SUMMARY Thoracolumbar burst fractures are common high-energy traumatic vertebral fractures caused by flexion of the spine, resulting in a compression force through the anterior and middle column of the vertebrae, leading to retropulsion of bone into the spinal canal and compression of the neural elements Diagnosis is made with radiographs of the thoracolumbar spine. CT scan is useful for fracture characterization and surgical planning Treatment varies from bracing to surgical decompression and stabilization depending on whether the patient has neurologic deficits or if the fracture being unstable with a risk of progressing into kyphosis Epidemiology Demographics often seen after falls from height or motorcycle accidents ETIOLOGY Pathophysiology mechanism axial loading with flexion pathoanatomy the thoracolumbar junction acts as a fulcrum for increased motion, making this area of the spine more vulnerable to traumatic injury login to view 1 more bullet neurologic deficits login to view 9 more bullets Associated injuries concomitant spine fractures occur in 20% traumatic durotomy associated with login to view 2 more bullets chest and intra-abdominal injuries common thoracic spine fractures with neurologic deficit login to view 1 more bullet flexion-distraction and fracture-dislocations login to view 1 more bullet long bone fractures can make rehabilitation difficult ANATOMY Thoracic osteology T1-10 are rigidly fixed to ribs that join anteriorly via the sternum least mobile portion of the entire spine T10-L2 is considered the thoracolumbar junction T10-12 have free-floating ribs and are more mobile than the upper thoracic spine transition from rigid thoracic spine to mobile lumbar spine acts as a stress riser and predisposes this region to injury Lumbar osteology increasingly more mobile with caudal progression increasingly prone to degenerative changes Denis three column system clinical relevance only moderately reliable in determining clinical degree of stability definitions anterior column login to view 2 more bullets middle column login to view 2 more bullets posterior column login to view 6 more bullets instability defined by login to view 4 more bullets Posterior ligamentous complex considered to be a critical predictor of spinal fracture stability consists of: supraspinous ligament interspinous ligament ligamentum flavum facet capsule evaluation determining the integrity of the PLC can be challenging login to view 7 more bullets Spinal cord spinal cord ends at L1-2 conus medullaris login to view 1 more bullet fractures that involve L1 can result in conus medullaris syndrome login to view 1 more bullet CLASSIFICATION Denis classification type A fracture of both endplates the bone is retropulsed into the canal type B fracture of the superior endplate common and occurs due to a combination of axial load with flexion type C fracture of the inferior endplate type D burst rotation, the mechanism of this injury is a combination of axial load and rotation this fracture type can be mistaken as a fracture-dislocation type E burst lateral flexion this type of fracture differs from the lateral compression fracture in that it presents an increase in the interpedicular distance on anteroposterior radiograph Thoracolumbar Injury Classification and Severity Score (TLICS) injury characteristic qualifier points injury morphology login to view 4 more bullets neurologic status login to view 5 more bullets posterior ligamentous complex integrity login to view 6 more bullets TLICS treatment implications scoring system designed to guide decision-making in patients with thoracolumbar spine injuries points based on three categories: login to view 3 more bullets score <4 points login to view 1 more bullet score =4 points login to view 1 more bullet score >4 points login to view 1 more bullet PRESENTATION History high-energy mechanism axial loading and flexion mechanisms login to view 2 more bullets Symptoms severe back pain radicular pain paresthesias Physical exam vital signs hypotension is common login to view 6 more bullets inspection logroll patient during initial assessment to avoid iatrogenic spinal cord injury in the setting of an unstable fracture pattern skin abrasions and ecchymosis login to view 1 more bullet palpation of spinous processes fluid collection crepitus increased interspinous distance login to view 1 more bullet localized tenderness neurologic examination motor sensory reflexes login to view 3 more bullets IMAGING Radiographs recommended views AP/lateral of the cervical, thoracic, and lumbar spine login to view 2 more bullets flexion and extension lateral radiographs login to view 1 more bullet findings login to view 10 more bullets CT scan indications fracture on plain films neurologic deficit in lower extremity inadequate plain-film evaluation login to view 1 more bullet most accurately assesses the extent of fragment retropulsion best assessed on the axial views better assessment of vertebral body comminution CT myelography indications alternative for patients with MRI incompatible implants (e.g. pacemaker) cannot assess the cord status consider traumatic durotomy MRI indications neurologic deficits on examination assess for a posterior ligamentous injury login to view 1 more bullet useful to evaluate for: level of conus relative to retropulsed bone spinal cord or thecal sac compression by disc or osseous material cord edema or hematoma login to view 7 more bullets injury of posterior ligament complex login to view 2 more bullets TREATMENT Nonoperative activity as tolerated +/- thoracolumbosacral orthosis indications login to view 6 more bullets modality login to view 4 more bullets outcomes login to view 4 more bullets Operative posterior instrumented fusion/stabilization without decompression indications login to view 6 more bullets technique login to view 2 more bullets outcomes login to view 1 more bullet neurologic decompression & spinal stabilization indications login to view 3 more bullets techniques login to view 16 more bullets outcomes login to view 2 more bullets TECHNIQUES Posterior instrumented fusion/stabilization without decompression approach posterior midline approach login to view 2 more bullets technique transpedicular screw fixation above and below the level of injury login to view 3 more bullets complications loss of sagittal plane correction Neurologic decompression & spine stabilization approach posterior approach login to view 3 more bullets anterior approach login to view 12 more bullets technique neural decompression login to view 17 more bullets arthrodesis login to view 9 more bullets complications posterior decompression login to view 5 more bullets anterior decompression login to view 4 more bullets COMPLICATIONS Entrapped nerve roots and dural tear from associated lamina fractures can be iatrogenic from decompression decreased risk of dural tears with anterior approach due to improved visualization of the thecal sac during decompression requires primary closure or reinforcement with dural patch prolonged recumbency postoperatively Pain most common can be due to overdistraction with instrumentation Progressive kyphosis common with unrecognized PLL injury increased comminution of the vertebral body loss of anterior column support Flat-back deformity leads to pain, a forward flexed posture, and easy fatigue can be due to post-traumatic syringomyelia Surgical site infection can occur in up to 10% of cases trauma predisposes to infection login to view 3 more bullets requires irrigation and debridement, followed by culture-specific antibiotics Pseudarthrosis can result from overdistraction due to instrumentation Iatrogenic neurologic injury can occur in 1% of cases causes include over-medialized pedicle screws inadvertent manipulation of the spinal cord