Orthopaedic Surgery - Thoracolumbar Spine Fracture and Dislocation

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Basics

Thoracolumbar fractures are among the most common:

Spinal fractures.

The region most frequently injured is the:

Thoracolumbar junction

particularly:

T11–L1.

This area is vulnerable because it represents a transition between the relatively rigid:

Thoracic spine

and the more mobile:

Lumbar spine.

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Associated Spinal Injuries

Additional spinal injuries may occur in up to approximately:

15% of patients.

These may be:

Contiguous

or

Noncontiguous.

For this reason, the:

Entire spinal column

should be considered during trauma assessment.

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Associated Abdominal Injuries

Abdominal injuries occur in approximately:

20% of patients

with significant thoracolumbar trauma.

Potential associated injuries include:

Splenic rupture

Liver laceration

Renal injury

and

Bowel injury.

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Denis Three-Column Classification

The classic:

Denis three-column system

divides the thoracolumbar spine into:

Anterior

Middle

and

Posterior columns.

Although modern treatment also relies on newer concepts such as mechanical stability and posterior ligamentous complex integrity, this classification remains useful for understanding:

Fracture morphology.

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Anterior Column

The anterior column consists of approximately the:

Anterior two-thirds of the vertebral body and intervertebral disc

together with the associated anterior supporting structures.

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Middle Column

The middle column includes the:

Posterior one-third of the vertebral body and disc

and the:

Posterior longitudinal ligament.

Disruption of the middle column historically has been considered an important marker of:

Potential instability.

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Posterior Column

The posterior column includes the:

Pedicles

Facet joints

Laminae

Transverse processes

and

Spinous processes

together with the posterior ligamentous structures.

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Minor Injuries

Minor thoracolumbar injuries include isolated fractures involving structures such as:

Spinous processes

Transverse processes

Pars interarticularis

and

Facets.

These injuries may still be clinically important depending on their:

Mechanism

and associated injuries.

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Major Injuries

Major thoracolumbar injuries include:

Compression fractures

Burst fractures

Flexion-distraction injuries

Fracture-dislocations

and

Distraction-extension injuries.

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Epidemiology

High-energy thoracolumbar trauma occurs most frequently in:

Young adults

particularly:

Males between approximately 15 and 30 years of age.

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Older Adults

Elderly patients with:

Osteopenia

or

Osteoporosis

may sustain vertebral fractures after relatively:

Low-energy trauma.

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Risk Factors

Important risk factors include:

Motor vehicle collisions

Falls from height

High-energy trauma

and

Osteoporotic bone.

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Associated Conditions

Thoracolumbar fractures may be accompanied by:

Neurologic injury

Spinal shock

Other spinal fractures

and significant:

Abdominal trauma.

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Spinal Shock

Following major spinal cord injury, patients may temporarily develop:

Flaccid paralysis

Loss of reflexes

and reduced:

Autonomic function

below the level of injury.

This transient state is known as:

Spinal shock.

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Diagnosis

Diagnosis requires careful assessment of:

Mechanism of injury

Spinal tenderness

Neurologic status

and

Imaging.

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History

For high-energy trauma, information should be obtained from:

The patient

and

Prehospital personnel

when available.

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Mechanism of Injury

Important mechanisms include:

Motor vehicle collision

Fall from height

Crush injury

and

Direct high-energy trauma.

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Relevant Medical History

Ask about conditions that may alter spinal biomechanics or bone quality, including:

Ankylosing spondylitis

Osteoporosis

Previous spinal surgery

Diabetes mellitus

and known:

Malignancy.

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Physical Examination

Repeated neurologic examination is essential.

Any deterioration may provide the earliest sign of:

Progressive neural compromise

or instability requiring:

Urgent intervention.

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Documentation

The initial examination should be documented carefully and compared with:

Prehospital findings

and subsequent:

Serial examinations.

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Inspection

Inspect the back and trunk for:

Ecchymosis

Seat-belt marks

Visible deformity

Step-off

or evidence of:

Open injury.

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Palpation

Palpate the:

Entire spinal column

for:

Tenderness

Gap

Step-off

or deformity.

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Motor Examination

Motor power should be graded using the:

Medical Research Council 0–5 scale.

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Grade 0

No visible or palpable muscle contraction.

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Grade 1

Flicker or trace contraction without joint movement.

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Grade 2

Full joint motion with gravity eliminated.

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Grade 3

Full joint motion against gravity.

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Grade 4

Movement against gravity and some external resistance.

