Skip to main content
SpringerLink
Log in

The radiologic assessment of posterior ligamentous complex injury in patients with thoracolumbar fracture

  • Original Article
  • Published:
European Spine Journal Aims and scope Submit manuscript

Abstract

Purposes

To discuss whether radiologic parameters are closely related to posterior ligamentous complex (PLC) injury identified by magnetic resonance imaging (MRI).

Methods

One hundred and five thoracolumbar fracture (T11–L2) patients were retrospectively analyzed in the study. The patients were divided into different groups by the status of the PLC on MRI: intact, incompletely ruptured and ruptured. The radiographic parameters included the anterior edge-inferior endplate angle (AEIEA), the anterior edge displacement (AED), the Cobb angle (CA), the region angle (RA), the sagittal index (SI), local kyphosis (LK), the anterior/posterior vertebral height ratio (A/P ratio), the anterior vertebral height ratio (AVH ratio), and bony fragment in front of the fractured vertebra (BFOFV). T test, Pearson’s Chi-square and multivariate logistic regression were calculated for the variables.

Results

Supraspinous ligament (SSL) rupture versus intact was not only associated with the occurrence of AEIEA <70°, LK >25° and BFOFV, but also with increased AED (9.89 ± 3.12 mm and 9.34 ± 3.36 mm, P = 0.034), RA (9.52 ± 3.93° versus 7.91 ± 3.99°, P = 0.042), and LK (23.98 ± 5.88° versus 15.55 ± 5.28°, P = 0.021). The indications for interspinous ligament (ISL) injury included AEIEA <75°, AEIEA <70° (P = 0.004 and P < 0.001, respectively), increased AED (P = 0.010), LK >25° (P = 0.024), AVH (P < 0.001), and BFOFV (P < 0.001). Multivariate logistic regression analysis revealed that AEIEA <70° and BFOFV were high risk factors for SSL rupture [standard partial regression coefficients (betas) were 0.439 and 0.408, P = 0.003 and 0.001, respectively] and ISL rupture (betas were 0.548 and 0.494, P = 0.028 and 0.001, respectively). Increased AED and LK >25° were also related to either ISL rupture (P = 0.035 and 0.001, respectively) or SSL rupture (P = 0.014 and 0.008, respectively).

Conclusion

Our data may prove useful in a preliminary assessment of the PLC integrity based on plain radiographic imaging. We show that radiologic indications, such as AEIEA <70°, BFOFV, LK >25°, and increased AED, are correlated with ISL or SSL rupture, while RA, CA, SI, A/P ratio, and AVH ratio are not.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

References

  1. Izzo R, Guarnieri G, Guglielmi G, Muto M (2013) Biomechanics of the spine. Part I: spinal stability. Eur J Radiol 82:118–126. doi:10.1016/j.ejrad.2012.07.024

    Article  PubMed  Google Scholar 

  2. Vaccaro AR, Lee JY, Schweitzer KM Jr, Lim MR, Baron EM, Oner FC, Hulbert RJ, Hedlund R, Fehlings MG, Arnold P, Harrop J, Bono CM, Anderson PA, Anderson DG, Harris MB, Spine Trauma Study G (2006) Assessment of injury to the posterior ligamentous complex in thoracolumbar spine trauma. Spine J 6:524–528. doi:10.1016/j.spinee.2006.01.017

    Article  PubMed  Google Scholar 

  3. Pizones J, Zuniga L, Sanchez-Mariscal F, Alvarez P, Gomez-Rice A, Izquierdo E (2012) MRI study of post-traumatic incompetence of posterior ligamentous complex: importance of the supraspinous ligament. Prospective study of 74 traumatic fractures. Eur Spine J 21:2222–2231. doi:10.1007/s00586-012-2403-z

    Article  PubMed  PubMed Central  Google Scholar 

  4. James KS, Wenger KH, Schlegel JD, Dunn HK (1994) Biomechanical evaluation of the stability of thoracolumbar burst fractures. Spine 19:1731–1740

    Article  CAS  PubMed  Google Scholar 

  5. Gillespie KA, Dickey JP (2004) Biomechanical role of lumbar spine ligaments in flexion and extension: determination using a parallel linkage robot and a porcine model. Spine 29:1208–1216

