Normal bireylerde nötral ve hiperfleksiyon pozisyonlarında torakolomber bölge inserspinöz mesafenin değerlendirilmesi

BENLİ, Teoman; KAYA, Alper; KÖKEN, MURAT; GÜÇLÜ, BERK; KARAGÜVEN, Doğaç

Normal bireylerde nötral ve hiperfleksiyon pozisyonlarında torakolomber bölge inserspinöz mesafenin değerlendirilmesi

Berk GÜÇLÜ, (Ufuk Üniversitesi, Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Ankara, Türkiye)

Teoman BENLİ, (Ufuk Üniversitesi, Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Ankara, Türkiye)

Alper KAYA, (Ufuk Üniversitesi, Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Ankara, Türkiye)

Doğaç KARAGÜVEN, (Ufuk Üniversitesi, Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Ankara, Türkiye)

Murat KÖKEN (Ufuk Üniversitesi, Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Ankara, Türkiye)

Journal of Turkish Spinal Surgery

12 1

Yıl: 2009 Cilt: 20 Sayı: 4 Sayfa Aralığı: 19 - 27 Metin Dili: Türkçe İndeks Tarihi: 29-07-2022

Normal bireylerde nötral ve hiperfleksiyon pozisyonlarında torakolomber bölge inserspinöz mesafenin değerlendirilmesi

Öz:

Vertebra kırıklarının en sık görüldüğü bölge torakolomber bölge olup, bu bölge kırıklarının en önemli komplikasyonu nörolojik defisit ve spinal instabilitedir. Bu iki komplikasyon cerrahi tedavi konusundaki en önemli endikasyonları oluşturmaktadır. Son yıllarda Spinal Travma Grubunun geliştirdiği sınışama, “Torakolomber Yaralanmaları Sınışama ve Skorlama Sistemi” (TLICS), spinal instabilite kavramının halen tartışmalı olduğu günümüzde, cerrahiye karar vermede önemli bir kolaylık sağlayan rehber olmak niteliğindedir. Ancak, sınışamada posterior ligamentöz kompleks (PLC) ile ilgili tanımlamalar nitel bir değerlendirmeyi içermektedir. Bu çalışmada PLC sağlam iken, yani normal bir bireyde nötral pozisyonda interspinöz mesafenin (ISD) ne olduğu ve hiperşeksiyonda yani ISD maksimum büyüklüğe ulaşmışken saptanan değerlerin belirlenmesi amaçlanmıştır. Bu amaçla 20-40 yaş arası daha önce hiçbir travma geçirmeyen ve vertebral hastalığı veya herhangi bir nedenle spinal cerrahi geçirmemiş sağlıklı 40 gönüllü erkek bireyde radyolojik olarak T11- T12 ve T12-L1 omurların interspinöz mesafeleri ölçülmüştür. Hasta evreninin yaş, kilo, boy ve ölçülen aralıklar açısından istatistikî olarak homojen olduğu saptanmıştır. T11-T12 ve T12-L1 arası mesafelerin nötralde sırasıyla ortalama 11.7 ± 1.7 mm ve 12.7 ± 1.5 mm olduğu ve hiperşeksiyonda ortalama sırasıyla % 26.5 ± 15.0 ve % 24.4 ± 16.6 arttığı belirlenmiştir. Hiperşeksiyonda her iki seviyede oluşan değişimin istatistikî olarak anlamlı olduğu (p<0.05) buna karşın değişim yüzdelerinin istatistikî olarak benzer olduğu belirlenmiştir (p>0.05). ‹nterspinöz mesafenin artışı T11-T12 ve T12-L1 arasında sırasıyla maksimum 5 mm ve 4.9 mm olduğu saptanmış ve bu bölge kırıklarının en sık görüldüğü yaş grubundaki normal bireylerde, bu seviyelerdeki interspinöz mesafe değerlerinin, saptanan bu değerlerin altında olduğunda PLC’nin intakt olduğu ve skorun sıfır olarak alınabileceği sonucuna varılmıştır. Sonuç olarak bu çalışmanın verilerine göre vertebra kırıklarının büyük kısmının görüldüğü torakolomber bölgede, son yıllarda geçerlilik ve güvenilirlik çalışmaları da yapılan TLICS sisteminde, PLC’nin sağlam olup olmadığının değerlendirilmesinde önemli basamaklardan biri için kalitatif bir değerlendirme yerine kantitatif bir ölçüm ile sonuca gitmenin mümkün olabileceği fikri elde edilmiştir.

