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Burst fracture without PLC injury
Introduction
Thoracolumbar vertebral body fractures are a common cause of spinal injury, where burst fractures account for up to 58% of all thoracolumbar fractures. These fractures can lead to pain and neurological deficit. In other cases, they may remain asymptomatic. The fracture itself may also lead to kyphotic deformity and spinal instability. When there is evidence of instability, kyphotic deformity, or even neurological deficit, surgical intervention is often recommended. These treatments can range from instrumentation alone to instrumentation and decompression via laminectomy or a combination of laminectomy and corpectomy. The management becomes difficult in those patients who are neurologically intact. In these patients, the most common presenting symptom is back pain. Occasionally, patients may complain of subjective weakness secondary to limited mobility and pain, but without objective findings. The management of patients who remain neurologically intact with thoracolumbar burst fracture becomes highly variable. This variability has led to the development of multiple scoring systems to help guide management. Of the available scoring system to determine which patient with thoracolumbar fracture will require surgical intervention, the Thoracolumbar Injury Classification and Severity (TLICS) score has been developed and widely accepted as a scoring system to identify those requiring surgical intervention by scoring based on fracture type, neurological deficit, and integrity of posterior ligamentous complex (see Chapter 24 , Table 1 ). Typically those with intact posterior ligamentous complex who are neurologically intact would not meet criteria for surgical intervention. The management of this subgroup of patients can become somewhat difficult as they are typically limited by their back pain. There have been numerous articles reporting excellent outcomes with conservative management, while others report advantage of surgical intervention in these patients. Management in these patients should be therefore individualized when these patients fail conservative management, which includes pain control, bracing, and physical therapy for early mobilization.
Example case
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Chief complaint: back pain
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History of present illness: A 64-year-old female suffered a fall with ongoing back pain. She was seen in the emergency room for this ongoing back pain. She noted that the pain improved in the recumbent position and worsened with ambulation. She denied any weakness or bowel/bladder dysfunction. She underwent imagines that revealed a T11–12 burst fracture with retropulsed bone fragments ( Figs. 25.1–25.3 ).
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Medications: none
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Allergies: no known drug allergies
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Past medical and surgical history: hypertension, osteoporosis
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Family history: noncontributory
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Social history: secretary, no smoking history, occasional alcohol
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Physical examination: awake, alert, and oriented to person, place, and time; cranial nerves II–XII intact; bilateral deltoids/triceps/biceps 5/5; interossei 5/5; iliopsoas/knee flexion/knee extension/dorsi, and plantar flexion 5/5
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Reflexes: 2+ in bilateral biceps/triceps/brachioradialis with negative Hoffman; 2+ in bilateral patella/ankle; no clonus or Babinski; sensation intact to light touch
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| Preoperative | ||||
| Additional tests requestedHounsfield Units in CT |
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DEXA |
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| Surgical approach selected | T10-L1 percutaneous fusion | If fails to mobilize with brace, T10-L1 percutaneous posterior fusion with T9 kyphoplasty | If develops progress deformity or pain, T12-L1 laminectomy and T9-L3 posterior fusion | T11-12 laminectomy and T10-L1 posterior fusion |
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| Goal of surgery | Stabilize spine | Stabilize spine with early mobilization, pain improvement, avoid progressive deformity | Decompress neural elements, stabilize spine/restore biomechanics | Stabilize spine with early mobilization, pain improvement, decompress thecal sac, avoid progressive deformity |
| Perioperative | ||||
| Positioning | Prone | Prone on Jackson table | Pone on Jackson table | Prone on Jackson table, no pins |
| Surgical equipment | Fluoroscopy |