    Article  PubMed  Google Scholar 

  6. Alapan Y, Demir C, Kaner T, Guclu R, Inceoglu S (2013) Instantaneous center of rotation behavior of the lumbar spine with ligament failure. J Neurosurg Spine 18:617–626. doi:10.3171/2013.3.SPINE12923

    Article  PubMed  Google Scholar 

  7. Holdsworth F (1970) Fractures, dislocations, and fracture-dislocations of the spine. J Bone Joint Surg Am 52:1534–1551

    Article  CAS  PubMed  Google Scholar 

  8. Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S (1994) A comprehensive classification of thoracic and lumbar injuries. Eur Spine J 3:184–201

    Article  CAS  PubMed  Google Scholar 

  9. Vaccaro AR, Oner C, Kepler CK, Dvorak M, Schnake K, Bellabarba C, Reinhold M, Aarabi B, Kandziora F, Chapman J, Shanmuganathan R, Fehlings M, Vialle L, Injury AOSC, Trauma Knowledge F (2013) AOSpine thoracolumbar spine injury classification system: fracture description, neurological status, and key modifiers. Spine 38:2028–2037. doi:10.1097/BRS.0b013e3182a8a381

    Article  PubMed  Google Scholar 

  10. Vaccaro AR, Lehman RA Jr, Hurlbert RJ, Anderson PA, Harris M, Hedlund R, Harrop J, Dvorak M, Wood K, Fehlings MG, Fisher C, Zeiller SC, Anderson DG, Bono CM, Stock GH, Brown AK, Kuklo T, Oner FC (2005) A new classification of thoracolumbar injuries: the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status. Spine 30:2325–2333

    Article  PubMed  Google Scholar 

  11. Gamanagatti S, Rathinam D, Rangarajan K, Kumar A, Farooque K, Sharma V (2015) Imaging evaluation of traumatic thoracolumbar spine injuries: radiological review. World J Radiol 7:253–265. doi:10.4329/wjr.v7.i9.253

    PubMed  PubMed Central  Google Scholar 

  12. Savage JW, Moore TA, Arnold PM, Thakur N, Hsu WK, Patel AA, McCarthy K, Schroeder GD, Vaccaro AR, Dimar JR, Anderson PA (2015) The reliability and validity of the thoracolumbar injury classification system in pediatric spine trauma. Spine 40:E1014–E1018. doi:10.1097/BRS.0000000000001011

    Article  PubMed  Google Scholar 

  13. Park HJ, Lee SY, Park NH, Shin HG, Chung EC, Rho MH, Kim MS, Kwon HJ (2016) Modified thoracolumbar injury classification and severity score (TLICS) and its clinical usefulness. Acta Radiol 57:74–81. doi:10.1177/0284185115580487

    Article  PubMed  Google Scholar 

  14. Pizones J, Sanchez-Mariscal F, Zuniga L, Alvarez P, Izquierdo E (2013) Prospective analysis of magnetic resonance imaging accuracy in diagnosing traumatic injuries of the posterior ligamentous complex of the thoracolumbar spine. Spine 38:745–751. doi:10.1097/BRS.0b013e31827934e4

    Article  PubMed  Google Scholar 

  15. Hiyama A, Watanabe M, Katoh H, Sato M, Nagai T, Mochida J (2014) Relationships between posterior ligamentous complex injury and radiographic parameters in patients with thoracolumbar burst fractures. Injury. doi:10.1016/j.injury.2014.10.047

    PubMed  Google Scholar 

  16. Dai LY, Ding WG, Wang XY, Jiang LS, Jiang SD, Xu HZ (2009) Assessment of ligamentous injury in patients with thoracolumbar burst fractures using MRI. J Trauma 66:1610–1615. doi:10.1097/TA.0b013e3181848206

