SPINE TRAUMA

1. THORACOLUMBAR SPINE
INJURY
PRESENTER:DR SUMAN SUBEDI
MODERATOR: ASSO PROF DR. PRAMOD DEVKOTA

2. CONTENTS
• ANATOMY
• EPIDEMIOLOGY
• ETIOLOGY
• MECHANISM OF INJURY
• CLASSIFICATION
• MANAGEMENT

4. Anatomy of Thoracic Spine
• Kyphosis is natural
alignment
• Narrow spinal canal
• Facet orientation
• Rib factor on stability
• Conus at T12-L1

5. Anatomy of Lumbar Spine
• Lordosis is natural
alignment
• Larger vertebral bodies
• Facet orientation
• Cauda equina

6. Transition Zone:
Predisposed to Failure
Little opportunity for force
dispersion
Central loading
of T-L junction
Not anatomically disposed
to transfer force

7. EPIDEMIOLOGY
• Between 5% and 10% of polytrauma patients suffer spinal fractures or
dislocations with 65% to 80% of these injuries occurring within the
thoracic or lumbar regions.
• The vast majority of these injuries affect the motion segments
between T11 and L2 at the thoracolumbar junction
• Thoracolumbar injuries are usually thought to exhibit a bimodal age
distribution, with peaks among males under 40 years of age and again
in the 50 to 70 age group which is made up of a higher percentage of
females compared to the younger age groups

9. The incidence of fractures of the thoracic and lumbar spine increases
sharply in elderly patients younger than 60 years, of 13 fractures per
100,000 which rose to more than 50 fractures/100,000 in patients
above 70 years of age and to above 100 fractures/100,000 for
individuals older than 80 year
Unfortunately, around 20% of patients with thoracolumbar fractures
will develop some type of neurologic deficit. This occurs in nearly 1 in
every 20,000 individuals living in the United States

10. Cause of injury
fall from height RTA Violence Gun shot
injuries
52.3
38.4
5 4.3
Upendra B, Khandwal P
,Chowdhury B, Jayaswal A: Correlation of outcome measures with
epidemiological factors in thoracolumbar spinal trauma. Indain J Orthop 2007
Oct;41(4):290-4.

11. Mechanisms of Injury for Thoracolumbar
Spine Fractures and Dislocations
• axial loading(compression)
• flexion
• extension (lumbar jack injuries) shear
• axial rotation
• Multiple injury: multiple level involvement can occur .
• High Suspicion For Abdominal and thoracic injury

12. • Pathogenic mechanisms fall into three main groups:
LOW-ENERGY INSUFFICIENCY FRACTURES – arising from
• comparatively mild compressive stress in osteoporotic bone
MINOR FRACTURES OF THE VERTEBRAL PROCESSES – due to
• compressive, tensile or torsional strains
HIGH-ENERGY FRACTURES OR FRACTURE-DISLOCATIONS – due
• to major injuries sustained in motor vehicle collisions, falls or diving
from heights, sporting events,
• horse-riding and collapsed buildings

13. Associated Injuries with Thoracolumbar
Spine Fractures and Dislocations
• 50% of individuals with thoracolumbar fractures will be diagnosed
with a nonspinal injury (involvement of one other organ system, 30%;
two systems, 20%; three or more systems
• 45% of patients with “seatbelt” fractures will also sustain some type
of intraabdominal injury such as a laceration of the spleen or liver

14. Signs and Symptoms: Initial Evaluation and
Management of Thoracolumbar Injuries
• Initial Evaluation
Advanced Trauma Life Support (ATLS) protocol
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

15. Complete Spine examination
 Thorough history
 Inspect and palpate entire spine
 Per anal examination :
sphincter tone
bulbocavernous reflex
anal wink
voluntary anal contraction
sensory examination

17. CLINICAL EVALUATION
Complete Neurological
Evaluation
Motor function
Sensory Testing
Reflex Examination

18. AMERICAN SPINE INJURY ASSOCIATION

20. REFLEX EXAMINATION

22. 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

23. Investigations :
• plain X-rays,
• CT and
• MRI studies
X-RAYS
• A-P &
• Lateral views

24. Antero-posterior view
 loss of lateral vertebral body height
 changes in horizontal and vertical interpedicular distance
 irregular distance between the spinous processes (equivocal sign)
 asymmetry of the spinal alignment
 subluxation of costotransverse articulations
 perpendicular or oblique fractures of the dorsal elements

25. Lateral view
 sagittal profile
 degree of vertebral body compression
 height of the intervertebral space interruption or bulging of the
posterior line of the vertebral body
 dislocation of a dorsoapical fragment

28. CT
:
• The axial view allows
an accurate
assessment of the
comminution of the
fracture
• and dislocation
of fragments
into the spinal
canal .

