Thoracolumbar Spine Fracture

What is Thoracolumbar Spine Fracture?

The area between T10-L2 known as the thoracolumbar junction, which is a part of the spine, is more likely to be affected by injury. This is because it’s a transition point from the less flexible upper part of the spine (attached to ribs on both sides) to the more flexible lower part.

Injuries to this section of the spine can potentially cause long-lasting nerve damage due to the pressure, stress and trauma and it requires immediate care and evaluation. These injuries often occur from car accidents, falls from high places, recreational activities, and workplace accidents. They are usually severe in nature, often come with additional injuries, and require proper management and treatment procedures.

There are guidelines available to ensure that people with these kinds of injuries receive the best possible care. For example, the American College of Surgeons has a protocol called “advanced trauma life support” (ATLS) for treating trauma. Research has shown that using this protocol can lower the rates of long-term health complications and death.

What Causes Thoracolumbar Spine Fracture?

The thoracolumbar spine, which is the part of the spine where it transitions from the mid-back to the lower back, can be injured by things like car accidents, falling from a great height, sports mishaps, and on-the-job injuries. Since the thoracolumbar junction, the specific part where these two spine sections meet, has a certain mechanical quality that makes it more susceptible to injuries than any other parts of the spine, it suffers injuries quite commonly.

With high-speed spine injuries, there’s a 25% chance of additional spinal cord injury. Such an injury can lead to severe health implications, including productivity loss and resulting in high societal costs. Furthermore, up to 25% of thoracolumbar fractures are accompanied by fractures in other parts of the spine, most often in the neck region.

Risk Factors and Frequency for Thoracolumbar Spine Fracture

Thoracolumbar traumatic injuries, also known as injuries to the middle and lower parts of the spine, used to be most common in those aged 15-29. However, the median age of people affected by this type of injury has now risen to 35. Around 27% of people with these injuries will have neurological deficits, which can lead to lifelong disabilities and a loss of economically productive years.

• 70% of such injuries happen without any immediate neurological harm, but still, 55% stay neurologically healthy.
• Further, out of 45% who do develop neurological symptoms, 26% have incomplete injuries and 19% have complete injuries.
• Most spine fractures (up to 75%) are happening within the T10-L2 area of the spine.

In the United States, around 17,000 new spinal cord injury cases occur each year. This equals roughly 54 cases per million people, with over 250,000 patients currently living with permanent deficits. These injuries are mainly caused by blunt trauma, with an incidence of 1.9% thoracic fractures.

• The rate of thoracolumbar junction fractures from car accidents is about 2.4%, and it’s growing over time.
• In patients with blunt trauma, the incidence of thoracolumbar junction fractures is approximated to 6.9%.
• An examination of patients with blunt trauma who were given a CT scan showed that up to 25% had thoracolumbar fractures.
• This type of injury is often undetected in regular X-ray images.
• The most common cause, in adults, is car accidents (making up 36.70% of cases) followed by falls from a height (31.70% of cases).
• As for people with paraplegia, their average lifetime costs due to this condition are around 2.5 million dollars per patient.

In China, the incidence rate of thoracolumbar junction fracture was found to be 2.4 patients per million, with a mean age of 49 years. The ratio of affected males to females is 1.4:1. In children, these fractures are rare, and they only present 2% of all spine fractures. Still, other reports have stated an incidence of 5%-34%. The most common cause in children is falling from a height, with 25% presenting a complete deficit and about 20% requiring surgery.

Signs and Symptoms of Thoracolumbar Spine Fracture

Thoracolumbar junction fractures, which commonly occur from high-impact incidents like car accidents and falls, vary in severity. There may be no associated neurological injury, or there may be significant signs and symptoms, depending on the patient’s condition. Information about the incident and the patient’s symptoms, such as the nature and duration of back pain, is crucial in assessing the potential injuries.

In instances where the patient is critically unwell, this information might have to be gathered from family members, first responders, other doctors, or the patient’s medical record. The associated back pain’s specific characteristics, like its exact location, quality, and triggers, are standard attributes that need evaluation.

• Intact function
• Incomplete deficits
• Complete neurological deficits

A patient with a thoracolumbar junction fracture could have any of the above conditions. The affected area’s location can determine these symptoms. For instance, if the injury is in the transition area, it could cause signs of both upper and lower motor neuron dysfunction. Injuries that happen above the T10 and below the L1 level are more likely to result in complete neurological deficits and radicular symptoms, respectively. This is due to the anatomy of the spinal cord, specifically, the position of the conus medullaris, which usually doesn’t extend below the L1 level.

