High-yield overview
T10-L2 Junction | TLICS Guides Treatment | PLC is Key
T12-L1Most common level
TLICS 4+Surgical threshold
PLCKey stability determinant
50%Of all spine fractures
TLICS CLASSIFICATION
TLICS 0-3
PatternStable pattern
TreatmentNon-operative (brace)
TLICS 4
PatternIndeterminate
TreatmentSurgeon discretion
TLICS 5+
PatternUnstable pattern
TreatmentSurgical stabilization
Critical Must-Knows
- TLICS score (morphology + PLC + neurology) guides treatment decisions
- Posterior ligamentous complex (PLC) is the key stability determinant
- T12-L1 junction is the most commonly injured level (transition zone)
- Burst fractures may be managed non-op if TLICS less than 4 and neurologically intact
- Short segment fixation (one above, one below) is current trend
Clinical Pearls
- "TLICS 4 or more indicates surgical management
- "Indeterminate PLC on imaging = 2 points, disrupted = 3 points
- "Neurogenic claudication suggests cauda equina level
- "Thoracolumbar junction is transition from rigid kyphotic thoracic to mobile lordotic lumbar
Clinical Imaging
Imaging Gallery
Critical Thoracolumbar Fracture Exam Points
TLICS Score
Three components: Morphology (1-4) + PLC status (0-3) + Neurological status (0-3). Score of 5 or more indicates surgery. PLC is worth most points and is the key determinant.
PLC Assessment
Posterior ligamentous complex = supraspinous, interspinous, ligamentum flavum, facet capsules. MRI essential for assessment. Widened interspinous space and T2 signal = disrupted.
Junction Biomechanics
T12-L1 is most vulnerable because it's a transition zone: rigid kyphotic thoracic spine meets mobile lordotic lumbar spine. Energy concentrates here.
Cord vs Cauda
Conus ends L1-L2. Above = cord injury (UMN signs). Below = cauda equina (LMN signs, bladder). Incomplete cauda has better prognosis than complete cord.
Quick Decision Guide
| TLICS Score | Pattern Example | Treatment | Key Pearl |
|---|---|---|---|
| 1-3 | Compression fracture, PLC intact | TLSO brace 8-12 weeks | Most common scenario - non-op works well |
| 4 | Burst, indeterminate PLC | Surgeon preference | MRI critical - PLC status determines treatment |
| 5-6 | Burst + disrupted PLC | Posterior stabilization | Short segment pedicle screws |
| 7+ | Translation + incomplete neuro deficit | Urgent posterior decompression + fusion | Consider anterior if significant vertebral body loss |
Mnemonic
MPNTLICS Score Components
| M | Morphology Compression=1, Burst=2, Translation/rotation=3, Distraction=4 |
| P | PLC status Intact=0, Indeterminate=2, Injured=3 |
| N | Neurological status Intact=0, Root=2, Complete cord=2, Incomplete=3 |
| M | Morphology Compression=1, Burst=2, Translation/rotation=3, Distraction=4 |
| P | PLC status Intact=0, Indeterminate=2, Injured=3 |
| N | Neurological status Intact=0, Root=2, Complete cord=2, Incomplete=3 |
Hook:MPN guides treatment: Morphology, PLC, Neurology - TLICS 5+ means surgery!
Mnemonic
SFLCPLC Components
| S | Supraspinous ligament Superficial posterior structure |
| F | Flavum (ligamentum) Between laminae |
| L | Interspinous Ligament Between spinous processes |
| C | Capsule (facet) Facet joint capsules |
| S | Supraspinous ligament Superficial posterior structure | L | Interspinous Ligament Between spinous processes |
| F | Flavum (ligamentum) Between laminae | C | Capsule (facet) Facet joint capsules |
Hook:The PLC is the posterior tension band - if disrupted, the spine is unstable in flexion!
Mnemonic
AMPDenis Three-Column Concept
| A | Anterior column Anterior 2/3 of body, disc, ALL |
| M | Middle column Posterior 1/3 of body, disc, PLL |
| P | Posterior column Posterior elements, PLC |
| A | Anterior column Anterior 2/3 of body, disc, ALL |
| M | Middle column Posterior 1/3 of body, disc, PLL |
| P | Posterior column Posterior elements, PLC |
Hook:Denis: Two-column injury = unstable. Middle column is the key to stability!
