Karwar Institute of Medical Sciences,

Karwar
DEPARTMENT OF ORTHOPAEDICS

Thoracic Spine Fracture

Seminar on

CHAIRPERSON: PRESENTED BY:

DR. Madhukar K.T. (Professor and Head of Department) Dr. SAURABH KUMAR
2ndYR PG IN ORTHOPAEDICS

Moderator:
Dr. Shreesha (Assistant Professor)
CONTEN
TS
• ANATOMY
• EPIDEMIOLOGY
• ETIOLOGY
• MECHANISM OF INJURY
• CLASSIFICATION
• MANAGEMENT
Anatomy of Thoracic
Spine
• Kyphosis is natural
alignment
• Narrow spinal
canal
• Facet orientation
• Rib factor on
stability
Anatomy of Lumbar
Spine
• Lordosis is natural
alignment
• Larger vertebral
bodies
• Facet orientation
Thoraco Lumbar junction
Transition zone:

Rigid, stable, kyphotic thoracic spine to

Mobile Lordotic Relatively Stable Lower
Lumbar Spine.

Hence susceptibility to injury.

Thoracic Spine: Lumbar spine:

-Coronally oriented facet -Sagital orientation of

joint facet joint

-thin I.V. disc -thicker I.V. disc

-the ribcage -Absent ribcage

-narrow spinal cord -Less incidence of

predisposes to spinal cord neurological damage
damage dueto large neural canal
and cauda equina nerve
root
EPIDEMIOLOGY
• More frequent in male

• Peak incidence is 20-40 yrs

• Mechanism of injury:
motor vehicle accident-50%
fall from height-25%

• Complete neurological injury-20%

• Incomplete neurological injury-15%
• Associated injuries more than 50%
Anatomically and functionally, the thoracic and lumbar spine can be divided
into three regions

-thoracic spine (T1-T10): 25-40%

-thoracolumbar junction(T10-L2): 50-60%
-the Lumbar spine(L3-L5): 10-14%

Thoracolumbar junction is the most common injury site

 Cause of
injury
52.3

38.4

5 4.3

fall from height RTA Violence Gun

shot
injuries

Upendra B, Khandwal P, Chowdhury B, Jayaswal A: Correlation of outcome measures

with epidemiological factors in thoracolumbar spinal trauma. Indain J Orthop 2007
Oct;41(4):290-4.
Mechanisms of Injury for Thoracolumbar
Spine Fractures and Dislocations
• axial loading(compression)
• flexion
• extension (lumbar jack injuries) shear
• axial rotation
 Associated Injuries with
Thoracolumbar Spine Fractures and
•Dislocations
50% of individuals with thoracolumbar fractures will be diagnosed
with a nonspinal injury (involvement of one other organ system, 30%;
two systems, 20%; three or more systems
• 45% of patients with “seatbelt” fractures will also sustain some type
of intraabdominal injury such as a laceration of the spleen or liver
Signs and Symptoms: Initial Evaluation and
Management of Thoracolumbar Injuries
• Initial Evaluation
 Advanced Trauma Life Support (ATLS) protocol
Strict precaution for immobilization in form of spine board
and cervical collar needed.
 Urgent transportation to adequately equipped tertiary
health centre.
 Resuscitation should begin immediately
Clinical Examination
 History

 Local Examination

 Neurological Evaluation

 ASIA Grading
AMERICAN SPINE INJURY
ASSOCIATION
REFLEX
EXAMINATION
COMPLETE VS
INCOMPLETE
Complete
No function below level of injury
Absence of sensation and voluntary movement in
S4/5 distribution

Incomplete
Preservation of sensation in S4/5 distribution
and voluntary control of anal sphincter
Investigations :
• plain X-rays,
• CT and
•MRI studies

X-RAYS
• A-P &
• Lateral views
 GOALS
• Identify the location and extent of injury

• Determine features of vertebral instability

• Assess the severity of neurological compession and injury

• Classify the injury pattern

• Identify multilevel injuries

Antero-posterior view:

 loss of vertebral body height

 changes in interpedicular distance (rotational component)
 irregular distance between the spinous processes (equivocal sign)
 asymmetry of the spinal alignment
 subluxation of costotransverse articulations
 perpendicular or oblique fractures of the dorsal elements
Lateral view

 Loss of anterior vertebral body height

 Dislocation
 Kyphosis>30 seen in O.D and decreased height
 Vertebral Body collapse>50%
 Loss of posterior vertebral body height
 Posterior cortical bulging
 Loss of spinal alignment
 Vertebra translation
 Spinous process fracture
 CT SCAN

• Most accurately depicts Bony injury.