Anahtar Kelime:

Konular: Cerrahi

The evaluation of the thoracolumbar region interspinous distance in the neutral and hiperflexion positions in the normal individuals

Öz:

The most important complications of the thoracolumbar fractures that are most frequent seen fractures of the vertebrae are neurological deficit and spinal instability. These two complications compose most important surgical indications. Recent years, the classification “Thoracolumbar Injury Classification and Scoring system (TLICS)” that developed by Spinal Trauma Group is a guide for decision making for surgery, while controversy continues in the spinal instability concept. But, descriptions about posterior ligamentous complex (PLC) have qualitative evaluations in this classification system. The aim of this study is to distinguish the interspinous distance (ISD) values both in neutral position in PLC intact healthy persons, and in hyperflexion that means ISD reaches maximum value. For this reason, ISD between T11-T12-L1 spinous process measured with radiology images in 20-40 years old 40 healthy volunteer males who did not have any trauma, spinal disorder or spinal surgery history. Patient demographics were determined homogeneous in age, weight, length and measured distances. Distances in neutral position between T11-T12 and T12-L1 were measured 11.7 ± 1.7 mm and 12.7 ± 1.5 mm, respectively, and values increased mean 26.5 ± 15.0 % and 24.4 ± 16.6 %, respectively in hyperflexion. The difference between in both two levels were statistically significant (p<0.05) while the percentages of differences found statistically similar (p>0.05). The difference of interspinous distance between T11-T12 and T12-L1 was found 5 mm and 4.9 mm, respectively. In healthy patients who are in the average age of the most common ages of the vertebral fractures occur, if the interspinous distance values in these levels are smaller than the appointed values, it can be said that the PLC is intact and the score can be taken as zero. According to the data of this study it was concluded that, in the thoracolumbar region that is most common site of the vertebral fractures, in the TLICS system that validity and reliability studies done in recent years, determination of the integrity of the PLC in one of the important steps, with quantitative measurement instead of qualitative analyses can be done for decision making.

Anahtar Kelime:

