THORACO-LUMBAR SPINE TRAUMA NORDIC TRAUMA COURSE 2016, AARHUS
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1 THORACO-LUMBAR SPINE TRAUMA NORDIC TRAUMA COURSE 2016, AARHUS Ken F. Linnau, MD, MS Emergency Radiology Harborview Medical Center University of Washington Seattle, WA
2 Thanks to Quynh T. Nguyen, MHS, PA-C Teaching Associate UW Medicine Harborview Radiology Seattle, WA
3 20 YOM FROM CONCRETE, WA FELL 20 FT ONTO CONCRETE AFTER 15 BEERS Concrete, WA Skagit County Population: nks
4 20 YOM FROM CONCRETE, WA FELL 20 FT ONTO CONCRETE AFTER 15 BEERS
5 20 YOM FROM CONCRETE, WA FELL 20 FT ONTO CONCRETE AFTER 15 BEERS T8
6 OUTLINE Epidemiology of thoracolumbar spine trauma Indications and techniques for imaging Classifications Case examples What to put in the report
7 EPIDEMIOLOGY MVC and MCC 45% Falls 20% Sports 15% Violence 15% Other 5% Men account for 80% of injuries Young adults and > 65 years
8 TL FRACTURE DISTRIBUTION Most TL fractures occur between T11-L2 Fulcrum of rigid thoracic and mobile lumbar spine Rib cage is protective Leucht-P, Fischer-K, et al. Injury, Int. J. Care Injured 40 (2009)
9 TL JUNCTION: BUCKET ON A STICK
10 33YOF, 8 FT FALL FROM LADDER, DECREASED MOTOR SCORE (86) T11
11 INDICATIONS: WHO SHOULD UNDERGO TL SPINE IMAGING? Clinical prediction rule for thoracolumbar spine imaging (Holmes-JF, J Emerg Med 2003) Detects all fractures (100% sensitive) Limited clinical utility (low specificity of 4%) TL imaging criteria: TL spine pain TL spine tenderness to palpation Decreased level of consciousness Peripheral nerve deficit Distracting injury Intoxication
12 INDICATIONS: WHO SHOULD UNDERGO TL SPINE IMAGING? Strongly consider thoracolumbar spine imaging in patients who have any of the following risk factors: 1. High risk of injury ( 7 RFs) 2. High risk physical exam findings after trauma (6 RFs) 3. High energy spine fracture at any level 4. High risk medical history: OI, AS or DISH (3RFs)
13 RADIOGRAPHY OR CT?
14 IMAGING CT is more sensitive than radiography (97 vs 78%) But no studies with clinical outcome measures Effect of CT scanning unknown Cost? Radiation exposure? Most trauma patients get whole body CT: Includes TL spine If Pan Scan (C/A/P) is obtained: Retro spines (limited evidence) Technique? (limited data) Medina-LS, Evidence-Based Imaging, Springer 2011 Robinson-JD, Optimizing Spinal Reformations on Trauma CT, ASER 2013
15 IMAGING Use MR if: Focal neurologic deficit Discordant neurological exam to injury level Worsening neuro deficit Assess PLC Ankylosing process: look for other injury levels in DISH Do not use MR as screening test: Isolated ligamentous injury without fracture in TL exceedingly uncommon
16 SPINE SURGEONS WANT TO KNOW Type of fracture Alignment Percent height loss Percent canal compromise PLC integrity: mention it even if it is normal
17 33YOF, 8 FT FALL FROM LADDER, DECREASED MOTOR SCORE (86) T11
18 33YOF, 8 FT FALL FROM LADDER, DECREASED MOTOR SCORE (86) T11 Focal kyphosis T11 Sagittal Coronal
19 CLASSIFICATION OF THORACO-LUMBAR INJURIES
20 HISTORY OF T-L SPINE FRACTURE CLASSIFICATIONS > 80 years of struggle: Boehler (1929): combines anatomy with mechanism Nicoll (1949): stability Holdsworth (1970): 2 column concept Denis (1983): 3 column concept, simple, but unable to distinguish stable from unstable Ferguson Allen (1983): addresses stability, complex, does not predict outcome AO/Magerl (1994): comprehensive, but complex (53 types of fractures) Sethi-MK et al. Spine Journal 2009; 9: 780
