Thoracolumbar Burst Fracture
Classification systems
- AO Spine thoracolumbar classification with the neurological and modifier grading
Mechanism
Axial compression, usually a fall from height or a motor vehicle collision, fails the vertebral body in compression and retropulses fragments — often the posterosuperior corner — into the canal. The thoracolumbar junction is the transition from a rigid kyphotic thoracic spine to a mobile lordotic lumbar spine, which concentrates stress and explains why most of these injuries occur there.
Age considerations
- Paediatric
- The elastic paediatric spine may sustain spinal cord injury without radiographic abnormality, so a normal plain film does not exclude a significant injury. Growth-related deformity progression must be followed.
- Young adult
- High-energy injury; assess for associated calcaneal and pelvic injuries from the same axial load, and screen the whole spine for non-contiguous injuries. Decision-making centres on neurology and posterior ligamentous complex integrity.
- Elderly
- Osteoporotic vertebral fractures may look like burst patterns; distinguish a low-energy insufficiency fracture from a high-energy burst, consider malignancy, and prioritise analgesia, early mobilisation and bone health over instrumentation.
Management options
Non-operative treatment with a brace or early mobilisationshowhide
Indication
Neurologically intact patients with an intact posterior ligamentous complex, acceptable kyphosis and no evidence of instability.
Implant design notes
No implant. A thoracolumbosacral orthosis or, increasingly, mobilisation without a brace in a stable single-column injury, with structured physiotherapy.
Approach
Non-operative, with defined clinical and radiographic surveillance.
Steps overview
- Perform and document a full neurological examination including perianal sensation and tone
- Obtain cross-sectional imaging for bony detail and magnetic resonance imaging to assess the posterior ligamentous complex
- Log-roll precautions until the injury is characterised and deemed stable
- Fit a brace if used, and mobilise with physiotherapy supervision
- Repeat standing radiographs to confirm the alignment does not deteriorate with load
- Review neurology at each visit; progressive kyphosis or new deficit changes the plan
Notes
Standing or sitting radiographs are the test that unmasks occult instability — supine films can look deceptively good.
Resident summary compiled from standard orthopaedic trauma teaching; verify against your departmental protocol.
Posterior instrumented stabilisationshowhide
Indication
Injuries with posterior ligamentous complex disruption, unacceptable kyphosis, progressive deformity, or associated injuries requiring early mobilisation.
Implant design notes
Pedicle screws and rods spanning the injured level, usually one or two levels above and below, restoring alignment by ligamentotaxis and three-point bending. Short-segment constructs may be augmented with screws in the fractured vertebra or with cement augmentation in poor bone.
Approach
Posterior midline approach, subperiosteal exposure of the posterior elements; minimally invasive percutaneous techniques are an alternative where no decompression is required.
Steps overview
- Position prone on a radiolucent frame with attention to alignment and pressure areas
- Confirm levels fluoroscopically before exposure
- Expose the posterior elements or place percutaneous screws under image guidance
- Insert pedicle screws with anatomical landmarks and fluoroscopic or navigated confirmation
- Reduce the kyphosis by rod contouring and compression or distraction as appropriate
- Decompress the canal if there is a neurological deficit attributable to retropulsed bone
- Confirm alignment and implant position, then mobilise with physiotherapy early
- Monitor neurology closely in the first postoperative days
Notes
Instrumentation without addressing significant canal compromise in a patient with a deficit is inadequate; conversely, canal remodelling occurs spontaneously in the neurologically intact patient, so canal narrowing alone is not an indication to decompress.
Resident summary compiled from standard orthopaedic trauma teaching; verify against your departmental protocol.
Decompression with anterior or combined reconstructionshowhide
Indication
Incomplete neurological deficit with significant anterior canal compression, or substantial vertebral body loss requiring anterior column support.
Implant design notes
Corpectomy with a cage or strut graft to restore the anterior column, usually with posterior instrumentation to complete a stable construct.
Approach
Anterolateral thoracoabdominal or retroperitoneal approach, or a posterior-only approach with transpedicular decompression depending on level and surgeon experience.
Steps overview
- Define the compressive lesion precisely on cross-sectional and magnetic resonance imaging
- Plan the approach with regard to the level, the diaphragm and the great vessels
- Perform the corpectomy and decompress the canal under direct vision
- Reconstruct the anterior column with a cage or strut graft of correct height
- Complete stabilisation posteriorly if the construct requires it
- Confirm alignment and canal clearance, then rehabilitate with a specialist team
Notes
Approach-related morbidity is significant; reserve it for patients where anterior compression or column loss genuinely dictates it.
Resident summary compiled from standard orthopaedic trauma teaching; verify against your departmental protocol.
Viva pearls
- The three factors that decide management are neurology, posterior ligamentous complex integrity and deformity — structure your answer around them.
- Magnetic resonance imaging is the test for the posterior ligamentous complex; cross-sectional imaging alone underestimates instability.
- The degree of canal compromise does not correlate simply with neurology, and the canal remodels over time in the intact patient.
- Always examine perianal sensation and tone and document a rectal examination — a missed cauda equina picture is indefensible.
- Screen the whole spine for non-contiguous injuries and the heels and pelvis for associated axial-load fractures.
- In the elderly, distinguish an osteoporotic insufficiency fracture from a high-energy burst and consider malignancy.
Sources for further reading
- Rockwood and Green's Fractures in Adults — thoracolumbar spine injuries
- Standard operative orthopaedics textbook — spinal trauma
- AO Spine classification resources as summarised in standard texts
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Resident-authored study summary in original wording, not reproduced from copyrighted source text.