Sometimes, the physical examination may reveal clear signs such as wider spaces between the spine’s bony parts or movement of these parts away from the center. A thorough motor and sensory examination is performed when the patient can cooperate. Based on the information from this examination, a score from the American Spinal Injury Association (ASIA) can be assigned. It’s crucial to evaluate the bulbocavernosus reflex (a reflex tested to evaluate the sensation in certain parts of the body) to determine if the patient is in spinal shock. If it’s overactive, it probably indicates a complete spinal cord injury. Finally, a rectal exam is done to assess the patient’s muscle tone.

Testing for Thoracolumbar Spine Fracture

When someone comes in with a potentially serious injury, the first steps include making sure they can breathe, that their ventilation is sufficient, and that their heart is working properly. After these immediate concerns are addressed, a more focused examination on the spine can begin. This includes checking motor and sensory functions to judge where the spinal cord injury might be. A rectal examination is also invaluable and can offer the only clear sign of neurological impact in patients with significant injuries, such as traumatic brain injuries.

To standardize this process, a universally recognized scale, known as the ASIA exam, is used. This system charts the extent and severity of a patient’s spinal cord injury, and can help to chart their treatment needs going forward. Ideally, this system should be applied within 72 hours of the initial injury, and grades a patient based on how much sensation and motion they can experience or perform below their injury level.

Here’s a simplified breakdown of the ASIA impairment scale:

* A – Full loss: No sensation or movement can be experienced below the injury.
* B – Limited loss: Sensation is still felt, but no movement can be made below the injury, including in the S4-S5 segments of the spine.
* C – Partial loss: There’s still some motor function and voluntary contraction below the injury level, but less than half of key muscles are rated at a muscle grade of 3 or above.
* D – Incomplete loss: Over half of key muscles below the injury level are still working, at a muscle grade of 3 or above.
* E – No loss: Sensation and movement are both normal.

Once the patient is stable and immediate, life-threatening concerns have been addressed, a full spinal scan should be performed. This is especially necessary in cases of traumatic injury, such as those caused by a blow or fall. Postponing this imaging could negatively impact the benefit a patient might gain from timely surgery.

In cases where a patient might have suffered a spinal fracture or injury, it’s essential for medical professionals to maintain a high level of awareness and suspicion. They should take all precautions until such fractures can be ruled out.

There are several ways to image the spine, including spine x-ray films, CT scans, and MRI scans. While simple x-ray films might not provide a lot of detail, they can be useful in the operating room and also for long-term monitoring, offering less radiation exposure.

CT scans offer a good view of bony structures in the spine, while MRIs provide better insight into ligaments and neural structures. Consequently, in instances where a patient is showing neurological loss, an MRI might be used to obtain a broader view of any damages. If a CT scan fails to show any fractures or dislocations, but the patient is experiencing clear neurological impacts, then an MRI can be used to assess damages like bone marrow swelling, changes in soft tissues, annular disruption, and herniated disk material, among other things.

Different classification systems have been proposed to best determine and describe spinal cord injuries. Among these, the TLICS scale developed by the Spine Trauma Study Group is regarded highly for its prognostic significance and its utility in helping to make decisions about operative versus nonoperative management. This scale takes into account the integrity of the posterior ligamentous complex, the nature of the fracture, and the presence of any neurological injury.

Finally, it’s worth noting that compression fractures, which only involve the anterior column, are the most common type of injuries and are typically stable. However, other injuries, like burst fractures and fracture dislocations, which involve both the anterior and posterior columns, are considered unstable and generally need to be stabilized as soon as possible.

Treatment Options for Thoracolumbar Spine Fracture

For all trauma patients, special precautions are taken to avoid worsen any potential spine injury until it has been confirmed they have no spine fracture. To do this, care is taken to prevent bending, extending, rotating, or twisting of the spine. Only after tests and physical examination show no risk of spinal instability, these precautions are lifted. Proper patient care to maintain blood flow to the spinal cord is critical, including support for airway, breathing, and blood circulation to ensure a mean arterial pressure above 85 mmHg. Depending on the severity of the instability or the involvement of the nervous system, the patient might need immediate surgery.

Injuries to the area where the thoracic spine meets the lumbar spine, although common, are very diverse. This diversity leads to differing views on the best treatment plan, whether surgical or non-surgical. A tool used to inform the treatment of spinal fractures is the TLICS scale. The stability of the spine is key to the decision-making process, often determining whether a fracture requires surgery or if it can be managed conservatively. Spinal instability is more likely when an MRI shows damage to the complex of ligaments at the back of the spine. Even if there are no nerve injuries, many of these fractures may need surgery for stabilization due to the extent of bone or ligament damage.

