The Pitfalls of Diagnosis and Treatment of Flexion Distraction Injuries of the Thoracic and Lumbar Spine: a Prospective Study

Czech version

Authors: L. Hrabálek ¹; J. Bučil ²; M. Vaverka ¹; M. Houdek ¹; D. Krahulík ¹; O. Kalita ¹
Authors‘ workplace: Neurochirurgická klinika, LF UP a FN Olomouc ¹; Radiologická klinika, LF UP a FN Olomouc ²
Published in: Cesk Slov Neurol N 2008; 71/104(2): 163-172
Category: Original Paper

Overview

The assessment of the degree of instability of an injured thoracic and lumbar spine is the basic prerequisite for choosing the adequate treatment procedure. That is the reason why so much emphasis is laid on precise imaging of the extent and location of damage caused to bone and ligament structures. Flexion distraction forms of injury render diagnosing based on normal skiagraphy and computer tomography rather difficult. An additional magnetic resonance imaging examination is a reliable method to detect loss of continuity of the posterior ligament complex. The authors evaluated 117 patients on a prospective basis of whom 14 (i.e. 12 %) had suffered a flexion distraction type of injury and had a high reliability record for magnetic resonance imaging examinations (100 %) in terms of evidence of posterior ligament complex injury, as compared with skiagraphy and computer tomography (71.4 %). Correct diagnosis is a result of a comprehensive assessment of all the above mentioned imaging methods and is the basis for the choice of adequate treatment. The choice of options for eventual surgery depends on the location and nature of spine injury. All surgeries for flexion distraction injuries in the studied group were sufficiently effective.

Key words:
injury – thoracic and lumbar spine – flexion distraction mechanism – spinal instability – magnetic resonance

Sources

1. Frankel HL, Mancock DO, Hyslop G, Melzak J, Michaelis LS, Ungar GH et al. The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. Paraplegia 1969; 7: 179–192.

2. Farcy JP, Weidenbaum M, Glassmann SD. Sagittal index in management of thoracolumbar burst fractures. Spine 1990; 15: 958–965.

3. Oner FC, van Gils AP, Faber JA, Dhert WJ, Verbout AJ. Some complications of common treatment schemes of thoracolumbar spine fractures can be predicted with magnetic resonance imaging: prospective study of 53 patients with 71 fractures. Spine 2002; 27: 629–636.

4. Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S. A comprehensive classification of thoracic and lumbar injuries. Eur Spine J 1994; 3: 184–201.

5. Denis F, Armstrong GW, Searls K, Matta L. Acute thoracolumbar burst fractures in the absence of neurological deficit. A comparison between operative and nonoperative treatment. Clin Orthop Relat Res 1984; 189: 142–149.

6. White AA, Panjabi MM. Clinical Biomechanics of the spine. Second ed. Philadelphia: JB Lippincott 1990.

7. Nicoll EA. Fractures of the dorso-lumbar spine. J Bone Joint Surg Am 1949; 31B: 376–394.

8. Holdsworth F. Fractures, dislocations and fracture dislocations of the spine. J Bone Joint Surg l963; 45: 6–20.

9. Holdsworth F. Fractures, dislocations and fracture-dislocations of the spine. J Bone Joint Surg Am 1970; 52: 1534–1551.

10. Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine 1983; 8: 817–831.

11. Panjabi MM, Oxland TR, Kifune M, Arand M, Wen L, Chen A. Validity of the three-column theory of thoracolumbar fractures. A biomechanic investigation. Spine 1995; 20: 1122–1127.

12. Ferguson RL, Allen BL jr. A mechanistic classification of thoracolumbar spine fractures. Clin Orthop Relat Res 1984; 189: 77–88.

13. Lukáš R, Taller S. Vývoj klasifikací zlomenin T-L páteře. Acta spondylologica 2002; 1: 31–38.

14. McAfee PC, Yuan HA, Frederickson 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; 65: 461–473.

15. Cantor JB, Lebwohl NH, Garvey T, Eismont FJ. Nonoperative management of stable thoracolumbar burst fractures with early ambulation and bracing. Spine 1993; 18: 971–976.

16. Shen WJ, Shen YS. Nonsurgical treatment of three-column thoracolumbar junction burst fractures without neurological deficit. Spine 1999; 24: 412–415.

17. Chow GH, Nelson BJ, Gebhard JS, Brugman JL, Brown CW, Donaldson DH. Functional outcome of thoracolumbar burst fractures managed with hyperextension casting or bracing and early mobilisation. Spine 1996; 21: 2170–2175.

18. Tezer M, Erturer RE, Ozturk C, Ozturk I, Kuzgun U. Conservative treatment of fractures of the thoracolumbar spine. Int Orthop 2005; 29: 78–82.

19. McCormack T, Karaikovic E, Gaines RW. The load sharing classification of spine fractures. Spine 1994; 19: 1741–1744.

20. Vaccaro AR, Lehman RA jr, Hurlbert RJ, Anderson PA, Harris M, Hedlund R et al. A new classification of thoracolumbar injuries: the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurological status. Spine 2005; 30: 2325–2333.

21. Neumann P, Nordwall A, Osvalder AL. Traumatic instability of the lumbar spine. A dynamic in vitro study of flexion-distraction injury. Spine 1995; 20: 1111–1121.

22. Lukáš R, Suchomel P, Šrám J, Endrych L. Klasifikací řízená volba operačního přístupu při operačním léčení zlomenin torakolumbární páteře. Rozhl Chir 2006; 85: 365–372.

