Thoracolumbar spine trauma usually occurs as a result of high-energy trauma (e.g., road traffic accidents, falls from heights).
May occur spontaneously in patients with osteoporotic, neoplastic, or metabolic disorders of the spine.
Initial on-the-scene evaluation involves performing a primary survey with ABC assessment with spinal motion restriction and hemorrhage control.
It is important to evaluate and assess thoracolumbar fractures for instability.
If surgical intervention is indicated, early surgery is recommended.
Thoracolumbar fractures are breakages in the vertebrae of the spinal column in the thoracic and lumbar regions. They may be associated with disruption of the ligamentous complexes, and can result in instability or compression of neural structures. Thoracolumbar fractures are the usual outcome of thoracolumbar trauma. Other outcomes include traumatic disk prolapse, ligamentous injury, and epidural hematoma causing pressure on the spinal cord or nerve roots; these occur very rarely without a fracture. This topic focuses on thoracolumbar spine fracture.
History and exam
Key diagnostic factors
- history of mechanical trauma
- past medical history of osteoporosis or neoplasm
- back pain
- acute numbness/paresthesia
- muscle spasticity/clonus (hypertonicity) or hypotonia
- hyperreflexia or hyporeflexia
- Hoffman sign
- positive Babinski sign
- spinal deformity
- loss of anal sphincter reflex
Other diagnostic factors
- absence of bulbocavernosus reflex (S3-S4)
- signs of spinal shock (hypotonia or flaccidity that resolves within 24 hours)
- urinary incontinence
- painless urinary retention
- falling from a height
- high-energy mechanism of injury
- age >65 years
- concomitant osteoporosis
- previous vertebral fracture
- underlying neoplastic lesion
- underlying metabolic or inflammatory disorders
- male sex
1st investigations to order
- Noncontrast multidetector CT spine (MDCT)
Investigations to consider
- thoracolumbar spine x-ray (anterior-posterior and lateral views)
- MRI spine
- CT myelography
- MRI with STIR sequence
- Whole body CT
at the scene: potential vertebral column injuries
Besnik Nurboja, BSc, MBBS, MD (Res), MRCS, FRCEM
Consultant in Emergency Medicine
Epsom and St Helier University Hospital NHS Trust
BN declares that he has no competing interests.
David Choi, FRCS(SN)
Consultant Neurosurgeon and Spinal Surgeon
The National Hospital for Neurology and Neurosurgery
DC declares that he has no competing interests.
Nils Ake Nystrom, MD, PhD
Department of Orthopedic Surgery and Rehabilitation
Division of Plastic and Reconstructive Surgery
University of Nebraska Medical Center
NAN is an author of a reference cited in this topic.
David W. Rowed, MD, FRCSC
Professor of Surgery
Division of Neurosurgery
University of Toronto
Department of Otolaryngology
Sunnybrook Health Sciences Centre
DWR declares that he has no competing interests.
Renn Holness, BSC, MBBS (Hons), FRCSC
Division of Neurosurgery
Dalhousie University & QEII Health Sciences Centre
RH declares that he has no competing interests.
Andre Tomasino, MD
Department of Neurological Surgery
Weill Cornell Medical College
New York-Presbyterian Hospital
AT declares that he has no competing interests.
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