Conservative management of thoracolumbar and lumbar spine compression and burst fractures: functional and radiographic outcomes in 136 cases treated by closed reduction and casting

Introduction  Both fractures of the lumbar spine and at the thoracolumbar junction are quite common. The treatment of these fracture types is discussed controversially. Some authors advocate surgical treatment even in fractures without neurologic compromise while other series report good results after non-operative treatment. Materials and methods  Between January 1997 and April 2004, 324 patients with spinal fractures were admitted to our institution. Hundred and thirty-six patients with compression and burst type fractures treated by closed reduction and casting were available for follow-up. Their medical records, radiographs and computer tomography scans were reviewed and their functional status was assessed. Results  94 male (69.1%) and 42 female (30.9%) patients with a mean age of 48.6 years (range 17–81) at time of injury were included. The thoracolumbar junction (T11-L1) was affected in 104 patients (76.5%). 23.5% had lumbar fractures. All of the burst type fractures with involvement of the posterior column affection were type A3.3. fractures according to the Magerl classification. Significant correction of radiographic parameters was achieved in the early postreduction period (P < 0.0001). Reduction could not be maintained at the final follow-up but still showed slight improvement compared to the initial presentation. Reduction could be maintained better in the thoracolumbar region than in the lumbar spine. Neurologic function was restored in all patients with unilateral radicular pain but only one patient recovered fully after cauda equina-syndrome. Patients after lumbar spine indicated a higher level of pain when compared to patients with fractures at the thoracolumbar junction. Discussion  Closed reduction and casting is a safe and effective method for treatment of compression and burst type fractures at the thoracolumbar junction and can restore neurologic function in patients with unilateral radicular pain. It is of limited value in lumbar fractures and in burst type fractures with posterior column involvement.     

Management of thoracolumbar spine fractures

Background contextTraumatic fractures of the spine are most common at the thoracolumbar junction and can be a source of great disability.PurposeTo review the most current information regarding the pathophysiology, injury pattern, treatment options, and outcomes.Study designLiterature review.MethodsRelevant articles, textbook chapters, and abstracts covering thoracolumbar spine fractures with and without neurologic deficit from 1960 to the present were reviewed.ResultsThe thoracolumbar spine represents a unique system from a skeletal as well as neurological standpoint. The rigid rib-bearing thoracic spine articulates with the more mobile lumbar spine at the thoracolumbar junction (T10 - L2), the site of most fractures. A complete examination includes a careful neurologic examination of both motor and sensory systems. CT scans best describe bony detail while MRI is most efficient at describing soft tissues and neurological structures. The most recent classification system is that of the new Thoracolumbar Injury Classification and Severity Score. The different fracture types include compression fractures, burst fractures - both stable and unstable -, flexion-distraction injuries and fracture dislocations. Their treatment, both operative and non-operative depends on the degree of bony compromise, neurological involvement, and the integrity of the posterior ligamentous complex. Minimally invasive approaches to the care of thoracolumbar injuries have become more popular, thus, the evidence regarding their efficacy is presented. Finally, the treatment of osteoporotic fractures of the thoracolumbar spine is reviewed, including vertebroplasty and kyphoplasty, their risks and controversies, and senile burst fractures, as well.ConclusionsThoracolumbar spine fractures remain a significant source of potential morbidity. Advances in treatment have minimized the invasiveness of our surgery and in certain stable situations, eliminated it all together.     

Functional outcome of low lumbar burst fractures. A multicenter review of operative and nonoperative treatment of L3-L5.

STUDY DESIGN: A retrospective review of 42 patients treated at three major medical centers for burst fractures of L3, L4, and L5. This is the largest low lumbar (L3-L5) burst fracture study in the literature to date. The study was designed to assess both radiographic and clinical outcomes in a cohort of patients treated during a 16-year period. OBJECTIVES: The objective of this study was to determine whether conservatively treated patients with low lumbar burst fractures had satisfactory outcomes compared with those in a surgically treated cohort of patients. The study included patients with and without neurologic deficits. SUMMARY OF BACKGROUND DATA: Burst fractures of the low lumbar spine (L3-L5) represent a small percentage of all spine fractures. The iliolumbar ligaments and location below the pelvic brim are two stabilizing factors that are unique to these fractures when compared with burst fractures at the thoracolumbar junction. METHODS: Forty-two (n = 42) patients with low lumbar burst fractures were identified from 1980 through 1996. Medical records, radiographs, and follow-up Dallas Pain Questionnaires were obtained. Loss of anterior vertebral height, kyphotic angulation, and amount of retropulsion were recorded at several phases of treatment. Mean follow-up time was 45.2 months (range, 5-132 months). Twenty patients were treated without surgery (18 were neurologically intact, and 2 had isolated nerve root injury), and 22 underwent surgery (14 had neurologic injury, 8 were intact). RESULTS: No patient showed neurologic deterioration, regardless of treatment. Fracture of the third lumbar segment showed the greatest tendency toward kyphotic collapse and loss of height in the nonoperative group, although this was not reflected in the final functional outcome of both groups. The ability to return to work and achieve a good-to-excellent long-term result was not significantly different among fracture levels or between surgical and nonsurgical treatments. CONCLUSIONS: The results of nonoperative treatment of low lumbar burst fractures were comparable with those of operative treatment. The rate of repeat surgery (41%) and absence of a clearly definable long-term functional or radiographic benefit in patients without neurologic compromise may make surgery less appealing.     

