Thoracolumbar Fractures

Posted bythespinebookadminPosted inTopics, Trauma

Background 

  • Most common injured part of spinal column 
  • 30% have FND 
  • T11-L2 injured  
    • Transition zone from stable to mobile 
      • Rotational and shear forces 
  • Anterior Column – 80% axial 
  • Posterior 80% torsion/ shear 
  • 6 forces 
    • Flex 
    • Ex 
    • Axial 
    • LC 
    • Rotation 
    • Distraction 
    • shear 

Classification Systems 

  • Denis 
    • 3 column theory 
    • 2 violated; instability 
    • Burst – Anterior and Middle violated 
  • AO classification 
    • Morphologic grading 
      • A compression 
      • B flexion distraction 
      • C dislocation 
  • TLICS 
    • Grading of severity to predict surgery or no surgery 
    • Morphology, neurology, PLC 

TLICS (Vaccaro) 

  • Points 
    • Use the most severe in each category 
    • 3 – non surgical 
    • 4 – indeterminate 
    • 5 – surgical 
  • 3 categories 
    • Morphology 
      • Compression 1 
      • Burst 2 
      • Rotational/ Translational 3 
      • Distraction 4 
    • Integrity of posterior ligamentous complex (what are 4 componenets) 
      • Intact 0 
      • Suspect/ Indeterminate 2 
      • Disrupted 3 
    • Neurologic status 
      • Intact 0 
      • Nerve root 2 
      • Complete cord 2 
      • Incomplete cord/ cauda equina 3 

AO Classification 

  • A – Compression 
    • A0 – SP or TP 
    • A1 – wedge (Posterior wall intact) 
    • A2 – pincer (coronal plane). Both endplates, no posterior wall 
    • A3 – single end plate + posterior wall “Incomplete Burst” 
      • Associated laminar fracture (not posterior tension band failure) 
        • Fracture of necessity 
    • A4 – double end plate + posterior wall “Burst” 
      • Associated laminar fracture (not posterior tension band failure) 
      • Compression between pedicles 
        • Fracture of necessaity 
  • B – Flexion Distraction (anterior fails in compression, posterior fails in distraction) 
    • B1 – “Chance” pure transosseous tension band disruption (through pedicles and SP 
      • Seatbelt fulcrum, axis of rotation is PLL 
      • Children seatbelt 
      • Assocaited 
      • GI (50%) 
    • B2 – osseoligamentous (can happen as a B2A3) 
    • B3 – hyperextension – through IV disk 
      • Ank Spond, DISH, OPLL 
  • C – Dislocation/ Translation 
    • Displacement in any direction 
  • N – Neurologic signs 
    • N0 – no FND 
    • N1 – transient FND 
    • N2 – radiculopathy 
    • N3 – incomplete SCJ 
    • N4 –  complete SCI 
    • Nx – not assessed 

Management 

  • Evaluate 
    • Stable 
    • Canal intact? 
    • Ligaments intact? 
  • Brace 
    • A1, A3 <40% height loss 
    • In compression fractuers with intact PLC, no advantage of TLSO vs PSIF 
  • PSIF 
    • 2 above 2 below (standard exam answer) 
    • Short segment 
      • Need intact anterior column 
    • Instrumentation no fusion 
  • Decompression 
    • When? 
      • Cord compression ie: burst 
    • Indirect (intact PLL) 
    • Direct 
      • Laminectomy and dural retraction for lumbar 
      • Transpedicular at cord/ conus 

Controversies in Burst 

  • Anterior vs posterior 
    • Anterior – only for severe comminution – expandable cag 
  • Historical Indications 
    • Local kyphosis >30 
    • Height loss >50% 
  • Short vs Long segment 
  • Direct vs Indirect reduction 
  • Fuse or not fuse (staged HW removal) 
  • Restore anterior column or shorten the segment 

Osteoporotics Compression Fractures 

  • Suspicion for mets 
    • Above T5 
    • Atypical XRs 
    • Constitutional 
    • Younger patient no fall 
  • MR signs of benign 
    • Low T1 
    • Fluid sign 
    • Retropusion of BV 
    • High T2 
  • MR signs malignant 
    • Replacement of marrow signal 
    • Convex posterior border 
    • Pedicle involvement 
    • Paraspinal mass 
    • Epidural mass 
  • Non op Management 
    • Use TLICS 
    • Historical Indications 
      • Neuro intact 
      • <50% heaith loss 
      • <30 kyphosis 
      • <50% canal 
      • Intact PLC 
    • Observation 
    • +/-TLSO (no strong recommendation) 
    • Bisphohonates (T Score -2.5) 
    • Calcitonin for 4 weeks (if acute <5d) 
  • Kyphoplasty 
    • “limited recommendation” 
      • Vertebroplasty – “strongly against” uses 
    • Continued pain after 6 weeks non op 
    • Burst – high risk for cement in canal 

Complications 

  • VB osteonecosis (Kummell’s disease) 
    • Post traumatic AVN 
  • 2 year mortality equivalent to hip fracture 
  • Deformitty 
    • Scoliosis 
    • Progressive kyphosis (unrecognized PLL injury) 
    • Flat back (pain, forward flexed posture) 
    • Post traumatic syrngomyelia 

Pearls 

  • Compression 
    • TLSO = PSIF 
  • Burst no FND 
    • TLSO = PSIF except PSIF has more disability and complications 
    • Controversial 
  • Follow TLICS for Op vs Non op 
    • Especially in Burst and Compression 

Burst fractures at the T-L junction will have all of the following characteristics, EXCEPT: 

Anterior and middle columns involved 

Lamina fractures are commonly associated (or “can be associated” – McGill version) 

Risk of nerve damage proportional to retropulsion of fragments 

Superior and inferior endplates can be fractured 

CONCLUSIONS: 

The neurologic recovery from thoracolumbar burst fractures is not predicted by the amount of initial canal encroachment