胸腰椎損傷の治療選択アルゴリズム（TLICS）

損傷型、後方靱帯組織損傷の有無、神経学的損傷程度から複合的に点数化して治療法を選択する。(翻訳・一部改変)
出典
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1: A new classification of thoracolumbar injuries: the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status.
著者: 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.
雑誌名: Spine (Phila Pa 1976). 2005 Oct 15;30(20):2325-33. doi: 10.1097/01.brs.0000182986.43345.cb.
Abstract/Text: STUDY DESIGN: A new proposed classification system for thoracolumbar (TL) spine injuries, including injury severity assessment, designed to assist in clinical management.
OBJECTIVE: To devise a practical, yet comprehensive, classification system for TL injuries that assists in clinical decision-making in terms of the need for operative versus nonoperative care and surgical treatment approach in unstable injury patterns.
SUMMARY OF BACKGROUND DATA: The most appropriate classification of traumatic TL spine injuries remains controversial. Systems currently in use can be cumbersome and difficult to apply. None of the published classification schemata is constructed to aid with decisions in clinical management.
METHODS: Clinical spine trauma specialists from a variety of institutions around the world were canvassed with respect to information they deemed pivotal in the communication of TL spine trauma and the clinical decision-making process. Traditional injury patterns were reviewed and reconsidered in light of these essential characteristics. An initial validation process to determine the reliability and validity of an earlier version of this system was also undertaken.
RESULTS: A new classification system called the Thoracolumbar Injury Classification and Severity Score (TLICS) was devised based on three injury characteristics: 1) morphology of injury determined by radiographic appearance, 2) integrity of the posterior ligamentous complex, and 3) neurologic status of the patient. A composite injury severity score was calculated from these characteristics stratifying patients into surgical and nonsurgical treatment groups. Finally, a methodology was developed to determine the optimum operative approach for surgical injury patterns.
CONCLUSIONS: Although there will always be limitations to any cataloging system, the TLICS reflects accepted features cited in the literature important in predicting spinal stability, future deformity, and progressive neurologic compromise. This classification system is intended to be easy to apply and to facilitate clinical decision-making as a practical alternative to cumbersome classification systems already in use. The TLICS may improve communication between spine trauma physicians and the education of residents and fellows. Further studies are underway to determine the reliability and validity of this tool.
Spine (Phila Pa 1976). 2005 Oct 15;30(20):2325-33. doi: 10.1097/01.brs...

脊椎晒骨模型

脊椎は後頭骨の直下から始まり、7個の頚椎、12個の胸椎、5個の腰椎、5個の仙椎が一体化した仙骨、および3～5個の尾椎から構成されている。頚椎部で前弯、胸椎部で後弯、腰椎部で前弯、仙尾骨部で後弯とゆるいS字状カーブの連続となっている。
出典
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脊椎損傷と脊髄損傷

脊椎の損傷が重篤となると、体幹支持性の喪失と内包する神経要素の損傷という2つの事態が生じる。
a：側面X線での第6/7頚椎レベルの脱臼像
b：MRI T2矢状断像で第6/7頚椎レベルの脊髄圧迫を認める。通常損傷部はT2矢状断像で高輝度を呈する。
出典
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ISNCSNI score（旧ASIA score）記入表

ASIA score記入表でのkey muscle、key sensory pointを用いて筋力、感覚障害を評価することで神経障害の程度が標準化でき、変化・改善を比較することも容易になる。
出典
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1: International Standards for Neurological Classification of Spinal Cord Injury: Revised 2019.
Top Spinal Cord Inj Rehabil. 2021 Spring;27(2):1-22. doi: 10.46292/sci2702-1.