    Article  PubMed  Google Scholar 

  17. McCormack T, Karaikovic E, Gaines RW (1994) The load sharing classification of spine fractures. Spine 19:1741–1744

    Article  CAS  PubMed  Google Scholar 

  18. Chen J, Jia YS, Sun Q, Li JY, Zheng CY, Du J, Bai CX (2015) Multivariate analysis of risk factors for predicting supplementary posterior instrumentation after anterolateral decompression and instrumentation in treating thoracolumbar burst fractures. J Orthopaedic Surg Res 10:17. doi:10.1186/s13018-015-0155-2

    Article  Google Scholar 

  19. Lee JY, Vaccaro AR, Schweitzer KM Jr, Lim MR, Baron EM, Rampersaud R, Oner FC, Hulbert RJ, Hedlund R, Fehlings MG, Arnold P, Harrop J, Bono CM, Anderson PA, Patel A, Anderson DG, Harris MB (2007) Assessment of injury to the thoracolumbar posterior ligamentous complex in the setting of normal-appearing plain radiography. Spine J 7:422–427. doi:10.1016/j.spinee.2006.07.014

    Article  PubMed  Google Scholar 

  20. Lee HM, Kim HS, Kim DJ, Suk KS, Park JO, Kim NH (2000) Reliability of magnetic resonance imaging in detecting posterior ligament complex injury in thoracolumbar spinal fractures. Spine 25:2079–2084

    Article  CAS  PubMed  Google Scholar 

  21. Haba H, Taneichi H, Kotani Y, Terae S, Abe S, Yoshikawa H, Abumi K, Minami A, Kaneda K (2003) Diagnostic accuracy of magnetic resonance imaging for detecting posterior ligamentous complex injury associated with thoracic and lumbar fractures. J Neurosurg 99:20–26

    PubMed  Google Scholar 

  22. Crosby CG, Even JL, Song Y, Block JJ, Devin CJ (2011) Diagnostic abilities of magnetic resonance imaging in traumatic injury to the posterior ligamentous complex: the effect of years in training. Spine J 11:747–753. doi:10.1016/j.spinee.2011.07.005

    Article  PubMed  Google Scholar 

  23. van Middendorp JJ, Patel AA, Schuetz M, Joaquim AF (2013) The precision, accuracy and validity of detecting posterior ligamentous complex injuries of the thoracic and lumbar spine: a critical appraisal of the literature. Eur Spine J 22:461–474. doi:10.1007/s00586-012-2602-7

    Article  PubMed  Google Scholar 

  24. Barcelos AC, Joaquim AF, Botelho RV (2016) Reliability of the evaluation of posterior ligamentous complex injury in thoracolumbar spine trauma with the use of computed tomography scan. Eur Spine J 25:1135–1143. doi:10.1007/s00586-016-4377-8

    Article  PubMed  Google Scholar 

  25. Radcliff K, Su BW, Kepler CK, Rubin T, Shimer AL, Rihn JA, Harrop JA, Albert TJ, Vaccaro AR (2012) Correlation of posterior ligamentous complex injury and neurological injury to loss of vertebral body height, kyphosis, and canal compromise. Spine 37:1142–1150. doi:10.1097/BRS.0b013e318240fcd3

    Article  PubMed  Google Scholar 

  26. Petersilge CA, Pathria MN, Emery SE, Masaryk TJ (1995) Thoracolumbar burst fractures: evaluation with MR imaging. Radiology 194:49–54. doi:10.1148/radiology.194.1.7997581

    Article  CAS  PubMed  Google Scholar 

  27. Farcy JP, Weidenbaum M, Glassman SD (1990) Sagittal index in management of thoracolumbar burst fractures. Spine 15:958–965

    Article  CAS  PubMed  Google Scholar 

  28. Nagel DA, Koogle TA, Piziali RL, Perkash I (1981) Stability of the upper lumbar spine following progressive disruptions and the application of individual internal and external fixation devices. J Bone Joint Surg Am 63:62–70

    Article  CAS  PubMed  Google Scholar 

  29. Cantor JB, Lebwohl NH, Garvey T, Eismont FJ (1993) Nonoperative management of stable thoracolumbar burst fractures with early ambulation and bracing. Spine 18:971–976

