Fractures of the thoracic and lumbar spine and thoracolumbar transition
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- Janel Bates
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1 Most spinal column injuries occur in the thoracolumbar transition, the area between the lower thoracic spine and the upper lumbar spine; over half of all vertebral fractures involve the 12 th thoracic and 1 st lumbar vertebrae. The high incidence of vertebral fractures in this region is due to special biomechanical factors that apply in the transitional sections of the physiological curvatures of the spinal column (lumbar lordosis, thoracic kyphosis) in this area. Spinal column, from side and rear 1st thoracic vertebra 12th thoracic vertebra 1st lumbar vertebra 5th lumbar vertebra Thoracic spine, side view 1st thoracic vertebra (Th1) 12th thoracic vertebra (Th12) Lumbar spine, side view 1st lumbar vertebra (L1) 5th lumbar vertebra (L5) Sacral vertebra (S1) 1
2 How are injuries of the thoracic and lumbar spine classified? Böhler was the first to publish a classification system for vertebral fractures in His system differentiated 5 subtypes. In subsequent years, various classification systems for vertebral fractures were introduced with respect either to the fracture type or fracture mechanism (such as those developed by Denis or Ferguson and Allen). The bony and ligamentous structures of the anterior and posterior column area of the vertebral segment and the intervertebral disc can be involved in all spinal column injuries. Mobile segment, side view, ligamentous apparatus Ligamentum longitudinale anterius, anterior longitudinal ligament Ligamentum longitudinale posterius, posterior longitudinal ligament Ligamentum supraspinale, supraspinal ligament Ligamentum interspinale, interspinal ligament Ligamentum flavum, yellow ligament Intervertebral disc Ligamentous apparatus, thoracic spine Transverse process, processus transversus Ligamentum longitudinale anterius, anterior longitudinal ligament Ligamentum costotransversarium, costotransverse ligament Ligamentum intertransversarium, intertransverse ligaments Rib, costa In 1994, F. P. Magerl introduced a classification system for the assessment of injuries to the thoracic and lumbar spine that is still used as the standard assessment system today. This classification system takes into account the forces acting upon the spinal column to cause the injury (compression, distractions, and translation/rotation forces) as well as the typical injury patterns observed in the vertebrae, intervertebral discs, and ligamentous apparatus as a result of the mechanics of an injury. There are three distinct types: Type A injuries are caused by compression forces. Type B injuries by distraction forces Type C injuries by rotation forces. The three injury types A, B and C are each subdivided into three subtypes with three subgroups each. 2
3 Type A injuries: Vertebral body compression (compression injury) Type A injuries are caused by axial forces. They affect the vertebral body with intact dorsal ligamentous structures: Type A injury A1: Depressed fractures (impaction fractures), with upper plate collapse and no involvement of the posterior vertebral margin. This is subdivided into the following: A1.1: Upper plate depression Upper plate depression 3
4 A1.2: Wedge fracture A1.2.1: Cranial wedge fracture Cranial wedge fracture A1.2.2: Lateral wedge fracture A1.3: Vertebral body impaction Vertebral body impaction 4
5 A2: Fissure fractures, characterized by fissure formation in the sagittal or frontal plane, where the degree of dislocation of the individual fragments differs. A2.1: A2.2: Sagittal fissure fracture Frontal fissure fracture Frontal fissure fracture A2.3: Pincer fracture Pincer fracture 5
6 A3: Burst fractures are frequently characterized by the shattering of the vertebral body with involvement of the posterior edge of the vertebra with the dorsal ligamentous apparatus intact. A3 fractures are frequently unstable and cause neurological symptoms due to the compression of the spinal cord resulting from the dislocation of the posterior fracture fragments with parts of the intervertebral disc into the spinal canal. A3.1: Incomplete burst fracture A3.1.1: Incomplete cranial burst fracture Incomplete cranial burst fracture A3.1.2: Incomplete lateral burst fracture A3.1.3: Incomplete caudal burst fracture A3.2: Burst-fissure fracture A3.2.1: Cranial burst-fissure fracture Cranial burst-fissure fracture front view Cranial burst-fissure fracture, rear view Cranial burst-fissure fracture, side view 6
