Thoracolumbar fractures : Wheeless' Textbook of Orthopaedics

- See:
- Burst Frx
- Thoracic & Thoracolumbar Spine :
- Posterolateral Decompression:

- Discussion:
- frx at this level are frequently due to relative immobility of thoracic spine compared to the lumbar spine;
- upper thoracic spine (T1 to T10) is stabilized by the ribs & facet orientation, and is less suseptible to trauma;
- at T12-L1 junction, however, there is a fulcrum of increased motion & this area is more commonly affected with spine trauma;
- mechanism:
- most often results from a combination of acute hyperflexion and rotation and consequently are more unstable;
- when a person is thrown from a moving vehicle, thoracolumbar frx dislocation frequently occurs;
- lap seat belt may be assoc w/ characteristic throracolumbar flexion distraction type of injury;
- prognosis for neurologic injury:
- majority of these injuries occur at T12, L1, L2;
- neurologic injury can be purely to the cord, to the cauda equina, or a mixture of both;
- most pts w/ traumatic paraplegia sustain vertebral injury at skeletal thoracolumbar junction where conus medullaris lies, & several
lumbar roots are descending to exit thru the appropriate foramen;
- it is not a purely spinal cord injury, but involves conus medullaris and descending roots of the cauda equina;
- most thoracic injuries with significant skeletal disruption will not demonstrate neurologic return despite anatomic stabilization;
- middle of T-spine is a vascular watershed area, & vascular insult can lead to cord ischemia; (see blood supply)
- it is difficult to prognosticate about injuries at thoracolumbar junction,
where there can be mixed cord & cauda equina lesions;
- spinal cord ends & caudal equina begins at level of L1 to L2, so lesions below L1 level carry better prognosis because nerve roots
and not cord is injured;
- references:
- Neurologic injury and recovery patterns in burst fractures at the T12 or L1 motion segment.

- Neuro Exam:
- because spinal cord terminates at this level, look for bladder & bowel signs & decrease movement & sensation in lower extremities;

- Radiographs:
- recognize stable vs unstable inuries:
- three column system is helpful in evaluating spinal injuries & determining which are stable or unstable;
- at the thoracolumbar junction, more than 20 deg of kyphosis indicates an unstable frx;
- thoracolumbar injuries seldom suddenly shift position but many slowly settle into malposition over several weeks following injury;
- this is a type of unstable injury;
- thoracolumbar injuries will be stable if middle column is intact, & will be unstable if disrupted, w/ the exception of upper thoracic
spine injuries;
- above T8, injury may disrupt middle column, but frx will still be stable manner if sternum and ribs in area of injury are OK;
- chest wall tends to splint the injury site, and if chest wall is unstable the injury will be unstable;
- references:
- Sagittal index in management of thoracolumbar burst fractures.
- CT scan prediction of neurological deficit in thoracolumbar burst fractures
- The value of computed tomography in thoracolumbar fractures: An analysis of one hundred consecutive cases and a new classification.
- Thoracolumbar fracture in blunt trauma patients: guidelines for diagnosis and imaging.

- Non Operative Treatment:
- hyperextension custom orthosis;
- references:
- The nonoperative treatment of burst fractures of the thoracolumbar junction.
- An analysis of conservative (non-surgical) management of thoracolumbar fractures and fracture-dislocations with neural damage.
- The management of burst fractures of the thoracic and lumbar spine. Experience in 53 patients.
- Long-term follow-up of nonoperatively treated thoracolumbar spine fractures.
- Thoracolumbar "burst" fractures treated conservatively. A long term follow up.

- Operative Treatment:
- Posterolateral Decompression
- most indicated for unstable burst frx w/ cord impingement along w/ dural tear and nerve root entrapment
from frx of posterior elements;
- Posterior Distraction Systems:
- Pedical Screw Implants:
- Anterior Decompression and Fusion
- most indicated for unstable burst frxs w/ cord impingement caused by bone fragments off the postero-superior vertebral body