Thoracolumbar Junction Injuries Research Articles

The value of the posterior ligamentous complex in traumatic injury of thoracolumbar junction. Part 2. Diagnostic methods

The posterior ligamentous complex (PLC) of the spinal motion segment consists of the supraspinous, interspinous ligaments, ligamentum flavum, and facet joint capsules. The state of this functional combination of ligamentous structures is considered a critical predictor of stability in traumatically injured spine. Despite the practical importance of the PLC concept, it has mainly been used for theoretical evaluation of spinal stability models for a long time. Literature analysis reveals a lack of consensus regarding diagnostic criteria for PLC injuries and their clinical significance. The results of some studies are conflicting. This review attempts to organize information on diagnostic methods for assessing the status of different elements of the PLC in traumatic injuries of the thoracolumbar junction. Currently, there is no universally accepted criteria to help verify PLC injuries. Many signs have diagnostic value, which can be categorized as direct or indirect based on the visualization method. Direct signs are based on the analysis of images that characterize specific anatomical structures. Indirect signs allow for the assessment of the PLC considering the state and location of adjacent, primarily bony, structures. The review examines the diagnostic capabilities of visualization methods such as spondylography, spiral computed tomography, magnetic resonance imaging, and ultrasound with identification of their main advantages and disadvantages. It is found that the broader capabilities of magnetic resonance imaging in visualizing soft tissue structures do not significantly improve diagnostic quality. Spiral computed tomography remains the leading method, both for evaluating bone traumatic changes and determining indirect signs of PLC injury. The development and clinical verification of spiral computed tomography characteristics for assessing the status of the ligamentous apparatus are important tasks in improving the quality of care for patients with thoracolumbar junction injuries.

Pediatric Spinal Trauma at a Single Level 1 Trauma Center: Review of 62 Cases.

Traumatic spinal injuries in children are uncommon and result in different patterns of injuries due to the anatomical characteristics of children's spines. However, there are only a few epidemiological studies of traumatic spinal injury in children. The purpose of this study was to investigate the characteristics of traumatic spinal injury in children. We retrospectively reviewed the cases of pediatric patients (age < 18 years) with traumatic spinal injury who were treated at a level 1 trauma center between January 2017 and December 2021. We divided them into three groups according to age and analyzed demographics, injury mechanism, level of injury, and injury pattern. A total of 62 patients (255 fractures) were included, and the mean age was 13.8 ± 3.2 years. There were 5 patients (22 fractures) in group I (0-9 years), 24 patients (82 fractures) in group II (10-14 years), and 33 patients (151 fractures) in group III (15-17 years). Both the Injury Severity Score and the Revised Trauma Score were highest in group I, but there was no statistical difference between the age groups. Fall from height was the most common injury mechanism, of which 63% were suicide attempts. The level of spinal injury was different in each age group, T10-L2 injury being the most common. In all age groups, the number of multilevel continuous injury was larger than that of single-level injury or multilevel noncontinuous injury. Surgical intervention was required in 33.9%, and mortality was 3.2%. In our study, fall from height was the most common mechanism of injury, and there were many suicide attempts associated with mental health issues. Thoracolumbar junction injuries were predominant, and the rate of multilevel contiguous injuries was high. The support and interest of the society and families for adolescent children seem crucial in preventing spinal trauma, and image testing of the entire spine is essential when evaluating pediatric spinal injuries.

Outcomes of Transpedicular Screw Fixation with Unstable Thoracolumber Spine Injury

Objective: To evaluate the role of transpedicular screw fixation of thoracolumber spinal injury in terms of postoperative pain control and neurological recovery. Study Design: Quasi experimental trial. Place and Duration: Study was conducted in the department of orthopedic and spinal surgery in Nishter Hospital Multan. Study was completed in one year duration from August 2017 to August 2018. Methodology: Study was initiated after permission from hospital academic affairs committee and written informed consent was obtained from patients. Sixty patients presented at orthopedic outpatient department with history of one week of unstable thoraco lumbar spine injury. Main variables were age, duration of surgery, duration of injury, control of pain, CSF leakage, nerv rout damage and wound infection. Results: Statistically significant between preoperative and postoperative, after one moth and after three months with regards to Frankel classification of neurological injury. Similarly, the difference was statistically significant between preoperative and postoperative, after one moth and after three months with regards to Denis pain scale at follow-up. Conclusion: Thoracolumbar junction injuries are common in young adults and Transpedicular screw fixation is useful choice for good pain control and achieving better neurological recovery in traumatic thoracolumbar fractures.

