Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

Featured on Channel NewsAsia

ThoracoLumbar Spine Fracture and Dislocation

Basics

Description
  • Most spine fractures occur in the thoracolumbar region.
  • TL1 is the most frequently injured area.
  • Concomitant spine injuries are present in up to 15% of patients.
  • Associated abdominal injuries are present in ~20% of patients.
  • The Denis 3-column classification (1,2) is the system most commonly used to describe thoracolumbar fractures.
    • Divides the thoracolumbar spine into 3 columns:
      • Anterior column: Anterior 2/3 of the vertebral body/disc
      • Middle column: Posterior 1/3 of the vertebral body/disc and posterior longitudinal ligament
      • Posterior column: Pedicles, facets, lamina, transverse, and spinous processes
    • Divides fractures into minor and major injuries:
      • Minor injuries: Fractures of spinous and transverse processes, pars interarticularis, and facets
      • Major injuries: Compression fractures, burst fractures, distraction-flexion injuries, fracture-dislocations, and distraction-extension injuries
Epidemiology
  • Most injuries occur in males 15-30 years old.
  • Motor vehicle accidents and other high-energy forces
  • Elderly patients with osteopenic/osteoporotic bones sustain fractures with low-energy injuries.
Risk Factors
  • Age 15 – 30 years
  • Motor vehicle accidents
  • High-energy trauma
  • Osteoporotic bone
Associated Conditions
  • Contiguous and noncontiguous spinal column injuries
  • Neurologic injuries
  • Spinal shock
  • Abdominal injuries:
    • Splenic rupture
    • Liver lacerations
    • Bowel injuries
Diagnosis
Signs and Symptoms
History
  • For high-energy trauma, obtain history from patient and the emergency medical personnel on the scene.
  • Question the patient about pertinent medical history (e.g., AS, previous spine surgery, etc.).
Physical Exam
  • 1 of the most important components of caring for trauma patients, particularly patients with spine injuries
  • Documentation of each examination is very important because deteriorating neurologic assessments often provide the 1st clue of an underlying injury.
  • Document the initial examination and compare it to the results of the examination in the field.
  • Inspect for any visible bruising, deformity, or step-offs around the spine.
  • Inspect for associated injuries (e.g., seat-belt marks).
  • Palpate the entire spine for areas of tenderness.
  • Grade the motor examination on a 5-point scale.
    • 0: No motor activity
    • 1: Flicker of activity
    • 2: Full motion across a joint without gravity
    • 3: Full motion across a joint against gravity
    • 4: Motion across a joint against some external resistance
    • 5: Motion across a joint against full external resistance
  • Assess the sensory levels.
    • T4: Nipple line
    • T7: Xiphoid process
    • T10: Umbilicus
    • T12: Inguinal crease
    • L1: Proximal 1/3 anterior thigh
    • L2: Middle 1/3 anterior thigh
    • L3: Over superior portion of patella
    • L4: Over medial malleolus
    • L5: Over dorsum of 3rd toe
    • S1: Over dorsum of small toe
  • Assess the reflexes.
    • L4: Patellar reflex
    • L5: No reflex
    • S1: Gastrocnemius-soleus reflex
  • Perform a rectal examination.
    • Tone
    • Volition
    • Perianal light touch and pinprick sensation
    • Bulbocavernosus reflex
    • Anal wink reflex
Tests
Lab
All trauma patients routinely undergo metabolic panel, complete blood cell count, prothrombin time/INR, partial thromboplastin time, and urinalysis.
Imaging
  • Radiography:
    • Trauma series:
      • Lateral cervical spine, chest, and pelvic radiographs
      • Radiographs of the spine are ordered if the patient is having back pain or an abnormality is noted on physical examination.
    • Thoracolumbar spine
  • CT:
    • Ordered for additional evaluation of an injury or abnormality seen radiographically
    • Also can be very useful for preoperative planning
  • MRI is ordered if soft-tissue injury (disc extrusion, ligamentous injury) is suspected because it cannot be visualized on CT.
Differential Diagnosis
  • In high-energy trauma, not much of a differential diagnosis exists, given the acute nature of the injury and the correlative findings on physical examination and imaging studies.
  • Patients >50 years old who sustain thoracolumbar spine fractures after low-energy trauma must be evaluated for osteoporosis, and pathologic fractures must be ruled out.
Treatment
Initial Stabilization
  • Nonoperative fractures can be treated in a TLSO with a cervical extender if the fracture is above T7 and a unilateral thigh extender if necessary.
  • Patients with fractures that may require surgical intervention can be on bed rest until they undergo definitive fixation.

