Management of Single Level

Junctional Thoracolumbar
Fractures: Our Experience at
SKIMS
Dr Kaushal Deep Singh
Dr Sajad Hussain Arif
Prof. Altaf Umar Ramzan
Department of Neurosurgery
Sher-i-Kashmir Institute of Medical Sciences (SKIMS)
Srinagar
 Thoracolumbar Junction
The susceptibility of the thoracolumbar
junction to injury is attributed mainly
to the following anatomical reason:
• Transition from a relatively rigid thoracic
kyphosis to a more mobile lumbar
lordosis occurs at T11–L2.
• Mechanical Difference: Lumbar spine
less stiff in flexion
• The facet joints of the thoracic region are
oriented in the coronal (frontal) plane,
limiting flexion and extension.
• In the lumbosacral region, the facet
joints are oriented in a more sagittal
alignment, which increases the degree
of potential flexion and extension.
 Transition Zone:
Predisposed to Failure
Little opportunity for force
dispersion

Central loading of
thoracolumbar junction

Not anatomically disposed

to transfer force
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Joaquim AF, Lawrence B, Daubs M, Brodke D, Tedeschi H, Vaccaro AR, et al.
Measuring the impact of the Thoracolumbar Injury Classification and Severity Score
among 458 consecutively treated patients. The journal of spinal cord medicine.
2014;37(1):101-6.
Reinhold M, Knop C, Beisse R, Audige L, Kandziora F, Pizanis A, et al. Operative treatment
of 733 patients with acute thoracolumbar spinal injuries: comprehensive results from the
second, prospective, Internet-based multicenter study of the Spine Study Group of the
German Association of Trauma Surgery. European spine journal : official publication of the
European Spine Society, the European Spinal Deformity Society, and the European Section
of the Cervical Spine Research Society. 2010;19(10):1657-76.
Li B, Sun C, Zhao C, Yao X, Zhang Y, Duan H, et al. Epidemiological profile of
thoracolumbar fracture (TLF) over a period of 10 years in Tianjin, China. The journal of
spinal cord medicine. 2018:1-6.
Aleem IS, DeMarco D, Drew B, Sancheti P, Shetty V, Dhillon M, et al. The Burden of
Spine Fractures in India: A Prospective Multicenter Study. Global spine journal.
2017;7(4):325-33.
Khurjekar K, Hadgaonkar S, Kothari A, Raut R, Krishnan V, Shyam A, et al. Demographics
of Thoracolumbar Fracture in Indian Population Presenting to a Tertiary Level Trauma
Centre. Asian Spine J. 2015;9(3):344-51.
SKIMS Overview
Our Experience:
Management of Throcolumbar
Junctional Fractures
 Our Experience
• Retrospective analysis of a prospectively
collected data
• March 2014 – March 2018
• 87 patients with single level thoraco-lumbar
junction fractures
• Operated by single level posterior
transpedicular fixation
• Minimum follow-up of 6 months
 GENDER DISTRIBUTION
• Eighty-seven patients were
included in the study. GENDER RATIO

• Of them, 75 were males and 12 Females, 12, 14%

were females (≈ 6.3:1).
• The mean age of our patients
was 35.6 years (range, 18–59
years).
• Among the males, the mean age
was 35.8 years (range, 18–59
years), while the mean age
Males, 75, 86%
among females was 34.1 years
(range, 21–54 years).
 GENDER DISTRIBUTION
Year of Male to Mean age Mean
Study No. of
Authors Location publication Female of patients Follow-up
Duration Patients
of study Ratio (years) (months)

Katsuura et American & >10000

2016 1993-2013 NA NA NA
al. European patients

Joaquim et
USA 2014 2000-2010 458 2.5:1 39.4 5.8
al.

Reinhold et Germany &

2010 2002-2003 733 2:1 41 14.5
al. Austria

No follow-
Li et al. China 2018 2006-2015 132 1.4:1 49.1
up
Aleem et
India 2017 2011-2012 192 1.53:1 51 30 days
al.

