Uploaded byMasato Tanaka
AOSPINE2010TLfx
1) The document discusses the classification and surgical treatment indications for thoracolumbar spinal injuries based on the AO classification system. 2) It describes the different AO fracture types (A, B, C) and indicates whether anterior or posterior surgical approaches are generally used to treat each type based on the degree of instability and neurological involvement. 3) Special fracture types in ankylosed spines are also discussed, noting that these fractures often require long posterior instrumentation and fusion due to the severe instability caused by disruption of three columns of the spine.
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AOSPINE2010TLfx
- 1. 2010.10.1 AOSpineAdvance Course Yokohama 2010 Surgical Indication for thoracolumbar injury - Anterior or posterior - Okayama University Masato Tanaka
- 2. 2010.9.30 AOSpineAdvance Course Yokohama 2010 Today’s content Classification of Thoracolumbar injury Principle of selection for anterior or posterior AO type A fracture AO type B fracture AO type C fracture Special type fracture
- 3. 1. Classification ofThoracolumbar injury London, St. Paul cathedral
- 4. Various classification ofTL fracture Classification Principle Merit Demerit Holdsworth (1970) Two-column Simple Too old Denis (1983) Three-column Simple Instability Ferguson&Allen (1984 ) Mechanical Instability Complicated McComack&Gaines (1994) Point system Clinical results no neurology AO/Magerl (1994) Morphologic Severity&Instability Complicated TLISS/TLICS / Vaccaro (2005) Point system Insta.&Clinical results Liability
- 5. Posterior Middle AnteriorOne-Column Two-Column Three-Column Stable Unstable Denis classification (Three column theory) Mechanical instability Neurologic instability Mechanical & Neurologic
- 6. 1. 胸腰椎圧迫骨折 Anterior (Thoracolumbar Compression Fractures) 2. 胸腰椎破裂骨折 A +M (Thoracolumbar Burst fractures) 3. 胸腰椎屈曲伸延損傷 M+ P (Thoracolumbar Flexion-Distraction Injuries) 4. 胸腰椎脱臼骨折 A + M + P (Thoracolumbar Fracture-Distraction Injuries) (Denis F, 1983, Spine) Denis classification (Three column theory) 利点：分類が簡単 欠点：重症度や不安定性 の詳細な評価が不能
- 7. McCormack and Gainesclassification (Lord shearing classification) A: Comminution/involvement B: Apposition of fragment C: Deformity correction (kyphotic correction) < 30% 30%~60% > 60% minimal At least 2mm displacement < 50% > 50% 3 ° 4 ° ~9 ° 10 ° (McCormack and Gaines, Spine, 1994) 6 and less = posterior 圧迫骨折と破裂骨折の重症度のみ
- 8. 1. TypeA 圧迫損傷 66.1 ％ (2/3) (Compression injuries) 1. Impaction Fx , 2. Split Fx, 3. Burst Fx 2. Type B 伸延損傷 14.5 ％ (Distraction injuries) 1. Posterior disruption, 2. Arch Fx, 3. Anterior dis. 3. Type C 多方向性損傷 19.4 ％ (Multidirectional with trans) 1. Anteroposterior, 2. Lateral, 3. Rotational (Magerl, 1994, Eur Spine J) AO classification (Comprehensive classification)
- 9. AO classification moreprecise VS more complicated Burst fx A A 3.1.1 Superior incomplete burst A 3.3.3 Complete axial burst Flexion-distraction fx B B 2.1 Transverse bicolumn B 2.2.2 Flexion spondylolysis
- 10. Impossible to classifyby another system Including severity From A to C From 1 to 3 AO classification
- 11. TLICS classification TLICSscoring Parameter Points 1. Morphology Compression fracture 1 Burst fracture 2 Translational/rotational 3 Distraction 4 2. Neurologic involvement Intact 0 Nerve root 2 Cord, conus medullaris Incomplete 3 Complete 2 Cauda equina 3 3. Posterior ligamentous complex Intact 0 Injury suspected/indeterminate 2 Injured 3 Management as per TLICS score Management Points Nonoperative 0–3 Nonoperative or operative 4 Operative ≥5 (Thoracolumbar Injury Classification and Severity Score) (Vaccaro et.al, 2005, Spine)
- 12. 2. Principle ofselection for anterior or posterior UK, Stonehenge
- 13. Principle of selectionfor anterior or posterior (Zdeblick AAOS 2009) 1. 胸腰椎圧迫骨折 Conservative (Thoracolumbar Compression Fractures) 2. 胸腰椎破裂骨折 Anterior or Posterior (Thoracolumbar Burst fractures) A (severe neurologic deficit) 3. 胸腰椎屈曲伸延損傷 Posterior (Thoracolumbar Flexion-Distraction Injuries) 4. 胸腰椎脱臼骨折 Posterior (Thoracolumbar Fracture-Distraction Injuries ) A & P (Severe type)
- 14. 3. AO typeA fractures London, Tower Bridge
- 15. Denis: TL CompressionFx AO : A 1.1 ～ A 1.3 (Impaction fx) A 1.1 end-plate impaction A 1.2 wedge impaction A 1.3 VB collapse 1. Structural stability Absolutely stable 2. Treatment Basically no surgical intervention Op indication: Young & >50 ％ compression Posterior (Bradford 1977, Denis 1988) >30% compression ？ (Garfin 1998) Conservative
- 16. Denis: ?? AO : A 2.1 ～ A 2.3 (Split fx) A 2.1 sagittal split A 2.2 coronal split A 2.3 pincer fx Structural stability Relatively stable 2. Treatment Basically no surgical intervention Neurological deficit is uncommon Op indication: large gap is filled with disc which results in a nonunion (Roy-Camille 1979) Anterior? Anterior?
