eMedicine Specialties > Orthopedic Surgery > Spine

Thoracic Spine Fractures and Dislocations

Michael Leahy, MD, Staff Physician, Department of Orthopedic Surgery, Baylor - All Saints Hospital, Harris Methodist Hospital of Fort Worth
Mark Rahm, MD, Vice Chair and Residency Program Director, Assistant Professor, Texas A&M University Health Science Center; Consulting Staff, Department of Orthopedic Surgery, Scott and White Memorial Hospital

Updated: Dec 12, 2007

Introduction

Thoracic spine fractures, especially those resulting from high energy, can be devastating, often resulting in permanent neurologic injury. Neurologic deficit is encountered in 10-25% of all spinal column injuries, irrespective of the level of injury. A deficit occurs in 15-20% of all thoracolumbar injuries. In the event of a complete neurologic injury, very few patients regain any useful motor function. Concomitant neurologic injury with spine fractures also adversely affects long-term survival. The 10-year survival rate for people younger than 29 years is 86%. This percentage drops precipitously to 50% for patients older than 29 years.

For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center. Also, see eMedicine's patient education article Vertebral Compression Fracture.

(See also the eMedicine articles Lower Cervical Spine Fractures and Dislocations, Lumbar Spine Fractures and Dislocations, Rehabilitation of Persons With Spinal Cord Injuries, and Spinal Dislocations, as well as Thoracoscopic Spine Surgery for Decompression and Stabilization of the Anterolateral Thoracic and Lumbar Spine, on Medscape.)

History of the Procedure

Documented treatment of spine fractures dates back several thousands of years. Closed treatment and manipulation to correct the sustained deformity were typically used. In the early 20th century, most treatment consisted of immobilization in hyperextension.

Treatment of spine fractures did not begin to evolve from universally closed treatments to the surgical modalities that are in place today until the advent of current anesthesia and radiographic techniques. Internal fixation was first seen after World War II. Initially, it was in the form of spinous process plating. Harrington then introduced his posterior spinal instrumentation. From this, modern surgical techniques and instrumentation have developed. Although the spinal stability and alignment established with these newer techniques have dramatically improved, improvement in neurologic deficits sustained in these injuries has remained relatively unchanged over the years of spine fracture management.

Problem

Thoracic spine fractures, especially those resulting from high energy, often result in permanent neurologic injury.

Frequency

See Etiology. The male-to-female ratio is roughly 4:1.

Etiology

Presentation

If neurologic deficit (spinal cord) is present and less than 8 hours have elapsed from the time of injury, begin treatment with high-dose methylprednisolone (5.4 mg/kg bolus followed by 30 mg/kg/h infusion for 23 h). Operative versus nonoperative treatment can be entertained based upon the clinical status of the patient and radiographic appearance of the fracture. The stability and location of the fracture and the underlying mechanism of injury all can play major roles in the decision whether to operate or treat conservatively.

Several distinct classification schemes are available to assess spinal stability. Holdsworth initially proposed the 2-column theory of spinal stability.⁴ In this model, the vertebra is divided into an anterior and posterior column. The anterior column consists of the vertebral body, intervertebral disc, anterior longitudinal ligament, and the posterior longitudinal ligament. The posterior column comprises the facets, neural arch, and interspinous ligaments. Disruption of one or more columns implies instability of the involved segment.

Denis expanded on this model, developing the most common model used for assessing spinal stability.⁵ In this model, the vertebra is divided into 3 columns: anterior, middle, and posterior. The anterior column comprises the anterior half of the vertebral body along with the anterior longitudinal ligament and the anterior portion of the annulus fibrosis. The middle column is made up of the posterior annulus fibrosus along with the posterior half of the vertebral body and the posterior longitudinal ligament. The posterior column consists of the posterior ligamentous complex and the posterior bony elements. When 2 of the 3 columns are disrupted, the fracture is considered unstable.⁵

Classification schemes generally also encompass mechanisms of injury and their resultant fracture patterns. Several different mechanisms of injury can occur within the thoracic spine. Most commonly, a combination of 1 or 2 mechanisms accounts for the injury. These mechanisms include the following:

