Assessing Classification Systems

Injury Morphology

Main Types Of Injury

• Compression injuries
• Distraction (excluding dislocations) injuries
• Translational injuries

To achieve greater reliability, most classifications have traditionally focused solely on morphology, rather than taking into account the associated injury mechanism.

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.

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