Updated: 6/23/2021

Thoracolumbar Fracture-Dislocation

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  • summary
    • Thoracolumbar Fracture-Dislocations are rare fractures associated with a posterior facet dislocation occurring at the thoracolumbar junction.
    • Diagnosis is made with radiographs of the thoracolumbar spine. CT scan is useful for fracture characterization and surgical planning.
    • Treatment is usually posterior open reduction with instrumented fusion. 
  • 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
    • Anatomic location
      • most commonly occur at the thoracolumbar junction
    • Risk factors
      • high energy injuries
        • motor vehicle accident (most common)
        • falls
        • sports
        • violence
  • Etiology
    • 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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