Mnemonic
TRANSThoracolumbar Junction
| T | Transition zone T12-L1 most common |
| R | Rigid thoracic above Rib cage stabilizes |
| A | And Connection point |
| N | No ribs lumbar below Mobile segment |
| S | Stress concentration Why fractures occur here |
| T | Transition zone T12-L1 most common | N | No ribs lumbar below Mobile segment |
| R | Rigid thoracic above Rib cage stabilizes | S | Stress concentration Why fractures occur here |
| A | And Connection point |
Hook:TRANS-ition from rigid to mobile is where energy concentrates and fractures occur!
Overview and Epidemiology
Thoracolumbar fractures are the most common spinal fractures, typically occurring at the thoracolumbar junction (T10-L2), with peak incidence at T12-L1.
Epidemiology:
- Bimodal distribution: young trauma, elderly osteoporotic
- Male predominance in high-energy trauma
- Female predominance in osteoporotic fractures
- MVA and falls are primary mechanisms
- Associated injuries common (50% have other injuries)
Why T12-L1?
The thoracolumbar junction (T12-L1) is where the rigid kyphotic thoracic spine (stabilized by rib cage) meets the mobile lordotic lumbar spine (no ribs). This creates a stress concentration - energy focuses here, making it the most common fracture site.
Associated injuries:
- Visceral (liver, spleen, kidneys)
- Other spine levels (10-15% have non-contiguous fractures)
- Lower extremity (calcaneus fractures with axial load)
- Head injuries
Anatomy and Biomechanics
Denis three-column concept:
| Column | Structures | Function |
|---|---|---|
| Anterior | Anterior 2/3 vertebral body, disc, ALL | Compression resistance |
| Middle | Posterior 1/3 vertebral body, disc, PLL | Key stability (compression and tension) |
| Posterior | Pedicles, facets, laminae, spinous processes, PLC | Tension band, flexion resistance |
Middle Column is Key
In Denis' concept, the middle column is the key to stability. Injury to the middle column (burst fracture) is more significant than anterior column alone (compression fracture). Two-column injury = unstable.
Posterior ligamentous complex (PLC): Components that form the posterior "tension band":
- Supraspinous ligament
- Interspinous ligament
- Ligamentum flavum
- Facet joint capsules
Why PLC is critical:
- Primary restraint to flexion
- If disrupted, spine fails in flexion
- Brace/cast cannot substitute for PLC
- This is why TLICS weights PLC at 3 points
Neurological anatomy:
- Conus medullaris ends T12-L2 (usually L1)
- Above conus: spinal cord injury (UMN)
- At conus: mixed picture
- Below conus: cauda equina (LMN, better prognosis)
Biomechanics of injury:
- Flexion-compression: Compression and burst fractures
- Flexion-distraction: Chance fractures, seat belt injuries
- Translation/rotation: Fracture-dislocations (most unstable)
- Extension: Hyperextension injuries (rare)
Classification Systems
Thoracolumbar Injury Classification and Severity Score (TLICS)
The TLICS is the most widely used classification for guiding treatment decisions.