Incidence and morbidity of concomitant spine fractures in combat-related amputees

Background contextHigh-energy blasts are the most frequent cause of combat-related amputations in Operations Iraqi and Enduring Freedom (OIF/OEF). The nondiscriminating effects of this mechanism often result in both appendicular and axial skeletal injuries. Despite this recognized coincident injury pattern, the incidence and consequence of spine fractures in trauma-related combat amputees are unknown.PurposeThis study sought to determine the incidence and morbidity of the associated spine fractures on patients with traumatic lower extremity amputation sustained during OIF/OEF.Study design/settingRetrospective case control.Patient sampleTwo hundred twenty-six combat-related lower extremity amputees presenting to a single institution and injured between 2003 and 2008 were included for analysis.Outcome measuresPhysiologic and functional outcome measures were used to determine the influence of spine fractures on combat amputees. Physiologic measures included intensive care unit (ICU) admission rates, injury severity score (ISS), rate of narcotic/neuropathic pain use, and heterotopic ossification (HO) rates. Functional outcome measures included return-to-duty rates and ambulatory status at final follow-up.MethodsData from 300 consecutive combat-related lower extremity amputations were retrospectively reviewed and grouped. Group 1 consisted of amputees with associated spine fractures, and Group 2 consisted of amputees without spine fractures. The results of the two groups were compared with regard to initial presentation and final functional outcomes.ResultsA total of 226 patients sustained 300 lower extremity amputations secondary to combat-related injuries, the most common mechanism being an improvised explosive device. Twenty-nine of these patients had a spine fracture (13%). Group 1 had a higher ISS than Group 2 (30 vs. 19, p<.001). Group 1 patients were also more likely to be admitted to the ICU (86% vs. 46%, p<.001). Furthermore, Group 1 patients had a significantly higher rate of HO in their residual limbs (82% vs. 55%, p<.005).ConclusionsThe incidence of spine fractures in combat-related amputees is 13%. The results suggest that combat-related amputees with spine fractures are more likely to sustain severe injuries to other body systems, as indicated by the significantly higher ISS and rates of ICU admission. This group also had a significantly higher rate of HO formation, which may be attributable to the greater local and/or systemic injuries sustained by these patients.     

Military penetrating spine injuries compared with blunt

Background contextThe nature of blunt and penetrating injuries to the spine and spinal column in a military combat setting has been poorly documented in the literature. To date, no study has attempted to characterize and compare blunt and penetrating spine injuries sustained by American servicemembers.PurposeThe purpose of this study was to compare the military penetrating spine injuries with blunt spine injuries in the current military conflicts.Study design/settingRetrospective study.Patient sampleAll American military servicemembers who have been injured while deployed in Iraq (Operation Iraqi Freedom) and Afghanistan (Operation Enduring Freedom) whose medical data have been entered into the Joint Theater Trauma Registry (JTTR).MethodsThe JTTR was queried for all American servicemembers sustaining an injury to the spinal column or spinal cord while deployed in Iraq or Afghanistan. These data were manually reviewed for relevant information regarding demographics, mechanism of injury, surgical intervention, and neurologic injury.ResultsA total of 598 servicemembers sustained injuries to the spine or spinal cord. Isolated blunt injuries were recorded in 396 (66%) servicemembers and 165 (28%) sustained isolating penetrating injuries. Thirty servicemembers (5%) sustained combined blunt and penetrating injuries to the spine. The most commonly documented injuries were transverse process fractures, compression fractures, and burst fractures in the blunt-injured servicemembers versus transverse process fractures, lamina fractures, and spinous process fractures in those injured with a penetrating injury. One hundred four (17%) servicemembers sustained spinal cord injuries, comprising 10% of blunt injuries and 38% of penetrating injuries (p<.0001). Twenty-eight percent (28%) of blunt-injured servicemembers underwent a surgical procedure compared with 41% of those injured by penetrating mechanisms (p=.4). Sixty percent (n=12/20) of blunt-injured servicemembers experienced a neurologic improvement after surgical intervention at follow-up compared with 43% of servicemembers (n=10/23) who underwent a surgical intervention after a penetrating trauma (p=.28). Explosions accounted for 58% of blunt injuries and 47% of penetrating injuries, whereas motor vehicle collisions accounted for 40% of blunt injuries and 2% of penetrating injuries. Concomitant injuries to the abdomen, chest, and head were common in both groups.ConclusionsBlunt and penetrating injuries to the spinal column and spinal cord occur frequently in the current conflicts in Iraq and Afghanistan. Penetrating injuries result in significantly higher rates of spinal cord injury and trend toward increased rates of operative interventions and decreased neurologic improvement at follow-up.     