• Axial compression: This type of injury results in a purely compressive load. Endplate failure occurs, followed by vertebral body compression. With higher energy, a centripetal displacement occurs, resulting in what is commonly referred to as a burst fracture. In severe burst fractures, discs become fragmented and the posterior elements are disrupted. Radiographically, this mechanism can manifest as a widened interpedicular distance (see Image 1).
• Flexion: This mechanism results in compression anteriorly. Disruption of posterior elements with flexion often results in instability of the involved area. If anterior compression exceeds 40-50%, the posterior ligamentous structures are often disrupted. Instability ultimately can result in progressive deformity and neurologic deficit if not appropriately stabilized.
• Lateral compression: This mechanism usually results in a stable injury unless disruption of posterior structures or associated axial compression occurs.
• Flexion-rotation: With a flexion-rotation injury, posterior ligamentous structures commonly fail. Oblique disruption of the anterior vertebral body and disc failure occur. This type of injury can result in what commonly is known as a slice fracture. With fractures of the facets and concomitant disruption of posterior elements, thoracic spine dislocation can occur.
• Shear: Shear injuries often result in severe ligamentous disruption and subsequent anterior, posterior, or lateral listhesis. Anterolisthesis is the most common of the 3, with complete spinal cord injury often being the unfortunate result. However, occasionally, concomitant fractures through the pars interarticularis result in autolaminectomy, with resultant neural sparing.
• Flexion-distraction: This injury is more commonly referred to as the seatbelt injury. The axis of flexion is anterior to the vertebral column. Osseous, disc, and ligamentous structures are disrupted either alone or in combination. Combined osteoligamentous or purely ligamentous injuries can be present, and this injury occurs most commonly at the thoracolumbar junction. Bilateral facet dislocation can occur (see Image 2).
• Extension: Tension is placed on the anterior longitudinal ligament, with compression occurring posteriorly. Facet, laminar, and spinous process fractures often occur. Most of these injuries are stable, provided that significant retrolisthesis does not occur.

In the Denis classification system, significant fractures are divided into the following groups: (1) primarily axial load injuries, including compression and burst fractures; (2) flexion-distraction injuries; and (3) fracture subluxation and/or dislocation (see Image 3). The mechanism of failure of the middle column further differentiates the various types of fractures. The middle column is spared in compression fractures, yielding a stable fracture. It fails in compression with burst fractures, distraction in seatbelt injuries, and shear and/or rotation injuries. Fracture dislocations yield unstable injuries.

The Denis classification system has been criticized due to its occasional inability to be used to adequately distinguish between stable and unstable fractures—for example the "stable" burst fracture. In addition, biomechanical studies have been performed that bring into question the importance of the middle column. McAfee recognized this and expanded upon the Denis classification scheme to further elucidate stable versus unstable fractures. His classification system emphasizes the posterior ligamentous complex as a major factor in fracture stability. While many classification systems exist, the Denis classification is probably the most frequently used.

Another shortcoming of structural or mechanistic classifications is that they often fail to take neurologic deficit into account. Significant neurologic injury implies instability irrespective of the fracture pattern in that the spine has failed in protecting the neural elements. In general, stable fracture patterns in a neurologically intact patient can be treated nonoperatively. Indications for surgery can vary and include significant neurologic deficit and fracture subluxations. Excessive deformity is also an indication, although defining this is difficult, and the effect of kyphosis on long-term results is uncertain. Kyphosis greater than 30º; may be associated with poorer long-term results, and kyphosis greater than 25º; is often mentioned as a relative indication for surgery.

The presence of other injuries also may affect the choice between operative and nonoperative treatment. The most predictable benefit of surgery is more rapid mobilization, which can be an important consideration in the patient who has experienced multiple traumatic injuries.

Indications

The primary goals of treatment for thoracic spine fractures include protecting the neural elements and preventing deformity and instability. Surgery often facilitates achieving these goals and often hastens the patient's rehabilitation. Hospital stays are often shorter with surgery. Surgery is particularly often beneficial in patients with multiple traumatic injuries. The ultimate decision to operate is based on many factors, including fracture morphology, and the choice is often complex (see Clinical). Surgical management should be strongly considered when neurologic deficit or significant deformity or instability is present. See Medical therapy for a discussion of indications for surgery in patients with specific thoracic spine injuries.

Relevant Anatomy

A thorough knowledge of thoracic spine anatomy is essential in the treatment of thoracic spine fractures. Twelve thoracic vertebrae exist. The normal thoracic spine has an inherent kyphotic curve ranging from 18-51°. The vertebral bodies are wedge-shaped, being larger posteriorly than anteriorly. The kyphosis of the thoracic spine results in a center of gravity anterior to the apical T7 vertebrae, resulting in compression anteriorly and tension posteriorly in the resting state.

