thoraco lumbar fracture

2. 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

3. Thoracic and lumbar fractures account for 50% of
all spinal traumatic fractures.
• Incidence.
4-5 per 100,000.
18 - 35 years.
Male Female = 4:1
Neurologic injury  25% of cases.
• 65% of TL#s occurs between the T9&L2 vertebrae.
(thoracolumbar Junction)

4. • Cervical - 7 vertebrae
• Thoracic - 12 vertebrae
• Lumbar - 5 vertebrae
• Sacral - 5 fused vertebrae
• Coccyx - 4 fused vertebrae
4

5. 5

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 attachement.
•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. ETIOLOGY
• High energy trauma (RTA 50%)
• Falls.
• Sports accident.
• Gunshot injury.
• Osteoporosis
• Tumors
• Weak bone(malnutrition,renal,RA,DM,endocrine).

11. – 16% major chest injury
– 10% major abdominal injury
– 8% long bone/ pelvic fractures
Spinal fracture should be suspected in;
1. Comatosed patient.
2. High energy trauma.
3. Evidence of neurological deficit.
4. Multiple injuries:

12. Missed TL#s reach 5%, And reach 22% in cervical fractures.
The main causes are,
• Poly trauma.
• low level of suspicion.
• Intoxication unconsciousness
• Failure to take proper radiographs.
• Failure to interpret the x ray.

13. CLASSIFICATION

14. Three column theory
ANTERIOR COLUMN
MIDDLE COLUMN
POSTERIOR COLUMN

16. Spinal Stability
• Categorized major spinal injury into 4
groups:
– 1. Compression Fracture
– 2. Burst Fractures
– 3. Flexion Distraction Injuries
– 4. Fracture Dislocations

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

20. Compression
Type A involves both
endplates, type B involves the
superior endplate, and type C
involves the inferior endplate.
In type D fractures, there is a
compression fracture of the
anteriovertebral body.

21. Compression Fracture

22. Compression Fractures
• Only anterior column injury
• Middle? and post. OK
• Ant. column less than 30%
• No more than 10 deg kyphosis
• No neuro injury

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

26. Burst Fracture

27. Burst
Type A involves
fractures of both
endplates, type B
involves fractures of the
superior endplate, and
type C involves
fractures of the inferior
endplate. Type D is a
combination of a type A
fracture with rotation.
Type E fractures exhibit
lateral translation.

28. Stable Burst
• Both ant and middle
column involvement
• Minimal kyphosis
• No neuro involvement
• No laminar fracture

29. Unstable Burst
• 3 column involvement
• Possible neuro
involvement
• Severe communition
• Significant pedicle
widening
• Look for laminar
fracture (asso. with
root entrapment)

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

33. Flexion Distraction/chance/seat belt
imjury
Types A and B occur at one level, either
through bone (A) or ligament (B). Type
C and D occur at two levels (motion
segments). Type C denotes that the
middle column failed through bone.
Type D denotes that the middle
column failed through ligament and
disc.

34. Flexion Distraction Injury

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

38. Flexion distraction
• Easy to miss- may look
benign
• Anterior column >
50% crushed
• Middle column mainly
intact
• Significant spinous
process widening
• Unstable

39. Fracture Dislocations
• Translation in lower
lumbar spine may be
developmental (nly L3-S1
spondylolysthesis)
• Always abnormal in
thoracic spine (ribs)
• Unstable
• Normally- neuro deficit
• Can be hidden at mid
thoracic spine
• 3 column injury

40. Fracture Dislocation

41. Fracture Dislocation
Type A are bony one-level injuries.
Type B are one-level ligamentous
injuries. Type C injuries are two-
level injuries that occur through
bone and/or ligament.

42. 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

43. Clinical Evaluation
E
• Pre Hospital care :
Strict precaution for immobilization in
form of spine board and cervical collar
needed.
Urgent transportation to adequately
equipped tertiary health centre.
Resuscitation should begin immediately .

44. • In Hospital Care
Primary survey: Airway
Breathing
Circulation
Disability
Exposure
Glasgow Coma Scale

45. Secondary survey : Complete Spine
examination
– Thorough history
– Inspect and palpate entire spine
– Per anal examination :
sphincter tone
bulbocavernous reflex
anal wink
voluntary anal contraction
sensory examination

46. RADIOLOGICAL ASSESMENT

47. X-RAYS Lateral View
• Alignment.
• Contour of bodies.
• Disc spaces.
• Angulation.
• Encroachment on canal.
• Loss of vertebral body height.

48. X-RAYS Lateral View
• Measurement of
degree of vertebral
body compression.

49. • Look at how the ant.&
post. aspects of the
body line up.
X-RAYS Lateral View

50. X-RAYS Lateral View
• Measure Kyphosis.
• Measure from
closest intact
endplates.

51. • Alignment
• Symmetry/ Shape of
pedicles
• Interpedicular distance
• Position of spinous process
• Contour of bodies
X-RAYS A-P view

52. X-RAYS A-P view
• Lateral vertebral body height.
• Interpedicular
distance.
• Distance between the spinous
processes.

53. Treatment

54. Goals
1. Maximise neurological recovery .
2. Maintain or restore spinal alignment.
3. Obtain a healed and stable spinal column.
4. Prevent future deformity.

55. Spinal Cord Injury
Methylprednisolone
• 30mg/kg iv bolus over 15min.
• 5.4 mg/kg/h infusion over 23 hrs (first 3 hours).
• 5.4 mg/kg/h for 47hrs (if > 3 – 8 hrs passed).
Proton pump inhibitor & LMW Heparin

56. Non-operative treatment
Bed Rest
• Strict bed rest for 3- 4 weeks.
• Avoid flexion, sit-ups, & spinal rotation.
• Avoid weight bearing.
• Bed rolling encouraged.

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

58. Braces
• TLSO brace
• 1) Hyperextenxion brace :
JEWETT

59. • 2) Sagital control:
• Taylor brace
• Both flexion and extension
restricted

60. • TLSO : 3)Sagital Coronal
control brace
• Knight-Taylor brace
• Has lateral bars for coronal
control

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

62. Surgical options
Anterior FixationPosterior Fixation

63. Vertebroplasty

64. Kyphoplasty

66. Anterior decompression and
stabilisation