Khurjekar No follow-
India 2015 2009-2014 92 8:1 32
et al. up

13.2
Our
India 2018 2014-2018 87 6.3:1 35.6 (minimum
experience
6 months)
 Age Wise Distribution of
Thoracolumbar Trauma
39
40
44.9%
35

30 21
25 (24.1%) 17
20 18.5%
10
15
11.5%
10

0
18-30 31-40 41-50 51-60
 Educational Level
30 27

25

20
13 14 13
15 11
10 5
3
5 1
0
 OCCUPATION
37
40
35
30
25
20
17
15 12 11
9
10
5 1
0
Labourers Masons, Students Govt. Others IT Sector
(Agricultural Carpenters, Employees
Activities) Painters and
Labourers
 Socio-economic Status
40
40
35 29
30
25 18
20
15
10
5
0
Less (< Rs. Middle (20,000 - Upper (>
20,000/m) 50,000/m) 50,000/m)
 Seasonal Distribution of
Thoracolumbar Trauma
36
40
35
30
26
25
17
20
15 9
10
5
0
Winter (Nov, Dec, Autumn (Aug, Summer (May, Spring (Feb, Mar,
Jan) Sep, Oct) June, July) Apr)
 MODE OF TRAUMA
MODE OF TRAUMA FALL FROM HEIGHT
Fall from height, 46, Fall from Fall from
53% hilly electric pole, 3,
Others, 4, 5% terrain, 5, 7% Fall from
11% stairs, 2, 4%

Fall from building, 13,

Road traffic accidents, 37, 28% Fall from tree,
42% 23, 50%
 Road Traffic Accidents
Slip or fall from a Fall from rooftop of
two wheeler, 6, bus, 3, 8% Others, 2, 5%
16%

Collision with another vehicle,

15, 41%
Collision with tree or other objects, 11, 30%
 Associated Injuries
30
30

25 20
20

15 11

10 5
5

0
Extremity Head Injury Blunt Trauma Blunt Trauma
Injury Chest Abdomen
 CAUSES OF DELAY
Cause of Delay in Seeking Specialized Treatmnet

42%

21%
17%
12%
8%

People from Far Poor Transport Lack of proper Financial Lack of

Flung areas Facilities referal constraints awareness
with no road about critical
conectivity nature of injury
Injury to Hospitalisation Interval

20

67

Within 24 Hrs After 24 Hrs

Vertebral Level of Fracture in
Thoracolumbar Region
40 L1, 37
35
30
D12, 22
25
20 D11, 11
15 L2, 17
10
5
0

D11
D12
L1
L2
 Thoracolumbar Injury Severity
40 Score
36
(TLICS)
35

30

25

20
16
15 12
10 10
10
6
5 2
0
4 5 6 7 8 9 10
 Admission - Surgery Interval
40
40

35

30 28
25

20

15 11
10 6
2
5

0
Less than 24 24 Hrs - 3 days 3 - 7 days 7 - 14 days Greater than
Hrs 14 days
 Neurological Improvement on
Follow-up at 6 months (Frankel
Grading)
35 32
29
30 27 28
25

20 17
15 11 11
9
10 6
5
3
0
A B C D E

At Presentation On Follow-up
 Our Experience: Results
Neurological Statuses in Injured Patients
Pre-operative versus Post-operative (at 6 months
follow-up)
Grade of A B C D E
Injury
ASIA Grading

At Presentation 17 11 29 27 3

At Follow-up 12 9 32 28 6
• 5 Grade A patients improved at 6 month follow-up. 3 improved to grade B and
2 to grade C.
• 5 Grade B patients improved. 4 patients improved to grade C and 1 to grade D.
• 3 Grade C patients improved. 2 patients improved to grade D and 1 to grade E.
• 2 Grade D patients improved to grade E status.
 Neurological Statuses in Injured Patients
Pre-operative versus Post-operative (at 6 months follow-up)
No. of At 6
ASIA Grading Patients at months
Presentation follow up
17 11

Bed-ridden
A
11 9
B 57 52
29 32
C
27 28
D
Ambulatory
3 6
E
5 patients improved from Grade A, B and C to Grade D and E
 Complications
Mortality

Meningitis

Depsession

Bedsore

DVT

LRTI

Surgical Site Infection

CSF Leak

Implant Failure

Malpositioning

0 1 2 3 4 5 6
Malposition
Hardware Failure
 Unique Things about Our
Study
• Largest study discussing only junctional
thoracolumbar fractures

• Largest study on operative management of single-

level thoracolumbar fractures

• Largest study on single-level transpedicular fixation

treatment outocmes

• Fall from height was the most common mode of injury

• Appropriately selected patients can have very good

recovery
 Take Home Message
• Awareness programs
• Encourage use of harnesses among painters, carpenters,
masons, labourers and farmers
• Follow traffic rules (use helmets/seat-belts)
• Prevent secondary injury to spine by immobilization and
proper referral.
• Fixation and decompression can provide functional and
rehabilitative improvements in appropriate patients.
• Social and emotional support
• Neurorehabilitation