Review Question - QID 3790

The patient has a L1 burst fracture with minimal retropulsion of bony fragments in the spinal canal. In the absence of neurological deficits and injury to the PLC, the most appropriate treatment is ambulation as tolerated with or without a thoracolumbrosacral orthosis (TLSO).

Thoracolumbar burst fractures are typically caused by an axial load with flexion and commonly found in this location due to increased motion at these segments. With an intact posterior ligamentous complex (PLC) and no neural compromise, TLSO is the mainstay of treatment. If there is evidence of neurological deficit and/or PLC injury, decompression and fusion are indicated. The degree of acceptable kyphosis is controversial. The choice of anterior versus posterior approach is based on ease of decompression.

Vaccaro et al. introduced a new classification system for thoracolumbar injuries, TLICS, based on morphological appearance, integrity of the posterior ligamentous complex, and neurological status. They advocate use of the system for nonoperative versus operative decision making and communication between surgeons.

Bailey et al. completed a randomized, nonblinded controlled trial to determine the efficacy of bracing for AO type A0-A3 thoracolumbar burst fractures. Both groups were encouraged to ambulate as tolerated and the no brace group had bending restrictions for 8 weeks. They found no difference in the Roland Morris Disability Questionnaire (RMDQ) score at 3 months after injury.

Figure A is sagittal CT scan of the lumbar spine showing a burst fracture of L1 with minimal retropulsion. Illustration A is the TLICS classification with score of 4 being the branch point for nonoperative versus operative management.

Incorrect Answers:
Answer 1: Bedrest is not required for management of burst fractures.
Answer 3-5: In the absence of neurological compromise or PLC injury, operative management is not indicated.