[Music] a thoracolumbar injury classification severity score or telex as we say it uh what this score does or this grading scale does is it looks at it offers a essentially a guide for surgeons when you're looking at something when you're looking at a patient's radiographic imaging you're looking at their neurologic exam it gives you an idea of what is the urgency of surgery or timing of surgery okay does this patient need surgery or not so there are three things that you look at okay two of them can be obtained from the imaging itself and one of them has to be obtained from the actual neurological exam so uh what you look at here and um what you see in this slide is basically you look at one the integrity of the posterior ligamentous complex or the plc and that comprise is comprised of ligamentum flavum facet capsule intraspinous ligament and supraspinous ligament and what that means is that if these are disrupted or suspected to be disrupted that confers a higher degree of instability to the spine than if you know that they're intact so things are like fracture dislocations or distraction type injuries uh often have involvement of the plc and as a result those are technically unstable injuries other things that i look at are the morphology of potentially compression fractures like bursts or partial burst fractures and last but not least we look at the patient's neurologic exam whether they are neurologically intact have an incomplete spinal cord injury complete spinal cord injury or things like quad aquina these are all taken into account into the severity scale and basically what it does is it says you know it's on a scale i forget the actual numbers itself but um higher numbers uh more points mean that this patient needs will likely need surgical intervention and lower points mean that this patient will can you could potentially wait and see or try conservative management um another variant of the uh t-lex there are many different let me put this right there many different grading scales for uh thoracolumbar injuries and one of them is the ao spine criteria and there are we have more slides on this and we'll look at it as well too so there's telex which is more clinically oriented and have a spine which is more morphology oriented um although there are more papers coming out to uh suggest that certain morpholo trying to convert a clinical significance to the morphologies of the injuries but this is what we use to kind of to describe the injuries a little bit better so you can have broadly speaking three different types of uh thoracolumbar type fractures on the ao spine criteria you have type a which are compression injuries they're only the anterior column um very generally do not involve a significant portion of the middle of column and do not involve the poster calm at all they have type b which are distraction injuries which by definition um have to involve the poster calm or disruption of the posterior attention band type c which are the fracture dislocation type injuries which are all these are the worst of the worst these these type of injuries are always unstable and always need um surgical intervention so what this does is as you can imagine there are no no no two traumas are similar everyone's trauma is unique in some way but what we try to do is we try to reduce some of the heterogeneity of the the radiographic imaging of traumas and we try to introduce homogeneity in the way we describe them the way we do research on them and the way that we um the way that we treat them so so you know it's it's good to and it's a good exercise i always would try to do this when i was describing um let's say burst fractures or vertebral body uh compression type fractures uh to my attendings i would tell them it's an ao spine uh type a3 for example or uh an ao spine type you know b2 or something like that and they would generally appreciate that because they knew exactly what i was talking about and it shows that i i took the time and the effort to look at the images and um get an idea of what uh you know what we were dealing with so um going back here um so we have uh type a fractures yes can you go back for a second yeah because our friend carlton watson asked a great question and i just want to address it real quick i tried to type it but i can't listen and type at the same time so i want to see it real quick so he asked if if you'd only do this at the initial injury or if you do it later to see if it's changed and just a fundamental concept about this and the way we go through them in the way that they spine tells you to go through this um classification when you're looking at the spine they come in the ear after initial injury you see the worst one first is it a translation is it already frankly unstable is there motion of one body on another such that there is cord injury cannot compromise if not then you move down to b is there a distraction is there both is there posterior attention band or anterior tension band injury a lot of times c by definition actually a lot of times all the time c by definition will have component of b c has to have b it has to have either anterior or posterior attention band injury in order to move like that c will also likely have a component of a it'll probably have some kind of a compression now if you rule out c and you go to b if you have answer posterior tension band injury you obviously don't have a c and it's not going to move to a c likely unless you throw them off the table or something they fall off the table i don't know whatever but it might have an a and if you're starting with an a if it's only anterior column if it's only involving the vertebral body itself no tension bands then it's not going to move to a b or a c again unless they fall off the table