Thoracolumbar Spine Injuries

What is a thoracolumbar spine injury?

This refers to trauma at the junction between the thoracic and lumbar spine, which may involve only the bones and ligaments or may be accompanied by injury to the spinal cord or cauda equina.

The thoracolumbar junction (T10–L2) is a transitional, biomechanically vulnerable zone: above lies the relatively rigid thoracic spine (reinforced by the rib cage), and below the more mobile lumbar region. High-energy deceleration, falls, or rotational forces may result in:

• compression or burst fractures,
• fracture–dislocations with vertebral translation,
• ligamentous disruption (posterior ligamentous complex),
• compression or transection of the spinal cord or nerve roots (cauda equina).

Severity ranges from isolated mechanical pain to complete paraplegia. Timely and appropriate management is critical to outcome.

How common is it & what are the main causes?

Spinal injuries overall are relatively uncommon, but when they occur they often represent life-threatening emergencies.

In most series, the principal causes include:

• Road traffic accidents (car, motorcycle, bicycle, pedestrian).
• Falls from height, stairs, ladders, or elevators.
• High-energy trauma (crush injuries, heavy object impact, interpersonal violence).
• Sports injuries (diving into shallow water, extreme sports, skiing).

Predisposing factors such as osteoporosis, spinal deformity, ankylosing spondylitis render the spine even more vulnerable and often result in atypical and unstable fracture patterns.

Why is the T10–L2 region so vulnerable?

The biomechanics of the thoracolumbar junction explain why it is so frequently and severely injured.

Key anatomical and mechanical features:

• Transitional zone – from rigid thoracic spine (stabilized by ribs) to the highly mobile lumbar region.
• Facet joint orientation – thoracic facets limit flexion–extension, whereas lumbar facets permit greater motion, creating stress at the junction.
• Posterior ligamentous complex (facet capsules, interspinous ligaments, ligamentum flavum) – serves as the principal restraint to flexion; disruption results in instability.
• The artery of Adamkiewicz often arises between T10–T12 (typically on the left), increasing the clinical significance of injuries in this region.

The combination of high-energy forces and the intrinsic biomechanical vulnerability of this transitional zone explains why injuries here are both frequent and potentially severe.

What symptoms may occur?

Clinical presentation depends on whether the injury is limited to osseous–ligamentous structures or involves the spinal cord/nerve roots.

Typical symptoms include:

• Severe pain in the lower thoracic or lumbar region following trauma.
• Localized tenderness along the spine, muscle spasm.
• Numbness or weakness in the legs (neurological deficit) – suggestive of spinal cord or nerve root injury.
• Difficulty moving or inability to stand/walk.
• Bladder or bowel dysfunction (urinary retention, incontinence) – an alarming sign of spinal cord injury or cauda equina syndrome.

In complete injuries, patients may present with paraplegia (total loss of motor and sensory function in the lower extremities), whereas incomplete injuries preserve some degree of function.

How is initial emergency management performed (ATLS, ASIA)?

Appropriate management begins at the scene and continues in the emergency department using a structured trauma protocol.

General principles (ATLS):

• Stabilization of vital functions (Airway, Breathing, Circulation).
• Spinal immobilization (collar, spinal board, log-roll for examination).
• Comprehensive neurological examination using the ASIA scale (American Spinal Injury Association), documenting injury level and severity (complete/incomplete).
• Prompt imaging evaluation (CT, MRI when indicated).

Early stabilization is essential: even minor movement in an unstable fracture can exacerbate spinal cord injury.

How is the diagnosis made – X-rays, CT, MRI?

Diagnosis is based on a combination of clinical assessment and advanced imaging, with computed tomography (CT) and magnetic resonance imaging (MRI) as primary tools.

Imaging modalities:

• Plain radiographs – may provide an initial overview (vertebral height, angulation, alignment), but have limited sensitivity.
• Computed tomography (CT) – the modality of choice for osseous injury: fractures, degree of comminution, involvement of posterior elements.
• Magnetic resonance imaging (MRI) – evaluates the spinal cord, intervertebral discs, ligaments, and detects hematomas or compression. STIR sequences help determine whether a lesion is acute and whether the posterior ligamentous complex is disrupted.

MRI is particularly important in patients with neurological deficits, to clarify the need for and type of decompression.

What does “stable” vs “unstable” fracture mean? (Denis, AO, TLICS in simple terms)

The concept of stability is central to management, determining whether non-operative treatment is sufficient or whether surgical stabilization is required.

