Updated: 5/30/2019

[Blocked from Release] Thoracic & Lumbar Trauma Introduction

Review Topic
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  • Potentially devastating due to
    • narrow canal
    • precarious blood supply
    • fulcrum of motion at thoracolumbar spine
  • Key concepts on evaluation and treatment
    • decompression of neurologic elements
      • fractures at the level of the spinal cord (above L1/2 ish) are much more vulnerable to neurologic injury than injuries below and require a more urgent treatment
    • restore stability of the spine
      • location of fracture determines required fixation technique
  • Anatomic regions of injury
    • thoracic spine (T2-T10)
      • fractures from T2-T10 are rare due to increased stability of thoracic spine (see anatomy below)
      • fractures include
        • burst fracture
        • osteoporotic compression fracture topic
        • fracture dislocation (rare but leads to paralysis in 80%)
    • thoracolumbar region (T11 to L2)
      • more commonly affected by spine trauma due to fulcrum of motion (intersection between stiff thoracic spine and increased motion of lumbar spine)
        • more than 50% of all thoracic and lumbar fractures occur in this region
      • common fracture patterns include
        • thoracolumbar burst fracture topic
        • Chance fracture topic
  • Biomechanics 
    • thoracic spine from T2 to T10 has increased stiffness due to 
      • increased rigidity by articulation with ribs
      • ribs articulate with sternum, adding secondary stability
      • facet joints oriented in coronal plane
      • disks are thin increasing stiffness and rotational stability
      • kyphosis concentrates axial load on anterior column
    • definitions of spinal stability topic
  • Blood supply
    • "watershed area" in middle thoracic spine
      • is a vascular watershed area
      • vascular injury can lead to cord ischemia
  • Spinal cord
    • spinal cord ends and cauda equina begins at level of L1/L2
      • variable so valuable to identify beginning of cauda equina on MRI in relation to pathology
      • injuries below L1 have a better prognosis because the nerve roots (cauda equina and nerve roots within thecal sac) are affected as opposed to the spinal cord
  • Magerl classification (of thoracic spine injuries)
    • Type A
      • compression caused by axial loading
    • Type B
      • B1: ligamentous distraction injury posterior
      • B2: osseoligamentous distraction injury posterior
    • Type C
      • multidirectional injuries, often fracture dislocations
        • very unstable with high likelihood of neurologic injury
  • AO classification (of thoracolumbar spinal fracture)
    • Type A: Compression injuries
    • Type B: Distraction injuries
    • Type C: Torsional injury
      • each type then broken down further into
        • fracture morphology
        • bony versus ligamentous failure
        • direction of displacement
  • Radiographs
    • obtain radiographs of entire spine (concomitant spine fractures in 20%)
  • CT scan indications
    • fracture on plain film
    • neurologic deficit in lower extremity
    • inadequate plain films
  • MRI useful to evaluate for
    • injury to anterior and posterior ligament complex
    • spinal cord compression by disk or osseous material
    • cord edema or hemorrhage
  • Treatment varies by condition, but the following should be considered
    • degree of neurologic deficits seen on physical exam
    • degree of spinal cord compression and imaging evidence of myelomalacia
    • spinal stability
  • Nonoperative
    • indications
      •  most thoracic and thoracolumbar fractures (burst and compression) can be treated nonoperatively when the patient is neurologically intact
        • treat in orthosis for 6 to 12 weeks depending on degree of instability
  • Operative
    • indications for surgery
      • progressive neurologic deficits
      • myelomalacia seen on MRI
      • gross spinal instability
        • posterior osseoligamentous stability compromised
Surgical Techniques
  •  Approaches
    • surgical approach is dictated by
      • site of compression (anterior or posterior)
        • unlike thecal sack, the spinal cord can not be manipulated or medialized
      • surgical window needed to restore spinal stability
        • often times anterior column needs to be reconstructed
    • thoracic approaches used include
      • midline posterior approach
        • indicated only when spinal cord compression is posterior
      • costotransverse
        • can be open or thoracosopic
      • transthoracic
    • closure
      • topical vancomycin powder has been shown to 
        • decrease the rate of postoperative SSI
        • does not increase the rate of vancomycin-resistant organisms
        • be cost-effective in high-risk patients

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