CASE REPORT

SENIOR CLINICAL CLERKSHIP

Period of November 22th Desember 20nd, 2010

Name

: Fitria Koeshardani, S. Ked

Intan Meilita, S.Ked
Vengky Utami, S.Ked

NIM

: 54061001080
04061001017
04061001095

DEPARTMENT OF NEUROLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY/ RSMH
PALEMBANG
2010
ENDORSEMENT PAGE

Case Report

Contusion of Spinal Cord

Presented by:
Fitria Koeshardani, S. Ked
Intan Meilita, S.Ked
Vengky Utami, S.Ked

54061001080
04061001017
04061001095

Has been accepted as one of requirements in undergoing senior clinical clerkship

period of November 22th December 20nd, 2010 in Department of Neurology
Faculty of Medicine Sriwijaya University / RSMH Palembang.
Palembang, December 2010
Advisor

Dr. H. A. Rachman Toyo, SpS(K)

NEUROLOGY MEDICAL RECORD

IDENTIFICATION
Name
Age
Gender
Marital Status
Religion
Address
Admission Date

: Mr. I
: 25 years old
: male
: unmarried
: Moslem
: stay out town
: December 1th 2010

ANAMNESIS (Auto Anamnesis)

The patient was admitted in the neurology ward in RSMH Palembang
because of paralysis of both legs and he complaints difficulty in urinating and
defecation since he fell from the palm tree.
2 weeks ago, the patient fell from a tree in the supine position, his back
hit first, and the patient immediately unable to move both his legs, he also
couldnt f eel sense from the umbilicus to the fingertips of both legs and
complaint difficulty in urinating and defecation.. Impairment of consciousness (-),
he didnt complain about nausea and vomiting. He was taken to the hospital
immediately.
Patient had no history of Hypertension. No history of getting fever. No
history of getting head injury. No history of diabetes mellitus. No history of
chronic cough, no history of lifting heavy load, no history of spinal bump
This illness was suffered for the first time
PHYSICAL EXAMINATION
PRESENT STATE
Internal State
Sense
Nutrition
Pulse
Respiratory rate
Blood pressure
Weight
Height

: E4M6V5
: sufficient
:82beats/min
:18 times/min
:110/80 mmHg
: 55 kg
: 164 cm

Lungs
Liver
Spleen
Extremities
Genital

: no abnormality
: no abnormality
: no abnormality
: no edema
: no abnormality

Psychiatric state

Attitude
Attention

:cooperative
:normal

Facial Expression
Physical contact

: natural
: normal

: brachiocephaly
: normocephaly
: yes
: no
: no

Deformity
Fracture
Fracture pain
Vessel
Pulsation

: no
: no
: no
: no widening
: no disorder

Neurological state
Head
Shape
Size
Symetric
Hematome
Tumor

Neck
Position
: straight
Torticolis
: no
Nape of neck stiffness : no

Deformity
Tumor
Vessels

: no
: no
: no widening

CRANIAL NERVES
Olfactorius nerve
Smelling
Anosmia
Hyposmia
Parosmia
Opticus nerve
Visual acuity
Campus visi

Anopsia
Hemianopsia
Oculi fundus
Edema papil
Atrophy papil
Retina bleeding
Occulomotorius, Trochlearis
and Abducens nerves
Diplopia
Eyes gap
Ptosis
Eyes position
Strabismus
Exophtalmus
Enophtalmus
Deviation conjugae
Eyes movement
Pupil
Shape
Size
Isochor/anisochor
Midriasis/miosis
Light reflex
direct
consensuil

Right
No disorder
No
No
No

Left
No disorder
No
No
No

Right
Not examined
V.O.D

Left
Not examined
V.O.S

No
No

No
No

No
No
No

No
No
No

Right
No
simetris
No

Left
No
simetris
No

No
No
No
No
no abnormality

No
No
No
No
no abnormality

Round
3mm
isochor
No

Round
3mm
isochor
No

+
+
+

+
+
+
5

Accessorius Nerve
Shoulder Raising
Head Twisting
Hypoglossus Nerve
Tounge Showing
Fasciculation
Papil Athrophy
Dysarthria
MOTORIC
Arms
Motion
Power
Tones
Physiological Reflex
Biceps
Triceps
Radius
Ulna
Pathological Reflex
Hoffman Tromner
Leri
Meyer
Trofik
LEG
Motion
Power
Tones
Clonus
Tigh
Foot
Physiological reflex
KPR
APR
Pathological reflex
Babinsky
Chaddock
Oppenheim
Gordon