Significantly less flexion capabilities exist in the thoracic spine relative to the cervical and lumbar spine. The C7-T1 articulation flexes approximately 9°, T1-T6 flexes 4°, and T6-7 to T12-L1 gradually increases to 5-12°. Less lateral bending occurs within the thoracic spine as well. Lateral bending is approximately 6° per level from T1-T10 and approximately 8° at the thoracolumbar junction. Axial rotation is 8° from T1-T8. This is largely due to the coronal orientation of the facets in the thoracic spine. The axial rotation of the lower thoracic spine and thoracolumbar junction is reduced to 2° below T10 due to the transition to more sagittally oriented facets than those seen in the lumbar spine.

The thoracolumbar junction is relatively susceptible to injury. Injuries in this region constitute 50% of all vertebral body fractures. The decrease in rib restraint is largely responsible for the susceptibility of this area to injury. Other factors include changes in stiffness in flexion and axial rotation and the changes in disc size and shape that occur at the transition between the thoracic and lumbar spine.

The terminal portion of the spinal cord, the conus medullaris, normally begins at the T11 level. It ends at the L1-2 disc space in males and slightly more proximally in females. The cauda equina emanates from this region and extends distally into the lumbosacral spine with each peripheral nerve root exiting at its corresponding neural foramen. The cauda equina is more resistant to injury and has greater potential for recovery than the spinal cord.

The diameter of the spinal canal is also of great significance in thoracic spine fractures. The canal diameter of the thoracic spine is narrower than that of the cervical and lumbar spine. At the T6 level, the long axis of the spinal canal is approximately 16 mm in diameter, whereas in the midcervical and midlumbar spine, the long axis is 23 mm and 26 mm, respectively. These dimensions have ramifications regarding the smaller amount of space available before cord compression is sustained in the event of a thoracic spine fracture. In addition, the smaller diameter may make fixation techniques such as sublaminar wire fixation more difficult and, thus, a less desirable method of stabilization.

The orientation and shape of the pedicles in the thoracic spine are different from those of their lumbar counterparts and can often preclude pedicle fixation. The pedicular isthmus width is smaller in the T-spine than in the lumbar spine. The transverse angle is approximately 27° medial inclination from posterior to anterior in the proximal thoracic spine, decreasing to 1° at T11 and to -4° at T12.

Contraindications

Relatively few contraindications exist to operative stabilization of unstable thoracic spine fractures. Patients who are unstable medically with thoracic spine fractures requiring operative intervention should not undergo surgical stabilization. Once the patient is in optimal medical condition, surgery should be undertaken. Operative intervention for thoracic spine fractures is also contraindicated in the presence of active infection.

Workup

Imaging Studies

• Anteroposterior (AP) and lateral radiographs of the thoracic spine: Radiographs are used initially to elucidate the fracture configuration. Radiographic evidence of a fracture at any level of the spine necessitates radiographic analysis of the entire spine.⁶
• CT scan: CT scans of the thoracic spine with sagittal reformatted images provide information regarding the extent of injury to the osseous structures and the posterior elements.
• MRI: This study is useful in evaluating soft-tissue injury to the ligaments, discs, and epidural spaces. MRI is most useful in patients when traumatic disc herniation, epidural hematoma, or spinal cord injury is suspected. In addition, MRI is used when CT and radiographic analysis do not adequately explain the patient's symptoms.⁷

Treatment

Medical Therapy

More severe injuries with 2-column involvement require more rigid immobilization. Standard thoracolumbosacral orthoses (TLSO), such as the Boston brace, provide good immobilization but only of the lower thoracic spine. The usefulness of TLSO is limited to injuries from about T7 distally. Extension of the brace to the cervical spine (cervical thoracolumbosacral orthoses [CTLSO]) can allow for immobilization of upper thoracic segments; however, these braces are very poorly tolerated by patients. Upper thoracic spine injuries are more difficult to treat with bracing, and if nonoperative immobilization of the upper thoracic spine is chosen, a halo with extended vest generally should be used.

