COMMINUTED FRACTURE OF THE THORACIC SPINE
JP Cashman". FL C a ï ty,
M Ryan', KMa,halingham' J
Dept ofTrauma and Orthopaedics', Dept
of Radiology, Cork University Hospital,
Wilton, Cork
Comminuted fractures of the spine are an uncommon group of injuries that most frequently occurfollowing high-speed collisions. Thoracic spinal fractures occur whenever forces exceed the strength and stability of the spine.They are a major cause of morbidity, particularly with regard to neurological disability and carry huge social and economic implications. While many options are available, scant evidence exists supporting operative over nonoperative treatment.
a mid thoracic fracture. CT of Thorax confirmed these findings and also demonstrated a small haemothorax. CT of Thoracic spine showed comminuted fractures of the bodies of the sixth, seventh and eighth thoracic vertebrae, without violation of the spinal canal or impingement of the spinal cord. Aortography outruled associated thoracic aortic injury. CT brain showed an undisplaced occipital fracture but no intra- cranial injury.
accident in which she was a restrained front seat
Following resuscitation, she was nursed overnight on a Turning Frame. Thereafter, she was treated surgically. Under general anaesthetic, she was positioned prone on a Wilson frame. Instrumented reduction and internal fixation of the fracture was carried out from the fourth thoracic vertebra to the tenth, using AO pedicle screws and rod fixation through a posterior approach. She had an uneventful post-operative period, being maintained on bed rest until the third day. She was mobilised in a spinal orthosis under physiotherapy supervision. She was discharged on the tenth day mobilising with crutches. At four-month follow-up, she was
passenger. She was cut free from the car by the
functioning normally and had no neurological deficit.
In this case report, we describe a patient who suffered a comminuted fracture of the sixth, seventh and eighth thoracic vertebral bodies without neurological deficit following a road traffic accident with a favourable outcome. f
k
f tf_ ^
A 17-year-old girl was brought by ambulance to
Emergency Department following a road traffic
emergency services. She complained of mid-thoracic back pain and chest pain. She was tachycardic and dyspnoeic. Clinical assessment confirmed that she
This case demonstrates a very dramatic injury with
was tender over her left chest and over her mid-
good functional outcome. In managing such an
thoracic spine.There was no distal neurological
injury, it is important to consider the mechanism of injury and to classify the injury so as to determine
deficit. Her Glasgow Coma Score was 14 out of 15.
appropriate management. We h ighligh t difficulties Chest x-ray confirmed three broken ribs, a pulmonary contusion, a widened mediastinum and
76
in selecting treatment for unstable thoracolumbar fractures and discuss pertinent economic issues.
IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 175 - NUMBER 4
The introduction of the penalty points system in
Figure i-
Irelandin2oo1sawaninitialreductioninoverall
approximately ii% of motorcyclists and 14% of car
3D RECONSTRUCTION OF CT THORACIC SPINE SHOWING ACOMM/NUTED FRACTURE OF THE 6TH,
occupants involved in motor vehicle accidents.
7THAND 8TH THORACIC
trauma figures, although there was no change in the rate of spinal injuries. Spinal injury occurs in
The majority of victims are young, with mean ages
VERTEBRAE
of 30.2 years for motorcyclists and 37.8 years for car occupants, and there is a male predominance (motorcycle 88.9%, car 6o.6%). 2 Formal classification allows for assessment of fracture pattern stability and the need for operative intervention. Denis proposed that for assessment of stability, the spine be considered as three columns
-
anterior, middle and posterior. 3
The Denis classification, while relatively simple, is
Figure 2—
incomplete and incomprehensive.The AO group
SAGITTAL SECTION OF CT OF THORACIC SPINE SHOWING THE EXTENT OF THE TRANSLATION OF THE FRAGMENTS, THOUGH WITHOUT IMPINGING ON THE
use a comprehensive classification system which includes three types of fractu res with 55 different subtypes. While more complete, it is cumbersome for daily practice. Both systems have been found to have significant inter-observer variability in their use. `This -
raises difficulties in determining which system to apply, and importantly, which fractures to operate on.
SPINAL CANAL
There is a paucity of evidence from high quality randomised trials on the relative effectiveness of operative and conservative treatment of unstable trau matic thoracol u m ba r fractu res. Retrospective studies have found favourable radiological outcomes following operative intervention with better resorption of retropulsed fractures in that group.)
studies indicate favourable short-term pain control
Figure3AXIAL SECTION OF CT THORACIC SPINE SHOWING DEGREE OF COMMINUTION OF THE ANTERIOR AND MIDDLE COLUMNS, ANDA PATENT
with surgery, though there is no appreciable difference
SPINAL CANAL
However, it has been found that surgical intervention carries a higher risk of wound infection (8% vs o %), while nonoperativetreatment results in longer hospital stay (24 days).' With regard to thoracolumbar spinal fractures without neurological injury, some
in long-term outcome in either group.' There is considerable range in hospital costs incurred depending on how such an injury is treated. In one review of the economic impact of these, stable fractures without neurological deficits which were treated nonoperatively inferred a cost of €5,ioo. Unstable fractures without neurological deficits which were treated nonoperatively had an average cost of €12,500, while those treated operatively had an average cost of €19,700. Unstable fractures with neurological deficits were usually treated surgically at an average cost of €31,9oo. 3 These factors
IRISH JOURNAL OF MEDICAL SCIENCE - VOLUME 175 • NUMBER 4
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COMMINUTED FRACTURE OF THE THORACIC SPINE
contribute in selecting treatment with increasing frequency in a more consumer driven health system.
3.
Denis F The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine. 1983;8(8):817-31.
4.
Wood KB, Khanna G,Vaccaro AR, Arnold PM, Harris MB, Mehbod AA Assessment of two thoracolumbar fracture classification systems as used by multiple surgeons.J
This case highlights difficulties with regard to optimal treatment of comminuted spinal fractures without neurological deficit and illustrates the high economic and personal cost associated with this type of injury.The optimal management of traumatic thoracic injuries remains a controversial issue. Adequate assessment is paramount in selecting the appropriate management. There is no clear consensus on the treatment of unstable thoracic fractures without neurological injury. In the absence of concomitant neurological injury, it is possible to achieve a good outcome regardless of how the fracture is treated.
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Lenehan B, Street J, Barry K, Mullan G Immediate impact of `penalty points legislation' on acute hospital trauma services. Injury 2005;36(8):912-6.
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Robertson A, BranfootT, Barlow IF, Giannoudis PV. Spinal injury patterns resulting from car and motorcycle accidents. Spine. 2002;27(24):2825 -3o.
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Gotzen L, Puplat D, Junge A. Indications, technique and results of monosegmental dorsal spondylodesis in wedge compression fractures (grade II)of the thoracolumbar spine. Unfallchirurg 1992 95:445 -454
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Van der Roer N, de Bruyne MC, Bakker FC, van Tulder MW, Boers M. Direct medical costs of traumatic thoracolumbar spine fractures. Acta Orthop. 2005;76(5):662-6.
Correspondence to: James Cashman, Dept of Orthopaedics, Cork University Hospital, Wilton, Cork; Tel: (027) 4546400; Email:
[email protected]
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