Assessing Classification Systems
for Thoracolumbar Spine Trauma
If spine pain becomes so severe that it disrupts daily life or is accompanied by swelling, tenderness, or redness, it’s important to seek medical attention.
At Complete Orthopedics, our expert spine specialists are adept at treating spine pain through both surgical and non-surgical means. We examine symptoms, diagnose the condition, and recommend suitable treatments, including surgery if necessary.
Serving New York City and Long Island, we partner with six hospitals to offer cutting-edge spine surgery and comprehensive orthopedic care. You can schedule a consultation with our orthopedic surgeons online or by phone.
Learn about the common causes of spine pain and the treatment options available, including when surgery might be the best choice.
Overview
Thoracolumbar spine trauma (TLT) refers to injuries affecting the thoracic and lumbar regions of the spine. Accurate classification of these injuries is critical for effective management and treatment. This comprehensive guide will delve into the main types of injuries, the significance of spinal instability and posterior ligamentous complex (PLC) disruption, neurological damage, and the primary systems used for classifying and managing thoracolumbar spine trauma.
Injury Morphology: Main Types of Injury
The classification of thoracolumbar spine injuries often focuses on injury morphology, emphasizing the physical appearance of the injury rather than the mechanism behind it. Understanding the main types of injury is essential for determining the appropriate treatment approach.
Compression Injuries
Compression injuries occur when a vertical force compresses the vertebrae, leading to fractures. These can range from simple fractures to more complex burst fractures, where the vertebral body is crushed and bone fragments may encroach on the spinal canal. This type of injury is commonly seen in falls or heavy object impacts.
Distraction Injuries
Distraction injuries, excluding dislocations, involve the pulling apart of the vertebrae, affecting both the anterior and posterior elements of the spine. These injuries typically result from flexion-distraction mechanisms, such as seatbelt injuries, where the spine is forcibly flexed and distracted.
Translational Injuries
Translational injuries are severe and involve the horizontal movement of one vertebra relative to another, often leading to significant instability. These can include lateral, ventral, or dorsal displacements and may be associated with proximal fractures of adjacent ribs or vertebrae. Such injuries are typically caused by high-energy trauma, such as motor vehicle accidents.
Spinal instability and PLC disruption
Injuries that can be categorized as unstable involve translational injury in the lateral, ventral, or dorsal directions, torsional or rotational injury, which may or may not involve dislocation, and is commonly linked to proximal fracture of adjacent ribs, as well as distraction injury.
The displacements observed on radiological exams may not always precisely indicate the degree of displacement that occurred at the time of injury. The radiological results indicating injury to the posterior ligamentous complex (PLC) may include:
- dislocated joint itself
- increase in the distance between adjacent spinous processes or their displacement laterally or rotationally
- separation, partial dislocation or complete dislocation of facet joints
- Hyperkyphosis
Occasionally, when you have a vertebral body (VB) fracture, it can be accompanied by distraction and rotational injuries. These types of fractures can happen when the spine is bent or twisted in a certain way. When this happens, the height of the VB is usually maintained or can even increase.
Still, there are cases where the VB can become compressed or burst due to other forces, like when the spine is compressed vertically. That’s why doctors at Complete Orthopedics always check for signs of injury to the posterior ligamentous complex (PLC) when we find a VB fracture.
Neurological damage
The most significant consequence of TLT is often the neurological deficit, which can severely affect a person’s abilities and daily life. Even though the initial damage to the spinal cord is primarily due to the traumatic event, any continued pressure on the neural tissue can worsen the overall prognosis and potentially make the injury even more severe.
Patients who are experiencing paraplegia may benefit from surgical treatment to enhance their rehabilitation care. In cases where there is spinal canal encroachment and resultant neurological damage, it is recommended to perform acute spinal canal decompression.
However, there is still some debate as to whether an anterior or posterior approach is more appropriate when dealing with incomplete spinal cord injury or cauda equina syndrome.
Temporary neurological deficits can have an impact on the decision-making process for surgery because assuming a standing position can increase the pressure on the fracture, causing an aggravation of any pain or deficit.
Guide For Management
The presence of Posterior Ligamentous Complex injury is often the primary factor that influences the decision to perform Thoracolumbar Spine Trauma Classification surgery.
Neurological damage in burst fractures is exacerbated by PLC disruption, with 80% of patients with unstable bursts and 22% with stable bursts experiencing neurological deficits.
Newer classification systems emphasize the significance of posterior stabilization, recommending the use of pedicle-screw constructs when there is a PLC injury to avoid delayed failure. Unstable burst fractures should not be treated with anterior decompression and fusion alone.
In treating spinal injuries, our doctors at Complete Orthopedics use TLICS system, which focuses on three aspects:
- the strength of the ligaments at the back of the spine (PLC)
- the patient’s neurological status
- the shape of the injury.
This helps decide on the best treatment for each patient. Recently, a new and more detailed version of this system called AOSpine TLSTC has been developed. Doctors can identify an injured PLC by looking for certain changes in the bones and ligaments of the spine. In some cases, even if the PLC is injured, the injury might still be stable enough to not need surgery.
