Multiple Spinal Extradural Arachnoid Cyst : A Case Report

Volume 4 | Issue 1 | Jan – June 2019 | Page 27-30 | Dhiraj V Sonawane, Bipul Kumar Garg, Harshit Dave, Vikramsinh Nangare, Ajay Chandanwale

Authors : Dhiraj V Sonawane [1], Bipul Kumar Garg [1], Harshit Dave [1], Vikramsinh Nangare [1], Ajay Chandanwale [1]

[1] Sir J.J. Group of Hospitals, Byculla Mumbai(400001).

Address of Correspondence
Dr. Bipul Kumar Garg,
Assistant Professor, Dept of Orthopaedics, J.J. Group of Hospitals Mumbai.
Email id:


Introduction: Spinal extradural arachnoid cysts(SEAC) are a rare cause of spinal cord compression, nerve root compression, or both, accounting for approximately 1-3% of all primary spinal space-occupying lesions. Multiple SEACs are rarely reported in the literature. Aim of this article is to illustrate our experience of surgical treatment of this rare but curable disease.
Case Report: We present a case report of 15-year-old boy who presented with progressive lower extremity weakness, pain and dysaesthesia. Magnetic resonance (MR) of the spine revealed two extradural arachnoid cysts. The patient underwent a thoracic laminoplasty for en bloc resection of the spinal extradural arachnoid cyst. Postoperatively, the patient’s motor strength and ambulation improved immediately.
Conclusion: We have described a rare case of back pain and leg weakness in patient with multiple thoracolumbar spinal extradural cysts. Clinical outcome after Laminoplasty and surgical excision of cyst was excellent and there has not been any evidence of cyst recurrence and symptomatic worsening till now(three years post surgical enbloc excision).
Keywords: spinal extradural arachnoid cyst, laminoplasty, excision


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How to Cite this Article: Sonawane DV, Garg BK, Dave H, Nangare V, Chandanwale A. Multiple Spinal Extradural Arachnoid Cyst : A Case Report. International Journal of Spine Jan-June 2019;4(1):27-30.

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A Prospective Study of Functional and Clinical Recovery Following Conventional Microlumbar Discectomy

Volume 4 | Issue 1 | Jan – June 2019 | Page 22-26 | M B Lingayat, Ghaniuzzoha Asadi

Authors : M B Lingayat [1], Ghaniuzzoha Asadi [2]

[1] Department of Orthopaedics, GMC, Aurangabad, Maharashtra, India, GMC, Aurangabad, Maharashtra, India.

Address of Correspondence
Dr. M. B. Lingayat,
Lotus Hospital, Pushpanagiri, Aurangabad. Maharashtra.


Background: Lumbar disc lesion is a common problem encountered in clinical practice. Historically, laminectomy was performed to remove the offending disc material, But it was associated with significant morbidity. Conventional Microlumbar discectomy has resulted in quick recovery and early return to work. Conventional Microlumbar discectomy has become the “Gold Standard” for treating lumbar disc lesion when surgery is indicated. The main objective is to study functional and clinical recovery following conventional microlumbar discectomy.
Methods: A Total of 40 patients who had single level disc herniation with radicular symptoms were operated by conventional microlumbar discectomy through period from September 2013 to August 2015. Results were measured using the Visual Analogue Scale(VAS) for leg pain and PROLO Economic and Functional Outcome Rating Scale. All quantitative data were summarized using mean and standard deviation.
Results: Marked improvement in Leg pain according to VAS (90% having no leg pain at last follow-up). Pre-operative Average VAS Score was 5 and post-operative last follow-up score was 1. According to PROLO Scale mean total score improved from 4.2 pre-operatively to 8.37 post-operatively and recovery rate was excellent in 95% cases. Most of the patients returned to their work of previous occupation with no restriction of any kind.
Conclusions: Conventional Microlumbar Discectomy is a safe, effective, reliable and least traumatic procedure for removal of lumbar disc lesion with very good long-term results. It resulted in early recovery and quick return to work. Good functional and clinical recovery achieved following surgery. It provided excellent pain relief.
Keywords: Lumbar disc lesion, conventional microlumbar discectomy, visual analog scale.


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How to Cite this Article: Lingayat MB, Asadi G. A Prospective Study of Functional and Clinical Recovery Following Conventional Microlumbar Discectomy. International Journal of Spine Jan-June 2019;4(1):22-26.

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Diagnosing Early Post-operative Spinal Infection – A Systematic Review

Volume 4 | Issue 1 | Jan – June 2019 | Page 10-15 | Ross B. Ingber

Authors : Ross B. Ingber [1]

[1] Northwell Health, Department of Radiology, Manhasset, New York

Address of Correspondence
Dr. Ross B. Ingber,
Northwell Health, 300 Community Drive Manhasset, NY 11030


Background: Early post-operative spinal infection (EPSI) is a potentially catastrophic complicationfollowing spinal surgeries.Although critically important, diagnosing spinal infections in the early post-operative period is challenging due to anelevation of serologicmarkers causedby invasive surgery.The purpose of thestudy is to find the indicators in bloodtest results to aid in thedifferentiation of EPSI.
Methods: Studies were systematicallyevaluated thePubMed, Embase, and Ovid peer-reviewed librarydatabases to assess all studiesthrough July 2015. The studies reviewed discussed erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and white blood cell (WBC) count in both infected and noninfected patients following orthopedic surgery. The literature was heterogeneous; however, areview of the articles illustrated the importance of serologic markers in diagnosing post-operative infection.
Results: There was a marked difference between the type of surgical procedures and timing for diagnosis in the studies evaluating WBC count, ESR, and CRP levels for the diagnosis of spinal infections.Furthermore, the sensitivity and specificity varied in the different procedures, timing for diagnosis, and cutoff value pointswithin each serologicmarker. However,thesecond peakin ESR and CRP levels could be utilized as an indicatorwhen attempting to diagnose an infection.
Conclusions: Based on this systematic review, it is difficult to recommend a specific marker or a specific level to determine EPSI. However, a combination of these markers in adjunction with clinical examination and imaging studies may aid in determiningEPSI.Studies are necessary to investigate the serologicmarkers based on the specific days after surgery and the size of spinal surgery. Finally, blood test results may be just supplemental information for the determination of EPSI.
Keywords: C-reactive protein, erythrocyte sedimentation rate, white blood cell count, post-operative infection, acute spine infection.


