THORACOLUMBAR FRACTURES
By
Dr. Rishit J Soni
2nd year Resident ,
Dept Of Orthopaedics,
C U Shah medical College,
Surendranagar
OUTLINE
Epidemiology
Clinical evaluation
ATLS
Neuro exam
Neurogenic / spinal shock
Classification of spinal cord injury
Grading system
Complete VS incomplete
Incomplete cord syndromes
OUTLINE
Radiographic Evaluation
Plain Xray
CT
MRI
Mylography
Spinal Stability
Classification of Fractures
Treatment of Specific Injuries
EPIDEMIOLOGY
Prevalence / Incidence : Thoracic and lumbar
fractures account for 30% to 50% of all spinal
injuries in trauma patients
Majority of thoracic and lumbar injuries occur
within the region between T11 and L1, commonly
referred to as the thoracolumbar junction
The thoracolumbar junction is a transition zone
between the relatively stiff thoracic spine,
stabilized by the costovertebral articulations, and
more mobile lumbar spine
Mechanism : axial loading(compression)
flexion
extension (lumbar jack injuries)
shear
axial rotation
Multiple injury: multiple level involvement can
occur .
High Suspicion For Abdominal and thoracic
injury
CLINICAL EVALUATION
E
Pre Hospital care :
Strict precaution for immobilization in form of
spine board and cervical collar needed.
Urgent transportation to adequately equipped
tertiary health centre.
Resuscitation should begin immediately .
In Hospital Care
Primary survey: Airway
Breathing
Circulation
Disability
Exposure
Glasgow Coma Scale
Secondary survey : Complete Spine examination
Thorough history
Inspect and palpate entire spine
Per anal examination :
sphincter tone
bulbocavernous reflex
anal wink
voluntary anal contraction
sensory examination
Neurogenic shock :
Heamodynamic instability that occurs with
rostral cord injury related to loss of sympathetic
tone to the peripheral vasculature and heart.
The consequences of which are bradycardia,
hypotension and hypothermia due to absent
thermoregulation.
Spinal Shock
It is temporary dysfunction of spinal cord with
loss of reflexes and sensory as well as motor
function caudal to the level of injury manifested
by
Absence of anal wink and bulbocavernous
reflexes.
It is a temporary phenomenon and recovers
within 24-48 hours even in severe injury.
CLINICAL EVALUATION
Complete Neurological Evaluation
Motor function
Sensory Testing
Reflex Examination
AMERICAN SPINE INJURY ASSOCIATION
REFLEX EXAMINATION
COMPLETE VS INCOMPLETE
Complete
No function below level of injury
Absence of sensation and voluntary movement in
S4/5 distribution
Incomplete
Preservation of sensation in S4/5 distribution and
voluntary control of anal sphincter
RELEVANT ANATOMY OF SPINAL
TRACKS
INCOMPLETE CORD LESION
Determined by anatomic location of tissue injury
Prognosis better than complete injury.
Important to determine zone of partial
preservation.
INCOMPLETE CORD LESION
Arrangment of
corticospinaltracks
Nerve fibres to upper
limb are centrally
situated as compared
to lower limb
CENTRAL CORD SYNDROME
MC type
Usually by
hyperextension
Weakness :
upper > lower
Distal>proximal
Variable sensory loss
Sacral sparing
Good prognosis
ANTERIOR CORD SYNDROME
Loss of motor, pain and
temperature below
level of injury
Preserved
proprioception and
light touch
Results d/t
hyperflexion injury in
which bone/disc
fragment compress ant
spinal artery or cord
POSTERIOR CORD SYNDROME
Affects dorsal column
Loss of proprioception,
vibratory sense below
level
Preserve other sensory
and motor function
Rare syndrome caused
by extension injury
BROWN SEQUARD SYNDROME
Hemisection of
spinal cord
Loss of ipsilateral
motor and
propioception
Loss of contralateral
pain and
temperature
Associated with facet
joint dislocation,
lamina /pedicle
fracture
CONUS MEDULLARIS SYNDROME
Injury to sacral cord and lumbar roots
At level of T11 to L1
Manifestation :Sphincter dysfunction
-Areflexic bowel and bladder
-Saddle anaesthesia
-Variable lumbar roots
involvement
CAUDA EQUINA SYNDROME
Injury to the lumbosacral nerve roots
within spinal canal below L1
Presents with
-Low back pain
-Lower limb weakness
-Sphincter dysfunction
-Areflexic bowel and bladder
-Saddle anaesthesia
-calf atrophy
Do Usg for noting post void residual
urine level pre op : prognostic
value(normal 50 to 100 ml)
BLADDER DYSFUNCTION
Innervation
Sympathetic (L1-L2): contracts internal sphincter
relaxes detrusors
ParaSympathetic (S2 S3 S4):
relaxes internal sphincter
contracts detrusors
Somatic(pudendal nerve S2 TO S4) : controls
external sphincter
AUTOMATIC BLADDER
If Lesion above S2
Loss of higher centre control,bladder function
controlled by spinal reflexes
Frequency and incontinence, bladder small
and sensitive to small changes in volume
AKA : UMN Type bladder / Cord Bladder
AUTONOMOUS BLADDER
If Lesion below S2
Loss of even spinal control,bladder fumntion
controlled by local myoneural reflexes
Flaccid ,atonic bladder with Overflow
incontinence
AKA : LMN Type bladder / Atonic /Isolated
Bladder
RADIOGRAPHIC EVALUATION
Trauma Series
AP / Lat thoracic and
lumbar spine
Oblique view
Flexion and extension view
Indicators of PLC disruption
Abnormal sagital or coronal plane translation
>2.5mm
Relative Increased inter spinous distance
> 50% loss of vertebral body height
> 30 degree of kyphosis
RADIOGRAPHIC EVALUATION
CT
provide finer detail of the bony
involvement in thoracolumbar
injuries
All cases of suspected injury to
posterior elements or posterior
vertebral body.
