Updated: 7/27/2021

Thoracolumbar Burst Fractures

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  • SUMMARY
    • Thoracolumbar Burst Fractures are a common high-energy traumatic vertebral fractures caused by flexion of the spine that leads to 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 is bracing or surgical decompression and stabilization depending on whether the patient has neurologic deficits and whether the facture is unstable with a risk of drifting into kyphosis.
  • Epidemiology
    • Demographics
      • often seen from falls from height or motor cycle accidents
  •   ETIOLOGY
    • Pathophysiology
      • mechanism
        • axial loading with flexion
      • pathoanatomy
        • at thoracolumbar junction there is fulcrum of increased motion that makes spine more vulnerable to traumatic injury
          • burst fractures typically occur between T10-L2 (thoracolumbar junction)
        • neurologic deficits
          • canal compromise often caused by retropulsion of bone
            • maximum canal occlusion and neural compression at moment of impact
            • tissue recoiling post-injury can minimize the extent of displacement
            • retropulsed fragments resorb over time and usually do not cause progressive neurologic deterioration
          • deficit type
            • location of stenosis relative to conus determines
              • spinal cord injury
              • conus medullaris syndrome
              • neurogenic claudication due to stenosis distal to conus
    • Associated injuries
      • concomitant spine fractures
        • occurs in 20%
      • traumatic durotomy
        • associated with 
          • lamina fractures
          • split spinous process
      • chest and intra-abdominal injuries
        • common
        • thoracic spine fractures with neurologic deficit
          • 1/3 associated with hemopneumothorax, major vessel injury, and diaphragmatic rupture
        • flexion-distration and fracture-dislocations
          • bowel rupture, major vessel injury, upper urinary tract injury, hepatic, splenic, and pancreatic lacerations
      • long bone fractures
        • can make rehabilitation difficult
  • ANATOMY
    • Thoracic osteology
      • T1-10 are rigidly fixed to ribs that join each other 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 to injury
    • Lumbar osteology
      • increasingly more mobile as progresses caudal
      • increasingly prone to degenerative changes
    • 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
    • Spinal cord
      • spinal cord ends at L1-2
        • conus medullaris
          • houses upper motor neurons on the sacral motor nerves
        • fractures involving L1 and result in conus medullaris syndrome
          • paralysis of the bowel and bladder with sparring of the motor nerve roots of the lower extremity
  • CLASSIFICATION
    • 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 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 (+2 points)
          • rotation/translation (+3 points)
          • distraction (+4 points)
        • neurologic status
          • intact (0 point)
          • nerve root (+2 points)
          • incomplete Spinal cord or conus medullaris injury (+3 points)
          • complete Spinal cord or conus medullaris injury (+2 points)
          • cauda equina syndrome (+3 points)
        • 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 points)
            • MRI shows some signal in region of interspinous ligaments
          • disrupted (+3 points)
            • 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
  • PRESENTATION
    • History
      • high-energy mechanism
        • axial-loading and flexion mechanisms
          • fall from height (e.g. fall from deer hunting stand, fall from ladder, etc.)
          • high-speed motor vehicle collision
    • Symptoms
      • severe back pain
      • radicular pain
      • parasthesias
    • Physical exam
      • vital signs
        • hypotension is common
          • neurogenic shock
            • hypotension with associated bradycardia
              • suggests spinal cord injury leading to loss of autonomic regulation
          • hypovolemic shock
            • hypotension with compensatory tachycardia
              • suggests massive hemorrhage from major vessel injury
      • inspection
        • log roll patient during initial assessment to avoid iatrogenic spinal cord injury in the setting of an unstable fracture pattern
        • skin abraisons and ecchymosis
          • open spinal fractures are uncommon
      • palpation of spinous processes
        • fluid collection
        • crepitus
        • increased interspinous distance
          • suggests injury to the posterior elements
        • localized tenderness
      • neurologic examination
        • motor
        • sensory
        • reflexes
          • absence of bulbocavernous reflex is considered spinal shock
            • can persist for up to 72 hours
            • hyperactive bulbocavernous reflex suggests disinhibition and a complete spinal cord injury
  • IMAGING
    • Radiographs
      • recommended views
        • AP/lateral cervical, thoracic, lumbar spine
          • often CT chest, abdomen, and pelvis done by trauma team and instead of radiographs
          • imaging of entire spine must be performed due to concomitant spine fractures in 20%
        • flexion and extension lateral radiographs
          • useful once patient is stabilized to get understanding of integrity of PLC
