Chapter 10

This chapter addresses traumatic fractures and dislocations to the thoracolumbar (TL) spinal column. These injuries are uncommon, and when present, are frequently overlooked. This is likely due to the fact that other more significant injuries in the traumatized patient distract the clinician and because signs and symptoms of the vertebral injury are often subtle.1 Early diagnosis and treatment of these injuries improves neurologic outcome.2

Imaging

In victims of blunt trauma receiving thoracic and/or lumbar spine radiographs, approximately 6% will have a fracture.3 The absence of back tenderness does not exclude a TL fracture, however, as 40% of patients with a fracture won't have pain or tenderness.4,5 Radiographs are recommended in the setting of high-energy trauma (fall > 10 ft, high speed motor vehicle collision) and one of the following4–8:

1. Back pain or midline back tenderness

2. Abnormal neurologic examination

3. Any other spine fracture

4. Glasgow Coma Scale < 15

5. Major distracting injury9

6. Alcohol or drug intoxication

Computed tomography (CT) scan is frequently indicated as it is more sensitive than plain films for detecting fractures.10 Multi-detector CT of the abdomen and chest with reconstructions of the spine is as accurate for detecting TL spine fractures as dedicated spinal CT.11 This technique also saves time and cost.12

Classification

Fractures of the TL spine are most common at the junction of the rigidly fixed thoracic spine and the flexible lumbar spine. Approximately 50% of all fractures of the TL region occur between T11 and L3.3 Fortunately, because the spinal canal is wider in this location than the cervical spine, complete cord lesions are less common.

In considering the stability of TL vertebral fractures, the three-column classification is conceptually the easiest to understand. In this system, developed by Denis, the spinal column is divided into three sections: anterior, middle, and posterior13,14 (Fig. 10–1). The anterior column consists of the anterior longitudinal ligament and the anterior half of the vertebral bodies and disks. The middle column is made up of the posterior longitudinal ligament and the posterior half of the vertebral bodies and disks. Lastly, the posterior column consists of the supraspinous and interspinous ligaments and facet joints. Mechanical stability is present if two of the three columns are intact.

Figure 10–1.

The three-column classification of the thoracolumbar spine.

Multiple mechanisms of injury have been described that produce somewhat predictable TL vertebral fractures. They include flexion, flexion-rotation, extension, compression, distraction, and shear (i.e., translational) forces. In the system developed by McAfee, three major forces (axial compression, axial distraction, and translational) act on the middle column to create five different injury patterns: wedge compression fracture, burst fracture, Chance fracture, flexion-distraction injuries, and translational injuries.15–17 These five injury ...

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

Subscription Options

AccessPhysiotherapy Full Site: One-Year Subscription

Connect to the full suite of AccessPhysiotherapy content and resources including interactive NPTE review, more than 500 videos, Anatomy & Physiology Revealed, 20+ leading textbooks, and more.