Thoracolumbar fractures

Most fractures occur at the thoracolumbar junction (T11–L2), where the stiff thorax meets the mobile lumbar spine. The key questions are whether the posterior wall is broken (burst, canal compromise), whether the posterior tension band is torn, and whether there is a neurological deficit.

Mechanism

Axial load with flexion (falls, road traffic); low-energy osteoporotic compression in the elderly.

Clinical findings

• Spinal precautions; full neurological examination (ASIA); palpate for a step or gap between spinous processes.
• Calcaneal fractures and a second spinal fracture are common with falls from height.

Imaging

• AP and lateral of the thoracolumbar spine (or CT directly in high-energy trauma: whole spine).
• CT for every fracture with suspected posterior wall involvement (burst): canal compromise, posterior elements.
• MRI if there is a neurological deficit or doubt about the posterior ligamentous complex (TLICS/AO "M1").
• Image the whole spine: non-contiguous fractures in about 10%.

• X-rays, then CT for any suspected fracture; MRI for neurological deficit, suspected posterior ligamentous injury, or to date osteoporotic fractures (oedema on STIR).

Classification

A0–A4

Compression injuries: A1 wedge (one endplate), A2 split, A3 incomplete burst (one endplate + posterior wall), A4 complete burst (both endplates).

B1–B3

Tension band failure: B1 bony Chance, B2 posterior ligamentous disruption, B3 hyperextension.

C

Translation or dislocation in any direction.

Modifiers

N0–N4 neurology, M1 posterior ligaments indeterminate, M2 comorbidity.

Types shown in 3D

A1 wedge

Compression of one endplate without involvement of the posterior wall. Stable: brace or nothing, early mobilisation.

A3 incomplete burst

One endplate and the posterior wall are broken; a fragment can be pushed back into the canal (retropulsion). Neurologically intact: often non-operative.

A4 complete burst

Both endplates and the posterior wall: more loss of height and more canal compromise. Operate if there is a deficit or major kyphosis.

B2 tension band

Posterior ligamentous complex torn in flexion–distraction: the spinous processes splay apart. Unstable: posterior instrumentation.

C translation

Displacement of the spine in any plane: all three columns are disrupted, usually with cord injury. Reduce and instrument.

Treatment

Non-operative

A0–A3 neurologically intact and stable: analgesia, early mobilisation with or without a brace; standing X-ray to check for progressive kyphosis.

Operative

Neurological deficit with canal compromise, B and C injuries, A4 with significant kyphosis: posterior pedicle-screw instrumentation, with decompression or anterior reconstruction as needed. Painful osteoporotic fractures not settling: consider vertebroplasty/kyphoplasty in selected cases.

Aftercare

Osteoporosis treatment after fragility fractures.

Complications

• Progressive kyphosis
• Neurological deterioration
• Adjacent fractures (osteoporosis)