Konular: Cerrahi

Belge Türü: Makale Makale Türü: Araştırma Makalesi Erişim Türü: Erişime Açık

1. Argenson C, Dintimille H. Unstable fractures of the spine. III. Instability. Experimental instability. Experimental traumatic lesions of the spine in monkeys. Rev Chir Orthop Reparatrice Appar Mot 1977; 63(5): 430-431.
2. Bauer RD, Errico TJ. Thoracolumbar spine injuries. In: Errico TJ, Bauer RD, Waugh T (Eds.), Spinal Trauma. JB Lippincott Company, Philadelphia, 1991; pp: 195-269.
3. Bono CM, Vaccaro AR, Hurlbert RJ, Arnold P, Oner FC, Harrop J, Anand N. Validating a newly proposed classification system for thoracolumbar spine trauma: looking to the future of the thoracolumbar injury classification and severity score. J Orthop Trauma 2006; 20(8): 567-572.
4. Bono CM, Vaccaro AR, Fehlings M, Fisher C, Dvorak M, Ludwig S, Harrop J. Measurement techniques for lower cervical spine injuries: consensus statement of the Spine Trauma Study Group. Spine 2006; 31(5): 603-609.
5. Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine 1983; 8(8): 817-831.
6. Dvorak MF, Fisher CG, Fehlings MG, Rampersaud YR, Oner FC, Aarabi B, Vaccaro AR. The surgical approach to subaxial cervical spine injuries: an evidence-based algorithm based on the SLIC classification system. Spine 2007; 32(23): 2620-2629.
7. Eastlack RK, Bono CM. Fractures and dislocations of the thoracolumbar spine. In: Bucholz RW, Heckman JD, Court-Brown CM (Eds.), Rockwood and Green’s Fractures in Adults. Volume-2, sixth edition, Lippincott Williams and Wilkins, Philadelphia, 2006; pp: 1543-1580.
8. Ferguson RL, Allen BL Jr. A mechanistic classification of thoracolumbar spine fractures. Clin Orthop Relat Res 1984; 189: 77-88.
9. Haba H, Taneichi H, Kotani Y, Terae S, Abe S, Yoshikawa H, Abumi K, Minami A, Kaneda K. Diagnostic accuracy of magnetic resonance imaging for detecting posterior ligamentous complex injury associated with thoracic and lumbar fractures. J Neurosurg 2003; 99 (1 Suppl): 20-26.
10.Haher TR, Felmly, O’Brien M. Thoracic and lumbar fractures: diagnosis and management. In: Bridwell KH, DeWald RL (Eds.), The Textbook of Spinal Surgery, Volume-2, Lippincott-Raven Publishers, Philadelphia, 1997; pp: 1763-1838.
11.Harrop JS, Vaccaro AR, Hurlbert RJ, Wilsey JT, Baron EM, Shaffrey CI, Fisher CG, Dvorak MF, Oner FC, Wood KB, Anand N, Anderson DG, Lim MR, Lee JY, Bono CM, Arnold PM, Rampersaud YR, Fehlings MG; Spine Trauma Study Group. Intrarater and interrater reliability and validity in the assessment of the mechanism of injury and integrity of the posterior ligamentous complex: a novel injury severity scoring system for thoracolumbar injuries. Invited submission from the Joint Section Meeting On Disorders of the Spine and Peripheral Nerves, March 2005. J Neurosurg Spine 2006; 4(2): 118-122.
12.Holdsworth FW. Fractures, dislocations and fracture-dislocations of the spine. J Bone Joint Surg 1963; 45-B: 6-20.
13.Lee HM, Kim HS, Kim DJ, Suk KS, Park JO, Kim NH. Reliability of magnetic resonance imaging in detecting posterior ligament complex injury in thoracolumbar spinal fractures. Spine 2000; 25: 2079-2084.
14.Lee JY, Vaccaro AR, Lim MR, Oner FC, Hulbert RJ, Hedlund R, Fehlings MG, Arnold P, Harrop J, Bono CM, Anderson PA, Anderson DG, Harris MB, Brown AK, Stock GH, Baron EM. Thoracolumbar injury classification and severity score: a new paradigm for the treatment of thoracolumbar spine trauma. J Orthop Sci 2005; 10(6): 671-675.
15.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. Assessment of injury to the thoracolumbar posterior ligamentous complex in the setting of normal-appearing plain radiography. Spine J 2007; 7(4): 422-427.
16.Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S. A comprehensive classification of thoracic and lumbar injuries. Eur Spine J 1994; 3(4): 184-201.
17.McAfee PC, Yuan HA, Fredrickson BE, Lubicky JP. The value of computed tomography in thoracolumbar fractures. An analysis of one hundred consecutive cases and a new classification. J Bone Joint Surg 1983;65-A(4): 461-473.
18.McCormack T, Karaikovic E, Gaines RW. The load sharing classification of spine fractures. Spine 1994;19: 1741-1744.
19.Nicoll EA. Fractures of the dorso-lumbar spine. J Bone Joint Surg 1949; 31B(3): 376-394.
20.Oner FC, Ramos LM, Simmermacher RK, Kingma PT, Diekerhof CH, Dhert WJ, Verbout.Classification of thoracic and lumbar spine fractures: problems of reproducibility. A study of 53 patients using CT and MRI. Eur Spine J 2002; 11(3): 235-245.
21.Raja Rampersaud Y, Fisher C, Wilsey J, Arnold P, Anand N, Bono CM, Dailey AT, Dvorak M, Fehlings MG, Harrop JS, Oner FC, Vaccaro AR. Agreement between orthopedic surgeons and neurosurgeons regarding a new algorithm for the treatment of thoracolumbar injuries: a multicenter reliability study. J Spinal Disord Tech 2006; 19(7): 477-482.