• Sensitivity and specificity>95%

• X rays can confuse compression and burst fracture

• Can detect visceral injuries too

•
Sagittal and coronal 2D or
3D reconstructions are helpful for
determining the fracture
pattern
MRI SCAN
To identify the extent of soft tissue injury

Indication:

• Pt. with neurological defecit

• Pt.with suspicious PLC injury
• MRI can be helpful in
determining the integrity of the
posterior ligamentous
structures and thereby
differentiate between a stable
and an unstable lesion.
 Instability
It is the ability of spine under physiological load to maintain relationship between
vertebrae in such a way that there is neither damage nor subsequent irritation to
Spinal cord or Nerve root

The Spine Trauma Study Group has defined three categories:

• Mechanical Stability(morphology of injury)

• Long term stability(integrity of PLC)
• Neurological Stability(presence or absence of deficit)
 Compression fracture
• Mechanism: Axial compression on anterior
column

• Failure through the anterior column

• Superior or inferior end plate alone, both end

plate, buckling of anterior cortex with endplate
preservation
 Burst fractures..
AP film Lateral film:
• Fracture of posterior wall cortex
Increase in interpediculate distance • Loss of height of posterior vertebral body
• Retropulsion of fragment into canal
 Burst Fracture
• Mechanism: Increased Axial compression

• Rarely preservation of endplates

• Plane radiographs are often diagnostic

• CT Scan is to distinguish compression from subtle burst fracture

 Unstable burst fractures..

• Loss of height >50%

• Kyphotic deformity >30 degrees

• Substantial posterior column

injury

• Progessive deformity

• Progessive neurological deficit

CHANCE FRACTURE AND CHANCE
VARIANTS(FLEXION DISTRACTION
INJURIES)
• Mechanism: Distractive forces on the spine

• Tension failure of the PLC and associated injuries to the anterior and
middle column.
 CHANCE
Purely osseus lesion as a horizontal fracture
extending through the spinous process
through the laminae and pedicles, and into the
vertebral bodies.
 Deni
Seat-Belt type injuries.. s

Chance fracture

Failure of both posterior and middle columns under tension forces

generated by flexion with its axis placed in the anterior column
Axis of rotation
If anterior to the spine: vertebral body intact; if such an injury is severe, all the
spine ligaments including the ALL maybe disrupted, resulting in severely unstable
injury

Within the anterior column: Vertebral body fracture.

 VARIANTS
• Variants of this injury involve disc and
ligamentous disruption with or without
fracture

• Anterior column disruption occurs through

the disc space, not the vertebral body , and
the post column disruption by facet
dislocation and ligamentous rupture, rather
than fracture through the pedicle
 Denis
Fracture
classification
 Holdsworth Classification
• Two column theory

• Spinal stability depends upon PLC

• Anterior column resist Compressive loads

• PLC resists Tensile force

 Denis Classification
• 3 Column Theory

• Mechanical and Neurological instability

• For unstable injury Middle and Posterior column must be disrupted

Dennis three column
concept..
Posterior tension band components
include:
•Posterior ligamentous complex: Supraspinous and interspinous ligaments,
ligamentum flavum

•Musculature: Longissimus, iliocostalis, spinalis, semispinalis, rotatores,

intertransversarii, multifidus

•Bone: Transverse and spinous processes, pedicles, facets

Failure under compression of
anterior column. The
middle column is intact
and acts as a hinge.
Thoracolumbar Injury Classification andSeverity
Score(TLICS)
 Evaluating
PLC..!!
Clinical signs: X ray: CT scan:
1. Palpable 1. Kyphosis 1. Diastasis of
>30 facet joints
interspinous degrees 2. Spinous
defect 2. > 50% process
2. Posterior compression of avulsion
tenderness anterior
vertebral body
3. MRI:
interspinous 1. Edema in region
spacing greater of PLC (T2)
than 7 mm
2. Disruption of
than adjacent
PLC components
vertebrae
(T1)
(SSL,ISL,LF,Capsule
Examples
Flexion Compression Fx