P.449
General Measures
  • Compression fractures:
    • Nonoperative treatment with a TLSO (add cervical extension if fracture is above T7)
    • Vertebral augmentation procedures (kyphoplasty and vertebroplasty) are used more frequently to treat osteoporotic and osteolytic vertebral compression fractures.
    • Treatment of the underlying osteoporosis is of critical importance in avoiding additional fractures.
  • Burst fractures:
    • Involve 2 of the 3 columns
    • Nonoperative treatment consists of progressive weightbearing in a TLSO
    • Surgery usually is indicated in the presence of:
      • Neurologic injury and/or kyphosis of >20
      • Facet subluxation
      • Increased interspinous distance
      • >50% loss of anterior vertebral body height
      • >50% canal occlusion
    • However, all these parameters are relatively soft, and the overall clinical scenario should be considered when deciding on nonoperative or surgical management.
  • Distraction-flexion injuries:
    • Distraction of the posterior elements usually leads to ligamentous injury, and compression of the anterior column leads to a vertebral body fracture.
    • Nonoperative management rarely is indicated because ligamentous healing is unpredictable in these unstable injuries.
    • During surgery, care should be taken to avoid causing spinal canal narrowing (with bone fragments or disc material) during fracture reduction.
  • Fracture-dislocations:
    • Findings include facet fracture-dislocation, rotational, or translational deformity.
    • Nonoperative management rarely is indicated because ligamentous healing is unpredictable in these unstable injuries.
    • Surgical intervention usually begins with a posterior reduction and stabilization before an anterior decompressive/fusion procedure can be considered.
  • Distraction-extension injuries:
    • Very rare; tend to occur in patients with underlying metabolic bone disease
    • Nonsurgical treatment is not a good option because these injuries are very unstable.
    • Surgery generally begins with posterior instrumentation and fusion, with possible anterior correction.
Activity
  • Patients treated with a TLSO or operative fixation can advance to progressive weightbearing.
  • Patients with neurologic injury need rehabilitation and can advance with activity, depending on the extent of injury.
Nursing
A sequential neurologic examination with vital signs should be performed by a trained medical practitioner.
Special Therapy
Patients with neurologic injury often need counseling and benefit from peer support groups.
Radiotherapy
Radiation therapy has a role for patients with pathologic thoracolumbar fractures to decrease tumor size and burden.
Physical Therapy
Plays a very important role in mobilizing patients after spinal injury, particularly those with neurologic injury
Medication
No role for maintenance opiates
First Line
  • Anti-inflammatory medications (as long as no gastrointestinal side effects occur)
  • Enteric-coated aspirin (fewer gastrointestinal side effects)
  • Acetaminophen
Second Line
COX-2 inhibitors (Be aware of changing side-effect profile.)
Surgery
  • The goal of surgery is to decompress the neural elements and achieve rigid spinal fixation.
  • The surgical approach is surgeon- and injury-pattern-dependent.
    • With the advent of pedicle screws, posterior instrumentation usually is favored because it allows excellent fixation and alignment of the spine without the morbidity associated with the anterior approach.
    • The anterior approach also has an important role in decompression when bone fragment retropulsion is present in the spinal canal.
Follow-up
Routine follow-up is at 2 weeks, 6 weeks, 3 months, 6 months, 1 year, 2 years, and then every 2 years thereafter.
Disposition
Issues for Referral
  • Patients with chronic pain issues should be referred to a pain medicine specialist.
  • Patients with neurologic injury should be followed by a physical medicine and rehabilitation specialist.
    • Neurologic consultation may be obtained if the pattern of neurologic deficit does not correlate with the spinal injury.
  • Physical and occupational therapists also play important roles in recovery.
Prognosis
  • Prognosis depends on injury severity.
  • Neurologically intact patients with low-energy injuries have excellent recovery.
  • Patients with neurologic injury have major issues that may require alteration in their personal and professional lives.
Complications
  • Surgical complications include:
    • Infection
    • Neurologic injury
    • Pseudarthrosis
    • Spinal deformity
    • Junctional degeneration and stenosis
    • Chronic pain and disability
  • Skin problems from pressure points on TLSO braces
Patient Monitoring
Patients are monitored for resolution of symptoms, fusion (if arthodesis was performed), and development of any complications.
Miscellaneous
Codes
ICD9-CM
  • 805.2 Dorsal [thoracic], closed
  • 805.3 Dorsal [thoracic], open
  • 805.4 Lumbar, closed
  • 805.5 Lumbar, open
  • 805.8 Unspecified, closed
  • 805.9 Unspecified, open
Patient Teaching
  • Patients should be educated about:
    • Being aware of progressive motor weakness and bladder/bowel dysfunction
    • The natural history of the condition
FAQ
Q. Who should care for patients with a thoracolumbar spine fracture dislocation and a major neurologic injury?
A. Patients benefit from a multidisciplinary team composed of orthopaedic surgeons, neurosurgeons, physiatrists, counselors, and others. Many complications may develop, requiring meticulous care.

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