This document discusses the anatomy and physiology of the thoracolumbar spine and classifies different types of thoracolumbar spine injuries. It describes the anatomy of the spinal cord, blood supply, and biomechanics of the thoracic and lumbar regions. Various injury mechanisms are outlined including compression fractures, burst fractures, and chance fractures. Imaging techniques like x-rays, CT, and MRI are discussed. The Denis three-column theory and TLICS classification system are introduced to classify injuries as stable or unstable. Non-operative and surgical treatment options are provided based on the injury classification.

1. THORACOLUMBAR SPINE INJURY
Dr. Kevin J. Ambadan

2. ANATOMY OF THE CORD AND CAUDA
• Spinal cord from foramen magnum to L1
• Conus at L1 for bowel and bladder (nervi eriganties S1-S5)
• Peripheral nerves for lower extremities start from T9-T12
• L1 roots start innervation of lower extremities
• Thoracic blood supply to the cord tenuous at T10-T12 (artery of Adamkowitz)
• Lumbar blood supply abundant

3. PHYSIOLOGICAL ANATOMY OF THE
THORACIC SPINE
• Facets lie in the frontal plane- allowing rotation
• Ribs resist rotation and add 3x the normal
stiffness in lateral rotation
• Kyphosis of the T spine loads the anterior column
• Lower 2 vertebra have floating ribs and no
costotransverse articulations
• Canal size in thoracic spine relatively small

4. PHYSIOLOGICAL ANATOMY OF THE
LUMBAR SPINE
• Large discs allow more ROM
• Facets prevent rotation
• Spinal canal wider
• Lordosis is natural alignment
• Lordosis loads the facets

5. THORACOLUMBAR JUNCTION
• Thoracic spine stiffer in flexion (ribs) than lumbar spine (stress riser)
• Lowest 2 thoracic vertebra have less extrinsic stability secondary to changes in facet
orientation and floating ribs (T11-12 have frontal facets but no conjoined ribs to
stabilize, therefore less rotational resistance)
• In pure axial loading, thoracic spine deforms into kyphosis and lumbar spine into
lordosis leaving the transition vertebra exposed to pure compression
• Force distributed over 10 thoracic and 4 lumbar vertebra is withstood only by 2
vertebra at the thoracolumbar junction

6. MECHANISMS OF INJURY
• Low-Energy Insufficiency Fractures arising from comparatively mild compressive
stress in osteoporotic bone
• Minor Fractures of the Vertebral Processes due to compressive, tensile or tortional
strains
• High-Energy Fractures or Fracture-Dislocations due to major injuries sustained in
motor vehicle collisions, falls or diving from heights, sporting events, horse-riding
and collapsed buildings.
• Neurological complications are mainly associated with the third group.

7. MECHANISMS OF INJURY
• Flexion Compression – failure of the anterior column and wedge-compression of the
vertebral body. Usually stable, but greater than 50 per cent loss of anterior height suggests
some disruption of the posterior ligamentous structures.
• Lateral compression – lateral wedging of the vertebral body resulting in a localized
‘scoliotic’ deformity.
• Axial compression – failure of anterior and middle columns causing a ‘burst’ fracture and
the danger of retropulsion of a posterior fragment into the spinal canal. Often unstable.
• Flexion–rotation – failure of all three columns and a risk of displacement or dislocation.
Usually unstable.
• Flexion–distraction – the so-called ‘jack-knife’ injury causing failure of the posterior and
middle columns and sometimes also anterior compression.
• Extension – tensile failure of the anterior column and compression failure of the posterior
column. Unstable.

8. IMAGING - XRAYS
AP View:
• May show loss of height or splaying of the vertebral body with a crush fracture.
• Widening of the distance between the pedicles at one level, or an increased distance
between two adjacent spinous processes, is associated with posterior column
damage.
Lateral View:
• Examined for alignment, bone outline, structural integrity, disc space defects and
soft-tissue shadow abnormalities.
• Evidence of fragment retropulsion towards the spinal canal.

9. IMAGING – CT & MRI
• Rapid screening CT scans are now routine in many accident units.
• More reliable than x-rays in showing bone injuries throughout the spine, and
indispensable if axial views are necessary,
• Eliminate the multiple attempts that may be required to ‘get the right views’ with
plain x-rays.
• MRI also may be needed to evaluate neurological or other soft-tissue injuries.

10. COBB’S ANGLE
• Used to classify sagittal plane deformity, especially in the setting
of traumatic thoracolumbar spine fractures.
• Cobb angle is defined as the angle formed between a line drawn
parallel to the superior endplate of one vertebra above the
fracture and a line drawn parallel to the inferior endplate of the
vertebra one level below the fracture.
• The Cobb angle is the preferred method of measuring post-traumatic
kyphosis in a recent meta-analysis of traumatic spine
fracture classifications
• Scoliosis is defined as a lateral spinal curvature with a Cobb angle
of 10° or more

12. CLASSIFICATION SYSTEM
• Holdsworth 2 column theory
• Denis 3 column theory

13. 3 COLUMN THEORY - DENIS 83
• Based on radiographic review of 412 cases
• 5 types, 20 subtypes
• Anterior- ALL , anterior 2/3 body
• Middle - post 1/3 body, PLL
• Posterior- all structures posterior to PLL
• Same as Holdsworth
• Posterior injury-not sufficient to cause instability
Spinal injury and Three column concept:
• One column injury is stable
• Two column injury is unstable
• Three column injury is invariably unstable

