Thoracolumbar Spine Trauma :

Evaluation and Classification

dr. DJATNIKA ADHIKARA YOENOES, SpB

Anatomy
 Thoracolumbar spine
consists of 12
thorasic vertebrae
and 5 lumbar
vertebrae.
 Thorasic  kyphotic,
Lumbar  Lordotic,
transition zone prone
to injury.
Anatomy
 Conus Medullaris at
level L1-2.
 Caudal  cauda
equina.
Clinical Evaluation
 Emergency transport with rigid cervical orthosis
and backboard.
1. Assess the patient : A, B, C, D.
2. Initiate resuscitation : address life-threatening
injuries.
3. Evaluate level of consciousness.
4. Evaluate injuries to the head, chest, abdomen,
pelvis, and spine.
5. Perform complete neurologic examination
Neurologic Evaluation
 The Neurologic examination for thoracolumbar
includes :
 Dermatomal sensory testing
 Motor function
 Reflex examination

Spinal Shock refers to flaccid paralysis due to a

physiologic disruption of all spinal cord function
 An accurate assessment of the patient’s
neurologic statuscan be made only when
patient has recovered from spinal shock,n
which resolves within 48 hours
 Bulbocavernosus reflex is the lowest cord
mediated reflex and is therefore the first to
return.
 Complete neurologic injury is marked by a
total absence of sensory and motor
function
 Cervicaltetraplegia
 Thoracic and lumbar paraplegia
 Incomplete neurologic lesion, residual spinal
cord and/ nerve root function exists below the
anatomic level of injury
 An incomplete spinal cord lesion may follow one
of four described classic pattern
 Anterior cord
 Central cord
 Brown-Sequard
 Posterior cord
Anterior Cord
 Affects the anterior 2/3 of cord
 Preserves the posterior
column: proprioception,
vibratory sensation
 Loss of all motor and sensory
below injured level
 Deep pressure sensation only
 Poor prognosis for motor
recovery
Central Cord
 Older patients with preexisting
spondylosis
 Spinal cord pinched by osteophytes
anteriorly and the underlying
hypertrophic ligamentum flavum
posteriorly; leads to significant injury to
the “central portion” of the cord Best
prognosis among common patterns
 Upper extremity > lower extremity
involvement
 Distal > proximal
 Earliest and greatest recovery in legs
followed by bladder
 Hand dexterity often slow to return, full
recovery variable
Brown Sequard
 Results from functional
hemisection of cord,
projectile or penetrating
wound
 Loss of ipsilateral motor
 Loss of contralateral pain,
temperature, and light
touch sensation
 80% recover bowel and
bladder function
Posterior Cord
 Rare
 Loss of vibration,
proprioception, touch
sensation
 Maintain ambulation
but rely on visual
input
Clinical Evaluation
 Chest and abdominal examination
 Examination and recognition of associated
internal injuries in the chest and abdomen
Radiolographics Evaluation
 Thoracolumbal AP and Lateral
radiographs.
 CT Scan or MRI  assess canal
compromise and evaluate the degree of
neural compression.
 CT scan – bony injuries
 MRI – soft tissue imaging:
 Spinal cord, intervertebral discs, ligamentous structures
 Classification
 Holdsworth (Two-
collumn model), 1963
 Ventral dari Posterior
Longitudinal Ligament 
Anterior Column.
 Dorsal dari Posterior
Longitudinal Ligament 
Posterior Column.
 Stability based on
intactness of the
“posterior ligament
complex”
 Wedge compression Fracture and
compression burst Fracture were
considered stable injuries
 Extension injuries and rotational fracture
dislocation were considered unstable
 Denis Classification, 1983

The three columns of the spine, as proposed by

Francis Denis. The anterior column (A) consists of the
anterior longitudinal ligament, anterior part of the
vertebral body, and the anterior portion of the annulus
fibrosis. The middle column (B) consists of the
posterior longitudinal ligament, posterior part of the
vertebral body, and posterior portion of the annulus.
The posterior column (C) consists of the bony and
ligamentous posterior elements. (Modified from Denis
F. The three-column spine and its significance in the
classification of acute thoracolumbar spinal injuries.
Spine 1983;8:817–831.)
Denis Classification, 1983
Denis Classification, 1983
Compression
 Hyper flexion or
compressive failure
 Anterior column
 Stable injury
Burst Fracture
 A – axial load, involves
both endplates
 B – superior endplate
burst
 C – inferior endplate burst
 D – combination of type A
with rotation
 E –lateral burst fracture
Stable Burst Fracture
 Failure of anterior and
‘middle’ columns
 Predominantly axial
load
 No posterior column
disruption
 Stable injuries
< 50% retropulsion
 <20 degrees kyphosis
Unstable Burst Fracture
 Posterior column
involvement !!!
 Distraction or
translation/rotation
injury mechanisms
Flexion-Distraction Injury
 Due to distraction
forces of middle and
posterior columns
 Usually secondary to
seat belt injuries
 Boney, purely soft
tissue, mixed
 Visceral injuries
common
Mechanistic Classification
 1984, Ferguson and Allen.
 Categorized injuries by forces  Mechanisms of injury
and modes of failure of elements of the spinal column.
 Compressive flexion injuries.
 Distractive flexion injuries.
 Lateral flexion injuries.
 Translation injuries.
 Torsional Flexion
 Vertical compression.
 Distractive extension.