Right
simetris
No disorder

Left
simetris
No disorder

No deviation
no
no
no

Right
Sufficient
5
Normal

Left
Sufficient
5
Normal

Normal
Normal
Normal
Normal

Normal
Normal
Normal
Normal

None
None
None
None

None
None
None
None

Right
Insufficient
0
decreasing

Left
Insufficient
0
decreasing

Negative
Negative

Negative
Negative

decreasing
decreasing

decreasing
decreasing

Negative
Negative
Negative
Negative
Negative

Negative
Negative
Negative
Negative
Negative

 Schaeffer
Negative
Negative
Negative
Negative
Rossolimo
Mendel Bechterew
No abnormality
Abdominal skin reflex
No abnormality
Upper
No abnormality
Middle
Not examined
Lower
Cremaster reflex
SENSORY
Hipestesi as high as 2 fingers under umbilicus until the fingertips of both legs.
PICTURE

VEGETATIVE FUNCTION
Micturition
: retensio urin
Defecation
: retensio alvi
Erection
: not examined
VERTEBRAL COLUMN
Kyphosis
: no
Lordosis
: no
Gibbus
: no
Deformity
: yes

Tumor
Meningocele
Hematome
Tenderness

: no
: no
: no
: no

SYMPTOMS OF MENINGEAL IRRITATION

Right
Nape of neck stiffness
Negative
Kerniq
Negative
Lasseque
Negative
Brudzinsky
Neck
Negative
Negative
Cheek
Negative
Symphisis
Negative
Leg I
Negative
Leg II
GAIT AND EQUILIBIRIUM
Gait Equilibirium and Coordination
Ataxia
: not exemined
Hemiplegic
: not exemined
Scissor
: not exemined
Propulsion
: not exemined
Histeric
: not exemined
Limping
: not exemined
Steppage
: not exemined
Astasia-Abasia
: negative
Limb Ataxia
: negative

Left
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative

Romberg
: negatif
Dysmetri
: negatif
finger finger
: normal
finger nose
: normal
heel - heel
: not exemined
Reboundphenomenon : not exemined
Dysdiadochokinesis : negative
Trunk Ataxia
: negative

MOTION ABNORMAL
Tremor
: no
Chorea
: no
Athetosis
: no
Ballismus
: no
Dystoni
: no
Myoclonus
: no
LIMBIC FUNCTION
Motoric aphasia
: no
Sensoric aphasia
: no
Apraksia
: no
Agraphia
: no
Alexia
: no
Nominal aphasia
: no
LABORATORY FINDINGS

BLOOD
Hb
Eritrocyte
Leukosit
Trombosit
Hematocrit
CK-NAK
CK-MB
Diff Count

: 11,3 g/dL
: 4,2 juta/mm3
: 9500 /mm3
: 421.000 /mm3
: 35 vol%
: 51 U/I
: 13 U/I
: 0/0/2/81/12/5

Total kolesterol
Kolesterol HDL
Kolesterol LDL
Trigliseride
Ureum
Kreatinin
Natrium
Kalium
Calsium

:116 mg/dL
: 37 mg/dL
: 61 mg/dL
: 91 mg/dL
: 60 mg/dL
: 1,1 mg/dL
: 135 mmolL
: 4,1 mmol/L
: 2,4 mmol/L

URINE
Epithel
Leucocyte
Eritocyte

: not performed
: not performed
: not performed

Protein
Glucose

: not performed
: not performed

FECES
Consistency
Slime
Blood
Amoeba coli/
Hystolitica

: not performed
: not performed
: not performed
: not performed
: not performed

Erytrocyte
Leucocyte
Worm egg

: not performed
: not performed
: not performed

Protein
Glucose
NaCl
Queckensted
Celloidal
Culture

: not performed
: not performed
: not performed
: not performed
: not performed
:

CEREBRO SPINAL FLUID

Colour
: not performed
Clarity
: not performed
Pressure
: not performed
Cell
: not performed
Nonne
: not performed
Pandy
: not performed
performed

SPECIFIC EXAMINATION
Cranium X- Ray
: not performed
Chest X- Ray
: normal thorax
Vertebral column X- Ray
:Compressive
fracture/burst
Spondylosetesis T 11-12
Electroencephalography
: not performed
Electroneuromyography
: not performed
Electrocardiography
: not performed
Arteriography
: not performed
Pneumography
: not performed