22.Schweitzer KM Jr, Vaccaro AR, Lee JY, Grauer JN; Spine Trauma Study Group. Confusion regarding mechanisms of injury in the setting of thoracolumbar spinal trauma: a survey of The Spine Trauma Study Group (STSG). J Spinal Disord Tech 2006; 19(7): 528-530.
23.Schweitzer KM, Vaccaro AR, Harrop JS, Hurlbert J, Carrino JA, Rechtine GR, Schwartz DG, Alanay A, Sharma DK, Anderson DG, Lee JY, Arnold PM. Interrater reliability of identifying indicators of posterior ligamentous complex disruption when plain films are indeterminate in thoracolumbar injuries. J Orthop Sci 2007; 12(5): 437-442.
24.Stadhouder A, Buskens E, de Klerk LW, Verhaar JA, Dhert WA, Verbout AJ, Vaccaro AR, Oner FC. Traumatic thoracic and lumbar spinal fractures: operative or nonoperative treatment: comparison of two treatment strategies by means of surgeon equipoise. Spine 2008; 33(9):1006-1017.
25.Vaccaro AR, Zeiller SC, Hulbert RJ, Anderson PA, Harris M, Hedlund R, Harrop J, Dvorak M, Wood K, Fehlings MG, Fisher C, Lehman RA Jr, Anderson DG, Bono CM, Kuklo T, Oner FC. The thoracolumbar injury severity score: a proposed treatment algorithm. J Spinal Disord Tech 2005; 18(3): 209-215.
26.Vaccaro AR, Lim MR, Hurlbert RJ, Lehman RA Jr, Harrop J, Fisher DC, Dvorak M, Anderson DG, Zeiller SC, Lee JY, Fehlings MG, Oner FC; Spine Trauma Study Group. Surgical decision making for unstable thoracolumbar spine injuries: results of a consensus panel review by the Spine Trauma Study Group. J Spinal Disord Tech 2006; 19(1): 1-10.
27.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 Group. Assessment of injury to the posterior ligamentous complex in thoracolumbar spine trauma. Spine J 2006; 6(5): 524-528.
28.Vaccaro AR, Baron EM, Sanfilippo J, Jacoby S, Steuve J, Grossman E, DiPaola M, Ranier P, Austin L, Ropiak R, Ciminello M, Okafor C, Eichenbaum M, Rapuri V, Smith E, Orozco F, Ugolini P, Şetcher M, Minnich J, Goldberg G, Wilsey J, Lee JY, Lim MR, Burns A, Marino R, DiPaola C, Zeiller L, Zeiler SC, Harrop J, Anderson DG, Albert TJ, Hilibrand AS. Reliability of a novel classification system for thoracolumbar injuries: the Thoracolumbar Injury Severity Score. Spine 2006;31(11 Suppl): S62- S69; discussion S104.
29.Vaccaro AR, Lim MR, Hurlbert RJ, Lehman RA Jr, Harrop J, Fisher DC, Dvorak M, Anderson DG, Zeiller SC, Lee JY, Fehlings MG, Oner FC; Spine Trauma Study Group. Surgical decision making for unstable thoracolumbar spine injuries: results of a consensus panel review by the Spine Trauma Study Group. J Spinal Disord Tech 2006; 19(1): 1-10.
1. Argenson C, Dintimille H. Unstable fractures of the spine. III. Instability. Experimental instability. Experimental traumatic lesions of the spine in monkeys. Rev Chir Orthop Reparatrice Appar Mot 1977; 63(5): 430-431.
2. Bauer RD, Errico TJ. Thoracolumbar spine injuries. In: Errico TJ, Bauer RD, Waugh T (Eds.), Spinal Trauma. JB Lippincott Company, Philadelphia, 1991; pp: 195-269.
3. Bono CM, Vaccaro AR, Hurlbert RJ, Arnold P, Oner FC, Harrop J, Anand N. Validating a newly proposed classification system for thoracolumbar spine trauma: looking to the future of the thoracolumbar injury classification and severity score. J Orthop Trauma 2006; 20(8): 567-572.
4. Bono CM, Vaccaro AR, Fehlings M, Fisher C, Dvorak M, Ludwig S, Harrop J. Measurement techniques for lower cervical spine injuries: consensus statement of the Spine Trauma Study Group. Spine 2006; 31(5): 603-609.
5. Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine 1983; 8(8): 817-831.
6. Dvorak MF, Fisher CG, Fehlings MG, Rampersaud YR, Oner FC, Aarabi B, Vaccaro AR. The surgical approach to subaxial cervical spine injuries: an evidence-based algorithm based on the SLIC classification system. Spine 2007; 32(23): 2620-2629.
7. Eastlack RK, Bono CM. Fractures and dislocations of the thoracolumbar spine. In: Bucholz RW, Heckman JD, Court-Brown CM (Eds.), Rockwood and Green’s Fractures in Adults. Volume-2, sixth edition, Lippincott Williams and Wilkins, Philadelphia, 2006; pp: 1543-1580.
8. Ferguson RL, Allen BL Jr. A mechanistic classification of thoracolumbar spine fractures. Clin Orthop Relat Res 1984; 189: 77-88.
9. Haba H, Taneichi H, Kotani Y, Terae S, Abe S, Yoshikawa H, Abumi K, Minami A, Kaneda K. Diagnostic accuracy of magnetic resonance imaging for detecting posterior ligamentous complex injury associated with thoracic and lumbar fractures. J Neurosurg 2003; 99 (1 Suppl): 20-26.
10.Haher TR, Felmly, O’Brien M. Thoracic and lumbar fractures: diagnosis and management. In: Bridwell KH, DeWald RL (Eds.), The Textbook of Spinal Surgery, Volume-2, Lippincott-Raven Publishers, Philadelphia, 1997; pp: 1763-1838.
