Classication and

Treatment of Thoracic
Fracture
Syah Reza Manefo

Neurosurgery Department
Faculty of Medicine
Padjadjaran University
RSHS Bandung 2022
 INTRODUCTION
Thoracic fractures in healthy individuals
uncommon stabilizing effect of the rib
cage.

high energy trauma and predisposing

conditions can increase the likelihood of
fracture

Multiple surgical techniques address spinal

instability, but the choice of surgery depends on the
level of injury and anatomy
 INDICATIONS
The goal of thoracic spine fracture treatment

Protecting the neural

• Preventing Deformity providing stability elements

• Adjunct to hasten rehabilitation,

SURGERY
shorten hospital stays, and
particularly in cases of multiple
injury
 ANATOMY

• The thoracic spine consists of 12 BONY STRUCTURE

The vertebral bodies (VB) anteriorly are load bearing and the
vertebrae with a physiologic arches posteriorly resist tension. The anteroposterior (AP) diameter
of the VB increases from T1 to T12, while the transverse diameter
kyphotic curve decreases from T1 to T3 and then increases to T12.

The VB sides are concave and the laminae are broad and heavily
overlapped. The pedicles project from the superior VB posteriorly.
The laminae extend dorsom Medially from the pedicles to fuse and
form the dorsal wall of the spinal canal

FACET
• From T1 to T10, the thoracic facets are oriented coronally. This
minimizes anterior translation during flexion.
• From T11 to T12, the facets have an oblique sagittal orientation to
limit rotation.
• The coronal facet orientation of the upper thoracic spine allows
for rotation around the craniocaudal axis (75 degrees of rotation
to each side) with the greatest rotation at T8-T9. In contrast,
lumbar spine rotation is limited by the orientation of the facets
and anterior annulus to only 10 degrees
 ANATOMY
RIBS
• The Rib heads articulate with the vertebrae and the disk. The rib
tubercle articulates with the transverse process at the
costotransverse articulation.
• Demifacets above and below the disk articulate with the head of
the rib to form the costovertebral joint (a synovial joint divided by
an intraarticular ligament into two separate compartments).
• the rib cage provides the thoracic spine with two to three times
the load bearing capacity before instability relative to other spine
segments. Sagittal and lateral fexion- extension are also
stabilized.
• The radiate and costotransverse ligaments bind the ribs to their
vertebrae additionally and provide stabilization.