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3. Sweet FA, Roh M, Sliva C. Intrawound application of vancomycin for prophylaxis in instrumented thoracolumbar fusions: Efficacy, drug levels, and patient outcomes. Spine 2011;36(24):2084-2088.
4. Molinari RW, Khera OA, Molinari WJ 3rd. Prophylactic intraoperative powdered vancomycin and postoperative deep spinal wound infection: 1,512 consecutive surgical cases over a 6-year period. Eur Spine J 2012;21 Suppl4:S476-S482.
5. Collins I, Wilson-MacDonald J, Chami G, Burgoyne W, Vineyakam P. The diagnosis and management of infection following instrumented spinal fusion. Eur Spine J 2008;17(3):445-450.
6. Hong HS, Chang MC, Liu CL, Chen TH. Is aggressive surgery necessary for acute postoperative deep spinal wound infection? Spine 2008;33(22):2473-2478.
7. Hsieh MK, Chen LH, Niu CC, Fu TS, Lai PL, Chen WJ. Postoperative anterior spondylodiscitis after posterior pedicle screw instrumentation. Spine J 2011;11(1):24-29.
8. Jonsson B, Soderholm R, Stromqvist B. Erythrocyte sedimentation rate after lumbar spine surgery. Spine 1991;16(9):1049-1050.
9. Khan MH, Smith PN, Rao N, Donaldson WF. Serum C-reactive protein levels correlate with clinical response in patients treated with antibiotics for wound infections after spinal surgery. Spine J 2006;6(3):311-315.
10. Lee JH, Lee JH, Kim JB, Lee HS, Lee DY, Lee DO. Normal range of the inflammation related laboratory findings and predictors of the postoperative infection in spinal posterior fusion surgery. ClinOrthopSurg 2012;4(4):269-277.
11. Mok JM, Pekmezci M, Piper SL, Boyd E, Berven SH, Burch S, et al. Use of C-reactive protein after spinal surgery: Comparison with erythrocyte sedimentation rate as predictor of early postoperative infectious complications. Spine 2008;33(4):415-421.
12. Nie H, Jiang D, Ou Y, Quan Z, Hao J, Bai C, et al. Procalcitonin as an early predictor of postoperative infectious complications in patients with acute traumatic spinal cord injury. Spinal Cord 2011;49(6):715-720.
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14. Gunne AF, Mohamed AS, Skolasky RL, van Laarhoven CJ, Cohen DB. The presentation, incidence, etiology, and treatment of surgical site infections after spinal surgery. Spine 2010;35(13):1323-1328.
15. Sugita S, Hozumi T, Yamakawa K, Goto T, Kondo T. White blood cell count and C-Reactive protein variations following posterior surgery with intraoperative radiotherapy for spinal metastasis. J Spinal Disord Tech 2015;38(1):17-23.
16. Weinstein MA, McCabe JP, Cammisa FP Jr. Postoperative spinal wound infection: A review of 2,391 consecutive index procedures. J Spinal Disord 2000;13(5):422-426.
17. Kang BU, Lee SH, Ahn Y, Choi WC, Choi YG. Surgical site infection in spinal surgery: Detection and management based on serial C-reactive protein measurements. J Neurosurg Spine 2010;13(2):158-164.
18. Meyer B, Schaller K, Rohde V, Hassler W. The C-reactive protein for detection of early infections after lumbar microdiscectomy. ActaNeurochir 1995;136(3-4):145-150.
19. Bible JE, Biswas D, Devin CJ. Postoperative infections of the spine. Am J Orthop 2011;40(12):E264-E271.
20. Wimmer C, Gluch H, Franzreb M, Ogon M. Predisposing factors for infection in spine surgery: A survey of 850 spinal procedures. J Spinal Disord 1998;11(2):124-128.
21. Kuhn MG, Lenke LG, Bridwell KH, O’Donnell JC, Luhmann SJ. The utility of erythrocyte sedimentation rate values and white blood cell counts after spinal deformity surgery in the early (</=3 months) post-operative period. J Child Orthop 2012;6(1):61-67.
22. Schinsky MF, Valle CJ, Sporer SM, Paprosky WG. Perioperative testing for joint infection in patients undergoing revision total hip arthroplasty. J Bone JtSurg Am 2008;90(9):1869-1875.
23. Spangehl MJ, Masri BA, O’Connell JX, Duncan CP. Prospective analysis of preoperative and intraoperative investigations for the diagnosis of infection at the sites of two hundred and two revision total hip arthroplasties. J Bone JtSurg Am 1999;81(5):672-683.
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How to Cite this Article: Ingber R B. Diagnosing Early Post-operative Spinal Infection – A Systematic Review. International Journal of Spine Jan-June 2019;4(1):10-15.

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Treatment Algorithm For Unstable Burst Fracture

Volume 1 | Issue 2 | Sep – Dec 2016 | Page 27-32 | Ketan Khurjekar, Himanshu Kulkarni, Mayur Kardile

Authors : Ketan Khurjekar [1], Himanshu Kulkarni [1], Mayur Kardile1 [1]

[1] Department of Spine Surgery, Sancheti Institute for Orthopaedics and Rehabilitation, Pune India

Address of Correspondence
Dr. Ketan Khurjekar
Department of Spine Surgery, Sancheti Institute for Orthopaedics and Rehabilitation, Pune India
Email :


Burst fractures comprise of approximately 17% of all thoracolumbar fractures. These type of fractures result from compression failure of both the anterior and middle columns under substantial axial loads [1]. Between the immobile, kyphotic thoracic spine above, and the relatively mobile, lordotic lumbar spine below, throracolumbar region makes a transition zone where all the stress forces are concentrated. This makes the thoraco lumbar zone more prone to injuries than any other part of the spinal column. According to Denis, a spinal fracture is described as burst if there is compression of the anterior column, fracture of the middle column, and retropulsion of bone fragments into the spinal canal [2]. As a result neurologic injury has been reported to occur in 30% of the patients with thoracolumbar fractures [3]. The management of thoracolumbar burst fractures remains challenging. An ideal treatment modality should induce neurological recovery, should correct the deformity efficiently and allow early mobilization, should enable minimization of loss of work hours and should have minimal treatment related complications. For years together, a lot has been written in literature about how these aims can be achieved, with strong proponents for both non-operative and operative treatments existing. This difference of opinion and polarising philosophies can be confusing for an inexperienced clinician. So we have tried to put forth step by step approach to decode the dilemma that is the unstable thoracolumbar burst fracture with the help of a case.

A 21 year old engineering student came to casualty with history of fall from height 4 hours back. Patient was unable to move both his lower limbs. Power in both Hips wad grade 2 for flexion, Grade 1 for Knee extension and Grade 0 for ankle and great toe movements. There was partial loss of sensations with diminished sensations present in L1-2-3 dermatomes and complete loss of sensations below that. There was loss of sensation for micturition, but it was associated with weak anal contraction. Patient was shifted to department of radiology and plane radiogram was done. Plain lateral radiogram showed fracture of L2 vertebral body with a retropulsed fragment crossing posterior vertebral line (Fig. 1).

After this, MRI scan of the thoracolumbar spine was done. The scan showed the retropulsed fragments causing severe compression of the cord (Fig. 2).
Once the imaging studies were done, following steps were followed.

Assesment of Neurology –
Assessment of neurology has to be the first thing to be considered in a methodical treatment approach. In most circumstances, the treatment protocol and prognosis depends upon early neurological state. Frankel categorised the spinal cord injuries in a comprehensive classification. The injury was divided into 5 types, from severe to less severe. Modification of Frankel grading was included in now widely accepted American Spine Injury Association grading (ASIA Grading) in 1997 which was revised in 2011 [4]. ASIA grading grades the injury into complete or incomplete, with extensive dermatomal and myotomal charting.
Power charting for upper and lower limb myotomes was done. According to Frankel grading, the injury was labelled as Frankel 3, since some voluntary motor function was preserved below level of lesion but too was weak to serve any useful purpose. Some sensations were preserved too.

Assessment of stability-
In 1949, Nicoll [7] first introduced the concept of posttraumatic spinal instability. He defined unstable spinal injuries based on the presence of subluxation or dislocation, disruption of interspinal ligaments, or laminar fractures at L4 or L5. This concept has been used as a base for all the treatment approaches for unstable injures. It was stated by White and Panjabi that a stable spine is able, under physiological load, to maintain its normal movement so that there is no initial or additional neurological deficit, no major deformity, and no incapacitating pain.8 They also made a check list for thoracic instability.
According to Denis [2], there are 3 types of instability in the thoracolumbar spine; the mechanical instability that refers to the potential of spinal collapse with subsequent deformity, the neurological instability that refers to the potential of further neurological injury, and the combined mechanical and neurologic instability. The 3-column model is useful for the assessment of spinal instability; any thoracolumbar burst fracture can be unstable, while middle 2, or 2-column failures are absolute criteria for instability.
Mcafee et al in 1984 described factors indicative of instability in compression burst fractures of thoracic lumbar junction. According this criteria, fracture in our case was considered unstable. The fracture had progressive neurological deficit, had >50% loss of vertebral height, local kyphosis > 20 degrees and retropulsion of a bony fragment in the canal was present (Fig. 3).