T.II

not

and

CT-Scan

: not performed

RESUME
IDENTIFICATION
Mr. I/ 25 years old/ male/ unmarried/ Moslem/ stay in town/ December 1th
2010
ANAMNESIS (Auto Anamnesis)
The patients was hospitalized in neurology ward of RSMH Palembang
because paralysis of both legs and he has problems in urination and defecation
since he fall from the palm tree.
2 weeks ago, when he was climbing palm trees, the patient fell from a
tree in the supine position, his back hit first, and directly the patient can not move
both his legs, patients also feel less sense on the part of umbilicus to the fingertips
of both legs , he has problems in urination and defecation.. Impairment of
consciousness (-), he didnt complain about nausea and vomiting. Patients are
taken directly to hospital.
Patient had no history of Hypertension. No history of getting fever. No
history of getting head injury. No history of diabetes mellitus. No history of
chronic cough, no history of lifting heavy load, no history of spinal bump
This illness was suffered for the first time
EXAMINATION
Present State
Sense
Blood pressure
Pulse
Respiratory rate
Temperature
Nutrition

: compos mentis (GCS 15: E4M6V5)

: 110 / 80 mmHg
: 82x/minute
: 18x/minute
: 36,5o C
: sufficient

Neurological state
motori
Motoric function
Motoric function
Motion
Power
Tones
Clonus
Physiological reflex
Pathological reflex

Arm

Leg

Right
Sufficient
5
Normal

Left
Sufficient
5
Normal

Normal
-

Normal
-

Right
Insufficient
0
Decreasing
Decreasing
-

Left
Insufficient
0
Decreasing
Decreasing
-

10

Sensory function
: Hipestesi as high as 2 fingers under umbilicus until the
fingertips of both legs.
Vegetative function : retensio urin
Retensio alvi
Limbic function
: No abnormality
Abnormal Movement : (-)
Gait & Stability
: not examined
Meningeal Irritation : (-)
LABORATORY FINDINGS
BLOOD
Hb
:11,3 g/dL (14-18)
Eritrosit
: 4,2 juta/mm3 (4,5-5,5 juta)
Kolesterol HDL
: 37 mg/dL (>55)
Hematokrit
: 35 vol% (40-48)
Ureum
: 60 mg/dL (15-39)
Diff Count
: 0/0/2/81/12/5 (0-1/1-3/2-6/50-70/20-40/2-8)
DIAGNOSIS
Clinical Diagnostic : Inferior flacid paraplegia + hipestesi as high as 2 fingers
under umbilicus until the fingertips of both legs.
Topical Diagnostic : Total transversal lesion medula spinalis T11-T12
Etiological Diagnostic: Contusio medula spinalis
MANAGEMENT
Non Medication :
- Immobilisation
- Catheter urethra
- NGT
Medication
:
IVFD RL gtt XX/min
Metilprednisolon 5,4 mg/kg BB blus followed by 30 mb/kg /hour
infussion for 23 hours
Vitamin B1, B6, B12 3x1 tab
PLANING
- CT Scan
- LP
- MRI
PROGNOSIS :

Quo ad vitam

: bonam

11

Quo ad functionam

: dubia ad malam

DISCUSSION
1. Myelitis

Found in patient:

Symptomps:
Fever
Neck stiffness and pain in posterior
of body
Asymetric motoric deficit

No fever
No neck stiffness and pain in posterior
of body
Paraparese inferior flaccid (symetric)

2. Spondylitis TB

Found on patient:

Chronic cough
Chronic and progressive weakness

No chronic cough
Weakness appear after trauma

3. Subdural Hematom spinalis

Found on patient:

History of trauma
Chronic and progressive weakness

History of trauma 2 weeks before

Weakness appear after trauma

4. Contusion of spinal cord

Found on patient:

History of trauma
Acute and permanent weakness

History of trauma 2 weeks before

Weakness appear after trauma

Conclusion: most likely diagnosis in this patient is contusio medulla spinalis

12

FOLLOW-UP
1. December 2th 2010
Complaint
: (-)
Generalis status
:
Sens
: E4M6V5
BP
: 110/80 mmHg
RR
: 19 x/m
o
Pulse
: 80 x/m
T
: 36,7 C
Neurologis Status
: stqa
Clinical Diagnostic : Inferior flacid paraplegia + hipestesi as high as 2 fingers
under umbilicus until the fingertips of both legs.
Topical Diagnostic : Total transversal lesion medula spinalis T11-T12
Etiological Diagnostic: Contusio medula spinalis
Therapy:
IVFD RL gtt XX/min
Vitamin B1, B6, B12 3x1 tab
2. December 3th 2010
Complaint
: (-)
Generalis Status
:
Sens
: E4M6V5
BP
: 110/80 mmHg
RR
: 18 x/m
o
Pulse
: 80 x/m
T
: 36,5 C
Neurologis status
: stqa
Clinical Diagnostic : Inferior flacid paraplegia + hipestesi as high as 2 fingers
under umbilicus until the fingertips of both legs.
Topical Diagnostic : Total transversal lesion medula spinalis T11-T12
Etiological Diagnostic: Contusio medula spinalis
Therapy:
IVFD RL gtt XX/min
Vitamin B1, B6, B12 3x1 tab
3. December 4th 2010
Complaint
: (-)
Generalis status
:
Sens
: E4M6V5
BP
: 110/80 mmHg
RR
: 19 x/m
o
Pulse
: 81 x/m
T
: 36,1 C
Status neurologis
: stqa
Clinical Diagnostic : Inferior flacid paraplegia + hipestesi as high as 2 fingers
under umbilicus until the fingertips of both legs.

13

Topical Diagnostic : Total transversal lesion medula spinalis T11-T12

Etiological Diagnostic: Contusio medula spinalis
Therapy:
IVFD RL gtt XX/min
Vitamin B1, B6, B12 3x1 tab
4. December 5th 2010
Complaint
: (-)
Generalis status
:
Sens
: E4M6V5
BP
: 110/80 mmHg
RR
: 20 x/m
o
Pulse
: 83 x/m
T
: 36,6 C
Status neurologis
: stqa
Clinical Diagnostic : Inferior flacid paraplegia + hipestesi as high as 2 fingers
under umbilicus until the fingertips of both legs.
Topical Diagnostic : Total transversal lesion medula spinalis T11-T12
Etiological Diagnostic: Contusio medula spinalis
5. December 6th 2010
Complaint
: (-)
Generalis status
:
Sens
: E4M6V5
BP
: 110/80 mmHg
RR
: 19 x/m
o
Pulse
: 80 x/m
T
: 36,7 C
Neeurologis status
: stqa
Clinical Diagnostic : Inferior flacid paraplegia + hipestesi as high as 2 fingers
under umbilicus until the fingertips of both legs.
Topical Diagnostic : Total transversal lesion medula spinalis T11-T12
Etiological Diagnostic: Contusio medula spinalis
Therapy:
IVFD RL gtt XX/min
Vitamin B1, B6, B12 3x1 tab

6. December 7th 2010

Complaint
: (-)
Generalis status
:
Sens
: E4M6V5
BP
: 110/70 mmHg
Pulsed
: 78 x/m

RR
: 20 x/m
o
: 36,4 C

14

Neurologis status
: stqa
Clinical Diagnostic : Inferior flacid paraplegia + hipestesi as high as 2 fingers
under umbilicus until the fingertips of both legs.
Topical Diagnostic : Total transversal lesion medula spinalis T11-T12
Etiological Diagnostic: Contusio medula spinalis
Therapy:
IVFD RL gtt XX/min
Vitamin B1, B6, B12 3x1 tab

15

LITERATURE
A. Introduction

Thoracic spine fractures, especially those resulting from high energy, can be
devastating, often resulting in permanent neurologic injury. Neurologic deficit is
encountered in 10-25% of all spinal column injuries, irrespective of the level of
injury. A deficit occurs in 15-20% of all thoracolumbar injuries. In the event of a
complete neurologic injury, very few patients regain any useful motor function.
Concomitant neurologic injury with spine fractures also adversely affects longterm survival. The 10-year survival rate for people younger than 29 years is 86%.
This percentage drops precipitously to 50% for patients older than 29 years.
The images below display some examples of burst fractures, flexion distraction
injury, and fracture dislocations.

Thoracic spine fractures and dislocations. Burst fracture

T12. Note the widened interpedicular distance.

16

Thoracic spine fractures and dislocations. Flexion

distraction injury with facet dislocation.

Thoracic spine fractures and dislocations. Fracture

dislocation T2-T3.

Thoracic spine fractures and dislocations. Preoperative

axial CT image of burst fracture with partial neurologic
deficit.

