Introduction

Trauma to the thoracic and lumbar spine mechanistically falls on a continuum. Current treatment algorithms for thoracolumbar spinal trauma are in part guided by evaluation of injury to a multitude of anatomical structures comprising the posterior ligamentous complex, fracture pattern, and neurological compromise. Objectives following treatment of thoracolumbar injury include the maintenance or restoration of spinal alignment and stability, preservation of neurologic status, early patient mobilization, and assistance with comanagement of other injuries in the setting of polytrauma. While there is not always consensus regarding selection of operative versus nonoperative intervention, we review in this chapter the basic concepts of management of thoracolumbar spinal injuries (▶Video 50.1).

I. History and Physical Examination

1. 
   

   Mechanism of injury

   
   
   
   
   1. 
      

      Usually high-energy mechanism with greater than 50% of thoracolumbar spine injuries occurring as a result of motor vehicle accidents.

      
      
   2. 
      

      Five to 20% have concomitant noncontiguous spinal injuries.

      
      
   3. 
      

      Identifying mechanism of injury provides information in regard to classification of injury pattern: Primary directional forces —axial compression, lateral compression, flexion, extension, distraction, shear, and rotation.

      
      
   4. 
      

      Association with pelvic and extremity fractures, head trauma, chest, and intra-abdominal injuries.

   
   
2. 
   

   Relevant past history

   
   
   
   
   1. 
      

      Inquire about patient’s history of congenital and acquired conditions:

      
      
      
      
      1. 
         

         Coagulopathy.

         
         
      2. 
         

         Prior spine surgery.

         
         
      3. 
         

         Spondyloarthropathy.

         
         
      4. 
         

         Ankylosing spondylitis/diffuse idiopathic skeletal hyperostosis.

   
   
3. 
   

   Physical examination

   
   
   
   
   1. 
      

      Maintain spinal precautions during inspection for lacerations, ecchymosis, tenderness to palpation, swelling, and step-off between spinous processes.

      
      
   2. 
      

      Secondary and tertiary survey for associated injuries.

      
      
   3. 
      

      Neurologic examination findings:

      
      
      
      
      1. 
         

         Motor examination graded 0 to 5 based on resistance, monitoring for new-onset weakness (▶ Table 50.1 ).

         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         

         Table 50.1 Motor strength testing

         Numerical motor grade	Corresponding motor function
         0	No muscle contraction
         1	Muscle movement visible but insufficient to cause joint motion
         2	Movement of the joint but muscle strength cannot overcome gravity
         3	Muscle strength can overcome gravity but not against resistance
         4	Movement against resistance, but muscle strength is not fully normal
         5	Normal muscle strength against full resistance

         
         
      2. 
         

         Sensory function examined by dermatomal distribution for decreased sensation.

         
         
      3. 
         

         Altered reflexes (i.e., abdominal, cremasteric, patellar, Achilles tendon).

         
         
      4. 
         

         Sustained clonus and positive Babinski’s sign: lateral aspect of the plantar surface of foot is stroked with an upgoing great toe.

         
         
      5. 
         

         Pain and temperature changes may be tested with sterile needle and alcohol swab.

      
      
   4. 
      

      Consideration given to patient experiencing spinal shock in the setting of complete spinal injury and should be reexamined when bulbocavernosus reflex is present.

II. Anatomy

1. 
   

   Three-column theory requires two-column destabilization prior to instability (▶ Fig. 50.1 ).

   

   
   
   
   
   1. 
      

      Anterior column: anterior longitudinal ligament (ALL), anterior two-thirds annulus, and anterior two-thirds vertebral body.

      
      
   2. 
      

      Middle column: posterior one-third annulus, posterior one-third vertebral body, and posterior longitudinal ligament (PLL).

      
      
   3. 
      

      Posterior column: neural arch, ligamentum flavum, facet joint, lamina, spinous process, and posterior ligamentous complex (PLC).

   
   
2. 
   

   Thoracic spine

   
   
   
   
   1. 
      

      Increased intrinsic stability as a result of rib cage, which produces long rigid lever arm during traumatic insult.

      
      
   2. 
      

      Smallest pedicle width at T4, T5, and T6.

      
      
   3. 
      

      Center of gravity located anterior to spine placing posterior elements under tension, while anterior/middle columns undergo axial compression.

      
      
   4. 
      

      Kyphosis in thoracic spine ranges from 20 to 45 degrees with transitional thoracolumbar junction having 0 to 3 degrees of lordosis.

   
   
3. 
   

   Lumbar spine

   
   
   
   
   1. 
      

      Most lordosis (20–80 degrees) in the lumbar spine originates from L4/L5 and L5/S1. Important to restore sagittal alignment upon surgical stabilization.

      
      
   2. 
      

      Very mobile in flexion/extension as a result of facets oriented in the sagittal plane, which become more coronal when moving caudally.

      
      
   3. 
      

      L3 or L4 pedicles are generally oriented perpendicular to the floor when patient is prone.

      
      
   4. 
      

      L1 pedicle has 5 degrees of medial convergence with general rule of additional 5 degrees per level when moving caudally.

III. Imaging

1. 
   

   Radiographs

   
   
   
   
   1. 
      

      Anteroposterior (AP) radiographs: Visualize coronal alignment, interpedicular distance, and for operative purposes, endplate overlap as well as position of spinous processes for instrumentation.

      
      
   2. 
      

      Lateral radiographs and flexion/extension views: Useful for vertebral body height, sagittal alignment, evaluation of posterior column, and dynamic instability.

   
   
2. 
   

   Computed tomography scan

   
   
   
   
   1. 
      

      Advantage of improved bony detail and fracture characterization (25% of burst fractures are missed on X-ray; ▶ Fig. 50.2 ).

      

      
      
   2. 
      

      Review fracture morphology and pedicle dimensions prior to operative intervention.

      
      
   3. 
      

      Facet widening, splayed spinous processes, and body translation could be indicators of instability.

   
   
3. 
   

   Magnetic resonance imaging

   
   
   
   
   1. 
      

      Damage to soft tissues and PLC seen on T2 sequence.

      
      
   2. 
      

      Correlation of neurologic deficits with sources of compression (i.e., hematoma).

      
      
   3. 
      

      May have role in prognostic implications in the setting of spinal cord injury.