Radiological outcome of operative treatment with posterior approach in patients with thoracolumbar junction traumatic injuries: A single-center pilot study in a developing country.

Background: The thoracolumbar junction (TLJ) represents a transition zone of the spine that leads to a high incidence of fractures. The treatment of burst fractures remains controversial regarding the ideal management. This study assessed the postoperative radiological outcome of TLJ fixation in patients with TLJ injuries who underwent surgery.Methods: All traumatic patients with TLJ injuries who were referred to the Khatam hospital of Zahedan between 2015 and 2020, with their thoracolumbar injury classification and severity score (TLICS) of four or more and who underwent surgery, were included in this study. The patients who entered the study were called for a follow-up examination. The degree of kyphosis, proximal junctional kyphosis, and fusion were assessed in these patients.Results: Among 273 patients, the average age was 43.5 ± 12.3 (21–73) years. One hundred and ninety-eight patients (72.5%) had no neurological symptoms at admission. Based on the above criteria, the kyphosis angle of these patients was calculated before surgery, which in 46 patients (16.8%), the kyphosis angle was more than 25°. Preoperation kyphosis was significantly associated with follow-up kyphosis (P < 0.001). Evidence of no fusion was also observed in 22 patients (8.1%). According to the Chi-square test, no association was observed between preoperative kyphosis and postoperative complications, including PJK and fusion (P > 0.05).Conclusion: According to our study, the posterior spinal fixation procedure is a low-complication method with an acceptable radiological outcome. Although kyphosis before surgery is a factor in developing long-term kyphosis, it is not associated with nonfusion and PJK.

Short Segment Posterior Instrumentation with Intermediate Screw in Thoracolumbar Junction Injury: Prospective Study

Short Segment Posterior Instrumentation with Intermediate Screw in Thoracolumbar Junction Injury: Prospective Study

Is focused magnetic resonance imaging adequate for treatment decision making in acute traumatic thoracic and lumbar spine fractures seen on whole spine computed tomography?

PURPOSETo assess whether a focused magnetic resonance imaging (MRI) limited to the region of known acute traumatic thoracic or lumbar fracture(s) would miss any clinically significant injuries that would change patient management. STUDY DESIGN/SETTINGA multicenter retrospective clinical study. PATIENT SAMPLEAdult patients with acute traumatic thoracic and/or lumbar spine fracture(s). OUTCOME MEASURESPathology identified on MRI (ligamentous disruption, epidural hematoma, and cord contusion), outside of the focused zone, an alteration in patient management, including surgical and nonsurgical, as a result of the identified pathology outside the focused zone. METHODSRecords were reviewed for all adult trauma patients who presented to the emergency department between 2008 and 2016 with one or more fracture(s) of the thoracic and/or lumbar spine identified on computed tomography (CT) and who underwent MRI of the entire thoracic and lumbar spine within 10 days. Exclusion criteria were patients with >4 fractured levels, pathologic fractures, isolated transverse, and/or spinous process fractures, prior vertebral augmentation, and prior thoracic or lumbar spine instrumentation. Patients with neurologic deficits or cervical spine fractures were also included. MRIs were reviewed independently by one spine surgeon and one musculoskeletal fellowship-trained emergency radiologist for posterior ligamentous complex (PLC) integrity, vertebral injury, epidural hematoma, and cord contusion. The surgeon also commented on the clinical significance of the pathology identified outside the focused zone. All cases in which pathology was identified outside of the focused zone (three levels above and below the fractures) were independently reviewed by a second spine surgeon to determine whether the pathology was clinically significant and would alter the treatment plan. RESULTSIn total, 126 patients with 216 fractures identified on CT were included, with a median age of 49 years. There were 81 males (64%). Sixty-two (49%) patients had isolated thoracolumbar junction injuries and 36 (29%) had injuries limited to a single fractured level. Forty-seven (37%) patients were managed operatively. PLC injury was identified by both readers in 36 (29%) patients with a percent agreement of 96% and κ coefficient of 0.91 (95% CI 0.87–0.95). Both readers independently agreed that there was no pathology identified on the complete thoracic and lumbar spine MRIs outside the focused zone in 107 (85%) patients. Injury outside the focused zone was identified by at least one reader in 19 (15%) patients. None of the readers identified PLC injury, cord edema, or noncontiguous epidural hematoma outside the focused zone. Percent agreement for outside pathology between the two readers was 92% with a κ coefficient of 0.60 (95% CI 0.48–0.72). The two spine surgeons independently agreed that none of the identified pathology outside of the focused zone altered management. CONCLUSIONSA focused MRI protocol of three levels above and below known thoracolumbar spine fractures would have missed radiological abnormality in 15% of patients. However, the pathology, such as vertebral body edema not appreciated on CT, was not clinically significant and did not alter patient care. Based on these findings, the investigators conclude that a focused protocol would decrease the imaging time while providing the information of the injured segment with minimal risk of missing any clinically significant injuries.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters

