Introduction 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 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 Chance fracture Anatomy 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 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 Classification 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 Imaging 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 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