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Grade 5

Normal strength against full resistance.

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Sensory Examination

A sensory level should be documented using reproducible:

Dermatomal landmarks.

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Thoracic Landmarks

Important landmarks include:

T4 – nipple line

T7 – xiphoid region

T10 – umbilicus

and

T12 – inguinal region.

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Lumbar and Sacral Landmarks

Additional landmarks include:

L1 – proximal anterior thigh

L2 – middle anterior thigh

L3 – region above the patella

L4 – medial malleolus

L5 – dorsum of the foot, classically near the third toe

and

S1 – lateral foot or small-toe region.

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Reflexes

Important lower-extremity reflexes include:

L4 – patellar reflex

and

S1 – Achilles reflex.

There is no routinely useful isolated:

L5 deep-tendon reflex.

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Sacral Examination

When neurologic injury is suspected, evaluate sacral function, including:

Perianal sensation

Voluntary anal contraction

and relevant:

Sacral reflexes.

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Rectal Examination

Assessment may include:

Anal tone

Voluntary contraction

and

Perianal light touch or pinprick sensation

in approximately the:

S2–S5 distribution.

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Bulbocavernosus Reflex

The:

Bulbocavernosus reflex

may help assess sacral reflex activity and can be useful during evaluation of:

Spinal shock.

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Anal Wink

The:

Anal wink reflex

may also provide information about:

Sacral neurologic integrity.

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Imaging

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Initial Trauma Imaging

In modern trauma care, imaging selection depends on:

Mechanism

Clinical examination

and trauma-system protocols.

CT is frequently used as the primary imaging modality in significant:

Thoracolumbar trauma.

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Plain Radiographs

AP and lateral spinal radiographs may demonstrate:

Compression

Loss of vertebral height

Kyphosis

Translation

or

Fracture-dislocation.

They may still be useful in selected:

Lower-energy injuries.

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CT

CT provides excellent visualization of:

Fracture morphology

Canal compromise

Posterior element injury

and

Bony retropulsion.

It is also extremely valuable for:

Preoperative planning.

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Entire-Spine Assessment

Because noncontiguous fractures can occur, imaging of the entire spine should be considered in patients with:

Major trauma

or one confirmed:

Spinal fracture.

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MRI

MRI is particularly useful when there is concern for:

Spinal cord injury

Disc herniation

Epidural hematoma

or

Posterior ligamentous complex injury.

These soft-tissue abnormalities may not be adequately demonstrated by:

CT.

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Differential Diagnosis

Not every vertebral deformity represents an:

Acute fracture.

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Developmental Wedging

Conditions such as:

Scheuermann kyphosis

or congenital:

Vertebral wedging

may mimic:

Compression fracture.

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Osteoporotic and Pathologic Fracture

Patients older than approximately:

50 years

who sustain fractures after relatively minor trauma should be evaluated for:

Osteoporosis.

A:

Pathologic fracture

from malignancy or other bone disease should also be considered when clinically appropriate.

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Treatment

Treatment depends on:

Fracture morphology

Mechanical stability

Neurologic status

Posterior ligamentous complex integrity

and overall:

Patient condition.

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Initial Stabilization

Patients with suspected unstable spinal injury should be handled with:

Spinal precautions

until the injury has been adequately:

Evaluated and stabilized.

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Stable Fractures

Stable injuries may be treated with:

Early mobilization

with or without a:

Thoracolumbosacral orthosis, or TLSO.

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Brace Selection

A TLSO may be modified depending on the:

Fracture level

and specific:

Biomechanical needs.

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Unstable Fractures

Patients awaiting operative stabilization may require:

Restricted mobilization

until definitive fixation is performed.

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Compression Fractures

Simple compression fractures generally involve primarily the:

Anterior column.

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Mild Compression Fractures

Neurologically intact patients with mild stable fractures may be treated with:

Analgesia

Early mobilization

and often:

No brace.

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TLSO for Compression Fracture

A TLSO may be used when it improves:

Comfort

or provides additional:

External support.

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Osteoporotic Compression Fractures

Management should include evaluation and treatment of the underlying:

Osteoporosis

to reduce the risk of:

Future fractures.

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Vertebral Augmentation

Procedures such as:

Kyphoplasty

or

Vertebroplasty

may be considered in carefully selected patients with painful:

Osteoporotic

or

Osteolytic vertebral compression fractures.

They are not required for most uncomplicated:

Compression fractures.