•Flexion compression (morphology) -

1
•Intact (neurology) - 0
•PLC (ligament) no injury - 0

Total 1 points- Non Op

Compression
Burst Fracture
•Flexion compression burst -
2
•Intact ( neurology) - 0
•PLC (ligament) no injury (0)

Total 2 points-Non Op
Compression
Burst-Complete Neuro Injury
•Axial compression burst with distraction posterior ligamentous
complex -4
•Complete (neurology) - 2
•PLC (ligament) injury - 3

Total 9 points-Surgery
Compression
Burst-Complete
•injury
Axial compression burst-2
• Complete (neurology)-2
• PLC (ligament) Intact-0

Points 4-Non Op vs Op
Translational/Rotation Injury

•Distraction, Translation/rotational,
compression injury - 4
•Complete (neurology) – 2
•PLC injury - 3

Total 9 points-
Surgery
Treatment -
Principles
1. To preserve neurological function

2. To minimize a perceived threat of neurological compression

3. To stabilize spine

4. To rehabilitate the patient

Medical management
Hemodynamic:
Aim: Maintain MAP >80 mmHg
X 48 hrs OR 24 hrs postoperatively
whichever longer
• Fluids +/- Vasopressors +/-
Inotropes
VTE prophylaxis
Decubitus ulcer prevention
Primary insult: at time of injury,non modifiable

Secondary- potentially modifiable, due to vascular dysfunction, edema, ischemia, free

radical production, inflammation and apoptotic cell death

For Secondary injury:

• Steroid’
• Gangliosides
• Nalaxone
• CCB
• Free radical scavangers
• Neurotropic agents
NASCIS 1
1984
two different doses of
methylprednisolone sodium succinate
(MPSS) within 48 h of acute spinal
cord injury
With results demonstrating no
significant difference in motor
recovery between groups
a placebo arm was conspicuously
absent in NASCIS I
NASCIS 2 NASCIS 3
1990 1998
involved a MPSS treatment arm with MPSS was administered for 24 or 48 h
a much higher, weight-based dose of and compared to tirilazad mesylate, a
MPSS compared to naloxone lipid peroxidation inhibitor.
treatment and placebo
Similar to NASCIS I, the primary
endpoint in NASCIS II was negative;
however, the authors emphasized the
positive results of a single, statistically
significant subgroup of patients
receiving MPSS within 8 h of injury
NASCIS II never reported the total
number of subgroups, so it is
impossible to know the appropriate
modified alpha for testing statistical
significance.
Complication and C/I
• Infection
• GI bleeding
• Pulmonary and endocrine problem
• Healing of spinal fusion

Not advised in:

• Pt. with comorbidities of GI tract

• Associated head injuries

Nonoperative
management
• Analgesics
• Braces
• physiotherapy
• Indications:
• Mechanically stable fractures
• Neurologically intact
• Acceptable alignment

• Prolonged bed rest:

• Too mechanically unstable to treat with brace, but for some reason surgery is
contraindicated or refused by the patient.
Bracing: When out of bed

• Mid-lumbar through Mid-thoracic injuries T7-L3: TLSO

• Upper thoracic injury at T6 or above: CTLSO
• Below L3: TLS orthosis with incorporation of thighs

• Biomechanics: Limit spinal motion + Load-sharing

• Mode of healing: Secondary
• Duration: 6 wks – 3 months (upto 4-6 months for 3 column burst fractures)
• Restrictions:
• Lifting >10 lbs & Performing bending or twisting activities
• Upright X-ray in brace at regular f/u (2 wk, 6 wk, every 6-8 wk)
• When brace discontinued (wean): Flexion and Extension X-ray (stability)
•v
Surgical Management
Goals of surgery:

• Achieving and Maintaining Anatomic reduction and stability

• Neural element Decompression

• Minimization of construct length

• Immediate mobilization

• Early Rehabilitation
 Surgical management Indication:
• Incomplete Neurological Defecit

• Progressive neurological Defecit

• Spinal Cord Compression

• Fracture Dislocation

• Kyphosis >30

• Concomitant injuries necessitating early mobilisation

Timing of Surgery
Vaccaro et al:

