Thoracic and Lumbar Fractures
Thoracic and lumbar vertebral fractures are traumatic injuries affecting the mid and lower back and account for a large share of all spinal fractures. They most often result from falls, motor vehicle accidents and sports injuries. The thoracolumbar junction (T11-L2) is the most frequent fracture site because it is the transition between the rigid thoracic spine and the mobile lumbar spine. Treatment may be conservative or surgical depending on the degree of instability, neurological status and pain severity.
Última atualização: 2026-06-07
Definition and Mechanisms
The thoracic spine (T1-T12) is more rigid because it is supported by the rib cage, and compression fractures are common, whereas the more mobile lumbar spine (L1-L5) is more prone to burst fractures and translational injuries. Maximum stress concentration occurs at the thoracolumbar junction between the two regions. The mechanism of injury determines the fracture type: axial loading produces compression or burst fractures; the flexion-distraction seen in seatbelt injuries produces the Chance fracture; and high-energy translation/rotation affects all three columns, causing severe instability and a high risk of cord injury.
Denis Three-Column Theory
Denis's three-column theory is used to assess spinal stability: the anterior column (anterior longitudinal ligament, anterior half of the vertebral body), the middle column (posterior half of the body, posterior longitudinal ligament) and the posterior column (pedicles, lamina, facet joints, posterior ligamentous complex). Involvement of one or two columns is generally considered a stable fracture, while involvement of all three indicates an unstable fracture. In current practice the AO Spine and TLICS classifications provide a more comprehensive assessment.
Symptoms
The principal finding is severe, localized back pain at the fracture site that worsens with sitting, standing and bending forward. Tenderness on palpation of the spinous process, ecchymosis and a kyphotic (gibbus) deformity may be seen. In thoracic cord injury, weakness or complete paralysis develops in the lower limbs (paraplegia) while the upper limbs are spared. In injuries below the L2 level, where the spinal cord ends, cauda equina syndrome (saddle numbness, asymmetric motor-sensory loss, bladder-bowel dysfunction) may occur. Because a Chance fracture can be accompanied by intra-abdominal organ injury, nausea, vomiting and abdominal distension are important.
Diagnosis
Diagnosis is established by systematic assessment in patients with a history of high-energy trauma. Computed tomography (CT) is the gold standard, clearly showing fracture lines, fragment displacement, spinal canal narrowing and posterior element injury. Magnetic resonance imaging (MRI) is essential for assessing posterior ligamentous complex injury, disc herniation, cord contusion and cauda equina compression; disruption of the posterior ligamentous complex is a marker of instability. Neurological status is assessed using the ASIA scale.
Treatment Decision with TLICS
The TLICS (Thoracolumbar Injury Classification and Severity Score) is often used in the treatment decision. Three parameters are scored: morphology (compression, burst, translation/rotation, distraction), the state of the posterior ligamentous complex (intact, indeterminate, disrupted) and neurological status. A total score of 3 or less generally supports conservative treatment, 4 indicates borderline cases (patient preference and clinical condition are decisive), and 5 or above supports surgical treatment.
Treatment
For stable compression fractures (intact PLC, no neurological deficit), immobilization with a thoracolumbar orthosis (TLSO) for 8-12 weeks, short-term rest and early mobilization are used, with a high success rate. Surgery is performed for unstable fractures, cord/cauda equina compression or progressive deficit. The most common method is posterior pedicle screw-rod fixation. In severe anterior collapse with canal compromise, anterior corpectomy and fusion may be needed, and in severe instability a combined (anterior-posterior) approach. In osteoporotic compression fractures with refractory pain, vertebroplasty/kyphoplasty can provide pain palliation.
Recovery and Prognosis
Early mobilization is possible after surgery, and because internal fixation usually provides adequate stability, an additional orthosis is not required in most cases. Bone healing is completed in 3-6 months. Prognosis is good in stable fractures without neurological injury; some patients may have mild chronic pain or residual kyphosis. When neurological injury is present, outcome depends on the level of injury and whether it is complete or incomplete; cauda equina injuries tend to have a better course than cord injuries. All outcomes are individual and cannot be guaranteed.
Referências
- Greenberg MS. Greenberg's Handbook of Neurosurgery. 10th ed. Thieme; 2023:1200-1219.
- Vaccaro AR, Oner C, Kepler CK, et al. AOSpine thoracolumbar spine injury classification system. Spine (Phila Pa 1976). 2013;38(23):2028-2037.
- Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine (Phila Pa 1976). 1983;8(8):817-831.
Este artigo é informativo e não substitui um exame médico. As decisões de diagnóstico e tratamento são individuais.