior elements. If the anterior wedging exceeds 40–50%, rupture of the posterior ligaments and facet joint capsules must be assumed [117]. In flexion/distraction injuries, the axis of flexion is moved anteriorly (towards the anterior abdominal wall), and the entire vertebral column is sub- jected to large tensile forces. These forces can produce: pure osseous lesion mixed osteoligamentous lesion pure soft tissue (ligamentous or disc) lesion In flexion/distraction injuries, the posterior ligamentous and osseous elements fail in tension Distraction leads to a horizontal disrupture of the anterior and/or posterior ele- ments. A distraction fracture that extends through the bone was first described by Chance [22]. This lesion involves a horizontal fracture, which begins in the spinous process, progresses through the lamina, transverse processes, and pedi- cles, and extends into the vertebral body. Depending on the axis of flexion the vertebralbodyanddiscmayruptureormaybecompressedanteriorlyas described above. Although any accident providing significant forward flexion combined with distraction can produce this type of injury, the typical cause is a motor vehicle accident with the victim wearing a lap seat belt. These injuries are associated with a high rate of hollow visceral organ lesions, typically of the small bowel, colon or stomach, but also pancreatic injuries have been reported [3, 13]. Hyperextension Hyperextension may result in anterior discoligamentous disruption and posterior compression fractures of facets, laminae, or spinous processes Extension forces occur when the upper part of the trunk is thrust posteriorly. This produces an injury pattern that is the reverse of that seen with flexion. Tension is applied anteriorly to the strong anterior longitudinal ligaments and anterior por- tion of the anulus fibrosus, whereas compression forces are transmitted to the posterior elements. This mechanism results in a rupture from anterior to poste- rior and may result in facet, lamina, and spinous process fractures [43]. Denis and Burks reported on a hyperextension injury pattern that they termed lumberjack fracture-dislocation [32]. The mechanism of this injury is a falling mass, often timber, striking the midportion of the patient’s back. The injury involves com- plete disruption of the anterior ligaments and is an extremely unstable injury pat- tern. These injuries are the result of a reversed trauma mechanism. The interver- tebral disc ruptures from anterior to posterior. The lesion may proceed into the posterior column and is then unstable against extension and shearing forces. Rotational Injuries Rotational injuries combine compressive forces and flex- ion/distraction mechanisms and are highly unstable Both compressive forces and flexion-distraction mechanisms may be combined with rotational forces and lead to rotational fracture dislocations. As rotational forces increase, ligaments and facet capsules fail and lead to subsequent disrup- tion of both the anterior and posterior elements. A highly unstable injury pattern will develop, i.e., the posterior ligaments and joint capsule will rupture and the 886 Section Fractures anterior disc and vertebral body will disrupt obliquely or will be compressed. Rotational forces may further be combined with shearing forces and lead to most unstable fractures (slice fractures, Holdsworth) [54]. These patients have often been thrown against an obstacle or hit by a heavy device. Thus, the patients often have widespread dermabrasions and contusions on the back. Shear Shear forces produce severe ligamentous disruption and are often associated with spinal cord injury Shear forces produce severe ligamentous disruption and may result in anterior, pos- terior or lateral vertebral displacement [98]. The most frequent type is traumatic anterior spondylolisthesis that usually results in a complete spinal cord injury. Classification Vertebral spine injuries are very heterogeneous in nature. Most important for the understanding and treatment of these injuries is the evaluation of spinal stability or instability, respectively. However, the conclusive evaluation of this question is difficult because the term “instability” is not yet clearly defined in the context of spinal disorders. Several classifications of spinal injuries have been introduced based primarily on fracture morphology and different stability concepts. White and Panjabi [118] defined clinical instability of the spine as shown in Table 1: Table 1. Definition of spinal instability Loss of the ability of the spine under physiologic loads to maintain relationships between vertebrae in such a way that there is neither damage nor subsequent irrita- tion to the spinal cord or nerve root and, in addition, there is no development of incapacitating deformity or pain from structural changes Physiologic loads are defined as loads during normal activity, incapacitating deformity as gross deformity unacceptable to the patient, and incapacitating pain as discomfort uncontrolled by non-narcotic analgesics. Presently, there is no generally used classification for thoracolumbar injuries. However, the most important classification of spinal injuries aims to differenti- ate between: stable fractures unstable