Classifying the fracture pattern –
Since Bohler first tried to classify thoracolumbar spine fractures combining both anatomic appearance and mechanisms of injury as early as in 1930, classification of spinal fractures to facilitate communication and encourage optimal treatment protocols has long been a focus of the spine community [9]. Numerous classification systems have been put forth till now. Discussion of all is beyond the scope of this topic but none has been proven to be a gold standard yet due to the complexity of spinal anatomy and mechanisms of injury, as well as widely differing philosophies in treatment[10].
Some classification systems have gained more acceptance than others though. In 1994, McCormack et al [11]. stated that in long bone fixation, load sharing between the bone and the implant is of paramount importance. It helps in uneventful healing of the fracture and prevents implant failure. They applied same concept in spinal fractures, and put forth a CT based Load sharing classification taking into account the amount of comminution, apposition and Kyphosis.
The fracture in this case was classified as a Grade 2, with moderate comminution (Fig. 4) apposition and Kyphosis. Fracture was also classified according to Thoracolumbar injury classification and severity score (TICS) which is useful guide to treatment options. The classification holds a scoring system categorising the injury into operative or non-operative category based on the score.
The score for our fracture was found to be 8, which indicated the management should be operative. Like other long bone fractures, AO classification was also introduced in as AO- Magerl classification [12]. The classification system failed to gain wide universal international adoption due to its complexity. SO, the system was revised in 2013 into 3 main injury patterns: type A (compression), type B (tension band disruption), and type C (displacement/translation) injuries[13].
Our facture was classified as L2-B2;N3;M1.

Management Options –
Ideally, the treatment Goal in burst fracture should be to
1. Effective correction the deformity
2. Induction neurological recovery
3. Should allow early mobilization
4. Should have minimal risk of complication
Because of different philosophical ideologies, and there has been considerable controversy on the efficacy of conservative treatment and the need for surgical intervention in burst fractures with intact neuro status.
Argument for proponents of Surgery has always been on points of additional stability, prevention of neurological deterioration, attainment of canal clearance, prevention of kyphosis and early relief of pain. Denis et al [2]. reported late neurological deterioration in 17% of conservatively treated patients. They stated that prophylactic stabilization and fusion of acute burst fractures without neurologic deficit have significant advantages over conservative treatment. Likewise, Bohlman et al too were biased towards operative intervention. They expressed that operative intervention enhances clinical outcome and facilitates early rehabilitation [14]. However, Many subsequent trials showed that deterioration of the neurological status in patents who had intact neurology initially was unlikely [15,16]. To comment about the concerns about the persistent canal compromise in neurologically intact patients, Shen et al [17]. noted a resorption of approximately 50% of the retroplused fragment within 12 months. Also, no statistical difference was found in the degree of spinal canal remodelling between patients treated conservatively and operatively [18]. Also, Some surgeons have chosen direct decompression and canal clearance when CT scan has showed more than 40 % canal compromise [19]. However paralysis occurs at the moment of injury and it is not related to position of bony fragment [26]. Also, High-speed video tests have shown that at higher levels of occlusion, the final position of the bone fragments was inadequately correlated with the maximum level of impingement [27].
So, even though the preferred treatment for these fractures with intact neurology is still an ongoing debate amongst clinician, data has shown no significant superiority of operative treatment over non operative treatment. TLICS is a useful tool to make the decision of preferred treatment modality easy.

In patients with progressive neurological deterioration, or ones with unstable fractures & complete neurological loss, there’s no debate about the choice of surgical intervention as a preferred treatment modality. It ensures decompression of the spinal canal and nerve roots, and gives the fractured spine sufficient stability and realignment with correction of kyphosis to start early mobilization and rehabilitation [14]. Timing of the surgery is also a debatable factor. It’s a common opinion that surgery at the earliest can be beneficial for ultimate outcome. Carlo Bellabarba et al in 2010 stated that stabilization within 72 hours was safe and decreased respiratory morbidity. But other than decreased ICU and overall hospital stay, no other significant benefit of early surgery was found. It was also stated that currently there is very low supporting evidence in literature for benefits early surgery [19]. Surgery for these fractures can be via Anterior, posterior or a combined approach. Fracture morphology, neurologic status, and surgeon preference play major roles in making the decision about preferred approach. Usually, the anterior approach surgery should be limitedly used for severe Denis type B fracture with direct reduction. The posterior approach is used in most Denis type A and B fractures with indirect reduction and has less complication [20]. Some authors also stated that anterior only showed statistically significant improvement in sagittal alignment in long term follow up than posterior only fixation [21]. Anterior and middle column injuries with partial neurology have been effectively treated by anterior approach; decompression under direct vision and sagittal alignment are the key factor.
In our experience, anterior decompression and reconstruction for burst fractures with anterior and median column injury is effective. Decompression and reconstruction can be performed under direct vision at one stage, and the sagittal alignment can be corrected at the same time. Since anterior approach has a more surgical morbidity than posterior approach, it should be reserved for patients with canal compromise >67%. Focal kyphosis > 30 degree [22].
But at the same time, The benefits of posterior approach cant be undermined. It is more than once described that creating a posterior tension band and stabilisation is biomechanicvally more stronger It helps in Indirect decompression by ligamentotaxis ( though, ligamentotaxis has been shown to be inefficient in greater than 50% canal compromise 22), direct access to spinal canal for decompression, relieve hematoma, repair dural tears and extricate trapped nerve roots. Direct canal decompression through a posterior approach can be obtained by laminectomy, pediculectomy, fragment reposition or fragment removal [23]. Also, adequate neural canal decompression can also be achieved by a new modified transpedicular approach less invasively to avoid anterior surgery [24]. Kaya et al extended the transpedicular decompression for spinal cord and nerves by posterior alone approach along with stabilisation and showed adequately good results for burst fracture (spine J 2004) In posterior approach, the extent of fixation should be decided according to the classification of the fracture. Short segment fixation could usually suffice in AO type A and B fractures. Long segment fixations should be carried out in AO type 3 fractures, severely comminuted fractures and osteoporotic bones [25]. We feel that incomplete neurological deficit with demonstrable radiological compression on MRI, should be subjected to canal clearance either by transpedicular approach or direct decompression, anteriorly or posteriorly. So patient underwent Posterior surgery on 3rd day after injury with laminectomy, transpedicular neural decompression with partial corpectomy, reduction, fixation of two levels above and below with pedicle screws and reconstruction of anterior column by transforaminal approach with partial bone graft and Titaneum cage.

Take Home message –
To conclude, unstable thoracolumbar junctional fracture are known to cause neurological deficit though that is not the rule. Neurological deficit and structural instability dictates Surgical Intervention Classifying the grade of Instability and establishing level of neurological deficit is paramount. Pendulum is shifting towards all posterior spine surgery. Every fracture is unique and management is tailor made. Depending on Fracture pattern, stability, neurology and disruption of ligament complex will dictate the treatment protocol. Anterior versus posterior, short versus long fixation, open decompression versus indirect decompression have been issues. In today’s era, every treatment protocol is evidence based and result oriented. Issues of anterior surgery are well described, morbidity of approach, risk to major vascular structures and organs, need definite consideration. We have given algorithm depending on the literature and their clinical experience over years of managing thoracolumbar fractures.


