Thoracic Spine Fractures and Dislocations Treatment & Management

Updated: Oct 16, 2018
  • Author: Brian J Page, MD; Chief Editor: Murali Poduval, MBBS, MS, DNB  more...
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Treatment

Approach Considerations

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. Ultimately, the decision whether to operate is based on many factors, including fracture morphology, and the choice is often complex (see Presentation).

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, though 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.

Relatively few contraindications exist for 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 an active infection.

Guidelines on management of thoracolumbar burst fractures are available from the Congress of Neurological Surgeons, [21] and guidelines on management of spinal cord injury (SCI) are available from AOSpine [22, 23, 24, 25, 26, 27]  (see Guidelines).

Timing of surgical treatment

The literature regarding the timing of surgical intervention for thoracic and lumbar fractures with an acute spinal cord injury (SCI) is scarce. However, several studies have looked at the timing of surgery in cervical spine trauma.

In particular, the Surgical Treatment of Acute Spinal Cord Injury Study (STASCIS), a prospective multicenter trial, examined the results of early vs late decompression surgery in cervical spine trauma. [28] Early decompression was defined as less than 24 hours, and late was defined as after 24 hours. A total of 313 patients were evaluated on the basis of cervical spinal cord compression identified on advanced imaging. The primary outcome studied was change in the American Spinal Injury Association (ASIA) Impairment Scale (AIS) from presentation to 6-month follow-up.

In this study, a higher rate of significant neurologic recovery was identified in the early decompression group. [28] However, these findings must be considered within the overall clinical context for each patient, in that these patients can have multisystem injuries that may preclude immediate operative intervention. A multidisciplinary approach should be followed in treating these patients and in determining the most appropriate time to operate.

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Nonoperative Therapy

Nonoperative treatment begins with pain management and attention to concomitant injuries. Mobilization with bracing can then begin if nonsurgical treatment is chosen. Use of the three-column rule can be helpful in determining brace types.

Single-column injuries (eg, compression fractures involving only the anterior column) are generally stable and can be treated with a simple extension orthosis to limit flexion. If contiguous fractures are encountered, the cumulative compression and angular deformities are considered in choosing between operative and nonoperative treatment. Isolated posterior-element fractures are usually stable, and conservative treatment with mobilization is appropriate. Light bracing can be used with these injuries for comfort and to hasten mobilization. [29, 30, 31, 32, 33]

More severe injuries with two-column involvement require more rigid immobilization. Standard thoracolumbosacral orthoses (TLSOs), such as the Boston brace, provide good immobilization, but only of the lower thoracic spine. The usefulness of TLSOs is limited to injuries from about T7 distally.

Extension of the brace to the cervical spine (cervical thoracolumbosacral orthoses [CTLSOs]) can allow 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; therefore, fracture instability is a relative indication for surgical stabilization.

Soliman et al evaluated 695 isolated compression fractures to the thoracic or lumbar spine, of which 195 derived from auto accidents (age range, 19-82 years; male-to-female ratio, 60:40). [34] No patient with compression of less than 40% underwent surgery unless he or she presented with a neurologic deficit. Patients without neurologic deficit underwent surgery only if they had compression of 40% or higher. The investigators found that the use of a TLSO in patients with less than 40% compression was of no value in terms of outcomes; the with-brace and without-brace groups had similar outcomes.

The treatment of burst fractures of the thoracic spine and the thoracolumbar junction is an area of debate. Surgical advocates believe that 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. [35]

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. [30, 31, 32, 36, 37, 38, 39, 40]

Additional studies have reported similar or even more beneficial results with nonoperative as opposed to 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 important, between the resolution of the deficit and surgical decompression. In addition, nonoperative treatment eliminates the risk of postoperative infection, which ranges from 7% to 15% in various studies.

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

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.

Steroid administration in trauma setting

Administration of methylprednisolone has been the topic of debate in the spine literature for quite some time; whether its efficacy and potential benefit outweigh its adverse effects has been a source of controversy in the treatment of SCI. [41, 42, 43, 44, 45, 46]

Methylprednisolone is a synthetic corticosteroid that acts to inhibit proinflammatory cytokine production. In the spine, its proposed effects include inhibition of lipid peroxidation, prevention of progressive ischemia development, reversal of intracellular calcium accumulation, and various other effects. [47]  The use of methylprednisolone in acute SCI has been extensively studied, most notably in National Acute Spinal Cord Injury Study (NASCIS), which sought to evaluate treatment strategies for reducing the effects of SCI. There were three different NASCIS trials, as follows:

  • NASCIS 1 studied the effects of high-dose versus low-dose methylprednisolone for the treatment of acute SCI [41] ; no difference between the two groups was found with respect to neurologic recovery of motor function or light touch sensation at 6 weeks or 6 months post injury, but wound complications and infections were found in the high-dose group  
  • NASCIS 2 examined the effects of an initial bolus of methylprednisolone followed by infusions consisting either methylprednisolone, naloxone, or placebo [42] ; initial analysis failed to identify any significant neurologic benefit in the steroid group, but subgroup analysis of individuals receiving methylprednisolone within 8 hours of injury demonstrated statistically significant motor and sensory improvement in short- and long-term follow-up
  • NASCIS 3 sought to investigate the efficacy of high-dose methylprednisolone for 24 versus 48 hours [44] ; significant results were found when methylprednisolone was given within 3-8 hours and continued for 48 hours

The results of these studies have been criticized by the medical community. For instance, it was noted that NASCIS 1 had no control group and that it reported a significant amount of side effects. Other criticisms focused on the methods of statistical analysis used. It was pointed out that in NASCIS 2, it took a secondary analysis of a patient subgroup to obtain a positive effect of methylprednisolone. It was also noted that the placebo group treated before 8 hours did poorly, in contrast to the placebo group treated after 8 hours. These findings raised questions about the validity of the subgroup analysis. Similar statistical anomalies were found in NASCIS 3, further fueling the criticism of these studies.

In summary, methylprednisolone is a treatment option in the setting of acute SCI; however, it is not the current standard of care, nor is it routinely used by all spine surgeons. Some medical centers have abandoned the use of methylprednisolone for this application altogether, whereas others use it intermittently. The standard protocol consists of administration within 8 hours of SCI in the form of an initial bolus of 30 mg/kg given over 15 minutes followed by infusion at a rate of 5.4 mg/kg/hr for 23 hours post injury. [48]

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Surgical Therapy

Surgical options

If surgical management is chosen, the next step is to determine the most appropriate approach: anterior, posterior, or both. [49, 50, 51, 52, 53] 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 goals of surgery in this group are realignment and stabilization, typically via a posterior approach. [49, 50, 51, 52]

When partial neurologic deficit is present, improving residual canal compromise is also a goal of surgery. This situation most typically occurs with burst fractures (see the image below). If performed early enough (generally within 72 hours), posterior instrumentation allows 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.

Thoracic spine fractures and dislocations. Preoper Thoracic spine fractures and dislocations. Preoperative axial CT image of burst fracture with partial neurologic deficit.

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 because of possible neural entrapment and dural tears. [54]

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; however, it may fail in compression. Surgical intervention for these fractures typically involves a posterior approach. To preserve the intact anterior column, anterior approaches are not routinely used in these injuries.

Fracture-dislocation injuries result in disruption of all three columns and, as a result, carry a high incidence of complete SCI. Therefore, the main objective of surgical intervention is solely to provide posterior stabilization facilitating early mobilization and rehabilitation. Anterior decompression and stabilization are performed after posterior surgical realignment of the fracture in rare cases where 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 had been used for many years to stabilize the spine with unstable fractures. The main disadvantage of Harrington rod instrumentation is that it requires two to three levels above and below the injured segment for stability. Additionally, it performs relatively poorly in three-column injuries because of the predisposition to overdistraction and the relatively high incidence of rod breakage and hook cutout. [55]

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 and wire migration. Because of these potential complications, many surgeons do not routinely use sublaminar wires in patients with incomplete neurologic injuries or normal neurologic status.

Harrington instrumentation has been supplanted by segmental instrumentation systems initially developed for scoliosis. These systems use multiple fixed anchors along the fixation rod. Multiple forces can be applied at different points, 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 they now allow for pedicle screw fixation as well.

Pedicle screw fixation allows instrumentation of vertebrae with fractured or absent laminae. In addition, it allows rigid bony purchase through all three columns. Because of this increased rigidity, fewer segments may be needed for stable fixation, allowing preservation of more motion segments. Preserving motion segments is less important in the thoracic spine; little motion is lost in comparison with the cervical and lumbar segments. However, limiting instrumentation of distal segments is important with thoracolumbar injuries. [36, 56, 57, 58]

Thoracic pedicle screw placement can be challenging because of the smaller dimensions of the thoracic pedicle as compared with the lumbar pedicle. [59]  At some institutions, cortical disruptions have been reported to occur as often as 50% of the time when standard fluoroscopic techniques are used. Computer image guidance is useful in dealing with difficult anatomy, as in the placement of thoracic pedicle screws and in rotational deformities. However, a clear role in spine trauma management has not been established.