SPINAL CORD

• The central thoracic spine also has a limited

blood supply, with a lower threshold for
vascular cord injury on kyphosis or
compression than the lumbar spine.
• Spinal cord injury to the upper thoracic
spine can have devastating sequelae while
root injury in the thoracic spine is far less
functionally relevant than in the lumbar
spine
 Evaluation and Diagnosis
PHYSYCAL SPINE EXAMINATION
• Direct examination includes visual inspection and palpation
of all spinal segments.
• instability(Grading by the American Spinal Injury Association
A step-o , localized tenderness, or a soft spot (from
laceration, swelling, or ecchymosis) may be the only sign
of instability.
• Soft-tissue trauma to the chest or abdomen may suggest a
seat-belt injury with a TL Fexion-distraction injury
NEUROLOGICAL EXAMINATION
• Motor strength, sensory function, and reflexes.
• If spinal cord injury is suspected, serial exams are necessary as
the neurologic exam may change, especially in settings of
(ASIA) Impairment Scale documents the level and severity of the
spinal cord injury)
• Patients with spinal cord injury should be tested for perianal
sensation, rectal tone, and bulbocavernosus reflex.
• Spine precautions should remain in place until spinal trauma is
excluded.
 INDICATIONS
CONSERVATIVE MANAGEMENT
• Can maintain alignment and
neurologic stability without
surgery.
• Stable fractures such as
uncomplicated compression
fractures may not require
bracing as the rib cage and
sternum buttress the spine
ORTHOSIS
• If support is needed, treated with an orthosis
often with inclusion of the cervical spine.
Cervical support could include a mandible,
occipital pads, or halo ring and may consist of a
cervicothoracic orthosis (CTO) or
cervicothoracolumbosacral orthosis (CTLSO).
• Orthoses and casts should be used with caution
1. Sensory deficits may lead to wound
breakdown due to pressure ulcerations from
an orthosis. Skin contact should be checked
frequently and routinely.
2. Orthoses and casts maybe diffcult for patients
to remove and the fitt may need to be
adjusted over time
 Indications for Surgical
Management
• Surgical decompression  neural
compression with worsening
neurologic deficit, myelopathy or
radiculopathy.
• In cases where the injury is complete,
ASIA A, surgery will likely not result in
neurologic improvement;
Surgical stabilization Worsening
neurologic deficit, disrupted posterior
ligamentous complex (PLC), dislocation of
the thoracic spine, failure to obtain or
maintain correction by nonsurgical
• Denis described a three-column model
of the spine. Many believe that
mechanical instability results from
disruption of two or three of the three
columns.
• The TLICS/TLISS provides guidelines
for when surgical intervention is
warranted.
 Indications for Surgical
Management
Cohen et al recommend operative reduction and
fusion for any neurologic dysfunction that meets
the follow ing criteria:
• Compressed vertebrae wedge fractures
measure over 40% in a young or middle aged
adult
• If the compression percentages for the
adjacent vertebral wedge fractures combine to
greater than 50%
• Acute kyphosis is present
Munting recommends surgery significant
pain + altered function is reported for a
posttraumatic deformity exceeding 20
degrees of sagittal index.
• Pain is often located about the apex of
the deformity. This kyphotic deformity
 Compensatory hyperlordosis in the
lumbar spine and/or hypokyphosis or
even lordosis in the thoracic spine
above the lesion and cause painful
muscle spasm
• Inability to maintain straight vision due
to severe kyphosis, pseudoarthrosis,
disk degeneration, progressive
neurologic deficit, and cosmesis.
 PREPROCEDURE CONSIDERATIONS
Radiographic Imaging
• Plain Radiography
Magnetic Resonance Imaging
AP and lateral plain X-rays of the thoracic and lumbar
spine • Associated soft tissue injury that will not
be visible on the CT
• Computed Tomography
In a study by Smith et al, nonreconstructed CT detected
TL fractures more accurately than plain radiographs and
• If the fracture appears to be associated
is recommended for diagnosis of TL fractures in acute with some pathology, then it may be helpful
trauma for patients with altered mental status. to include enhanced images in the MRI to
• Information includes canal narrowing due to determine if the bone appears to have an
retropulsed fragments, better evaluation of unstable
rotational injuries, and indirect assessment of associated infection or tumor
ligamentous and disk injuries.
• Facet dislocation and posterior interspinous widening
(“naked facet sign.”)
• CT myelogram may demonstrate areas of com
pression of the thecal sac
 MANAGEMENT
Medication
• Steroids have had waxing and waning popularity
in the setting of acute spinal cord injury.
• Antibiotics: If the patient has an associated
infection, it may be benecial.Otherwise standard
preoperative antibiotics are used, typically
cefazolin.
Guidelines for Operative Management
McAfee et guidelines based on specic injury patterns
• Compression fracture: observation with follow -up or
prefabricated brace immobilization for 12 weeks
• Stable burst: custom fitting orthosis or cast immobilization for
12 weeks. L4 and above: TLSO; L5: HTLSO; if kyphosis 15
degrees, hyperextension cast.
• Unstable burst: surgical decompression and stabilization
(approach controversial). Consider emergent posterior short-
segment decompression and fusion (with external
immobilization in a custom TLSO for 12 weeks),
• Flexion-distraction (and Chance injury): consider
hyperextension cast for a purely osseous injury with no
associated neurologic deficit. Consider posterior short-
segment stabilization and fusion for associated neurologic
injury or abdominal injury or when spine injury is primarily
ligamentous.
• Fracture-dislocation: posterior long-segment surgical
stabilization with pedicle screw fixation two to three levels
above and below the injury with local bone graft fusion
 MANAGEMENT
Guidelines for Operative Management Guidelines for Operative Management