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5. Frankel HL, Hancock DO, Hyslop G, et al. The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. Paraplegia 1969;7(3):179–192
6. American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2000; Atlanta, GA, Reprinted 2008.
7. Nicoll EA. Fractures of the dorso-lumbar spine. J Bone Joint Surg Br. 1949; 31(3):376-395.
8. Panjabi MM, Thibodieau LL, Crisco JJ, White AA. What constitutes spinal instability? Clin Neurosurg. 1988; (34):313-319
9. Bohler L. Die techniek de knochenbruchbehandlung imgrieden und im kriege. Verlag von Wilhelm Maudrich 1930 (in German).
10. Joon Y. Lee et al, Thoracolumbar injury classification and severity score: a new paradigm for the treatment of thoracolumbar spine trauma, J Orthop Sci (2005)
11. McCormack, Thomas MD; Karaikovic, Eldin MD; Gaines, Robert W. MD
Spine:The Load Sharing Classification of Spine Fractures, SPINE vol9, pp1741-1744, J.B Lippincott
12. Magerl F, Aebi M, Gertzbein SD, et al. A comprehensive classification of thoracic and lumbar injuries. Eur Spine 1994;3: 184-201.
13. Alexander R. Vaccaro et al, AOSpineThoracolumbar Spine Injury Classification System, SPINE Volume 38, Number 23, pp 2028-2037 Spine 2013, Lippincott Williams & Wilkins
14. Fan KF, Tu YK, Hsu RW et al (1997) The high fixation failure rate of short segment pedicle instrumentation for unstable thoracolumbar burst fractures. Orthop Trans 21:267
15.Celibi L, Muratli HH, Dogan O et al (2004) The efficacy of nonoperative treatment of burst fractures of the thoracolumbar vertebrae. Acta Orthop Traumatol Turc 38(1):16–22
16. Shen WJ, Liu TJ, Shen YS (2001) Nonoperative treatment versus posterior fixation for thoracolumbar junction burst fractures without neurologic deficit. Spine 26:1338–1345
17. Lu J, Ashwell KW, Waite P (2000) Advances in secondary spinal cord injury: role of apoptosis. Spine 25:1859–1866
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19. Bellabarba C, Fisher C, Chapman JR, Dettori JR, Norvell DC. Does early fracture fixation of thoracolumbar spine fractures decrease morbidity or mortality? Spine (Phila Pa 1976). 2010 Apr 20;35(9 Suppl):S138-45.
20. Wu H, Fu C, Yu W, Wang J. The options of the three different surgical approaches for the treatment of Denis type A and B thoracolumbar burst fracture. Eur J Orthop Surg Traumatol. 2014 Jan;24(1):29-35.
21. Zahra B, Jodoin A, Maurais G, Parent S, Mac-Thiong JM. Treatment of thoracolumbar burst fractures by means of anterior fusion and cage. J Spinal Disord Tech. 2012 Feb;25(1):30-7.
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How to Cite this Article: Khurjekar K, Kulkarni H, Kardile M. Treatment Algorithm for Unstable Burst Fractures . International Journal of Spine Sep-Dec 2016;1(2):27-32.

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Thoracolumbar Fractures: Classification and Clinical Relevance

Volume 1 | Issue 2 | Sep – Dec 2016 | Page 14-21 | Ajoy Prasad Shetty, Srikanth Reddy Dumpa, S Rajasekaran

Authors : Ajoy Prasad Shetty [1], Srikanth Reddy Dumpa [1], S Rajasekaran [1]

[1] Department of Spine Surgery, Ganga Hospital, 313, Mettupalayam road, Coimbatore, India.

Address of Correspondence
Dr. Ajoy Prasad Shetty
Department of Spine Surgery, Ganga Hospital, Coimbatore, India.
Email :


Classification systems of throcolumbar fractures have undergone many changes. From being completely descriptive to predicting prognosis and helping in decision making. An ideal system should be simple, reliable, comprehensive, and reproducible, should facilitate communication between surgeons and also guide the treatment. This review provides an overview on the evolution of various classification system & discusses the merits of the current systems.
Keyowrd: Throcolumbar fractures, classifications.


Thoracolumbar (TL) region is defined as the region between T10- L2 vertebral bodies [1] .The fractures of the thoracolumbar region constitute a spectrum of injuries ranging from simple undisplaced stable fracture to an unstable fracture dislocation. Injuries in this region are more common as it is transition zone between kyphotic thoracic region and the lordotic lumbar region, also transits from stiff thoracic spine to a mobile lumbar spine along with the change of orientation of facet joints from coronal to sagittal .In addition, the location of the body’s center of gravity anterior to the body causes compression forces to be transmitted to the anterior vertebral bodies & distraction of the posterior elements [1,2].
Bohler first classified TL fractures eight decades ago, which was followed by multiple fracture classifications [3]. Though there are various classification systems there is no consensus on which is the most applicable. The various classification systems has been described based on the mechanism of injury , morphology of the fracture , two or three column injuries including posterior ligamentous complex and presence of neurological deficit . The complex vertebral anatomy and ligamentous structures are to be included into the fracture classification making it difficult to classify. Occurrence of new pattern of injuries and advanced investigations create a lacunae in previous classification.
Fracture pattern depends on the mechanism of injury and the forces acting at specific position of spine. Rationale of stability of TL fractures is the one which dictates the treatment. The concept of stability has varied from posterior ligamentous complex injury, two column concept, and three column concept and scoring systems with time.
Plain radiographs & computer tomography (CT) are the investigative modality of choice for evaluating TL fractures. Even though MRI might be able to image the posterior ligamentous complex, its role in TL fractures is still not well defined. MRI is definitely indicated when there is disparity between the neurological level of injury and skeletal injury, and in patients with worsening of neurological deficit after admission. MRI may also have a role in evaluating the posterior ligamentous complex to differentiate between a stable or unstable burst fractures. Rajasekaran et al concluded that the MRI did offer modest gain in sensitivity in Posterior ligament complex (PLC) injuries but did not support the need for routine MRI for classification in assessing instability or need for surgery [ 4,5]. The classification systems are based on static images of the spinal injuries. The available imaging techniques are taken in supine position which cannot identify reduced thoracolumbar subluxation as well as the extent of deformity.
An ideal system should be simple, reliable, comprehensive, and reproducible, should facilitate communication between surgeons and also guide the treatment. This review provides an overview on the evolution of various classification system & discusses the merits of the current systems.

Thoracolumbar Classification systems
Bohler Classification [3 ]
First description of Thoracolumbar fractures in 1930 which was mainly descriptive based on plain radiographs . Classified into five categories: compression, flexion- distraction injury, extension, shear fractures and rotational injuries.
Watson Jones classification [6 ]
First classification to highlight the importance of posterior ligamentous complex (PLC). Described seven fracture types of which three are essential : simple wedge , comminuted fracture and fracture- dislocation.
Holdsworth Classification [7 ]
Holdsworth mechanistic classification revolutionized the classification system by introducing the concept of two columns .Spine was divided into two columns :anterior (vertebral body and intervertebral disc)and posterior (neural arch and posterior ligamentous complex)[Figure 1]. Based on the injury pattern he divided spinal fractures into five types: pure flexion, flexion rotation, extension, vertical compression or direct shearing force. The involvement of both the columns rendered the spine unstable .

