thoracolumbar fractures orthopaedic

1. THORACOLUMBAR
FRACTURE
SITI AISHAH MOHD ZAMERI

2. OUTLINE
 Epidemiology
 Anatomy
 Clinical evaluation
◦ ATLS
◦ Neuro exam
◦ Neurogenic / spinal shock
 Classification of injury
◦ Grading system
◦ Complete VS incomplete
• Classification of Fractures
 Radiographic Evaluation
◦ Plain Xray
◦ CT
◦ MRI
 Treatment

3. 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

4. ANATOMY
 29 vertebrae organised in 4 curves:
 - Thoracic and Sacral (kyphosis)
 - Cervical and Lumbar (lordosis)
 Thoracic spine: made rigid with ribcage
articulation. Facet joint in coronal plane limits
flexion/extension.
 Lumbar spine: Facet joints in sagittal plane
increase flexion/extension but decrease
lateral bending/rotation.
 Thoracolumbar junction: Facet joint in
oblique orientation, provide support and
resistance of forces on spine.

7. Functional spinal unit
Composed of:
 2 adjacent
vertebrae
 Facet joint
 Inter vertebral disc
 Intervening
ligaments
7
This unit is responsible for Movement of
spine

8. Thoracic Spine
 Kyphotic Curve.
 Ribs  more stiffness, resist
rotation.
 T11,T12 have floating ribs;
No costotransverse articulations.
No sternal attachment.
•Facet orientation 
limited
flexion/extension.
•Canal is relatively small.

9. Lumbar Spine
 Lordotic Curve.
 Large discs  More mobility
 Spinal canal wider.
 Spinal cord ended at L1.
 Facet orientation  more
flexion/extension.

10. INITIAL ASSESSMENT
 ABC & Immobilisation: pt should be
immobilise until stability of fractures can
be assessed adequately- avoid
loss/worsening of neurological deficit
 Neurological exam: motor, sensation,
bulbocavernous reflex, per rectal exam.
 Neurological deficit from TL fractures can
involve spinal cord or cauda equina
 70% of TL injury do not have associated
neurological deficits.

11. CLASSIFICATION OF
INJURY
 ASIA CHARTING GRADE:
 A- Complete- no sacral motor/
sensory
 B- Incomplete- Sacral sensory
sparing.
 C- Incomplete- Motor sparing (<3)
 D- Incomplete- Motor sparing (>3)
 E- Normal motor / sensory

14. Neurogenic shock :
Haemodynamic 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.

15. 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.
Determined by anatomic location of tissue
injury
 Prognosis better than complete injury.
 Important to determine zone of partial
preservation.

17.  45% of TL#s.
 Anterior column failure
(Anterior or lateral flexion)
 Middle, Post. Column intact.
 Usually no Neurological deficits.
COMPRESSION (WEDGE)
FRACTURE

19. Flexion Fracture Pattern
 Compression fracture. While the
front (anterior) of the vertebra breaks
and loses height, the back (posterior)
part of it does not. This type of fracture
is usually stable (the bones have not
moved out of place) and is rarely
associated with neurologic problems.
Compression fractures commonly
occur in patients with osteoporosis.

20. Burst fractures
• 15 % of TL#s
• Anterior& middle column failure.
(Axial compression)
 Most common at T/L junction
 Neurological deficit.

22. Flexion Fracture Pattern
 Axial burst fracture. In this type of
fracture, the vertebra loses height on
both the front and back sides. It is
often caused by landing on the feet
after falling from a significant height.
 Failure of anterior and middle column
causing a burst fracture and the
danger of retropulsion of a posterior
fragment into the canal. Often
unstable

23. FLEXION-DISTRACTION = SEAT-BELT-TYPE =
CHANCE #
 Posterior &middle columns
failure.
(hyperflexion then tension
forces)
 Anterior column 
- partial damage.
- functions like a hinge.

25. Extension Fracture Pattern
 Flexion/distraction (Chance)
fracture. The vertebra is literally
pulled apart (distraction). This type of
fracture can occur in a head-on car
collision when the upper body is
thrown forward while the pelvis is
stabilized by a lap seat belt.
 The so called ‘jack-knife’ injury
causing failure of posterior and middle
columns and sometimes anterior
compression

26. Rotation Fracture Pattern
 Transverse process fracture. This
uncommon fracture results from
rotation or extreme sideways (lateral)
bending. It does not usually affect
stability.
 Fracture-dislocation. This is an
unstable injury involving bone and/or
soft tissue in which a vertebra moves
off an adjacent vertebra
(displacement). These injuries
frequently cause serious spinal cord
compression.

27. Fracture-Dislocation
 Failure of all columns
(compression, tension,
rotation, or shear).
 anterior hinge is
disrupted.
 Dislocation.
 Severe neurological
deficit.

