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Pure bone thoracolumbar chance fracture


Introduction

The thoracolumbar junction is a region of biomechanical transition from the relatively stiff thoracic spine to the more flexible lumbar spine, which makes it susceptible to injury from high-velocity trauma. Fractures of the thoracolumbar junction are associated with an approximately 25% risk of spinal cord injury. Historically, there has been a general lack of consensus regarding the surgical management of thoracolumbar fractures, primarily driven by presence of level I evidence supporting the use of orthosis for patients with stable burst fractures and no neurological deficits. Many clinicians have developed strategies to better classify thoracolumbar fractures and determine which fractures would be considered unstable and require instrumentation. In this chapter, we will discuss the most frequently employed classification systems while we discuss the presentation and management of a patient with a thoracolumbar fracture.

Example case

  • Chief complaint: mid back pain

  • History of present illness: This is an 81-year-old female who was seen in the emergency room after a car accident. She has mid back pain with midline palpation and no leg symptoms. The patient underwent a computed tomography (CT) and magnetic resonance imaging (MRI) of the lower thoracic and lumbar spine concerning for a pure bone Chance fracture of T12 ( Fig. 27.1 ).

    Fig. 27.1, Preoperative computed tomography (CT) and magnetic resonance imaging (MRI) of the thoracolumbar spine. (A) Mid sagittal and (B) axial CT centered at the level of T12 images demonstrating a fracture extending from the T12 vertebral body into the posterior elements of the spine. A small fragment of retropulsed bone can also be visualized. The axial image demonstrates fracture lines extending through bilateral pedicles. (C) Mid sagittal T2 and (D) sagittal short tau inversion recovery (STIR) MRI demonstrating mild retropulsion of a bone fragment, with no significant impingement on the spinal cord. The STIR image demonstrates a significant amount of edema in the T12 vertebral body as well as soft tissue edema posteriorly.

  • Medications: Eliquis, hydrochlorothiazide, tramadol

  • Allergies: no known drug allergies

  • Past medical history: atrial fibrillation, previous stroke

  • Past surgical history: L4–5 and L3–4 anterior lumbar interbody fusion

  • Family history: no history of malignancies

  • Social history: no smoking, no alcohol use

  • Physical examination: awake, alert, and oriented to person, place, and time; cranial nerves II–XII intact; bilateral deltoids/triceps/biceps 5/5; interossei 5/5; iliopsoas/knee flexion/knee extension/dorsi, and plantar flexion 5/5

  • Reflexes: 2+ in bilateral biceps/triceps/brachioradialis with negative Hoffman; 2+ in bilateral patella/ankle and no clonus or Babinski, sensation intact to light touch

  • Laboratories: all within normal limits

  • Jason Cheung, MD

  • Orthopaedic Surgery

  • The University of Hong Kong

  • Queen Mary Hospital

  • Pokfulam, Hong Kong SAR, China

  • Scott Daffner, MD

  • Orthopaedic Surgery

  • West Virginia University

  • Morgantown, West Virginia, United States

  • Gordon Deen, MD

  • Neurosurgery

  • Mayo Clinic

  • Jacksonville, Florida, United States

  • Michael G. Fehlings, MD, PhD

  • Neurosurgery

  • University of Toronto

  • Toronto, Canada

Preoperative
Additional tests requested

  • Serum tumor markers

  • Hematology evaluation

  • Cardiology consultation

  • Osteoporosis medication Blood tests including bone profileOsteoporosis investigation

  • Upright AP and lateral T- and L-spine x-rays

  • Vitamin D level

  • Endocrinology evaluation

None

  • CT complete spine

  • T- and L-spine x-rays

  • CT chest and abdomen

  • Hematology evaluation

  • Medicine evaluation

Surgical approach selected TLSO brace, osteoporosis medication If kyphotic deformity, intractable pain, and/or neurological deficit, posterior T10-L2 cement-augmented fusion TLSO brace, no surgery offered T11-L1 posterior percutaneous fusion