29. • Sagittal and coronal 2D or 3D
reconstructions are helpful for
determining the fracture pattern

30. MRI
:
• In the presence of neurological deficits, MRI is recommended to
identify a possible
• cord lesion or a cord compression that may be
due
to
disc or
fracture fragments
or epidural
hematoma

31. • MRI can be helpful
in determining the
integrity of the
posterior
ligamentous
structures and
thereby
differentiate
between a stable
and an unstable
lesion.

32. Dennis three column concept..

33. Middle column providing greatest
mechanical stability

34. Failure under compression of
anterior column. The middle
column is intact
and acts as a hinge.

35. Failure under axial load of both
the anterior and middle column
originating at the
level of one or both end plates
of the same vertebrae

36. Burst fractures..
Lateral film:
• Fracture of posterior wall cortex
• Loss of height of posterior vertebral body
• Retropulsion of fragment into canal
AP film
Increase in interpediculate distance

37. Unstable burst fractures..
• Loss of height >50%
• Kyphotic deformity >30 degrees
• Substantial posterior column injury
• Progessive deformity
• Progessive neurological deficit

38. Seat-Belt type injuries..
Denis
Failure of both posterior and middle columns under tension forces
generated by flexion with its axis placed in the anterior column
Chance fracture

39. Fracture classification
Denis

41. McCormack

42. Vaccaro, A.R. et al, Spine 2005

43. Thoracolumbar Injury Classification and Severity Score(TLICS)

44. Evaluating PLC..!!
Clinical signs:
1. Palpable
interspinous
defect
2. Posterior
tenderness
X ray:
1. Kyphosis >30
degrees
2. > 50%
compression of
anterior
vertebral body
3. interspinous
spacing greater
than 7 mm than
adjacent
vertebrae
CT scan:
1. Diastasis of facet
joints
2. Spinous process
avulsion
MRI:
1. Edema in region of
PLC (T2)
2. Disruption of PLC
components (T1)
(SSL,ISL,LF,Capsule)

46. Examples
Flexion Compression Fx
•Flexion compression (morphology) - 1
•Intact (neurology) - 0
•PLC (ligament) no injury - 0
Total 1 points- Non Op

47. Compression
Burst Fracture
•Flexion compression burst - 2
•Intact ( neurology) - 0
•PLC (ligament) no injury (0)
Total 2 points-Non Op

48. Compression
Burst-Complete Neuro Injury
•Axial compression burst with distraction posterior ligamentous
complex -4
•Complete (neurology) - 2
•PLC (ligament) injury - 3
Total 9 points-Surgery

49. Compression
Burst-Complete injury
• Axial compression burst-2
• Complete (neurology)-2
• PLC (ligament) Intact-0
Points 4-Non Op vs Op

50. Translational/Rotation Injury
•Distraction, Translation/rotational,
compression injury - 4
•Complete (neurology) – 2
•PLC injury - 3
Total 9 points-
Surgery

51. Treatment - Principles
1. To preserve neurological function
2. To minimize a perceived threat of neurological compression
3. To stabilize spine
4. To rehabilitate the patient

52. Medical management
Hemodynamic:
Aim: Maintain MAP >80 mmHg
X 48 hrs OR 24 hrs postoperatively
whichever longer
• Fluids +/- Vasopressors +/-
Inotropes
VTE prophylaxis
Decubitus ulcer prevention

54. Nonoperative management
• Analgesics
• Braces
• physiotherapy
• Indications:
• Mechanically stable fractures
• Neurologically intact
• Acceptable alignment
• Prolonged bed rest:
• Too mechanically unstable to treat with brace, but for some reason surgery is
contraindicated or refused by the patient.

55. Bracing: When out of bed
• Mid-lumbar through Mid-thoracic injuries T7-L3: TLSO
• Upper thoracic injury at T6 or above: CTLSO
• Biomechanics: Limit spinal motion + Load-sharing
• Mode of healing: Secondary
• Duration: 6 wks – 3 months (upto 4-6 months for 3 column burst fractures)
• Restrictions:
• Lifting >10 lbs & Performing bending or twisting activities
• Upright X-ray in brace at regular f/u (2 wk, 6 wk, every 6-8 wk)
• When brace discontinued (wean): Flexion and Extension X-ray (stability)

56. • v

58. POSTRIOR
SURGERY:PRIMARILY FOR
REALIGNMENT AND
STABILIZATION
Advantages :
avoids the morbidity of anterior exposure in patients who
potentially have concomitant pulmonary or abdominal
injuries.
• shorter operative times
• decreased blood loss
• functional outcomes are similar to those
following anterior surgery
Disadvantages: no direct approach to site of
pathology

59. Initially hooks and wires
were used
Pedicle screws with rods
most commonly used with
rods for stabilisation now.
Sites
1) thoracic : immediately
lateral to middle of facet joint
along superior third of
transverse process

60. 2) lumbar vertebrae:
Intersection of line bisecting the
transverse process and line
passing along lateral aspect of
facet joint
Other methods
 mamillary process
 pars interarticularis method

61. POSTERIOR REALIGNMENT AND FIXATION

63. ANTERIOR
SURGERY
• Indicated for decompression of the
neural elements.
• It provides direct visualization of the
anterior thecal sac and is the most
reliable method of spinal canal
decompression
• Higher morbidity
• Decompression followed by void filling
with autograft/ allograft / cage
insertion
• Fixation by plates and screws/ rods -screw-
staple construct.