15. CLASSIFICATION OF INJURIES
• Simple Compression (1-2 column injury)
• Stable burst (2-3 column injury)
• Unstable burst (3 column injury)
• Flexion distraction (2 nonconjoined columns)
• Chance (3 column failure all in tension)
• Fracture dislocation (3 column injury)
• Pure Dislocation (rare) (3 column injury)
• Pathological (any and all)
• Insufficiency (any and all)
• Multiple contiguous fractures (nly 1-2 columns)

16. COMPRESSION FRACTURES
• Only anterior column injury
• Middle and post. OK
• Ant. column less than 30%
• No more than 10 degrees kyphosis
• No neuro injury

17. FLEXION DISTRACTION
• Easy to miss - may look benign
• Anterior column > 50% crushed
• Middle column mainly intact
• Significant spinous process widening
• Unstable

18. STABLE BURST
• Both ant and middle column involvement
• Minimal kyphosis
• No neuro involvement
• No laminar fracture

19. UNSTABLE BURST
• 3 column involvement
• Possible neuro involvement
• Severe communition
• Significant pedicle widening
• Look for laminar fracture (asso. with root entrapment)

20. CHANCE FRACTURES
• Old “Seatbelt injuries”
• Center of rotation is anterior to ALL
• May be “bony” chance or purely ligamentous
• Normally neuro intact
• “Bony” stable, ligamentous unstable even though all are 3 column
injuries

21. FRACTURE DISLOCATIONS
• Translation in lower lumbar spine may be developmental (nly L3-S1
spondylolysthesis)
• Always abnormal in thoracic spine (ribs)
• Unstable
• Normally- neuro deficit
• Can be hidden at mid thoracic spine
• 3 column injury

22. PATHOLOGICAL FRACTURES
• Normally in patient with history of CA
• May be hard to distinguish from insufficiency fracture
• May be multiple levels
• Fracture out of proportion to force of trauma
• Suspicion calls for MRI and ?Bx

23. INSUFFICIENCY FRACTURES
• Normally in elderly females
• Osteopenia/malacia
• Bones have “washed out” appearance
• Minimal force vectors
• Multiple levels (normally)
• Kyphosis greater than 70 degrees may need surgery
• ?Vertebroplasty

24. THORACOLUMBAR
INJURY
CLASSIFICATION
AND SEVERITY
SCORE
(TLICS)

25. TREATMENT
• Injuries with 3 points or less = Non Operative
• Injuries with 4 points = Non-Op vs Op
• Injuries with 5 points or more = Surgery

26. EXAMPLES
FLEXION COMPRESSION #
•Flexion compression (morphology) - 1
•Intact (neurology) - 0
•PLC (ligament) no injury - 0
Total Points = 1 point.
Non-Operative

27. COMPRESSION
BURST FRACTURE
•Flexion compression burst - 2
•Intact ( neurology) - 0
•PLC (ligament) no injury (0)
Total Points = 2 point.
Non-Operative

28. COMPRESSION
BURST # - COMPLETE NEURO INJURY
•Axial compression burst with distraction posterior ligamentous complex -4
•Complete (neurology) - 2
•PLC (ligament) injury – 3
Total Points = 9 point.
Surgery

29. NON-OPERATIVE TREATMENT OF
THORACIC SPINE INJURIES
Brace or Cast Treatment
• Compression Fractures
• Stable Burst Fractures
• Pure Bony Flexion-Distraction Injury

30. SURGICAL MANAGEMENT OF
THORACOLUMBAR INJURIES
• Unstable burst fractures
• Purely ligamentous
• Facet dislocations
• Translational injuries
• Neurologic deficit

31. ANTERIOR COLUMN # TREATMENT
• Simple compressions can be placed in a Jewett or
TLSO off the shelf brace and discharged from the
ED or office as long as pain is controlled, fracture
is stable with new standing x-rays in brace and
they don’t have an ileus. Cannot treat fractures
above T6 without cervical extension

32. TLSO

33. STABLE BURSTS AND LATERAL COMPRESSION #
• Pain management
• Brace management
• Off the shelf TLSO (ThoracoLumboSacral Orthosis) for simple
compressions greater than 30% and lateral compressions
• CASH (Cruciform Anterior Spinal Hyperextension) brace for
insufficiency #

34. CASH

35. COMPLICATIONS FROM FRACTURE
• Pneumothorax (thoracic Fxs with asso rib Fxs)/
• Ileus (30-60%)
• Splenic, liver and vessel injury (mechanism of injury)
• DVT/PE
• Decubitis
• UTI
• Pneumonia
• Renal failure (hydronephrosis from cauda equina involvement)

36. SURGICAL INDICATIONS
• Neurological Involvement
• Flexion distraction injury
• Greater than 50% canal compromise with >15 degrees kyphosis
• >25 degrees kyphosis
• Failure of stress testing (severe pain, angulation above 25 degrees, neuro
symptoms)
• Fracture dislocations
• Soft tissue “chance” fractures

37. LAMINECTOMY
• Indications:
• Comminuted posterior elements causing direct neural compression
• Epidural hematoma requiring evacuation
• Repair of dural tear associated with burst and laminar fractures during posterior
instrumentation and fusion
Contraindications:
• Canal compromise >67%
• Delay in operative treatment for > 4 days
• Where pedicle screw insertion is not feasible (atypical morphology, small dimension
or traumatic fracture)
Requires intact PLC

38. VERTEBROPLASTY AND KYPHOPLASTY
Indications:
• Osteoporotic VCF not responding to conservative management
• Spinal metastatic lesions & fractures
• Hemangiomas
Goal of vertebroplasty is to improve strength and stability
Goal of Kyphoplasty is to restore vertebral body height and stability. The use of baloon
creates a void for cement placement under lower pressure and thus results in lower
incidence of cement extravasation
Can be safely done in patients with refractory pain to conservative treatments.

39. THANK YOU