Component 1: Morphology (1-4 points)
| Pattern | Points | Description |
|---|---|---|
| Compression | 1 | Loss of vertebral height, anterior wedge |
| Burst | 2 | Anterior and posterior cortex involvement, canal compromise |
| Translation/rotation | 3 | Horizontal displacement or rotation |
| Distraction | 4 | Abnormal separation of vertebrae (flexion or extension) |
Component 2: Posterior Ligamentous Complex (0-3 points)
| PLC Status | Points | Imaging Findings |
|---|---|---|
| Intact | 0 | Normal anatomy, no widening |
| Suspected/Indeterminate | 2 | Interspinous widening, subtle T2 signal |
| Injured | 3 | Facet diastasis, T2 signal in PLC, widened spinous processes |
Component 3: Neurological Status (0-3 points)
| Status | Points | Description |
|---|---|---|
| Intact | 0 | No deficit |
| Nerve root injury | 2 | Radiculopathy |
| Complete cord/conus/cauda | 2 | Complete deficit |
| Incomplete cord/conus/cauda | 3 | Incomplete - needs decompression |
| Cauda equina syndrome | +1 | Add to score for ongoing compression |
TLICS Treatment Threshold
- TLICS 0-3: Non-operative (brace)
- TLICS 4: Surgeon discretion (often non-op if PLC intact)
- TLICS 5+: Operative
Clinical Assessment
History:
- Mechanism (MVA, fall from height, fall from standing)
- Energy level guides suspicion
- Neurological symptoms (weakness, numbness, bowel/bladder)
- Previous spine problems
- Osteoporosis risk factors
Physical examination:
Spine Examination
- Inspection: Bruising (especially transverse), deformity, swelling
- Palpation: Tenderness, step-off, interspinous gap
- Neurological: Complete lower limb neuro exam
- Log-roll: Full spine palpation
Associated Injuries
- Abdominal: Seat belt sign = 50% have intra-abdominal injury
- Calcaneus: Axial load mechanism
- Other spine levels: 10-15% non-contiguous
- Head: Altered consciousness affects exam reliability
Neurological examination:
Cord vs Cauda Equina Injury
| Feature | Cord (above L1) | Cauda Equina (below L1) |
|---|---|---|
| Reflexes | Hyperreflexia, Babinski+ | Hyporeflexia/areflexia |
| Tone | Increased (spasticity) | Decreased (flaccid) |
| Pattern | Symmetric, level-dependent | Asymmetric, root pattern |
| Bladder | Spastic, small capacity | Atonic, overflow |
| Prognosis | Variable | Better (peripheral nerve) |
Key Dermatomal and Myotomal Landmarks
- L1: Inguinal region
- L2: Anterior thigh, hip flexion
- L3: Knee, knee extension
- L4: Medial ankle, ankle dorsiflexion
- L5: Dorsal foot, big toe extension
- S1: Lateral foot, ankle plantarflexion
- S2-5: Perianal sensation (critical for complete vs incomplete)
Investigations
Imaging Protocol
ImmediateCT Thoracolumbar Spine
First-line in trauma. Thin-cut from T10-L3 (extend as needed). Sagittal and coronal reconstructions. Assess morphology, canal compromise, posterior element injury.
If neurological deficit or PLC assessment neededMRI
Essential for PLC and cord. STIR best for ligament injury. T2 for cord edema/contusion. Helps differentiate indeterminate from injured PLC.
Elderly or osteoporoticConsider DEXA
Bone quality affects treatment. May influence decision for cement augmentation or longer constructs.
Post-operativeCT at 6-12 months
Assess fusion. Earlier if concern about hardware or loss of correction.
CT interpretation:
Key features to assess:
- Vertebral body: Loss of height (%), endplate involvement
- Canal compromise: Percentage occlusion
- Posterior elements: Pedicle fractures, facet injuries, lamina fractures
- Spinous process widening: Suggests PLC injury
- Translation/rotation: Highly unstable pattern
MRI for TLICS scoring:
MRI Signs of PLC Injury
- Widened interspinous space with T2/STIR hyperintensity
- Facet widening or subluxation with fluid
- Disruption of supraspinous ligament (high signal replacing dark line)
- Ligamentum flavum signal change
These findings convert "indeterminate" (2 points) to "injured" (3 points) on TLICS.
Imaging Selection Guide
| Scenario | Imaging | Key Question |
|---|---|---|
| High-energy trauma | CT thoracolumbar | Rule out fracture, assess morphology |
| Fracture found, neurologically intact | MRI if surgical candidate | PLC status for TLICS |
| Neurological deficit | Urgent MRI | Cord/cauda compression, surgical planning |
| Elderly, low-energy fall | CT, consider MRI if surgery | Multiple levels, PLC status |
Management
Algorithm
Conservative Treatment
Indications (TLICS 0-3):
- Compression fracture with intact PLC
- Some burst fractures with TLICS less than 4
- Neurologically intact
- Stable fracture pattern
Protocol:
Non-Operative Protocol
Week 0-2Acute phase
Pain control, bed rest as needed, log-roll precautions. May stand with TLSO if tolerated.
Week 2-12Bracing phase
TLSO brace (thoracolumbar sacral orthosis) full-time except sleeping. Serial X-rays at 2, 6, 12 weeks. Monitor for kyphosis progression.
Week 12+Weaning phase
Gradual brace weaning. Physiotherapy for core strengthening. Return to activities based on symptoms and imaging.
