THORACO-LUMBAR FRACTURES

OF SPINE
Anatomy:
• Cervical - 7 vertebrae
• Thoracic -12 vertebrae
• Lumbar - 5 vertebrae
• Sacral - 5 fused vertebrae
• Coccyx - 4 fused vertebrae
Lateral (Side) Spinal Column

Cervical ( Lordosis J

Thoracic ( Kyphosis )

Lumbar ( Lordosis )

Sacral ( Kyphosis >

Coccyx ( Tailbone ) _I
 Ligimentnm
tla\iim
** Anteiio*
longitudinal
ligament
Zygapofrfiyseal
joint

NJudein
Su pi a «¡pin ou?
ligament
* Poste» io*
longitudinal

Intel spinous
ligament
* Vcftchul
body

lig. I * indicjtn pain -sen sin g «Jiuctuic?

 Functional spinal unit

Functional spinal unit

is composed of Supraspinous ftgom

Superior vertebra
• two adjacent vertebrae : apu I

• Facet joint Nucleus

Disc annulus
• inter vertebral disc and hdpiate
Inferior vertebra Interspinous Igament

• intervening ligaments
Focet joint

This unit is responsible

for Movement of joint
4
 Physiological Anatomy of the Thoracic
Spine
• Facets lie in the frontal plane- allowing rotation
• Ribs resist rotation and add 3x the normal stiffness in
lateral rotation
• Kyphosis of the T spine loads the anterior column
• Lower 2 vertebra have floating ribs and no
costotransverse articulations
• Canal size in thoracic spine relatively small
 Physiological Anatomy of the
Lumbar Spine

• Large discs allow more ROM

• Facets prevent rotation as
they aranged in saggital plain
• Spinal canal wider
• Lordosis loads the facets
 Thoracolumbar Junction
The susceptibility of the thoracolumbar junction to
injury is attributed mainly to the following anatomical
reasons:
• The transition from a relatively rigid thoracic
kyphosis to a more mobile lumbar lordosis occurs
at T11-12. •

• The lowest thoracic ribs (T11 and T12) provide less

stability at the thoracolumbar junction region
compared to the upper thoracic region, because
they do not connect to the sternum and are free floating.
• The facet joints of the thoracic region are
oriented in the coronal (frontal) plane, limiting
flexion and extension .
• In the lumbosacral region, the facetjoints are
oriented in a more sagittal alignment, which
increases the degree of potential flexion and
extension
ETIOLOGY
• High energy trauma
• Fall from height
• Sports accident
• Violent act, such as a gunshot wound
• osteoporosis
• tumors
• other underlying conditions that weaken bone
CLASSIFICATION
 Denis Three column theory :
• The vertebral column is divided into three columns

1. ANTERIOR

2. MIDDLE
Posterior mam■ AnufKM
Column column Column

3. POSTERIOR Columns
Anterior column :
anterior longitudinal
ligament,
the anterior half of the
vertebral body and
the anterior portion of
the annulus fibrosus.
Middle column

posterior longitudinal
ligament,
the posterior half of
the vertebral body and
the posterior aspect of
the annulus fibrosus.
posterior column :
the neural arch,
ligamentum flavum
the facet joint, and
the interspinous
ligaments
Denis Classification of Spinal Trauma

Major Injuries Minor Injuries

COMPRESSION transverse processes fx

BURST articular process fx pars

SEAT-BELT-TYPE interaiticularis fx spinous

FRACTURE-DISLOCATION process fx
COMPRESSION FRACTURE:

• Results from Anterior or lateral flexion

• Failure of anterior column

• The middle column is intact and acts as a hinge.

• There may be a partial failure of the posterior
column, indicating the tension forces at that
level.
• Usually no Neurological deficits are noted.
4 subtypes on basis of
end plate involvement

# of both end plates

# of superior end
plate
# of inferior end plate
both end plates intact
 Burst fractures
• Occurs due to Axial compression resulting in Failure
of anterior and middle column

• If posterior column involved results in

instability

Most common at T/L junction

5 subtypes on basis of end
plate involvement

• # of both end plates

• # of superior end plate
• #of inferior end plate
• both end plates intact
• Burst lateral flexion
FLEXION-DISTRACTION OR SEAT-BELT-
TYPE INJURY or CHANCE #
• Both posterior and
middle columns fail
due to hyper-flexion
and subsequent
tension forces. •
Fracture- Dislocation
• Presents with failure of all three
columns under compression, tension,
rotation, or shear.
• It is similar to seat-belt-type injury.
However, the anterior hinge is also disrupted
and some degree of dislocation is present.
 Three subtypes of fracture-dislocations based
on mechanism of injury: •

• flexion rotation
• Flexion-distraction
• Shear type
flexion rotation:
There is a complete
disruption of the
posterior and
middle columns
under tension and
rotation.
The anterior column
in rotation or
compression and
rotation.
Flexion-distraction
Tension failure of
posterior and middle
columns .
With tear of the anterior
annulus fibrosus, and
stripping of the anterior
longitudinal ligament.
Neurological deficit(75%)
Shear :
• Shear failure of all
three columns,
• commonly in postero-
anterior direction

