 Good morning everybody, I think it is best to begin with a case, best to discuss a case. So here this is an old case I think 2010, 8 year old child who came with a history that a big iron gate fell on his back, I do not know how it happened but fall of iron gate over back and all he had was if you see the power over here upper limbs are absolutely normal the lower limbs is weak, 3 by 5 power and one ankle is much more weaker than the rest of the joints, upper limbs are normal and he also had some breathing problem, there was no history of unconsciousness so you can safely say that probably there was no head injury, no vomiting, no ENT bleeding, no seizures, nothing to suggest any head injury. So it looked like a complete spinal injury but he also had a lot of respiratory difficulty, how do you proceed, what do you do? Well we have a admitting protocol here that everybody gets a CT, it is bang on admission, so this is what happened on CT, so what kind of injury do you think this is? It is important to you know classify all these injuries at least in your mind and it is better if you do it on paper and put it in the file so that management of subsequent cases becomes much easier. I think we will talk about that later, one of the simple classifications which helps you manage these patients better is the AO classification, we will talk about that. A, B and C, yeah there are three types of basically injuries A, B and C, A is only when the anterior part is injured, it is not very difficult to remember, A is anterior, only the anterior it may be a crush, it may be a burst, it may be whatever it is, it is only anterior injury, the rest everything at the back is intact, that is more or less what is A, B is when there is injury to the posterior element also, there could be something to the anterior but there is also posterior and C is when there is some rotation, very simple to remember, if it is only anterior it is A, if it is posterior also then it is B, if there is some element of rotation it is C, simple classification but there are other things to classify or sub-classify these fractures, A has different types, B has different types, C has different, we will come to that as we go along. So, based upon that what do you think is the simple classification A, B, C, what do you think this is, yeah it is definitely C, there seems to be some kind of rotation here, there seems to be injury to the body anteriorly, so it is a mixed type, it is anterior as well as posterior both seem to be injured, so it is a type C injury but so what do you do with this, how do you manage this, there is this child in the casualty, he had some injury in the chest, he had respiratory problem, so when we got a CT done of the chest, this is what had happened, his diaphragm had ruptured and he had a big diaphragmatic hernia also, that was pressing half the lung is collapsed because of the diaphragmatic hernia and you see all the abdominal contents in the thoracic cavity, so after I think it took one day to realize all these things, ultimately we discovered that he had these two injuries, so how do you go ahead now, what do you do, first thing has to be managed is the chest injury, no doubt about it, so important point to look from this is if there is any major spinal injury, you must look for injuries elsewhere, you must more often than not there would be something else which requires more attention than the spinal injury, if it is pressing on the respiratory tract, if the respiration is affected or if some major vessel or a peritoneum or intraperitoneum or some hematoma, some bleeding somewhere, you must see all that very important because the amount of force required to break a vertebra like that is very unlikely that it has not caused any other injury, more often than not it does cause some other organ injury or major system injury, so you must look at that, so this child had both diaphragmatic hernia because of the diaphragm rupture and a lumbar vertebra fracture, so this was dealt with first, they actually repaired the diaphragm, they pushed all the contents back into the abdominal cavity and repaired the diaphragm and the child was well and we waited for a couple of days till he recovered from his chest problem, so now we have the chest has been managed and now we have this kind of vertebra, what do you think should be done, this is the body which is split almost in half, it seems to have been pushed back into the spinal canal which is probably causing multiple roots are getting affected because thankfully there is no spinal cord over here, so it is all cordyquine eye injury and you can see the different pieces in the reconstructed images here, how do you think are you going to manage this, so you classified this some kind of a fracture C, now there are C is also three types C1, C2, C3, now let us come to the subclassification of C, first let me show you the slide which talks about the all the three types of classification, so type A is basically only when the anterior part of the body is injured, type B is when the posterior part is also injured and type C is when there is some kind of rotation present, I am sorry this is not a very clear picture, it is a bit blurred but if you