eMedicine Specialties > Orthopedic Surgery > Spine

Thoracic Spine Fractures and Dislocations: Treatment

Author: Michael Leahy, MD, Staff Physician, Department of Orthopedic Surgery, Baylor - All Saints Hospital, Harris Methodist Hospital of Fort Worth
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
Contributor Information and Disclosures

Updated: Dec 12, 2007

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.

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