頚胸椎MRI T2矢状断像

第5/6頚椎レベルと第8/9胸椎レベルでの2重脊椎・脊髄損傷を認める。
出典
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Allen & Ferguson分類

頚椎損傷を受傷機転別に分類してあり、さらに程度によるステージ分けもされている。
出典
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1: A mechanistic classification of closed, indirect fractures and dislocations of the lower cervical spine.
著者: Allen BL Jr, Ferguson RL, Lehmann TR, O'Brien RP.
雑誌名: Spine (Phila Pa 1976). 1982 Jan-Feb;7(1):1-27. doi: 10.1097/00007632-198200710-00001.
Abstract/Text: Closed, indirect fractures and dislocations of the lower cervical spine occur in families or groups within which there is a spectrum of anatomic damage to a cervical motion segment. This study of 165 cases demonstrates the various spectra of injury, called phylogenies, and develops a classification based on the mechanism of injury. The common groups are compressive flexion, vertical compression, distractive flexion, compressive extension, distractive extension, and lateral flexion. The probability of an associated neurologic lesion relates directly to the type and severity of cervical spine injury. With use of the classification, it is possible to formulate a rational treatment plan for injuries to the cervical spine.
Spine (Phila Pa 1976). 1982 Jan-Feb;7(1):1-27. doi: 10.1097/00007632-1...

胸腰椎損傷に対するAOSpine分類とその発生頻度

CTアンギオ（A-P像）

右椎骨動脈は閉塞して走行が見られない
出典
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脊椎損傷と脊髄損傷の合併例の術後単純X線画像とCT画像

脱臼していた第6/7頚椎レベルは整復され（→）、第6、7頚椎に刺入された椎弓根スクリューにて良好なアライメントに固定されている。またCT画像ではスクリューは正確に椎弓根内に刺入されている。
脊椎損傷と脊髄損傷の合併例：[ID0602]
出典
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第1腰椎破裂骨折例の単純X線像

正面像（a）では、椎弓根間の拡大および椎弓の横骨折を認める。側面像（b）では椎体の楔状化を認め、椎体後壁は不鮮明である。

第1腰椎破裂骨折例のCTおよびMRI像例

CT矢状断像(a)と横断像(b)では、椎体の高度破壊と脊柱管内に陥入した椎体後壁骨片を認める。MRI（C）では破壊骨片による骨髄円錘部の圧迫と髄内輝度変化、そして後方の棘突起、靱帯複合体の損傷を認めた。

第1腰椎破裂骨折例の術後単純X線像頚椎カラーの装着

第12胸椎-第2腰椎間は後方から椎弓根スクリューとフックで連結固定されている。破壊された第1腰椎椎体の亜全摘、脊柱管内骨片の切除後、腸骨移植により、良好なアライメントで骨癒合が得られている。

第1腰椎破裂骨折例の術後CTおよびMRI画像

CTでは脊柱管内骨片は完全に切除除圧され、移植された腸骨は上下の椎体と癒合している。またMRIでは完全に除圧されているが円錐部に髄内高輝度画像を認める。
出典
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非骨瘍性頚髄損傷例の術前・術後の単純X線およびMRI像

a：術前X線
b：術前MRI
c：術後X線
d：術後MRI
術前多髄節で脊髄圧迫を認め、C3/4レベルでは髄内高輝度変化を認める。術後は脊髄の除圧が得られている。
出典
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sacral sparing（仙髄部回避）

肛門周囲の知覚の有無・肛門の自力収縮・第1足趾の底屈が可能かを検査する。1つでも残存していれば陽性である。

ASIA Impairment scale

A～Eの5段階のグレードに分類され、Aは完全麻痺、B～Dは不全麻痺、Eは正常（麻痺なし）である。

頚椎X線

a：正面像
b：側面中間位
c：前屈位
d：後屈位
出典
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軸椎(第2頚椎)ハングマン骨折のLevine分類

TypeⅠ、Ⅱ、Ⅲに分類されている。TypeⅡは第2/3頚椎椎間板損傷合併の有無により、TypeⅡとTypeⅡ-A（椎間板損傷あり）にさらに分類されている。
出典
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1: The management of traumatic spondylolisthesis of the axis.
著者: Levine AM, Edwards CC.
雑誌名: J Bone Joint Surg Am. 1985 Feb;67(2):217-26.
Abstract/Text: Fifty-two patients with traumatic spondylolisthesis of the axis were admitted to the University of Maryland Spinal Injury Center between 1977 and 1982. There were fifteen Type-I fractures, twenty-nine Type-II fractures, three Type-IIa fractures, and five Type-III fractures. Associated neurological deficits were found in only four patients, although unassociated neurological deficits such as closed head injury were seen in eleven patients. Thirteen patients had other fractures of the cervical spine. Type-I fractures were stable injuries and were treated with collar protection. Most Type-II injuries were reduced with the patient in halo traction, and then immobilization in a halo vest was used. Type-IIa injuries, as they showed increased displacement in traction, were reduced with gentle extension and compression in a halo vest. Type-III injuries were grossly unstable and required surgical stabilization. All of the fractures healed, although the use of early halo-vest immobilization for displaced fractures resulted in significant residual deformity. The radiographic patterns of the fracture types and the resulting data on clinical stability suggested a correlation between the fracture type and the mechanism of injury. Type-I injuries resulted from a hyperextension-axial loading force; Type-II injuries, from an initial hyperextension-axial loading force followed by severe flexion; Type-IIa injuries, from flexion-distraction; and Type-III injuries, from flexion-compression.
J Bone Joint Surg Am. 1985 Feb;67(2):217-26.

