1. COMPLEX THORACIC INJURIES
Avelino Parajón
Servicio de Neurocirugía
Hospital Universitario Puerta de Hierro Majadahonda, Madrid

2. THORACIC SPINE
T1-T10
THORACOLUMBAR SPINE
T11-L2
LUMBAR SPINE
L3-L5

3. THORACOLUMBAR FRACTURES
MEN: WOMEN 2/3:1/3
20-40 YEARS OLD
15-20% OF FRACTURES
2/3 OF SPINE FRACTURES

4. THORACIC COMPLEX INJURIES
TRAUMA / ATLS
ABC / GCS
SPINE EXAM
RED FLAGS
INSPECT AND PALPATE ENTIRE SPINE
THOROUGH RX EXAM

5. SPINAL CORD INJURY ASSESMENT
MANY GRADING SYSTEMS
IMPAIRMENT BASED
FRANKEL
ASIA
YALE
MOTOR INDEX
FUNCTION BASED
MODIFIED BARTHEL INDEX

6. SPINAL CORD INJURY ASSESMENT
COMPLETE
NO FUNCTION BELOW LEVEL OF INJURY
ABSENCE OF SENSATION AND VOLUNTARY MOVEMENT IN S4/5 DISTRIBUTION
INCOMPLETE
PRESERVATION OF SENSATION IN S4/5 DISTRIBUTION AND VOLUNTARY CONTROL OF ANAL SPHINCTER

7. DENIS, 1983, 3 COLUMNS MAGERL, 1994, AO VACCARO, 2006, TLICS
BÖHLER, 1929
WATSON-JONES, 1931
NICOLL, 1949
HOLDSWORTH, 1963, 2 COLUMNS
LOUIS-GOUTALLIER, 1977
DENIS, 1983, 3 COLUMNS
FERGUSON-ALLEN, 1984
MAGERL, 1994, AO
McCORMACK, 1994, LOAD SHARING
VACCARO, 2005, TLISS
VACCARO, 2006, TLICS

8. HOLDSWORTH
STABLE
COMPRESSION
BURST
UNSTABLE
ROTATION
DISLOCATION

11. DENIS CLASSIFICATION-compression fractures
50%
COMPRESSION
ANTERIOR COLUMN
STABLE
NO NEURO DEFICIT
NON SURGICAL
/SURGICAL

12. DENIS CLASSIFICATION- compression fractures
WITH ANTERIOR WEDGING
WITH LATERAL WEDGING

13. DENIS CLASSIFICATION-burst fractures
20%
COMPRESSION
ANTERIOR AND MIDDLE COLUMN
UNSTABLE
MAY HAVE NEURO DEFICIT
SURGERY

14. DENIS CLASSIFICATION-burst fractures
FRACTURE OF BOTH ENDPLATES
FRACTURE OF THE SUPERIOR ENDPLATE
FRACTURE OF THE INFERIOR ENDPLATE
BURST + ROTATION
BURST + LATERAL FLEXION

15. DENIS CLASSIFICATION-flexion distraction fx
UNCOMMON
FLEXION + DISTRACTION
MIDDLE AND POSTERIOR COLUMNS
UNSTABLE
USUALLY NO NEURO DEFICIT
FX. CHANCE

16. DENIS CLASSIFICATION- flexion distraction fx
PURE OSSEOUS DISCONTINUITY, 1 LEVEL (CHANCE)
OSSEOUS- LIGAMENTOUS DISCONTINUITY, 1 LEVEL
OSSEOUS DISCONTINUITY, 2 LEVELS
OSSEOUS-LIGAMENTOUS DISCONTINUITY, 2 LEVELS

18. DENIS CLASSIFICATION- chance fracture

19. DENIS CLASSIFICATION-fracture dislocation
25%
FLEXION-ROTATION FLEXION DISTRACTION
THREE COLUMNS
UNSTABLE
NEURO DEFICIT
SURGERY

20. DENIS CLASSIFICATION-fracture dislocation

21. AO CLASSIFICATION
A- COMPRESSION
B- DISTRACTION
C- ROTATION

23. AO CLASSIFICATION- A A.1 IMPACTATIONN A.2 SECTION A.3. BURST
A.1.1 of superior endplate
A.1.2 wedge
A.1.3 vertebral body colapse
A.2 SECTION
A.2.1 sagital section
A.2.2 coronal section
A.2.3 Pincer fracture
A.3. BURST
A.3.1. incomplete
A.3.2. with section
A.3.3 complete