B. Etiology
The vast majority of spine fractures occur as a result of motor vehicle accidents
(45%), falls (20%), sports (15%), acts of violence (15%), and miscellaneous
activities (5%). The percentage secondary to acts of violence is higher in urban
areas.
C. Presentation
An extensive physical examination should be performed and neurologic status
should be documented upon initial presentation. Concomitant injuries should be
assessed, and the patient's overall physical condition should be optimized

17

promptly.2 Once the patient is stabilized hemodynamically and other visceral

injuries have been investigated and excluded, definitive treatment of the thoracic
spine injury can be contemplated.4,5,6
If neurologic deficit (spinal cord) is present and less than 8 hours have elapsed
from the time of injury, begin treatment with high-dose methylprednisolone (5.4
mg/kg bolus followed by 30 mg/kg/h infusion for 23 h). Operative versus
nonoperative treatment can be entertained based upon the clinical status of the
patient and radiographic appearance of the fracture. The stability and location of
the fracture and the underlying mechanism of injury all can play major roles in the
decision whether to operate or treat conservatively.
Several distinct classification schemes are available to assess spinal stability.
Holdsworth initially proposed the 2-column theory of spinal stability. 7 In this
model, the vertebra is divided into an anterior and posterior column. The anterior
column consists of the vertebral body, intervertebral disc, anterior longitudinal
ligament, and the posterior longitudinal ligament. The posterior column comprises
the facets, neural arch, and interspinous ligaments. Disruption of one or more
columns implies instability of the involved segment.
Denis expanded on this model, developing the most common model used for
assessing spinal stability.8 In this model, the vertebra is divided into 3 columns:
anterior, middle, and posterior. The anterior column comprises the anterior half of
the vertebral body along with the anterior longitudinal ligament and the anterior
portion of the annulus fibrosis. The middle column is made up of the posterior
annulus fibrosus along with the posterior half of the vertebral body and the
posterior longitudinal ligament. The posterior column consists of the posterior
ligamentous complex and the posterior bony elements. When 2 of the 3 columns
are disrupted, the fracture is considered unstable.8
Classification schemes generally also encompass mechanisms of injury and their
resultant fracture patterns. Several different mechanisms of injury can occur
within the thoracic spine. Most commonly, a combination of 1 or 2 mechanisms
accounts for the injury. These mechanisms include the following:

Axial compression: This type of injury results in a purely compressive

load. Endplate failure occurs, followed by vertebral body compression.
With higher energy, a centripetal displacement occurs, resulting in what is
commonly referred to as a burst fracture. In severe burst fractures, discs
become fragmented and the posterior elements are disrupted.
Radiographically, this mechanism can manifest as a widened
interpedicular distance. The image below depicts a burst fracture.

18

Thoracic spine fractures and dislocations.

Burst
fracture
T12.
Note
the
widened
interpedicular distance.

Flexion: This mechanism results in compression anteriorly. Disruption of

posterior elements with flexion often results in instability of the involved
area. If anterior compression exceeds 40-50%, the posterior ligamentous
structures are often disrupted. Instability ultimately can result in
progressive deformity and neurologic deficit if not appropriately
stabilized.

Lateral compression: This mechanism usually results in a stable injury

unless disruption of posterior structures or associated axial compression
occurs.

Flexion-rotation: With a flexion-rotation injury, posterior ligamentous

structures commonly fail. Oblique disruption of the anterior vertebral body
and disc failure occur. This type of injury can result in what commonly is
known as a slice fracture. With fractures of the facets and concomitant
disruption of posterior elements, thoracic spine dislocation can occur.

Shear: Shear injuries often result in severe ligamentous disruption and

subsequent anterior, posterior, or lateral listhesis. Anterolisthesis is the
most common of the 3, with complete spinal cord injury often being the
unfortunate result. However, occasionally, concomitant fractures through
the pars interarticularis result in autolaminectomy, with resultant neural
sparing.

Flexion distraction: This injury is more commonly referred to as the

seatbelt injury. The axis of flexion is anterior to the vertebral column.

19

Osseous, disc, and ligamentous structures are disrupted either alone or in

combination. Combined osteoligamentous or purely ligamentous injuries
can be present, and this injury occurs most commonly at the
thoracolumbar junction. Bilateral facet dislocation can occur. The image
below depicts a flexion distraction injury.

Thoracic spine fractures and dislocations.

Flexion
distraction
injury
with
facet
dislocation.

Extension: Tension is placed on the anterior longitudinal ligament, with

compression occurring posteriorly. Facet, laminar, and spinous process
fractures often occur. Most of these injuries are stable, provided that
significant retrolisthesis does not occur.

In the Denis classification system, significant fractures are divided into the
following groups: (1) primarily axial load injuries, including compression and
burst fractures; (2) flexion-distraction injuries; and (3) fracture subluxation and/or
dislocation. The image below depicts a fracture dislocation.