29. Compression vs Burst
fractureCompression Burst
result of injury, commonly fall onto
the buttock or pressure from
normal activities, to the weakened
vertebrae due to osteoporosis
high-energy axial loading spinal trauma that
results in disruption of the posterior vertebral
body cortex with retropulsion into the spinal
canal.
-Vertebral fracture should be
diagnosed when there is loss of
height in the anterior, middle, or
posterior dimension of the vertebral
body that exceeds 20%.
-Osteoporotic spine fractures can
be graded based on vertebral
height loss as:
mild: 20-25%
moderate: 25-40%
severe: >40%
Radiographic features
General features include:
-loss of vertebral height on lateral views:
anterior portion is commonly compressed
more than the posterior portion of the
vertebral body
-fracture always involves the posterior
vertebral body cortex
-burst vertebral body on axial CT
-retropulsed fragments into the spinal canal
may occur
-vertical fracture through the posterior
elements is usually present in more severe
trauma
-Interpedicular widening
-consequent cord contusion may occur and it

30. BURST FRACTURE

31. IMAGING
 X RAYS
 AP- pedicles, vertebral
body, disc spaces,
spinous process
 Lateral- vertebral
body height, disc
space relations, VB
alignments, paraspinal
swellings

32. X RAY
 In presence of injury,
the entire spine
should be imaged to
rule out
noncontiguous
injuries.
 Degree of kyphosis
can be measured
using Cobb
measurement.

33. CT SCAN
 provide finer detail of the
bony involvement in
thoracolumbar injuries
 All cases of suspected
injury to posterior
elements or posterior
vertebral body.
 Axial images readily
demonstrate the degree
of canal compromise
from retropulsed
fragments

34. MRI SCAN
◦ Indicated in cases of
neurological deficit with
inconclusive radiographs
◦ Allows visualisation of
soft tissue component of
spinal injuries.
◦ Useful at thoracolumbar
junction due to variable
location of conus
medullaris.

35. TREATMENTS
 Modality :
 Non operative : - 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 over 15 minutes, 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

36. TLICS Scoring
 Thoracolumbar Injury
Classification
System (TLICS) categorizes
injuries based on
◦ morphology of injury
◦ neurologic injury
◦ posterior ligamentous complex
integrity
 treatment recommendation
based on total score
◦ nonsurgical = 3 or lower
◦ indeterminate = 4
◦ surgical = 5 or higher

37. Non-operative treatment
Indications:
 Ant. vertebral height loss < 40%.
 Canal compromise < 40%.
 kyphosis < 25 degrees.
Bed Rest
 Strict bed rest for 3- 4 weeks.
 Avoid flexion, sit-ups, & spinal rotation.
 Avoid weight bearing.
 Bed rolling encouraged.

38. Bracing
 Treated with brace for 6-8
weeks.
 Wear on whenever upright.
• Ambulation & Transfers.
• Solid healing  8-12 weeks.

39. Operative treatment
Indications:
 Ant. vertebral height loss > 40%.
 Canal compromise > 40%.
 Kyphosis > 25 degrees.
 Neural compression.
Aim
 Neural Decompression.
 Stabilization.
 Solid fusion.

40. Surgical options
Anterior
Fixation
Posterior
Fixation

41. Rehabilitation
 Physiotherapy.
 Bladder dysfunction: Intermittent cath.
Supra-pubic cath.
 Bowel dysfunction: high fluids, fibers, Prokinetic.
 Spasticity: Stretching exercises, Baclofen, surgical.
 DVT prevention.
 Chest physiotherapy.
 Bed sore prevention: Postural change/2h, Air
mattress,
High protein diet.

42. REFERENCES
 Thoracolumbar fracture, Dr roshit J suni.
http://www.slideshare.net/RishitSoni1/thoracolumbar-
fractures-51706226?qid=b2c05a34-6ca8-45c5-907a-
3ebff9a13d7e&v=&b=&from_search=2
 Apley’s Systems of Orthopaedic and Fracture, 9th edition.
 Thoracolumbar spinal injury, Michael Heinzelmann, Guido
A. Wanner.
 Orthobullet : Thoracolumbar burst fracture.
http://www.orthobullets.com/spine/2022/thoracolumbar-
burst-fractures
 Spinal cord injuries, thoracolumbar fracture, Dr Donald S
Corenman http://www.slideshare.net/neckandback/spinal-
cord-injuries-spinal-fracture-thoracolumbar-fracture-
colorado-spine-surgeon?qid=09a0ed15-bbe5-42df-a2fd-
ddb0162d9f58&v=&b=&from_search=1
 Thoracolumbar and lumbar burst fractures, Dr Susan Salas
http://www.jefferson.edu/content/dam/tju/jmc/files/neurosurg
ery/ThoracolumbarGrandRounds.pdf