All cases present with

neurologic deficit
 Thoracolumbar Injury
Classification and Severity Score
POINTS
• FRACTURE MECHANISM
• Compression fracture 1
• Burst fracture 1
• Translation/rotation 3
• Distraction 4
• NEUROLOGICAL INVOLVEMENT
• Intact 0
• Nerve root 2
• Cord, conus medullaris, incomplete 3
• Cord, conus medullaris, complete 2
• Cauda equina 3
• POSTERIOR LIGAMENTOUS COMPLEX INTEGRITY
• Intact 0
• Injury suspected/indeterminate 2
• Injured 3
 SPINAL STABILITY
• Spinal injury is considered unstable if normal
physiological load cause further neurological
damage , chronic pain & deformity

• Instability exists if any of two columns are

disrupted
• In T-L stability if middle column is intact, # is
usually stable .
 Three Degrees of instability:
First degree : (Mechanical instability):
Severe compression #
Seat belt injury
Second degree: (Neurological instability)
Burst # with out neurological deficit Third
degree : (Both)
Burst # with neurological deficit
Fracture dislocation
Clinical presentation
History
• The history of a patient who sustained a
thoracolumbar spinal injury is usually obvious.
The cardinal symptoms are:
• pain
• loss of function (inability to move)
• sensorimotor deficit
• bowel and bladder dysfunction
 The history should include a detailed
assessment of the injury, i.e.:
• type of trauma (high vs. low energy)
• mechanism of injury (compression,
flexion/distraction, hyperextension, rotation,
shear injury)
• In patients with neurological deficits, the
history must be detailed regarding:

• time of onset
• course (unchanged, progressive, or improving)
Concomitant Non-spinal Injuries
• one-third of all spine injuries have concomitant
injuries
• Most frequently found concomitant injuries are:
1. head injuries (26%)
2. chest injuries (24%)
3. long bone injuries (23%)
Physical Findings
• The inspection and palpation of the spine
should include the search for:
• swellings
• Tenderness
• skin bruises, lacerations, ecchymoses
• open wounds
• hematoma
• spinal (mal)alignment
 Neurological evaluation :
• ASIA form is used to record the neurological
findings

Neurological deficit of the patient Depends upon

Complete or incomplete injury of the cord .
• Complete - flaccid paralysis + total loss of sensory & motor
functions

• Incomplete - mixed loss

- Anterior sc syndrome
- Posterior sc syndrome
- Central cord syndrome
- Brown sequard’s syndrome
- Cauda equina syndrome

36
Dermatomal Sensory Testing

1. C-5—Area over the deltoid

2. C-6—Thumb
3. C-7—Middle finger
4. C-8—Little finger
5. T-4—Nipple
6. T-8—Xiphoid sternum
7. T-10—Umbilicus
8. T-12—Symphysis
9. L-4—Medial aspect of the leg
10. L-5—Space between the first
and second toes
11. S-l—Lateral border of the
foot
12. S-3—Ischial tuberosity area
13. S-4 and S-5—Perianal region
Lumbar and Sacral Motor Root Function

L1-2

L3,4

L5. S1

FIG U K L 23 A screening examination of the lower extremities

assesses the motor function of the lumbar and first sacral nerve
• ms: hip adductors—LI —L2: knee extension—L3—L4; kne
flexion L5—SI; great toe extension — L5; great toe flexion — SI.
i Benson. D.R.; and Keenan. T.L.: Evaluation and Treatment of Trauma to
the VertebraI Column. Instr. Course Lect., 39:583. 1990.)
 Reflex Examination

Reflex Testing in Thoracolumbar Injuries

Reflex Level Tested

Superficial abdominal T7-T10

(above umbilicus) Tll-Ll
Superficial abdominal T12-L1
(below umbilicus) L3-L4
Cremasteric reflex SI
Knee jerk 52- S4
Ankle jerk 53- S4
Anal wink Brain/cord
Bulbocavernosus reflex continuity
«/

Plantar response
 Grading of Spinal Cord Injury
TABLE 23-1
Frankel Classification of Neurologic Deficits
in Patients With Spinal Cord Injuries
A. Absent motor and sensory function
B. Sensation present, motor function absent
C. Sensation present, motor function active but not useful
(grade 2—3/5)
D. Sensation present, motor function active and useful
(grade 4/5)
E. Normal motor and sensory function

40
Investigations
• plain X-rays,
• CT and
• MRI studies

X-RAYS
• A-P &
• Lateral views
Antero-posterior view
• loss of lateral vertebral
body height

• changes in horizontal and

vertical interpedicular
distance
• 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
• sagittal profile

• degree of vertebral
body compression

• height of the
intervertebral space
The axial view allows an
accurate assessment of
the comminution of the
fracture
and dislocation of
fragments into the
spinal canal.
• Sagittal andcoronal 2D or 3D reconstructions
are helpful for determining the fracture
pattern
MRI :
• In the presence of neurological deficits, MRI is
recommended to identify a possible
cord lesion or a cord compression that may be
due to disc or
fracture fragments or
epidural hematoma
MRI can be helpful in
determining the
integrity of the
posterior
ligamentous
structures and
thereby differentiate
between a stable and
an unstable lesion.