21 HISTORY OF T-L SPINE FRACTURE CLASSIFICATIONS Limitations of older spine classifications : Assumed mechanism of injury Ignore ligaments (stability) Limited clinical relevance Some are descriptive Most are not validated or have poor validity. No gold standard
22 TLICS Thoraco-Lumbar Injury Classification and Severity scale Morphology and severity Treatment considerations: stability Predictive of outcomes And it works similarly in the c spine (Sub-axiaL Injury Classification and Severity Scale (SLIC) Vaccaro-AR et al, Spine 2005
23 TLICS Thoraco-Lumbar Injury Classification and Severity scale Limitations: Methodology behind scale? Prediction of outcome not proven yet So far validation studies by same group (STSG)
24 Assignment of point values in the TLICS system Injury morphology Compression 1 Burst component 1 Translation rotation 3 Distraction 4 PLC integrity Intact 0 Indeterminate 2 Disrupted 3 Neurological status Intact 0 Nerve root injury 2 Complete 2 Incomplete (cord or cauda equina) 3 Point value Acta Orthopaed 2008; 79(4): 461
25 TLICS MORPHOLOGY Morphology (radiographs, CT or MR): Compression (1 pt): failure under axial load Burst (+1) = 2pts Rotation or translation (3 pts): Sagittal and coronal reformations useful Distraction: circumferential disruption (4pts) Can be combined with compression type injury More severe component used to determine treatment
26 50 YOM FALL T4 TLICS Morphology : Compression fracture 1 point
27 33YOF, 8 FT FALL FROM LADDER, DECREASED MOTOR SCORE (86) T11 TLICS Morphology : Compression fracture With burst: 2 points
28 50 YOM PARAGLIDING CRASH TLICS Morphology : Rotation: 3 points
29 20 YOM FROM CONCRETE, WA FELL 20 FT ONTO CONCRETE AFTER 15 BEERS T8 T8 TLICS Morphology : Distraction 4 points
30 PLC Posterior Ligamentous Complex: posterior tension band Facet capsules Inter- and supraspinous ligs Lig flavum PLC is independent component of surgical decision making Ligamentous integrity is proportional to stability Poor healing capability
31 TLICS PLC INTEGRITY PLC directly visualized on MR PLC competence indirectly inferred (radiographs, CT) Abnormal bony relation ships Posterior ligamentous complex (PLC): Intact: 0 pts Indeterminate: 2 pts Disrupted: 3 pts
32 20 YOF MVC, SEATBELT SIGN, ASIA D PLC: Disrupted 3 points
33 20 YOF MVC, SEATBELT SIGN, ASIA D Sagittal STIR PLC: Disrupted 3 points
34 16 YOM MCC, NO MOTOR BELOW T4 T7 T7 T6-T7 flexion distraction injury
35 PEARL: BURST VS DISTRACTION Burst: facet widening Distraction: unroofing, empty facet
36 TLICS NEUROLOGICAL STATUS Important indicator of severity of injury Single most influential predictor of outcome Incomplete neurologic injury: emergent surgery Surgery even if no instability Intact: (ASIA E): 0 points Root injury: 2 points Complete cord (ASIA A): 2 points Incomplete cord or cauda equina: (ASIA B, C, D): 3 points
37 30 YOM HIT BY TREE 24 YOM HSROMVC T8 T7 Flexion Distraction Injury Flexion Distraction Injury ASIA A: no sensory or motor function in LE ASIA E: normal sensory, 5/5 motor function in LE
38 30 YOM HIT BY TREE 24 YOM HSROMVC ASIA A at 6 mo F/U: No sensory function No motor function ASIA E at 6 mo F/U: Swims Plays Basketball Near normal