    Article  CAS  PubMed  Google Scholar 

  30. Rechtine GR (1999) Nonsurgical treatment of thoracic and lumbar fractures. Instr Course Lect 48:413–416

    CAS  PubMed  Google Scholar 

  31. Heuer F, Schmidt H, Klezl Z, Claes L, Wilke HJ (2007) Stepwise reduction of functional spinal structures increase range of motion and change lordosis angle. J Biomech 40:271–280. doi:10.1016/j.jbiomech.2006.01.007

    Article  PubMed  Google Scholar 

  32. Daffner RH, Deeb ZL, Goldberg AL, Kandabarow A, Rothfus WE (1990) The radiologic assessment of post-traumatic vertebral stability. Skeletal Radiol 19:103–108

    CAS  PubMed  Google Scholar 

  33. Panjabi MM, Hausfeld JN, White AA 3rd (1981) A biomechanical study of the ligamentous stability of the thoracic spine in man. Acta Orthop Scand 52:315–326

    Article  CAS  PubMed  Google Scholar 

  34. McAfee PC, Yuan HA, Fredrickson BE, Lubicky JP (1983) The value of computed tomography in thoracolumbar fractures. An analysis of one hundred consecutive cases and a new classification. J Bone Joint Surg Am 65:461–473

    Article  CAS  PubMed  Google Scholar 

  35. Keynan O, Fisher CG, Vaccaro A, Fehlings MG, Oner FC, Dietz J, Kwon B, Rampersaud R, Bono C, France J, Dvorak M (2006) Radiographic measurement parameters in thoracolumbar fractures: a systematic review and consensus statement of the spine trauma study group. Spine 31:E156–E165. doi:10.1097/01.brs.0000201261.94907.0d

    Article  PubMed  Google Scholar 

  36. Pizones J, Izquierdo E, Sanchez-Mariscal F, Zuniga L, Alvarez P, Gomez-Rice A (2012) Sequential damage assessment of the different components of the posterior ligamentous complex after magnetic resonance imaging interpretation: prospective study 74 traumatic fractures. Spine 37:E662–E667. doi:10.1097/BRS.0b013e3182422b2b

    Article  PubMed  Google Scholar 

  37. Vaccaro AR, Rihn JA, Saravanja D, Anderson DG, Hilibrand AS, Albert TJ, Fehlings MG, Morrison W, Flanders AE, France JC, Arnold P, Anderson PA, Friel B, Malfair D, Street J, Kwon B, Paquette S, Boyd M, Dvorak MF, Fisher C (2009) Injury of the posterior ligamentous complex of the thoracolumbar spine: a prospective evaluation of the diagnostic accuracy of magnetic resonance imaging. Spine 34:E841–E847. doi:10.1097/BRS.0b013e3181bd11be

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

This work is supported by Grant from National Nature Foundation of China (Grant No. 81371988), National Nature Foundation of China (Grant No. 30700843), and Natural Science Foundation of Zhejiang Province for Distinguished Young Scholars (Grant No. LR12H06001), and Major science and technology program for medical and health of Zhejiang Province (Grant No. WKJ-ZJ-1527).

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, The Second Affiliated Hospital of Wenzhou Medical University, 109 Xueyuanxi Road, Wenzhou, 325000, Zhejiang Province, China

    Jiao-Xiang Chen, Amit Goswami, Dao-Liang Xu, Jun Xuan, Hai-Ming Jin, Hong-Ming Xu, Feng Zhou, Yong-Li Wang & Xiang-Yang Wang

Authors
  1. Jiao-Xiang Chen
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Amit Goswami
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Dao-Liang Xu
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jun Xuan
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Hai-Ming Jin
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Hong-Ming Xu
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Feng Zhou
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Yong-Li Wang
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Xiang-Yang Wang
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Xiang-Yang Wang.

Ethics declarations

Conflict of interest

None of the authors has any potential conflict of interest.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Chen, JX., Goswami, A., Xu, DL. et al. The radiologic assessment of posterior ligamentous complex injury in patients with thoracolumbar fracture. Eur Spine J 26, 1454–1462 (2017). https://doi.org/10.1007/s00586-016-4687-x

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00586-016-4687-x

Keywords

Search

Navigation