Thoracolumbar Fractures: A Review of Classifications and Surgical Methods

Thoracolumbar fractures are an important topic in spinal surgery. In this article, the instability of the thoracolumbar fracture classifications and surgical treatments are discussed, with a particular focus on treatment concepts that are based on the modern classification systems. Introduction Thoracolumbar junction has unique anatomical and biomechanical features because of this region is a transition region from kyphotic thoracal segment to lordotic lumbar segment just like other junctional regions such as servicothoracic and lumbosacral region. Force transmission at these sites is the essential factor for clearly understanding of fracture mechanisms. The kyphotic position of the thoracic spine and the body’s center of gravity being located anterior to the spine causes compressive forces to be transmitted anterior to the vertebral body along with a tensile stretch or distraction of the posterior elements. The exact mechanism of individual thoracolumbar traumatic injuries is complex and depends on the exact posture of the spine at the time of force application. An important factor affecting the resistance to flexion, extension, coronal rotation and dislocations is the structure and orientation of the facet joints at this region. The facet joints of the upper thoracic spine have a coronal orientation and resist flexion and extension but, at the lumbar spine facet joints have sagittal orientation and this anatomic feature allows increased flexion and extension [1]. The term of thoracolumbar junction is generally used for T10-L2 vertebral bodies as described by Stagnara et al. [2]. This region especially predisposed for injury due to absence of costovertebral structures that provide additional supporter for vertebral column, and uncompleted transition to the full lumbar lordosis [2]. The management of thoracolumbar fractures is highly controversial, and there is no generally accepted treatment method [3,4]. The main point of discussion is the stability of the vertebral column [5]. This location is the region in which most fracture classifications are defined, and in the literature, there are many treatment options, varying from palliative treatment to early surgical treatment [6-10]. According to [email protected], 70% of thoracolumbar fractures are concluded cases, and these cases are mostly burst fractures. This statement suggests that there is no consensus about what we will do for certain fractures. There is several classification systems of thoracolumbar spine fractures defined in literature aiming to provide standardization in surgery of this situation [6,11-14]. The aim of this review is to compose a generally accepted treatment algorithm and to embed the combined approach. The classification systems in the literature are briefly summarized below. Boehler Classification In 1930, Boehler defined a classification for thoracolumbar fractures and divided these fractures in to five categories including compression fractures, flexion-distraction injuries with anterior injury secondary to compression and posterior injury secondary to distraction, extension fractures with injury to anterior and posterior longitudinal ligaments, *Corresponding author: Ali Fahir Ozer, Koc University Medical School, Neurosurgery Department, Istanbul, Turkey, Tel: 90 (212) 338-1401; Fax: 90 (212) 338-1559; E-mail: [email protected] Received June 30, 2015; Accepted August 10, 2015; Published August 12, 2015 Citation: Gomleksiz C, Egemen E, Senturk S, Yaman O, Aydın AL, et al. (2015) Thoracolumbar Fractures: A Review of Classifications and Surgical Methods. J Spine 4: 250.doi:10.4172/2165-7939.1000250 Copyright: © 2015 Gomleksiz C, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. shear fractures, and rotational injuries [15,16]. Watson-Jones Classification In 1938, Watson-Jones described the instability concept and its effect on the treatment of thoracolumbar injuries as an addition of Boehler’s study [17]. The importance of Watson-Jones classification is the first classification system that calling attention to the integrity of the posterior ligamentous complex (PLC) is essential for spinal stability. His classification system is consisting of seven fracture types but there are three major patterns: simple wedge fractures, comminuted fractures, and fracture dislocations. Nicoll Classification In 1949, Nicoll improved former classification systems with using anatomical classification [3]. Nicoll defined four specific structures involved in the mechanical stability of the spine: the vertebral body, the disc, the intervertebral joints, and the interspinous ligament [16]. According to his concept, the main determinant factor in stability was the integrity of the interspinous ligament. Holdsworth Classification After 25 years from Nicoll, Holdsworth described a two-column theory in 1963 [18,19]. The main points of him classification are mechanism of injury, presumed forces acting upon the spinal column and the associated paraspinal soft tissues. He defined the posterior column as the “posterior ligamentous complex”. According to Holdsworth, spinal stability depends on the integrity of the posterior ligamentous complex. He defined six groups in his study, which included 1000 patients: anterior wedge compression fracture, dislocation, rotational fracture-dislocation, extension injury, burst fracture, and shearing fracture. A compression injury at the anterior column will cause distraction in the posterior column; likewise, compression at the posterior column will cause a distraction injury in Citation: Gomleksiz C, Egemen E, Senturk S, Yaman O, Aydın AL, et al. (2015) Thoracolumbar Fractures: A Review of Classifications and Surgical Methods. J Spine 4: 250.doi:10.4172/2165-7939.1000250