64.12 Fractures of the thoracic and lumbar spine

The spinal cord ends at L1. A patient with a fracture at or above this level is usually either grossly injured and paraplegic, or has a stable fracture. Below this level he can have an unstable fracture and a normal cauda equina. If a patient has no cord injury, you can easily miss these fractures, especially if he has severe injuries elsewhere, or is unconscious. His spine can be injured by a force which compresses or flexes it, usually at T7–T8, the apex of his thoracic kyposis, at T12–L1, the thoraco-lumbar junction, or at L4–L5. The result can be a wedge fracture, a burst fracture, or a fracture dislocation.

If a patient has a fracture especially a wedge fracture, after only a minor injury, suspect that it may be pathological, and the result of a secondary tumour or osteoporosis. If all you can see is a widened disc space, count his spinous processes, and see if they match his vertebral bodies. The widened disc space may be all that remains of a vertebral body.

If his fracture is stable by the criteria (1), (2), and (3) in Section 64.5, the active movements regime described below will give better results than a plaster cast and be cheaper.

If his fracture is unstable his accompanying paraplegia dominates his management. Fixation with interspinous plates is not established as better than conservative management which almost always leads to stable union in 6 to 10 weeks. The position in which the fracture unites is unimportant. He will probably be no better off in a referral hospital than in your hands.

FRACTURES OF THE THORACIC AND LUMBAR SPINE

Assess whether the patient’s fracture is stable or not by the criteria already described (64.5). If you are in doubt, treat his injury as unstable.

STABLE FRACTURES Treat wedge fractures, minor burst fractures, and laminar fractures in the same way. Treat the patient in bed with fracture boards under a 10 cm foam rubber mattress. Put a pillow between his legs and a pillow under his back when he is lying on his side.

Keep him in bed until he can arch his back sufficiently for you to be able to put your hand underneath it, and until he is sufficiently pain–free to walk, if necessary, with crutches. He can get up when pain allows him to, usually in about 3 weeks.

UNSTABLE FRACTURES are usually fractures of the posterior elements with subluxation.

If the patient is not paraplegic, keep him in bed. Turn him 2 hourly in one piece, using at least 3 people. Use his right and left sides, the supine, the lateral, and the prone positions. At about 3 weeks he can start to turn himself using a balkan beam and a handle.

When pain at rest has gone and light bouncing with a clenched fist causes little pain, usually at 6 to 10 weeks, mobilize him, at first with someone either side of him, and then using crutches.

If he is paraplegic, concentrate on his morale, his skin, his bladder, and his bowels, rather than on his fracture. Turn him 2 hourly and care for his skin as in Section 64.15.

When you turn him, put blocks of foam rubber underneath him, so as to minimize displacement of his spine. For example, put a block under the fracture when he lies on his back. This will encourage moderate extension and reduce the tendency of his spine to collapse. Change and adjust these blocks each time you turn him.

If you cannot get foam rubber blocks, or if adjusting them each time you turn him takes too long, forget about them and nurse him on a thick rubber mattress.

After 6 to 8 weeks in bed, when his spine is no longer painful or tender, mobilize him as effectively as his paraplegia will permit.

CAUTION! Never apply a cast if he is paraplegic. It will rapidly cause ulcers in his anaesthetic skin.