Fischer et al evaluated the feasibility and accuracy of minimally invasive transpedicular screw placement in 35 cervicothoracic fractures (28 traumatic, three pathologic, three infectious, and one osteoporotic) with the help of computed tomography (CT)-controlled guide wires (293 guide wires were inserted). [60]  They found that treating vertebral fractures with a guide wire–based pedicle screw insertion technique under CT imaging yielded very high accuracy and a low complication rate.

The osseous structures are generally fused concomitantly with posterior instrumentation. Some surgeons fuse only the injured vertebral segments and subsequently perform staged removal of hardware as opposed to fusing the entire length of the instrumentation. With modern segmental fixation, fewer segments must be instrumented to provide stability. In the main thoracic spine, where motion preservation is less critical, it is common for the entire instrumented region to be fused. [61, 62]

Minimally invasive surgical techniques with percutaneous pedicle screw placement has gained popularity over the past few years. Such techniques aim to minimize soft-tissue injury and perioperative morbidity. Early studies demonstrated shorter operating times, shorter hospital stays, reductions in intraoperative blood loss, and lower infection rates. [63]  The development of navigation systems has reduced insertion time and radiation exposure while maintaining accurate screw placement. [64]

Individual anatomic factors and posterior element fracture morphology can affect the surgeon's choice of anchors. In the thoracic spine, it is not uncommon for pedicles to be too small to allow screw placement. In these situations, hooks or bands may be considered. Generally, depending on the injury, two or three segments of fixation above and below the level of injury are required if hooks or bands alone are used. With pedicle screws, fixation often can be limited to one or two segments. The image below shows a burst fracture after stabilization.

Thoracic spine fractures and dislocations. Burst f 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.
Thoracic spine fractures and dislocations. Pedicle Thoracic spine fractures and dislocations. Pedicle screw fixation of a T12 burst fracture.

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. Historically, transpedicular bone grafting also was performed in an attempt to improve the anterior column. Studies have shown little difference with this technique in regard to 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. Their use often requires reconstruction of the anterior column with strut grafting, cages, or both. Historically, anterior instrumentation also required the use of posterior instrumentation because of the lack of stability of the older fixation systems. Newer anterior systems, however, have been developed that provide enough structural stability to allow them to be used alone. They 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 two-above and two-below pedicle screw construct.

Advantages of the anterior approach include direct neural decompression and preservation of motion segments at the thoracolumbar junction. However, because of the morbidity of this approach and advances in posterolateral approaches to the spine, posterior fixation techniques are much more commonly used than the direct anterior approach.

The 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 after the operation than those in whom stabilization is delayed. Early fixation results in less time in the intensive care unit, reduced need for ventilator support, fewer pulmonary complications, and a shorter overall hospital stay. [65]

Preparation for surgery

Upon initial presentation, an extensive physical examination should be performed and the patient's neurologic status 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.

Operative details

Care must be taken in 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 should be monitored during surgery with intraoperative evoked potentials (motor and sensory) 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) and CT can also be used to evaluate for residual compression.

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Postoperative Care

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, though postoperative bracing sometimes may be required. If a partial neurologic deficit persists, follow-up CT may be performed to evaluate the adequacy of the decompression. [66]

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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; the incidence is variable with reports ranging from 0.46% to 17%. [67]  Injury can occur as a result of overdistraction, overcompression, or insertion of various forms of instrumentation.

Dural tears can occur during exposure, instrumentation, or decortication, and they may also be a result of the traumatic injury. In the case of dislocation and traumatic laceration, realignment of the spine often results in stopping the cerebrospinal fluid (CSF) leak, with no need for further specific treatment of the dura. [68]  If repair is deemed necessary, 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 that are not amenable to primary repair. Lumbar transdural drains can be placed to decrease pressure across the tear and facilitate healing. [68]

Infection can occur as a result of surgical treatment. 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. A 6-week course of intravenous antibiotics followed by a course of oral antibiotics is routinely administered in conjunction with these measures.

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Long-Term Monitoring

With surgically corrected thoracic spine fractures, early follow-up examination to assess wound healing is necessary within the first few postoperative weeks. Subsequent clinical examinations to assess functional status and neurologic function, as well as radiographic examinations, should take place 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 (eg, no lifting of weights exceeding 20 lb [~9 kg] and no impact activities) for 5-6 months.

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