remember these three basic things you would easily be able to classify, it is either A, B or C and then you can read up and then reclassify, how will you manage, what will you do, so even the approach may be posterior but it would need an anterior column support also, so you need to tackle this shattered vertebra, you need to push back the bony elements which are encroaching into the canal and you need to stabilize it and graft it so that it fuses, now which approach you use, some people can do everything from one approach, from the posterior approach, some people may take a two approaches anterior as well as posterior, but I think this since there is no spinal cord here you can easily get around the dura and do everything from the back, there should not be much of a problem even putting a cage anterior support to the column even from the back, so this was what the MRI looked like, so what kind of an injury is this, now let us forget the A O classification for a minute, what all do you think is injured over here, it is a three column injury definitely, so generally the rule of the thumb is if it is a three column injury you need anterior support as well as posterior, usually you do not get by with one, even if you do it will probably fail in a few months time, so you do need anterior and posterior reconstruction in this case, how you manage to do it is your skill and how much you can do from one approach, what else, what kind of injury is this, if you describe it in old, it is a kind of a shear injury, you see it is just been sheared off like this and this part of the spine or the lumbar vertebra and the sacrum and the rest is just got separated, so through and through everything starting from the ligament at the back and the bone, maybe it is through the disc I do not know and plus the vertebra is shattered, so it is a mixed injury but it is definitely type C and it will need anterior and posterior stabilisation, so there is another classification which is being hotly debated now which is and all these anatomical classifications earlier never took into account the neurology which is very important, after all all these injuries cause neurological deficit, so now there is a classification proposed by a few people, the thoracolumbar injury they made a consortium and then unanimously they have agreed that the neurology should also be included, it should also be given points and then you decide about the management also including the neurology and it is called the T-lix that the thoracolumbar injury classification score or something like that and all these three things are given importance, then bony injury, the neurological injury and the posterior ligament is complex that is the ligaments at the back, they are very important, you must consider them also, so it is a very useful classification still not you know accepted worldwide but I think it makes sense to include neurology also, because if there is neurological deficit you need to do something about it and if not then maybe you just conserve it, if there is no deficit the bones will fuse one day or the other it may fuse in a wrong manner, it may be there may be some malunion but it will fuse but if there is neurological deficit you need to rescue the neurology, so it does make a difference on the management if there is neurological deficit and so it should be included in the classification, which all the other previous classifications lacked they never took into account neurology, so I would advise you to read this carefully the T-l-i-c-s and start using it if you are managing spinal injuries, so these are the questions, well do you think conservative, can we conserve this patient, there is not much injury just a foot drop, I want somebody to list out what is the exact indication for surgery, why do you need to fix this patient, what will happen if you leave him without any surgery, so it may lead to further deformity, one, well neurology it's already there, I mean his low limbs are weak he's got foot drop, almost zero power on one limb, the bladder is involved, so neurology is already there, mobilization, it will be difficult to mobilize the patient because if you want to wait till this fracture heals it will heal, one day those fractures will unite, it may take months and he may lie in bed for months and the neurology won't recover, if there is any chance of neurological recovery it is with getting the roots away from the bony part which is pressing on it, so these three points are important, one neurology rescue the neurology, two mobilize the patient as quickly as possible and three to prevent future damage, it may involve more roots, it may slip further, it may worsen, the moment the spine starts taking some load it may slip further, so conservative is out, it's already late, I mean I don't know what is your definition of early and late, but early means within 48 hours which we didn't manage it because the diaphragmatic hernia needed to be repaired first or the diaphragmatic rupture needed to be repaired first, but there is still debate going on in the world whether spinal injury should be dealt with immediately or can you wait because if you look at the neurology, if a neuron or if the neural