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- Management of thoracolumbar spine trauma: An overview
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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.
Improving your care of patients with spinal cord injury/disease.
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.
Fractures of the thoracic and lumbar region constitute a spectrum of injuries ranging from the simple undisplaced fractures to complex fracture dislocations. The thoracic spine is functionally rigid due to coronally oriented facet joints, thin intervertebral discs and the ribcage.
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Thus, it requires huge amounts of energy to produce fractures and dislocations. The narrow spinal canal in this region predisposes to spinal cord damage resulting in a high incidence of neurological deficit. The lumbar spine, on the other hand, is relatively flexible due to the thicker intervertebral discs, sagittal orientation of facet joints and the absence of the rib cage.
The relatively lesser incidence of neurological injury in lumbar fractures can be attributed to the large size of the neural canal and the greater resilience of the cauda equina nerve roots.
The thoracolumbar junction TL2 is uniquely positioned in between the rigid thoracic spine and the mobile lumbar spine.
This transition from the less mobile thoracic spine with its associated ribs and sternum to the more dynamic lumbar spine subjects the thoracolumbar region to significant biomechanical stress. There are standard classification systems that have been described based on fracture morphology, injury mechanism, neurological deficit and injury to posterior ligamentous complex PLC. Radiographs are the basic investigation while computed tomography CT scan provides information on the extent on bony injury and magnetic resonance imaging MRI scan shows injury to the spinal cord and soft tissue structures.
However, despite extensive studies on this common injury, controversies still exist regarding the appropriate radiological investigations, the type of Nonoperative treatment, the indications for surgical management, the timing of surgery, approach and type of surgery, need for fusion and the role of spinal canal decompression.
Management of thoracolumbar spine trauma: An overview
This review provides an overview of the epidemiology, biomechanical principles, radiological and clinical evaluation, and evolution of classification system and management principles. In an epidemiological study by Hu et al. Injuries to the thoracolumbar spine are usually the result of high-energy blunt trauma. Sixty-five percent of thoracolumbar fractures occur due to motor vehicle injuries and falls from a height, with the remainder contributed by sports injuries and violence.
Since these are high-velocity injuries, thoracolumbar fractures are commonly associated with other injuries like rib fractures, pneumo-hemothorax, and rarely great vessel injuries, hemopericardium and diaphragmatic rupture 9 , 10 [ Figure 1 ].
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Seat-belt chance fractures and flexion distraction injuries are often associated with intraabdominal visceral injuries. Long bone fractures and head injuries are also common and can often lead to missed injuries of the spine. Systemic injuries associated with thoracolumbar fractures. Needless to say, any suspected spinal trauma patient in the emergency room should be evaluated following the basic principles of trauma assessment including primary and secondary survey.
Once life-threatening injuries are prioritized, a careful history about the injury mechanism and information pertaining to any back or neck pain and neurological symptoms are acquired.
Diagnosis and management of traumatic cervical central spinal cord injury: A review
Patients typically present with a history of trauma following a road traffic accident, fall from height, a direct blow to the spine or rarely gunshot injuries. Axial, nonradiating back pain of stabbing or aching quality is the most common symptom. Patients with neurological injury complain of weakness, paresthesia or anesthesia below the injury level and urinary retention. Thorough inspection of the spine should be performed after a careful log roll maneuver to look for abrasions, tenderness, local kyphosis and a palpable gap in between spinous processes.
As the spinal cord ends at the L1-L2 level, and the cauda equina fills the distal canal, varied neurological injury patterns can be observed with thoracolumbar fractures. Neurological injuries above L1 can damage the spinal cord producing a typical upper motor neuron injury. Injuries much below L1-L2 affect only the cauda equina roots involving few or multiple nerve roots resulting in lower motor neuron type injury.
Conus medullaris syndrome characterized by exclusive damage to sacral innervations to the bowel and bladder, with intact lumbar nerve roots, is a unique feature of TL1 injury [ 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. Standard radiographic evaluation includes antero-posterior and lateral radiographs.
Radiographic evaluation should include spinal alignment, presence of any rotation or translation, assessment of the kyphosis, loss of vertebral height, and widened inter-pedicular or inter-spinous distance.
MRI scan provides information on spinal cord or root injury, presence and extent of cord edema and hemorrhage, and epidural hematoma. The incidence of noncontiguous spinal fractures is 1.
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.
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Biomechanics of the load bearing and supporting structures of the vertebral column form the basis of understanding the spinal injuries and their classification systems. The classification of thoracolumbar fractures has evolved over the years as the understanding of the spinal biomechanics, mechanism of injury and identification of vertebral stability improved.
Early classification systems described by Boehler and Jones were descriptive systems, based only on radiographs. This system is simple and includes most injuries observed in clinical practice.
