A thoracolumbar fracture means that a bone is broken in the middle or lower back region of the spine. A low-energy injury is more likely to cause an injury to the intervertebral disc, yet a high-energy trauma such as a motor vehicle accident or fall is more likely to fracture the bone. Thoracolumbar fractures and dislocations are typically classified according to their injury/fracture pattern, as described by Denis.
A compression fracture affects only the anterior column and does not compromise the posterior wall of the vertebral body or cause bony comminution or compression of the neural elements. A burst fracture affects the anterior and middle column, and in severe cases, causes instability of the posterior column. There is a fracture involving the posterior wall of the vertebral body, which can protrude posteriorly and cause spinal canal compromise and neurologic injury. Chance fractures primarily affect the posterior column, either by a ligamentous disruption or fracture through the spinous process and vertebrae. Fracture/dislocations of the thoracolumbar spine are the most severe injuries and are generally associated with an injury to the spinal cord or neurologic structures. The fracture and ligament damage typically involves all three columns, and the vertebrae are often drastically mal-aligned and displaced from one another.
Thoracolumbar Fracture Types
- Compression Fracture
- Burst Fracture
- Chance Fracture (Flexion/Distraction injury)
How is it diagnosed?
A thoracolumbar spine fracture should always be suspected when a patient has been involved in a trauma or accident, especially those patients with back pain. The diagnosis can be complicated when the symptoms or physical findings are atypical. Some patients with other fractures or injuries will complain about pain in other locations, but not complain of back pain. At times, patients may downplay the severity of the motor vehicle accident or trauma. These scenarios may sway the clinician away from ordering thoracic and lumbar X-rays and imaging studies, which are crucial in the diagnosis of thoracolumbar injuries. It is important for the clinician to conduct a thorough history and clinical examination, especially inspection and palpation of the spine, prior to formulating a diagnosis so as not to misdiagnose this condition. Any patient involved in a severe accident or trauma, especially those patients with back pain, should be carefully evaluated with X-rays and additional imaging studies if necessary to accurately diagnose a thoracolumbar injury.
What are the treatment options?
The treatment options for patients with a thoracolumbar fracture can be categorized as conservative, or nonoperative, and surgical, operative. Nonoperative treatments include brace (orthotic) treatment and medications. There is a wide range of thoracolumbar orthoses, which range from soft corsets to hard plastic thoracolumbosacral orthoses (TLSO). Surgical treatments frequently involve posterior spinal fusion and instrumentation, which involves small metal screws and rods to stabilize the spine. Other options include anterior decompression and fusion, with or without instrumentation. Severely unstable fractures may require anterior and posterior spinal surgery. The overall goals of treatment are to preserve or improve neurologic function, provide stability and decrease pain. Accomplishing these goals with conservative means is generally preferred. Some thoracolumbar fractures and dislocations are highly unstable and will not adequately heal on their own, and surgical stabilization must be performed. Surgical decompression, or removal of bone fragments off of the spinal cord, may also be necessary to maximize a patient’s chances for neurologic improvement and recovery from a spinal cord injury.
Although there are guidelines for the treatment of thoracolumbar fractures and dislocations, the specific treatment of a thoracolumbar fracture and/or dislocation ultimately depends on a number of factors.
- type and location of fracture
- severity of fracture and amount of displacement
- presence of spinal cord/nerve compression
- presence of neurologic dysfunction or spinal cord injury
- patient’s age, medical condition and associated injuries
The clinician should carefully evaluate a patient’s injuries, and with the general management guidelines for thoracolumbar fractures in mind, individualize the treatment based on all of the above-mentioned factors.