structures are damaged and you wait for more than six hours we say it's irreversible damage anyway, so what exactly is the definition of early and it's very uncommon for any center to manage to do a spinal fixation within six hours of injury, it's very very difficult, especially in our setup it is almost impossible, so we are not very well equipped to discuss this early versus late, most of the cases which we manage here are late, they are definitely few days after injury, so this of course first because it affects respiration, so this we did first and we thought that the child's respiration was really bad, so we thought we don't want to subject him to a long surgery in the same sitting, so we split it into two, we first repaired the diaphragmatic hernia, I mean the general surgeons repaired it and then we did it, here we decided to wait because there was nothing to gain, he was already injured, he had neurological deficit which wasn't worsening, he was in the hospital for a day before the diaphragm got repaired, he was the same as an admission, so we decided to split it into two so that give him a better chance, if his lungs are working better, he stands a better chance of withstanding the spinal surgery, so how do you manage this, the anterior procedure we already discussed, it can be everything can be done from the back, but some people I don't know, some of you may prefer to go anterior, it depends upon your skill, I would like to do everything from the back, it's so much more easy, so much more easy, you don't have to worry about the abdominal and the pelvic contents, so what do you fuse, it's a fracture, it's not a degeneration, the bone quality is good, everything was fine before he got hit by that gate, all fractures will heal, you just have to keep the bones together they'll heal, so in my mind I would use the shortest possible segment if it's traumatic, but if it's a degenerative problem which is affecting bone quality, the fusion is in question, etc, etc, then I would use a long segment, because my goal is to stabilize and fuse this area, and in trauma it's a healthy bone which is got fractured, otherwise there was nothing wrong with this child, so I would try and use the shortest segment as possible, so this is the thoracol number injury classification severity score in detail, there are three, one is the morphology of the injury, it gives points to that, neurological status, it gives points to that, and PLC starts for the posterior ligamentous complex, it gives points to that, so if the ligamentous complex is intact, it gives the score of zero, if there is injury suspected and indeterminate it gives the score of two, how do you make that out, any ideas, MRI, hyper intense signal on MRI, that will give you a suspicion that there is something wrong with it, and if there is a definite injury you can see that the bones are apart from each other, that means it's definitely torn, then you give it a score of three, and similarly for the neurological status intact gets a score of zero, nerve root injury only gets a root score of two, everything else is three, two and three, chorda equina is three according to this scoring, injury morphology, compression, burst, translation or rotation and distraction, so distraction gets the maximum points, if there is distraction it causes more injury, more serious injury than any other injury, so based upon this classification this child gets a score three for the rotation and translation element, chorda equina he gets three, and the PLC is injured he gets three, so it's probably a maximum, I think one shot of maximum score, so ten, so the idea of this scoring is if it is more than five or equal to five it definitely needs surgery, that is the idea of this classification, and it takes into account neurology, so I think it is personally it is a better option to use this than the earlier anatomic classification which never took into account neurology, you just treat x-rays and MRIs which is useless, you have to treat neurology, according to that this score is more than five, so it definitely needs surgery, this is of the theory behind all these classifications, what is load sharing, what is load bearing, what happens, what is short segment, what is long segment, there's a lot of theory available, you can search all that and read it, so the diaphragmatic hernia repair was done first and the second surgery was done one week later, so we did a L5 corpectomy, a cage was placed and a fusion achieved using autologous bone graft and we mixed it with those hydroxyapatite crystals and fixation was using lumboparticle screws and sacral plus iliac spine screws, we needed more support here so this was done and we achieved a 360 degree fusion, anteriorly there was cage and posteriorly there were pedicle screws, so post-operative with the chest had become much better both the lungs had expanded, ultimately he was discharged with this kind of a configuration, we managed to reduce it and to fix this, the cage was placed in the in place of the L5 vertebral body discharged after the second surgery and nine months later when he came for the follow-up, I think this was the second follow-up, apart from the foot drop he was fine, he