The treatment of burst fractures of the thoracic spine and the thoracolumbar junction is an area of debate. Surgical advocates believe surgery allows earlier mobilization and return to function, more pain relief, and better correction of any kyphotic deformity that exists. Studies have failed to show a significant difference in results in patients without neurologic injury as long as significant posterior column injury is not present. Significant remodeling of the spinal canal has been shown to occur within the first year in burst fractures treated nonoperatively. Residual kyphosis is also seen, but the degree of kyphosis present does not correlate with the patient's pain or functional abilities.^{9,10,11,12,13,14,15}

Additional studies have been performed that reveal similar or even more beneficial results with nonoperative verus operative treatment of thoracic spine fractures, both with and without neurologic deficit. No correlation has been shown between neurologic deficit and the extent of canal compromise or, more importantly, between the resolution of the deficit and surgical decompression. In addition, the risk of postoperative infection is eliminated with nonoperative treatment, which ranges from 7-15% in various studies. If immobilization with prolonged bed rest is chosen as the method of treatment, strict deep venous thrombosis (DVT) prophylaxis, the use of a kinetic bed, vigilant inspection for decubitus ulcers, and aggressive respiratory therapy must be implemented to prevent the complications that can arise with bed rest.

Flexion-distraction injuries involving significant disruption of the supporting ligamentous structures are generally unstable and are managed surgically.

Surgical Therapy

If surgical management is chosen, the next step is determining the most appropriate approach: anterior, posterior, or both.^16,17,18,19 Many factors, including fracture morphology and neurologic status, can play a role in this decision. Patients with complete neurologic deficit who are no longer in spinal shock have very little chance of significant neurologic recovery. The primary goal of surgery in this group is realignment and stabilization, typically through a posterior approach.^16,17,18,19

When partial neurologic deficit is present, improving residual canal compromise is also a goal of surgery. This situation most typically occurs with burst fractures. If performed early enough (generally within 72 h), posterior instrumentation allows for distraction and correction of sagittal alignment and successful indirect decompression of the spinal canal. Laminectomy with transpedicular decompression also can improve the canal clearance achieved through a posterior approach (see Image 4). Laminectomy should never be performed alone in the treatment of thoracic burst fractures. Another option is anterior decompression and fusion with instrumentation. Surgeon preference often plays a role, as does fracture morphology. Concomitant lamina fractures with posterior canal compromise generally necessitate beginning with a posterior approach due to possible neural entrapment and dural tears.²⁰

Flexion-distraction injuries result in disruption of the posterior and middle columns in tension. Very often, the anterior column remains intact, acting as a hinge. Surgical intervention for these fractures typically involves a posterior approach. Anterior approaches are not routinely used in these injuries, to preserve the intact anterior column.

Fracture-dislocation injuries result in disruption of all 3 columns and, as a result, carry a high incidence of complete spinal cord injury. Therefore, the main objective of surgical intervention is solely to provide posterior stabilization facilitating early mobilization and rehabilitation. Anterior decompression and stabilization is performed following posterior surgical realignment of the fracture in rare instances in which partial neurologic deficit exists in the presence of significant anterior neural compression.

Various methods exist for surgical stabilization, as do many opinions and accounts in the literature supporting the numerous techniques. Harrington rods have been used for many years to stabilize the spine with unstable fractures. Routinely, it requires spanning 2-3 levels above and below the injured segment. This type of fixation creates a large moment arm, conferring a high degree of stability to the construct. The disadvantage of Harrington rod instrumentation is the involvement of several motion segments. They perform relatively poorly in 3-column injuries, however, due to predisposition to overdistraction and the relatively high incidence of rod breakage and hook cut out (7-10%).

Hybrid constructs consisting of spinous process and sublaminar or Luque wires provide segmental fixation with improved results. A disadvantage of this mode of fixation is the risk of neurologic injury with sublaminar wire passage. Due to this potential complication, sublaminar wires are not routinely used in patients with incomplete neurologic injuries or normal neurologic status.

While Harrington instrumentation can be used, it has, for the most part, been supplanted by newer segmental instrumentation systems initially developed for scoliosis. These systems use multiple fixed anchors along the fixation rod. Application of multiple forces at different points is possible, resulting in a relatively low incidence of fixation failure. Compression, distraction, and translation are all possible within the same construct. Initially, these systems used hooks (sublaminar, pedicle, and transverse process) for fixation, and most now allow for pedicle screw fixation as well.

Pedicle screw fixation allows for instrumentation of vertebrae with fractured or absent laminae. In addition, pedicle screw fixation allows for rigid bony purchase through all 3 columns. Because of this increased rigidity, often fewer segments are necessary for stable fixation, allowing the preservation of more motion segments. Preserving motion segments is of less importance in the thoracic spine, as little motion is lost compared with the cervical and lumbar segments. However, limiting instrumentation of distal segments is of importance with thoracolumbar injuries.^12,21,22

The osseous structures are fused concomitantly with posterior instrumentation. Some surgeons fuse only the injured vertebral segments with subsequent staged removal of hardware. Other surgeons fuse the entire length of the instrumentation. This results in loss of motion at additional segments. As mentioned, this is of less importance in the thoracic spine. With modern segmental fixation, fewer segments need to be instrumented to provide stability, and generally, the entire instrumented region is fused.^23,24

Individual anatomic factors, such as the presence of lamina fractures, often dictate choice of anchors. In the thoracic spine, it is not uncommon for pedicles to be too small to allow screw placement. Depending on the injury, generally 2-3 segments of fixation above and below the level of injury are required if hooks alone are used. With pedicle screws, this often can be limited to 1-2 segments (see Image 5).