Sometimes there are difficulties in distinguishing between stable and unstable burst fractures, and determining whether certain types of fractures require surgery. Literature showed that there are varying treatment preferences for 15 out of 19 controversial fractures, indicating that doctor’s experiences and preferences play a significant role in treatment decisions rather than relying on clinically validated criteria.
Our doctors use different systems to decide whether or not surgery is needed for spinal fractures. TLSTC is neglecting anterior column support when making this decision. This means that it is unclear whether surgery is needed for burst fractures that don’t cause any neurological problems.
Literature has suggested a modified system that looks at other factors like the height loss of the vertebral body, spinal stenosis, and the status of the PLC on an MRI.
The TLSTC system uses three important factors to diagnose and treat spinal injuries:
- injury morphology
- PLC disruption
- neurological damage
The severity of VB comminution, which can affect spinal stability, is often ignored by most classification systems. Severity scores are used to make diagnosis and treatment consistent across patients.
Thoracolumbar Injury Classification and Severity Score (TLICS)
The TLICS system evaluates three main aspects:
Injury Morphology: The shape and type of the injury.
PLC Integrity: The strength and condition of the ligaments at the back of the spine.
Neurological Status: The patient’s neurological condition.
These factors help determine the best treatment for each patient. Recently, the AOSpine TLSTC, a more detailed version of this system, has been developed. This newer system provides a comprehensive approach to classifying thoracolumbar spine injuries, considering various factors that affect stability and neurological outcomes.
Decision-Making Challenges
Differentiating between stable and unstable burst fractures and deciding on the necessity of surgery can be challenging. Literature indicates that treatment preferences vary, often influenced by the surgeon’s experience and the specific clinical scenario. Inconsistent application of classification criteria can lead to varied treatment outcomes.
Modified Classification Systems
Recent suggestions include modified systems that consider additional factors like vertebral body height loss, spinal stenosis, and PLC status on MRI. These aim to address the limitations of current classification methods, ensuring a more nuanced and effective approach to TLT management.
Conclusion
Effective management of thoracolumbar spine trauma requires a thorough understanding of injury morphology, spinal stability, and neurological implications. Classification systems like TLICS and AOSpine TLSTC provide valuable frameworks for guiding treatment decisions. Continuous advancements and modifications in these systems aim to enhance the accuracy of diagnoses and the efficacy of treatments, ultimately improving patient outcomes.
At Complete Orthopedics, our experts utilize these advanced classification systems to provide tailored and effective treatment plans for patients with thoracolumbar spine injuries. By focusing on injury morphology, PLC integrity, and neurological status, we ensure that each patient receives the most appropriate and effective care.
If you are interested in knowing more about assessing classification systems for thoracolumbar spine trauma, you have come to the right place! Our team is dedicated to staying at the forefront of medical advancements, ensuring that we provide the highest quality of care for our patients.
Do you have more questions?
What is the difference between compression, distraction, and translational injuries?
Compression injuries occur when vertical forces compress the vertebrae, often resulting in fractures. Distraction injuries involve the pulling apart of vertebrae, typically caused by flexion-distraction forces. Translational injuries involve horizontal movement of one vertebra relative to another, often leading to significant instability and usually resulting from high-energy trauma.
How do compression fractures differ from burst fractures?
Compression fractures typically involve the collapse of the anterior part of the vertebral body without significant displacement of bone fragments. Burst fractures, on the other hand, involve the entire vertebral body being crushed, with bone fragments potentially encroaching on the spinal canal and posing a risk to the spinal cord and nerves.
Why is it important to classify thoracolumbar spine injuries based on morphology?
Classifying injuries based on morphology helps in understanding the physical characteristics of the injury, which is crucial for determining the appropriate treatment strategy. This approach provides a more reliable assessment of the injury’s severity and potential impact on spinal stability and neurological function.
What are the common causes of distraction injuries?
Distraction injuries are commonly caused by flexion-distraction mechanisms, such as those seen in seatbelt injuries during car accidents. These injuries result from a combination of forces that pull the vertebrae apart, affecting both the anterior and posterior elements of the spine.
Why are translational injuries considered more severe?
Translational injuries are considered more severe because they involve significant horizontal displacement of vertebrae, leading to major instability. This type of injury often results in severe damage to the spinal cord and surrounding structures, necessitating complex surgical intervention to restore stability and function.
What constitutes an unstable spinal injury?
An unstable spinal injury typically involves translational movement, torsional or rotational forces, or distraction injuries that compromise the integrity of the spine. These injuries often result in significant displacement and may be associated with fractures of adjacent ribs or vertebrae.
How is the posterior ligamentous complex (PLC) assessed?
The PLC is assessed through radiological imaging, which may show increased distance between spinous processes, lateral or rotational displacement, and partial or complete dislocation of facet joints. Clinical examination and MRI can also help in identifying PLC injuries.
Can vertebral body (VB) fractures be stable even if PLC is injured?