Within 72hr after injury and after 5 days

Found out no Significant neurological benefit

LaRosa et al:

Within 24 hr and after 24 hr and conservative management

Early Decompression resulted in better outcome

 POSTERIOR APPROACH

Advantages :
avoids the morbidity of anterior exposure in patients who potentially have
concomitant pulmonary or abdominal injuries.
• shorter operative times
• decreased blood loss
• functional outcomes are similar to those following anterior
surgery
Disadvantages: no direct approach to site of
pathology
 Indication:
MC approach for vast majority of Thoracolumbar fractures

Unstable burst fracture with intact neurology

Flexion Distraction injury
Chance fracture

Posterior pedicle screw fixation has been shown to be simple ,familiar, efficient,
reliable, and safe for the reduction and stabilization of most fracture and remains the
most popular technique
Initially hooks and wires
were used
Pedicle screws with rods
most commonly used
with rods for
stabilisation now.
Sites
1) thoracic :
immediately lateral to
middle of facet joint along
superior third of
transverse process
2) lumbar vertebrae:
Intersection of line bisecting
the transverse process
and line
passing along lateral aspect
of
facet joint
Other methods
 mamillary process
 pars interarticularis
method
POSTERIOR
REALIGNMENT AND
FIXATION
 ANTERIOR
SURGERY
• Indicated for decompression of
the neural elements.
• It provides direct visualization of
the anterior thecal sac and is t h e
m o s t reliable method of spinal
canal decompression
• Higher morbidity
• Decompression followed by void
filling
with autograft/ allograft /
cage insertion
• Fixation by plates and screws/ rods -
screw- staple construct.
Ligamentotaxis
Indirect Decompression
By distraction and ligamentotaxis

Best result:
• Within 48 hrs
• Moderate canal compession(50%)

Poor Result:
• Severe Spinal cord compromise(67%)
• If surgery is planned for more than 72 hrs postsurgery
• Due to early fracture consolidation
 Transpedicular Approach
Potential indication: a patient with a fracture above the conus with a posterior
failure and neurological deficit with canal intrusion a ventral piece of bone between
the pedicles where the dura and cord should not be retracted

In the lumbar spine below the conus, as the dura could be retracted, enabling direct
decompression of fragment by either tamping the fragment forward or by direct
removal.
 Costotransversectomy
Better decompression as allows through bony removal.

Provides anterior column support and deformity correction through

Corpectomy

Indication: a pt who has thoracic or TL injury (L2 or above) with failure of

posterior tension band and significant anterior column injury, with or without
a retropulsed ventral fragment and a neurological defecit.
Disadvantage:

Instrumentation failure
Pseudoarthrosis
Infection
Risk of SCI
Inadequate neurological decompression
Insuffecient correction of kyphosis
Need for late instrumentation removal
 Anterior Approach
Preferred approach in the setting of severe canal stenosis and neurological injury

Can be utilized alone or in conjuction with a posterior instrumented fusion.

Advantages:

• Direct visualization and decompression of the neural elements

• Restoration of anterior column and
• Kyphosis correction
ContraIndication for Standalone Anterior
Approach
• PLC insufficiency
• Osteoporosis

Relative contraindication:

• Morbid obesity and severe pulmonary disease

• Low lumbar fracture at L4 or L5
Combined Approach
Indication:
Incomplete Spinal Cord Injury(SCI) with canal stenosis of greater than 75% and
injury to PLC

Advantages:

• Improved Sagittal alignment

• Thorough spinal cord neural decompression
• Stabilisation of the disrupted PLC
 Post Op Management
• DVT Prophylaxis
Mechanical (e.g., sequential compression devices) is used
preoperatively on all pts
Pharmacological anticoagulation begins after 48 hrs

• Inferior Vena Cava(IVC) filter should also be considered for highriskpts to

prevent pulmonary embolus

• Bending and Lifting activities restricted for 12 weeks

• Radiographs are routinely taken at the time of hospital discharge ,then at 6,12
and 24 week postop and annually afterwords

• CT can be usedtoevaluate the adequacy of canal decompression and to evaluate

for possible implant failure, malposition, or non union
 Percutaneous Vertebroplasty and
Kyphoplasty
• They are two percutaneous interventional procedures used to treat symptomatic,
nonhealing fragility fractures of the spine by injecting polymethyl methacrylate
(PMMA) into the vertebral body thereby providing structural support.

