What are the treatment options for Thoracolumbar (Thoraco-Lumbar) fractures?

From the Guidelines

Thoracolumbar fractures require prompt evaluation and management based on fracture stability, neurological status, and patient factors, with a focus on minimizing morbidity, mortality, and improving quality of life. Initial treatment includes immobilization, pain control with NSAIDs like ibuprofen (400-800mg every 6-8 hours) or acetaminophen (1000mg every 6 hours), and possibly muscle relaxants such as cyclobenzaprine (5-10mg three times daily) for associated spasm.

Key Considerations

• Stable fractures without neurological deficits can often be managed conservatively with bracing (thoracolumbosacral orthosis) for 8-12 weeks and gradual mobilization.
• Unstable fractures, those with significant deformity (kyphosis >30°), canal compromise >50%, or neurological deficits typically require surgical intervention with spinal fusion and instrumentation.
• Surgical approaches may be anterior, posterior, or combined depending on fracture characteristics.
• Rehabilitation is crucial regardless of treatment approach, focusing initially on core strengthening and gradually progressing to more intensive physical therapy.
• Patients should be monitored for complications including progressive deformity, chronic pain, and neurological deterioration.
• The thoracolumbar junction (T11-L2) is particularly vulnerable to injury due to the transition from the rigid thoracic spine to the more mobile lumbar spine, with classification systems like the Thoracolumbar Injury Classification and Severity Score (TLICS) guiding treatment decisions based on fracture morphology, posterior ligamentous complex integrity, and neurological status 1.

Special Considerations

• For patients with pathologic fracture with neurologic effects, surgical consultation and radiation oncology consultation are usually appropriate 1.
• For patients with pathologic fracture with severe and worsening pain, a multidisciplinary approach including interventional radiology, surgery, and radiation oncology consultation is recommended 1.
• For patients with pathologic fracture with spinal deformity or pulmonary dysfunction, a multidisciplinary approach including interventional radiology, surgery, and radiation oncology consultation is recommended 1.
• Medical management can be performed as an adjunct to other therapies, but spinal deformity or pulmonary dysfunction warrants other treatments 1.

From the Research

Overview of Thoraco Lumbar Fractures

• Thoracolumbar spine fractures are common injuries that can result in significant disability, deformity, and neurological deficit 2, 3.
• The thoracolumbar junction is a point of high kinetic energy transfer and often results in thoracolumbar fractures 4.
• New classification systems for thoracolumbar spine fractures are being developed to standardize evaluation, diagnosis, and treatment 2, 4.

Classification and Management

• Different classification systems exist, including the AO spine knowledge forum classification of thoracolumbar trauma and the Thoracolumbar Injury Classification and Severity Score 2, 3.
• Treatment includes both nonoperative and operative methods, selected based on the degree of bony injury, neurological involvement, presence of associated injuries, and the integrity of the posterior ligamentous complex 2, 3.
• The ideal classification that is simple, comprehensive, and guides management is still elusive 3.

Nonoperative Management

• There is no agreement on the optimal method of conservative treatment for traumatic thoracolumbar burst fractures 5.
• Recent randomized controlled trials have yielded conflicting results when comparing nonoperative to operative treatment of thoracolumbar burst fractures without neurological deficits 5.
• High-level studies have investigated the conservative management of traumatic thoracolumbar burst fractures, and there is no superior conservative management technique over another in neurologically intact patients 5.

Indications for Nonsurgical Treatment

• Compression type and stable burst fractures can be managed conservatively, but surgery may be indicated if there is major vertebral body damage, kyphotic angulation, neurological deficit, or spinal canal compromise 6.
• AO type B, C fractures are preferably treated surgically 6.
• Future research is necessary to tackle the relative paucity of evidence pertaining to patients with thoracolumbar fractures 6.