Treatment of thoracolumbar fracture

Abstract

The most common fractures of the spine are associated with the thoracolumbar junction. The goals of treatment of thoracolumbar fracture are leading to early mobilization and rehabilitation by restoring mechanical stability of fracture and inducing neurologic recovery, thereby enabling patients to return to the workplace. However, it is still debatable about the treatment methods. Neurologic injury should be identified by thorough physical examination for motor and sensory nerve system in order to determine the appropriate treatment. The mechanical stability of fracture also should be evaluated by plain radiographs and computed tomography. In some cases, magnetic resonance imaging is required to evaluate soft tissue injury involving neurologic structure or posterior ligament complex. Based on these physical examinations and imaging studies, fracture stability is evaluated and it is determined whether to use the conservative or operative treatment. The development of instruments have led to more interests on the operative treatment which saves mobile segments without fusion and on instrumentation through minimal invasive approach in recent years. It is still controversial for the use of these treatments because there have not been verified evidences yet. However, the morbidity of patients can be decreased and good clinical and radiologic outcomes can be achieved if the recent operative treatments are used carefully considering the fracture pattern and the injury severity.

Keywords: Fracture; Minimally invasive surgery; Thoracolumbar spine; Treatment.

Fig. 1

A 42-year-old male patient with falling injury. Conus medullaris syndrome was diagnosed with symptoms including loss of perianal sensation, bladder and bowel dysfunction at the time of injury. (A) Burst fractures at L1 on sagittal computed tomography (CT) scan at the time of injury. (B) Around 50% of canal involvement by retropulsed bony fragments on axial CT scan at the time of injury. (C, D) Plain radiographs after indirect reduction and instrumented fusion with posterior approach. (E) Postoperative axial CT scans showing canal decompression by indirect reduction.

Fig. 2

A 31-year-old male patient who sustained seat belt injury from motor vehicle accident. (A) A wedge deformity at T12 and an increased interspinous distance on sagittal computed tomography scan (arrow). (B) Posterior ligament complex injury on T2 fat suppression sagittal magnetic resonance imaging (arrow head). (C, D) Anteroposterior and lateral radiograph images of flexion distraction injury after the indirect reduction and posterior instrumented fusion using the posterior approach.

Fig. 3

A 47-year-old male patient with fracture-dislocation injury. (A) Lateral translation of L3 compared to L2 on anteroposterior radiographs (arrow) right after the injury. (B) Posterior translation of L3 to L2 on sagittal computed tomography (CT) scan right after the injury. (C) Bony fragment within the spinal canal on preoperative axial CT scan. (D) Bony fragments were not reduced after the reduction and posterior instrumented fusion (arrow head). (E, F) Anteroposterior and lateral radiographs after removal of bony fragments and fusion with cages through the anterior approach.