had some control of the bladder, not all but some control of the bladder as well and he's going, he's doing fine and this was the CT scan done I think few months after the surgery, we showed the cage is still in place, everything seems to be fine it is taking all loads and the child is going to school, so we wanted to check whether one of the roots is getting caught in the screws because what that is the foot drop is the only thing which did not improve so we check that and all the screws were all right so it wasn't that but then and we actually went ahead after the fuse that we went ahead and removed all the screws and rods because we wanted to conserve as much motion as possible and you could see good fusion inside the cage and we thought it is quite stable and we went ahead and removed all the rods and screws it worked very well so now we have a four-year follow-up on this, he's going to school, he's doing everything on his own, he still has some occasional incontinence and the foot drop persists but otherwise he's fine, it's a four year follow-up now and it's become solid, fused well so this case tells you about classification of thoracolumbar fractures, you talked about AO classification, you talked about the T-lix, you talked about management approach, how do you do it? For any spinal injury you should look for other injuries also and more often than not there are significant injuries, you should look for them, you should treat them, some of them require more urgent management than the spinal injury itself so you need to do all that before you take the patient for a spinal injury fixation. So another, I always like to discuss cases because that gives you a better idea than just discussing theory. 29-year-old male fell from roof two days before admission did not become unconscious, again there doesn't seem to be any head injury here over here, inability to move both lower limbs, loss of sensations below nipples, he was on a Foley's catheter, he fell somewhere in Uttarakhand and he was brought to Delhi, he came here two or three days after his injury, alert oriented tachycardia, mild hypertension, pallor, no head injury, zero power in the lower limbs, five by five in the upper limbs, sensory level below D3, reflexes 2 plus in the upper limbs, absent in the lower limbs, plantar's mute, no other injury, what do you think? There's a complete neurological deficit, he's paraplegic, there is no sensation below D3, so it puts a high dorsal level injury, what do you do? I must have lost some blood, maybe there is some other injury, so what will you do? If all these things come, it may look like a simple dorsal spinal injury but there may be something else, you must look at everything, so we got the x-ray done, I've cropped it, I've cropped the x-ray, there was some hemothorax here and some blood in the lung etc etc but what do you think of this x-ray? Upper cord is the spine is here and the lower spine is here, so it seems to have completely sliced off and it's lying side by side, so horrible injury, horrible injury, what do you do? He's come three days after injury, so basically this was this question, what do you do? The answer to this is you investigate everything, you don't jump for any surgery, you look at the whole patient from head to foot very carefully, so we got an x-ray done which included the neck x-ray also and this was what was there in the neck x-ray, what do you think it is? So there is an odontoid fracture, it seems to be a type 2 odontoid fracture, it seems to have sliced off at the level of the shoulder and the whole thing has shifted back but his upper limbs are normal, he's got no complaints with upper limbs, the power is good, the sensations are intact, reflexes are 2 plus and he's got that horrible thoracic spine injury lower down, now what do you do? How will the MRI help? His power is intact in the upper limbs, the lower limbs is zero, it's a complete level, it's a three-day old injury and you can see that the cord has been sliced in half, probably lying by side by side, how is the MRI going to help? So the integrity of the transverse ligament will tell you about which approach you can take for this, so which approach do you think you will take for this? What do you think has happened to the transverse ligament? Probably gone, you don't know but the way it has gone back is almost the whole width of the body, it's lying here, so very difficult for the transverse ligament to stretch so much around the odontoid and still be intact, probably it's broken, anyway so the first thing I did was to put him on traction, I said let me try to reduce this, so you put him on traction whatever you could get, it was made of steel, you put him on traction and this is what happened after traction, so now after three days we have this patient who has this reduced odontoid fracture and a thoracic spine injury who's lying supine with traction on his head, now what do you do? So some people want to do an odontoid screw, some people want to turn him over and then do everything from the back, that is fix the C1C2 as well as tackle the dorsal spine, so that is a debatable question, that is a debatable question, this was the CT, what we managed to do with