Lumbar burst fracture

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Introduction

First defined by Holdsworth1

Fracture caused by axial load leading to herniation of the nucleus pulposus of the vertebral disk through the upper end plate.

Disruption of the vertebra from within.

Denis 3-column theory as a compression fracture of the anterior and middle vertebral columns, which causes retropulsion of a posterior vertebral body fragment into the spinal canal.2

Nonoperative treatment

Indications

Neurologically intact 2- and 3-column injured Denis type A, B, and C thoracolumbar burst fractures with intact facet joints.

Angular deformity less than 208, a residual canal exceeding 50% of normal, and an anterior vertebral body height greater than 50% of the posterior height.4

Posterior ligaments are intact.5

Kyphotic angle less than 35 degrees 6

Load sharing classification - reliable and easy-to-use classification for the conservative treatment.

Operative treatment

The goals of surgical treatment of thoracolumbar spinal fractures include

(1) decompression of the spinal canal and nerve roots to facilitate neurologic recovery.

(2) restoration and maintenance of vertebral body height and alignment.

(3) prevention of development of posttraumatic progressive deformity with subsequent neurologic deficit.

(4) rigid fixation to facilitate patient care and allow early ambulation and rehabilitation.

Indications

Neurologic deficit

Unstable burst fracture.

Kyphotic angle more than 35 degrees.6

No correlation between the degree of canal compromise and any clinical symptoms.

No degree of canal compromise would by itself serve as an indication for operative intervention and decompression in this fracture in neurologically intact patients.7

Kyphotic deformity 8

Surgical Approaches

Anterior
Posterior - progressive loss of correction of the angle of kyphosis after posterior stabilization alone 9

Combined anterior and posterior

Decompression, correction, and interbody fusion with a single posterior approach.

References

1 Holdsworth F. Fractures, dislocations and fracture-dislocations of the spine. J Bone Joint Surg Br 1963;45:6 - 20

2 Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine 1983;8: 817- 31.

3 Agus H, Kayali C, Arslantas M. Nonoperative treatment of bursttype thoracolumbar vertebra fractures: clinical and radiological results of 29 patients. Eur Spine J 2005;14:536 - 40.

4  Hitchon PW, Torner JC, Haddad SF, Follett KA. Management options in thoracolumbar burst fractures. Surg Neurol 1998; 49:619 - 27

5 Tezer M, Erturer RE, Ozturk C, Ozturk I, Kuzgun U. Conservative treatment of fractures of the thoracolumbar spine. Int Orthop 2005; 29:78 - 82.

6 Reid DC, Hu R, Davis LA, Saboe LA. The nonoperative treatment of burst fractures of the thoracolumbar junction. J Trauma 1988;28: 1188- 94.

7 Wood K, Buttermann G, Mehbod A, Garvey T, Jhanjee R, Sechriest G, Butterman G. Operative compared with nonoperative treatment of

a thoracolumbar burst fracture without neurological deficit: a prospective, randomized study. J Bone Joint Surg Am 2003; 85:773 – 81.

8 Farcy JP, Weidenbaum M, Glassman SD. Sagittal index in management of thoracolumbar burst fractures. Spine 1990;15: 958- 65

9 Lakshmanan P, Jones A, Mehta J, Ahuja S, Davies PR, Howes JP. Recurrence of kyphosis and its functional implications after surgical stabilization of dorsolumbar unstable burst fractures. Spine J. 2009 Dec;9(12):1003-9.

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