The significance of thoracolumbar spinal canal size in spinal cord injury patients

STUDY DESIGN: A prospective, consecutive case series. OBJECTIVES: To determine the relation between spinal canal dimensions and Injury Severity Score and their association with neurologic sequelae after thoracolumbar junction burst fracture. SUMMARY OF BACKGROUND DATA: There is a relation in the cervical spine between spinal canal dimension and its association with neurologic sequelae after trauma. A similar relation at the thoracolumbar junction has not been conclusively established. METHODS: Forty-three patients with thoracolumbar junction burst fractures (T12-L2),13 with and 30 without neurologic deficit, were included. Computed tomographic scans were used to measure the sagittal and transverse diameters and the surface area of the spinal canal at the level of injury, as well as one level above and one level below the fracture level. Injury severity score was calculated for both groups. Statistical analysis comparing those with a neurologic deficit to those without was performed by Student's t test. RESULTS: The ratio of sagittal-to-transverse diameter at the level of injury was significantly smaller in patients with a neurologic deficit than in those without a neurologic deficit (P < 0.05). The mean transverse diameter at the level of injury was significantly larger in patients with neurologic deficit than in the neurologically intact patients (P < 0.05). The surface area of the canal at the level below the injury was significantly larger in the patients with a neurologic deficit than in those without a deficit (P < 0.05). Patients with a neurologic deficit had a statistically higher Injury Severity Score when admitted than those without a neurologic deficit (P < 0.0001), although the difference became insignificant after the neurologic component of the scoring system was eliminated. CONCLUSION: There are no anatomic factors at the thoracolumbar junction that predispose to neurologic injury after burst fracture. The shape of the canal after injury, however, as determined by the sagittal-to-transverse diameter ratio, was predictive of neurologic deficit.     

Association between Osteoporotic Vertebral Compression Fractures and Age,Bone Mineral Density,and European Quality of Life-5 Dimensions in Korean Postmenopausal Women: A Nationwide Cross-sectional Observational Study

BackgroudThe purpose of this study was to investigate the characteristics of osteoporotic vertebral compression fractures (OVCFs) in Korean postmenopausal women and the association between OVCFs and clinical factors such as age, bone mineral density (BMD), and quality of life.MethodsAccording to the population distribution in four regions in Korea, 1,281 postmenopausal female patients were recruited from nationwide orthopedic outpatient clinics. Radiologic, asymptomatic, and within 3 months of OVCF groups were analyzed based on age, fracture location, and prevalence according to BMD. In addition, BMD, T-score, body mass index, and European Quality of Life-5 Dimensions (EQ-5D) were investigated in the three groups, and the differences between groups were compared and analyzed.ResultsThe prevalence of radiologic OVCFs at the T11–L1 was 3.7 times higher in the 70s group (44.0%) than in the 50s group (11.9%). Femur and total hip BMD were significantly lower in patients with thoracolumbar junction fractures than in patients with L2–5 fractures, whereas no difference was observed in lumbar spine BMD. Of the three OVCF groups, the within 3 months of OVCF group had the lowest lumbar spine T-score of −2.445. The asymptomatic OVCF group also showed significantly lower lumbar spine T-score than did the group without radiologic OVCFs (p < 0.001). The EQ-5D showed a significant decrease in the radiologic OVCF group (p < 0.001) and within 3 months of OVCF group (p < 0.001).ConclusionsThe prevalence of OVCFs in the thoracolumbar junction rapidly increases with old age and low BMD in Korean postmenopausal women. Femur and total hip BMD are more predictive of thoracolumbar junction fractures than lumbar spine BMD. Patients with radiologic OVCFs had a significantly lower quality of life than no OVCF group. Therefore, this study shows it is important to treat and prevent osteoporosis before an OVCF occurs.     