the traction on before the, in fact this was done before the traction was the CT scan which showed, so I think it's unlikely for the transverse ligament to be intact in this, the whole thing is lying behind so it's unlikely, so we had this before traction, we had this after the traction everything is reduced and this was the thoracic injury, the CT of the thoracic spine, what kind of injury is this according to this classification, which you learn two classifications, type C, so it's a complicated injury, AO classification C and Tlix, again 9 or 10 probably, everything, probably 10, so it definitely needs stabilization for reduction of this, but I don't know if we can help the neurology in any way for this patient, I think the goal should be to keep the upper limbs intact, so the focus has to be on the odontoid fracture and management of that rather than lower down, okay so this was the CT scan, the rest of the CT scan, so there seems to be this slip, the facet joint seems to have slipped over one another, you can see that over here and there is some anterior procedure because they're not in one plane, so it's probably slipped anterior which we saw posterior rather the C1 and the piece of odontoid has slipped backwards and that's why you see this lateral mass but you don't see the lower lateral mass because they're lying into different planes so what do you do in such a case? Posterior for everything, dorsal and cervical, anterior for cervical and posterior for dorsal, you can put a screw, stabilize the odontoid then turn him over and deal with the dorsal spine I had some people say they would do anterior lateral for the thoracic spine also, what do you think? Would you do anterior lateral for the dorsal spine? I wouldn't, you couldn't go laterally instead of going in odontoid screw, expose the joint anteriorly and stabilize the joint anteriorly, why not? It's already reduced, we saw it or that it was reduced so the lateral masses are going to be near each other so you could do that. On either side of the midline you fuse the joints and it's very stable. I first put in a odontoid screw anteriorly that's what I did put in a screw anteriorly turned him over and then we dealt with everything from the back this is a good distractor you know this is not available in many places old instrument it just hooks on to the vertebra above and below and distracts the whole thing. The spinal cord was completely shattered the dura was cut and we had to tie off, we actually had to tie off the sac which was horrible so there was no chance of any improvement for the lower limbs that was for sure but we wanted to do that so that the kyphosis doesn't keep on increasing or the spine doesn't keep sliding down and he could be mobilized and we managed to put in particular screws two or three levels above and two or three levels below and these two impacted and rotated things we could align them properly and fix it and this was the final result this was the thoracic part and this so you see a funny thing over here while I did that I also did a galleys fusion here put in a cable and a bone graph because I wasn't sure like you said the mistake I made was I didn't think of the transfer ligament before I just thought oh it's got reduced fantastic let me just put a screw that stabilizes the odontoid turn him over and I'll fix the thoracic spine and we are done with it I put in the screw and then when they turned him over I didn't feel comfortable I said look this transfer ligament might be broken and this screw is not going to hold so I said let me stabilize it with this and this was way back ten years ago he ultimately went on a wheelchair he recovered from all that from his lung contusion and everything the wounds healed and this thing held together his upper limbs remain fine but he was wheelchair bound for the rest of his life another thing you know the crux of the matter here is undiagnosed other injuries that is the most important thing you must look at and this was Dr. Prasad's thesis unfortunately we lost him to an accident but very good thesis he studied these many patients 255 patients with moderate and severe head injuries between 2006 and 2007 most of them were traffic accidents and he revealed that 26 percent 26.7 percent of these head injured patients had a spinal injury 26 percent so moderate and severe head injury you must look at the spine the whole spine very carefully because the patient is unconscious he's not going to tell you anything it's your responsibility to look at everything the most important point from this thesis was that the very important 26 percent is a lot one in four more than one in four so look before you leave think of the transfers ligament before I should have done it I shouldn't have put the orentoids clue I should have just turned him over done everything from the back and with massive trauma look at the whole spine please look at the whole spine there may be something else which needs attention so in two cases you can cover so many things you can do orentoid anterior posterior thoracic injuries classification management I always think that discussing cases is much more than better than doing theory thank you very much for your attention