Associated abdominal ,pelvic
and thoracic injury ruled out of
respective Ct cans
Axial images readily
demonstrate the degree of canal
compromise from retropulsed
fragments
empty or naked facet sign : facet
dislocation
RADIOGRAPHIC EVALUATION
MRI
Indicated in cases of neurological deficit with
inconclusive radiographs
discherniations, epidural hematomas, or spinal cord
edema easily visualised
Both intrinsic and extrinsic cord injuries.
Important tool in assessing the integrity of the PLC
TERMS
Compression :
wedge-type fractures of the anterior and
middle aspects of the vertebral body. no
involvement of the posterior vertebral body
Burst :
Has compression of posterior part of body
also. Has associated retropulsed bony fragment
in canal.
SPINAL STABILITY
Holdsworth 1963
2 column theory
SPINAL STABILITY
Denis 1983
CT Scan
3 column theory
Stability based on
integrity of middle
coloumn
SPINAL STABILITY
Categorized major spinal injury into 4 groups:
1. Compression Fracture
2. Burst Fractures
3. Flexion Distraction Injuries
4. Fracture Dislocations
COMPRESSION
Type A involves
both endplates,
type B involves
the superior
endplate, and
type C involves
the inferior
endplate. In type
D fractures, there
is a compression
fracture of the
anteriovertebral
BURST
Type A involves
fractures of both
endplates, type B
involves fractures
of the superior
endplate, and type
C involves
fractures of the
inferior endplate.
Type D is a
combination of a
type A fracture
with rotation. Type
E fractures exhibit
lateral translation.
FLEXION
DISTRACTION/CHANCE/SEAT BELT
IMJURY
Types A and B occur at one
level, either through bone (A)
or ligament (B). Type C and D
occur at two levels (motion
segments). Type C denotes that
the middle column failed
through bone. Type D denotes
that the middle column failed
through ligament and disc.
FRACTURE DISLOCATION
Type A are bony one-
level injuries.
Type B are one-level
ligamentous injuries.
Type C injuries are
two-level injuries
that occur through
bone and/or
ligament.
WHITE AND PUNJABI
MCAFEE SYSTEM
6 categories:
wedge-compression fractures
stable burst fractures :intact posterior coloumn
unstable burst fractures
Chance fractures(flexion distraction injury) :
flexion around axis anterior to ALL
flexion-compression injuries: flexion around axis
posterior to ALL
translational injuries
AO CLASSIFICATION SYSTEM
/MAGERL
MCCORMACK GRADING
Used in Burst fr
Score more than 6
indicative of use of
longer posterior
fixation or supplement
with anterior .
TREATMENT
Modaility :
Non operativeve : Analgesics
Braces
physiotherapy.
steroids :Most benefit occurs in the first 8 hours, and
additional effect occurs within the first 24 hours
Methylprednisolone bolus 30 mg/kg, then infusion 5.4 mg/kg/h
Infusion for 24 hours if bolus given within 3 hours of injury
Infusion for 48 hours if bolus given within 3 to 8 hours after
injury
No benefit if methylprednisolone started more than 8 hours
after injury
Operative : posterior stabilisation
anterior decompression and stabilisation
BRACES
TLSO brace
1) Hyperextenxion
brace : JEWETT
2) Sagital control:
Taylor brace
Both flexion and
extension restricted
TLSO : 3)Sagital
Coronal control brace
Knight-Taylor brace
Has lateral bars for
coronal control
POSTRIOR SURGERY:PRIMARILY
FOR REALIGNMENT AND
STABILIZATION
Advantages :
avoids the morbidity of anterior exposure
in patients who potentially have concomitant
pulmonary or abdominal injuries.
shorter operative times
decreased blood loss
functional outcomes are similar to those
following anterior surgery
Disadvantages: no direct approach to site of
pathology
Initially hooks and
wires were used
Pedicle screws wit
rods most commonly
useds with rods for
stabilisation now.
