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Burst Fracture

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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


Clinical Features


Evaluation

Radiographs

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:

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


References


  1. Holdsworth F. Fractures, dislocations and fracture-dislocations of the spine. J Bone Joint Surg Br 1963;45:6 - 20.
  2. Esses SI, Botsford DJ, Kostuik JP. Evaluation of surgical treatment for burst fractures. Spine 1990;15:667- 73.
  3. Gertzbein SD: Scoliosis Research Society. Multicenter spine fracture study. Spine (Phila Pa 1976) 17:528–540, 1992
  4. Denis F. Spinal instability as defined by the three-column spine concept in acute spinal trauma. Clin Orthop 1984;189:65- 76.
  5. Dai, Li-Yang, et al. "A review of the management of thoracolumbar burst fractures." Surgical neurology 67.3 (2007): 221-231.
  6. 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.
  7. 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.
  8. 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:
23 November 2020 15:30:11
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