BACKGROUND CONTEXT Although there were many studies about the application of the TLICS classification to thoracolumbar spine injuries, large-scale studies of efficacy in treated patients were rarely investigated. PURPOSE This study aimed to assess the efficacy of TLICS classification in the selection of treatment methods for patients with thoracolumbar spine injury. METHODS From 2000 to 2016, we retrospectively studied 330 patients who were treated for thoracolumbar spine injuries. Clinical results and radiological data were studied and analyzed using ASIA scale, Magerl/AO classification and TLICS classification. RESULTS Among 330 patients, 139 patients (42.1%) received conservative treatment and 191 patients (57.9%) received surgical treatment. Of the 139 patients who underwent conservative treatment, 128 patients (92.1%) were consistent with the recommended treatment in TLICS. Of the patients who underwent conservative treatment, 10 patients (7.2%) failed conservative treatment and required surgical treatment. On the other hand, out of a total of 191 patients who underwent surgical treatment, 160 patients (83.8%) were consistent with the recommended treatment in TLICS. CONCLUSIONS The TLICS classification is highly effective in the conservative treatment of thoracolumbar junction injury. In addition, it has relatively good efficacy in surgical treatment

Retrospective Analysis of Thoracolumbar Junction Injuries Using the Thoracolumbar Injury Severity and Classification Score, American Spinal Injury Association Class, Injury Severity Score, Age, Sex, and Length of Hospitalization.

Retrospective review of patient cohort. Our goal was to assess the validity of the Thoracolumbar Injury Classification and Severity (TLICS) score system by comparing the TLICS system to prior management of thoracolumbar injuries at our institution between January 1, 2006 to March 31, 2011. TLICS was introduced in 2005 to classify and assign treatment recommendations for injuries based on 3 axes: mechanism of injury, integrity of the posterior ligamentous complex, and neurological status. We retrospectively obtained and analyzed patient data regarding thoracolumbar junction injuries at a major academic medical center servicing level I trauma. In addition, we compared the American Spinal Injury Association (ASIA) class at time of injury to last follow-up to determine if there was any change in neurological status after intervention. We also compared sex, injury severity score (ISS), length of hospitalization, and age between nonoperatively and operatively treated patients. Included in our study were 201 patients (70% male and 30% female). We found the TLICS system agreed with prior thoracolumbar junction injury management at our institution 98% of the time in nonoperatively treated patients and 78% of the time in operatively treated patients. Age, sex, and ISS were not statistically significant factors in patients who were treated operatively versus nonoperatively, however, there was a trend towards higher ISS in operatively treated patients. Average TLICS score between nonoperative and operative groups was 1.56 and 4.8, respectively, and was a statistically significant difference. There was no statistically significant difference in ASIA class improvement between operative and nonoperative treatment, however, this is likely because of having only 20 patients in this subcohort. Of note, about 50% of the 17 operatively treated patients had improvement in ASIA class. Our data suggest that TLICS is a valuable tool in a spine surgeon's armamentarium in treating thoracolumbar junction injuries. Some surgeons might be more likely to operate on thoracolumbar junction injuries that should be treated nonoperatively according to the TLICS score. As with all classification schemes, the TLICS system should be used in conjunction with sound clinical judgment.