7 A3.2.2: Lateral burst-fissure fracture A3.2.3: Caudal burst-fissure fracture A3.3: Complete burst fracture A3.3.1: Pincer burst fracture A3.3.2: Complete flexion burst fracture A3.3.3: Complete axial burst fracture Complete axial burst fracture, rear view Complete axial burst fracture, side view Type B injuries: Injuries of the anterior and posterior vertebral elements with distraction (distraction injuries) In type B injuries, distraction results in the rupturing of the anterior and/or posterior elements of the mobile segment. Type B injury 7
8 B1: With dorsal rupture of the intervertebral joints (flexion-distraction injuries) B1.1: With rupture of the intervertebral disc B1.1.1: Flexion subluxation Flexion subluxation B1.1.2: Anterior luxation Anterior luxation 8
9 B1.1.3: Flexion subluxation or anterior luxation with fracture of the articular processes Flexion subluxation or anterior luxation with fracture of the articular processes B1.2: With type A fracture of the vertebral body Flexion subluxation type B1.2.1 with cranial wedge fracture of type A1.2.1 Flexion subluxation type B1.2.1 with cranial wedge fracture of type A
10 Flexion subluxation type B1.2.1 with pincer fracture type A2.3 Flexion subluxation type B1.2.1 with pincer fracture type A2.3 Flexion subluxation type B1.21 with incomlete cranial brust fracture, type A3.1.1 B1.2.2: Anterior luxation with cranial wedge fracture, type A1.2.1 Typ B1.2.2 Anterior luxation with cranial wedge fracture, type A1.2.1 also possible combination: Flexion subluxation type B1.2.1 with incomplete cranial burst fracture, type A
11 B1.2.3: Flexion subluxation with fracture of the articular processes and vertebral body fracture Flexion subluxation with fracture of the articular processes and vertebral body fracture B2: Dorsal rupture through the vertebral arch (flexion-distraction) B2.1: Horizontal rupture of the vertebra Horizontal rupture of the vertebra 11
12 B2.2: Flexion spondylolysis with rupture of the intervertebral disc B2.3: Flexion spondylolysis with rupture of the intervertebral disc Flexion spondylolysis with vertebral body fracture Flexion spondylolysis with vertebral body fracture 12
13 B3: Ventral rupture, splitting the intervertebral disc (hyperextension injury) B3.1: Hyperextension subluxation B3.1.1: Without articular process fracture Ventral rupture, splitting the intervertebral disc without articular process fracture B3.1.2: With articular process fracture or fracture of the pedicles B3.2: Hyperextension spondylolysis Hyperextension spondylolysis 13
14 B3.3: Posterior luxation (one of the most severe spinal column injuries, often involving complete paraplegic paralysis) Posterior luxation Type C injuries: Injuries of the anterior and posterior vertebral elements with rotation (rotation or torsion injury) Type C injuries are either type A injuries in combination with additional rotation, or type B injuries in combination with rotation and shearing fractures. These fractures are in most cases unstable, with high rates of neurological complications. Typ C injury 14
15 C1: Type A with rotation C1.1: Rotation wedge fracture Rotation wedge fracture, front view C1.2: Rotation split fracture C1.2.1: Sagittal rotation split fracture C1.2.2: Frontal rotation split fracture C1.2.3: Rotation pincer fracture C1.2.4: Vertebral body separation Rotation wedge fracture, side view Rotation wedge fracture, from the rear Vertebral body separation, front view Vertebral body separation, side view Vertebral body separation, view from above 15
16 C1.3: Rotation burst fracture C1.3.1: Incomplete rotation burst fracture C1.3.2: Rotation burst-fissure fracture C1.3.3: Complete rotation burst fracture Complete rotation burst fracture, front view Complete rotation burst fracture, rear view Complete rotation burst fracture, side view C2: Type B1 with rotation C2.1: Type B1 with rotation (torsion) C2.1.1: Rotation flexion subluxation Rotation flexion subluxation, from the front Rotation flexion subluxation, from the side 16
