Management of Thoracolumbar Fractures

Abstract

Thoracolumbar region is the most commonly affected region of spine in trauma, but still no consensus exists on various aspects of its management. The management of thoracolumbar fractures has evolved considerably with time, but there are certain areas where there is still no consensus. Only few level I evidence are available to make any recommendation. This article reviews the current literature on evaluation, treatment, timing of surgery, choice of approach, and length of fusion.

Keywords

thoracolumbar fracture - spinal fractures - pedicle screws - spine fractures

• References

• 1 Gertzbein SD. Scoliosis Research Society. Multicenter spine fracture study. Spine 1992; 17 (5) 528-540
• 2 DeWald RL. Burst fractures of the thoracic and lumbar spine. Clin Orthop Relat Res 1984; (189) 150-161
• 3 Rajasekaran S, Kanna RM, Shetty AP. Management of thoracolumbar spine trauma: An overview. Indian J Orthop 2015; 49 (1) 72-82
• 4 Tearse DS, Keene JS, Drummond DS. Management of non-contiguous vertebral fractures. Paraplegia 1987; 25 (2) 100-105
• 5 Gupta A, el Masri WS. Multilevel spinal injuries. Incidence, distribution and neurological patterns. J Bone Joint Surg Br 1989; 71 (4) 692-695
• 6 Cotler JM, Vernace JV, Michalski JA. The use of Harrington rods in thoracolumbar fractures. Orthop Clin North Am 1986; 17 (1) 87-103
• 7 Stein DM, Roddy V, Marx J, Smith WS, Weingart SD. Emergency neurological life support: traumatic spine injury. Neurocrit Care 2012; 17 (Suppl. 01) S102-S111
• 8 Wirz M, Zörner B, Rupp R, Dietz V. Outcome after incomplete spinal cord injury: central cord versus Brown-Sequard syndrome. Spinal Cord 2010; 48 (5) 407-414
• 9 Sidhu GS, Ghag A, Prokuski V, Vaccaro AR, Radcliff KE. Civilian gunshot injuries of the spinal cord: a systematic review of the current literature. Clin Orthop Relat Res 2013; 471 (12) 3945-3955
• 10 Vale FL, Burns J, Jackson AB, Hadley MN. Combined medical and surgical treatment after acute spinal cord injury: results of a prospective pilot study to assess the merits of aggressive medical resuscitation and blood pressure management. J Neurosurg 1997; 87 (2) 239-246
• 11 Wintermark M, Mouhsine E, Theumann N , et al. Thoracolumbar spine fractures in patients who have sustained severe trauma: depiction with multi-detector row CT. Radiology 2003; 227 (3) 681-689
• 12 Lee HM, Kim HS, Kim DJ, Suk KS, Park JO, Kim NH. Reliability of magnetic resonance imaging in detecting posterior ligament complex injury in thoracolumbar spinal fractures. Spine 2000; 25 (16) 2079-2084
• 13 Lee JY, Vaccaro AR, Schweitzer Jr KM , et al. Assessment of injury to the thoracolumbar posterior ligamentous complex in the setting of normal-appearing plain radiography. Spine J 2007; 7 (4) 422-427
• 14 McEvoy RD, Bradford DS. The management of burst fractures of the thoracic and lumbar spine. Experience in 53 patients. Spine 1985; 10 (7) 631-637
• 15 Vaccaro AR, Lehman Jr RA, Hurlbert RJ , et al. A new classification of thoracolumbar injuries: the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status. Spine 2005; 30 (20) 2325-2333
• 16 Winklhofer S, Thekkumthala-Sommer M, Schmidt D , et al. Magnetic resonance imaging frequently changes classification of acute traumatic thoracolumbar spine injuries. Skeletal Radiol 2013; 42 (6) 779-786
• 17 Vaccaro AR, Rihn JA, Saravanja D , et al. Injury of the posterior ligamentous complex of the thoracolumbar spine: a prospective evaluation of the diagnostic accuracy of magnetic resonance imaging. Spine 2009; 34 (23) E841-E847
