Burst Fracture

A burst fracture is a fracture through the anterior and middle columns of the
vertebra in the thoracolumbar region usually associated with significant trauma.
Patients with stable fractures who are neurologically intact without posterior
ligamentous complex disruption can usually be managed nonoperatively.

History

• Do you have other sites of pain along your spine?

• Do you have any weakness, numbness, or tingling?
• Are you able to urinate? Do you have bowel or bladder incontinence?
• Do you have pain along any of your extremities?

Physical Exam

• Trauma evaluation (Appendix A)

• Complete Neurologic Exam (Appendix A)

Diagnosis

Imaging

• Entire spine XRs—AP, lateral, oblique views

• T/L-spine CT—Evaluate extent of fracture, bony retropulsion (Fig. 1)

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Fig. 1 L1 burst fracture

• T/L-spine MRI—Assess canal compromise, cord signal changes and compres-

sion of neural elements, edema, hemorrhage, and disruption in the posterior liga-
mentous complex (PLC)

Classification

• TLICS (see Chapter “Thoracolumbar Fractures”)

• ASIA (see Chapter “Incomplete Spinal Cord Injury”)

Treatment Plan

Nonoperative Treatment

• For stable burst fractures without neurologic compromise

° Favorable results compared to surgical management

– Short term: lower pain, less complications
– Long term: lower pain, better function
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• LSO (lumbar) vs. TLSO (thoracolumbar)

° Pain control
° Facilitates early function

Operative Indications

• Instability/disruption of PLC
• Neurologic deficit (attention also to bowel and bladder function)

° Favorable results with early intervention <48 h

° Incomplete SCI—to preserve function and prevent further deterioration
° Complete SCI—to facilitate rehabilitation
• Progressive spinal deformity
• Progressive neurological deficit
• Inability to mobilize
• Polytrauma
• Inability to brace (e.g.: due to large habitus)

Surgical Options

• Posterior fusion

° 1–2 levels above and below

° ± Minimally invasive
• Decompression

° Indications:
– Incomplete neurological deficit
– Severe radiculopathy secondary to posttraumatic canal stenosis
– Bowel/bladder dysfunction

° Direct: Remove retropulsed bone: laminectomy, extracavitary, transpedicular

– Anterior corpectomy
– Transpedicular approach

° Indirect: Via ligamentotaxis, restoring height with posterior instrumentation

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References

Spivak JM, Vaccaro AR, Cotler JM. Thoracolumbar spine trauma: II. Principles of management.
J Am Acad Orthop Surg. 1995;3:353–60.
Wood KB, Buttermann GR, Phukan R, Harrod CC, Mehbod A, Shannon B, et al. Operative com-
pared with nonoperative treatment of a thoracolumbar burst fracture without neurological defi-
cit: a prospective randomized study with follow-up at sixteen to twenty-two years. J Bone Joint
Surg Am. 2015;97(1):3–9.