23. Lee HM, Kim HS, Kim D, Suk KS, Park JO, Kim NH. Reliability of magnetic resonance imaging in detecting posterior ligament complex injury in thoracolumbar spinal fractures. Spine 2000; 25: 2079–2084.

24. Adams MA, Hutton WC, Stott JR. The resistance to flexion of the lumbar intervertebral joint. Spine 1980; 5: 245–253.

25. Nagel DA, Koogle TA, Piziali RL, Perkash I. Stability of the upper lumbar spine following progressive disruptions and application of individual internal and external fixation devices. J Bone Joint Surg Am 1981; 63: 62–70.

26. Pearcy M, Portek I, Shepherd J. Three-dimensional x-ray analysis of normal movement in the lumbar spine. Spine 1984; 9: 294–297.

27. Levine AM, Bosse M, Edwards CC. Bilateral facet dislocations in the thoracolumbar spine. Spine 1988; 13: 630–640.

28. Leferink VJ, Veldhuis EF, Zimmermann KW, ten Vergert KW, ten Duis HJ. Classificational problems in ligamentary distraction type vertebral fractures: 30% of all B-type fractures are initially unrecognised. Eur Spine J 2002; 11: 246–250.

29. Petersilge CA, Pathria MN, Emery SE, Masaryk TJ. Thoracolumbar burst fractures: evaluation with MR imaging. Radiology 1995; 194: 49–54.

30. An HS, Andreshak TG, Nguyen, Williams A, Daniels D. Can we distinguish between benign versus malignant compressive fractures of the spine by magnetic resonance imaging? Spine 1995; 20: 1776–1782.

31. Blumenkopf B, Juneau PA 3rd. Magnetic resonance imaging (MRI) of thoracolumbar fractures. J Spinal Disord 1988; 1: 144–150.

32. Lecouvet FE, Vande Berg BC, Maldague BE, Michaux L, Laterre E, Michaux JL et al. Vertebral compression fractures in multiple myeloma. Part I. Distribution and appearance at MR imaging. Radiology 1997; 204: 195–199.

33. Wittenberg RH, Hargus S, Steffen R, Muhr G, Bötel U. Noncontiguous unstable spine fractures. Spine 2002; 27: 254–257.

34. Oner FC, van Gils AP, Dhert WJ, Verbout AJ. MRI findings of thoracolumbar spine fractures: a categorisation based on MRI examinations of 100 fractures. Skeletal Radiol 1999; 28: 433–443.

35. Oner FC, van der Rijt R, Ramos LM et al. Changes in the disc space after thoracolumbar spine fractures. J Bone Joint Surg Br 1998; 80: 833–839.

36. Oner FC, van der Rijt R, Ramos LM, Groen GJ, Dhert WJ, Verbout AJ. Correlation of MR images of disc injuries with anatomic sections in experimental thoracolumbar spine fractures. Eur Spine J 1999; 8: 194–198.

37. Emery SE, Pathria MN, Wilber RG, Masaryk T, Bohlman HH. Magnetic resonance imaging of posttraumatic spinal ligament injury. J Spinal Disord 1989; 2: 229–233.

38. Terk MR, Hume-Neal M, Fraipont M, Ahmadi J, Colletti PM. Injury of the posterior ligament complex in patients with acute spinal trauma: evaluation by MR imaging. AJR Am J Roentgenol 1997; 168: 1481–1486.

39. Haba H, Taneichi H, Kotani Y, Terae S, Abe S, Yoshikawa H et al. Diagnostic accuracy of magnetic resonance imaging for detecting posterior ligamentous complex injury associated with thoracic and lumbar fractures. J Neurosurg 2003; 99(Suppl 1): 20–26.

40. Moon SH, Park MS, Suk KS, Suh JS, Lee SH, Kim NH et al. Feasibility of ultrasound examination in posterior ligament complex injury of thoracolumbar spine fracture. Spine 2002; 27: 2154–2158.

41. Levi AD, Hurlbert RJ, Anderson P, Fehlings M, Rampersaud R, Massicotte EM et al. Neurologic deterioration secondary to unrecognized spinal instability following trauma-a multicenter study. Spine 2006, 31: 451–458.

42. Krbec M, Štulík J. Ošetření zlomenin Th-L páteře vnitřním fixatérem (zhodnocení 120 operovaných případů). Acta Chir Orthop Traumatol Czech. 2001; 68: 77–84.

43. Liu YJ, Chang MC, Wang ST, Yu WK, Liu CL, Chen TH. Flexion-distraction injury of the thoracolumbar spine. Injury 2003; 34: 920–923.

44. Štulík J, Krbec M, Vyskočil T. Použití biokeramiky při ošetřování zlomenin TL páteře. Acta Chir Orthop Traumatol Czech. 2002; 69: 288–294.

45. Alanay A, Yazici M, Acaroglu E, Turhan E, Cila A, Surat A. Course of nonsurgical management of burst fractures with intact posterior ligamentous complex: An MRI study. Spine 2004; 29: 2425–2431.

46. Kočiš J, Wendsche P, Višňa P, Mužík V. Méně invazivní retropleurální – retroperitoneální přístup k torakolumbální páteři. Acta Chir Orthop Traumatol Czech. 2002; 69: 285–287.

47. Mumford J, Weinstein JN, Spratt KF, Goel VK. Thoracolumbar burst fractures, the clinical efficacy and outcome of nonoperative management. Spine 1993; 18: 955–970.

48. Weinstein JN, Collalto P, Lehmann TR. Thoracolumbar ,,burst“ fractures treated conservatively: A long term follow-up. Spine 1988; 13: 33–38.