20

Thoracic spine fractures

dislocation T2-T3.

and

dislocations.

Fracture

The mechanism of failure of the middle column further differentiates the various
types of fractures. The middle column is spared in compression fractures, yielding
a stable fracture. It fails in compression with burst fractures, distraction in seatbelt
injuries, and shear and/or rotation injuries. Fracture dislocations yield unstable
injuries.
The Denis classification system has been criticized due to its occasional inability
to be used to adequately distinguish between stable and unstable fracturesfor
example the "stable" burst fracture. In addition, biomechanical studies have been
performed that bring into question the importance of the middle column. McAfee
recognized this and expanded upon the Denis classification scheme to further
elucidate stable versus unstable fractures. His classification system emphasizes
the posterior ligamentous complex as a major factor in fracture stability. While
many classification systems exist, the Denis classification is probably the most
frequently used.
Another shortcoming of structural or mechanistic classifications is that they often
fail to take neurologic deficit into account. Significant neurologic injury implies
instability irrespective of the fracture pattern in that the spine has failed in
protecting the neural elements. In general, stable fracture patterns in a
neurologically intact patient can be treated nonoperatively. Indications for surgery
can vary and include significant neurologic deficit and fracture subluxations.
Excessive deformity is also an indication, although defining this is difficult, and
the effect of kyphosis on long-term results is uncertain. Kyphosis greater than 30;
may be associated with poorer long-term results, and kyphosis greater than 25; is
often mentioned as a relative indication for surgery.
The presence of other injuries also may affect the choice between operative and
nonoperative treatment. The most predictable benefit of surgery is more rapid
mobilization, which can be an important consideration in the patient who has
experienced multiple traumatic injuries.

D. Workup
Anteroposterior (AP) and lateral radiographs of the thoracic spine:
Radiographs are used initially to elucidate the fracture configuration.
Radiographic evidence of a fracture at any level of the spine necessitates
radiographic analysis of the entire spine.9

21

 CT scan: CT scans of the thoracic spine with sagittal reformatted images

provide information regarding the extent of injury to the osseous structures
and the posterior elements.1
MRI: This study is useful in evaluating soft-tissue injury to the ligaments,
discs, and epidural spaces. MRI is most useful in patients when traumatic disc
herniation, epidural hematoma, or spinal cord injury is suspected. In addition,
MRI is used when CT and radiographic analysis do not adequately explain
the patient's symptoms.
E. Treatment
Medical Therapy
Nonoperative treatment begins with pain management and attention to
concomitant injuries. Mobilization with bracing can then begin if nonsurgical
treatment is chosen. Use of the 3-column rule can be helpful in determining brace
types. Single-column injuries, such as compression fractures involving only the
anterior column, are generally stable injuries and can be treated with a simple
extension orthosis to limit flexion. If contiguous compression fractures are
encountered, the cumulative compression and angular deformities are considered
when choosing operative versus nonoperative treatment. Isolated posterior
element fractures are usually stable, and conservative treatment with mobilization
is appropriate for these injuries. Light bracing can be used with these injuries for
comfort and to hasten mobilization.11,12,13,14,3
More severe injuries with 2-column involvement require more rigid
immobilization. Standard thoracolumbosacral orthoses (TLSO), such as the
Boston brace, provide good immobilization but only of the lower thoracic spine.
The usefulness of TLSO is limited to injuries from about T7 distally. Extension of
the brace to the cervical spine (cervical thoracolumbosacral orthoses [CTLSO])
can allow for immobilization of upper thoracic segments; however, these braces
are very poorly tolerated by patients. Upper thoracic spine injuries are more
difficult to treat with bracing, and if nonoperative immobilization of the upper
thoracic spine is chosen, a halo with extended vest generally should be used.
The treatment of burst fractures of the thoracic spine and the thoracolumbar
junction is an area of debate. Surgical advocates believe surgery allows earlier
mobilization and return to function, more pain relief, and better correction of any
kyphotic deformity that exists. Studies have failed to show a significant difference
in results in patients without neurologic injury as long as significant posterior
column injury is not present. Significant remodeling of the spinal canal has been
shown to occur within the first year in burst fractures treated nonoperatively.
Residual kyphosis is also seen, but the degree of kyphosis present does not
correlate with the patient's pain or functional abilities.12,13,14,15,16,17,18

