Indicaii terapeutice n fracturile vertebrale toraco-lombare utiliznd scorul TLICS

C. E. Popescu, L. Eva, B. Costchescu, M. Dabija, Raluca Munteanu, D. Andronic, R. Sandu Anda Eanu ,N. Albert, E. Moldovanu Spitalul Clinic Prof. N. Oblu Iai

Leziunile traumatice ale coloanei vertebrale toraco-lombare reprezint mai mult de 50% din totalul fracturilor vertebrale i sunt nsoite de un numr apreciabil de leziuni medulare. n ciuda progreselor tehnologice impresionante din ultimii 20 de ani, procesul decizional n ceea ce privete tratamentul acestor leziuni rmne controversat.

Why an AO spine Injury Classification System?

More than 60 classification systems - none is universally accepted - some are used extensively (Denis, AO Magerl) - only a few have been evaluated for reliability and validity Need for standardization and validation - common language for spine surgeons - comparability and reliability of clinical data

In 2005, Spine Trauma Study Group (STSG) proposed a new classification and scoring system for thoracolumbar spinal injuries. The classification system was constrained to include: a description of the major morphometric features of the thoracolumbar injury, an analysis of injury severity, an assessment of both mechanical and neurologic aspects of an injury, reproducibility, usefulness in prospective research settings, flexibility to evolve through future clinical studies

1)

2) 3)
4) 5) 6)

Three major variables were identified as critical to clinical decision-making: 1. the morpholgy of injury fracture pattern (as determined by imaging studies); 2. integrity of the posterior ligamentous complex (PLC); 3. neurologic status

Morphology

Type Compression

Qualifiers

Points
1

burst

1 3

Translational/ rotational
Distraction

Integrity of PLC

PLC disrupted in tension, rotation, or translation

Intact

Points

Suspected/indeterminate

Injured

Neurologic status
Involvement
Qualifiers Points

intact Nerve root Cord, conus complete

0 2 2

incomplete
Cauda equina

3
3

Injury severity score

3 - conservative treatment 5 - surgical treatment 4 - indeterminate

1. Instability - White & Panjabi clinical instability definition - a more meaningful categorization might reflect different categories of instability rather than degrees of instability: Immediate mechanical stability (suggested by the morphology of injury) Long-term stability (indicated by integrity of the PLC) Neurologic stability (indicated by the presence or absence of a deficit) 2. Validity and Reliability 3. Treatment Algorithms

Alexander R. Vaccaro et al: A New Classification of Thoracolumbar Injuries The Importance of Injury Morphology, the Integrity of the Posterior Ligamentous Complex, and Neurologic Status SPINE Volume 30, Number 20, pp 23252333 ,2005

Qualifiers

influence treatment and therefore need to be considered before blindly acting on a comprehensive injury severity score. These clinical qualifiers have a variable influence depending on many different factors but can often cause an otherwise nonsurgical patient to become surgical and vice versa irrespective of any type of numerical classification. Local - extreme kyphosis or collapse, lateral fracture angulation, open fractures, overlying burns, multiple adjacent rib fractures, or inability to brace. Remote comorbidities - sternum fracture, severe closed head injury, limb amputation, and multisystem trauma. systemic considerations - rheumatoid arthritis, ankylosing spondylitis, osteoporosis,obesity, patient age, and even general health.

Burst 2p neurologic intact no PLC injury

Load-sharing classification (McCormack)

P.M., 65 ani, leziune tip B T11, fr deficit TLICS 5

Control la 3 luni

Control la 6 luni

Leziuni traumatice toraco-lombare fractur cominutiv L2, TLICS 8

Fractur-luxaie T3-T4 deficit neurologic incomplet , TLICS 7

Fractur-luxaie T12-L1 deficit neurologic complet, TLICS 9

Luxaie T12-L1 deficit neurologic complet, TLICS 9

Fractur cominutiv L1 imagini intraop.

Fractur-luxaie T11-T12, TLICS 6

Fixri posterioare lungi morb pott L3-L4

Fractur cominutiv T4 i T5 13 ani tentativ autolitic, TLICS 8

Fractur cominutiv L1 abord anterior

Veche fractur L2, cifoz segmentar

Concluzii

TLICS clasificare + sistem de scoring ce ia n considerare aspectul morfologic, integritatea CLP i statusul neurologic S-a dovedit extrem de util, reproductibil, de ncredere Utilizat n Clinica nostra de 3 ani cu rezultate foarte bune