THORACOLUMBAR SPINE INJURY

A 44-year-old man has jumped from the fifth floor of a building and has been brought to the emergency department. He is complaining of back pain and spinal precautions have been taken. This is an image from the CT taken in the emergency department.

How would you investigate and manage this patient in the emergency department?

 This patient should be treated along ATLS guidelines to ensure that life- and limbthreatening injuries are identified and treated appropriately. With respect to this specific injury, I would maintain spinal precautions and examine the patient carefully looking for any sign of neurological deficit.

  The CT shows a fracture at the level of L2. This is a burst fracture pattern with involvement of the anterior, middle and posterior columns.  The CT image shows significant loss of vertebral height and retropulsion of fracture fragments and spinal canal compromise.

What are the indications for surgery in this injury?

 Fractures with associated neurological injury should be considered for surgery as should fractures where there is 30 degrees or more of kyphosis, compromise of the spinal canal by 50% or more and where there is progressive collapse into kyphosis or risk of this. I would also consider surgery in polytraumatised patients or where bracing is ineffective because of other injuries or body habitus. Loss of 50% of vertebral height or more suggests injury to the posterior ligamentous complex and resulting instability. Most other fractures can be treated in a thoracolumbar spinal orthosis (TLSO) to be worn whenever the patient is upright. If there is any doubt as to the stability of a fracture then I would arrange for an MRI to examine the integrity of the posterior ligamentous complex. I would check that bracing maintains satisfactory position with serial standing radiographs following application of the TLSO.

  These indications for surgery have been consolidated into an injury scoring system, the Thoracolumbar Injury Classification and Severity Score (TLICS), which incorporates injury morphology, posterior ligamentous complex integrity and neurological status. A score of 4 is said to be the threshold at which operative management is considered.

What surgical approach would you use for this fracture and which levels would you choose to stabilise?

 Surgery aims to decompress neural elements where required, reduce persisting spinal deformity, provide mechanical stability to spinal elements and allow bony healing.

  Where decompression is required, I would achieve this through an anterior approach. For this patient who is neurologically intact I would choose a posterior approach to reduce residual kyphosis and achieve instrumented segmental fusion using pedicle screws. In this case, I would instrument one level above and two levels below the fracture level. In cases of very poor bone quality or where the vertebral body has lost 50% or more of its original height then short segment fusion would be more prone to failure and I would instrument two levels above and below the fracture.

What do you understand about the terms neurogenic shock and spinal shock?

 Neurogenic shock results from disruption of the sympathetic pathways in the spinal cord with resultant uncontrolled peripheral vasodilation, a decrease in peripheral vascular resistance and a profound reduction in blood pressure. Depending on the level of spinal cord injury, there may also be a loss of sympathetic cardiac innervation with a resultant bradycardia. These features allow differentiation from hypovolaemic shock where the patient will appear peripherally shut down and tachycardic.

  The term spinal shock refers to the complete loss of all neurological activity (motor, sensory, reflex and autonomic) below the level of spinal cord injury. Following a variable time period, from several days up to 6 weeks, spinal reflexes are expected to return and eventually become exaggerated as the syndrome of spasticity develops