Review Question - QID 217038

The injury pattern is that of a burst fracture at L1 contiguous with a compression fracture at L2. There is associated kyphosis, but there is no spinous process widening, edema in the posterior column, or neurologic injury giving this patient a TLICS score of <4. Nonoperative treatment is recommended for TLICS <4.

The appropriate treatment for thoracolumbar trauma has been debated and contested in the orthopaedic community. Scores and classification schemes like the TLICS and AOSpine Trauma Classification (AOSTC) have been popularized and found to be reliable in guiding treatment. The patient above has a burst fracture and compression fracture of the thoracolumbar spine without neurologic deficit and no given evidence for PLC instability. Therefore, a TLICS score of 2-3 (if the combined fractures are added together) would suggest nonoperative treatment with bracing until the fracture has healed. One key part to note is that TLICS was generated in 2005 and AOSTC in 2013, so the cited papers from 1999 (Wood et al) and 2003 (McLain et al) involved surgically treated patients who would now follow the nonoperative treatment algorithm.

Wood et al. completed a randomized trial investigating operative versus nonoperative (using body cast or orthosis) management of stable TL burst fractures without neurological deficit. At an average of 44 months follow-up, they found no difference in multiple endpoints, including VAS pain scores, degree of kyphosis, amount of canal remodeling, and ability to return to work. Interestingly, there was a trend towards better SF-36 and Oswestry Disability Index scores in the nonoperative group, while also keeping overall costs of patient care at 20% of the operative group.

Interestingly, the same group from above reported on outcomes 16 - 22 years from their original treatment date. 19 patients from the operative group and 18 patients from the nonoperative group were evaluated and found to have no significant difference in kyphosis with improved pain and PRO scores in the nonoperative group.

McLain et al. completed a prospective, longitudinal study of multiply injured patients treated with segmental instrumentation for spinal fractures with a minimum 2-year follow-up. 27 of the 75 total patients studied presented with severe polytrauma (ISS > 26) and were stratified into 2 groups, those who underwent surgical stabilization within 24 hours of presentation and those who had surgery 24-72 hours after presentation. 63% had a neurologic injury at the time of presentation. Neither group developed complications such as DVT, PE, decubitus ulcers, iatrogenic neurologic injury, or deep wound infections. They concluded that stabilization within 24 hours of presentation in severe polytrauma patients is safe both in the short and long term.

Figure A is an axial CT scan of the thoracolumbar junction showing a burst fracture of the vertebral body without significant canal compromise. Figure B is a sagittal CT scan showing a burst fracture at L1 and compression fracture at L2. Figure C is a sagittal T2 weighted MRI showing the fractures at L1 and L2 without edema extending into the PLC, indicating the posterior column is not compromised.

Illustration A is a table of the TLICS classification scheme. Illustration B is a picture of the AOSTC classification scheme. Illustration C is a sagittal MRI showing a compromised PLC with a supraspinous ligament rupture in the setting of a lumbar burst fracture. This patient would therefore have a TLICS of 5 or more depending on neurologic status and they would require surgery.

INCORRECT ANSWERS:
Answer 1: Anterior and posterior approaches would be utilized in injuries that involved canal compromise and posterior column instability.
Answer 2: Without neurologic deficit, anterior corpectomy and fusion are not recommended.
Answer 3: Bed rest for an extended period is not recommended for stable thoracolumbar injuries as this increases complications like decubitus ulcers, DVT, pulmonary compromise, and deconditioning.
Answer 5: This patient does not have evidence of posterior column instability, and does not require posterior fusion.