- 17. A 3.1 incompleteburst A 3.2 burst-split A 3.3 complete burst Structural stability Relatively unstable 2. Treatment Basically surgical intervention Lamina split may mean cauda equina extruding Op indication: almost all cases Posterior < Anterior Denis: TL Burst Fx AO : A 3.1 ～ A 3.3 (Burst fx) Anterior
- 18. A 3.1.1 Superiorincomplete burst A 3.3.3 Complete axial burst Gains score Age, BMD Conservative Posterior Tokuhashi Ito Anterior Taneichi apposition 2 Yukawa Denis: Burst fx or AO: A3 Severity is important
- 19. Gains score 7-8and less Posterior 8-9 and more Anterior Old Pt Young Pt Denis: TL Burst Fx Our solution AO : A 3.1 ～ A 3.3
- 20. Post op X-pPreop CT 19 yrs M, L1 Burst fx, AO Type A3.1 （ Gains score 6 ）
- 21. Pre op X-pPost op X-p Preop CT 21 yrs M, T12 Burst fx, AO Type A3.2 （ Gains score 8 ）
- 22. 4. AO typeB fractures London, Big Ben
- 23. Denis: TL Flexion-DistractionInjuries AO : B1-3 (anterior & posterior element injury with distraction) B1 ligamentous Structural stability Relatively unstable 2. Treatment Basically surgical intervention Neurological deficit is higher than A Usually posterior B1.3 & B2.3 + A3.3 anterior & posterior B2 osseous B2 disc Posterior
- 24. 60yrs M, L1Flexion-Distraction Injuries AO B2.3.1+A3.1.1 (osseous with A)
- 25. 60yrs M, L1Flexion-Distraction Injuries AO B2.3.1+A3.1.1 (osseous with A)
- 26. 5. AO typeC fractures London, Buckingham palace
- 27. C1 A withrotation Structural stability Absolutely unstable 2. Treatment Surgical intervention Neurological deficit is the highest ASIA A >50% Usually long posterior C2 B with rotation C3 rotational shear Denis: TL Fx-Dislocation AO : C1-3 (anterior and posterior element injury with rotation) Long posterior
- 28. 35 yrs M,Th8.9 Fx & dislocation & hemothorax AO: C1.1 (A with rotation: wedge fracture)
- 29. 35 yrs M,Th8.9 Fx & dislocation & hemothorax AO: C1.1 (A with rotation: wedge fracture)
- 30. 35 yrs M,Th8.9 Fx & dislocation & hemothorax AO: C1.1 (A with rotation: wedge fracture)
- 31. 5. Special typefractures Ramses British museum Rosetta stone
- 32. Character of Fracturein Ankylosed Spine Gap Bamboo spine Basically unstable (Three column injury)
- 33. Thoracolumbar Flexion-Distraction Injuries AO type B3 ; Anterior disruption through the disc Hyperextension Injuries Character of Fracture in Ankylosed Spine
- 34. 73 yrs M, DISH + L1 fracture
- 35. 73 yrs M, DISH + L1 fracture
- 36. Treatment (similar to fracture of extremity) Posterior long fusion
- 37. Of the 122spine fractures in 112 consecutive patients with ASD, the majority were transdiscal extension injuries, most commonly affecting C6-C7 . Spinal cord injury was present in 58% of the patients. Mortality was 32% over a 7-year period. Surgery was performed on 67% of patients, consisting primarily of multilevel posterior instrumentation 3 levels above and below the injury.
- 38. 72 yrs M,L4 fracture, AO typeA1.1.3 Pedicle screws are easy to pull-out Severe osteoporotic spine
- 39. 74 yrs F,T12 fracture, AO typeA1.1.3 If posterior long fusion was performed, adding on phenomina will be ocuured.
- 40. 44.2° Th12 76yrs F, T11.12 fracture, AO typeA1.1.3
- 41. Pedicle subtraction osteotomy(PSO) is one solution for osteoporotic spine. Th12 Th12 44.2° 27.0° 76 yrs F, T11.12 fracture, AO typeA1.1.3
- 42. New solutions arecoming soon! Vertebroplasty Kyphoplasty Perforated screws with dual core & double lead Synthes Medtronic
- 43. Thank you foryour attention