Yes, some vertebral body fractures can be relatively stable even if the PLC is injured. However, the overall stability of the spine must be carefully assessed to determine if surgical intervention is necessary. MRI can be particularly useful in evaluating the extent of PLC injury.
Why is PLC injury significant in thoracolumbar trauma?
PLC injury is significant because it plays a critical role in maintaining spinal stability. Damage to the PLC can lead to increased instability and higher risk of neurological deficits. Accurate assessment of PLC integrity is essential for determining the appropriate surgical approach.
What are the signs of PLC injury on an MRI?
Signs of PLC injury on MRI include disruption of the interspinous and supraspinous ligaments, separation or dislocation of facet joints, and abnormal widening between spinous processes. MRI provides a detailed view of the soft tissues and ligaments, aiding in accurate diagnosis.
How does thoracolumbar trauma lead to neurological deficits?
Neurological deficits from thoracolumbar trauma occur when bone fragments or displaced vertebrae compress the spinal cord or nerve roots. The initial traumatic event can cause direct damage, and ongoing pressure from unstable fractures can exacerbate the injury.
What are the implications of neurological deficits in thoracolumbar trauma?
Neurological deficits can significantly impact a patient’s mobility, sensation, and overall quality of life. Severe deficits may lead to conditions like paraplegia, necessitating comprehensive rehabilitation and, in some cases, surgical intervention to decompress the spinal canal.
When is spinal canal decompression recommended?
Spinal canal decompression is recommended when there is significant encroachment on the spinal canal causing neurological deficits. Acute decompression can relieve pressure on the spinal cord and nerves, potentially improving neurological outcomes.
What factors influence the choice between anterior and posterior surgical approaches?
The choice between anterior and posterior approaches depends on the specific injury characteristics, including the location and extent of spinal cord compression, the presence of PLC injury, and the overall stability of the spine. Surgeon’s experience and patient-specific factors also play a role in this decision.
What is the TLICS system?
The Thoracolumbar Injury Classification and Severity Score (TLICS) system is a framework used to classify thoracolumbar spine injuries based on three main factors: injury morphology, PLC integrity, and neurological status. It helps guide treatment decisions and assess the need for surgical intervention.
Can temporary neurological deficits affect surgical decisions?
Yes, temporary neurological deficits can influence surgical decisions. Increased pressure on the spine from standing or movement can aggravate pain or deficits, highlighting the need for careful assessment and timely intervention to prevent worsening of the condition.
How does the AOSpine TLSTC differ from TLICS?
The AOSpine Thoracolumbar Spine Injury Classification System (TLSTC) is a more detailed version of the TLICS, providing a comprehensive approach to classifying thoracolumbar spine injuries. It includes additional factors and offers more specific guidance on treatment options.
Why is posterior stabilization recommended for PLC injuries?
Posterior stabilization using pedicle-screw constructs is recommended for PLC injuries to prevent delayed failure and maintain spinal stability. This approach addresses the disruption of the posterior elements, which is crucial for restoring overall spinal integrity.
What challenges exist in distinguishing stable and unstable burst fractures?
Distinguishing between stable and unstable burst fractures can be challenging due to variations in fracture patterns and individual patient factors. Accurate assessment requires thorough radiological and clinical evaluation to determine the extent of instability and need for surgical intervention.
How do surgeons determine the need for surgery in burst fractures without neurological problems?
Surgeons consider various factors, including the height loss of the vertebral body, the degree of spinal canal stenosis, and the status of the PLC on MRI. Even in the absence of neurological problems, these factors help assess the potential for future instability and guide surgical decisions.
What are the limitations of current classification systems?
Current classification systems may overlook factors like the severity of vertebral body comminution and the exact degree of instability. Additionally, they might not fully capture the complexity of individual injuries, leading to variations in treatment approaches.
How can modified classification systems improve treatment outcomes?
Modified classification systems incorporate additional factors such as vertebral body height loss, spinal stenosis, and detailed PLC status. These refinements provide a more nuanced assessment, leading to more accurate diagnoses and tailored treatment plans.
Why is it important to consider vertebral body comminution in classification?
Vertebral body comminution affects spinal stability and can influence treatment decisions. Severe comminution may necessitate more aggressive surgical interventions to restore stability and prevent further complications.
How do severity scores help in managing thoracolumbar spine injuries?
Severity scores provide a standardized way to assess and compare the severity of injuries across different patients. These scores help ensure consistency in diagnosis and treatment, facilitating better communication among healthcare providers and improving overall patient outcomes.
What role does MRI play in evaluating thoracolumbar spine injuries?
MRI plays a crucial role in evaluating thoracolumbar spine injuries by providing detailed images of the soft tissues, ligaments, and intervertebral discs. It helps assess the extent of PLC injury, spinal canal encroachment, and other critical factors influencing treatment decisions.
I am Vedant Vaksha, Fellowship trained Spine, Sports and Arthroscopic Surgeon at Complete Orthopedics. I take care of patients with ailments of the neck, back, shoulder, knee, elbow and ankle. I personally approve this content and have written most of it myself.
Please take a look at my profile page and don't hesitate to come in and talk.