Clinical Relevance of Bohler, Watson – Jones and Holdsworth Classification :
Bohler was the first to give a descriptive classification of TL fractures. Later Watson Jones introduced the concept of instability and attributed it to PLC injury. Nicoll stated that integrity of interspinous ligament is important for spinal stability. Holdsworth introduced the concept of columns and stated that the involvement of the posterior column renders the spine unstable . All these classifications are simple and state fracture patterns but are not predictive of outcome [8].

Denis Classification [ 9] :
Three column concept of Denis redefined the fracture pattern and classification of TL injuries. Computer Tomography (CT) analysis was done which helped to look more clearly into the fracture anatomy and patterns. Denis divided spine into three columns : Anterior, middle and posterior.
Anterior column includes the anterior half of vertebral body and anterior half of vertebral disc ,Middle column consists of posterior half of vertebral body and posterior half of vertebral disc and posterior column is similar to the posterior column proposed by Holdsworth[Figure 2]. According to Denis injury to middle column implies spinal instability . Classification proposed by Denis includes four types which have further subtypes [Table 1]:

Compression fractures: Failure of the anterior column under compression.
Burst fractures : Failure of the anterior and middle columns with fracture of the vertebral body under axial load
Seat belt injuries : Failure of the posterior and middle column, under flexion-distraction forces
Fracture dislocations : Failure of all the three columns
Denis highlighted the importance of neurological status and described three forms of instability by degrees. The first degree corresponds to isolated mechanical instability, second-degree includes injuries with neurologic component but no mechanical instability and third degree refers to injuries with mechanical and neurologic instability.
Denis classification is simple and highlights the relationship between neurologic injury and stability ,but it did not distinguish between stable and unstable patterns. Middle column as described by Denis is not an anatomical part but is an arbitrary division in the vertebral body itself. It has moderate inter -observer reliability and also does not predict outcome[10].

Mc Afee Classification [ 11]
McAfee based on study of 100 consecutive patients categorized the failure of the middle column into one of the three modes : axial compression, axial distraction & translation.
McAfee classification reinforces the importance of middle column in spinal stability , redefines the burst fractures into stable and unstable fractures ,further divided the seat belt injury into bony chance and flexion distraction injury. He described six injury patterns:
• Wedge-compression fracture : Injury causing isolated failure of the anterior column
• Stable burst fracture : Anterior and middle columns fail in compression with no loss of integrity of the posterior elements.
• Unstable burst fracture: Anterior and middle columns fail in compression and the posterior column is disrupted
• Chance Fracture : Horizontal avulsion injury of vertebral body as result of flexion about an axis anterior to the longitudinal ligament.
• Flexion-distraction injury : Compressive failure of the anterior column while the middle and posterior columns fail in tension.
• Translational injuries : Complete disruption of neural canal which shear failure of all three columns.

Wedge compression and stable burst fractures are stable and can be treated conservatively. Vertebral body height loss more than 50 %, kyphosis > 30 , facet joint subluxation, progressive neurological deficits and spinal canal occlusion by bone fragments in a CT with existence of incomplete neurological deficits were defined as instability criteria. According to these criteria all translational injuries, fracture dislocations , posterior ligamentous injuries with kyphosis greater than 30 degrees are unstable injuries and will need surgery . This classification is one of the most popular and practical which is still in use in clinical practice .
McCormack Load Sharing Classification [12]
First point based classification system to guide the treatment patterns based on score. Based on communition ,apposition and kyphosis reduction point scoring system was used for quantification [Figure 3]. McCormack et al. introduced this classification to predict the risk of implant failure after posterior short segment fixation for thoracolumbar fractures and was mainly applicable to Burst fractures . They proposed score greater than 7 points has greater failure rates with short segment fixation and requires anterior fixation.
The scoring system, mainly focuses on vertebral body fractures rather than posterior ligamentous complex and is not related to mechanism of injury. Thus this classification system is an adjunctive tool especially in burst fractures but cannot replace other classification systems . Li- yang Dai et al have shown a high level of interobserver & intraobserver reliability of load sharing classification in assessment of tharacolumbar burst fractures [13]. This classification has lost its significance in the recent years due to the increased use of “intermediate screw concept (pedicle screw in the fractured vertebral body ) in the surgical management of Burst fractures [14].

Magerl in 1994 after an extensive analysis on 1445 cases came with a comprehensive classification which defines all the fracture patterns of TL injuries. Two column concept has been highlighted and was used for description of TL fractures. This is a complete classification which not only incorporates the mechanism of injury but also defines the fracture pattern. The classification proposes three types of injury mechanism: compression (type A), distraction (type B) and torsion (type C) [Figure 4]. They defined the fractures based on severity starting from simple patterns to more complex ones. Stability was also addressed by this fracture classification stating simple fractures as stable and complex ones as unstable. Though it defines the fracture in a more extensive way with total of 53 subtypes, this makes it complex and difficult.
Despite widespread usage of the AO/Magerl classification, it has lower inter-observer reliability and is less useful in therapeutic decision making and prognostic purposes .Blauth et al. have reported that the inter-observer reliability of the AO classification was low (fair agreement, κ = 0.33), and when the injury was classified into subgroups, the inter-observer reliability decreased further[16]. Oner et al. and Wood et al. have also reported that the Denis classification system (κ= 0.60 and 0.606) showed higher inter-observer reliability than the AO classification system (κ = 0.35 and 0.475)[10,17]. Neurologic injury is not addressed, which is a drawback to this classification. This classification has recently been simplified by the AO Spine Knowledge forum and will be discussed later.

TLICS : Thoracolumbar Injury Classification And Severity Score [18]
Spine Trauma study group came with a new classification system in 2005 that was designed to depict the features important to predict spinal instability, future deformity & progressive neurologic compromise . To guide a treatment protocol, they designed a 10 point scoring system considering three principal parameters- Injury morphology, Posterior ligamentous complex (PLC) status and neurological injury [Table 2] .The PLC includes the supraspinous ligament ,interspinous ligament ,ligamentum flavum & the facet joint capsule .
A score less than 4 indicates non-surgical treatment, while a score greater than 4 indicates the need of surgical treatment because of significant instability. A total score of 4 may be treated either surgically or non-surgically.
They defined three categories of instability
a) Immediate mechanical instability (suggested by the morphology of injury)
b) Long term stability ( indicated by integrity of the PLC )
c) Neurologic stability ( indicated by the presence or absence of instability)
The TLICS guides not only the need for surgery but the surgical approach as well [Table 3]
Though this system predicts outcome, the validation studies are performed by the authors which questions the reliability. Moreover the major determinants taken into consideration are independent of each other which may sometimes misguide treatment. MRI is needed for knowing the integrity of PLC which is one of the limitation to this classification.
Comparing the reliability of Denis, AO, and TLICS systems Lenarz et al. and observed that in all the three systems variation in reliability was present [19]. They noted the highest reliability in the senior resident group and attending spine surgeon group and the lowest reliability in the non – spine attending orthopedists and junior residents. The highest inter observer and intraobserver reliability was noted for the neurologic status. They concluded that the TLICS is an acceptably reliable system when compared with the Denis and AO systems. Joaquim et al in a retrospective case series noted that the TLICS score treatment recommendation matched the surgical treatment in 47 of the 49 patients studied[20] .

