Thoracolumbar Fracture

Question 1

Where do spinal fracture tend to occur?

Answer 1

At zones of mechanical transition

Question 2

What is the most commonly fractured region?

Answer 2

Thoracolumbar junction (T11-L2) with 40-60% of all spinal fracture occurring there

Question 3

Three columns of the spine

Answer 3

Anterior column - ALL and anterior half of the vertebral body and disc

Middle column - Posterior half of the vertebral body and disc + PLL

Posterior column - Posterior ligamentous complex, facet joint capsule, ligamentum flavum, interspinous and supraspinous ligaments + vertebral arches

Question 4

Classification of thoracolumbar fractures

Answer 4

AO classification

Type A - Compression injuries

Type B - Distraction injuries

Type C - Translation injuries

Question 5

Explain Burst fracture

Answer 5

Substantial compressive force acting through anterior and middle column of the vertebrae.

This leads to retropulsion of bone into spinal canal

This can lead to spinal cord injury

Incomplete burst = One end plate

Complete burst = Both end plates

Question 6

Explain Chance Fracture

Answer 6

From excessive flexion of the spine and involve all three spinal columns

They are unstable and will often need surgical intervention to stabilise.

Occur follwoing head-on road traffic accident if the patient was only wearing a lap belt e.g.

Commonly associated with abdominal injuries for that reason.

Question 7

Clinical features

Answer 7

Usually occur in osteoporotic atients and from low impact injuries.
It can be the first symptom of osteoporosis .

Young = high impact.

Back pain (not always especially if distracting injuries)

Can have neurological involvement depending on level of spinal cord that is involved (if it is involved)

Neurological examination should be done

Question 8

Dx

Answer 8

Any sort of back pain

Disc prolapse

Degenerative disease of spine

Malignancy

Infection

Question 9

Ix

Answer 9

Plain film radiograph (AP + lateral) - 1st line for suspected spinal column injury without neurological involvement

CT - If X-ray is abnormal or if neurological involvement

If a new spinal column fracture is found -> Image rest of spinal column.

MRI can be used for concurrent injury of soft tissue structures.

If young -> Suspect pathology and also do a screen for serum calcium and myeloma.

Question 10

General management

Answer 10

ATLS guidance with appropriate immobilisation

Restrict movement to prevent damage to spinal cord.

Question 11

Indications of non-operative management

Answer 11

Stable thoracolumbar fractures

Question 12

Non-surgical management

Answer 12

Extension bracing + lumbar corsets to resist progressive kyphosis and support spine.

Adequate analgesia and physiotherapy

Question 13

What is used to quantify the likelihood of instability and requirement for surgery?

Answer 13

Thoraco-Lumbar injury classification and severity (TLICS)

Question 14

Explain TLICS

Answer 14

Morphology
Wedge compression fracture = 1p
Translation/rotation fracture = 3p
Distraction fracture = 4p

Integrity of Posterior Ligamentous complex
Intact = 0p
Suspected or indeterminate = 2p
Injured = 3p

Neurological status
Intact = 0p
Nerve root = 2p
Cord or conus medullaris is incomplete = 3p
Cord or conus medullaris is complete = 2p
Cauda equina = 3p

Score of 5 or more are considered unstable

3 or less usually considered stable

Question 15

Surgical management

Answer 15

Decompression and instrumented spinal fusion

Stabilisation is done posterior approach with patient lying prone.

Fixation by pedicle screws and rods