Posterior Ligamentous Complex Injuries of the Thoracolumbar Spine: Importance and Surgical Implications.

Aren Joe Bizdikian,Rami El Rachkidi

doi:10.7759/cureus.18774

Abstract

The soft tissues surrounding the spine play a primordial role in its stability, the most important of which are located posteriorly and are deemed the posterior ligamentous complex (PLC). Injuries to the PLC in the setting of thoracolumbar trauma are often dreaded and little attention has been given to them in the management protocols of thoracolumbar trauma. This review aims to summarize and contextualize current concepts in PLC injuries of the thoracolumbar spine with the aim to provide a clear guide for clinical management.Injuries to the PLC may be suspected on the clinical exam but are often missed, leading to serious complications, including instability and neurological compromise. The diagnosis is often made indirectly by spinal radiographs and CT-scanning or by direct visualization of soft tissues via magnetic resonance imaging. The latter remains the standard imaging modality and is mandatory for patients with a high suspicion of PLC injury. PLC injuries are associated with vertebral fractures and follow a progressive pattern of severity, depending on the mechanism of injury and extent of trauma. Surgical management is warranted, as PLC damage renders the spine unstable. Although fusion was once the standard of care and remains applicable for certain patients, recent endeavors of temporary spinal fixation without fusion are increasingly gaining traction in patients with PLC injuries.In conclusion, PLC injuries are challenging as they are often missed, poorly understood, and are not easily managed. Proper diagnosis and management are crucial to avoid long-standing complications such as spinal instability. Considering the paucity of available data on such an important topic in thoracolumbar trauma, this review article aims to contextualize current concepts in PLC injuries in order to demystify this sparsely covered subject.

Highlights

BackgroundThe spine serves many roles, including locomotion and the protection of the spinal cord, functions that would not be possible without stability, a feature enabled by the vertebrae themselves, surrounding ligaments, intervertebral discs, and facet joints [1]
While much importance has been attributed to thoracolumbar fractures, data found on posterior ligamentous complex (PLC) injuries pales in comparison
Many classification systems have been proposed for thoracolumbar trauma, PLC injuries have been superficially and sporadically addressed, and most studies lack granularity on the severity of this injury [4,5,6,7,8]

Summary

Introduction

The spine serves many roles, including locomotion and the protection of the spinal cord, functions that would not be possible without stability, a feature enabled by the vertebrae themselves, surrounding ligaments, intervertebral discs, and facet joints [1]. A recent study showed that, after reducing the gap in PLC injuries of the cervical spine, ligamentous healing may be achieved in most patients without the need for spinal fusion [45]. One study by Kim et al [66] on subjects with flexion/distraction fractures with PLC injury showed favorable results for instrumentation without fusion, with little loss in vertebral height or progressive kyphosis. There is increasing evidence that thoracolumbar injuries with a ruptured PLC may be effectively treated by temporary spinal fixation without fusion, with little to no progressive kyphosis or sagittal imbalance being reported up to 10 years after hardware removal (Figures 8a, 8b) [38,46,53,66,74]. A CT scan of the fractured segment should be obtained prior to removal in order to assess bony healing [46]

Conclusions

Disclosures

Panjabi MM

Findings

13. Bogduk N