AO Spine Thoracolumbar Spine Injury Classification [21]
The AO spine knowledge forum in 2013 has proposed a comprehensive Spine Injury Classification System which includes the
1. Morphology of the fracture
2. Neurological status and
3. Patient-specific clinical modifiers.

1 .Morphological Classification
This is based on Magerl classification which is modified by the AOSpine Knowledge forum.and is based on mode of failure of the spinal column [ Figure 5].

Type A
Involve anterior element fracture without PLC involvement. They are subdivided into five subtypes [Figure 6]. These subtypes are used in description of vertebral body fractures in B and C types.

A0 : Minor Nonstructural fractures( transverse process or spinous process fractures )
A1 : wedge compression fractures( fracture involving one end plate without involvement of the posterior wall of the vertebral body ) [Figure 7]

A2 : Split fractures( pincer type fractures involving both endplates but does not involve the posterior vertebral wall [Figure 8]

A3 : Incomplete burst fractures(Fractures with involvement of the posterior vertebral wall & spinal canal and involving one end plate ) [Figure 9]

A4: Complete burst fractures(Fractures with involvement of the posterior vertebral wall & spinal canal and involving both end plate ) [Figure 10]

These fracture are due to failure of posterior or anterior constraints such as PLC or anterior longitudinal ligament
B1 : Chance fracture or transosseous tension band disruption [Figure 11]
B2 : Posterior tension band disruption ( includes osteoligamentous chance ,flexion distraction injuries and burst fractures with involvement of PLC ) [Figure 12]

B3 : Hyperextension injury through disc or vertebral body with disruption of anterior longitudinal ligament ( classical seen in stiff spine eg. Ankylosing spondylitis ) [Figure 13]

These fractures are characterized by displacement of the cranial or the caudal vertebral fractures segments in any plane ( any translation injury ) [Figure 14]. No subtypes are classified due to possibility of various configurations. Any associated vertebral body fracture should be specified separately ( eg : A1, A2, A3 , A4). Any associated posterior tension band injuries should be specified separately (eg: B1,B2, B3).

2.Neurologic Injury
This takes into consideration of the neurologic status at the moment of admission
N0 : Neurologically intact
N1 : Transient neurologic deficit , which is no longer present
N2 : Radicular symptoms
N3 : Incomplete spinal cord injury or any degree of cauda equina injury
N4 : Complete spinal cord injury
NX : Neurologic status is unknown due to sedation or head injury.

3 .Clinical Modifiers
M1 : Indeterminate posterior complex injury
M2 : Patient specific comorbidity ( includes but not limited to ankylosing spondylitis , rheumatologic conditions , DISH, osteoporosis, or burns affecting the skin overlying the injured spine )

This system is designed to be comprehensive with high interobserver reliability and good predictor of outcome. Similar to the AO/Magerl system it delineates the stable and unstable fractures thus helping in treatment guidelines. This classification system is being subjected to rigorous scientific assessement. Kepler et al in a survey of 100 AO spine members confirmed the hierarchial structure of the AOSpine thoracolumbar Spine Injury Classification system and the possibility of the development of a globally applicable injury severity scoring system[22] . Kaul et al in a multicenter study compared the reliability of AO Spine thoracolumbar Spine injury classification and TLICS ,observed better reliability with the AO spine classification [23]
Overview of Thoracolumbar Fracture Classifications (Table 4)

Guide to treatment based on New AO Classification
We propose the following factors to be considered based on AO classification system for the management of TL fractures.
1. Clinical scenario
2. Severity of the injury
3. Neurologic status
4. Associated polytrauma

Plain radiographs and CT are absolutely essential to classify the factors. MRI may be usual to identify PLC injury & hence in diagnosis of B2 type injuries. Simple fractures like TYPE A0, A1, A2 can be treated conservatively. Type B and C are better treated by surgical method. Management of A3 & A4 fractures depend on the presence of neurological deficit , kyphosis , communition and patient modifiers.

Posterior ligamentous complex plays an important role in long term functional outcome. Clinical findings like severe tenderness and palpable posterior gap suggests PLC injury. Radiological signs such as widening of interspinous distance, facet disruption, Local Kyphosis > 20 and vertebral body comminution to be considered as indicators of associated PLC injury.Surgical management is advised in such situations. Patients with neurologic injury must be surgically treated with or without direct decompression. The choice of surgical approach & technique has not proved to have any impact on the clinical and radiological outcome, hence currently there is no definitive recommendation . It depends on the training , center, & the understanding & beliefs of the surgeon .


The classification of TL fractures has been evolving over the last 9 decades. There is no universally accepted classification so far to guide the treatment. Historically McAfee, AO/Magerl and Load sharing classification had been widely in use but none proved flawless. TLICS came with scoring system which guides treatment and predictor of outcome which is widely in use but had its own pitfalls.. The AO spine thoracolumbar classification system and its attempt at developing a injury severity scoring system is the most recent and the promising classification so far . The AO spine thoracolumbar classification system should be able to guide treatment and predict the outcome to overcome the pitfalls of other classifications. However clinical experience and clinical scenario should not be outweighed by these classification systems to guide the treatment.


1. Stagnara P, De Mauroy JC, Dran G, Gonon GP, Costanzo G, Dimnet J, Pasquet A. Reciprocal angulation of vertebral bodies in a sagittal plane: approach to references for the evaluation of kyphosis and lordosis. Spine. 1982 Jul 1;7(4):335-42.
2. Smith HE, Anderson DG, Vaccaro AR, Albert TJ, Hilibrand AS, Harrop JS, Ratliff JK. Anatomy, biomechanics, and classification of thoracolumbar injuries. InSeminars in Spine Surgery 2010 Mar 31 (Vol. 22, No. 1, pp. 2-7). WB Saunders.
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4. Rajasekaran S, Vaccaro AR, Kanna RM, Schroeder GD, Oner FC, Vialle L, Chapman J, Dvorak M, Fehlings M, Shetty AP, Schnake K. The value of CT and MRI in the classification and surgical decision-making among spine surgeons in thoracolumbar spinal injuries. European Spine Journal. 2016 Jun 1:1-7.
5. Rajasekaran S, Maheswaran A, Aiyer SN, Kanna R, Dumpa SR, Shetty AP. Prediction of posterior ligamentous complex injury in thoracolumbar fractures using non-MRI imaging techniques. International orthopaedics. 2016 Mar 17:1-7.
6. Watson-Jones R. The results of postural reduction of fractures of the spine. J Bone Joint Surg Am. 1938 Jul 1;20(3):567-86.
7. Holdsworth F. Review article fractures, dislocations, and fracture-dislocations of the spine. J bone joint surg Am. 1970 Dec 1;52(8):1534-51.
8. Verlaan JJ, Diekerhof CH, Buskens E, Van der Tweel I, Verbout AJ, Dhert WJ, Oner FC. Surgical treatment of traumatic fractures of the thoracic and lumbar spine: a systematic review of the literature on techniques, complications, and outcome. Spine. 2004 Apr 1;29(7):803-14.
9. Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. spine. 1983 Nov 1;8(8):817-31.
10. Oner F, Ramos L, Simmermacher R, Kingma P, Diekerhof C, Dhert W, Verbout A. Classification of thoracic and lumbar spine fractures: problems of reproducibility. European Spine Journal. 2002 Jun 1;11(3):235-45.
11. McAfee PC, Yuan HA, Fredrickson BE, Lubicky JP. The value of computed tomography in thoracolumbar fractures. An analysis of one hundred consecutive cases and a new classification. J Bone Joint Surg Am. 1983 Apr 1;65(4):461-73.
12. McCormack T, Karaikovic E, Gaines RW. The load sharing classification of spine fractures. Spine. 1994 Aug 1;19(15):1741-4.
13. Dai LY, Jiang LS, Jiang SD. Conservative treatment of thoracolumbar burst fractures: a long-term follow-up results with special reference to the load sharing classification. Spine. 2008 Nov 1;33(23):2536-44.
14. Shen WJ, Liu TJ, Shen YS. Nonoperative treatment versus posterior fixation for thoracolumbar junction burst fractures without neurologic deficit. Spine. 2001 May 1;26(9):1038-45.
15. Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S. A comprehensive classification of thoracic and lumbar injuries. European Spine Journal. 1994 Aug 1;3(4):184-201.
16. Blauth M, Bastian L, Knop C, Lange U, Tusch G. [Inter-observer reliability in the classification of thoraco-lumbar spinal injuries]. Der Orthopade. 1999 Aug;28(8):662-81.
17. Wood KB, Khanna G, Vaccaro AR, Arnold PM, Harris MB, Mehbod AA. Assessment of two thoracolumbar fracture classification systems as used by multiple surgeons. J Bone Joint Surg Am. 2005 Jul 1;87(7):1423-9.
18. Vaccaro AR, Lehman Jr RA, Hurlbert RJ, Anderson PA, Harris M, Hedlund R, Harrop J, Dvorak M, Wood K, Fehlings MG, Fisher C. A new classification of thoracolumbar injuries: the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status. Spine. 2005 Oct 15;30(20):2325-33.
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21. Vaccaro AR, Oner C, Kepler CK, Dvorak M, Schnake K, Bellabarba C, Reinhold M, Aarabi B, Kandziora F, Chapman J, Shanmuganathan R. AOSpine thoracolumbar spine injury classification system: fracture description, neurological status, and key modifiers. Spine. 2013 Nov 1;38(23):2028-37.
22. Kepler CK, Vaccaro AR, Schroeder GD, Koerner JD, Vialle LR, Aarabi B, Rajasekaran S, Bellabarba C, Chapman JR, Kandziora F, Schnake KJ. The Thoracolumbar AOSpine Injury Score. Global spine journal. 2016 Jun;6(04):329-34.
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How to Cite this Article: Shetty AP, Dumpa SR, Rajasekaran S. Thoracolumbar Fractures: Classification and Clinical Relevance.. International Journal of Spine Sep-Dec 2016;1(2):14-21.