Research comparing surgical treatment versus non-surgical treatments for these fractures has not shown a clear advantage to either approach. Non-surgical treatments could include back braces, plaster casts, or body casts, usually for about 12 weeks. Most of the compression fractures, which are generally stable, can be treated simply with observation or bracing.

If surgery is needed, there are different approaches including from the front, back, side, or using a combination. The location of the injury often determines whether a front or back approach is best. Surgical techniques vary widely, and could involve spinal fusion from the back or front, or using screws to stabilize the spine. Spinal monitoring is routinely used during surgery. Wearing a brace after surgery usually doesn’t improve the outcome, but might provide comfort.

Certain fractures known as “burst” fractures can be treated with a brace if they’re stable. Unstable burst fractures are usually treated with screws inserted into the spinal bones. If surgery is performed from the front, the fractured bone is removed and replaced by a bone graft or a metallic or synthetic cage. Fractures caused by bending and pulling damage require back surgery, involving linking together several spinal bones to restore spine alignment. Dislocated fractures, which are very unstable, are typically treated with early decompression involving stabilizing the spine from the back. Some surgeons prefer using minimally invasive procedures to minimize the impact of open surgery on these patients.

What else can Thoracolumbar Spine Fracture be?

If someone has recently had an injury, and they’re now experiencing new symptoms like pain or neurological issues (like numbness or weakness), a fracture caused by the trauma might seem like a likely diagnosis. However, doctors also need to rule out existing conditions that may also be contributing to these symptoms. These might include:

• Differing spine structures (Anatomical variant)
• Fracture due to brittle bones (Osteoporosis fracture)
• Inflammation and fusion of the spine joints – a condition called Ankylosing spondylitis
• Diseases causing spine stiffness (Stiff-spine diseases)
• Spinal tumors
• Cancer spread to the spine (Spine metastatic disease)
• Non-healing of the spine after surgical repairs (Pseudoarthrosis from previous spine instrumentation)

What to expect with Thoracolumbar Spine Fracture

Fractures in the thoracolumbar junction, the region where the middle and lower section of the spine meet, can lead to severe consequences. These include a negative impact on a patient’s overall health care and societal productivity due to the associated high costs. According to a systematic review conducted, no specific conservative treatment method displays a clear advantage over others.

Factors that contribute to the development of neurological deficits, such as loss of muscle function or sensation, include the size of the spinal canal and the degree of compression in the anterior or front part of the vertebral bone. The recovery of these neurological functions depends on various factors such as the type and location of the fracture, ASIA score (a scale to determine the severity of the spinal cord injury), and the presence of other medical conditions. Timely intervention in patients with neurological deficits often leads to a better prognosis or medical outcome.

Patients with a grade D or E impairment on the ASIA scale may fully recover and return to a similar health status as the general population. However, patients with more significant neurological deficits may experience difficulties in returning to work.

Possible Complications When Diagnosed with Thoracolumbar Spine Fracture

Here is a list of possible complications that can occur during or after a surgical procedure:

• Sepsis, a severe infection that can spread throughout the body
• Aspiration bronchopneumonia, a type of pneumonia that can occur when substances are inhaled into the lungs
• Neurological deficits, where damage to the nervous system causes loss of movement or sensation
• Deep venous thrombosis, a blood clot that forms in a deep vein
• Surgical wound infection, an infection that develops at the site of a surgical incision
• Cerebrospinal fluid leakage, a condition where the fluid that surrounds the brain and spinal cord leaks out
• Pseudoarthrosis, a condition where a broken bone fails to heal properly
• Adjacent level disease, a condition where disease or injury occurs near a previous surgical site
• Excessive blood loss during surgery
• Complications related to anesthesia, the drugs used to put a patient to sleep during surgery

Preventing Thoracolumbar Spine Fracture

Fractures in the thoracolumbar junction, the area where the middle and lower spine meet, can significantly affect a person’s health and well-being. To prevent these injuries, it’s essential to avoid activities where falls are likely, such as climbing trees. If you’re working at high elevations or engaging in recreational sports, always prioritize safety by using security ropes and wire cables. Also, refrain from driving if you’re under the influence of drugs or alcohol.

The severity of the neurological damage will determine if patients can return to work. Some may continue to experience debilitating pain. However, using a brace after surgery doesn’t necessarily affect the level of pain, the ability to return to work, or the likelihood of hardware (like screws or plates) failure. For a quicker recovery and return to a productive lifestyle, it’s crucial to follow the recommendations of your physical therapy program.