The condition of the anterior column also can affect instrumentation choices. If severe comminution or kyphosis is present anteriorly, extending the length of the posterior instrumentation or improving anterior support should be considered. This is often an issue with burst fractures, and anterior strut graft fusion may be required. Historically, transpedicular bone grafting also was performed in an attempt to improve the anterior column. Studies have shown little difference with this technique in hardware failure and final vertebral height. Thus, in unstable fracture patterns with anterior column involvement, dorsal stabilization with concomitant or staged anterior interbody fusion provides a more stable construct, with improved maintenance of reduction.

Anterior instrumentation systems also have been developed for the treatment of spinal fractures. Use of anterior systems often requires reconstruction of the anterior column with strut grafting, cages, or both. Anterior instrumentation historically also required the use of posterior instrumentation due to the lack of stability of the older fixation systems. Newer constructs, however, have been developed that provide enough structural stability to be used alone. Newer systems are extremely rigid, and some have been shown to provide greater torsional stiffness than the intact spine. Biomechanical studies have shown that this type of fixation can be equal in strength to a 2-above and 2-below pedicle screw construct (see Image 6).

Timing of surgery is also an important issue in the treatment of thoracic spine fractures. Progressive neurologic deficit in the presence of continued canal compromise is an accepted indication for immediate decompression and stabilization. Quite often, patients with thoracic spine fractures have concomitant injuries, making the timing of spinal stabilization difficult to plan. Some studies suggest that patients with thoracic spine fractures treated within 72 hours, irrespective of concomitant injuries, do much better physiologically postoperatively than those in whom stabilization is delayed. Early fixation results in less time in the intensive care unit, less ventilator support, decreased rate of pulmonary complications, and less overall time in the hospital.

Preoperative Details

Upon initial presentation, an extensive physical examination should be performed and the patient's neurologic status should be documented . Concomitant injuries should be assessed, and the patient's overall physical condition should be optimized promptly. Next, a thorough evaluation of the fracture pattern with appropriate radiologic studies is necessary to select the appropriate type of instrumentation to be used.

Intraoperative Details

Care must be taken positioning patients for surgery after induction of anesthesia. Intraoperative radiographs should be obtained to assess hardware placement and adequacy of reduction. In patients without neurologic deficit or with a partial deficit, neurologic function may be monitored during surgery with intraoperative evoked potentials, a wake up test, or both as the patient's condition allows. Determining the adequacy of decompression can be difficult if a posterior approach is chosen. Plain films can be helpful, and pedicle resection can allow anterior access without cord manipulation. Intraoperative spinal sonography (IOSS) also can be used to evaluate for residual compression.

Postoperative Details

Early mobilization and rehabilitation are essential to decrease postoperative complications and to achieve the highest level of functional status attainable. Serial neurologic examinations are performed in the acute postoperative setting to assess for changes in neurologic status. Adequate stabilization is often achieved with instrumentation alone, although postoperative bracing sometimes may be required. If a partial neurologic deficit persists, a follow-up CT scan can be obtained to evaluate the adequacy of the decompression.⁶

Follow-up

With surgically corrected thoracic spine fractures, early follow-up examination to assess wound healing is necessary within the first few weeks postoperatively. Subsequent clinical examinations to assess functional status and neurologic function, as well as radiographic examinations, should occur frequently over the first year, followed by annual examinations thereafter if necessary. Significant loss of correction, change in neurologic function, or increase in pain level warrants further workup.

Nonoperative treatment of thoracic spine injuries requires close clinical and radiographic follow-up. Two-column injuries generally require 3 months of bracing, at which point weaning can begin. Activities are often restricted (no lifting of >20 lb, no impact activities) for 5-6 months. With significant changes in any of the above parameters, surgical intervention could possibly be warranted.

Complications

Even with careful preoperative planning and meticulous surgical technique, complications can occur during surgical treatment of a thoracic spine fracture. DVT, pulmonary embolism, urinary tract infections, and even death can occur with any surgical procedure, and measures should be taken to prevent such complications.