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Thoracolumbar Fractures – “Changing Perspectives”.

Volume 1 | Issue 2 | Sep – Dec 2016 | Page 9-13 | Raghava D Mulukutla

Authors : Raghava D Mulukutla [1]

[1] Director & Chief of Spine Surgery
Udai Omni & Apollo Health city

Address of Correspondence
Dr. Raghava D.Mulukutla
Director & Chief of Spine Surgery
Udai Omni & Apollo Health city


Road traffic accidents are commonest cause of Thoracolumbar fractures which may or may not be associated with neurological injuries. Most of the classification are purely descriptive, but recently focus has shifted in developing more prognostic classifications. Diffirent management approaches are defined depending on the fracture type and the scenario is still remains a dynamic and evolving one. The current review aims to provide an overview of changing perspectives in this field
Keywords: Thorocolumbar fractures, management options.


The thoracic spine which is fixed and the lumbar spine which is mobile predisposes this area for fractures and it is not surprising that this area which is a transitional zone accounts for nearly 58% of spinal injuries [1]. Pre existing Osteopenia or osteoporosis and other metabolic disorders can precipitate fractures in this area. However severe injuries with or without neurological deficit are mostly due to road traffic accidents, fall from heights or industrial injuries. Since the early part of 20th century various classifications have emerged and till date there is no thoracolumbar fracture classification system that is perfect and classification systems are still evolving. Various treatment options including non operative treatments, short segment fusions, and more recently minimally invasive surgical techniques are used by surgeons in managing these injuries. It is important not to overlook other serious associated injuries and if present should be addressed first before undertaking surgery of thoracolumbar spinal injuries. Neurological deficits are not uncommon with more serious thoracolumbar trauma and it is important to protect the spine during transport and emergency stabilization of the patient up until final treatment [2].

The Ever Evolving Classifications
Classification of thoracolumbar fractures is important to identify stable and unstable injuries and help strategize treatment and to study the results of such treatments across various centres. Ideally, classifications should be easily understandable in clinical settings, reproducible, simple and direct the treating surgeon to appropriate management protocols. Newer classifications systems continue to emerge and is it is true to mention that there is no universally acceptable classification of thoracolumbar fractures.

The initial classification systems started with descriptive terms3 and later biomechanical factors such as anatomical regions and mechanical forces acting on the spinal column were introduced. Boehler [4] was the first to classify thoracolumbar fractures and he described five categories.
1. Compression fractures
2. Flexion –distraction injuries
3. Extension fractures with injury to anterior and posterior long. Ligament.
4. Shear fractures and
5. Rotational injuries

Watson Jones [5] introduced the concept of instability and was one of the first few to recognize the importance of posterior longitudinal ligament in maintaining spinal stability. There were seven types in his classification of Thoraco lumbar injuries with three major patterns: viz. a. simple wedge fractures b. comminuted fractures and c. Fracture dislocations

Nicoll [6] described anatomical classification and felt that the major determinant of stability was the interspinous ligament.3 Holdsworth7 was the first to coin the term “Burst Fracture” and introduced the “column concept” dividing the spine into two major columns : anterior column comprising the vertebral body and disc and the posterior column comprising the facet joints and posterior ligamentous complex. He felt that if both columns are disrupted the fracture would then be unstable. Kelly and Whitesides8 working on the Holdsworth concept felt that all burst fractures are inherently unstable.
With the advent of CT scans and after a review of 412 patients Denis presented his 3 column concept which is widely accepted [9]. He postulated that ALL (anterior longitudinal ligament), anterior half of the vertebral body and disc form the anterior column; PLL (Posterior longitudinal ligament) posterior half of vertebral body and disc constitute the middle column and the remaining posterior elements comprising the posterior column. The middle column according to Denis is the key for the stability of thoracolumbar fractures. Anterior column transmits 30% body weight and posterior column about 20%. However Anterior and Middle columns both resist 70-80% of body weight in flexion and the middle and posterior column resist 60% of body weight in extension. In Compression Fractures there is an anterior column failure and Burst fractures are secondary to Anterior and Middle column failure .Seat belt injuries are due to flexion distraction forces with failure of middle and posterior columns . In fracture dislocation all the three columns fail. Many surgeons do not agree that all Burst fractures are unstable; which is contrary to Denis classification where if two columns are involved in a fracture, then that fracture must be unstable [3,10].
The Holdsworth and Denis classification systems are anatomical classifications systems and they do not take into account the mechanisms of injuries of thoracolumbar fractures. McAfee [11] described a classification system where both the mechanism of injury and morphology of the fracture were included and he made the important contribution of describing the failure of the middle column due to a. axial compression b. axial distraction and c. translation.

Ferguson and Allen [12] proposed a mechanistic classification system and the mechanisms described are a. flexion compression, b. axial compression c. flexion distraction d. hyperextension –compression e. hyperextension distraction f. rotation –shear.