Sites
1) thoracic :
immediately lateral to
middle of facet joint
along superior third of
transverse process
2) lumbar vertebrae:
Intersection of line
bisecting the
transverse process and
line passing along
lateral aspect of facet
joint
Other methods
mamillary process
pars interarticularis
method
POSTERIOR REALIGNMENT AND
FIXATION
ANTERIOR SURGERY
Indicated for decompression of the neural
elements.
It provides direct visualization of the anterior
thecal sac and is the most reliable method of
spinal canal decompression
Higher morbidity
Decompression followed by void filling with
autograft/ allograft / cage insertion
Fixation by plates and screws/ rods -screw-staple
construct.
ANTERIOR DECOMPRESSION AND
STABILISATION
COMBINED APPROACH
Advantages:
maximization of canal clearance,
immediate circumferential stability
optimized fusion rates.
Disadvantage
superadded morbidity of two procedure
Usually opted as 2 stage procedure : post ct scan
shows increased deformity or has residual
neurological deficit
COMPRESSION FRACTURE
<10% vertebral height loss :no need external support.
<30% to 40% height loss and <20 degrees to 25
degrees kyphosis : Jewett brace for 6 to 8 weeks.
In fractures below T5, a plaster jacket or TLSO can be
used.
In higher fractures, a cervical component should be
added to the brace.
50% height loss or >30 degrees kyphosis suggests
PLC disruption, and posterior stabilization is
recommended.
An MRI scan should be used to examine the integrity
of the PLC
BURST FRACTURE
Failure of anterior and middle column
Axial compression
+/- failure of posterior column
Compression or tensile force
Most common at T/L junction
BURST FRACTURE
Stable :
No PLC injury without neurologic deficit
Radiographic criteria for non operative
less than 25 degrees to 30 degrees of kyphosis,
less than 50% height loss,
absence of interspinous process widening,
less than 50% canal compromise
MRI evidence of discontinuity or continuity of the
PLC
TLSO( hyperextension) Brace applied for 3 months
X-ray and clinical follow-up examinations are
scheduled at 2 weeks, 1 month, 2 months, and 3
months. At the 3-month follow-up, x-rays are made
out of the brace to ensure stable alignment.
UNSTABLE BURST FRACTURE
Need operative stabilization
Posterior instrumentation and fusion:
PLC disruption in neurologically intact
patients.
<50% height loss: short-segment stabilization
>greater than 50% or extensive comminution:
pedicle screws are placed two levels above and
below the fractured vertebra.
Neurological deficit :
Complete injury
Earlystabilization
Neurological outcome not changed by
decompression
Incomplete injury
Stabilization
and decompression beneficial .
Improvement may occur
DECOMPRESSION
Posterior
Indirect (distraction and ligamentotaxis)
Direct
Transpedicle approach
posterolateral appoach
laminotomy/ laminectomy
Anterior
Partial / complete corpectomy
FLEXION DISTRACTION INJURY
Bone or soft tissue?
SEAT BELT / CHANCE
INJURY
Associated with intra-abdominal pathology.
Purely Osseous injuries can be treated
nonoperatively
If the injury is ligamentous or osseoligamentous,
surgical stabilization is indicated
Single-segment posterior fusion is usually
adequate.
Surgeons should check that the pedicles at
adjacent levels are intact prior to surgery.
If not : longer fixation is required
In about 15% of cases, there is associated burst
fracture configuration.
In about 5% of cases, there is an associated
herniated disc : Anterior decompression
FRACTURE DISLOCATION
High energy trauma
There is a high incidence of complete
neurologic deficit
Goal:
Stabilization for early mobilization
Long posterior pedicle screw constructs are
best for thoracolumbar fracture-
dislocations.
Up to 50% dural tears have been noted.
Short-segment spinal fixation may not
provide adequate stabilization
GUN SHOT WOUNDS
Rare injury
Transabdominal bullets :
higher source of
contamination
Complete injury more
common than incomplete
Retained bullets may
cause to lead toxicity
TREATMENT OVERVIEW
COMPRESSION FRACTURE
BURST FRACTURE
FLEXION DISTRACTION INJURY
FRACTURE DISLOCATION
MINOR INJURY
Thank You