Neurologic injury can occur during spine surgery; incidence is approximately 1%. Injury can occur as a result of overdistraction or overcompression or from insertion of the various forms of instrumentation.

Dural tears can occur during exposure, instrumentation, or decortication. They also may be caused by fractures of the lamina. The full extent of the tear should be completely exposed, and primary repair should be attempted if possible. Muscle or fascial grafts can be used for large tears not amenable to primary repair. Lumbar transdural drains can be placed to decrease pressure across the tear and facilitate healing.

Infection can occur as a result of surgical treatment of thoracic spine fractures. Infections superficial to the fascia can be treated with debridement with packing or closure over a drain. Infections deep to the fascia require prompt surgical debridement with retention of bone graft and instrumentation. The wound can be serially debrided or closed over deep drains or over an inflow-outflow system providing constant irrigation of the wound. Six weeks of intravenous antibiotics followed by a course of oral antibiotics are routinely administered in conjunction with the above treatments.

Outcome and Prognosis

The results are favorable for correction of deformity, maintenance of reduction, healing, and fusion rates. Overall clinical outcome is generally good, depending on the patient's final neurologic function. Return of neurologic function, however, is variable, with little significant recovery seen in complete injuries irrespective of treatment.

Future and Controversies

Video-assisted thorascopic surgery (VATS) allows for minimally invasive correction of spinal deformities. Currently in some centers, it is performed for thoracic spine fractures requiring anterior bone grafting and stabilization. The benefits of this minimally invasive approach have yet to be proven, and the learning curve is steep; however, the morbidity of an open thoracotomy is avoided. Research continues in many areas, including spinal cord injuries and timing of surgery, in regard to neurologic function.

Thoracic pedicle screw placement can be challenging due to the smaller dimensions of the thoracic pedicle compared to the lumbar pedicle. Cortical disruptions have been reported to occur up to 50% of the time at some institutions using standard fluoroscopic techniques. Computer image guidance is useful when dealing with difficult anatomy, such as in placing thoracic pedicle screws and in rotational deformities. However, a clear role in spine trauma management has not been found.

Multimedia

Media file 1: Thoracic spine fractures and dislocations. Burst fracture T12. Note the widened interpedicular distance.

Media file 2: Thoracic spine fractures and dislocations. Flexion distraction injury with facet dislocation.

Media file 3: Thoracic spine fractures and dislocations. Fracture dislocation T2-T3.

Media file 4: Thoracic spine fractures and dislocations. Preoperative axial CT image of burst fracture with partial neurologic deficit.

Media file 5: Thoracic spine fractures and dislocations. Burst fracture with partial neurologic deficit after stabilization with medial resection of right pedicle to allow access to anterior fragment.

Media file 6: Thoracic spine fractures and dislocations. Pedicle screw fixation of a T12 burst fracture.

Media file 7: Thoracic spine fractures and dislocations. Anteroposterior (AP) radiograph of T12 burst fracture treated with cage strut and anterior instrumentation.

Media file 8: Thoracic spine fractures and dislocations. Lateral radiograph of T12 burst fracture treated with cage strut and anterior stabilization.

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Keywords

spinal column injury, thoracolumbar injuries, neurologic injury, thoracic spine fractures, Denis classification, pedicle screw fixation

Contributor Information and Disclosures

Author

Michael Leahy, MD,  Staff Physician, Department of Orthopedic Surgery, Baylor - All Saints Hospital, Harris Methodist Hospital of Fort Worth
Disclosure: Nothing to disclose.

Coauthor(s)

Mark Rahm, MD, Vice Chair and Residency Program Director, Assistant Professor, Texas A&M University Health Science Center; Consulting Staff, Department of Orthopedic Surgery, Scott and White Memorial Hospital
Mark Rahm, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, North American Spine Society, Texas Medical Association, and Texas Orthopaedic Association
Disclosure: Nothing to disclose.

Medical Editor

Lee H Riley III, MD, Chief, Division of Orthopedic Spine Surgery, Assistant Professor, Departments of Orthopedic Surgery and Neurosurgery, Johns Hopkins University
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

William O Shaffer, MD, Associate Professor & Residency Program Director, Department of Orthopedic Surgery, University of Kentucky at Lexington
William O Shaffer, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Southern Medical Association, and Southern Orthopaedic Association
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD, Consulting Surgeon, Broward Hand Center, Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine
Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society
Disclosure: Nothing to disclose.

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