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Introduction
  • Fractures associated with posterior facet dislocation occuring at the thoracolumbar junction (AO type C)
  • Epidemiology
    • incidence
      • approx. 4% of spinal cord injuries admitted to Level 1 trauma centres
      • 50-60% of fracture-dislocations are associated with spinal cord injuries
    • demographics
      • 4:1 male-to-female ratio
    • location
      • most commonly occur at the thoracolumbar junction
    • risk factors
      • high energy injuries 
        • motor vehicle accident (most common)
        • falls
        • sports
        • violence
  • Pathophysiology
    • mechanism of injury
      • acceleration/deceleration injuries
      • resultng in hyperflexion, rotation and shearing of the spinal column
    • associated injury
      • neurologic deficits
      • head injury
      • concomitant injuries in thorax and abdomen
  • Classification Systems
    • Thoracolumbar Injury Classification System (TLICS) 
      • categorizes injuries based on
        • morphology of injury
        • neurologic injury
        • posterior ligamentous complex integrity
      • treatment recommendation based on total score
        • nonsurgical = 3 or lower
        • indeterminate = 4
        • surgical = 5 or higher
Anatomy
  • Lumbothoracic junction
    • Definition
      • T10 - L2
      • transition zone between thoracic spine (kyphosis) and lumbar spine (lordosis) 
    • Pathoanatomy
      • greater mobility in the lumbar spine compared to thoracic spine 
      • results in an area of the spine that is vulnerable to shearing forces
      • high risk of injury to the spinal cord, conus or cauda equina depending on the patients anatomy and degree of dislocation
Presentation
  • Pre-hospital
    • patients almost exclusively present as a major trauma with or without neurological deficit
    • transportation to a trauma center using spine immobilization precautions with a spinal board and cervical collar.
  • Clinical Approach
    • ATLS
      • Airway, Breathing, Circulation 
      • Neurological assessment
        • Inspection
          • open injury
          • deformity (e.g. kyphosis)
        • Palpation
          • point tenderness
          • step-off deformity
          • crepitus
        • Neurological Impairment
          • GCS
          • ASIA Impairment score
          • sensory, motor, or reflexes impairment
          • rectal examination
      • History
      • Physical examination
Imaging
  • Radiographs   
    • recommended views
      • AP and lateral view of thoraco-lumbar spine
    • indications
      • suspected spinal column injury with bone tenderness
      • recognize stable versus unstable spine injuries
    • findings
      • fracture type, pattern and dislocation
  • CT scan  
    • indications
      • better visualization of fracture pattern and type compared to plain radiographs (e.g. unilateral facet dislocations, etc)
      • blunt trauma patients requiring a CT scan to screen for other injuries
    • findings
      • cannot adequately visualize and describe the spinal canal and other associated ligaments
  • MRI
    • indications
      • better visualisation of the spinal cord and supporting ligamentous structures
      • level of neurological deficit does not align with apparent level of spinal injury
    • findings
      • important to evaluate for injury to the posterior longitudinal ligament
Treatment
  • Operative
    • posterior open reduction with instrumented fusion   
      • indications
        • most patients with thoracolumbar fracture dislocation
        • unstable fracture patterns 
        • disrupted supporting ligamentous structures
      • technique
        • midline incision 
        • identify fracture-dislocation site
        • use pedicle screws for distraction to obtain anatomical reduction
        • insert posterior instrumentation two levels above and two levels below the site of injury
      • outcomes
        • early decompression and instrumentation has been shown to have better outcomes than delayed surgery or non-operative treatment 
        • obtain postoperative CT/MRI to see if their is any residual anterior compression
Complications
  • Neurological injury
  • Cauda equina syndrome
  • DVT 
  • Non-union after spinal fusion
  • Post-traumatic pain
    • most commoncomplication
    • greater with increased kyphotic deformity
  • Deformity
    • scoliosis
    • progressive kyphosis
      • common with unrecognized injury to PLL
    • flat back
      • leads to pain, a forward flexed posture, and easy fatigue
    • post-traumatic syringomyelia
 

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