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Burst Fractures

Burst fractures result from:

Axial compression

and commonly involve the:

Anterior and middle columns.

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Retropulsion

Fragments of the posterior vertebral body may be driven into the:

Spinal canal.

The presence of canal compromise alone does not automatically mandate:

Surgery.

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Nonoperative Burst-Fracture Treatment

Neurologically intact patients with stable alignment may be treated with:

Early mobilization

with or without a:

TLSO.

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Surgical Considerations for Burst Fractures

Surgery is more strongly considered when there is:

Neurologic injury

Progressive deformity

Mechanical instability

or major disruption of the:

Posterior ligamentous complex.

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Historical Radiographic Thresholds

Historical factors associated with operative treatment include:

Kyphosis greater than approximately 20°

Facet subluxation

Increased interspinous distance

More than 50% loss of vertebral body height

and

More than 50% canal compromise.

These thresholds should not be interpreted in isolation.

The overall:

Clinical and mechanical context

is more important than any single measurement.

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Flexion-Distraction Injury

Flexion-distraction injuries are often called:

Chance fractures

or

Seat-belt injuries.

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Mechanism

These injuries involve distraction of the:

Posterior spinal structures

with compression or fracture of the:

Anterior column.

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Ligamentous Injury

When the injury is primarily ligamentous, healing may be less reliable and the injury is generally:

Unstable.

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Abdominal Injury Association

Flexion-distraction injuries have a strong association with:

Intra-abdominal trauma

particularly:

Bowel injury.

A careful abdominal assessment is therefore essential.

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Nonoperative Management

Selected purely bony Chance fractures in neurologically intact patients may occasionally be treated:

Nonoperatively.

However, injuries with substantial:

Ligamentous disruption

more commonly require:

Surgical stabilization.

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Fracture-Dislocation

Fracture-dislocations may demonstrate:

Facet fracture-dislocation

Rotation

and

Translation.

These injuries are generally:

Highly unstable.

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Neurologic Risk

Because of major displacement, fracture-dislocations carry a high risk of:

Spinal cord

or

Cauda equina injury.

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Treatment of Fracture-Dislocation

Nonoperative treatment is rarely appropriate.

Surgery usually begins with:

Reduction

and

Posterior stabilization.

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Distraction-Extension Injury

Distraction-extension injuries are:

Uncommon

and often occur in patients with an unusually rigid spine, such as those with:

Ankylosing spondylitis

Diffuse idiopathic skeletal hyperostosis

or other disorders affecting:

Spinal biomechanics.

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Stability

These injuries are typically:

Highly unstable

and usually require:

Operative fixation.

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Surgical Strategy

Treatment commonly involves:

Posterior instrumentation and fusion

with additional anterior reconstruction when required by:

Fracture morphology.

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Activity

Patients treated with stable fixation or a suitable brace may advance toward:

Progressive mobilization and weight bearing

as allowed by:

Fracture stability

and

Neurologic status.

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Neurologic Injury

Patients with neurologic deficits require individualized:

Rehabilitation

based on the level and completeness of:

Spinal cord or cauda equina injury.

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Nursing Care

Serial assessment should include:

Vital signs

and repeated:

Neurologic examinations.

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Change in Neurologic Status

Any deterioration in:

Strength

Sensation

or

Sacral function

requires prompt:

Reassessment.

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Counseling

Patients with spinal cord injury may require:

Psychological support

and counseling regarding:

Mobility

Employment

Independence

and long-term:

Lifestyle adaptation.

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Physical Therapy

Physical therapy plays an essential role in:

Mobilization

and

Functional recovery.

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Benefits of Early Rehabilitation

Appropriate rehabilitation may reduce complications such as:

Pressure injury

Pneumonia

Venous thromboembolism

Contractures

and

Disuse osteoporosis.

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Occupational Therapy

Occupational therapy is particularly important for patients with neurologic injury who require adaptation for:

Transfers

Self-care

Mobility

and

Activities of daily living.

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Medication

Pain control should be individualized.

There is generally no role for routine:

Long-term maintenance opioid therapy.

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First-Line Analgesia

Options may include:

Acetaminophen

and

NSAIDs

when medically appropriate.

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NSAIDs

Anti-inflammatory medications should be used cautiously in patients with:

Renal disease

Gastrointestinal risk

or other relevant:

Contraindications.

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Opioids

Short-term opioid therapy may be appropriate for:

Severe acute fracture pain

particularly during the early:

Post-traumatic period.