Imaging follow-up:
- X-rays at 2, 6, 12 weeks
- Look for kyphosis progression more than 10-15 degrees
- If progressing: consider surgery
When Non-Op Fails
Convert to surgery if:
- Kyphosis progresses more than 10-15 degrees
- Neurological deterioration
- Unable to mobilize with brace
- Uncontrolled pain
Surgical Technique
Consent Points
- Neurological injury: Rare if no deficit pre-op
- Infection: 1-3%
- Hardware failure: 5-15% (higher in short segment)
- Need for revision/additional levels: 5-10%
- Adjacent segment disease: Long-term risk
- DVT/PE: 2-5%
Equipment Checklist
- Imaging: Fluoroscopy or navigation
- Pedicle screws: Appropriate sizes, polyaxial heads
- Rods: Pre-contoured or malleable
- Decompression instruments: If laminectomy planned
- Cell saver: For major reconstructions
Complications
| Complication | Incidence | Prevention/Management |
|---|---|---|
| Hardware failure | 5-15% | Adequate construct length, consider index screws |
| Loss of correction | 10-20% | Include index level, cement augmentation in osteoporosis |
| Non-union/pseudarthrosis | 5-10% | Bone graft, smoking cessation |
| Adjacent segment disease | Up to 30% long-term | Short segment when possible |
| Neurological injury | Less than 1% | Navigation, neuromonitoring, careful technique |
| Infection | 1-3% | Prophylactic antibiotics, meticulous technique |
| DVT/PE | 2-5% | Mechanical and chemical prophylaxis |
Hardware failure:
- More common in short segment constructs
- Risk factors: osteoporosis, severe kyphosis, anterior column deficiency
- Prevention: index level screws, cement augmentation, consider anterior column support
Loss of correction:
- Kyphosis recurrence after initial reduction
- Prevention: adequate construct, address anterior column if significant loss
Postoperative Care
Rehabilitation Timeline
ImmediateDay 0-2
- Wound drain (remove 24-48h)
- DVT prophylaxis
- Pain management
- Early mobilization if neurology intact
EarlyWeek 1-2
- Mobilize with physio
- Brace (TLSO) if additional support desired
- Wound check at 2 weeks
IntermediateWeek 2-12
- Progressive activity
- X-rays at 6 weeks
- Core strengthening program
Late3-12 months
- CT fusion assessment 6-12 months
- Return to work/activity based on imaging and symptoms
- Long-term surveillance for adjacent disease
Bracing post-operatively:
- Variable practice
- Some surgeons use TLSO 6-12 weeks for additional support
- Others rely on instrumentation alone
- Consider in osteoporosis, single-level short segment, compliance concerns
Outcomes and Prognosis
Neurological outcomes:
- Intact: Stays intact with appropriate treatment
- Cauda equina: Good potential for recovery if decompressed
- Incomplete cord/conus: Moderate potential
- Complete: Poor neurological prognosis
Non-operative outcomes:
- Good for stable fractures (TLICS 0-3)
- 10-15% develop progressive kyphosis
- Most return to normal function
Surgical outcomes:
- High fusion rates with instrumentation
- Kyphosis correction maintained in 80-85%
- Adjacent segment disease main long-term concern
Evidence Base
TLICS: Defining Classification
Vaccaro et al • Spine (2005)
Key Findings:
- Introduced the Thoracolumbar Injury Classification and Severity Score (TLICS)
- Three components: injury morphology, posterior ligamentous complex integrity, neurological status
- Composite score stratifies patients into operative and non-operative groups
- Developed by international Spine Trauma Group consensus
Clinical Implication: TLICS provides a reproducible, treatment-guiding classification that integrates PLC status and neurology - the dominant decision tool in contemporary practice.
Limitation: Initial publication based on expert consensus; reliability/validity established in later studies.
AO Spine Thoracolumbar Classification
Vaccaro et al • Spine (2013)
Key Findings:
- International consensus morphological system: Type A (compression), Type B (tension band), Type C (displacement/translation)
- Adds neurological grade (N0-N4, NX) and patient-specific modifiers (M1-M2)
- Substantial interobserver reliability for injury type (kappa = 0.72)
- Designed to harmonise global communication and research
Clinical Implication: The AO Spine system is the most widely adopted descriptive classification internationally; the linked TL AO Spine Injury Score (TL AOSIS) extends it to treatment guidance.