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| Medications | Maintain MAP | Acetaminophen, gabapentin | None | Steroids, maintain MAP, possible osteoporotic medication |
| Anatomical considerations | Transverse process, pedicles, vertebral body | Spinal cord, descending aorta | Spinal cord, pedicle orientation | Spinal cord, pedicle orientation |
| Complications feared with approach chosen | Cortical violation | Progressive kyphosis, prolonged immobilization, junctional pathology | Spinal instability, spinal cord injury, ongoing neural compression | Spinal cord injury, dural tear and CSF leak, screw malposition, delayed instability and progressive kyphosis, delayed mobilization with medical complications |
| Intraoperative | ||||
| Anesthesia | General | General | General | General |
| Exposure | T10-L1 | T10-L1 | T9-L3 | T10-L1 |
| Levels decompressed | None | None | T12-L1 | T11-12 |
| Levels fused | T10-L1 | T10-L1 | T9-L3 | T10-L1 |
| Surgical narrative | Position prone, x-ray to confirm alignment and level, percutaneous screw placement using biplanar localization of T10-L1 pedicles bilaterally, percutaneous titanium rod, standard closure | Preflip MEP, position prone, postflip MEP, biplanar localization of T10-L1 pedicles, percutaneous placement of T10-L1 pedicle screws bilaterally, augment T10 and L1 screws with PMMA, T9 kyphoplasty, percutaneous titanium rod, standard closure | Position prone, fluoroscopy to mark levels and plan incision, midline incision, dissect to transverse processes bilaterally, laminectomy over both fractures levels if there is neural compression, place all pedicle screws using Lenke technique, O-arm spine to confirm screw placement, contour rods, use ligamentotaxis if there is concern for a fragment in the canal by locking in screws above and below fracture and distracting, confirm decompression with ultrasound or O-arm, footed tamp if ongoing compression on fragment, final tighten screws, decorticate, arthrodesis using autograft and allograft, close in layers over a drain | Position prone, IOM setup and checked, intraoperative fluoroscopy to mark levels and visualize fracture, midline skin incision and dissection down to fascia, subperiosteal dissection to expose posterior elements including facet capsule and transverse processes one level above higher fracture and two levels below lower fracture, registration of surgical navigation, entry points based on navigation and intraoperative fluoroscopy, drill entry point with high-speed drill, size and length of screws estimated with preoperative images and navigation, place pedicle screws one level above higher fracture and two levels below lower fracture, intraoperative spin to confirm screw position, decortication of spinous process/laminae/facet joints, laminectomy of fracture levels with high-speed drill and Kerrison rongeurs, adequate decompression confirmed with ultrasound, if still compression can push fractured fragments forward with Epstein curette, place slightly kyphotic rod, lay autograft on decorticated bone, closure in layers with subfascial drain |
| Complication avoidance | Percutaneous placement of pedicle screws | Pre- and postflip MEP, percutaneous placement of pedicle screws, augment screws with PMMA | Pedicle screws using Lenke technique, O-arm spin to confirm position of screws, ligamentotaxis if necessary, ultrasound or O-arm to confirm decompression | Surgical navigation, ultrasound to determine adequacy of decompression, push fractured fragments forward if necessary for better decompression |
| Postoperative | ||||
| Admission | Floor | Floor | Floor | Floor |
| Postoperative complications feared | Infection, hardware failure | Kyphosis, pulmonary complications | Kyphosis, pseudoarthrosis | Screw malposition, instrumentation failure, worsening neurological function, CSF leak |
| Anticipated length of stay | 1 day | 2 days | 3–4 days | 1–2 days |
| Follow-up testing |
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CT T-L spine within 24 hours of surgery and 6 months after surgery |
| Bracing | None | TLSO for comfort | None | None |
| Follow-up visits | 2 weeks, 1 month, 2 months, 3 months, 6 months, 1 year after surgery | 4 weeks, 3 months, 6 months, 1 year, 2 years after surgery | 6 weeks, 6 months, 1 year after surgery | 10–14 days, 4 weeks, 3 months, 6 months, 1 year after surgery |
CSF , cerebrospinal fluid; CT , computed tomography; DEXA , dual-energy x-ray absorptiometry; IOM , intraoperative monitoring; MAP , mean arterial pressure; MEP , motor evoked potentials; MIS , minimally invasive surgery; MRI , magnetic resonance imaging; PMMA , polymethylmethacrylate; SSEP , somatosensory evoked potentials; TLSO , thoracic lumbar sacral orthosis.
Differential diagnosis
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Burst fracture
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Compression fracture
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Osteomyelitis
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