25. AO CLASSIFICATION- B B.1 predominantly ligamentous lessions
B.1.1 transverse disruption of disc
B.1.2 tipo A (compression)+ disrupture post ligam
B.2 predominantly bone lessions
B.2.1 transverse fractures of 2 columns+lig
B.2.2 flexión con espondilolysis
B.2.3 A (anterior compression)+ flexion distraction posterior
B.3. lessions by hyperextension-shearing trhough the disc
B.3.1. hyperextension and lubluxation
B.3.2. Hiperextensión and spondylolisis
B.3.3 posterior dislocation

27. Tipo C: ROTATION C.1 ROTATION + A C.1.1 ROTATIONN+ A1 (wedge)
C.1.2 ROTATIO+ A2 (section)
C.1.3. ROTATION+ A3 (burst)
C.2 ROTATION + B
C.2.1 ROTATION+ B1
C.2.2 ROTATION + B2
C.2.3 A ROTATION+ B3
C.3. ROTATION + SHEARING
C.3.1. slice shearing
C.3.2. oblique shearing

29. ¿¡¡ TREATMENT OPTIONS!!?

30. McCORMACK “LOAD SHARING CLASSIFICATION”
COMMINUTION
APPOSITION OF FRAGMENTS
KYPHOTIC DEFORMITY

31. McCORMACK “LOAD SHARING CLASSIFICATION”

34. McCORMACK “LOAD SHARING CLASSIFICATION”
LESSIONS WITH SURGICAL INDICATION AND < 7 POINTS
POSTERIOR APPROACH
LESSIONS > 7 POINTS
ANTERIOR APPROACH

35. Vaccaro- TLISS MECHANISM OF INJURY LESSION OF POST. LIGAMENT COMPLEX
NEUROLOGICAL DEFICIT

36. Vaccaro- TLISS MECHANISM OF INJURY COMPRESSION 1 POINT
TRASLATION/ROTATION 3 POINTS
DISTRACTION 4 POINTS

37. Vaccaro- TLISS LESSION OF POSTERIOR LIGAMENT COMPLEX INTACT 0 POINTS
SUSPECTED 2 POINTS
KNOWN 3 POINTS

38. Vaccaro- TLISS NEUROLOGICAL DEFICIT RADICULAR 2 POINTS
INCOMPLETE CONUS/SPINAL CORD 2 POINTS
COMPLETE CONUS/ S. CORD 2 POINTS
CAUDA EQUINA POINTS

39. VACCARO- TLISS TLISS <4 NON SURGICAL TREATMENT
TLISS 4 NON SURGICAL / SURGICAL
TLISS >4 SURGICAL TREATMENT

40. Vaccaro- TLICS LESSIONAL MORPHOMETRY COMPRESSION 1 POINT BURST 1 POINT
TRASLATION / ROTATION 3 POINT
DISTRACTION 4 POINT

41. THORACOLUMBAR FRACTURES
SURGICAL INDICATIONS:
>20º KYFOSIS
>10º CORONAL PLANE DEFORMITY
LIGAMENTOUS INSTABILITY (TYPE B)
LESIONES ROTACIONALES ( TYPE C)
CANAL STENOSIS 35-55%
HIGH LOSS >50%
MOBILITY IN POLITRAUMA PATIENTS
WORSENING NEUROLOGICAL DEFICIT

42. ANTERIOR APPROACH INDICATIONS
BURST FRACTURE + INCOMPLETE PARAPLEGIA
LOW PROBABILITY OF REDUCTION BY POST APPROACH
RETROPULSION WITH STENOSIS > 67%
ANTERIOR COMMINUTION WITH ANGULATION > 30º
> 4 DAYS SINCE TRAUMA
INSUFFICIENT NEUROLOGICAL IMPROVEMENT AFTER POST DECOMPRRESION
ANTERIOR COLUMN RECONSTRUCTION AFTER POSTERIOR STABILIZATION
TRAUMATIC DISC HERNIATION WITH LESSION BY FLEXION- DISTRACTION

43. ANT+ POST VS SHORT POST FUSION
RANDOMIZED PROSPECTIVE STUDY: SHORT FUSION ENDS UP IN LOST OF CORRECTION
BUT THIS DON´T CORRELATE TO CLINICAL WORSENING
Korovessis et al. Spine 2006, 31:

44. SURGERY VS CONSERVATIVE IN AO A FX
2 PROSPECTIVE RANDOMIZED STUDIES
Wood: J Bone Joint Surg Am 85: , 2003
Siebenga: Spine 31(25): , 2006

46. SURGERY VS CONSERVATIVE IN AO A FX
RANDOMIZED, PROSPECTIVE, UNICENTRIC
HIPOTHESIS:
SURGERY IS BETTER THAN CONSERVATIVE IN
THORACOLUMBAR FRACTURES
BURST
STABLES
AND WITHOUT NEURO DEFICIT

47. SURGERY VS CONSERVATIVE IN AO A FX
SHORT POSTERIOR FIXATION AND FUSION
ANTERIOR STABILIZATION AND FUSION
CONSERVATIVE TREATMENT
BRACE

48. SURGERY VS CONSERVATIVE IN AO A FX
EVALUATION
SF 36
ROLAND AND MORRIS DISABILITY QUESTIONNAIRE
OSWESTRY
INITIAL AND FINAL KYPHOTIC DEFORMITY
RETURN TO WORK

49. SURGERY
CONSERVATIVE
INITIAL KYPHOTIC DEF
10º
11.3º
FINAL KYPHOTIC DEF
13º
13.8º
INITIAL CANAL STENOSIS
39 %
34 %
FINAL CANAL STENOSIS
22 %
19 %
OWESTRY
NO DIF
SF 36
RETURN TO WORK

50. SURGERY VS CONSERVATIVE IN AO A FX
LEVEL 2-2 STUDY(POOR QUALITY RANDOMIZED)
FOLLOW UP < 80 %
BAD SELECTION OF GROUPS
HETEROGENOUS SURGICAL GROUP
STABILIZATION 2 TO 5 LEVELS
ANTERIOR APPROACH

52. SURGERY VS CONSERVATIVE IN AO A FX
HYPOTHESIS:
SURGICALLY TREATEDD FRACTURES HAVE BETTER RX AND CLINICAL OUTCOMES COMPARED TO THOSE MANAGED NON SURGICALLY
THORACOLUMBAR FRACTURES (T10-L4)
AO A TYPE (EXCLUDED A1.1.)
NO NEURO DEFICIT(FRANKEL E)

53. SURGERY VS CONSERVATIVE IN AO A FX
FOLLOW UP
RX EVALUATION
LOCAL SAGITAL ANGLE
REGIONAL SAGITAL ANGLE
RMDQ-24
VAS SPINE SCORE
VAS DEL DOLOR

56. SURGERY VS CONSERVATIVE IN AO A FX
A3 FRACTURES (BURST): BETTER FUNCTIONAL RESULTS WITH SURGERY
BETTER KYPHOTIC CORRECTION WITH SURGERY
NO CLINICAL- RADIOLOGICAL CORRELATION

58. SURGERY VS CONSERVATIVE IN AO A FX
RANDOMIZED, PROSPECTIVE, MULTICENTRIC
FX CLASSIFICATION ACCORDING TO AO AND LSC
NO SURGERY
REST 5 DAYS
FISIOTHERAPY
JEWETT ORTHESIS 3 MONTHS
SURGERY
BISEGMENTAL POSTERIOR FIXATION USS SYNTHES

60. ANTERIOR APPROACH TO THORACIC FRACTURES
BETTER DECOMPRESSION
BETTER KYPHOTIC CORRECTION
LESS PAIN

61. ANTERIOR APPROACH TO THORACIC FRACTURES
TECHNIQUE
THORACOTOMY
THORACOPHRENOLAPAROTHOMY
LEFT SIDE T12-L3
RIGHT SIDE T6-T11

66. 1. Patient History MALE 59 YEARS OLD HIPERCHL
MOTORCICLE ACCIDENT 12/10/09 IN MOROCCO
REFERRED TO OUR HOSPITAL 15/10/09
INTENSE BACK PAIN
NORMAL NEURO EXPLOR.
FRANKEL E
T12 AO A3

67. 2. Diagnosis

70. 4. Postoperative Management
24 h MOVILIZATION
TERMOPLASTIC ORTHESIS
3 DAYS POSTOP IN-HOSPITAL STAY
NO SIGNIFICANT BLOOD LOSS
NO OPIOID POSTOP

71. 5. Outcome 3 mos.: No pain No neuro deficit Return to normal life
Return to work