Limitation: Consensus-derived; reliability lower for Type A subtypes and for PLC-dependent B2 distinction.
Operative vs Non-operative for Stable Burst Fractures (Long-term RCT)
Wood et al • J Bone Joint Surg Am (2003)
Key Findings:
- Prospective RCT: 47 patients with stable burst fracture and no neurological deficit
- Operative (arthrodesis/instrumentation) vs non-operative (cast/orthosis)
- No significant difference in pain or return to work at mean 44 months
- Complications more frequent in the operative group
Clinical Implication: Non-operative treatment is appropriate for neurologically intact stable burst fractures - surgery confers no major long-term advantage.
Limitation: Small sample; later 16-22 year follow-up (Wood 2015, PMID 25568388) actually favoured non-operative care for pain and disability.
Fracture-level (Index) Screw in Short-segment Fixation
Guven et al • J Spinal Disord Tech (2009)
Key Findings:
- Prospective RCT, 72 patients with unstable thoracolumbar burst fractures, 4 groups
- Adding a screw at the fractured level improved intraoperative correction and its maintenance
- Benefit most pronounced in the short-segment fixation subgroup
- Mean follow-up 50 months
Clinical Implication: Incorporating an index-level screw in short-segment constructs improves kyphosis correction and immediate stability.
Limitation: Single-centre RCT; specific implant systems and radiographic (not patient-reported) primary outcomes.
PLC Disruption on CT/MRI: Reliability
Schweitzer, Vaccaro et al • J Orthop Sci (2007)
Key Findings:
- Spine Trauma Study Group inter-rater study of PLC injury indicators
- Facet diastasis on CT was the most reliable single indicator of PLC disruption (kappa = 0.40)
- Posterior oedema-like signal on T2 FAT SAT MRI showed fair agreement (70.5%)
- Identification of frankly disrupted PLC on T1 MRI was poor (48.9% agreement)
Clinical Implication: No single imaging sign is definitive for PLC injury; combine facet diastasis on CT with T2/STIR signal to inform the TLICS indeterminate (2) vs injured (3) distinction.
Limitation: Modest case number; observer agreement only fair, underscoring the indeterminate PLC category.
Cement Augmentation of Pedicle Screws in Osteoporotic Bone
Choma et al • Spine (2012)
Key Findings:
- Human osteoporotic cadaveric biomechanical study
- PMMA cement augmentation significantly increased pedicle screw pullout strength
- Fenestrated screws confined cement to the vertebral body, reducing canal extrusion risk
- High-viscosity PMMA was safely injectable through fenestrations
Clinical Implication: Cement (PMMA) augmentation, ideally via fenestrated screws, enhances fixation in osteoporotic thoracolumbar fractures requiring instrumentation.
Limitation: Cadaveric biomechanical model; does not capture in-vivo fusion, cement leakage, or clinical outcomes.
Surgical Timing in Acute SCI (STASCIS)
Fehlings, Vaccaro et al • PLoS One (2012)
Key Findings:
- Prospective multicentre cohort, 313 patients with acute cervical SCI
- Early (less than 24h) vs late decompression
- Early surgery: 19.8% achieved 2 or more grade AIS improvement vs 8.8% late (adjusted OR 2.8)
- No increase in complications or mortality with early surgery
Clinical Implication: Early decompression (less than 24h) improves neurological recovery in cervical SCI; the principle is widely extrapolated to thoracolumbar injuries with incomplete deficit and ongoing compression.
Limitation: Cohort enrolled cervical SCI only; direct thoracolumbar randomised evidence is lacking.
Exam Viva Scenarios
Use these scenarios to practise clinical reasoning and management decisions
CLINICAL SCENARIOStandard
Scenario 1: Burst Fracture TLICS Scoring
CLINICAL PROMPT
"A 28-year-old man falls from 4 meters landing on his feet. CT shows an L1 burst fracture with 40% canal compromise. He is neurologically intact. MRI shows no PLC injury. What is your assessment and management?"