11.Harrop JS, Vaccaro AR, Hurlbert RJ, Wilsey JT, Baron EM, Shaffrey CI, Fisher CG, Dvorak MF, Oner FC, Wood KB, Anand N, Anderson DG, Lim MR, Lee JY, Bono CM, Arnold PM, Rampersaud YR, Fehlings MG; Spine Trauma Study Group. Intrarater and interrater reliability and validity in the assessment of the mechanism of injury and integrity of the posterior ligamentous complex: a novel injury severity scoring system for thoracolumbar injuries. Invited submission from the Joint Section Meeting On Disorders of the Spine and Peripheral Nerves, March 2005. J Neurosurg Spine 2006; 4(2): 118-122.
12.Holdsworth FW. Fractures, dislocations and fracture-dislocations of the spine. J Bone Joint Surg 1963; 45-B: 6-20.
13.Lee HM, Kim HS, Kim DJ, Suk KS, Park JO, Kim NH. Reliability of magnetic resonance imaging in detecting posterior ligament complex injury in thoracolumbar spinal fractures. Spine 2000; 25: 2079-2084.
14.Lee JY, Vaccaro AR, Lim MR, Oner FC, Hulbert RJ, Hedlund R, Fehlings MG, Arnold P, Harrop J, Bono CM, Anderson PA, Anderson DG, Harris MB, Brown AK, Stock GH, Baron EM. Thoracolumbar injury classification and severity score: a new paradigm for the treatment of thoracolumbar spine trauma. J Orthop Sci 2005; 10(6): 671-675.
15.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. Assessment of injury to the thoracolumbar posterior ligamentous complex in the setting of normal-appearing plain radiography. Spine J 2007; 7(4): 422-427.
16.Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S. A comprehensive classification of thoracic and lumbar injuries. Eur Spine J 1994; 3(4): 184-201.
17.McAfee PC, Yuan HA, Fredrickson BE, Lubicky JP. The value of computed tomography in thoracolumbar fractures. An analysis of one hundred consecutive cases and a new classification. J Bone Joint Surg 1983;65-A(4): 461-473.
18.McCormack T, Karaikovic E, Gaines RW. The load sharing classification of spine fractures. Spine 1994;19: 1741-1744.
19.Nicoll EA. Fractures of the dorso-lumbar spine. J Bone Joint Surg 1949; 31B(3): 376-394.
20.Oner FC, Ramos LM, Simmermacher RK, Kingma PT, Diekerhof CH, Dhert WJ, Verbout.Classification of thoracic and lumbar spine fractures: problems of reproducibility. A study of 53 patients using CT and MRI. Eur Spine J 2002; 11(3): 235-245.
21.Raja Rampersaud Y, Fisher C, Wilsey J, Arnold P, Anand N, Bono CM, Dailey AT, Dvorak M, Fehlings MG, Harrop JS, Oner FC, Vaccaro AR. Agreement between orthopedic surgeons and neurosurgeons regarding a new algorithm for the treatment of thoracolumbar injuries: a multicenter reliability study. J Spinal Disord Tech 2006; 19(7): 477-482.
22.Schweitzer KM Jr, Vaccaro AR, Lee JY, Grauer JN; Spine Trauma Study Group. Confusion regarding mechanisms of injury in the setting of thoracolumbar spinal trauma: a survey of The Spine Trauma Study Group (STSG). J Spinal Disord Tech 2006; 19(7): 528-530.
23.Schweitzer KM, Vaccaro AR, Harrop JS, Hurlbert J, Carrino JA, Rechtine GR, Schwartz DG, Alanay A, Sharma DK, Anderson DG, Lee JY, Arnold PM. Interrater reliability of identifying indicators of posterior ligamentous complex disruption when plain films are indeterminate in thoracolumbar injuries. J Orthop Sci 2007; 12(5): 437-442.
24.Stadhouder A, Buskens E, de Klerk LW, Verhaar JA, Dhert WA, Verbout AJ, Vaccaro AR, Oner FC. Traumatic thoracic and lumbar spinal fractures: operative or nonoperative treatment: comparison of two treatment strategies by means of surgeon equipoise. Spine 2008; 33(9):1006-1017.
25.Vaccaro AR, Zeiller SC, Hulbert RJ, Anderson PA, Harris M, Hedlund R, Harrop J, Dvorak M, Wood K, Fehlings MG, Fisher C, Lehman RA Jr, Anderson DG, Bono CM, Kuklo T, Oner FC. The thoracolumbar injury severity score: a proposed treatment algorithm. J Spinal Disord Tech 2005; 18(3): 209-215.
26.Vaccaro AR, Lim MR, Hurlbert RJ, Lehman RA Jr, Harrop J, Fisher DC, Dvorak M, Anderson DG, Zeiller SC, Lee JY, Fehlings MG, Oner FC; Spine Trauma Study Group. Surgical decision making for unstable thoracolumbar spine injuries: results of a consensus panel review by the Spine Trauma Study Group. J Spinal Disord Tech 2006; 19(1): 1-10.
27.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 Group. Assessment of injury to the posterior ligamentous complex in thoracolumbar spine trauma. Spine J 2006; 6(5): 524-528.
28.Vaccaro AR, Baron EM, Sanfilippo J, Jacoby S, Steuve J, Grossman E, DiPaola M, Ranier P, Austin L, Ropiak R, Ciminello M, Okafor C, Eichenbaum M, Rapuri V, Smith E, Orozco F, Ugolini P, Şetcher M, Minnich J, Goldberg G, Wilsey J, Lee JY, Lim MR, Burns A, Marino R, DiPaola C, Zeiller L, Zeiler SC, Harrop J, Anderson DG, Albert TJ, Hilibrand AS. Reliability of a novel classification system for thoracolumbar injuries: the Thoracolumbar Injury Severity Score. Spine 2006;31(11 Suppl): S62- S69; discussion S104.
29.Vaccaro AR, Lim MR, Hurlbert RJ, Lehman RA Jr, Harrop J, Fisher DC, Dvorak M, Anderson DG, Zeiller SC, Lee JY, Fehlings MG, Oner FC; Spine Trauma Study Group. Surgical decision making for unstable thoracolumbar spine injuries: results of a consensus panel review by the Spine Trauma Study Group. J Spinal Disord Tech 2006; 19(1): 1-10.

