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Treatment Options for Thoracolumbar Spine Fractures

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Treatment Options for Thoracolumbar Spine Fractures Treatment Options for Thoracolumbar Spine Fractures &Eldin E. Karaiković¹*, Hector O. Pacheco² . Assistant Professor, Northwestern University, and Director of the Spine Center and Lead Physician, Orthopaedic Surgery, Evanston Northwestern Healthcare, Chicago, Illinois, U.S.A. Assistant Professor, Chief of Spine Surgery, Department of Orthopaedics and Rehabilitation, Texas Tech University, El Paso, Texas. * Corresponding author: Eldin E. Karaiković, MD, PhD, ENHMG Orthopedic Surgery, Central Street, Suite , Evanston, IL , U.S.A., or [email protected] Abstract A decision for operative versus nonoperative management of thoracolumbar fractures should NEV- ER be based solely on one factor. Only after a thorough physical, neurological, and spinal examina- tion, and an assessment of a patient’s prior activity, social and educational background and patient’s expectations, one should review the patient’s radiographs and CT scans to determine risks and benefi ts of operative versus nonoperative care. Both treatment options are discussed in this paper. As a surgical option our preference is short-segment instrumentation and fusion. Careful and ap- propriate patient selection and an excellent operative technique insure the minimum complications. KEY WORDS: thoracolumbar spine fractures, load-sharing classifi cation, short segment fusion BOSNIAN JOURNAL OF BASIC MEDICAL SCIENCES 2005; 5 (2): 20-26 ELDIN E. KARAIKOVIĆ, HECTOR O. PACHECO: TREATMENT OPTIONS FOR THORACOLUMBAR SPINE FRACTURES Th ere are three fundamental questions that every spine mobilized as soon as a brace is applied, an indication surgeon must answer when treating a patient with for surgical stabilization should be strongly considered. a spine fracture. First, should the fracture be treated operatively or nonoperatively. Second, if an opera- BRACING tive treatment is recommended, how many spinal seg- It is accepted that compression fractures with up ments should be instrumented and/or fused (short vs. to degree of kyphosis can be successfully treated long segment fusion). Lastly, which surgical approach with bracing. Some fracture types as a fl exion-distrac- should be undertaken: anterior, posterior or combined. tion fractures with bony involvement (“bony seat belt fractures, bony Chance fracture”) can be successfully Fracture anatomy should never be used as a single treated with bracing. Flexion-distraction injuries of the criterion to determine fracture treatment because if thoracolumbar spine with complete disruption of the there is no neurological deficit, any fracture can be ligamentous structures and, no or minimal bony in- treated either operatively or nonoperatively. The ma- volvement (“soft seat belt injuries, soft tissue Chance jority of the spine fractures, especially in the thoracic fractures”) are not suitable for bracing and should be spine can be successfully treated nonsurgically with stabilized surgically. A minority of authors has made bracing or adequate length of the bed rest. Patient the attempts to popularize bracing for certain types of selection is fundamental for nonoperative manage- burst fractures but that has not been widely accepted. ment. Besides anatomical characteristics of a fracture For the majority of the thoracolumbar fractures use of other factors critical for fracture management in- a high profi le thoracolumbar orthosis (TLSO) is recom- clude patient’s age, general health, expectations, and mended. High profi le TLSO’s extend from the sternum compliance. An overactive, debilitated, demented to the pubis. Th ese orthoses are made of fi berglass of dif- or noncompliant patient who is unwilling or unable ferent thicknesses that successfully restrict most of the to follow treatment instructions is particularly at risk. motion in the thoracolumbar spine. TLSO’s are made as a “clam shell” with anterior and posterior parts inter- NON-OPERATIVE TREATMENT connecting together and secured with Velcro fastening straps. Th is orthosis design feature allows easy removal The treatment for the majority of the thoracolumbar for hygiene and skin care. Low profi le TLSO’s extend fractures is non-operative. Non-operative treatment from the xyphoid to pubis and are mostly used for post- options are no bracing, bracing with early ambulation, operative bracing of the lower lumbar spine, and very bracing with delayed ambulation or defi ned period of rarely for non-operative treatment of lower lumbar frac- bed rest with bracing. tures. If a fracture is localized in the upper thoracic spine or cervicothoracic junction a TLSO brace with cervi- BED REST cal extension (CTLSO) is recommended. Th e CTLSO Treatment with bed rest is not a preferable choice any brace prevents most