  • Surgical approach if 21 years old

  • Surgical approach if 80 years old

  • Same approach

  • Same approach

  • Percutaneous fixation

  • Open fusion

  • Same approach

  • Same approach

  • TLSO brace

  • Same approach

Goal of surgery Depends on the findings above but if tumor related we will require biopsy, staging and stabilization and adjuvant treatment as necessary Stabilization of spine, early mobilization Stabilization of fracture, pain control, maintain neurological function
Perioperative
Positioning Prone on Jackson table Prone
Surgical equipment

  • IOM (MEP/SSEP)

  • Fluoroscopy

  • Bone cement

  • IOM (MEP/SSEP)

  • Fluoroscopy

  • O-arm

  • Surgical navigation

Medications Maintain MAP >80 None
Anatomical considerations Pedicles, nerve roots, spinal cord, T9-10 and L2-3 facet capsules Pedicles
Complications feared with approach chosen Pseudoarthrosis, instrumentation failure Epidural hematoma, malpositioned screws, loss of fixation, medical complications
Intraoperative
Anesthesia General General
Exposure T10-L2 T11-L1
Levels decompressed None None
Levels fused T10-L2 T11-L1
Surgical narrative Preflip IOM, position prone, recheck IOM, midline posterior incision, standard exposure of T10-L2, take care to not disrupt T9-10 or L2-3 facet capsules, expose just enough over transverse processes to be able to identify landmarks, place fenestrated screws bilaterally from T10-L2 avoiding T12, confirm position of screws with x-ray, inject 1–1.5 cc of cement through each screw under fluoroscopy, contour titanium rods and seat within screw heads, apply end caps and tighten, irrigate wound, decorticate exposed lamina and T10-L2 facet joints, place bone graft and/or extender, layered closure with possible drain Delay surgery by 72 hours because of anticoagulant, sandwich flip on Allen table, position prone, check alignment with fluoroscopy, mark T10-L1 levels, small incision over T10 spinous process and clamp reference frame to T10 spinous process, O-arm spin and register navigation, stab incisions to cannulate T11-L1 bilateral pedicles with K-wires, place percutaneous dilators and cannulate pedicles bilaterally, place rod percutaneously, tighten all connections, confirm hardware location with fluoroscopy, infiltrate each incision with anesthetic
Complication avoidance Preflip IOM, take care to not disrupt T9-10 or L2-3 facet capsules, cement augmented screws, avoid cement in T12 (fracture level), use less rigid rods Delay surgery due to anticoagulant, surgical navigation, percutaneous fusion
Postoperative
Admission Floor Stepdown unit Floor Floor
Postoperative complications feared Anemia, infection, instrumentation failure, adjacent segment degeneration Epidural hematoma, malpositioned screws, loss of fixation, medical complications
Anticipated length of stay 2–3 days 2 days 2–3 days 2–3 days
Follow-up testing Thoracic spine x-rays 3 months and 6 months after discharge

  • CT T-L spine prior to discharge

  • Upright T- and L-spine x-ray prior to discharge, 6 weeks, 3 months

  • Outpatient physical therapy 3 months after surgery

  • Flexion/extension x-rays 6 months, 12 months, 24 months after surgery

Thoracic spine x-rays 2 and 4 weeks after discharge

  • T-L spine x-rays prior to discharge, 6 weeks, 3 months, 6 months, 12 months, 24 months after surgery

  • CT 6 months after surgery

  • Resume anticoagulation after 2 weeks

  • Osteoporosis evaluation

Bracing TLSO brace for 3 months None Aspen TLSO brace for 6 weeks None
Follow-up visits 3 months and 6 months after discharge 2 weeks, 6 weeks, 3 months, 6 months, 12 months, 24 months after surgery 6 weeks after discharge 6 weeks, 3 months, 6 months, 12 months, 24 months after surgery
AP , Anteroposterior; CT , computed tomography; IOM , intraoperative monitoring; MAP , mean arterial pressure; MEP , motor evoked potentials; SSEP , somatosensory evoked potentials; TLSO , thoracic lumbar spine orthosis.

Differential diagnosis

  • ▪

    Pure bone Chance fracture

  • ▪

    Burst fracture

  • ▪

    Acute disc herniation

  • ▪

    Muscle strain

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