22

Additional studies have been performed that reveal similar or even more
beneficial results with nonoperative verus operative treatment of thoracic spine
fractures, both with and without neurologic deficit. No correlation has been shown
between neurologic deficit and the extent of canal compromise or, more
importantly, between the resolution of the deficit and surgical decompression. In
addition, the risk of postoperative infection is eliminated with nonoperative
treatment, which ranges from 7-15% in various studies. If immobilization with
prolonged bed rest is chosen as the method of treatment, strict deep venous
thrombosis (DVT) prophylaxis, the use of a kinetic bed, vigilant inspection for
decubitus ulcers, and aggressive respiratory therapy must be implemented to
prevent the complications that can arise with bed rest.
Flexion-distraction injuries involving significant disruption of the supporting
ligamentous structures are generally unstable and are managed surgically.
Surgical Therapy
If surgical management is chosen, the next step is determining the most
appropriate approach: anterior, posterior, or both.19,20,21,22 Many factors, including
fracture morphology and neurologic status, can play a role in this decision.
Patients with complete neurologic deficit who are no longer in spinal shock have
very little chance of significant neurologic recovery. The primary goal of surgery
in this group is realignment and stabilization, typically through a posterior
approach.19,20,21,22
When partial neurologic deficit is present, improving residual canal compromise
is also a goal of surgery. This situation most typically occurs with burst fractures.
If performed early enough (generally within 72 h), posterior instrumentation
allows for distraction and correction of sagittal alignment and successful indirect
decompression of the spinal canal. Laminectomy with transpedicular
decompression also can improve the canal clearance achieved through a posterior
approach. The image below depicts a burst fracture before surgery.

23

Thoracic spine fractures and dislocations. Preoperative

axial CT image of burst fracture with partial neurologic
deficit.

Laminectomy should never be performed alone in the treatment of thoracic burst

fractures. Another option is anterior decompression and fusion with
instrumentation. Surgeon preference often plays a role, as does fracture
morphology. Concomitant lamina fractures with posterior canal compromise
generally necessitate beginning with a posterior approach due to possible neural
entrapment and dural tears.23
Flexion-distraction injuries result in disruption of the posterior and middle
columns in tension. Very often, the anterior column remains intact, acting as a
hinge. Surgical intervention for these fractures typically involves a posterior
approach. Anterior approaches are not routinely used in these injuries, to preserve
the intact anterior column.
Fracture-dislocation injuries result in disruption of all 3 columns and, as a result,
carry a high incidence of complete spinal cord injury. Therefore, the main
objective of surgical intervention is solely to provide posterior stabilization
facilitating early mobilization and rehabilitation. Anterior decompression and
stabilization is performed following posterior surgical realignment of the fracture
in rare instances in which partial neurologic deficit exists in the presence of
significant anterior neural compression.
Various methods exist for surgical stabilization, as do many opinions and accounts
in the literature supporting the numerous techniques. Harrington rods have been
used for many years to stabilize the spine with unstable fractures. Routinely, it
requires spanning 2-3 levels above and below the injured segment. This type of
fixation creates a large moment arm, conferring a high degree of stability to the
construct. The disadvantage of Harrington rod instrumentation is the involvement
of several motion segments. They perform relatively poorly in 3-column injuries,
however, due to predisposition to overdistraction and the relatively high incidence
of rod breakage and hook cut out (7-10%).
Hybrid constructs consisting of spinous process and sublaminar or Luque wires
provide segmental fixation with improved results. A disadvantage of this mode of
fixation is the risk of neurologic injury with sublaminar wire passage. Due to this
potential complication, sublaminar wires are not routinely used in patients with
incomplete neurologic injuries or normal neurologic status.

24

While Harrington instrumentation can be used, it has, for the most part, been
supplanted by newer segmental instrumentation systems initially developed for
scoliosis. These systems use multiple fixed anchors along the fixation rod.
Application of multiple forces at different points is possible, resulting in a
relatively low incidence of fixation failure. Compression, distraction, and
translation are all possible within the same construct. Initially, these systems used
hooks (sublaminar, pedicle, and transverse process) for fixation, and most now
allow for pedicle screw fixation as well.
Pedicle screw fixation allows for instrumentation of vertebrae with fractured or
absent laminae. In addition, pedicle screw fixation allows for rigid bony purchase
through all 3 columns. Because of this increased rigidity, often fewer segments are
necessary for stable fixation, allowing the preservation of more motion segments.
Preserving motion segments is of less importance in the thoracic spine, as little
motion is lost compared with the cervical and lumbar segments. However,
limiting instrumentation of distal segments is of importance with thoracolumbar
injuries.15,24,25
The osseous structures are fused concomitantly with posterior instrumentation.
Some surgeons fuse only the injured vertebral segments with subsequent staged
removal of hardware. Other surgeons fuse the entire length of the instrumentation.
This results in loss of motion at additional segments. As mentioned, this is of less
importance in the thoracic spine. With modern segmental fixation, fewer segments
need to be instrumented to provide stability, and generally, the entire instrumented
region is fused.26,27
Individual anatomic factors, such as the presence of lamina fractures, often dictate
choice of anchors. In the thoracic spine, it is not uncommon for pedicles to be too
small to allow screw placement. Depending on the injury, generally 2-3 segments
of fixation above and below the level of injury are required if hooks alone are
used. With pedicle screws, this often can be limited to 1-2 segments. The image
below shows a burst fracture after stabilization.

