Oliver I. Schmidt, Ralf H. GahrTrauma Centre

St. Georg Clinic Leipzig, Germany

Pitfalls in Spinal Fracture

Classification

CL

AS

SIF

ICA

TIO

N

Magerl, M. Aebi, et al., „A Comprehensive Classification Of Thoracic and Lumbar Injuries“, Eur Spine J (1994) 3: 184 -201

Comprehensive Classification for Type of vertebral fracture and injury mechanism

Treatment options can be based on classification result

Standardized Nomenclature, Golden Standard

Separation into stable and unstable conditions

AA

Groups

Subgroups

CompressionCompressionCC

Groups

Subgroups

Axial torqueAxial torqueBB

Groups

Subgroups

DisruptionDisruption

Three fundamental types of injury

CL

AS

SIF

ICA

TIO

N

Pure axial compression force=> No Injury to Posterior Column

Compression injury of the anterior (and medial) column, only

Osteoporotic fractures:old vs. fresh/active

PITFALL

TY

PE

A

Type A – Vertebral Body Compression

AVOID PITFALL

3. X-Ray:- Check for sclerosis of fractured vertebra - Look for additional fractures in the spinal column

1. Check history of point of injury

4. If available or in doubt, go for MRI (T2-Fat saturated)

2. Do check for local pain / association to fracture height

TY

PE

A

Where´s the fresh osteoporotic # ?!

TIRM T2w TSE T1w

?

TY

PE

A

Type B1.1: Posterior ligament. Lesion

Hyperflexion of the spine=> Injury to Posterior Column

Ruptur to PLC presents w/osigns of vertebral fracture

PITFALL

TY

PE

B

3. X-Ray:- Check Alignement of all three spinal columns- Look for widened interspinous space in PLC - Look for facet diastasis/luxation

1. Check history for any distraction/hyperflexion injury

4. If available or in doubt, go for MRI

2. Clinical Signs of posterior injury: local tenderness, Hematoma, Proc. Spinosi #, Supraspinous Lig. #

TY

PE

B

AVOID PITFALL

Type B1.2: Posterior Distraction – Anterior Compression

Hyperflexion of the spine Posterior distraction Posterior Column Injury Anterior Compression vertebral compression fracture

vertebral fracture is recognizedbut posterior injury overlooked

PITFALL

TY

PE

B

If Type A injury is diagnosed, always assume injuryto posterior column:

3. X-Ray:- Check Alignement of all three spinal columns- Look for widened interspinous space in PLC - Look for facet diastasis/luxation- Look for pedicle fracture, ? Pedicle Position

1. Check history for any distraction/hyperflexion injury

4. If available or in doubt, go for MRI

2. Clinical Signs of posterior injury

TY

PE

B

AVOID PITFALL

Type B2: Posterior Distraction w. osseous Lesion

Hyperflexion of the spine Posterior distraction Injury to Posterior Column

Traumatic Spondylosis

TY

PE

B

Type B3: Anterior Distraction

Hyperextension of the spine Anterior distraction Anterior Column Injury

pure discoligamentous Injury w/o vertebral fracture

Discoligamentous injury w/osigns of vertebral fracture

PITFALL

TY

PE

B

=> Characteristic injury mechanism

TY

PE

B

Type B3: Anterior Distraction

1. Check history for any hyperextension injury

3. If available or in doubt, go for MRI

2. Rule out intraabdominal injury: Hyperextension canlacerate mesenteric trunc or Pancreas => Abdominal Exam, Ultrasound, CT

TY

PE

B

AVOID PITFALL

Type C1: Rotational/Axial Injury with compression

Axial Rotation & Type A injury of the spine => Instability

TY

PE

C

Type A fracture diagnosed, butSigns of Rotational Injury overlooked

PITFALL

3. X-Ray:- Check for Signs of discoligamentous injury- Signs of Rotational Injury: Transverse Proc. #, lateral vertebral bulge Fragment, asymmetrical vertebral #

4. If available or in doubt, go for MRI

2. Rule out intraabdominal injury: Rotation canlacerate mesenteric trunc or Pancreas => Abdominal Exam, Ultrasound, CT

TY

PE

C

AVOID PITFALL

1. Check history for any rotational injury (insufficient data, in most cases)

TY

PE

C

Stable Type A Fracture ?!

TY

PE

C

Stable Type A Fracture ?!

Exzentric Proc. Spin.

Fracture of Proc. Transv.

Lateral Bulge

=> Nope ! Unstable Type C1

Type C2: Rotational/Axial Injury with distraction

Axial Rotation & Type B Injury of the spine => Instability

TY

PE

C

Type B fracture diagnosed, butSigns of Rotational Injury overlooked

PITFALL

Type C3: Pure Rotational/Axial Injury

Pure Axial Rotation Injury of the spine => Instability

TY

PE

C

CAVE ! - Smooth transition from Type A to B and C Fractures- Always rule out higher grade injury

GU

IDE

LIN

ES

Type A

Stable

Type C

Unstable

Type B

Thank You