        • findings
          • AP shows
            • widening of pedicles
            • coronal deformity
          • lateral shows
            • retropulsion of bone into canal
            • extent of retropulsion can be underestimated with plain radiographs alone
            • kyphotic deformity
            • chance-like spinous process fx
          • flexion/extension
            • diastasis of spinous process with flexion indicates soft tissue injury to PLC
    • CT scan
      • indications
        • fracture on plain film
        • neurologic deficit in lower extremity
        • inadequate plain films
          • higher sensitivity at detecting acute spine fractures than plain films
      • most accurately assesses the extent of fragment retropulsion
        • best assess on the axial views
      • better assessment vertebral body comminution
    • CT myelography
      • indications
        • alternative for patients with pacemaker and other implants that are MRI incompatible
        • cannot assess the cord status
        • consider traumatic durotomy
    • MRI
      • indications
        • whenever neurological deficits
        • assess the presence of a posterior ligamentous injury
          • should be performed in nearly every case, unless radiographs and CT clearly suggest injury
      • useful to evaluate for
        • level of conus relative to retropulsed bone
        • spinal cord or thecal sac compression by disk or osseous material
        • cord edema or hematoma
          • cord edema
            • fusiform cord enlargement
            • increased signal intensity on T2-weighted images
          • cord hematoma
            • decreased singal intensity on T2-weighted images
            • halo of T2 enhancement for surrounding edema
          • presence of cord edema more than 2 vertebral levels and hematoma are poor prognostic signs for functional motor recovery
        • injury posterior ligament complex
          • increased signal intensity on T2 weighted images in PLC is concerning for instability and may warrant surgical intervention
          • best visualized on the sagittal images
  • TREATMENT
    • Nonoperative
      • activity as tolerated +/- thoracolumbosacral orthosis
        • indications
          • patients that are neurologically intact and mechanically stable
            • posterior ligament complex preserved
            • no focal kyphosis on flexion and extension lateral radiographs
            • kyphosis < 30° (controversial)
            • vertebral body has lost < 50% of body height (controversial)
          • TLICS score = 3 or lower
        • modality
          • thoracolumbar orthosis
            • recent evidence shows no clear advantage of TLSO on outcomes
              • if it provides symptomatic relief, may be beneficial for patient
              • bracing may not be suitable for those with associated abdominal or chest injuries
        • outcomes
          • retropulsed fragments resorb over time and usually do not cause neurologic deterioration
          • decreased complication rates in neurologically intact patients treated nonsurgically
          • equivalent outcomes in neurologically intact patients
          • prolonged bedrest associated with increased deconditioning and recumbency complications (pneumonia, DVT, etc.)
    • Operative
      • posterior instrumented fusion/stabilization without decompression
        • indications
          • unstable fracture pattern as defined by
            • injury to the Posterior Ligament Complex (PLC)
            • progressive kyphosis
            • lamina fractures (controversial)
            • polytrauma
              • surgical stabilization can assist with recovery and rehabilitation of other injuries
        • technique
          • may be performed with percutanous pedicle screws using fluoroscopy or navigation
          • may extend instrumentation further than level of arthrodesis (fuse short, instrument long)
        • outcomes
          • unstable injuries are more likely to benefit from surgical stabilization compared to nonsurgical treatment
      • neurologic 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
          • TLICS score = 5 or higher
        • techniques
          • while classic teaching was anterior approach is required to eliminate anterior pathology, with modern techniques decompression can be performed with
            • posterior approach
              • favored when
                • below conus so possible to medialize thecal sac to perform decompression of canal / posterior corpectomy and expandable cage
                • injury to posterior ligamentous complex so posterior tension-band stabilization required
                • fracture dislocations
            • anterior/direct lateral approach
              • favored when
                • neurologic deficits caused by anterior compression (bony retropulsion) , especially above the conus medullaris (above L2)
                • allow for thorough decompression of the thecal sac
                • substantial vertebral body comminution in order to reconstitute the anterior column
                • kyphotic deformity >30°
                • chronic injuries
                  • greater than 4-5 days from the injury
              • cons
                • must consider level of diaphragm
        • outcomes