64. ANTERIOR DECOMPRESSION AND STABILISATION

66. COMBINED
APPROACH
Advantages:
• maximization of canal clearance,
• immediate circumferential
stability optimized fusion
rates.
Disadvantage
• superadded morbidity of two
procedure
Usually opted as 2 stage procedure : post ct
scan shows increased deformity or has
residual neurological deficit

67. COMPRESSION FRACTURE
• <10% vertebral height loss :no need external
support.
• <30% to 40% height loss and <20 degrees to 25
degrees kyphosis : Jewett brace for 6 to 8
weeks.
• In fractures below T5, a plaster jacket or TLSO can be
used.
• In higher fractures, a cervical component should be
added to the brace.
• 50% height loss or >30 degrees kyphosis suggests
PLC disruption, and posterior stabilization is
recommended.
• An MRI scan should be used to examine the integrity of
the PLC

69. BURST FRACTURE
Failure of anterior and middle column
Axial compression
+/- failure of posterior column
Compression or tensile force
Most common at T/Ljunction

70. BURST
FRACTURE
• Stable :
• No PLC injury without neurologicdeficit
Radiographic criteria for non operative
• less than 25 degrees to 30 degrees of kyphosis, less than 50% height loss,
• absence of interspinous process widening, less than 50% canal compromise
MRI evidence of discontinuity or continuity ofthe
PLC
TLSO( hyperextension) Brace applied for 3 months
X-ray and clinical follow-up examinations are
scheduled at 2 weeks, 1 month, 2 months,
and 3 months. At the 3-month follow-up, x-
rays are made out of the brace to ensure
stable alignment.

71. UNSTABLE BURST
FRACTURE
Need operative stabilization
Posterior instrumentation and fusion:
PLC disruption in neurologically intact
patients.
<50% height loss: short-segment stabilization
>greater than 50% or extensive comminution:
pedicle screws are placed two levels above and
below the fractured vertebra.

73. Neurological deficit :
Complete injury
Early stabilization
Neurological outcome not changed by
decompression
Incomplete injury
Stabilization and decompression beneficial .
Improvement may occur

74. DECOMPRESSION
Posterior
Indirect (distraction and ligamentotaxis)
Direct
Transpedicle approach
posterolateral appoach
laminotomy/ laminectomy
Anterior
Partial / completecorpectomy

75. FLEXION DISTRACTION INJURY
Bone or soft tissue?

76. SEAT BELT / CHANCE
INJURY
Associated with intra-abdominal pathology.
Purely Osseous injuries can be treated
nonoperatively
If the injury is ligamentous orosseoligamentous,
surgical stabilization is indicated
Single-segment posterior fusion is usually
adequate.
Surgeons should check that the pedicles at
adjacent levels are intact prior to surgery.
If not : longer fixation is required
In about 15% of cases, there is associated burst
fracture configuration.
In about 5% of cases, there is an associated
herniated disc : Anterior decompression

78. FRACTURE
DISLOCATION
High energy trauma
There is a high incidence ofcomplete
neurologic deficit
Goal:
Stabilization for early mobilization
Long posterior pedicle screw constructs are best
for thoracolumbar fracture- dislocations.
Up to 50% dural tears have been noted.
Short-segment spinal fixation may not
provide adequate stabilization

79. GUN SHOT
WOUNDS
Rare injury
Transabdominal bullets :
higher source of
contamination
Complete injury more
common than incomplete
Retained bullets may
cause to lead toxicity

80. TREATMENT OVERVIEW

81. Postoperative protocol
• Posterior stabilization: Postoperative mobilization on orthosis on D1
and continued upto 8-12 weeks
• Anterior stabilization: Bed rest until chest tube removed  TLSO
worn all time when spine is >30 degrees from horizontal plane 
TLSO used for 12-16 weeks

82. Complications
• Of injuries:
1. Skin problems
2. VTE
3. Urosepsis
4. Sinus bradycardia
5. Orthostatic hypotension
6. Autonomic dysreflexia
7. Major depressive disorder
• Of fixation:
1. Dural tear
2. Iatrogenic neural injury
3. Pseudoarthrosis
4. Failure of fixation
5. Iatrogenic flat back
6. Infection
7. Medical complications

83. REFERENCES
1. Apley and Solomon’s System of Orthopedics and Trauma – 10th
Edition
2. Campbell’s Operative Orthopedics – 14th Edition
3. Rockwood and Greens Fractures in Adults – 9th Edition
4. AOSpine Masters Series – Volume 6

84. Thank You