17 C2.1.2: Rotation flexion subluxation with articular process fracture C2.1.3: Unilateral luxation Unilateral luxation, from the rear Unilateral luxation, from the side C2.1.4: Anterior rotation luxation without/with articular process fracture C2.1.5: Rotation flexion subluxation without/with articular process fracture with vertebral body fracture C2.1.6: Unilateral luxation with vertebral body fracture C2.1.7: Anterior rotation luxation without/with articular process fracture with vertebral body fracture C2.2: Type B2 with rotation C2.2.1: Horizontal rupture of the vertebral body with rotation Horizontal rupture of the vertebral body with rotation, side view Horizontal rupture of the vertebral body with rotation, rear view 17
18 C2.2.2: Rotation flexion spondylolysis with intervertebral disc rupture C2.2.3: Rotation flexion spondylolysis with vertebral body fracture C2.3: Type B3 with rotation C2.3.1: Unilateral hyperextension subluxation without/with articular process or pedicle fracture C2.3.2: Unilateral hyperextension spondylolysis C2.3.3: Posterior rotation luxation C3: Rotation shear fractures C3.1: Slice fracture (Holdsworth) C3.2: Rotation oblique fracture Rotation oblique fracture What are the possible symptoms of thoracic and lumbar spine fractures? The instability of spinal column injuries, and therefore the risk of neurological complications, increases over the progression from type A to type C. The following symptoms may be present, depending on the fracture type: Pain (local, movement-induced, radiating) Medullary symptoms with incomplete or complete paraplegia Radicular symptoms Spinal shock Specific symptoms of additional secondary injuries 18
19 How is the injury diagnosed? If a vertebral fracture is suspected, an accident victim must be treated with utmost caution. Examination, positioning, and transport must be carried out safety and gently so as not to provoke any worsening of the initial status. The clinical and neurological examinations provide information on: The vertebral height of the injury (reference muscles, reflex status, sensomotor status) Medullary or radicular symptoms Any secondary injuries Radiological diagnostics are based on conventional x-ray images of the thoracic or lumbar spine in 2 planes, though the pain experienced by the accident victim often makes it difficult to adjust the image planes with a high level of accuracy, compromising the value of the information obtained in the x-rays to a considerable degree. Computer tomography with reconstruction images allows for exact imaging of the destroyed vertebral elements. Nuclear magnetic resonance tomography allows for the clear imaging of injuries of the spinal cord, spinal nerves, and ligamentous apparatus. How are thoracic and lumbar spine fractures treated? Objectives of surgical treatment of spinal column injuries: In a complete or incomplete paraplegic syndrome, rapid decompression of the pinched spinal cord and spinal nerves must be achieved to improve the neurological symptoms or prevent further worsening. The stability of the spinal column must be restored. The correct axial position of the spinal column, in particular the sagittal profile with physiological spinal column curvatures (lordosis/kyphosis), must be reconstructed. The fusion length (spondylodesis segments) must be selected so as to ensure the stability of the whole while fusing as few mobile segments as possible. Early mobilization and rehabilitation to expedite the reintegration of the injured person into his or her private and professional environment. Stable fractures of the thoracic or lumbar spinal column without neurological complications, such as impaction fractures of type A1, are treated conservatively. Unstable fractures, such as burst fractures of type A 3, flexion distraction injuries of type B, or rotation injuries of type C, undergo surgical treatment. Depending on the level of the injury along the spine and the extent of spinal cord and spinal nerve damage, a number of surgical options are available for the stabilization of thoracic and lumbar spine fractures with dorsal (from the back), ventral (from the front) or combined dorsoventral access. The following surgical methods are frequently used in the surgical treatment of thoracic and lumbar vertebra fractures: Ventral decompression and ventrally instrumented spondylodesis Ventral decompression, ventral support with dorsal compression spondylodesis Dorsal decompression, dorsal stabilization, ventral support and dorsal compression spondylodesis 19
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