          • studies have suggested posterior distraction instrumentation with ligamentotaxis have similar clinical and radiographic outcomes as anterior decompression and 360° stabilization
          • over distraction of the anterior column can lead to pseudoarthrosis, chronic pain, and recurrent deformity
  • TECHNIQUES
    • Posterior instrumented fusion/stabilization without decompression
      • approach
        • posterior midline approach
          • subperiosteal elevation of paraspinal musculature
          • expose lateral to the transverse processes
      • technique
        • transpedicular screw fixation above and below the level of injury
          • historically involve three levels above and two levels below the level of injury
            • modern constructs typically involve one level above and one level below the injury
              • short segment fixation not suitable for injuires involving the thoracolumbar junction
      • complications
        • loss of sagittal plane correction
    • Neurologic decompression & spine stabilization
      • approach
        • posterior approach
          • typically posterior midline approach
            • subperiosteal elevation of paraspinal musculature
            • expose lateral to the transverse processes
        • anterior approach
          • lumbar spine
            • anterior retroperitoneal or transperitoneal approach
              • left paramedian incision
            • suitable for levels below L1
          • thoracolumbar junction
            • lateral lumbotomy
            • suitable for injuries at T11-L1
            • left-sided approach to avoid liver obstructing access
          • thoracic spine
            • lateral thoracotomy
              • right-sided approach to avoid major vessels
              • appropriate for injuries above T11
      • technique
        • neural decompression
          • direct decompression
            • posterior decompression
              • retropulsed bone can be removed via transpedicular approach
                • usually done below the level of the conus medullaris (L2)
                • significant dural retraction required, which may iatrogenically damage the cord
                • avoid laminectomy if possible as it will further destabilize the spine by compromising the posterior supporting structures
            • anterior decompression
              • corpectomy performed with direct removal of canal-occupying fragments
                • ipsilateral pedicle and transverse process are removed
                • corpectomy performed until the medial wall of the contralateral pedicle is visualized
              • preferrable for fractures at or above the level of the conus medullaris (L1-2)
          • indirect decompression
            • distraction and lordosing rod construct leads to ligamentotaxis of the retropulsed fragments
              • attachements of the annulus fibrosis and posterior longitudinal ligament to the fragments facilitates reduction
              • less effective if performed 4-5 days after the injury
            • restored height and sagittal alignment with posterior instrumentation
            • monoaxial screws provided greater distractive forces for deformity correction
        • arthrodesis
          • posterior fusion
            • usually performed with locally harvested autograft and freeze-dried cancellous allograft +/- BMP
            • posterior instrumentation should be under distraction and lordosis to restore vertebral body height and achieve indirect decompression
          • anterior fusion
            • structural bone graft placed in corpectomy site to reconstitute the anterior column
              • tricortical iliac crest autograft
              • humeral or tibial allograft
              • expandable metal cages with locally harvested autograft
            • can be stabilized with anterior instrumentation, posterior instrumentation, or both
      • complications
        • posterior decompression
          • dural tear
          • iatrogenic cord injury
            • excessive thecal retraction above the conus medullaris
          • iatrogenic instability
            • laminectomy in the setting of disrupted posterior ligamentous complex
        • anterior decompression
          • ileus
            • transperitoneal approach to the lumbar spine
          • pleural effusion
            • related to approaches requiring thoractomy
  • 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 closure primarily or reinforced with dural patch
        • prolonged recumbency postoperatively
    • Pain
      • most common
      • over distraction with instrumentation
    • Progressive kyphosis
      • common with unrecognized injury to PLL
      • increased comminution of the vertebral body
        • loss of anterior column support
    • Flat back
      • leads to pain, a forward flexed posture, and easy fatigue
      • post-traumatic syringomyelia
    • Surgical site infection
      • can occur in up to 10% of cases
        • trauma predisposes to infection
          • catabolic state
          • increased soft tissue damage
          • inflammatory response
      • requires irrigation and debridement with culture specific antibiotics
    • Pseudoarthrosis
      • can result from overdistraction instrumentation
    • Iatrogenic neurologic injury
      • can occur in 1% of cases
      • causes include
        • over medialized pedicle screws
        • inadvertant manipulation of the spinal cord
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Questions (25)