軸椎(第2頚椎)歯突起骨折のAnderson分類

TypeⅠ、Ⅱ、Ⅲに分類されている。TypeⅡは手術適応となり、TypeⅢは症例により手術適応となる。
出典
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1: Fractures of the odontoid process of the axis.
J Bone Joint Surg Am. 1974 Dec;56(8):1663-74.

Denisの3 column theory

Anterior(前方支柱）、Middle(中央支柱)、Posterior（後方支柱）の3 columnに分け、2カ所以上が損傷されると不安定性が強いと判断される。
出典
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1: The three column spine and its significance in the classification of acute thoracolumbar spinal injuries.
著者: Denis F.
雑誌名: Spine (Phila Pa 1976). 1983 Nov-Dec;8(8):817-31. doi: 10.1097/00007632-198311000-00003.
Abstract/Text: From a retrospective study of 412 thoracolumbar injuries, the author introduces the concept of middle column or middle osteoligamentous complex between the traditionally recognized posterior ligamentous complex and the anterior longitudinal ligament. This middle column is formed by the posterior wall of the vertebral body, the posterior longitudinal ligament and posterior annulus fibrosus. The third column appears crucial, as the mode of its failure correlates both with the type of spinal fracture and with its neurological injury. Spinal injuries were subdivided into minor and major. Minor injuries are represented by fractures of transverse processes, facets, pars interarticularis, and spinous process. Major spinal injuries are classified into four different categories: compression fractures, burst fractures, seat-belt-type injuries, and fracture dislocations. These four well-recognized injuries have been studied carefully in clinical terms as well as on roentgenograms and computerized axial tomograms. They were then subdivided into subtypes demonstrating the very wide spectrums of these four entities. The correlation between the three-column system, the classification, the stability, and the therapeutic indications are presented.
Spine (Phila Pa 1976). 1983 Nov-Dec;8(8):817-31. doi: 10.1097/00007632...

