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Burst Fracture
From WikiSM
Contents
Other Names
- Thoracolumbar Burst Fractures
- Thoracic Burst Fracture
- Lumbar Burst Fracture
Background
- This page describes burst fractures of the thoracolumbar spine
- Defined as compression fracture that results in injury to the posterior Vertebral Body with retropulsion into the spinal canal
History
- First described by Holdsworth in 1963[1]
Epidemiology
- 90% of spinal fractures occur within the thoracolumbar spine[2]
- As many as 60% are burst fractures[3]
Pathophysiology
- Involves compression with axial load, typically with flexion
- Force through anterior and middle column with posterior force vector
- This causes retropulsion of bone into canal
- Majority occur at the thoracolumbar junction, a transition point from the kyphotic thorax to lordotic lumbar spine
- Stability of fracture is controversial
- Radiographic parameters are used to evaluate stability
- kyphotic angle, anterior vertebral height, posterior vertebral height, and canal compromise
- Presence/ absence of neurological symptoms
- Denis: 3 column theory[4]
- Vertebral body can be divided into anterior, middle and posterior column
Pathoanatomy
Risk Factors
- Unknown
Differential Diagnosis
- Fractures
- Neurological
- Musculoskeletal
- Autoimmune
- Infectious
- Pediatric
Clinical Features
- General: Physical Exam Back
- History
- Physical Exam
- Special Tests
Evaluation
Radiographs
- Standard Thoracic Spine Radiographs, Standard Lumbar Spine Radiographs
- Findings
- AP: widening of pedicals, deformity in coronal plane
- Lateral: retropulsion into canal, kyphosis
CT
- Better evaluation of osseous pathology
MRI
- Useful to evaluate
- Spinal Cord, thecal scal
- Soft tissue structures
- Posterior Ligament complex
Classification
Denis Classification
- Type A
- Fracture of both end-plates
- Bone is retropulsed into the canal.
- Type B
- Fracture of the superior end-plate
- Common, occurs due to a combination of axial load with flexion.
- Type C
- Fracture of the inferior end-plate.
- Type D
- Burst rotation
- May be misdiagnosed as a fracture-dislocation
- Mechanism: axial load and rotation.
- Type E
- Burst lateral flexion
Thoracolumbar Injury Classification and Severity Score
- Injury morphology
- Compression (+1 point)
- Burst (+1)
- Rotation/translation (+3)
- Distraction (+4)
- Neurologic status
- Intact (+0 point)
- Nerve root (+2)
- Incomplete Spinal cord or conus medullaris injury (+3)
- Complete Spinal cord or conus medullaris injury (+2)
- Cauda equina syndrome (+3)
- Posterior ligamentous complex integrity
- Intact (+0 point)
- Suspected/indeterminate (+2 point)
- Disrupted (+3 point)
Management
- Management is somewhat controversial, especially without neurological benefit
- Treatment goals
- Stabilize the spine
- Prevent short, long-term deformity
- Prevent neurological decline
- Nonoperative advantages
- Avoid risks of surgical intervention
- Decreased costs
- Surgical advantages[5]
- Better correction of kyphotic deformity
- Greater initial stability
- Opportunity to perform direct or indirect decompression of neural elements
- Decreased requirements for external immobilization
- Earlier return to work
Prognosis
- Most patients do well if neurologically intact initially
- Nonoperative: most investigators have found rare or no neurologic deterioration in initially neurologically intact patients[6]
- Remodeling is shown to occur in patients treated either operatively or nonoperatively
Nonoperative
- Indications
- Must be neurologically intact
- Intact posterior ligament complex
- Consider with kyphosis <30°, vertebral body lost <50% height
- 2- and 3-column injured Denis type A, B, and C thoracolumbar burst fractures with intact facet joints[7]
- Single-level closed burst fracture and no fracture dislocations or pedicle fractures[8]
- Conservative treatment consists of combination of:
- Limiting motion of the spine
- Postural reduction
- Bed rest
- Thoracolumbar Orthosis
- Functional rehabilitation
Operative
- Indiocations
- Neurological deficits
- Unstable fracture pattern including injury to posterior ligament complex, kyphosis
- Technique
- Posterior spinal fusion
- Anterior decompression, stabilization
- Posterior decompression, fusion
- Posterior corpectompy, ventral decompression
Rehab and Return to Play
Rehabilitation
- Needs to be updated
Return to Play
- Needs to be updated
Complications
- Structural
- Kyphosis
- Scoliosis
- Loss of normal lumbar lordosis
- Neurological
- Neuropathy
- Myelopathy
- Chronic pain
See Also
- Internal
- External
- Sports Medicine Review Back Pain: https://www.sportsmedreview.com/by-joint/back/
References
- ↑ Holdsworth F. Fractures, dislocations and fracture-dislocations of the spine. J Bone Joint Surg Br 1963;45:6 - 20.
- ↑ Esses SI, Botsford DJ, Kostuik JP. Evaluation of surgical treatment for burst fractures. Spine 1990;15:667- 73.
- ↑ Gertzbein SD: Scoliosis Research Society. Multicenter spine fracture study. Spine (Phila Pa 1976) 17:528–540, 1992
- ↑ Denis F. Spinal instability as defined by the three-column spine concept in acute spinal trauma. Clin Orthop 1984;189:65- 76.
- ↑ Dai, Li-Yang, et al. "A review of the management of thoracolumbar burst fractures." Surgical neurology 67.3 (2007): 221-231.
- ↑ Cantor JB, Lebwohl NH, Garvey T, Eismont FJ. Nonoperative management of stable thoracolumbar burst fractures with early ambulation and bracing. Spine 1993;18:971- 6.
- ↑ Agus H, Kayali C, Arslantas M. Nonoperative treatment of burst type thoracolumbar vertebra fractures: clinical and radiological results of 29 patients. Eur Spine J 2005;14:536 - 40.
- ↑ Shen WJ, Liu TJ, Shen YS. Nonoperative treatment versus posterior fixation for thoracolumbar junction burst fractures without neurologic deficit. Spine 2001;26:1038- 45.
Created by:
John Kiel on 9 May 2020 22:15:47
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Last edited:
5 October 2022 23:56:01
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