Posterior Stabilization for Thoracolumbar Spine Fractures
Lawrence I. Karlin, MD
Indications
Unstable spine fracture (Figure 17-1).
Instability determined by extent of bone and ligamentous injury.
Clear indication for posterior stabilization is disruption of posterior ligamentous complex (PLC) (Figure 17-2).
Fracture morphology is modifying factor; more unstable patterns (translation/rotation or distraction) require more extensive constructs than less unstable patterns (compression/burst)
Unstable spine fracture with complete neurologic deficit
Unstable spine fracture with incomplete neurologic deficit
 Figure 17-1 ▪ CT scan demonstrating displace chance fracture. |
 Figure 17-2 ▪ MRI demonstrating signal changes indicative of posterior tension band injury. |
Sterile Instruments/Equipment
Standard spine surgery instrument trays
Retractors
Cobb elevators
Rongeurs, Kerrison, bone scalpel
Allograft
Hemostatic and dural repair agents-fibrin sealant, absorbable gelatin sponge
Spinal instrumentation
Size dependent on age and bodyweight of patient
Pedicle screws, hooks, and sublaminar bands
Neurophysiologic monitoring
SSEP, transcranial MEP, EMG
Fluoroscopy
Patient Positioning (Figure 17-3)
Extreme care must be taken turning spine patients prone
Large number of team members to allow for turning in a log-roll manner safely
Alternatively, a rotating spine table is available which allows to turn bed 180° from supine to prone.
Prone on a radiolucent spine table (Figure 17-4)
Prone face holder
Bolsters under chest and iliac crest keeping abdomen free for venous return (4-post frame)
Arms placed with elbows at 90° and shoulders abducted 45° to 60°
Position hips to aid fracture reduction; extend as needed to encourage lumbar lordosis.
Perform fluoroscopic views, AP and lateral of spine, once positioned to redefine the deformity. A radiopaque marker will aid in determining the incision site.
 Figure 17-3 ▪ Standard spine table with headrest and positioning bolsters. |
Surgical Approaches (Figure 17-5)
Posterior incision centered over injury with length determined by number of levels
Unstable spine injuries frequently have spinous process/fascial/musculature disruption with large hematoma with disruption of standard planes
Beware of facet and ligamentum flavum disruption, exposed or injured dura, and nerve root entrapment.
Confirm levels fluoroscopically after exposure (Figure 17-6).
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