PRACTICAL APPROACH
This patient has sustained an **L1 burst fracture** from a high-energy axial load mechanism. I will assess using the **TLICS classification**. **TLICS Score calculation:** - **Morphology**: Burst fracture = 2 points - **PLC status**: MRI shows intact PLC = 0 points - **Neurological status**: Intact = 0 points - **Total TLICS Score = 2** A score of **2 is in the non-operative range** (0-3). **My management:** Despite the significant canal compromise (40%), the key factors are: - PLC is intact (stable posterior tension band) - Neurologically intact - Low TLICS score **Non-operative treatment:** - **TLSO brace** for 8-12 weeks - Serial X-rays at 2, 6, 12 weeks - Monitor for kyphosis progression (more than 10-15 degrees indicates surgery) - Gradual mobilization with brace - Core strengthening physiotherapy **Follow-up:** If kyphosis progresses or neurological symptoms develop, I would convert to surgical stabilization with posterior pedicle screw fixation. The Wood et al RCT showed no functional difference between operative and non-operative treatment for stable burst fractures without neurological deficit, supporting this approach.
KEY CLINICAL POINTS
TLICS score: Burst=2 + PLC intact=0 + Neuro intact=0 = 2
TLICS 2 is in non-operative range
Canal compromise alone doesn't mandate surgery
PLC integrity is the key factor
TLSO brace for 8-12 weeks with serial imaging
COMMON PITFALLS
Operating just because of canal compromise
Forgetting to check PLC on MRI
Incorrect TLICS scoring
Not following up for kyphosis progression
FURTHER QUESTIONS
"What if the PLC was disrupted?"
"What if kyphosis increases to 25 degrees at 6 weeks?"
"How would you manage if this was an L4 fracture (conus level)?"
CLINICAL SCENARIOChallenging
Scenario 2: Distraction Injury with Neurological Deficit
CLINICAL PROMPT
"A 35-year-old restrained passenger in an MVA presents with T12-L1 distraction injury on CT. She has ASIA D incomplete paraparesis. MRI confirms PLC disruption and cord edema. Describe your surgical approach."
PRACTICAL APPROACH
This is a **flexion-distraction injury** at the thoracolumbar junction with **incomplete neurological deficit** - a surgical emergency. **TLICS Score:** - **Morphology**: Distraction = 4 points - **PLC status**: Disrupted = 3 points - **Neurological status**: Incomplete cord = 3 points - **Total TLICS = 10** This definitively requires **surgical stabilization**. **Urgency:** Given the incomplete neurological deficit with cord compression (edema), this should be treated **urgently within 24 hours** based on STASCIS evidence. **Surgical approach:** **Posterior pedicle screw fixation** is my approach of choice. **Positioning:** Prone on Jackson table, abdomen free. Neuromonitoring (SSEPs and MEPs) baseline before positioning. **Technique:** - Midline incision T11-L2 - Subperiosteal exposure to transverse processes - Pedicle screw placement T11, T12, L1, L2 (two above, two below) - Given the distraction injury, I will use **compression** across the construct (not distraction) to reduce the diastasis - Consider laminectomy only if direct decompression needed **Why longer construct?** Distraction injuries are highly unstable with complete PLC failure. I would use **two levels above and below** for more rigid fixation. **Post-operative:** - ICU monitoring - DVT prophylaxis - Early rehabilitation - TLSO brace for 6-12 weeks
KEY CLINICAL POINTS
Distraction injury = 4 points morphology (highest)
PLC always disrupted in distraction = 3 points
Incomplete neuro = urgent surgery
Use COMPRESSION across distraction injury (not distraction)
Longer construct for distraction injuries
COMMON PITFALLS
Using distraction to reduce (you use compression for distraction injuries)
Short segment fixation for highly unstable distraction
Delaying surgery when incomplete deficit present
Forgetting neuromonitoring
FURTHER QUESTIONS
"Would you add anterior column support?"
"What if this was at L3-4 (below conus)?"
"How would you manage a concurrent Chance fracture pattern?"
CLINICAL SCENARIOCritical
Scenario 3: Hardware Failure After Short Segment Fixation
CLINICAL PROMPT
"A 55-year-old diabetic smoker presents 6 weeks after posterior short segment fixation (T12-L2) for an L1 burst fracture. X-rays show screw pullout and progressive kyphosis to 30 degrees. How do you manage this?"