In simple terms:

• Stable fracture: although bone injury is present, the spine remains mechanically stable overall – there is no tendency for further displacement or spinal cord compression during routine activities.
• Unstable fracture: posterior ligamentous disruption or significant translation/rotational deformity is present – the spine is at risk of further displacement with movement, potentially worsening neurological injury.

Classification systems used in practice:

• AO classification – Type A (compression), B (distraction/flexion), C (rotational/translation injuries).
• TLICS (Thoracolumbar Injury Classification and Severity Score) – incorporates:
  • fracture morphology,
  • integrity of the posterior ligamentous complex,
  • neurological status (ASIA).
  A total score > 4 generally indicates surgical management.

These systems allow for a structured, evidence-based decision-making process and a common language among specialists.

When is bracing sufficient and when is surgery required?

Not all patients require surgery. The decision depends on stability, neurological status, and the patient’s overall condition.

Conservative management (non-operative)

Typically recommended when:

• the fracture is compressive or low-grade burst type,
• the posterior ligamentous complex is intact,
• there is no or only mild radicular symptomatology, without significant neurological deficit,
• spinal alignment is acceptable (minimal kyphosis).

Management includes:

• Bracing (thoracolumbar orthosis, TLSO) for support and motion restriction.
• Early but cautious mobilization – avoiding prolonged bed rest.
• Analgesic therapy & physiotherapy.
• Close radiological follow-up to monitor for progressive kyphosis or instability.

Surgical management

Indicated when one or more of the following are present:

• Unstable fracture (posterior ligamentous rupture, significant displacement, flexion-distraction injury).
• Neurological deficit due to spinal cord or nerve root compression.
• Severe kyphosis or vertebral height loss with risk of progressive deformity.
• Failure of conservative treatment (intractable pain, radiographic progression).

The goal of surgery is neural decompression (when required) and instrumented fusion to stabilize and restore alignment.

What surgical options exist (posterior, anterior, 360°)?

The thoracolumbar region can be approached posteriorly, anteriorly, or with a combined strategy, depending on fracture type and neurological involvement.

Posterior approach

• Most common technique: pedicle screw fixation above and below the fracture with rods (spinal fusion).
• Often combined with posterior decompression (laminectomy, removal of compressive posterior elements).
• In many cases, minimally invasive (MIS) placement of screws and rods is feasible.

Anterior or thoracoabdominal/lumbar approach

• Primarily used when neural compression is predominantly anterior (e.g., burst fracture with retropulsion).
• Allows vertebral body removal (corpectomy) and placement of a cage and plate.
• Access via thoracotomy (T6–T12), thoracoabdominal, or retroperitoneal approach for L1–L5.

Combined (360°) approach

In highly unstable injuries with marked deformity and neurological compromise, a combined anterior and posterior fusion may be required, in one or two stages, to achieve maximal stability and decompression.

Technique selection is individualized based on fracture morphology, overall condition, associated injuries (polytrauma), patient age, and functional prognosis.

What follows – rehabilitation & daily life?

Surgery or conservative stabilization is only the beginning. Neurorehabilitation is equally important to the operative intervention itself.

Rehabilitation typically includes:

• Early mobilization (as stability permits): sitting, assisted ambulation, avoidance of prolonged bed rest.
• Physiotherapy – core and lower limb strengthening, postural training, occupational therapy.
• For patients with neurological impairment: specialized rehabilitation centers (seating systems, gait aids, transfer training, bladder/bowel programs).
• Psychological support – spinal cord injury represents a major life event for the patient.

Many patients, particularly those without complete neurological injury, can return to a high level of function and independence with appropriate treatment and rehabilitation.

What are potential complications & what is post-traumatic syringomyelia?

Even with optimal management, severe spinal injuries may be associated with short- and long-term complications.

Possible complications:

• Progressive kyphosis and deformity if adequate stability is not achieved.
• Chronic mechanical pain in the thoracic or lumbar spine.
• Spasticity, neuropathic pain, dysesthesias.
• Bladder and bowel dysfunction (particularly in high or complete lesions).
• Pressure ulcers, infections, thrombosis – especially in patients with significant motor impairment.

Post-traumatic syringomyelia

In some patients, months or years after injury, a CSF-filled cavity (syrinx) may develop within the spinal cord, gradually enlarging and compressing adjacent tissue.

Symptoms suggestive of syringomyelia include:

• new or progressive weakness or numbness above the original level of injury,
• changes in pain distribution,
• new spasticity or deterioration in gait.

Therefore, long-term follow-up is essential in patients with severe spinal cord injury, with MRI reassessment if clinical status changes.