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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Thoracic spine fracture-dislocation in a 33F (C2718) Gustavo Azevedo Spine - Thoracolumbar Fracture-Dislocation E 10/29/2016 1108 17 2 Fracture -Dislocation D11-D12 with paraplegia (C1834) Venkataramanan Swaminathan Spine - Thoracolumbar Fracture-Dislocation E 3/22/2014 222 2 8