PRACTICAL APPROACH
This patient has **hardware failure** with **progressive kyphosis** - a common complication of short segment fixation, particularly with risk factors like diabetes and smoking. **Assessment:** - **Current neurological status**: Full exam, compare to pre-op - **Imaging**: CT to assess screw position, fusion status, bone quality - **Risk factor modification**: Smoking cessation, diabetes control **Why did this fail?** - Risk factors: Diabetes (impaired healing), smoking (inhibits fusion) - Short segment (4 screws) has higher failure rate than longer constructs - Possible osteoporosis (not mentioned but should be assessed) - Anterior column deficiency not addressed initially **Management options:** **Option 1: Revision posterior with longer construct** - Add levels (two above, two below = T11-L3) - Consider cement-augmented screws given likely poor bone quality - Add index level screws at L1 if salvageable **Option 2: Combined anterior-posterior** - If significant anterior column deficiency - Anterior corpectomy and cage for structural support - Plus extended posterior instrumentation **My recommendation:** Given the 30-degree kyphosis and anterior column involvement: - **Anterior corpectomy L1** with structural cage - **Extended posterior instrumentation** T11-L3 with cement augmentation - This addresses both the anterior column deficiency and provides robust posterior fixation **Adjuncts:** - Bone graft for fusion - Smoking cessation program - Consider teriparatide for bone quality - TLSO post-operatively for 12 weeks
KEY CLINICAL POINTS
Short segment fixation has 10-15% failure rate
Risk factors: smoking, diabetes, osteoporosis
Options: extend posterior or add anterior
Cement augmentation in poor bone quality
Address anterior column if deficient
COMMON PITFALLS
Simple revision with same construct (will fail again)
Not addressing underlying bone quality
Ignoring anterior column deficiency
Not counseling on smoking cessation
FURTHER QUESTIONS
"How would you augment screws with cement?"
"What DEXA T-score would concern you?"
"Would you use BMP in this revision case?"
MCQ Practice Points
TLICS Scoring Question
Q: A patient has an L1 burst fracture with PLC disruption on MRI and is neurologically intact. What is the TLICS score? A: Morphology (burst) = 2 + PLC (disrupted) = 3 + Neurology (intact) = 0 = TLICS 5 (surgical indication)
PLC Components Question
Q: What structures make up the posterior ligamentous complex? A: Supraspinous ligament, interspinous ligament, ligamentum flavum, and facet joint capsules.
Junction Anatomy Question
Q: Why is T12-L1 the most common fracture level? A: It is the transition zone between the rigid kyphotic thoracic spine (rib stabilization) and the mobile lordotic lumbar spine. Energy concentrates at this junction.
Conus Level Question
Q: At what level does the conus medullaris typically end? A: L1-L2 (ranges T12-L2). Injuries above this level involve the cord; below involve only cauda equina.
Fixation Construct Question
Q: What modification to short segment fixation reduces failure rates? A: Adding index level screws (screws into the fractured vertebra) improves kyphosis control and reduces implant failure.
Ligamentotaxis Question
Q: What is ligamentotaxis and when does it work? A: Using distraction to reduce retropulsed fragments via the intact PLL. Works best if PLL intact, surgery within 72 hours, and adequate distraction achieved.
Guidelines, Registries & Global Practice
Global epidemiology:
Thoracolumbar fractures are the most common spinal column injuries, concentrated at the T10-L2 junction with peak incidence at T12-L1. A bimodal pattern is seen worldwide: high-energy injuries (road trauma, falls from height) in young men, and low-energy osteoporotic fractures in older women. In resource-limited settings, road-traffic and fall mechanisms dominate, and short-segment pedicle screw fixation can be delivered safely and cost-effectively - a Cambodian series reported good neurological recovery in 65% of incomplete spinal cord injuries treated operatively at a cost of US$100-280 per surgery (Chua et al, World Neurosurg 2018, PMID 29550593, DOI).