APA	GÜÇLÜ B, BENLİ T, KAYA A, KARAGÜVEN D, KÖKEN M (2009). Normal bireylerde nötral ve hiperfleksiyon pozisyonlarında torakolomber bölge inserspinöz mesafenin değerlendirilmesi. , 19 - 27.
Chicago	GÜÇLÜ BERK,BENLİ Teoman,KAYA Alper,KARAGÜVEN Doğaç,KÖKEN MURAT Normal bireylerde nötral ve hiperfleksiyon pozisyonlarında torakolomber bölge inserspinöz mesafenin değerlendirilmesi. (2009): 19 - 27.
MLA	GÜÇLÜ BERK,BENLİ Teoman,KAYA Alper,KARAGÜVEN Doğaç,KÖKEN MURAT Normal bireylerde nötral ve hiperfleksiyon pozisyonlarında torakolomber bölge inserspinöz mesafenin değerlendirilmesi. , 2009, ss.19 - 27.
AMA	GÜÇLÜ B,BENLİ T,KAYA A,KARAGÜVEN D,KÖKEN M Normal bireylerde nötral ve hiperfleksiyon pozisyonlarında torakolomber bölge inserspinöz mesafenin değerlendirilmesi. . 2009; 19 - 27.
Vancouver	GÜÇLÜ B,BENLİ T,KAYA A,KARAGÜVEN D,KÖKEN M Normal bireylerde nötral ve hiperfleksiyon pozisyonlarında torakolomber bölge inserspinöz mesafenin değerlendirilmesi. . 2009; 19 - 27.
IEEE	GÜÇLÜ B,BENLİ T,KAYA A,KARAGÜVEN D,KÖKEN M "Normal bireylerde nötral ve hiperfleksiyon pozisyonlarında torakolomber bölge inserspinöz mesafenin değerlendirilmesi." , ss.19 - 27, 2009.
ISNAD	GÜÇLÜ, BERK vd. "Normal bireylerde nötral ve hiperfleksiyon pozisyonlarında torakolomber bölge inserspinöz mesafenin değerlendirilmesi". (2009), 19-27.