• VCFs are defined as a loss of about 20% or at least 4 mm of anterior, middle, or

posterior vertebral height.

• The thoracolumbar spine (T12-L2) is the most frequently affected site (60-75%),
followed by the lower lumbar region (L2-L5)
Unlike vertebral burst or Chance fractures, a compression fracture does not
compromise the posterior tension band

Therefore, compression fractures are deemed stable fractures.

Indications:

• The majority of patients can be treated with observation and a gradual return to
activity. Symptoms typically resolved within 4-6 weeks.

• Surgical intervention is indicated for certain patients who suffer from significant
pain and morbidity after this time period.

• In recently published AAOS (American Academy of Orthopedic Surgeon)

guidelines for osteoporotic compression fractures, they recommend strongly against
the use of vertebroplasty.
• However, kyphoplasty remains a viable option for the treatment of these
injuries.
Contraindications:

• An absolute contraindication to vertebroplasty and kyphoplasty is an asymptomatic

compression fracture.

• The procedure should not be performed if there are ongoing local or systemic
infectious processes such as osteomyelitis or discitis.

• Fracture extension into the posterior vertebral body wall that can risk cement
extravasation into the spinal canal

• Severe compression fractures/deformity

Complications:

•Infection and bleeding: Universally recognized risks of any interventional procedure.

•Radiculopathy or neurological deficit: If the spinal needle violates the inferior or

medial wall of the pedicle during entry, there is a significant risk of damage to a nerve
root or the spinal cord.

•The most common complication associated with vertebroplasty is PMMA leakage

into the surrounding tissue, intradiscal, and spinal canal. This is more common for VP.

•Pulmonary embolization

•Spinal stenosis: Cement leakage into the epidural

 Complication
Dural tear,Vascular and neurological injury, infection, implant failure, non union,
and loss of correction with late deformity

Screw related complication,such as neurological, visceral, or vascular are very

rare

The proximity of vertebral bodies to structure like lungs and pleura can result in
Pneumothorax, effusion or esophageal injury

Vascular injury can also occur while performing the corpectomy, placing the
graft, and inserting the screws
 Contemporary Concept
Spinal stabilization without fusion:
Healing without permanent stiffness

Rod long fusion short method – local fusion limited to the injured levels and
subsequent rod removal 1 year later

Good result
-in ankylosed spine AS or DISH
-Flexion-Distraction and Chance variant also heals rapidly
Advantages

Shorter operative time and less blood loss

Disadvantages:
• Recurrent kyphosis after instrumentation removal
• Instrumentation failure
• Possible need for removal of instrumentation, and/or
• Facet arthrosis
 MIS(percutaneous screw)

• Relies on muscle splitting rather than muscle stripping

• Minimising blood loss
• Less surgical time
• Less surgical site infection
Indication:

• Fracture through ankylosed spine segment

• Flexion distraction injuries with primary bony component
• Unstable burst fracture in neurologically intact patients and multiple and multiple
level fractures

Contraindication:

• Incomplete neurological injury that necessitates direct compression

• Fracture dislocation in neurologically intact pt
• In cases of delayed fixation in which postural reduction isnot expected to restore
adequate spinal alignment
 Cement Usage
• Can be utilized in combination with open surgery or percutaneous pedicle
screw instrumentation

• Can avoid anterior/combined approach

• Mostly used in osteoporotic bone with Tscore <2.5

• Uses Bone Filling Device which is also percutaneous

• Avoided with open approach as Most common complication is Embolus

Complicatio
ns
• Of injuries: • Of fixation:
1. Skin problems 1. Dural tear
2. VTE 2. Iatrogenic neural injury
3. Urosepsis 3. Pseudoarthrosis
4. Sinus bradycardia 4. Failure of fixation
5. Orthostatic hypotension 5. Iatrogenic flat back
6. Autonomic dysreflexia 6. Infection
7. Major depressive disorder 7. Medical complications
REFERENC
ES
1. Apley and Solomon’s System of Orthopedics and Trauma – 10th
Edition
2. Campbell’s Operative Orthopedics – 14th Edition
3. Rockwood and Greens Fractures in Adults – 9th Edition
4. AOSpine Masters Series – Volume 6
Thank