(SBQ18SP.19.1) All of the following are variables used to calculate the Thoracolumbar Injury Classification and Severity (TLICS) score EXCEPT:

QID: 213185
1

Percent spinal canal compromise

67%

(1178/1757)

2

Fracture morphology (compression vs. burst)

4%

(62/1757)

3

Nerve root symptoms

13%

(229/1757)

4

Cauda equina syndrome symptoms

13%

(223/1757)

5

Posterior ligamentous complex integrity

3%

(49/1757)

L 3 A

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(SBQ18SP.20) A 19-year-old male is evaluated in the trauma bay following a snowmobile accident. He is conscious and reporting severe low back pain. On exam, he is ASIA B. Imaging is obtained and demonstrates an L1 burst fracture with 60% retropulsion into the thecal sac, as well as translation of L1 on L2. There is significant edema on the MRI STIR sequence involving the paraspinal musculature, interspinous ligament, and ligamentum flavum. What is the recommended treatment for this injury?

QID: 211322
1

Reassessment upon return of the bulbocavernosus reflex

10%

(161/1550)

2

Pain control and early mobilization with or without bracing

1%

(12/1550)

3

Posterior percutaneous instrumentation utilizing ligamentotaxis for indirect reduction

9%

(145/1550)

4

Corpectomy with placement of an interbody cage

1%

(13/1550)

5

Corpectomy with placement of an interbody cage and posterior instrumentation

78%

(1205/1550)

L 2 A

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(SBQ12SP.95) A 42-year-old carpenter sustains a 10 foot fall from a ladder and sustains a fracture at L1. On imaging there is fracture extension into the posterior vertebral body and a widened interpedicular distance. Magnetic resonance imaging shows the posterior ligamentous complex is intact. Which of the following statements is true regarding this injury pattern?

QID: 3793
1

Canal compromise greater than 50% warrants decompression and fusion

25%

(627/2473)

2

A nerve root deficit is an absolute indication to proceed with surgery

24%

(603/2473)

3

Patients with adequate pain control can begin early ambulation without bracing

39%

(975/2473)

4

Fusion must involve 3 levels above and below the injured level

3%

(85/2473)

5

Stabilization with percutaneous screws without fusion is contraindicated.

6%

(152/2473)

L 5 A

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(OBQ10.47) In patients with a stable thoracolumbar burst fracture and no neurologic deficits, operative treatment has what long term outcome when compared to nonoperative management.

QID: 3135
1

Improved sagittal balance

14%

(582/4276)

2

Decreased pain scores

5%

(207/4276)

3

Improved return to work status

6%

(248/4276)

4

Improved function

2%

(76/4276)

5

Increased disability and complications

74%

(3146/4276)

L 2 A

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(OBQ09.98) You are seeing a 68-year-old female who fell out of her second story apartment window. She complains of severe low back pain and right buttock pain. Her neurologic exam shows she is an ASIA E. Imaging shows a L3 burst fracture with 10 degrees of kyphosis, 30% loss of vertebral body height, and retropulsion of bone with 20% occlusion of the spinal canal. There is no evidence of edema in posterior ligament complex on MRI. What is the most appropriate treatment?

QID: 2911
1

Spinal traction with bedrest for a minimum of 6 weeks

1%

(43/3293)

2

Spinal orthosis and early mobilization as tolerated

88%

(2914/3293)

3

Laminectomy and lateral recess decompression

1%

(39/3293)

4

Laminectomy and 4 level posterior instrumented fusion

5%

(172/3293)

5

Anterior corpectomy with decompression and staged 4 level posterior instrumented fusion

3%

(108/3293)

L 1 A

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(OBQ08.112) In a neurologically intact patient with the injury pattern shown in Figure A, B and C, what is the advantage of surgical treatment compared to early mobilization in a thoracolumbosacral orthosis?

QID: 498
FIGURES:
1

Decreased kyphosis over time

11%

(414/3824)

2

Decreased residual back pain

3%

(115/3824)

3

Lower cost of hospitalization

1%

(28/3824)

4

Earlier return to work

6%

(216/3824)

5

No advantage - equivalent clinical outcomes

79%

(3035/3824)

L 2 A

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(OBQ06.93) A 32-year-old male sustained an L4 burst fracture in a car accident five days ago. On initial presentation he was neurologically intact and treated in a thoracolumbar orthosis. In the last two days he has noticed increasing difficulty voiding, decreased perianal sensation, and weakness to ankle plantar flexion. Radiographs, computed tomography, and magnetic resonance imaging are shown in Figures A through D. What is the most appropriate next step in treatment?

QID: 204
FIGURES:
1

Electromyography

0%

(12/4170)

2

Spinal dose corticosteroids with inpatient observation

1%

(35/4170)

3

A decompressive lumbar laminectomy without fusion

14%

(594/4170)

4

Percutaneous posterior instrumented stabilization from L2 to L5 with indirect decompression via distraction ligamentotaxis

11%

(476/4170)

5

Anterior decompresssion with strut grafting followed by posterior instrumentation

73%

(3028/4170)

L 2 D

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(OBQ04.41) A 32-year-old man presents to the emergency department after sustaining a L1 burst fracture in a fall. A careful neurologic exam shows he is an ASIA E. MRI shows mild vertebral retropulsion with 10% central canal stenosis and no evidence of injury to the posterior ligament complex. Which of the following is true regarding surgical decompression and fixation when compared to nonoperative treatment with bracing?

QID: 102
1

Patients treated with surgery return to work earlier.

2%

(85/3972)

2

Patients treated with surgery have decreased pain scores.

1%

(34/3972)

3

Patients treated with surgery have increased complication rates.

79%

(3126/3972)

4

Patients treated with surgery have improved final SF-36 scores.

1%

(46/3972)

5

All of the above

17%

(665/3972)

L 2 A

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