ThoracoLumbar Spine Fracture and Dislocation

By admin On Mar 12, 2024

Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.

Title: 5-Minute Orthopaedic Consult, 2nd Edition

> Table of Contents > ThoracoLumbar Spine Fracture and Dislocation

ThoracoLumbar Spine Fracture and Dislocation

Dhruv B. Pateder MD

Basics

Description

Most spine fractures occur in the thoracolumbar region.
T11–L1 is the most frequently injured area.
Concomitant spine injuries are present in up to 15% of patients (1–5).
Associated abdominal injuries are present in ~20% of patients (1–5).
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 (3–5).
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 0–5-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 (S2–S5)
- 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.

References

1. Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine 1983;8:817–831.

2. Denis F. Spinal instability AS defined by the three-column spine concept in acute spinal trauma. Clin Orthop Relat Res 1984;189:65–76.

3. Singh K, Vaccaro AR. Thoracic and lumbar trauma. In: Bono CM, Garfin SR, Tornetta P, et al., eds. Spine. Philadelphia: Lippincott Williams & Wilkins, 2004:45–57.

4. Spivak JM, Vaccaro AR, Cotler JM. Thoracolumbar spine trauma: II. Principles of management. J Am Acad Orthop Surg 1995;3:353–360.

5. Spivak JM, Vaccaro AR, Cotler JM. Thoracolumbar spine trauma: I. Evaluation and classification. J Am Acad Orthop Surg 1995;3:345–352.

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.