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Thoraco-lumbar fractures

Description

The thoraco-lumbar area of the spine is the most common site of spinal fractures representing 72.5 % of all spinal fractures in the U.S. each year. Most of these injuries are a direct result of a high impact traumatic force that disrupts the 3 column stability of the spine and can be associated with or without neurological compromise.

Structure and function

The thoracic spine follows a kyphotic curve and the lumbar spine conforms to a lordotic curve. Any fracture type may disrupt these normal angulations. Ribcage articulations at the thoracic vertebrae as well as the facet joint complex in the coronal plane both limit flexion and extension. The lumbar spine differs in that the facet complex is more sagitally oriented which increases flexion and extension but decreases lateral bending and rotation. At the transition zone between the thoracic and lumbar vertebrae called the TL junction, the facet joints are obliquely oriented which provides support and resistance to 35-45% of torsional and shear forces on the spine.

Commonly, the Denis 3 Column Classification of the spine helps to understand TL fracture subtypes. The anterior column is comprised of the anterior longitudinal, anterior anulus fibrosis, and anterior half of the vertebral body. The middle column is made up of the posterior longitudinal ligament, posterior anulus fibrosis, and the posterior half of the vertebral body. Lastly, the posterior column refers to the pedicles, facet joints, lamina, spinous processes, interspinous and supraspinous ligaments. 

Epidemiology

Occurrence follows a bi-modal distribution.  Males ages 15-29 have a high incidence as a result of injuries sustained in motor vehicle accidents. Almost half (52%) of fractures occur between the T11 and L1 vertebrae, 32% occur at the L1-L5 vertebral segments and 16% occur within the T1-T10 vertebrae.

The geriatric population is also more effected due to the high incidence of osteoporosis. In this group, low-energy trauma can cause fractures in this group.

Clinical presentation

As is standard protocol in traumatic injuries, the airway must be secured, breathing must be sufficient and circulation must be hemodynamically stable. Patients should be immobilized immediately to avoid worsening of any neurological deficits. This should involve use of a cervical spine collar, log rolling procedure and use of a spine board.

Sensory, motor and rectal examinations should be proceed in awake patients. Any deformity should be assessed via careful observation of the spinal column. Pain can be assessed by careful palpation. A detailed neurologic examination is crucial to determine any spinal cord or nerve root (cauda equina) injuries. 

Associated injuries are common in up to 50% of patients. These can include intra-abdominal bleeding from liver and splenic injuries, and arterial or venous vessel injuries. Additionally a hemothorax or pulmonary contusion should be assessed. 

Assessment 

Upper extremity evaluation includes the following nerve roots:

C5: shoulder abduction

C6:wrist extension

C7:wrist flexion

C8:finger flexion

T1: finger abduction

Lower extremity neurologic evaluation includes the following nerve roots:

L1: hip flexion

L2: hip adduction

L3: knee extension

L4: ankle dorsiflexion

L5: toe extension

American Spinal Injury Association (ASIA) Classification of Injury

A= Complete- no sacral motor or sensory function through the S4 and S5 segments. 

B= Incomplete- sacral sensory sparing that extends through the S4 and S5 segments. Motor function is not preserved

C=Incomplete- motor sparing below the neurological level and a majority of muscles have a muscle grade of less than 3

D= Incomplete- motor sparing below the neurological level and a majority of muscle have a muscle grade of greater than or equal to 3

E= Normal- Motor and sensory function is normal

Red flags

Make sure to assess bowel and bladder dysfuction as well as any associated leg weakness. Significant fractures at the level of the conus medullaris (L1-L2) can cause these deficiencies.

The patient should be taken off of the spine board as soon as it is safe to avoid skin breakdown.

Differential diagnosis

Herniated disk- patient will have back pain that radiates down the legs, and past the knees. However there will be no history of trauma.

Spinal stenosis- the pain is worse with walking and relieved with flexion. Also the patient will not have history of trauma.

Ankylosing spondylitis- patient will have morning back stiffness which improves with exercise

Spinal infection- the patient will present with fever and chills, back pain persistent at rest, and worse at night. This should be assessed in patients with the following risk factors: age > 50 years, chronic steroid use, immunocompromised status, and Intravenous Drug Users

Vertebral malignancy- This should be assessed in patients with persistent back pain > 6 weeks, back pain worse at night, unexplained weight loss, history of malignancy or age >50 years.

Fracture- These will often times be supported by a history of recent trauma.

Objective evidence

Imaging

Imaging of the setting of acute spinal trauma should be undertaken if: 1)back pain or midline tenderness 2)local signs of injury e.g. bruising 3)abnormal neurological signs 4) concomitant cervical spine fracture 5) Glasgow Coma Score of <15 6)major distracting injury and 7) alcohol or drug intoxication.

Anteroposterior (AP) and lateral radiographs should be inspected with special regards to any of the following features suggestive of a fracture.  Interpedicular distance widening, interspinous process widening, and abnormal kyphosis deformity are all indicative of further imaging and evaluation.

