Overview
The thoracolumbar spine is the most commonly injured region of the spine; these injuries usually follow high-energy blunt trauma and are often associated with visceral injuries (Campbell). Treatment aims to relieve ongoing neural compression, correct deformity and restore stability with the least risk and morbidity (Campbell). Pedicle screw and rod fixation is the preferred posterior instrumentation because it fixes all three columns and allows shorter constructs than hooks (Rockwood).
Evaluation (Campbell)
ATLS with a secondary survey that includes inspection and palpation of the entire spine, motor and sensory examination, rectal examination with voluntary anal contraction, and the bulbocavernosus reflex if cord injury is present; record on the ISCoS form.
CT of the chest, abdomen and pelvis with sagittal and coronal reformats is the standard evaluation.
MRI assesses the posterior ligamentous complex (PLC); in a systematic review MRI changed classification in 17% and the treatment plan in 22% of patients.
Classification
TLICS (Campbell)
Component | Points |
|---|---|
Morphology: compression 1; burst 2; translation/rotation 3; distraction 4 | 1-4 |
Neurology: intact 0; nerve root 1 (as tabulated in Campbell); complete cord/conus 2; incomplete cord/conus 3; cauda equina 3 | 0-3 |
PLC: intact 0; suspected/indeterminate 2; injured 3 | 0-3 |
Score 3 or less: nonoperative; 5 or more: operative; 4: either, depending on comorbidities and other injuries. About 60% of patients scoring 4 undergo surgery.
AO Spine thoracolumbar classification (TL AOSIS) (Campbell)
Type A (compression): A0 minor process fractures; A1 wedge-impaction (one endplate, no posterior wall); A2 split/pincer (both endplates, no posterior wall); A3 incomplete burst (posterior wall, one endplate); A4 complete burst (posterior wall, both endplates). A vertical laminar fracture does not constitute tension band failure.
Type B (tension band): B1 transosseous (Chance); B2 posterior osseoligamentous disruption with a type A fracture; B3 hyperextension (anterior), common in ankylosing disorders.
Type C: displacement or dislocation.
Neurology: N0 intact, N1 transient, N2 radicular, N3 incomplete cord or cauda equina, N4 complete cord, NX not examinable, + continued compression. Modifiers: M1 indeterminate tension band injury; M2 patient comorbidity (e.g., ankylosing spondylitis).
The TL AOSIS score guides treatment like TLICS: 3 or less nonoperative, 6 or more operative, 4-5 either.
Nonoperative Treatment (Campbell)
Most thoracolumbar fractures have no deficit and no instability.
Systematic reviews have not shown a clear outcome benefit from bracing. The authors consider an orthosis at or below T7, favored at T12-L2, with more comminution and kyphosis (especially over 15 degrees): a Jewett brace, or a TLSO if there is significant lateral collapse. A3 fractures with mild kyphosis are often treated without a brace.
Check upright radiographs in the brace after mobilization; wear the orthosis whenever upright beyond 30 degrees for 8-12 weeks. Progression of deformity is an indication for surgery.
Osteoporotic fractures: relative rest and symptomatic treatment for 4-6 weeks, treatment of osteoporosis; kyphoplasty if pain persists and the posterior wall is intact.
Operative Decision-Making
Little advantage of surgery over nonoperative care in functional recovery has been shown for neurologically intact burst fractures; controversy remains for TLICS 4 / A4 injuries. The authors treat these nonoperatively when there is no deficit and sagittal alignment is satisfactory on upright films (Campbell).
Patients with cord, conus or cauda equina injury are usually treated operatively to facilitate rehabilitation and recovery (Campbell).
Timing: surgery within 72 hours reduced cardiac, pulmonary and infectious complications in a large series; very early (4 hours) decompression is safe but without clear advantage over 24-48 hours (Campbell).
Canal compromise is not itself an indication for decompression. Canal encroachment at impact is about 85% greater than on static images, and the canal remodels after conservative care; direct decompression is not indicated without neurologic deficit (Campbell).
Indirect decompression by ligamentotaxis works for burst fractures with intact spanning ligaments; avoid distraction in type C translational injuries, where it can lengthen and injure the cord (Campbell).
Short-segment fixation (one level above and below) has been associated with hardware failure and kyphosis in burst fractures because the deficient anterior column exposes the posterior construct to cantilever loads. Rockwood limits it to young, healthy patients with good bone and strong screw purchase, and recommends extending at least two levels above and below in osteoporotic bone, the thoracic spine or thoracolumbar junction, or severely comminuted bodies; anterior column support (transpedicular graft, cement, or corpectomy) reduces failure.
Anterior decompression and reconstruction is favored by Campbell for severe but incomplete cord injury at T12-L3 with ongoing compression; posterior surgery is quickest, with the least blood loss and cost, and outcomes are similar across approaches.
