Management of thoracolumbar spine trauma: An overview

Abstract

Thoracolumbar spine fractures are common injuries that can result in significant disability, deformity and neurological deficit. Controversies exist regarding the appropriate radiological investigations, the indications for surgical management and the timing, approach and type of surgery. This review provides an overview of the epidemiology, biomechanical principles, radiological and clinical evaluation, classification and management principles. Literature review of all relevant articles published in PubMed covering thoracolumbar spine fractures with or without neurologic deficit was performed. The search terms used were thoracolumbar, thoracic, lumbar, fracture, trauma and management. All relevant articles and abstracts covering thoracolumbar spine fractures with and without neurologic deficit were reviewed. Biomechanically the thoracolumbar spine is predisposed to a higher incidence of spinal injuries. Computed tomography provides adequate bony detail for assessing spinal stability while magnetic resonance imaging shows injuries to soft tissues (posterior ligamentous complex [PLC]) and neurological structures. Different classification systems exist and the most recent is the AO spine knowledge forum classification of thoracolumbar trauma. Treatment includes both nonoperative and operative methods and selected based on the degree of bony injury, neurological involvement, presence of associated injuries and the integrity of the PLC. Significant advances in imaging have helped in the better understanding of thoracolumbar fractures, including information on canal morphology and injury to soft tissue structures. The ideal classification that is simple, comprehensive and guides management is still elusive. Involvement of three columns, progressive neurological deficit, significant kyphosis and canal compromise with neurological deficit are accepted indications for surgical stabilization through anterior, posterior or combined approaches.

Keywords: Spinal injuries; lumbar vertebrae; management; thoracic vertebrae; thoracolumbar trauma; treatment protocols.

Figure 1

Systemic injuries associated with thoracolumbar fractures. (a) T12-L1 dislocation associated with left diaphragmmatic rupture and herniation of intraabdominal contents. (b) T7-T8 translational injury associated with massive hemothorax on the left side

Figure 2

American Spinal Injury Association (ASIA) form for standard neurologic classification of spinal cord injury (from ASIA)

Figure 3

X-ray thoracolumbar spine lateral view (a) and magnetic resonance imaging of conus medullaris syndrome showing fracture of L1 vertebra resulting in injury to the conus medullaris

Figure 4

Computed tomography (CT) scan provides excellent delineation of bony injuries. In this patient with A1 injury of the L3 vertbral body seen in the lateral radiograph (a), CT scan showed horizontal split of L2 spinous process indicating a flexion-distraction injury

Figure 5

(a) Lateral radiograph of thoracolumbar spine showing a burst fracture of L1 vertebral body. (b) Sagittal magnetic resonance image shows a hyper intense signal of the posterior ligamentous complex (yellow arrow) indicating injury, which is not detected in the radiograph

Figure 6

Stable burst fracture of L2 vertebral body treated by conservative care. Lateral radiograph at the end of 1-year shows good fracture healing. Clinical pictures show good functional outcome

Figure 7

X-ray thoracolumbar spine lateral view showing (a) L1 flexion-distraction injury (b) treatment with posterior short segment fixation and intermediate screws (c) Lateral radiograph performed at the end of 1-year shows good fracture healing