The AO – Magerl [13] classification and subsequent modifications of this classification system is very comprehensive and divides these injuries into Type A: compression; Type B : distraction and Type C : rotation and /or shear. Type A injuries are mostly simple and stable and Type C being very unstable injuries.
McCormack and Gains[14] described a Load sharing classification to predict implant failure and the need for additional Anterior surgery.
The Spine Trauma study group described the Thoracolumbar Injury Severity Score (TLISS) and The Thoracolumbar Injury classification and severity system (TLICS). This study based their severity scores on the a. mechanism of injury, b. integrity of Posterior ligament complex and c. the Neurologic status [15,16]. They recommended non operative treatment for scores less than 3 and surgery for scores more than 5 with a score of 4 to be treated with our without surgery [17].

AP and Lateral Radiographs, CT scans, MRI are all routinely used in the work up for thoracolumbar injuries. Standing lateral Radiographs and dynamic X-rays have little role in the acute setting but when safe to do and not uncomfortable to the patient are useful to monitor vertebral collapse, progression of deformity if any and overall sagittal alignment of the spine.18 Whilst CT scans are useful in accurate classification of the thoracolumbar fractures, they are especially useful to rule out a chance fracture.18 MRI is invaluable to identify epidural haematoma, SCIWORA, injury to the disc and most importantly the posterior ligamentous injury. With increasing availability of scanning machines, and with improvements in image quality, acquisition time, and image reformatting there has been a dramatic change in the commonly used algorithms [19].

Management Strategies
The steroid controversy : In the 1990s use of Methylprednisolone in the treatment of acute spinal cord injury became a routine following publication of NASCIS II trials [20,21]. However, Hurlbert et al [22] from an evidence based approach reported that methylprednisolone cannot be recommended for routine use in SCI. They also concluded that prolonged administration for up to 48 hours may be harmful to the patient and suggested that methylprednisolone should be considered to have investigational (unproven) status only. Most surgeons today have abandoned the use of methylprednisolone in the management of acute spinal cord injury following thoracolumbar trauma.

Compression Fractures
These injuries mostly involve the anterior column without involvement of the middle and posterior columns and are usually managed conservatively with analgesics, and restricted activity and strict bed rest may not be necessary. Most surgeons use front back support or TLSO or modifications of various hyper extension braces. However Giele et al [23] found no evidence to support that these braces are effective in Thoraco lumbar fractures. Vertebroplasty, Balloon Kyphoplasty are some of the procedures employed for pain relief. In those who present late with significant symptomatic kyphotic deformity or with late onset paraparesis, it is important to restore the sagittal balance with Pedicle subtraction osteotomy.
In spite of a large volume of literature on Burst fractures and their management, there is still no consensus on their management. The classification systems that are available are many and not universally acceptable leading further to the confusion about management of these injuries [24]. The problem is compounded when there is a neurological injury associated with these injuries. With fall from heights being the commonest cause of these injuries in India, the incidence of Neurological events is much higher at 60% compared to 40 % reported by various US studies [17].
Burst fractures are also classified as Stable and Unstable . Stable burst fractures are two column injuries. In the absence of neurological deficits and when not associated with other systemic injuries there is a trend amongst some surgeons to manage these injuries conservatively [25]. Those who manage these injuries conservatively believe that there is spontaneous remodeling of the spinal canal. However this view is not shared by many and conservative management demands regular radiological and clinical follow up to document late collapse and progression of kyphotic deformity.
Surgery: Neurological deficit and instability are definite indications for surgery in burst Thoraco lumbar fractures. In the presence of neurological deficit it is important to decompress the spinal cord. There is controversy regarding timing of surgery in those patients with neurological deficit. A few authors have advocated early surgery in patients with Neurological deficit [26], but there is no evidence that emergency surgical decompression has better outcomes. In the presence of progressive neurological deficit it is unwise to delay surgery and should be performed as early as possible. Controversy also exists as to the choice of approach in these fractures. McCormack based on their load sharing classification proposed that those with a score of 6 or less can be managed by posterior approach and those with a score of 7 or more should be managed by anterior approach. The anterior approach is indicated in those patients with extensive comminution of the vertebral body with severe retropulsion of fragments into the spinal canal. However there has been a recent trend to manage these burst fractures through a posterior only approach. Biomechanically placing short pedicle screws in the fractured vertebral body prevents implant failure. Short pedicle screws help in correcting the kyphotic deformity and in increasing the stiffness of the construct [2,27]. There is also controversy in literature about fusion following stabilization with some surgeons advocating fusion in predominantly ligamentous injuries [17].

Flexion –Distraction Injuries
Chance fractures or sea belt injuries are flexion distraction injuries with failure of all three columns in tension and the disruption of posterior elements may be osseous, ligamentous or both [28]. It is prudent to look for Intra abdominal injuries as they are sometimes associated with these injuries [29]. Some of these fractures without neurological deficit and in the absence of visceral injuries can be managed with a hyperextension brace. The trends in management of these fractures appears to be posterior approach when there is no neurological deficit or when there is a nerve root injury and in the presence of spinal cord or cauda equina injury a combined approach may be more appropriate [30].

Fracture Dislocations
According to TLICS classification these are inherently unstable injuries and need stabilization. They are typically 3 column injuries and it is commonly believed that pure hyperflexion or hyperextension alone may not produce thoracolumbar fracture dislocations and that there is always an additional rotational force that produces these injuries [31]. Fracture dislocations are associated with severe neurological deficits, except in those rare instances where a concomitant neural arch fracture may be associated with intact neurological function [32]

Biomechanics of Instrumentation
That Posterior pedicular instrumentation provides a slightly greater stiffness than anterior plate systems is proven by biomechanical studies. However these systems do not provide enough stiffness in axial rotation. Bence et al [33] believe that a combined approach is biomechanically superior to either an anterior or posterior approach alone in management of Thoraco lumbar trauma.

Long or Short constructs?
Opinion amongst surgeons is divided as to the number of levels to be instrumented in fractures of thoracolumbar spine. Short segment instrumentation has greater chance of instrumentation failure compared to longer constructs. However extending fusion to the lower lumbar vertebrae is not advisable and last instrumented vertebra should be L3 or above to minimise the risk of degeneration of lower lumbar discs [34].
The advantages of long segment constructs being that they resist bending forces much better than short segment instrumentation and help prevent kyphosis. There is also less pull out failure and a satisfactory spinal alignment can be achieved with long constructs [30]. According to Joseph et al [35]Short segment instrumentation is ideal for flexion distraction injuries.

Minimally Invasive Surgery In Thoraco Lubar Trauma(MIS)

MIS technologies are evolving and there is no long term studies to give definite guidelines. The posterior instrumentation by MIS technique works like an internal tension band while the fracture is healing. Some times anterior approaches are supplemented by MIS posterior instrumentation techniques.


Thoracolumbar trauma can range from simple fractures to more serious and complex fracture dislocations sometimes associated with life threatening injuries with or without neurological deficits. There is no universally acceptable classification system so far and some of these may not have much use in clinical settings. There are no randomized controlled trials comparing various treatment modalities and it is therefore not surprising that there is hardly any evidence based guidelines in the management of these injuries [30].

With better understanding of the morphology and mechanism of injury, a variety of treatment options are advocated for these injuries. There is a trend to manage stable burst fractures without neurological injury conservatively. However, more studies are needed to validate conservative treatment vs surgery, and in those with neurological deficits early vs. elective decompression of spinal cord and role of fusion in management of thoracolumbar fractures. It is important for the treating surgeon to understand the morphology of these fractures and the mechanisms responsible and plan and execute appropriate treatment strategies.


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How to Cite this Article: Mulukutla RD. Thoracolumbar fractures – “Changing Perspectives”. International Journal of Spine Sep-Dec 2016;1(2):9-13.

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