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The Journal of Bone and Joint Surgery, Vol 65, Issue 4 461-473, Copyright © 1983 by Journal of Bone and Joint Surgery, Inc
The value of computed tomography in thoracolumbar fractures. An analysis of one hundred consecutive cases and a new classification
PC McAfee, HA Yuan, BE Fredrickson and JP Lubicky
We studied 100 consecutive patients with potentially unstable fractures and
fracture-dislocations by multiplane computed tomography. The mechanism of
failure of the middle osteoligamentous complex of the spine (posterior
longitudinal ligament, posterior part of the vertebral body, and posterior
annulus fibrosus) was determined by three-dimensional analysis. Three modes
of middle-column failure were used to classify the injuries: axial
compression (seventy-three patients), axial distraction (fifteen patients),
and translation within the transverse plane (twelve patients). Fifty of
eighty-six patients who were evaluated in the acute phase of injury
underwent operative stabilization, and the mechanism of middle-column
disruption determined the type of instrumentation that was used.
Compression and distraction injuries of the middle complex could be
appropriately treated by Harrington distraction and compression
instrumentation, respectively. However, in translational injuries (torn
posterior longitudinal ligament) routine Harrington instrumentation was
contraindicated due to the risk of overdistraction. Translational injuries
were associated with the greatest degree of instability and often had
complete ligament discontinuity at the level of the affected vertebrae.
Patients with a translational injury had the most severe neural deficits
(six of eleven patients studied acutely having a complete spinal cord
lesion). Translational injuries of the middle column were treated by
segmental spinal instrumentation to provide strong fixation with minimum
risk of neural sequelae from passing sublaminar wires. Moreover,
postoperative use of a cast over insensate skin was not required. Computed
tomography was more sensitive than any other modality in the diagnosis of
disruption of the posterior elements in unstable burst fractures, and
computer-reconstructed sagittal images were accurate in evaluating the
nature of facet-joint failure in distraction injuries. Computed tomography
with metrizamide proved superior to either conventional tomography or
myelography alone in localizing the site of neural canal compromise in
acute thoracolumbar injuries. The mode of failure of the middle
osteoligamentous complex as visualized by computed tomography determined
the pattern of spinal injury, the severity of the neural deficit, the
degree of instability, and the type of instrumentation required.
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