A Demographic Study of Thoracolumbar Junction Fracture in a Developing Country and its Social Impact

Introduction: Spinal cord injury due to traumatic accidents is a major cause of disability throughout the world. Among the spinal injury patients more than 30% suffered from Thoracolumbar Spine (TLS) injury with great preponderance to Thoracolumbar Junction (T10-L2) injury. Delay or inappropriate management of these patients leads to a great socio-economical impact on the society. Methods and materials: This was a prospective study on 38 patients who were admitted in the Neurosurgery Department at Dhaka Medical College and Hospital (DMCH) in the period of January 2010 to December 2011 with thoracolumbar junction injuries and were analyzed regarding demographic patterns after getting approval of the Ethical Committee of Bangladesh College of Physician and Surgeons (BCPS) and DMCH. Patients with single level Thoracolumbar Junction Injury (D10-L2) and who had TLICS score ≥ 4 were included in this study. Patients with TLICS score ≤ 3, multiple level thoracolumbar junction injury, associated other injuries like head injury, abdominal injury, long bone fractures and any pathological thoracolumbar fractures were excluded. Result: There were 36 males and 2 females with average age of 29.42 ± 8.11 years (range 17-50 years). Fall from height was the commonest (79%) cause of injury. Most of the patients were farmers and came from lower income class. Most of the patients 29(76.3%) were illiterate. The mean time interval from injury to admission was found to be 8.97 ± 10.11 days (2 to 60 days). Conclusion: In this study large number of patients was in their active period of life. Due to lack of awareness in their working place, proper counseling and appropriate management of these patients eventually become burden to their family and society. This burden can be minimized with good governance regarding safety measurement in working place and raising awareness among people in their active lives.

Thoracolumbar junction injuries after rollover crashes: difference between belted and unbelted front seat occupants

Motor vehicle collision (MVC) is one of the most common causes of thoracolumbar junction (TLJ) injury. Although it is of no doubt that the use of seatbelt reduces the incidence and severity of MVC-induced TLJ injury, how it is protective for front-seat occupants of an automobile after rollover crashes is unclear. Among 200 consecutive patients with a major TLJ (Th11-L2) injury due to high-energy trauma admitted from 2000 to 2004, 22 patients were identified as front-seat occupants of a four-wheel vehicle when a rollover crash occurred. The 22 patients were divided into two groups: 10 who were belted, and 12 who were unbelted. Patients' demographics including the mean Injury Severity Score (ISS), incidence of neurologic deficit, level of TLJ injury, and type of TLJ injury according to the AO fracture classification were compared between the two groups. Neurologic deficit was present exclusively in the unbelted group, and the difference in the incidence was statistically significant (P = 0.04). Similarly, AO type B/C injury was present exclusively in the unbelted group. The belted group had a significantly lower mean ISS than the unbelted group (P < 0.01). Comparison between the ejected and non-ejected victims within the unbelted group revealed no statistical difference in the incidence of neurologic deficit or type of injury. It is likely that the high incidence of neurologic deficit in the unbelted group was due to the high incidence of AO type B/C injury. This study indirectly proves the efficacy of seatbelt in reducing the severity of rollover-induced TLJ injury. Because of the limited number of cases, it is uncertain whether ejection from vehicle, which occurs exclusively in the unbelted victims, is a crucial factor in determining the severity or type of injury after rollover crashes.

Posterior Instrumentation Surgery for Thoracolumbar Junction Injury Causing Neurologic Deficit

Thoracolumbar junction (TLJ) injury is one of the most common spine injuries. TLJ injury manifesting as neurologic deficit usually requires surgery because of the underlying spinal instability and/or neural compression. The objectives of surgical treatment are to restore biomechanical stability of the spine and/or to achieve neural decompression. The short-term outcomes were evaluated of 32 patients with symptomatic TLJ (T11-L2) injury who underwent posterior instrumentation surgery in the acute stage between 2000 and 2004. Seventeen patients had unstable burst fracture and 15 patients had either flexion-distraction or fracture-dislocation injury of the TLJ. Fifteen patients had American Spinal Injury Association (ASIA) classification Grade-A, eight had Grade-B, seven had Grade-C, and two had Grade-D preoperative neurologic deficits. All patients underwent posterior instrumentation surgery using pedicle screws and connecting rods, fixed to two vertebral levels above and below the injured segment. No patient experienced neurologic deterioration perioperatively. Postoperative recovery evaluated 3 months after discharge heavily depended on the preoperative neurologic status: patients with ASIA Grade-A deficits usually had limited neurologic recovery, whereas some with Grade-C or D became ambulatory. Complications occurred in five patients, but none suffered death or permanent morbidity. Posterior instrumentation surgery is a safe and efficacious treatment for patients with symptomatic TLJ injury. Long-term efficacy of the posterior instrumentation surgery is less clear, because of the limited duration of the follow-up period.

