Thoracolumbar spine fracture

• Finite element analysis of percutaneous uniplanar screw fixation in the treatment of thoracolumbar fractures
• Generalizable model to predict new or progressing compression fractures in tumor-infiltrated thoracolumbar vertebrae in an all-comer population
• Early Return to Play Following Conservative Treatment of a Lumbar Flexion-Distraction Injury in a Professional Soccer Player: A Case Report
• Lumbar Disc Degeneration and Vertebral Fracture at the Thoracolumbar Junction Are Risk Factors for Chronic Low Back Pain With Disability: Seven Years' Follow-Up of the Wakayama Spine Study
• AO Spine Clinical Practice Recommendations: Reducing the Surgical Footprint of Surgery for Spinal Metastases
• Effects of vitamin D3, omega-3 s and a simple home exercise program on incident vertebral fractures: the DO-HEALTH randomized controlled trial
• Efficacy and safety of posterior short-segment versus long-segment pedicle screws fixation for thoracolumbar burst fractures: A systematic review and meta-analysis
• Treatment of thoracolumbar fractures with severe collapse of the anterior and middle columns via balloon-assisted endplate reduction, transpedicular bone grafting and pedicle screw fixation

see Three column model.

A thoracolumbar spine fracture means that a bone is broken in the thoracic (middle) or lumbar (lower back) region of the spine.

Thoracolumbar spine fracture epidemiology.

see Thoracolumbar spine fracture classification.

The causes of Thoracolumbar spine fracture are different depending on the patient's age. In younger patients, the fracture is more likely to occur due to high-energy trauma, such as motor vehicle accidents, motorcycle accidents, and falling injuries. However, in the elderly, even falls from a standing position to the ground can cause fractures due to osteoporosis and decreased cognition.

A pathological fracture see Osteoporotic fracture.

Fracture dislocation of the thoracic spine is a rare spine injury often resulting from high-energy trauma. Associated soft-tissue thoracic injuries are common and are compounded by the often-associated paraplegia. Exceptionally, there are some cases of thoracic spine dislocations without neurological injuries ¹⁾.

Associated injuries include vertebral endplate avulsion, ligamentous injuries, and hip and pelvic fractures. Thoracolumbar spine fractures may be associated with hemodynamic instability as a result of hemothorax or aortic injury. Fractures of the transverse processes may be associated with abdominal trauma (e.g. renal injuries at L4–5).

Thoracolumbar Spine Fracture Diagnosis.

see Thoracolumbar spine fracture treatment.

Twenty to forty percent of fractures are associated with neurologic injuries.

If the patients involve in a severe trauma, the complications, such as paralysis and deformity, may occur after that accident. Even if the patients do not experience any complications, there could be limits of daily activities or difficulty to return to work due to chronic pain.

A retrospective review of adult patients, with single-level, TLJ (T11-L2) fractures, treated with posterior fixation between 2007 and 2014 at a regional spinal centre. Short segment posterior fixation (SSPF) and Long segment posterior fixation (LSPF) were defined as pedicle screw fixation at one and two levels above and below the vertebral fracture, respectively. Construct failure was defined as instrument breakage or screw pull-out requiring operative intervention. Two independent assessors measured the kyphotic Cobb angle at up to six months.

A total of 28 patients were included with a median age of 38 years (range 20-76 years) and median follow-up period of 14 months (4-41 months). All patients sustained traumatic fractures and the male to female ratio was 19:9. AOSpine Thoracolumbar Classification System classes were: A (29%), B (50%) and C (21%). SSPF and LSPF were performed in 17 (61%) and 11 (39%) patients, respectively. There was no significant difference in age (Fisher's exact, p > 0.99), AO fracture class (chi-squared, p = 0.510), preop TLICS score (independent t-test, p = 0.668) and length of stay (independent t-test, p = 0.106) between the groups. Construct failure occurred in three SSPF cases (3-14 months postop) and was associated with an increased mean loss of correction. By six months, the Cobb angle had increased significantly in the SSPF group (paired t-test, p = 0.049), but not the LSPF group (paired t-test, p = 0.157).

Data identified a trend towards better clinical and radiological outcomes in the LSPF, compared to the SSPF group. Although supported by some studies, these findings should be evaluated in future clinical trials ²⁾.