Concomitant fractures of the acetabulum and spine: a retrospective review of over 300 patients

BACKGROUND: The incidence and spectrum of concomitant acetabulum and spine trauma has not been clearly defined. METHODS: We retrospectively reviewed 307 acetabulum fracture patients over 5 years, and evaluated this cohort for concomitant spine injuries. Patient and injury demographics, spine and neurologic injury and delay in diagnosis were examined. RESULTS: Complete data were available for 275 (90%) of the cohort, and 55 spine injuries (54 fractures and 1 traumatic disc herniation) were identified in 34 patients. Thus, the incidence of concomitant acetabulum and spine fractures was approximately 13% (34 of 275). Four percent of the patients sustained significant thoracolumbar fractures (burst, flexion-distraction, or dislocation). An average 8.6-day delay in diagnosis occurred in three spine fracture patients. One suffered progressive neurologic injury. CONCLUSIONS: It is essential that the traumatologists have a high index of suspicion for spine injury, particularly thoracolumbar injury in patients who sustain fractures of the acetabulum. We recommend early thoracolumbar computed tomography imaging in patients with fractures of the acetabulum if plain radiographs are not possible or inadequate.     

Thoracic spine fractures

Fractures of the thoracic spine (T2-T12) should be considered as a separate entity because of the anatomic features of the rib cage and spinal canal in this region. Fifty-seven patients sustained this injury over a 10-year period (16% of thoracic, thoracolumbar, and lumbar fractures). Twenty-eight fracture dislocations, 25 compression fractures, and 1 burst fracture were seen. Three injuries, combining elements of a burst fracture and a dislocation, were designated "burst-dislocations." Apart from compression fractures, a direct blow was often the implicated mechanism of injury. Significant associated injuries were uncommon. Fracture-dislocations were often associated with neurologic injury and compression fractures with long-term pain. Operative treatment appeared to afford the best results for stabilization and pain relief.     

Are spine injuries sustained in battle truly different?

Background contextThe severity and prognosis of combat-related injuries to the spine and spine injuries sustained unrelated to direct combat have not been previously compared. Differences may have implications on tactics, treatment strategies, and directions for future research.PurposeCompare the severity and prognosis of battle and nonbattle injuries to the spine.Study designRetrospective study.Patient sampleAmerican military personnel who were injured in a combat zone and whose medical data were abstracted in the Joint Theater Trauma Registry (JTTR).MethodsThe JTTR was queried using International Statistical Classification of Diseases, Ninth Revision codes to identify all individuals who sustained battle and nonbattle injuries to the neck, back, spinal column, or spinal cord in Operation Iraqi Freedom or Operation Enduring Freedom from October 2001 to December 2009. Medical records of all identified servicemembers were individually reviewed. Demographic information, including sex, age, military rank, date of injury, and final disposition, was obtained for all patients. Spinal injuries were categorized according to anatomic location, associated neurologic involvement, precipitating mechanism of injury (MOI), and concomitant wounds. These data points were compared for the groups battle spine injuries (BSIs) and nonbattle spine injuries (NBSIs).ResultsFive hundred two servicemembers sustained a total of 1,834 battle injuries to the spinal column, including 1,687 fractures (92%), compared with 92 servicemembers sustaining 267 nonbattle spinal column injuries, with 241 (90%) fractures. Ninety-one BSI servicemembers (18% of patients) sustained spinal cord injuries (SCIs) with 41 (45%) complete SCIs, compared with 13 (14% of patients) nonbattle SCIs with six (46.2%) complete injuries (p=.92). The reported MOI for 335 BSI servicemembers (66.7%) was an explosion compared with one NBSI explosive injury. Eighty-four patients (17%) sustained gunshot wounds (GSWs) in battle compared with five (5.2%) nonbattle GSWs. Fifteen patients (3.0%) sustained a battle-related fall compared with 29 (30%) nonbattle-related falls. Battle spine injury servicemembers underwent significantly higher rates of surgical interventions (p<.0001), were injured by high-energy injury mechanisms at a significantly greater rate (p<.0001), and demonstrated a trend toward lower neurologic recovery rates after SCI (p=.16).ConclusionsBattle spine injury and NBSI are separate entities that may ultimately have disparate long-term prognoses. Nonbattle spine injury patients, although having similar MOIs compared with civilian spinal trauma, maintain a different patient demographic. Further research must be directed at accurately quantifying the long-term disabilities of all spine injuries sustained in a combat theater, whether they are the result of battle or not.     

