Thoracolumbar Spine Burst Fractures

Injuries to the thoracolumbar spine are usually the result of high-energy blunt trauma. The mechanism of thoracolumbar spine burst fractures is compression failure of the anterior and middle columns under an axial load with or without failure of the posterior osseoligamentous complex.

Classification of Spine Burst Fractures

McAfee described burst fractures as being stable or unstable:

• In stable burst fractures, the anterior and middle columns fail in compression, with no loss of integrity of the posterior osseoligamentous complex.
• In unstable burst fractures, the anterior and middle columns fail in compression, and the posterior osseoligamentous complex is disrupted. The posterior column can fail in compression, lateral flexion or rotation.

See Also: Hangman’s Fracture

McAfee noted that unstable fractures were associated with early progression of neurological deficits and spinal deformity as well as late onset of neurological deficits and mechanical back pain. Factors indicative of instability in burst fractures included >50% canal compromise, >15–25° of kyphosis and >40% loss of anterior body height.

Radiology

Characteristic radiographic features of a burst fracture include loss of posterior vertebral body height, posterior vertebral body angle >100°, a break in the posterior aspect of the vertebral body with narrowing of the spinal canal on the lateral view and widening of the interpedicular distance on anteroposterior view.

Spine Burst Fractures Treatment

Patients with stable burst fractures who are neurologically intact can be managed in a TLSO or with hyperextension casting. Unstable burst fractures with intact neurology should be considered for a surgical stabilization. These injuries can be stabilized either posteriorly with indirect decompression or interiorly by direct decompression and stabilization.

The load sharing classification by McCormack et al. helps to decide between an anterior and a posterior procedure. A point value is assigned to the degree of vertebral body comminution, fracture fragment apposition and kyphosis. Injuries with scores greater than 6 would be better treated with the addition of anterior column reconstruction to posterior stabilization. Greater than 50% canal compromise, even if the patient is neurologically intact, is often mentioned as a criterion for surgery. The fact that the patient remains neurologically intact is evidence enough that the degree of canal compromise is not sufficient to cause neural damage and hence the need for surgical decompression of the canal is not present.

In patients who are neurologically incomplete or with cauda equina injury an anterior decompression, reconstruction and stabilization are advocated. In the presence of a compromised posterior ligamentous complex, the anterior vertebral reconstruction may require augmentation with a posterior stabilization. Posterior decompression (indirect decompression via ligamentotaxis or posterior/posterolateral decompression) and fixation is an alternative procedure for these injuries.

Posterior surgery avoids the morbidity of anterior exposure in patients who have concomitant pulmonary or abdominal injuries; it also has shorter operative times and decreased blood loss. The anterior procedure, however, is preferred as most authors are of the opinion that posterior decompression is not as effective in ensuring optimal neural decompression as an anterior decompression. In the presence of a complete neurological injury decompression to regain neurological function is generally felt to be of little or no benefit. Hence, surgical treatment is limited to a posterior approach aimed at stabilization and realignment.

References & More

1. Mercer’s Textbook of Orthopaedics and Trauma, Tenth edition.
2. Fernández-de Thomas RJ, De Jesus O. Thoracolumbar Spine Fracture. [Updated 2023 Aug 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562204/
3. Roblesgil-Medrano A, Tellez-Garcia E, Bueno-Gutierrez LC, Villarreal-Espinosa JB, Galindo-Garza CA, Rodriguez-Barreda JR, Flores-Villalba E, Eugenio Hinojosa-Gonzalez D, Figueroa-Sanchez JA. Thoracolumbar Burst Fractures: A Systematic Review and Meta-Analysis on the Anterior and Posterior Approaches. Spine Surg Relat Res. 2021 Oct 11;6(2):99-108. doi: 10.22603/ssrr.2021-0122. PMID: 35478987; PMCID: PMC8995121. Pubmed