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INTRODUCTION

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This chapter addresses traumatic fractures and dislocations to the thoracolumbar (TL) spinal column. With the exception of vertebral compression fractures, TL spine injuries are uncommon, and when present, are frequently overlooked. This is likely due to the fact that other more significant injuries in the traumatized patient distract the clinician and because signs and symptoms of the vertebral injury are often subtle.1 Early diagnosis and treatment of these injuries improves neurologic outcome.2

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Imaging

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In victims of blunt trauma receiving thoracic and/or lumbar spine radiographs, approximately 6% will have a fracture.3 Imaging is recommended in the setting of one of the following4–8:

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  • Back pain or midline back tenderness

  • Abnormal neurologic examination

  • Any other spine fracture

  • Glasgow Coma Scale <15

  • Major distracting injury9

  • Alcohol or drug intoxication

  • High-energy mechanism (fall >10 ft, high-speed motor vehicle collision [MVC])

  • Cervical spine fracture

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The imaging modality is controversial, but computed tomography (CT) scan is more sensitive than plain films for detecting fractures.7,10 Multidetector CT of the abdomen and chest with reconstructions of the spine is as accurate for detecting TL spine fractures as dedicated spinal CT.11 This technique also saves time and cost.12

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Patients that have a normal mental status, no signs of intoxication, a normal physical and neurologic exam, no suspicion for a high-energy mechanism, and no complaint of TL spine pain can be reliably excluded from a TL spine injury with no need for radiologic evaluation.7

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Classification

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Fractures of the TL spine are most common at the junction of the rigidly fixed thoracic spine and the flexible lumbar spine. Approximately 50% of all fractures of the TL region occur between T11 and L3.3 However, because the spinal canal is wider in this location than in the cervical spine, complete cord lesions are less common.

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Several classification schemes exist that attempt to predict both the bony and neurologic stability of the injury. In 2005, the Thoracolumbar Injury Classification and Severity Score (TLICS) was developed that used the fracture morphology (compression, rotational/translation, or distraction), patient's neurologic status, and the integrity of the posterior ligamentous complex, as seen on advanced imaging, to predict stability and the need for operative intervention.13,14

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The three-column classification system developed by Denis, divides the spinal column into three sections: anterior, middle, and posterior (Fig. 10–1). The anterior column consists of the anterior longitudinal ligament and the anterior half of the vertebral bodies and discs. The middle column is made up of the posterior longitudinal ligament and the posterior half of the vertebral bodies and discs. Finally, the posterior column consists of the supraspinous and interspinous ligaments and facet joints. Mechanical stability is present if two or three columns are intact. Although this scheme is simple to understand, ...

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