Guideline and classification landscape (side-by-side):
Classification & Guidance by Body
| Body / System | Tool | Treatment driver | Evidence basis |
|---|---|---|---|
| Spine Trauma Group (TLICS) | TLICS score | Morphology + PLC + neurology; surgery if 5 or more | Consensus; reliability validated (Level 4) |
| AO Spine / AOSpine | AO Spine TL + TL AOSIS | Type A/B/C + neurology + modifiers | International consensus, kappa 0.72 (Level 4) |
| AAOS / North American practice | TLICS-based algorithms | Non-op for intact stable burst | RCT-supported for stable burst (Level 2) |
| NICE (UK) NG41 | Spinal injury assessment pathway | Imaging triage, early specialist referral | Guideline consensus + evidence review |
| BOA / BASS (UK) BOAST | Spinal clearance & SCI standards | Timely transfer, MRI for cord/PLC | Standards of care (consensus) |
Registry & system evidence:
- No dedicated international thoracolumbar fracture registry exists comparable to arthroplasty registries; outcome evidence derives from RCTs, prospective cohorts (e.g. STASCIS) and national spinal-injury databases.
- National spinal cord injury registries and trauma networks (e.g. UK Major Trauma Network, Australian state trauma systems, North American Spinal Cord Injury models systems) report epidemiology and rehabilitation outcomes rather than implant survival.
Practice variation:
- TLICS 4 (indeterminate): the principal area of global disagreement - surgeon discretion drives wide variation between operative and non-operative care.
- Construct length: short-segment fixation predominates in North America/Europe; longer constructs and routine index-level screws are favoured for higher-energy or osteoporotic patterns.
- Bracing after surgery and for stable burst fractures: practice is inconsistent and increasingly questioned by trials showing equivalence of no-brace protocols.
- Anterior vs posterior approaches: anterior/combined surgery is more common where significant anterior column loss or direct decompression is prioritised.
Differential Diagnosis of a Thoracolumbar Vertebral Lesion
| Diagnosis | Distinguishing features | Key investigation |
|---|---|---|
| Acute traumatic fracture | High-energy mechanism, acute pain, marrow oedema on STIR | CT for morphology, MRI (STIR) for acuity/PLC |
| Osteoporotic insufficiency fracture | Low-energy/no trauma, older patient, anterior wedging, often multiple | MRI for acuity; DEXA; assess for occult malignancy |
| Pathological/metastatic fracture | Pedicle destruction, posterior wall convexity, soft-tissue mass, known primary | MRI with contrast, CT, staging/biopsy |
| Osteoporotic vs malignant (Schmorl/benign) | Benign: retropulsion of a posterior fragment, band-like oedema; malignant: epidural mass, pedicle involvement | MRI (diffusion/chemical-shift), biopsy if uncertain |
| Ankylosing spondylitis / DISH fracture | Rigid fused spine, trivial trauma, transverse 'carrot-stick' fracture, high instability | CT whole spine (often unstable; low threshold for fixation) |
| Infection (spondylodiscitis) | Insidious pain, fever, raised inflammatory markers, endplate/disc destruction | MRI with contrast, blood cultures, biopsy |
Medicolegal Considerations
Documentation requirements:
- Complete neurological examination at presentation
- TLICS score or equivalent classification
- MRI interpretation for PLC status
- Treatment rationale documented
- Informed consent including hardware failure risks
Common issues:
- Missed diagnosis (inadequate imaging)
- Delayed surgery with neurological deficit
- Failure to document baseline neurology
- Inadequate follow-up and progression to kyphosis
THORACOLUMBAR FRACTURES
Clinical summary
TLICS Classification
- •Morphology: Compression=1, Burst=2, Translation=3, Distraction=4
- •PLC: Intact=0, Indeterminate=2, Injured=3
- •Neurology: Intact=0, Root=2, Complete=2, Incomplete=3
- •TLICS 0-3=non-op, 4=indeterminate, 5+=surgical
Key Anatomy
- •T12-L1 most common (transition zone)
- •Conus ends L1-L2 (above=cord, below=cauda)
- •Denis three columns: anterior, middle, posterior
- •PLC is the key stability determinant
Treatment Algorithm
- •TLICS less than 4, PLC intact: TLSO brace 8-12 weeks
- •TLICS 5+: Posterior pedicle screw fixation
- •Incomplete neuro deficit: Urgent surgery
- •Significant anterior loss: Consider combined approach
Surgical Pearls
- •Short segment + index screws reduces failure
- •Distraction injuries: use COMPRESSION (not distraction)
- •Ligamentotaxis works if PLL intact and less than 72h
- •Cement augmentation in osteoporosis
Complications
- •Hardware failure: 5-15%
- •Loss of correction: 10-20%
- •Adjacent segment disease: up to 30%
- •Risk factors: smoking, diabetes, osteoporosis