fractures This concept was first introduced by Nicoll in 1949 [89] and is still the most widely accepted differentiation. However, this classification is insufficient to give detailed treatment recommendations. Holdsworth [54] was the first to stress the mechanism of injury to classify spi- nal injuries and described five different injury types. Kelly and Whitesides [61, 119] reorganized the mechanistic classification and defined the two column con- cept, which became the basis of the AO classification (see below). Louis further modified this structural classification scheme and suggested the posterior facet joint complex of each side to become a separate column [79]. The ventral column consists of the vertebral body; the two dorsal columns involve the facet articula- tions of both sides. Roy-Camille was concerned about the relationship of the injury to vertebra, especially the neural ring, and the spinal cord. He described the “segment moyen,” referring to the neural ring, and related injury of the seg- ment moyen to instability [99]. This aspect led to the term of the so-called “mid- dle column,” which is not a distinct anatomic column. Thoracolumbar Spinal Injuries Chapter 31 887 Denis Classification The middle column became a central part of the classification of spinal injuries according to Denis [30], which is in widespread use in the United States. Accord- ingly, the vertebral column is divided into three columns [30]: anterior column middle column posterior column The anterior column consists of the ventral longitudinal ligament (VLL), the anterior anulus fibrosus, and the anterior halfof the vertebral bodies. Themiddle column consists of the posterior longitudinal ligament (PLL), the dorsal anulus fibrosus, and the dorsal half of the vertebral bodies. Finally, the posterior column consists of the bony neural arch, posterior spinous ligaments and ligamentum flavum,aswellasthefacetjoints. Denis considered the middle column to be the key structure. A relevant injury to the middle column was therefore the essential criterion for instability. Accord- ing to the Denis classification, rupture of the posterior ligamentous complex only creates instability if there is concomitant disruption of at least the PLL and dorsal anulus. However, the middle column is not clearly defined either anatomically or biomechanically, i.e., the middle column bony part resists compression forces, The Denis classification does not allow for a detailed fracture classification and the ligamentous part resists distraction forces. Although the three column concept by Denis raised several concerns, his classification is still frequently used, because it is simple and includes all the injury patterns most commonly seen. Denis distinguished minor and major injuries: minor injuries included fracturesofthearticular,transverse,andspinousprocessesaswellasthepars interarticularis. Major spinal injuries were divided into compression fractures, burst fractures, flexion-distraction (seat-belt) injuries, and fracture dislocations. AO Classification The AO/ASIF (Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation) classification introduced by Magerl et al. in 1994 [80] is increasingly being accepted as the gold standard for documentation and treat- ment of injuries of the vertebral spine. The AO classification is based on the “two column theory”describedby Holdsworth [54, 55] and Kelly and Whitesides [61, 119]. The AO classification considers the spine to comprise two functionally separate supportive columns. The anterior column consists of the vertebral body and the intervertebral discs and is loaded in compression. The posterior column consists of the pedicles, the laminae, the facet joints, and the posterior ligamentous complex, and is loaded in tension. According to the common AO classification system, injuries are catego- rized with increasing severity into types ( Fig. 1): Type A: compression injuries Type B: distraction injuries Type C: rotational injuries Type A injuries are the result of compression by axial loading (e.g., compression and burst fractures). Type B injuries are flexion-distraction or hyperextension injuries and involve the anterior and posterior column. Disruption may occur in the posterior or anterior structures. Type C fractures are the result of a compres- sion or flexion/distraction force in combination with a rotational force in the horizontal plane (e.g., fracture dislocations with a rotatory component). Each type is classified into three major groups (1–3) of increasing severity ( Fig. 2)and can further be divided into subgroups and specifications ( Table 2). 888 Section Fractures . injuries and to identify a possible cord lesion ✔ Primary goals of treatment are prevention and limitation of neurological injury as well as res- toration of spinal stability, regardless of whether. fractures of the atlas. Spine 17:1285–90 878 Section Fractures 151. Paeslack V, Frankel H, Michaelis L (1973) Closed injuries of the cervical spine and spinal cord: results of conservative treatment of. kyphosis, a good clearance of the spinal canal from anterior and the laminectomy from posterior ( k), and a bony healing of the local bone transplant of the lateral side of the cage ( l). Fortunately,