• 18 Joaquim AF, Ghizoni E, Tedeschi H, Batista UC, Patel AA. Clinical results of patients with thoracolumbar spine trauma treated according to the Thoracolumbar Injury Classification and Severity Score. J Neurosurg Spine 2014; 20 (5) 562-567
• 19 van Middendorp JJ, Patel AA, Schuetz M, Joaquim AF. The precision, accuracy and validity of detecting posterior ligamentous complex injuries of the thoracic and lumbar spine: a critical appraisal of the literature. Eur Spine J 2013; 22 (3) 461-474
• 20 Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine 1983; 8 (8) 817-831
• 21 Nicoll EA. Fractures of the dorso-lumbar spine. J Bone Joint Surg Br 1949; 31B (3) 376-394
• 22 Holdsworth F. Fractures, dislocations, and fracture-dislocations of the spine. J Bone Joint Surg Am 1970; 52 (8) 1534-1551
• 23 Louis R. Unstable fractures of the spine. III. Instability. A. Theories concerning instability [in French]. Rev Chir Orthop Repar Appar Mot 1977; 63 (5) 423-425
• 24 Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S. A comprehensive classification of thoracic and lumbar injuries. Eur Spine J 1994; 3 (4) 184-201
• 25 McAfee PC, Yuan HA, Fredrickson BE, Lubicky JP. The value of computed tomography in thoracolumbar fractures. An analysis of one hundred consecutive cases and a new classification. J Bone Joint Surg Am 1983; 65 (4) 461-473
• 26 Koh YD, Kim DJ, Koh YW. Reliability and Validity of Thoracolumbar Injury Classification and Severity Score (TLICS). Asian Spine J 2010; 4 (2) 109-117
• 27 Lewkonia P, Paolucci EO, Thomas K. Reliability of the thoracolumbar injury classification and severity score and comparison with the denis classification for injury to the thoracic and lumbar spine. Spine (Philapa 1976) 2012; 37 (26) 2161-2167
• 28 Bracken MB, Shepard MJ, Collins WF , et al. A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury. Results of the Second National Acute Spinal Cord Injury Study. N Engl J Med 1990; 322 (20) 1405-1411
• 29 Eck JC, Nachtigall D, Humphreys SC, Hodges SD. Questionnaire survey of spine surgeons on the use of methylprednisolone for acute spinal cord injury. Spine (Phila Pa 1976) 2006; 31 (9) E250-E253
• 30 Hurlbert RJ, Moulton R. Why do you prescribe methylprednisolone for acute spinal cord injury? A Canadian perspective and a position statement. Can J Neurol Sci 2002; 29 (3) 236-239
• 31 Giele BM, Wiertsema SH, Beelen A , et al. No evidence for the effectiveness of bracing in patients with thoracolumbar fractures. Acta Orthop 2009; 80 (2) 226-232
• 32 Folman Y, Gepstein R. Late outcome of nonoperative management of thoracolumbar vertebral wedge fractures. J Orthop Trauma 2003; 17 (3) 190-192
• 33 Shen WJ, Liu TJ, Shen YS. Nonoperative treatment versus posterior fixation for thoracolumbar junction burst fractures without neurologic deficit. Spine 2001; 26 (9) 1038-1045
• 34 Seybold EA, Sweeney CA, Fredrickson BE, Warhold LG, Bernini PM. Functional outcome of low lumbar burst fractures. A multicenter review of operative and nonoperative treatment of L3-L5. Spine 1999; 24 (20) 2154-2161
• 35 Celebi L, Muratli HH, Doğan O, Yağmurlu MF, Aktekin CN, Biçimoğlu A. The efficacy of non-operative treatment of burst fractures of the thoracolumbar vertebrae [in Turkish]. Acta Orthop Traumatol Turc 2004; 38 (1) 16-22
• 36 Resch H, Rabl M, Klampfer H, Ritter E, Povacz P. Surgical vs. conservative treatment of fractures of the thoracolumbar transition [in German]. Unfallchirurg 2000; 103 (4) 281-288
• 37 Dai LY. Remodeling of the spinal canal after thoracolumbar burst fractures. Clin Orthop Relat Res 2001; (382) 119-123
• 38 Chipman JG, Deuser WE, Beilman GJ. Early surgery for thoracolumbar spine injuries decreases complications. J Trauma 2004; 56 (1) 52-57
