Lumbar InjuriesLumbar Injuries

George SapkasGeorge SapkasAsc. ProfessorAsc. Professor

11stst Orthopaedic Dept. Orthopaedic Dept.Medical SchoolMedical School

Athens UniversityAthens University

Basic Mechanical PrinciplesBasic Mechanical Principles

ClassificationClassification

THE THREE COLUMN SPINE THE THREE COLUMN SPINE and its significance in the classification of and its significance in the classification of

acute thoracolumbar spinal injuries.acute thoracolumbar spinal injuries. Denis F. Denis F. ((Spine 1983Spine 1983))

DESTRUCTIONDESTRUCTION22

out of theout of the33

COLLUMNSCOLLUMNS

MAJOR INSTABILITYMAJOR INSTABILITY

A comprehensive classification of A comprehensive classification of thoracic and lumbar injuries.thoracic and lumbar injuries.

Magerl F, Aebi M, Gertzbein SD, Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S. Harms J, Nazarian S.

Eur Spine J 1994Eur Spine J 1994

Type AType A

Type BType B

Type CType C

DESTRUCTIONDESTRUCTIONof theof the

33COLLUMNSCOLLUMNS

MAXIMUM INSTABILITYMAXIMUM INSTABILITY

ROTATIONAL ROTATIONAL INJURIESINJURIES

RADIOLOGICAL RADIOLOGICAL INVESTIGATIONSINVESTIGATIONS

A.S.I.A. classificationA: Complete sensomotor deficitB: Complete motor paralysis

Sensory normalC: Useless motor capacityD: Useful motor capacityE: Normal

TREATMENTTREATMENT

Injuries of the Upper Cervical Spine

C1– C2

Injuries of Middle and Lower Cervical Spine

C3 – C7

Injuries of Thoracic Spine

T1 – T11

Injuries of the Thoraco-lumbar Spine

T11 – L1

Injuries of the Lumbar Spine

L2 – L5

Check listCheck listofof

Lumbar instabilityLumbar instability

Radiological parametersRadiological parameters

Kyphosis of the vertebral body

Segmental kyphosis

Disc height

Vertebral body height:Beck index

White A- Panjabi M Clinical Biomechanics of the Spine

1978.

Check l ist for the diagnosis of cl inical instabil i ty in lumbar spine

Element Point value

Anterior elements destroyed or unable to function2

Posterior elements destroyed or unable to function2

Radiographical criteriaA. Flexion / extension x- rays

1. Sagital plane transplantation > 4.5 mm or 15% (2pts)2. Sagital plane rotation

> 15o at L1 – L2 , L2 – L3, L3 – L4 (2pts)> 20o at L4 – L5 (2pts)> 25o at L5 – S1 (2pts)OR

4

B. Resting x-rays

1. Sagital plane displacement > 4.5 mm or 15% (2 pts)2. Relative sagital plane amgulation > 22o (2 pts)

Cauda equina damage 3

Dangerous loading aticipated 1

Total of 5 or more = unstable

Purposes of Operative Purposes of Operative TreatmentTreatment

A.A. The stabilization of the spineThe stabilization of the spine

B.B. The decompression of the spinal cord-The decompression of the spinal cord-nervesnerves

C.C. The correction of the spinal deformityThe correction of the spinal deformity

Posterior procedure

Case B.P.

M – 55 yrs

Fall

Level : L2

Type: A3

N(-)ve

A.S.I.A. : E

IMPLANTS : LEGACY (SOFAMOR-DANEK)

Case B. Lyr.

F – 53 yrs

Fall

Level : L2

Type: A3.3

N(-)ve

A.S.I.A. : E

IMPLANTS : M.O.S.S. - Miami

Case GAR. MAN.

F – 16 + 6 yrs

R.T.A.

Level : L3

Type: A3.1 + B1.2

N(+)ve

A.S.I.A. : D

IMPLANTS : M.O.S.S. - Miami

Case M. I.

F – 76 yrs

Fall

Level : L2

Type: A2

N(-)ve

A.S.I.A. : E

IMPLANTS : CD-Horizon

Case A.K.

F – 34 yrs

Fall

Level : L3

Type: A3.3

N(+)ve

A.S.I.A. : B - C

IMPLANTS : a) TITANIUM MESH + MOSS b) ISOLA

Case J.TS.

M – 24 yrs

Fall

Level : L3

Type: A3.2

N(+)ve

A.S.I.A. : B - C

IMPLANTS : M.O.S.S. - Miami

Inadequate reduction decompression and stabilizations

Anterior ±

Posterior procedure

Case K. M.

F – 39 yrs

Fall

Level : L2

Type: A3.2

N(+)ve

A.S.I.A. : C

IMPLANTS : Autologous Iliac Graft

Case K. M. –M.

M – 48 yrs

Fall

Level : L4

Type: A3.3

N(+)ve

A.S.I.A. : D

IMPLANTS : a) Cage expandable (ULRICH) b) M.O.S.S. - Miami

Osteoporotic fractures

CT-scan

Spinal fixationSpinal fixation

Posterior stabilizationPosterior stabilization

Anterior – Posterior

Stabilization

N(+)VEN(+)VE

Anterior Anterior Posterior Posterior

StabilizatioStabilization n

Minimal invasive techniques

Vertebroplasty - Kyphoplasty

Kyphoplasty