Thoracolumbar fracture-dislocations are high-energy injuries that resulting in a highly unstable spine associated with neurologic deficit which often is complete. These are less common than burst fractures or flexion distraction injuries.
By definition, fracture-dislocation are three column injuries. The mechanism of injury usually involves a combination of forces, including flexion, extension, shear, torsion, and compression.
These injuries are also associated with other musculoskeletal and visceral injuries often.
Fracture dislocations are caused by hyperflexion and rotation forces. One of the example is when a patient is ejected from a vehicle at high speed.
Evaluation of the patient is done in the same manner for any spinal injury. But here a few precautions are very important.
Because these injuries are highly unstable, even the neurologically intact patient must be carefully protected during any necessary testing or emergent operative procedures.
Xrays would reveal the pattern and severity of the injury. On lateral views, a translational deformity or listhesis at the site of injury is visible. The facets are fractured due to substantial translational or rotational forces and displacement may be appreciated on both AP and lateral x-rays. MRI would delineate neurological injury in detail. CT scanning and reconstruction sequences are very important in characterizing these injuries more accurately.
As fracture dislocation injuries to the spine are quite unstable injuries, these are mostly treated with decompression and surgical stabilization. Even in neurologically intact patients surgery is indicated so as the risk of further damage by unstable spine is nulled. Direct decompression is indicated for those patients with an incomplete injury and hopes of improvement.
In case of complete cord injury, stabilization is indicated for the purpose of rehabilitation.
Rarely, when the patient is not fit for surgical treatment or is not willing to for surgery, reduction can be attempted through postural manipulation. Nonoperative treatment requires an extended period of bracing and bed rest.
Posterior surgery is usually most useful for achieving reduction and stability after these injuries. The surgery involves fracture reduction, decompression, fixation with pedicle screws and fusion of the vertebrae.
Because of the severe ligamentous disruption and gross instability that occurs, long fusions have been advocated.
If the spinal stability is restored, the patient can be mobilized as required to improve pulmonary function and general medical care. External immobilization or bracing is usually not necessary but may be given on individual basis.