of the fl exion, extension and lateral more. Prolonged bed rest even for a few days increases bending. Jewett braces can be used in the treatment of a risk of deep venous thrombosis (DVT), pulmonary the thoracolumbar fractures but their weight due to met- complications and pressure decubiti formation. If for al bars, often exceeds the weight of TLSO and for this any reason patients with spine fractures should be reason have fallen out of favor for fracture management. on a prolonged bed rest a chemical and/or mechani- cal DVT prophylaxis with aggressive pulmonary toilet CASTING should be initiated. Patients with spinal cord injuries Body casting with either plaster of Paris or fi berglass is treated with or without surgical stabilization are espe- not used any more due to a patient’s inability to eff ec- cially prone to these complications. Careful daily skin tively perform skin care and hygiene. Casts are heavier inspection especially around bony prominences and and their fi t and eff ectiveness depends on the skill of the skin care with washing, massage, powdering and ap- person applying them. Soft lumbosacral corsets are used plication of lotions are essential. Because of the above in treatment of osteoporotic fractures in elderly patients mentioned complications related to prolonged re- whose diminished physical strength reduces their abil- cumbency, bed rest is no longer considered as an ac- ity to carry a somewhat heavy TLSO. Th ey are usually cepted initial treatment method. If a fracture can not used in conjunction with a walker in order to decrease be maintained stable enough in a brace and patient axial load of the upper body on the broken vertebra. BOSNIAN JOURNAL OF BASIC MEDICAL SCIENCES 2005; 5 (2): 20-26 ELDIN E. KARAIKOVIĆ, HECTOR O. PACHECO: TREATMENT OPTIONS FOR THORACOLUMBAR SPINE FRACTURES Surgical Treatment of predict with great accuracy, the occurrence of a post- Thoracolumbar Fractures operative pedicle screw fracture for spine fractures PATIENT SELECTION treated with short segment instrumentation and fu- Once the decision for surgical treatment is made a sion. The Load-Sharing Classification of spinal frac- surgeon has to answer two questions: ) how many tures is generated by the review of preoperative plain spinal segments should one instrument and perform radiographs, and sagittal and axial CT scans, which either short or long segment fusion, and ) which sur- provide data regarding three separate characteristics gical approach should one use either anterior, poste- of the fracture site. These are: comminution, apposi- rior or combined. Details regarding the patient’s age, tion of fragments and deformity correction (Figure ). general health, compliance, future endeavors, and the All three factors used in our system quantify the comminu- surgeon’s expertise in a particular system are essential tion of the vertebral body that occurred during the injury. component to treatment decision-making. For exam- Each of these factors is subdivided into three de- ple, a young active patient with no medical problems grees of severity and graded by awarding point whose life expectancy is long should be considered dif- for mild, points for moderate, and points for ferently that a patient in elderly with multiple medical most severe. Every fracture regardless of the mech- problems and sedentary lifestyle. Anterior approach anism can be graded from a minimum total of through thoracotomy or laparotomy might not be three points to a maximum total of nine points. suitable if not being dangerous for a patient with pul- The Load-Sharing Classification by itself does not monary or other medical complications, and a surgical recommend a decision for operative or nonopera- treatment should be tailored to the patient condition. tive treatment of a specific spine fracture. However, If a surgical treatment is chosen, in order to optimize it does help the surgeon to understand the qual- a satisfactory surgical outcome a surgeon should un- ity of load-sharing transferred across the fracture derstand the mechanical properties of any given im- site and the spinal implant after surgical fixation. plant and determine a patient’s willingness and abil- ity to comply with treatment recommendations. At Translational displacement the same time, the patient should understand basic Translational displacement represents lateral or ante- principles of the spinal fi xation system used and con- rior-posterior disruption of the sagittal, coronal or axial comitantly take the responsibility for his/her recov- spinal column alignment. It indicates serious multiple ery. Th e patient should be aware that noncompliance spinal ligament disruption, which we use to define a with postoperative instruction could lead to failure fracture-dislocation. It ranges from subtle to severe. of the device and possible need for surgical
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