or something bad happens to them so really only you only need to do this at the initial skin you don't need to do this again it's a classification to see where they go immediately where you're triaging this person in terms of management you agree with that brazilian is that a good answer yeah so you want to uh you want to um so for the telex and ao spine you want to do it at the time of uh when they arrive the the difference is i think what you're referring to carlton is the asia scale and uh although we do do the asia scale at the time of the injury it's not technically correct we generally should the the most accurate asia uh scale in terms of grading the severity of spinal cord injury it's somewhere between 48 and 72 hours after the injury so that's how we get a better idea of what the patient's true asia scale is now this is more uh a a clinical decision rules on whether or not you should you can potentially conservatively manage this patient who comes in with like say a type a2 type fracture versus somebody who needs to go to the or right away so that's how that's you you want to do a spine and telex at the time of um the skin so this is why it's good that we're doing this together because i just learned something there too because when we're doing this when this person comes in here i'm reading that ct and i'm giving you one of those injuries you're looking at it too but supposedly i'm the one that's the expert on the ct but i don't know anything about the age i don't know anything about the patient so there's more to it so that's why it's good that we're working these patients up all together as a team yeah exactly totally agree so um going on to the different types of ao this is now we're talking about ao spine criteria again it was fine it talks more about the morphology of the injury that that's the the main uh goal of the ao spying criteria um with a secondary goal of guiding clinical decision making okay it's not as well defined as telex telex's goal is to decide whether or not this patient needs surgery or you can or something indeterminate or whether you can maybe conservatively manage it okay so telex for clinical ao spine for morphology so you can see here it goes from a there's an a0 which is basically insignificant type fractures and then it goes from a1 to a4 and this generally confers the severity of the type of injury however these a2 type fractures which is interesting is these a2 fractures aren't are um highly unlikely to heal well unlike oblique type fractures these often need some sort of surgical intervention versus a3 which um potentially based on uh the patient's neurologic exam their age their their degree of um you know their bone quality their health you could potentially conservatively manage these and then these a4s tend to also need to be uh surgically managed so it sees a little there's a little bit of it's not it's as straightforward as you would think um oftentimes uh the best way to know whether or not certain patients need surgical intervention is getting if they can tolerate it a weight-bearing x-ray and that's where the utility comes in because you can see um you know you're not when you're someone's getting a ct or an or an mri they're laying supine on a table and they're not in their true physiologic alignment when they're standing up i mean things can drastically change and someone's standing up so the utility of x-ray is not for a patient of lace supine utility of the x-ray in this setting is to have them stand up and take a look and i will say this again if you have a patient image or service with trauma and some sort of fracture the spine they cannot leave your service unless they have an upright or weight-bearing x-ray okay it's the most important scan they're going to get more important than cp or mri is is the uh a weight-bearing scan so make sure every trauma patient has an upright or standing ap and lateral lumbar or if they have a cervical injury cervical x-ray before they get discharged okay super important and if they have a collar make sure they're in a collar when they get that x-ray because then you know how that patient's likely gonna heal if you decided to treat this patient conservatively and in the case of a lumbar fracture you want them to be let's say an lso or tlsl all right so um okay because i know there are people they're not just neurosurgery people here they're radiology people here too so just real quick about the way i tell people to look at this when we're looking at the fracture so if we know it's anterior column only these a types what i tell people to do again you're going from worst to least bad you want to rule out the very worst thing first so we would start with a4 so see if they have an a4 you look at the posterior cortex is the posterior cortex involved if it is you know it's three or four so that's a burst a complete burst or an incomplete burst the next thing you look at is the end plates so if it's just one end plate that's incomplete so that's a three point eight three thank you if it's both end plates it's a four which is a complete burst now that split fracture that i'm glad you said that really because i didn't know i thought those were more severe but i didn't know the significance of the healing so that's interesting um but despite that the posterior cortex is intact there's no chance of retropulsion of fragments into the canal and then a like you said it's just a one end plate we see those all the time um probably not very significant in the least bad but always go from the worst to the least so look at that posterior cortex first [Music] hey everyone ryan rad here from neurosurgerytraining.org if you like that video subscribe and donate to keep our content available for medical students across the world