39 Assignment of point values in the TLICS system Injury morphology Compression 1 Burst component 1 Translation rotation 3 Distraction 4 PLC integrity Intact 0 Indeterminate 2 Disrupted 3 Neurological status Intact 0 Nerve root injury 2 Complete 2 Incomplete (cord or cauda equina) 3 TLICS 3 Non-operative TLICS = 4 Either TLICS 5 Operation Acta Orthopaed 2008; 79(4): 461
40 TLICS Case description: Level, calculate TLICS for each level Morphology and bony description PLC Neuro Consider clinical qualifiers: Excessive angulation in the coronal plane Systemic comorbidities
41 SPINE SURGEONS WANT TO KNOW Type of fracture Alignment Percent height loss Percent canal compromise PLC integrity: mention it even if it is normal
42 33YOF, 8 FT FALL FROM LADDER, DECREASED MOTOR SCORE (86) T11 T11
43 33YOF, 8 FT FALL FROM LADDER, DECREASED MOTOR SCORE (86) T2 STIR T2 MPGR
44 33YOF, 8 FT FALL FROM LADDER, DECREASED MOTOR SCORE (86) TLICS Morphology: Burst PLC integrity: Indeterminate Neuro Status: Incomplete 2 points 2 points 3 points Total TLICS: 7 points
45 20 YOF MVC, SEATBELT SIGN, ASIA D TLICS Morphology: Distraction 4 points PLC integrity: Disrupted 3 points Neuro Status: Incomplete 3 points Total TLICS: 10 points
46 20 YOF MVC, SEATBELT SIGN, ASIA D
47 20 YOF MVC, SEATBELT SIGN, ASIA D TLICS Morphology: Distraction 4 points PLC integrity: Disrupted 3 points Neuro Status: Incomplete 3 points Total TLICS: 10 points
48 29 YOF HS MVC (65MPH), SEAT BELT
49 29 YOF HS MVC (65MPH), SEAT BELT
50 29 YOF HS MVC (65MPH)
51 29 YOF HS MVC (65MPH), SEAT BELT TLICS Morphology: Distraction 4 points PLC integrity: Disrupted 3 points Neuro Status: Normal 0 points Total TLICS: 7 points
52 71YOM FALL, ASIA E (NO DEFICITS)
53 71YOM FALL TLICS Morphology: Distraction 4 points PLC integrity: Normal 0 points Neuro Status: Normal 0 points Total TLICS: 4 points TLICS Qualifier: Ankylosing Spondylitis
54 TLICS QUALIFIERES Fracture characteristics Excessive angulation in the coronal plane Systemic conditions Anklylosing spondylitis DISH Overall health Associated injuries CHF, etc. Confounding factors to be considered in addition to TLICS May alter treatment decisions
55 SPINAL FRACTURE IN PATIENTS WITH ANKYLOSING SPINAL DISORDER Disseminated Idiopathic Skeletal Hyperostosis (DISH) Ankylosing Spondylitis (AS) Share clinical features: Functional spinal ankylosis, poor bone quality, older age Altered biomechanics: Long lever arms due to spinal stiffness More susceptible to unstable injuries (3-column hyperextension) Delayed diagnosis in 20% of cases, 8% multilevel injury CT or MR of entire spine Require long segment Posterior Segmental Instrumentation and Fusion (PSIF) Caron-T et al. Spine May15; 35(11): E458-64, PMID:
56 71YOM FALL, ASIA E, AS
57 SUMMARY Clinical prediction rules less useful in TL Reformat Thoracic and Lumbar Spine from Pan Scan (C/A/P CT) CT more sensitive than radiographs Consider using TLICS In your report, mention PLC even if it is normal
58 Thank you.
59 SELECTED REFERENCES Medina-LS, Blackmore-CC, Applegate-KE, Eds. Evidence-based Imaging. Springer 2011 Sethi-MK et al. The evolution of thoracolumbar injury classification systems. Spine Journal 2009; 9: 780 Vaccaro-AR et al. A new classification of thoracolumbar spine injuries. Spine 2005; 30 (20): Caron-T et al. Spine May15; 35(11): E458-64, PMID:
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