summary Thoracolumbar fracture-dislocations are rare injuries 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 approximately 4% of spinal cord injuries that are admitted to level 1 trauma centers 50-60% of fracture-dislocations are associated with spinal cord injuries Demographics 4:1 male-to-female ratio Anatomic location most commonly occurs 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 resulting in hyperflexion, rotation, and shearing of the spinal column associated injuries neurologic deficits head injury concomitant injuries in the thorax and abdomen Classification systems Thoracolumbar Injury Classification and Severity Scale (TLICS) categorizes injuries based on: injury morphology neurologic injury posterior ligamentous complex integrity treatment recommendations are based on total score nonsurgical ≤3 indeterminate = 4 surgical ≥5 Anatomy Thoracolumbar junction definition T10-L2 transition zone between thoracic spine (kyphosis) and lumbar spine (lordosis) pathoanatomy greater mobility in the lumbar spine compared to the thoracic spine results in an area that is vulnerable to shearing forces high risk of injury to the spinal cord, conus, or cauda equina, depending on the patient's anatomy and degree of dislocation Presentation Pre-hospital patients almost exclusively present after major trauma, with or without neurologic deficits patients should be transported to a trauma center using spine immobilization precautions with a backboard and cervical collar Clinical approach ATLS airway, breathing, circulation neurologic assessment inspection open injury deformity (e.g. kyphosis) palpation point tenderness step-off deformity crepitus neurologic Impairment GCS ASIA Impairment score impairment of sensation, motor function, or reflexes rectal examination history physical examination Imaging Radiographs recommended views AP and lateral views of thoracolumbar spine indications suspected spinal column injury with bone tenderness determine stable vs. 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) blunt trauma patients requiring a CT scan to screen for other injuries findings injury status of the spinal canal and other associated ligamentous structures MRI indications better visualization of the spinal cord and supporting ligamentous structures level of neurologic 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 and 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 anatomic 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 nonoperative treatment obtain postoperative CT/MRI to evaluate for residual anterior compression Complications Neurologic injury Cauda equina syndrome DVT Nonunion after spinal fusion Post-traumatic pain most common complication greater risk with increased kyphotic deformity Deformity scoliosis progressive kyphosis common with an unrecognized injury of the PLL flat back syndrome leads to pain, a forward flexed posture, and easy fatigue post-traumatic syringomyelia