The second multicenter study (MCSII) of the

Spine Study Group of the German Association of
Trauma Surgery reviewed traumatic TL (T1-L5)
injuries as an update to MCSI.
• 733 patients with acute TL injuries treated
surgically: 380 (51.8%) patients were operated
on by posterior stabilization and instrumentation
• 34 (4.6%) had an anterior procedure alone
• 319 (43.5%) had combined posteroanterior
procedures.
• Overall they found:
1. Short angular stable implant systems
Conventional nonangular stabilization systems
2. Posttraumatic deformity combined
posteroanterior surgery.
3. Five percent of all patients required revision
surgery for perioperative complications
 Operative Field Preparation
Positioning
• The patient is intubated supine.
• Pressure points are padded
• Intraoperative monitoring including
somatosensory evoked potentials
(SSEP) and motor evoked potentials
should be considered.
Prior To Incision
• The skin is prepped in sterile fashion and the incision is
inltrated w ith lidocaine 1% w ith epinephrine 1:100,000
Localization
• Imaging and physical exam review is critical to
determine the surgical levels.
• Preoperative imaging may include localization using
cross table lateral plain with a radiopaque marker. Prior
to Incision • The skin is prepped in sterile fashion and
the incision is in ltrated w ith lidocaine 1% w ith
epinephrine 1:100,000
 APPROACHES
Posterior Approaches

• The mainstay of spine procedures.

• The most common posterior approach (laminectomy with or without instrumentation) is used commonly for radiculomyelopathy from thoracic disk
herniation, spondylosis, and trauma with stable spine along with some tumors and infection.
• Tailored for access to a region of interest from directly midline to the spinal canal (e.g., laminectomy) to further posterolateral in attempts to reach
anterior to the canal (e.g., transpedicular, costotransversectomy, lateral extracavitary approaches)

Posterolateral Approaches
to the Anterior Thoracic
Spine

• Include the transpedicular, costotransversectomy, and posterolateral extracavitary.

• Greater visualization of the anterior spine as exposure extends farther laterally from midline with greater dissection of the ribs. The
transpedicular corpectomy is the easiest progression from the direct midline approach. It avoids surgical morbidity of anterior
exposure while providing relatively good access to the anterolateral spinal cord and may be performed in combination to
laminectomy. The costotransversectomy utilizes a midline or paramedian incision and involves complete removal of the rib head
and transverse process and provides greater visualization for partial vertebrectomy. The lateral extracavitary approach utilizes a
hockey stick posterolateral incision without violating the chest cavity and provides good visualization and decompression of the
anterior thecal sac.
• the lateral portion of the vertebral canal and the anterolateral portion of the thoracic vertebral bodies.
Costotransversectomy  removal of traumatic bone fragments or other foreign bodies in trauma and useful in
cases may not tolerate a formal(age or pulmonary pathology)
 APPROACHES
Anterior Approach:
Thoracotomy
• Often critical in trauma.
• Makes it far easier to perform multilevel decompression and stabilization through a single approach with possibility of anterior
stabilization.
• For fractures involving the anterior elements of T1 or T2, an anterior approach can be used that is similar to an anterior
cervical corpectomy and fusion. However, T3-T5 cannot be reached effectively from the front unless the chest is opened by
performing a manubrial resection or sternotomy and are often best accessed through a transthoracic approach.
• A transthoracic approach (Thoracotomy or thoracoscopy) provides optimal exposure of the anterior dura and posterior
longitudinal ligament. There are also associated complications including pneumothorax, pulmonary contusion, pneumonia,
pleural effusion, empyema, and possible need for an access surgeon.
POSTERIOR APPROACH
Posterolateral Approach: Transpedicular Corpectomy
Anterior Approach: Transthoracic Vertebrectomy
 CLOSING
Closing

• Surgical wounds are closed in layers.

• A drain is placed above the fascia to prevent hematoma formation.
• The skin is closed with inverted 3-0 absorbable sutures followed by
benzoin and adhesive strips.
• Require wound closure around a chest tube to allow drainage from
the pleural space. can be placed directly on water seal if no leak is
suspected. A postoperative chest X-ray is obtained to check for
pneumothorax or hemothorax. The chest tube can be removed when
output is less than 100 m L/day
 POSTOPERATIVE MANAGEMENT
Monitoring
• Patients should be followed closely postoperatively with neurologic checks.
• Patients with more extensive procedures observed overnight in the intensive care unit

Medication
• Postoperative antibiotics should be administered for 24 hours or as long as the drain is in place
 POSTOPERATIVE MANAGEMENT
Further management
• Limited physical activity with no bending, lifting, or twisting until the fusion has had time for completion
• After that time, then the patient may benefit from physical therapy to regain strength

Radiographic Imaging
• Postoperative lmaging  visualize the construct and the degree of realignment of the spine.
• If the patient has any new symptoms or fails to improve, then more detailed imaging is indicated such as MRI
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