From a retrospective study of 412 thoracolumbar region injuries, Denis introduces the concept of middle column or middle osteoligamentous complex between the traditionally recognized posterior ligamentous complex and the anterior longitudinal ligament. This middle column is formed by the posterior wall of the vertebral body, the posterior longitudinal ligament and posterior annulus fibrosus. The third column appears crucial, as the mode of its failure correlates both with the type of spinal fracture and with its neurological injury. Spinal injuries were subdivided into minor and major. Minor injuries are represented by fractures of transverse processes, facets, pars interarticularis, and spinous process. Major spinal injuries are classified into four different categories: compression fractures, burst fractures, seat-belt-type injuries, and fracture dislocations. These four well-recognized injuries have been studied carefully in clinical terms as well as on roentgenograms and computerized axial tomograms. They were then subdivided into subtypes demonstrating the very wide spectrums of these four entities. The correlation between the three-column system, the classification, the stability, and the therapeutic indications are presented ³⁾.

A 25-year-old primigravida at 24 weeks of gestation presented after falling off a fast-moving motorcycle one month prior. She had sustained a severe back injury and had difficulty walking. Magnetic resonance imaging showed an acute kyphosis secondary to comminuted anterior wedge compression fractures of the L2 and L3 vertebral bodies and L2/3 disc involvement with retropulsion of the fracture fragments into the central canal resulting in severe central canal stenosis. After multidisciplinary discussion, the patient underwent posterior decompression, reduction and stabilization with pedicle screws. The patient had good neurological recovery at discharge and the pregnancy progressed normally. Three months later, at 39 weeks of gestation, the patient had an uneventful spontaneous delivery of a healthy newborn. This case illustrates the importance of multidisciplinary management of spinal cord injury in a pregnant patient ⁴⁾

An 80-year-old man with spinal metastases presented with acute onset of severe back pain, and investigations revealed a fracture of a metastatic lesion in T10-T12 in the range of Diffuse Idiopathic Skeletal Hyperostosis. They performed posterior fixation with a percutaneous pedicle screw system using a penetrating endplate technique. The patient's back pain improved, and he was able to mobilize with minimal assistance and survived for 8 months with a good quality of life. Spinal fracture accompanied by DISH sometimes occurs with severe instability because of injury across 3-column injury and its long lever arm. Spinal instability neoplastic score indicates instability of pathological fractures of spinal metastases but needs to be evaluated carefully when DISH is present. The prevalence of DISH is increasing in the elderly, and penetrating endplate screws can be an effective option in posterior fusion surgery for patients with DISH and spinal metastases ⁵⁾

Modern Thoraco-Lumbar Implants for Spinal Fusion

This book presents an updated perspective on spinal implants currently used in thoracolumbar spine surgery, leading to a rigid or dynamic stabilization. The development of new surgical devices and techniques is mostly focused on a spinal fusion for lumbar instability due to trauma, tumours or degenerative or infectious diseases. Pedicle screw fixation and fusion are currently considered to be the gold standard for most of the above-mentioned pathologies, and modern implants are designed to improve the accuracy of pedicle-screw placement and to allow the use of new surgical techniques and minimally invasive approaches. The content is relevant for surgeons, orthopaedic specialists, neurosurgeons, physiotherapists and osteopaths.

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A 76-year-old male was admitted due to a thoracic spine fracture at T11 with AOSpine thoracolumbar spine injury classification system Subtype A4 and TLICS 5. He does not exhibit adverse reactions to medications and is a former smoker with hypertension, type 2 diabetes, and dyslipidemia. Additionally, he has stable chronic obstructive pulmonary disease (COPD) and permanent atrial fibrillation, for which he is anticoagulated with Eliquis.

In his medical history, there is a notable incident of upper gastrointestinal bleeding (UGIB), where Barrett's esophagus and Mallory-Weiss/esophageal ulcer were observed, but without active bleeding. He has also been previously admitted for angina pectoris.

The patient has been clinically stable from a respiratory standpoint and experienced only one mild exacerbation in the last year. His regular treatment includes medications for dyslipidemia, anxiety, COPD, hypertension, and anticoagulation with Eliquis. Additionally, he takes Zaldiar for pain management.

In the current context, the patient presents dorsolumbar trauma following a fall, resulting in radicular pain, progressive loss of strength in the lower limbs, and an inability to walk.

Imaging studies reveal a transverse-AOSpine thoracolumbar spine injury classification system Subtype A4 of Th11 with retrolisthesis and retropulsion of the posterior wall into the spinal canal.

In the cardiological examination, the presence of permanent atrial fibrillation and hypertensive heart disease is confirmed. The patient is currently being treated with tiotropium.