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Introduction
  • 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
Anatomy
  • 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
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 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
Imaging
  • 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
Treatment
  • 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
Techniques
  • 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
Complications
  • 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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(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? Review Topic

QID: 498
FIGURES:
1

Decreased kyphosis over time

10%

(275/2621)

2

Decreased residual back pain

2%

(65/2621)

3

Lower cost of hospitalization

1%

(19/2621)

4

Earlier return to work

5%

(139/2621)

5

No advantage - equivalent clinical outcomes

81%

(2111/2621)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(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? Review Topic

QID: 2911
1

Spinal traction with bedrest for a minimum of 6 weeks

1%

(20/2344)

2

Spinal orthosis and early mobilization as tolerated

91%

(2143/2344)

3

Laminectomy and lateral recess decompression

1%

(19/2344)

4

Laminectomy and 4 level posterior instrumented fusion

4%

(85/2344)

5

Anterior corpectomy with decompression and staged 4 level posterior instrumented fusion

3%

(69/2344)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(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. Review Topic

QID: 3135
1

Improved sagittal balance

14%

(448/3225)

2

Decreased pain scores

4%

(141/3225)

3

Improved return to work status

5%

(165/3225)

4

Improved function

1%

(45/3225)

5

Increased disability and complications

75%

(2413/3225)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(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? Review Topic

QID: 204
FIGURES:
1

Electromyography

0%

(12/3233)

2

Spinal dose corticosteroids with inpatient observation

1%

(22/3233)

3

A decompressive lumbar laminectomy without fusion

13%

(428/3233)

4

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

10%

(313/3233)

5

Anterior decompresssion with strut grafting followed by posterior instrumentation

75%

(2440/3233)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(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? Review Topic

QID: 102
1

Patients treated with surgery return to work earlier.

2%

(62/3114)

2

Patients treated with surgery have decreased pain scores.

1%

(25/3114)

3

Patients treated with surgery have increased complication rates.

81%

(2507/3114)

4

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

1%

(30/3114)

5

All of the above

15%

(481/3114)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
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