APA	GÜÇLÜ B, BENLİ T, KAYA A, KARAGÜVEN D, KÖKEN M (2009). Normal bireylerde nötral ve hiperfleksiyon pozisyonlarında torakolomber bölge inserspinöz mesafenin değerlendirilmesi. Journal of Turkish Spinal Surgery, 20(4), 19 - 27.
Chicago	GÜÇLÜ BERK,BENLİ Teoman,KAYA Alper,KARAGÜVEN Doğaç,KÖKEN MURAT Normal bireylerde nötral ve hiperfleksiyon pozisyonlarında torakolomber bölge inserspinöz mesafenin değerlendirilmesi. Journal of Turkish Spinal Surgery 20, no.4 (2009): 19 - 27.
MLA	GÜÇLÜ BERK,BENLİ Teoman,KAYA Alper,KARAGÜVEN Doğaç,KÖKEN MURAT Normal bireylerde nötral ve hiperfleksiyon pozisyonlarında torakolomber bölge inserspinöz mesafenin değerlendirilmesi. Journal of Turkish Spinal Surgery, vol.20, no.4, 2009, ss.19 - 27.
AMA	GÜÇLÜ B,BENLİ T,KAYA A,KARAGÜVEN D,KÖKEN M Normal bireylerde nötral ve hiperfleksiyon pozisyonlarında torakolomber bölge inserspinöz mesafenin değerlendirilmesi. Journal of Turkish Spinal Surgery. 2009; 20(4): 19 - 27.
Vancouver	GÜÇLÜ B,BENLİ T,KAYA A,KARAGÜVEN D,KÖKEN M Normal bireylerde nötral ve hiperfleksiyon pozisyonlarında torakolomber bölge inserspinöz mesafenin değerlendirilmesi. Journal of Turkish Spinal Surgery. 2009; 20(4): 19 - 27.
IEEE	GÜÇLÜ B,BENLİ T,KAYA A,KARAGÜVEN D,KÖKEN M "Normal bireylerde nötral ve hiperfleksiyon pozisyonlarında torakolomber bölge inserspinöz mesafenin değerlendirilmesi." Journal of Turkish Spinal Surgery, 20, ss.19 - 27, 2009.
ISNAD	GÜÇLÜ, BERK vd. "Normal bireylerde nötral ve hiperfleksiyon pozisyonlarında torakolomber bölge inserspinöz mesafenin değerlendirilmesi". Journal of Turkish Spinal Surgery 20/4 (2009), 19-27.