Be cautious with posterior decompression when there are vertical laminar fractures: dural tears with entrapped roots are frequent (Campbell).
Technique 48.15: Posterior Segmental Fixation with Pedicle Screws (Campbell)
Setup and exposure
Use a fully radiolucent table; position prone on a four-post frame or chest rolls to obtain postural reduction.
Use neuromonitoring in intact or incomplete patients if the canal will be manipulated (distraction, ligamentotaxis). Give tranexamic acid (authors: 20 mg/kg load, then 2 mg/kg/hour).
Image to confirm postural reduction and plan the incision; prepare the iliac crest if graft is needed.
Score the skin from one spinous process above to one below the instrumented vertebrae; infiltrate dilute epinephrine (1 mg in 500 mL saline).
Dissect to the fascia, preserve it for closure, confirm the level radiographically and expose subperiosteally to the tips of the transverse processes.
Release muscle carefully at the fracture level, watching for CSF leak or free nerve roots.
Thoracic pedicle screws
Obtain a true AP view: sharp superior endplate, symmetric pedicles, spinous process centered.
With a burr at the superomedial base of the transverse process, open the cortex at the 2-o'clock position on the right pedicle (10 o'clock on the left).
Advance the probe medially from the lateral toward the medial pedicle cortex so that its tip reaches the medial border of the pedicle image at a depth of 18-20 mm, by which point it has entered the vertebral body; direct it slightly caudally.
Advance to the desired depth; sound all four walls and the anterior body with a ball-tipped probe.
Place the largest screw the pedicle accepts (narrowest at T4-T6); tap dense bone or large screws and resound.
If the pedicle is too narrow, use an in-out-in path through the costovertebral joint (less purchase).
Polyaxial screws are usual; monoaxial screws give more rigidity and help reduction.
Lumbar pedicle screws
At L1-L2 (narrow pedicles) use the thoracic AP technique; for L3 and below use a true lateral view with superimposed pedicles.
Traditional trajectory: open the cortex just posterior to the junction of the transverse process and superior articular mass, in line with the pedicle bisector on the lateral view (near the pars-superior articular junction). Avoid the facet at the top instrumented level. Decorticate the transverse process before screw insertion.
Advance the probe anteriorly and medially (about 0-10 degrees at L1 to 20-30 degrees at L5) to the anterior third of the body.
Sound all walls; place the largest screw that fits easily (larger screws risk pedicle fracture); tap sclerotic bone.
Place bone graft on the decorticated bed before inserting the screw; confirm with an end-on view.
Cortical bone trajectory (CBT) (Campbell)
Inferomedial-to-superolateral path that increases cortical contact and pull-out strength, useful in osteoporosis; contraindicated with spondylolysis.
Start on the pars below the facet: 7 o'clock on the right and 5 o'clock on the left pedicle on the AP view; aim 25-30 degrees cranial and 10 degrees lateral, ending at 1 o'clock (right) / 11 o'clock (left). Depth 40-50% of the body; screws usually 4.5-5.5 mm. The dense pars splits if the screw is too large.
Rod placement and closure
Complete any direct decompression (transpedicular or costotransversectomy) before rod placement.
Cut the rod with extra length if distraction is planned; undercontour the kyphosis so reduction of the rod into the screw heads helps correct the deformity.
Reduce the rod with multiple reducers to avoid excessive pull on any screw; loosely insert blockers.
Apply distraction or compression as the injury requires, contour in situ if needed, then final-tighten; add crosslinks if necessary.
Confirm reduction on AP and lateral views.
Decorticate posterior elements and transverse processes and graft with local or iliac autograft (in the lumbar spine before screw placement).
Close the fascia over a drain with sutures through the spinous processes; subcuticular skin closure.
Posterolateral decompression (Campbell)
Effective at the thoracolumbar junction and lumbar spine: hemilaminectomy and pedicle removal with a high-speed burr, then undercut and impact retropulsed fragments anteriorly into the body. Riskier in the thoracic spine where the cord has less room.
Postoperative Care (Campbell)
CT to verify screw position and residual compression in patients with deficits.
Mobilize on the first postoperative day with an orthosis for 8-12 weeks, guided by pain and radiographic healing.
References
Williams KD. Fractures, dislocations, and fracture-dislocations of the spine. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Philadelphia: Elsevier; 2026. Chapter 48, Technique 48.15.
Kitto A, Edwards O, Tannoury C. Thoracolumbar spine fractures and dislocations. In: Tornetta P III, Ricci WM, Ostrum RF, McKee MD, Ollivere BJ, de Ridder VA, eds. Rockwood and Green's Fractures in Adults. 10th ed. Philadelphia: Wolters Kluwer; 2024. Chapter 49. (Turkish edition: Erişkin Kırıkları.)