ThoracoLumbar Spine Fracture and Dislocation

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
  • 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 (15).
  • Associated abdominal injuries are present in ~20% of patients (15).
  • 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
  • Most injuries occur in males 15–30 years old (35).
  • 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
Signs and Symptoms
  • 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
All trauma patients routinely undergo metabolic panel,
complete blood cell count, prothrombin time/INR, partial thromboplastin
time, and urinalysis.
  • 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.
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.


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.
  • 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.
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.
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
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.)
  • 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.
Routine follow-up is at 2 weeks, 6 weeks, 3 months, 6 months, 1 year, 2 years, and then every 2 years thereafter.
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 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.
  • 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.
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.
  • 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
Q. Who should care for patients with a thoracolumbar spine fracture dislocation and a major neurologic injury?
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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