Thoracolumbar injuries

Question 1

Why is the upper thoracic spine less susceptible to trauma/

Answer 1

t1-t10 stabilised by ribs and sternum so more stable

Question 2

Why is the thoracolumbar junction most common area for fracture?

Answer 2

Transitional area from relatively rigid movements to more mobile movement

Question 3

Where does the spinal cord end?

Answer 3

L1/2 so lesions below L1 have better prognosis because the nerve roots not the spinal cord are affected.

Question 4

Can you name a classification system for thoracolumbar fractures ?

Answer 4

TLICS

Thoracolumbar injury and classification severity score

Question 5

Can you describe the classification system for thoracolumbar fractures ?

Answer 5

Broken down into
FRACTURE MORPHOLOGY
NEUROLOGY
POST LONGITUDINAL LIGAMENT

FRACTURE:
COMPRESSION FRACTURE - 1 POINT 
BURST FRACTURE- 2 POINTS 
ROTATION/TRANSLATION- 3 POINTS
DISTRACTION- 4 POINTS

NEUROLOGY
INTACT =0
NERVE ROOT=2
COMPLETE CORD INJURY=2
INCOMPLETE CORD INJURY=3
CAUDA EQUINA=3

PLL
INTACT=0
INJURY SUSPECTED =2
INJURED=3 palpable gap between spinous processes/ interspinous widening

Question 6

How does TLICS aid management?

Answer 6

A score of 5> - unstable and requires OP fixation
a score of <3 - stable no operation
a score 4 - indistinct

Question 7

What is the mechanism for a compression fracture to occur ?

Answer 7

AXIAL load

common fracture pattern

Question 8

What is the mechanism for a burst fracture to occur ?

Answer 8

axial load with flexion

RETROPULSION OF FRAGMENTS-> canal compromise max at time of impact

Question 9

What is the mechanism for a translation/rotation fracture to occur ?

Answer 9

TORSIONAL SHEAR

Question 10

What is the mechanism for a distraction fracture to occur ?

Answer 10

TENSILE force

Question 11

What other classification systems do you know of for these fractures ?

Answer 11

DENIS 3 column theory

Question 12

What ligaments make up the PLL?

Answer 12

Supraspinous ligaments
interspinous ligaments
ligamentum flavum
facet capsule

Question 13

what investigations are helpful in dx of a burst fracture ?

Answer 13

X-rays- ap - widening of pedicles, coronal deformity
lateral shows retropulsion and kyphotic deformity

CT- fractrue and neurological deficit

MRI- useful to evaluate the spinal cord/ thecal sac compression by disc or osseous material. cord oedema or haemorrhage.. identity any injury to PLL

Question 14

How does this classification aid management?

Answer 14

disruption of the middle column- widening of interpedicular distances on ap radiographs or a chance in height of the post cortex of body o lat view= UNSTABLE injury and may require OP fixation

Question 15

When would a fracture be fixed?

Answer 15

TLICS score >5
fractures >30 degrees of KYPHOSIS
>50% loss of vertebral height
PLL disrupted
neurological compromise

Question 16

Can you describe the 3 locations of the columns?

Answer 16

Anterior- from Ant Longitudinal log-> ant 2/3 res of vertebral body
Middle- post 1/3 vertebral body-> Post longitudinal ligament
Posterior- everything posterior to PLL- pedicels, facets, ligamentum flavum, spinous process,

Question 17

What surgery would be performed in the unstable cases?

Answer 17

DECOMPRESSION for progressive neurological deficit emergency or incomplete cord injury
POSTERIOR INSTRUMENTATION AND FUSION - extending 3 levels above and 2 levels below fracture. modern pedicle screws changes this to one level above and one level below. Laminectomy is avoided as it could further destabilise the spine compromising the post supporting structures

Question 18

When would a fracture be tx non op? and what would this be?

Answer 18

TLICS <50% loss of vertebral height
Intact PLL

Thoracolumbar orthosis or casting with serial X-rays to confirm maintenance of alignment