Outcomes of polysegmental ventral system application for thoracolumbar junction injuries

Clinical cases of surgical treatment of patients with thoracolumbar junction injuries are presented. Unstable injuries at this level are proposed to be treated with polysegmental vebtral systems.

Thoracolumbar junction injuries after motor vehicle collision: are there differences in restrained and nonrestrained front seat occupants?

Motor vehicle collision (MVC) is one of the most common causes of thoracolumbar junction (TLJ) injury. Although there is little doubt that the use of seat belts reduces the incidence and severity of TLJ injury after MVC, the mechanism by which this is protective against TLJ injury for drivers and passengers is relatively unknown. Thirty-nine patients with TLJ (T11-L2) injury who were front seat occupants of a four-wheeled vehicle at the time of MVC (frontal crash) were admitted between 2000 and 2004. The 39 patients were divided into two groups: 18 who had been restrained and 21 who had not been restrained at the time of the MVC. Patient demographics, including the mean Injury Severity Scale score, incidence of neurological deficit, level of TLJ injury, and type of TLJ injury according to the Denis classification were compared. The incidence of neurological deficit in the restrained group was significantly lower compared with the nonrestrained group (5.6% compared with 33.3%, p < 0.05). The incidence of flexion-distraction/fracture-dislocation injuries in the restrained group was also significantly lower (0.0% compared with 33.3% in the nonrestrained group, p < 0.01). The restrained group was significantly older (37.4 +/- 3.6 years compared with 28.0 +/- 2.5 years in the nonrestrained group, p < 0.05), but otherwise there were no significant differences between the two groups regarding the patients' demographic data. It is likely that the high incidence of neurological deficit in the nonrestrained front seat motor vehicle occupants who had a TLJ injury was mostly due to the high incidence of flexion-distraction/fracture-dislocation injuries. This retrospective study indirectly shows the efficacy of three-point seat belt systems in reducing the severity of a TLJ injury after an MVC. Compression/burst fractures still occur in restrained front seat occupants, however, and elucidation of the injury mechanism of such axial loading fractures may be important to improve safety further for automobile occupants.

Deterioration following spinal cord injury. A multicenter study.

The results are presented of a prospective study of the course of 283 spinal cord-injured patients who were consecutively admitted to five trauma centers participating in the Comprehensive Central Nervous System Injury Centers' program of the National Institutes of Health. Of the 283 patients, 14 deteriorated neurologically during acute hospital management. In 12 of the 14, the decline in neurological function could be associated with a specific management event, and in nine of these 12 the injury involved the cervical cord. Nine of the 14 patients who deteriorated had cervical injuries, three had thoracic cord injuries, and two had thoracolumbar junction injuries. Management intervention was identified as the cause of deterioration in four of 134 patients undergoing operative intervention, in three of 60 with skeletal traction application, in two of 68 with halo vest application, in two of 56 undergoing Stryker frame rotation, and in one of 57 undergoing rotobed rotation. Early surgery on the cervical spine when cord injury is present appears hazardous, since each of the three patients with a cervical cord injury who deteriorated was operated on within the first 5 days. No such deterioration was observed following surgery performed from the 6th day on. In two other patients, deterioration did not appear to be related to management but was a direct product of the underlying disease or of systemic complications. Deterioration following hospitalization for spinal cord injury is relatively uncommon--4.9% in this large series. In most instances, decline in function could be attributed to specific management procedures. These changes must not be interpreted as representing failure to provide optimal care but rather should be seen as the inevitable product of an attempt to manage patients with spinal cord and column injuries, many of which are clearly unstable.

Lumbo-sacral spinal cord injuries.

Thirty-three cases of spinal cord complications in thoraco-lumbar junction injuries were studied, classified in four groups according to the gravity of the lesion and the clinical and electromyographic neurological signs. An original system of graphic representation was used. The spinal lesion was probably secondary to the interruption of arterial vascularisation in the lumbo-sacral spinal cord in two groups and symptomatic of previous contusions in the others. Finally some correlations were established between types of spinal lesions and functional vesico-recto-sphincter and sexual repercussions.