In , Magerl analyzed cases of thoracolumbar injuries and presented a comprehensive AO classification of thoracolumbar fractures based on the mechanism of injury and morphological pattern of the fracture.
McCormack et al. This classification intends only to identify fractures that would require supplemental anterior fixation following a posterior surgery.
Based on the severity scores within these three categories, a total score is calculated that can be used to guide treatment. Blauth et al. Lenarz et al. In each group, the neurologic status had the highest inter observer and intraobserver reliability.
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The AO spine knowledge forum has proposed a recent comprehensive modified AO classification including morphology of the fracture, neurological status, and description of relevant patient-specific modifiers. The classification appears much simpler and equally comprehensive when compared with the previous AO classification and includes important information about neurology and posterior ligamentous structures. Throughout resuscitation in the emergency room and subsequent care, all efforts must be taken to immobilize spinal injury patients safely and intermittently log roll to prevent pressure sore formation.
Stabilization of unstable injured motion segments plays an important role in preventing further injury.
In a patient with SCI, injury to neural structures occurs both at the time of injury primary — nonmodifiable and in the subsequent period due to vascular dysfunction, edema, ischemia, electrolyte shifts, free radical production, inflammation and delayed apoptotic cell death secondary — potentially modifiable. These include the steroids antiinflammatory , gangliosides, naloxone opiate receptor antagonist , calcium channel blockers, free radical scavengers and neurotropic agents.
Steroids were extensively employed in the clinical treatment of SCI beginning in the mids. In rat SCI models, steroids have been shown to improve neurological recovery. Coleman et al. Most thoracolumbar fractures are stable injuries amenable to nonoperative management. Simple compression or stable burst fractures without neurologic complications can typically be treated with commercially available thoracolumbar orthoses, or a hyperextension cast that permit early ambulation 37 , 38 [ Figure 6 ].
There is no consensus on the exact duration of treatment.
The advantages of a brace or cast over unprotected ambulation have also not been studied. However, it has been shown that external support has no mechanical stabilizing effect on the lumbar spine. 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. The advantages of operative treatment of thoracolumbar fractures over the nonoperative approach include avoiding an orthosis in the presence of multiple injuries, skin injuries, and obesity, immediate mobilization and earlier rehabilitation and better restoration of sagittal alignment. On the other hand, the benefits of surgical treatment must be carefully weighed against the potential surgical morbidity.
Conventional open surgical techniques can be associated with morbidity because of approach-related muscle injury, increased infection rates and higher blood loss.
In general, operative treatment is indicated mainly for unstable spinal injuries such as flexion distraction injuries, unstable burst fractures and fracture dislocations. Though operative treatment reduces pain and enables early mobilization and rehabilitation, there is no difference between operative and nonoperative treatment regarding neurological recovery and long term functional outcomes.
The severity of neurological injury is determined by the extent of neuronal injury incurred at the time of primary injury. But it is still worthwhile considering early surgical decompression in patients with incomplete SCI in the presence of spinal cord compression.
Despite the lack of clear level I or II scientific evidence, the general accepted indications for operative treatment are given in Table 2. There is no consensus on how early to operate on a patient with SCI.
Vaccaro et al. Early decompression resulted in better outcomes statistically when compared with delayed decompression and conservative management. In the presence of progressive incomplete neurological deficit and spinal cord compression, it is prudent to perform urgent surgical stabilization and decompression.
Patients with normal neurology and those with complete neurological deficit are optimized for surgery which can be performed at the earliest safe situation for the patient.
There is no evidence to perform surgery in the midnight. Different surgical approaches and techniques have been described for thoracolumbar fractures including posterior, anterior and combined approaches. However, scientific evidence lacks to support the selection of one surgical technique as advantageous over the other. Factors, such as an anesthetic and surgical burden to the patient, morbidity, complication rates, costs, and surgeon's expertise should be taken into account in the choice of surgical approach.
Posterior short segment fixation including the proximal and distal adjacent normal vertebrae is the most commonly performed surgery for the vast majority of thoracolumbar fractures unstable burst fractures with intact neurology, flexiondistraction injury, Chance fractures. Fracture reduction can be achieved by a combination of postural reduction, and by distraction through ligamentotaxis.
Posterior pedicle screw fixation has been shown to be simple, familiar, efficient, reliable, and safe for the reduction and stabilization of most fractures and remains the most popular technique.
Disadvantages include instrumentation failure, pseudarthrosis, infection, risks of SCI, inadequate neurological decompression, insufficient correction of kyphosis and the need for late instrumentation removal. Each of these factors was subdivided into three grades of severity and was scored on a point system from 1 to 3, with a higher number indicating increased severity.