頚椎損傷の治療選択アルゴリズム（SLICS）

損傷型、後方靱帯組織損傷の有無、神経学的損傷程度から複合的に点数化して治療法を選択する。
出典
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1: The subaxial cervical spine injury classification system: a novel approach to recognize the importance of morphology, neurology, and integrity of the disco-ligamentous complex.
著者: Vaccaro AR, Hulbert RJ, Patel AA, Fisher C, Dvorak M, Lehman RA Jr, Anderson P, Harrop J, Oner FC, Arnold P, Fehlings M, Hedlund R, Madrazo I, Rechtine G, Aarabi B, Shainline M; Spine Trauma Study Group.
雑誌名: Spine (Phila Pa 1976). 2007 Oct 1;32(21):2365-74. doi: 10.1097/BRS.0b013e3181557b92.
Abstract/Text: STUDY DESIGN: The classification system was derived through a literature review and expert opinion of experienced spine surgeons. In addition, a multicenter reliability and validity study of the system was conducted on a collection of trauma cases.
OBJECTIVES: To define a novel classification system for subaxial cervical spine trauma that conveys information about injury pattern, severity, treatment considerations, and prognosis. To evaluate reliability and validity of this system.
SUMMARY OF BACKGROUND DATA: Classification of subaxial cervical spine injuries remains largely descriptive, lacking standardization and prognostic information.
METHODS: Clinical and radiographic variables encountered in subaxial cervical trauma were identified by a working section of the Spine Trauma Study Group. Significant limitations of existing systems were defined and addressed within the new system. This system, as well as the Harris and Ferguson & Allen systems, was applied by 20 spine surgeons to 11 cervical trauma cases. Six weeks later, the cases were randomly reordered and again scored. Interrater reliability, intrarater reliability, and validity were assessed.
RESULTS: Each of 3 main categories (injury morphology, disco-ligamentous complex, and neurologic status) identified as integrally important to injury classification was assigned a weighted score; the injury severity score was obtained by summing the scores from each category. Treatment options were assigned based on threshold values of the severity score. Interrater agreement as assessed by intraclass correlation coefficient of the DLC, morphology, and neurologic status scores was 0.49, 0.57, and 0.87, respectively. Intrarater agreement as assessed by intraclass correlation coefficient of the DLC, morphology, and neurologic status scores was 0.66, 0.75, and 0.90, respectively. Raters agreed with treatment recommendations of the algorithm in 93.3% of cases, suggesting high construct validity. The reliability compared favorably to the Harris and Ferguson & Allen systems.
CONCLUSION: The Sub-axial Injury Classification and Severity Scale provides a comprehensive classification system for subaxial cervical trauma. Early validity and reliability data are encouraging.
Spine (Phila Pa 1976). 2007 Oct 1;32(21):2365-74. doi: 10.1097/BRS.0b0...

胸腰椎損傷の治療選択アルゴリズム（TLICS）

損傷型、後方靱帯組織損傷の有無、神経学的損傷程度から複合的に点数化して治療法を選択する。(翻訳・一部改変)
出典
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1: A new classification of thoracolumbar injuries: the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status.
著者: 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.
雑誌名: Spine (Phila Pa 1976). 2005 Oct 15;30(20):2325-33. doi: 10.1097/01.brs.0000182986.43345.cb.
Abstract/Text: STUDY DESIGN: A new proposed classification system for thoracolumbar (TL) spine injuries, including injury severity assessment, designed to assist in clinical management.
OBJECTIVE: To devise a practical, yet comprehensive, classification system for TL injuries that assists in clinical decision-making in terms of the need for operative versus nonoperative care and surgical treatment approach in unstable injury patterns.
SUMMARY OF BACKGROUND DATA: The most appropriate classification of traumatic TL spine injuries remains controversial. Systems currently in use can be cumbersome and difficult to apply. None of the published classification schemata is constructed to aid with decisions in clinical management.
METHODS: Clinical spine trauma specialists from a variety of institutions around the world were canvassed with respect to information they deemed pivotal in the communication of TL spine trauma and the clinical decision-making process. Traditional injury patterns were reviewed and reconsidered in light of these essential characteristics. An initial validation process to determine the reliability and validity of an earlier version of this system was also undertaken.
RESULTS: A new classification system called the Thoracolumbar Injury Classification and Severity Score (TLICS) was devised based on three injury characteristics: 1) morphology of injury determined by radiographic appearance, 2) integrity of the posterior ligamentous complex, and 3) neurologic status of the patient. A composite injury severity score was calculated from these characteristics stratifying patients into surgical and nonsurgical treatment groups. Finally, a methodology was developed to determine the optimum operative approach for surgical injury patterns.
CONCLUSIONS: Although there will always be limitations to any cataloging system, the TLICS reflects accepted features cited in the literature important in predicting spinal stability, future deformity, and progressive neurologic compromise. This classification system is intended to be easy to apply and to facilitate clinical decision-making as a practical alternative to cumbersome classification systems already in use. The TLICS may improve communication between spine trauma physicians and the education of residents and fellows. Further studies are underway to determine the reliability and validity of this tool.
Spine (Phila Pa 1976). 2005 Oct 15;30(20):2325-33. doi: 10.1097/01.brs...

脊椎晒骨模型

脊椎は後頭骨の直下から始まり、7個の頚椎、12個の胸椎、5個の腰椎、5個の仙椎が一体化した仙骨、および3～5個の尾椎から構成されている。頚椎部で前弯、胸椎部で後弯、腰椎部で前弯、仙尾骨部で後弯とゆるいS字状カーブの連続となっている。
出典
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1: 著者提供