Computed tomography in the axial, coronal and sagittal planes allow the surgeon to clearly identify fracture pattern. CT evidence will allow for evaluation of any retropulsed bone into the canal, laminar fractures, pedicular evaluation for screw fixation, and facet joint subluxation suggestive of a possible capsular or Posterior Ligamentous complex injury.

Magnetic resonance imaging (MRI) can be helpful in assessment of neural compression, edema patterns, and bony and soft tissue structures. Hyperintensity of the posterior ligamentous structures on fat suppressed T2-weighted images suggests edema and PLC injury.

Risk factors and prevention

Traumatic conditions known to be associated with fracture severity include: fall from a height of greater than 3 meters (10 feet), motor vehicle accidents of greater than 60 mph, motor vehicle accident with ejection from the vehicle, evidence of seat belt sign on the front trunk of the patient, back pain, lower limb neurological deficits (weakness, paralysis or numbness) or sphincter disturbances.

If low energy- injury occurs then the following conditions should be ruled out: osteoporosis, neoplastic disorders (multiple myeloma, or metastatic disease), or underlying metabolic pathologies (osteogenesis imperfecta, rheumatoid arthritis, ankylosing spondylitis). 

Treatment options

Thoracolumbar injury classification and severity score (TLICSS) developed by Vaccaro et al. uses three primary variables (injury morphology, neurologic status of the patient and integrity of the PLC) indicators to dictate surgical treatment. Points are assigned based on the severity in each category and totaled. Injuries with 3 points or less are treated non-operatively. Injuries with scores of 5 or more are treated operatively. Lastly, a score of 4 may be treated operatively or non-operatively based on other clinical parameters.

Table 1: Thoracolumbar Injury Classification and Severity Score System

 

1. Description

Points

a. Compression fracture

1

b. Burst Fracture

2

c. Translational/ rotational

3

d. Distraction

4

2. PLC

Points

a. Intact

0

b. Suspected/ indeterminate

2

c. Injured

3

3. Neurological Status

Points

Nerve root

2

Cord, Conus medullaris -- Incomplete

3

                                  -- Complete

2

Cauda equina

3

Non-operative treatment

A large proportion of patients can be treated in a non-operative fashion. Ideal candidates include those who: are neurologically intact,  have compression or burst fracture assessment on imaging studies, have integrity of the PLC and those patients with a sagittal deformity of <25 degrees. Once these patients are stabilized they should be fitted with a custom molded orthosis (thoracolumbar spinal orthosis, TLSO) or placed in a cast. Once fitted AP and lateral radiographs are obtained to ensure correct overall coronal and sagittal alignment.

Operative treatment

Depending on fracture subtype surgical interventions vary.

Operative Treatment choices include the following:

1) Vertebroplasty or kyphoplasty (percuntaneous cement stabilization procedures): in cases of compression fractures, and select burst fracture cases

2) External fixation: useful in reduction of retropulsed bony fragments in the days immediately following injury

3) Anterior decompression and fusion: allows for reconstruction of the anterior and middle columns. instrumentation may augment stability. A posterior approach may be needed if the PLC is compromised.

4) Posterior fusion: Surgery is indicated when the PLC has been injured. This technique may be combined with transpedicular/ lateral extracavitary approach to allow for additional anterior column support; To avoid high failure rates extension of the fusion should be two levels above and below the level of the injury.

Outcomes

Long term follow up studies are few and varied in the literature. However, instrumentation failure rate has been reported up to 15% in patients undergoing surgical treatment and after 5 years follow up. However this study showed that only 1/3 of patients required revision surgery.

Pseudarthrosis after instrumentation varies from 2-8% of cases with the highest occurrence at the thoracolumbar junction.

Two long term randomized, prospective trials compared the results of patients undergoing surgical versus non-surgical treatment for stable thoracolumbar burst fractures without neurologic involvement found no significant differences between the two groups. (1,2).  However unstable injuries are more likely to benefit from surgical intervention.

Complications with the anterior technique are related to approach morbidity including: pulmonary impairment, visceral or vessel disruption, ileus, infection, and incisional herniation. Most of these events can be avoided with the thorough operative planning, meticulous technique and attentive postoperative care.

The posterior approach to thoracolumbar fractures has been shown to have excellent overall results with minimal complications.

Miscellany

- A majority of thoracolumbar fractures can be treated in a conservative fashion.

-A very thorough physical examination and imaging studies are crucial to establish the correct diagnosis and treatment.

-Emphasis and assessment should be placed on the mechanism of injury, neurologic status of the patient and integrity of the PLC to help stratify patients into operative or non-operative treatment.

Key terms

spine, trauma, fractures, thoracic, lumbar

Skills

Conduct a physical examination on a patient with suspected spinal cord injury, ASIA classification system, TLICS classification system, fracture types, ability to interpret CT and MRI evidence of fracture subtypes and PLC integrity 

Content

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