Thoracic/Lumbar Spine Fracture

Thoracic/Lumbar Spine Fracture

David Ray Velez, MD

Table of Contents

Anatomical Columns
Classification
Treatment

See Also:
*Spinal Cord Injury (SCI)
*Cervical Spine Fracture

Anatomical Columns

Anterior Column: Anterior Half of the Vertebral Body and Anterior Longitudinal Ligament (ALL)

Middle Column: Posterior Half of the Vertebral Body and Posterior Longitudinal Ligament (PLL) 

Posterior Column: Facets, Lamina, Spinous Process, and Interspinous Ligament

Thoracic (Left) and Lumbar (Right) Vertebrae

Classification

Compression (Wedge) Fracture

  • Fracture of the Anterior Column Only
  • Cause: Flexion Injury
  • A Common “Fragility Fracture” – Fracture After a Low-Energy Impact Such as a Ground Level Fall (Indicating Osteoporosis)
  • Generally Stable

Wedge (Compression) Fracture

Burst Fracture

  • Fracture of the Anterior and Middle Columns
  • May Have Retropulsion into the Spinal Canal
  • Cause: Compressive Forces
  • Typically Occur from T10-L2 Due to the Fulcrum at the Thoracolumbar Junction
  • Dennis Classification:
    • Type A: Fracture of Both Superior and Inferior End-Plates
    • Type B: Fracture of the Superior End-Plate Only
    • Type C: Fracture of the Inferior End-Plate Only
    • Type D: Burst Rotation
    • Type E: Burst Lateral Flexion
  • Generally Unstable

Burst Fracture

Chance “Seat Belt” Fracture

  • Fracture Pattern:
    • Anterior and Middle Column Fractures
    • Tear in the Posterior Ligament
    • Auricular Process Fracture
  • Cause: Flexion-Distraction Injuries
  • Most Common Cause: Seatbelts (Particularly Lap Belts with No Shoulder Component)
  • Generally Unstable
  • Strongly Associated with Intra-Abdominal Injury (50%)

Chance Fracture

Transverse Process (TP) Fracture

  • Fracture of the Transverse Process
  • Stable

Spinous Process (SP) Fracture

  • Fracture of the Spinous Process
  • Stable

Transverse Process Fracture

Spinous Process Fracture

Treatment

Stability is Based on the Middle Column and Posterior Ligament Complex

Signs of Instability

  • 50% Loss of Height
  • 30° of Angulation
  • Multiple Levels Involved

Emergent Surgical Decompression Indications

  • Open Fractures
  • Not Reducible
  • Cord Compression
  • Worsening Neurologic Dysfunction

Definitive Management

  • Compression (Wedge) Fracture: Bracing to Inhibit Flexion
    • May Require Surgical Stabilization if the PLL is Disrupted
  • Burst Fracture: Surgical Stabilization
    • May Consider Nonoperative Bracing if Neurologically Intact with Preserved Posterior Ligamentous Complex, Kyphosis < 30° and Height Loss < 50%
  • Chance Fracture: Surgical Stabilization
    • Order of Repair: Exploratory Laparotomy (If Indicated) Before Operative Spinal Stabilization
    • May Consider Nonoperative Bracing if Neurologically Intact with Preserved Posterior Ligamentous Complex
  • Transverse Process Fracture: Nonoperative Management with Pain Management
  • Spinous Process Fracture: Nonoperative Management with Pain Management

Bracing

  • Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) Brace – For High Thoracic Fractures (Above T6)
  • Thoracic-Lumbar-Sacral Orthosis (TLSO) Brace – For Fractures T6 or Below and Above L3-L4
  • Lumbar-Sacral Orthosis (LSO) Brace – Only for Lower Lumbar Fractures (L3-L5)