25

Thoracic spine fractures and dislocations. Burst fracture

with partial neurologic deficit after stabilization with
medial resection of right pedicle to allow access to
anterior fragment.

The condition of the anterior column also can affect instrumentation choices. If
severe comminution or kyphosis is present anteriorly, extending the length of the
posterior instrumentation or improving anterior support should be considered.
This is often an issue with burst fractures, and anterior strut graft fusion may be
required. Historically, transpedicular bone grafting also was performed in an
attempt to improve the anterior column. Studies have shown little difference with
this technique in hardware failure and final vertebral height. Thus, in unstable
fracture patterns with anterior column involvement, dorsal stabilization with
concomitant or staged anterior interbody fusion provides a more stable construct,
with improved maintenance of reduction.
Anterior instrumentation systems also have been developed for the treatment of
spinal fractures. Use of anterior systems often requires reconstruction of the
anterior column with strut grafting, cages, or both. Anterior instrumentation
historically also required the use of posterior instrumentation due to the lack of
stability of the older fixation systems. Newer constructs, however, have been
developed that provide enough structural stability to be used alone. Newer
systems are extremely rigid, and some have been shown to provide greater
torsional stiffness than the intact spine. Biomechanical studies have shown that
this type of fixation can be equal in strength to a 2-above and 2-below pedicle
screw construct. In the image below, pedicle screw fixation of a burst fracture is
displayed.

Thoracic spine fractures and dislocations. Pedicle screw

fixation of a T12 burst fracture.

26

Timing of surgery is also an important issue in the treatment of thoracic spine

fractures. Progressive neurologic deficit in the presence of continued canal
compromise is an accepted indication for immediate decompression and
stabilization. Quite often, patients with thoracic spine fractures have concomitant
injuries, making the timing of spinal stabilization difficult to plan. Some studies
suggest that patients with thoracic spine fractures treated within 72 hours,
irrespective of concomitant injuries, do much better physiologically
postoperatively than those in whom stabilization is delayed. Early fixation results
in less time in the intensive care unit, less ventilator support, decreased rate of
pulmonary complications, and less overall time in the hospital.

F. Prognosis
The results are favorable for correction of deformity, maintenance of reduction,
healing, and fusion rates. Overall clinical outcome is generally good, depending
on the patient's final neurologic function. Return of neurologic function, however,
is variable, with little significant recovery seen in complete injuries irrespective of
treatment.
G. Complication
Even with careful preoperative planning and meticulous surgical technique,
complications can occur during surgical treatment of a thoracic spine fracture.
DVT, pulmonary embolism, urinary tract infections, and even death can occur
with any surgical procedure, and measures should be taken to prevent such
complications.
Neurologic injury can occur during spine surgery; incidence is approximately 1%.
Injury can occur as a result of overdistraction or overcompression or from
insertion of the various forms of instrumentation.
Dural tears can occur during exposure, instrumentation, or decortication. They
also may be caused by fractures of the lamina. The full extent of the tear should be
completely exposed, and primary repair should be attempted if possible. Muscle
or fascial grafts can be used for large tears not amenable to primary repair.
Lumbar transdural drains can be placed to decrease pressure across the tear and
facilitate healing.
Infection can occur as a result of surgical treatment of thoracic spine fractures.
Infections superficial to the fascia can be treated with debridement with packing
or closure over a drain. Infections deep to the fascia require prompt surgical
debridement with retention of bone graft and instrumentation. The wound can be
serially debrided or closed over deep drains or over an inflow-outflow system

27

providing constant irrigation of the wound. Six weeks of intravenous antibiotics

followed by a course of oral antibiotics are routinely administered in conjunction
with the above treatments.

28

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