Thoracolumbar Spine - Fracture

THORACOLUMBAR SPINE

Fractures of the thoracolumbar spine may involve (1) the vertebral body, (2) the laminae and articulating processes, and (3) the spinous processes or transverse processes. The T12 to L2 area of the spine is most vulnerable to fracture. Fractures generally result from indirect trauma caused by excessive loading, sudden mus-cle contraction, or excessive motion beyond physiologic limits. Osteoporosis contributes to vertebral body collapse (compression fracture).

Stable spinal fractures are caused by flexion, extension, lateral bending, or vertical loading. The anterior structural column (ver-tebral bodies and disks) or the posterior structural column (neural arch, articular processes, ligaments) has been disrupted. Unstable fractures occur with fracture-dislocations and exhibit disruption of both anterior and posterior structural columns. The potential for neural damage exists.

The patient with a spinal fracture presents with acute tender-ness, swelling, paravertebral muscle spasm, and change in the normal curves or in the gap between spinous processes. Pain is greater with moving, coughing, or weight bearing. Immobiliza-tion is essential until initial assessments have determined whether there is any spinal cord injury and whether the fracture is stable or unstable. Few spinal fractures are associated with neurologic deficits. If spinal cord injury with neurologic deficit does occur, it usually requires immediate surgery (laminectomy with spinal fusion) to decompress the spinal cord.

Medical Management

Stable spinal fractures are treated conservatively with limited bed rest. The head of the bed is elevated less than 30 degrees until the acute pain subsides (several days). Analgesics are prescribed for pain relief. The patient is monitored for a transient paralytic ileus caused by associated retroperitoneal hemorrhage. Sitting is avoided until the pain subsides. A spinal brace or plastic thoracolumbar orthosis may be applied for support during progressive ambulation and resumption of activities.

The patient with an unstable fracture is treated with bed rest, possibly with the use of a special turning device (eg, Stryker frame) to maintain spinal alignment. Neurologic status is monitored closely during the preoperative and postoperative periods. Within 24 hours after fracture, open reduction, decompression, and fixation with spinal fusion and instrument stabilization are usually accomplished. Postoperatively, the patient may be cared for on the turning device or in a bed with a firm mattress. Progressive ambulation is begun a few days after surgery, with the patient using a body brace orthosis. Patient teaching emphasizes good posture, good body mechanics, and, after healing is sufficient, back-strengthening exercises.