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Oliver I. Schmidt, Ralf H. Gahr Trauma Centre St. Georg Clinic Leipzig, Germany

Pitfalls in Spinal Fracture Classification. Oliver I. Schmidt, Ralf H. Gahr Trauma Centre St. Georg Clinic Leipzig, Germany. Magerl, M. Aebi, et al., „A Comprehensive Classification Of Thoracic and Lumbar Injuries“, Eur Spine J (1994) 3: 184 -201.

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Oliver I. Schmidt, Ralf H. Gahr Trauma Centre St. Georg Clinic Leipzig, Germany

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  1. Pitfalls in Spinal Fracture Classification Oliver I. Schmidt, Ralf H. Gahr Trauma Centre St. Georg Clinic Leipzig, Germany

  2. Magerl, M. Aebi, et al., „A Comprehensive Classification Of Thoracic and Lumbar Injuries“, Eur Spine J (1994) 3: 184 -201 Standardized Nomenclature, Golden Standard CLASSIFICATION Comprehensive Classification for Type of vertebral fracture and injury mechanism Separation into stable and unstable conditions Treatment options can be based on classification result

  3. C Groups Subgroups A Groups Subgroups B Groups Subgroups Compression Disruption Axial torque Three fundamental types of injury CLASSIFICATION

  4. PITFALL Type A – Vertebral Body Compression Pure axial compression force => No Injury to Posterior Column Compression injury of the anterior (and medial) column, only TYPE A Osteoporotic fractures: old vs. fresh/active

  5. AVOID PITFALL 1. Check history of point of injury 2. Do check for local pain / association to fracture height • 3. X-Ray: • Check for sclerosis of fractured vertebra • Look for additional fractures in the spinal column TYPE A 4. If available or in doubt, go for MRI (T2-Fat saturated)

  6. TIRM T2w TSE T1w Where´s the fresh osteoporotic # ?! TYPE A ?

  7. PITFALL Type B1.1: Posterior ligament. Lesion Hyperflexion of the spine => Injury to Posterior Column TYPE B Ruptur to PLC presents w/o signs of vertebral fracture

  8. AVOID PITFALL • Check history for any • distraction/hyperflexion injury 2. Clinical Signs of posterior injury: local tenderness, Hematoma, Proc. Spinosi #, Supraspinous Lig. # TYPE B • 3. X-Ray: • Check Alignement of all three spinal columns • Look for widened interspinous space in PLC • Look for facet diastasis/luxation 4. If available or in doubt, go for MRI

  9. PITFALL Type B1.2: Posterior Distraction – Anterior Compression • Hyperflexion of the spine • Posterior distraction • Posterior Column Injury • Anterior Compression • vertebral compression fracture TYPE B vertebral fracture is recognized but posterior injury overlooked

  10. AVOID PITFALL If Type A injury is diagnosed, always assume injury to posterior column: 1. Check history for any distraction/hyperflexion injury 2. Clinical Signs of posterior injury TYPE B • 3. X-Ray: • Check Alignement of all three spinal columns • Look for widened interspinous space in PLC • Look for facet diastasis/luxation • Look for pedicle fracture, ? Pedicle Position 4. If available or in doubt, go for MRI

  11. Type B2: Posterior Distraction w. osseous Lesion • Hyperflexion of the spine • Posterior distraction • Injury to Posterior Column • Traumatic Spondylosis TYPE B

  12. PITFALL Type B3: Anterior Distraction • Hyperextension of the spine • Anterior distraction • Anterior Column Injury pure discoligamentous Injury w/o vertebral fracture TYPE B Discoligamentous injury w/o signs of vertebral fracture

  13. Type B3: Anterior Distraction TYPE B => Characteristic injury mechanism

  14. AVOID PITFALL • Check history for any • hyperextension injury 2. Rule out intraabdominal injury: Hyperextension can lacerate mesenteric trunc or Pancreas => Abdominal Exam, Ultrasound, CT TYPE B 3. If available or in doubt, go for MRI

  15. PITFALL Type C1: Rotational/Axial Injury with compression Axial Rotation & Type A injury of the spine => Instability TYPE C Type A fracture diagnosed, but Signs of Rotational Injury overlooked

  16. AVOID PITFALL • Check history for any rotational • injury (insufficient data, in most cases) 2. Rule out intraabdominal injury: Rotation can lacerate mesenteric trunc or Pancreas => Abdominal Exam, Ultrasound, CT TYPE C • 3. X-Ray: • Check for Signs of discoligamentous injury • Signs of Rotational Injury: Transverse Proc. #, lateral • vertebral bulge Fragment, asymmetrical vertebral # 4. If available or in doubt, go for MRI

  17. Stable Type A Fracture ?! TYPE C

  18. Lateral Bulge Fracture of Proc. Transv. Exzentric Proc. Spin. Stable Type A Fracture ?! TYPE C => Nope ! Unstable Type C1

  19. PITFALL Type C2: Rotational/Axial Injury with distraction Axial Rotation & Type B Injury of the spine => Instability TYPE C Type B fracture diagnosed, but Signs of Rotational Injury overlooked

  20. Type C3: Pure Rotational/Axial Injury Pure Axial Rotation Injury of the spine => Instability TYPE C

  21. Type A Type B Type C Stable Unstable • CAVE ! • Smooth transition from Type A to B and C Fractures • Always rule out higher grade injury GUIDELINES

  22. Thank You

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