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Radiotherapy

Radiotherapy may have a role in selected patients with:

Radiosensitive tumors

causing pathological thoracolumbar:

Fractures.

Its purpose is primarily to reduce:

Tumor burden

and improve:

Local disease control.

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Surgery

The goals of surgery are to:

Restore alignment

Stabilize the spinal column

and, when necessary,

Decompress neural structures.

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Surgical Approach

The optimal approach depends on:

Fracture morphology

Neurologic compression

Bone quality

and surgeon:

Experience.

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Posterior Instrumentation

Posterior instrumentation is commonly favored because it provides effective:

Reduction

Fixation

and

Correction of alignment

without the additional morbidity of a major:

Anterior approach.

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Neural Decompression

Decompression is indicated when there is clinically significant compression of the:

Spinal cord

Conus medullaris

or

Cauda equina

and when decompression is expected to improve:

Neurologic outcome or mechanical stability.

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Anterior Approach

An anterior approach may be useful when substantial:

Vertebral body destruction

or

Anterior canal compression

requires direct:

Decompression and reconstruction.

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Retropulsed Fragments

Anterior surgery may be particularly useful for selected cases involving significant:

Retropulsed vertebral-body fragments

compressing the:

Anterior spinal canal.

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Fusion

Fusion may accompany fixation when:

Instability

Major ligamentous disruption

or extensive bony injury prevents reliable healing without:

Arthrodesis.

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Follow-Up

Patients with major injuries often benefit from coordinated follow-up involving:

Spine surgery

Rehabilitation medicine

Physical therapy

and

Occupational therapy.

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Rehabilitation Facility

Patients with severe neurologic injury may recover best initially in a specialized:

Inpatient rehabilitation facility.

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Pain Specialist Referral

Persistent chronic pain may warrant referral to:

Pain medicine.

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Rehabilitation Medicine

Patients with spinal cord or cauda equina injury should be followed by:

Physical medicine and rehabilitation specialists.

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Neurology Consultation

Neurologic consultation may be useful when the pattern of deficit does not correlate with the identified:

Spinal injury.

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Prognosis

Outcome depends strongly on:

Fracture severity

and particularly on:

Neurologic status.

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Neurologically Intact Patients

Patients with stable low-energy injuries and preserved neurologic function usually have an:

Excellent prognosis.

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Neurologic Injury

Patients with significant neurologic deficits may experience long-term effects on:

Mobility

Bladder and bowel function

Employment

and

Independence.

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Complications

Potential complications include:

Infection

Neurologic deterioration

Pseudarthrosis

Spinal deformity

Junctional degeneration

Spinal stenosis

Chronic pain

and

Disability.

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Brace-Related Complications

TLSO braces can cause:

Skin irritation

Pressure injury

and discomfort over:

Bony prominences.

Regular skin checks are important.

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Pseudarthrosis

Failure of an intended fusion to heal may cause:

Persistent pain

Implant failure

or progressive:

Deformity.

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Junctional Degeneration

Long spinal fusion constructs may increase mechanical stress at adjacent levels, contributing to:

Junctional degeneration

or

Stenosis.

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Chronic Pain

Persistent pain may arise from:

Residual deformity

Neurologic injury

Degenerative change

or

Postoperative complications.

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Patient Monitoring

Patients should be monitored for:

Pain resolution

Neurologic recovery

Maintenance of alignment

and

Fracture healing.

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Fusion Monitoring

If arthrodesis has been performed, follow-up should also evaluate for:

Solid fusion

and

Implant stability.

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Red-Flag Findings

Urgent reassessment is required for:

New or progressive weakness

New sensory loss

Loss of bowel or bladder control

Increasing saddle anesthesia

or

Worsening spinal deformity.

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Key Principle

Thoracolumbar spine fractures most commonly involve the:

T11–L1 junction, where the rigid thoracic spine transitions to the more mobile lumbar spine.

Evaluation must include careful assessment for:

Noncontiguous spinal injury, neurologic compromise, and associated abdominal trauma.

CT is the principal imaging study for defining:

Fracture morphology, while MRI is especially useful for evaluating:

Spinal cord, disc, epidural, and posterior ligamentous complex injury.

Stable fractures may often be treated with:

Early mobilization with or without a TLSO, whereas unstable injuries such as:

Fracture-dislocations, major ligamentous flexion-distraction injuries, and distraction-extension injuries

usually require:

Operative stabilization.

The major goals of treatment are to preserve or restore:

Neurologic function, spinal alignment, mechanical stability, and early safe mobilization.