• 39 Oner FC, Wood KB, Smith JS, Shaffrey CI. Therapeutic decision making in thoracolumbar spine trauma. Spine 2010; 35 (21, Suppl): S235-S244
• 40 Dashti H, Lee HC, Karaikovic EE, Gaines Jr RW. Decision making in thoracolumbar fractures. Neurol India 2005; 53 (4) 534-541
• 41 Dai LY. Principles of management of thoracolumbar fractures. Orthop Surg 2012; 4 (2) 67-70
• 42 Karaiković EE, Pacheco HO. Treatment options for thoracolumbar spine fractures. Bosn J Basic Med Sci 2005; 5 (2) 20-26
• 43 Dimar II JR, Glassman SD, Raque GH, Zhang YP, Shields CB. The influence of spinal canal narrowing and timing of decompression on neurologic recovery after spinal cord contusion in a rat model. Spine (Phila Pa 1976) 1999; 24 (16) 1623-1633
• 44 Chapman JR, Anderson PA. Thoracolumbar spine fractures with neurologic deficit. Orthop Clin North Am 1994; 25 (4) 595-612
• 45 Esses SI, Botsford DJ, Kostuik JP. Evaluation of surgical treatment for burst fractures. Spine 1990; 15 (7) 667-673
• 46 McCormack T, Karaikovic E, Gaines RW. The load sharing classification of spine fractures. Spine 1994; 19 (15) 1741-1744
• 47 Parker JW, Lane JR, Karaikovic EE, Gaines RW. Successful short-segment instrumentation and fusion for thoracolumbar spine fractures: a consecutive 41/2-year series. Spine 2000; 25 (9) 1157-1170
• 48 Crutcher Jr JP, Anderson PA, King HA, Montesano PX. Indirect spinal canal decompression in patients with thoracolumbar burst fractures treated by posterior distraction rods. J Spinal Disord 1991; 4 (1) 39-48
• 49 Willén J, Lindahl S, Irstam L, Nordwall A. Unstable thoracolumbar fractures. A study by CT and conventional roentgenology of the reduction effect of Harrington instrumentation. Spine 1984; 9 (2) 214-219
• 50 Yazici M, Gulman B, Sen S, Tilki K. Sagittal contour restoration and canal clearance in burst fractures of the thoracolumbar junction (T12-L1): the efficacy of timing of the surgery. J Orthop Trauma 1995; 9 (6) 491-498
• 51 Sasso RC, Cotler HB. Posterior instrumentation and fusion for unstable fractures and fracture-dislocations of the thoracic and lumbar spine. A comparative study of three fixation devices in 70 patients. Spine 1993; 18 (4) 450-460
• 52 Boerger TO, Limb D, Dickson RA. Does ‘canal clearance’ affect neurological outcome after thoracolumbar burst fractures?. J Bone Joint Surg Br 2000; 82 (5) 629-635
• 53 Carlson GD, Minato Y, Okada A , et al. Early time-dependent decompression for spinal cord injury: vascular mechanisms of recovery. J Neurotrauma 1997; 14 (12) 951-962
• 54 Yang M, Ding GZ, Xu ZJ. Surgical Outcome in Thoracolumbar Fractures Managed by Short-segment Pedicle Instrumentation. Ann Acad Med Singapore 2014; 43 (1) 24-32
• 55 Charles YP, Zairi F, Vincent C , et al Minimally-invasive posterior surgery for thoracolumbar fractures: new trends to decrease muscle damage. Eur J Orthop Surg Traumatol 2012; 22 (1) 1-7
• 56 Court C, Vincent C. Percutaneous fixation of thoracolumbar fractures: current concepts. Orthop Traumatol Surg Res 2012; 98 (8) 900-909
• 57 Oner FC, van der Rijt RR, Ramos LM, Dhert WJ, Verbout AJ. Changes in the disc space after fractures of the thoracolumbar spine. J Bone Joint Surg Br 1998; 80 (5) 833-839
• 58 Wang XY, Dai LY, Xu HZ, Chi YL. Kyphosis recurrence after posterior short-segment fixation in thoracolumbar burst fractures. J Neurosurg Spine 2008; 8 (3) 246-254
• 59 Dai LY, Jiang LS, Jiang SD. Conservative treatment of thoracolumbar burst fractures: a long-term follow-up results with special reference to the load sharing classification. Spine 2008; 33 (23) 2536-2544