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  • Defined as vertebral fracture with compromise of the anterior and middle column 
    • can be unstable because both anterior and middle columns are involved
  • Mechanism 
    • axial loading with flexion
    • at thoracolumbar junction there is fulcrum of increased motion that makes spine more vulnerable to traumatic injury
  • Neurologic deficits
    • canal compromise often caused by retropulsion of bone
    • maximum canal occlusion and neural compression at moment of impact
    • retropulsed fragments resorb over time and usually do not cause progressive neurologic deterioration
  • Associated injuries
    • concomitant spine fractures in 20%
    • lamina fracture is associated with dural tear and entrapped nerve roots
  • Denis three column system 
    • clinical relevance
      • only moderately reliable in determining clinical degree of stability
    • definitions
      • anterior column  
        • anterior longitudinal ligament (ALL)
        • anterior 2/3 of  vertebral body and annulus
      • middle column  
        • posterior longitudinal ligament (PLL)
        • posterior 1/3 of vertebral body and annulus
      • posterior column  
        • pedicles
        • lamina
        • facets
        • ligamentum flavum
        • spinous process
        • posterior ligament complex (PLC)
      • instability defined by 
        • injury to middle column
          • as evidenced by widening of interpedicular distance on AP radiograph
          • loss of height of posterior cortex of vertebral body
        • disruption of posterior ligament complex combined with anterior and middle column involvement
  • 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
        • conditions where PLC is clearly ruptured
          • bony chance fracture
          • widening of interspinous distance
          • progressive kyphosis with nonoperative treatment
          • facet diastasis
        • conditions where integrity of PLC is indeterminant
          • MRI shows signal intensity between spinous process
  • Dennis classification
    • Type A
      • fracture of both end-plates. The bone is retropulsed into the canal.
    • Type B
      • fracture of the superior end-plate. It is common and occurs due to a combination of axial load with flexion.
    • Type C
      • fracture of the inferior end-plate.
    • Type D
      • Burst rotation. This fracture could be misdiagnosed as a fracture-dislocation. The he mechanism of this injury is a combination of axial load and rotation.
    • Type E
      • Burst lateral flexion. This type of fracture differs from the lateral compression fracture in that it presents an increase of the interpediculate distance on anteroposterior roentgenogram
  • Thoracolumbar Injury Classification and Severity Score   
    • injury characteristic qualifier points
      • injury morphology
        • compression (1 point)
        • burst (+1 point)
        • rotation/translation (+3 point)
        • distraction (+4 point)
      • neurologic status
        • intact (+0 point)
        • nerve root (+2 point)
        • incomplete Spinal cord or conus medullaris injury (+3 point)
        • complete Spinal cord or conus medullaris injury (+2 point)
        • cauda equina syndrome (+3 point)
      • posterior ligamentous complex integrity
        • intact (+0 point)
          • no interspinous ligament widening seen with flexion views. MRI shows no edema in interspinous ligament region
        • suspected/indeterminate (+2 point)
          • MRI shows some signal in region of interspinous ligaments
        • disrupted (+3 point)
          • widening of interspinous distance seen
    • TLICS treatment implications
      • score <  4 points
        • Nonsurgical management
      • score = 4 points
        • Nonsurgical or surgical managment
      • score > 4 points
        • surgical management indicated
  • Radiographs
    • recommended views
      • obtain radiographs of entire spine (concomitant spine fractures in 20%)
    • AP shows
      • widening of pedicles
      • coronal deformity
    • lateral shows
      • retropulsion of bone into canal
      • kyphotic deformity
  • CT scan 
    • indications
      • fracture on plain film
      • neurologic deficit in lower extremity
      • inadequate plain films
  • MRI
    •  useful to evaluate for
      • spinal cord or thecal sac compression by disk or osseous material
      • cord edema or hemorrhage
      • injury posterior ligament complex
        • signal intensity in PLC is concerning for instability and may warrant surgical intervention
  • Nonoperative
    • ambulation as tolerated with or without a thoracolumbosacral orthosis q q q q q q q
      • indications
        • patients that are neurologically intact and mechanically stable
          • posterior ligament complex preserved
          • kyphosis < 30° (controversial)
          • vertebral body has lost < 50% of body height (controversial)
        • TLICS score = 3 or lower
      • thoracolumbar orthosis q
        • recent evidence shows no clear advantage of TLSO on outcomes
          • if it provides symptomatic relief, may be beneficial for patient
      • outcomes
        • retropulsed fragments resorb over time and usually do not cause neurologic deterioration
  • Operative
    • surgical decompression & spinal stabilization
      • indications
        • neurologic deficits with radiographic evidence of cord/thecal sac compression
          • both complete and incomplete spinal cord injuries require decompression and stabilization to facilitate rehabilitation
        • unstable fracture pattern as defined by
          • injury to the Posterior Ligament Complex (PLC) 
          • progressive kyphosis
          • lamina fractures (controversial)
        • TLICS score = 5 or higher
  • Posterior Spinal Fusion Alone (no decompression)
    • indications
      • progression kyphosis or clear injury to posterior ligament complex, but with no significant neurologic compression
  • Anterior decompression and stabilization (with or without posterior stabilization) q
    • indications
      • indicated when neurologic deficits caused by anterior compression (bony retropulsion) 
      • scientific data has not shown a benefit to early decompression and stabilization
    • technique
      • usually includes corpectomy and strut grafting followed by anterior +/- posterior instrumentation
      • advantage is that you do not need to do a laminectomy which will further destabilize the spine by compromising the posterior supporting structures
  • Posterior Decompression and Fusion 
    • indications
      • unstable fracture pattern with no need for neurologic decompression
      • complete neurologic injury (allows earlier rehab)
    • neural decompression
      • direct decompression
        • retropulsed bone can be removed via transpedicular approach
      • indirect decompression
        • via ligamentotaxis may occur by restoring height and sagittal alignment with posterior instrumentation
    • arthrodesis
      • fusion should be performed with instrumentation
      • instrumentation should be under distraction to restore vertebral body height and achieve indirect decompression
      • historically it was recommended to instrument three levels above and two levels below
        • modern pedicle screws have changes this to one level above and one level below
      • avoid laminectomy if possible as it will further destabilize the spine by compromising the posterior supporting structures
  • Posterior Corpectomy , Ventral Decompression, Cage and Instumented 360 Degree Fusion
    • indications
      • indicated when neurologic deficits caused by anterior compression (bony retropulsion) 
      • scientific data has not shown a benefit to early decompression and stabilization
    • technique
      • unilateral pedicle resection required
      • faciliated with new expandable cages
    • complications
      • dural tear
      • radiculopathy/deficits due to nerve root injury
  • Entrapped nerve roots and dural tear
    • from associated lamina fractures
  • Pain
    • most common
  • Progressive kyphosis
    • common with unrecognized injury to PLL
  • Flat back
    • leads to pain, a forward flexed posture, and easy fatigue
    • post-traumatic syringomyelia

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