Lag screw fixation of remote bilateral pedicle fractures of the fourth and fifth lumbar vertebrae after a single gunshot wound: a case report and technical pearl

Background contextOf the injuries involving the lumbar spine, pedicle fractures are among the least common; those involving bilateral pedicles are rare.PurposeThe aims of the study were to provide the first documentation of bilateral pedicle fractures at two consecutive levels after a gunshot, to review the mechanism of injury, and to evaluate a nonfusion treatment option for pedicle fractures.Study designThis is a technical note and case report.Outcome measureThe outcome measures were lumbar range of motion, return of motor and sensory functions, and return to normal activities.MethodsA 20-year-old male sustained bilateral pedicle fractures at L4 and L5 with a massive dural tear, progressive neurologic deficits, and urinary incontinence. He underwent repair of the dural tear and lag screw fixation of the pedicle fractures without fusion.ResultsThe patient had full range of motion of his lumbar spine, full strength in his lower extremities, and bladder control.ConclusionsThis is the first report of bilateral multilevel lumbar pedicle fractures after a single penetrating gunshot wound. The case documents this injury pattern after a gunshot, reviews the mechanism of injury, and presents the successful application of a nonfusion treatment option.     

Evaluation and management of combat-related spinal injuries: a review based on recent experiences

Background contextThe current approach to the evaluation and treatment of military casualties in the Global War on Terror is informed by medical experience from prior conflicts and combat encounters from the last 10 years. In an effort to standardize the care provided to military casualties in the ongoing conflicts, the Department of Defense (DoD) has published Clinical Practice Guidelines (CPGs) that deal specifically with the combat casualty sustaining a spinal injury. However, the combat experience with spine injuries in the present conflicts remains incompletely described.PurposeTo describe the CPGs for the care of the combat casualty with suspected spine injuries and discuss them in light of the published military experience with combat-related spinal trauma.Study designLiterature review.MethodsA literature review was conducted regarding published works that discussed the incidence, epidemiology, and management of combat-related spinal trauma. The CPGs, established by the DoD, are discussed in light of actual military experiences with spine trauma, the present situation in the forward surgical teams and combat support hospitals treating casualties in theater, and recent publications in the field of spine surgery.ResultsIn the conventional wars fought by the United States between 1950 and 1991 (Korea, Vietnam, Gulf War I), the incidence of spine injuries remained close to 1% of all combat casualties. However, in the Global War on Terror, the enemy has relied on implements of asymmetric warfare, including sniper attacks, ambush, roadside bombs, and improvised explosive devices. The increase in explosive mechanisms of injury has elevated the number of soldiers exposed to blunt force trauma and, consequently, recent publications reported the highest incidence of combat-related spinal injuries in American military history. Wounded soldiers are expeditiously evacuated through the echelons of care but typically do not receive surgical management in theater. The current CPGs for the care of soldiers with combat-related spinal injuries should be re-examined in light of data regarding the increasing number of spine injuries, new injury patterns, such as lumbosacral dissociation and low lumbar burst fractures, and recent reports within the field of spine surgery as a whole.ConclusionsAmerican and coalition forces are sustaining the highest spine combat casualty rates in recorded history and previously unseen injuries are being encountered with increased frequency. While the CPGs provide useful direction in terms of the evaluation and management of combat casualties with spine injuries, such recommendations may warrant periodic re-evaluation in light of recent combat experiences and evolving scientific evidence within the spine literature.     

Alterations of the biomarker S-100B and NSE in patients with acute vertebral spine fractures

Background contextAlthough several publications concerning the use of the biomarkers S100B and neuron-specific enolase (NSE) in vertebral spine fractures in animal experimental studies have proven their usefulness as early indicators of injury severity, there are no clinical reports on their effectiveness as indicators in patients with spinal injuries. As these biomarkers have been examined, with promising results, in patients with traumatic brain injury, there is a potential for their implementation in patients with vertebral spine fractures.PurposeTo investigate the early serum measurement of S100B and NSE in patients with vertebral spine fractures compared with those in patients with acute fractures of the proximal femur.Study designProspective longitudinal cohort study.Patient sampleA cohort of 34 patients admitted over an 18-month period to a single medical center for suspected vertebral spine trauma. Twenty-nine patients were included in the control group.Outcome measuresS100B and NSE serum levels were assessed in different types of vertebral spine fractures.MethodsWe included patients older than 16 years with vertebral spine fractures whose injuries were sustained within 24 hours before admission to the emergency room and who had undergone a brief neurologic examination. Spinal cord injuries (SCIs) were classified as being paresthesias, incomplete paraplegias, or complete paraplegias. Blood serum was obtained from all patients within 24 hours after the time of injury. Serum levels of S100B and NSE were statistically analyzed using Wilcoxon signed-rank test.ResultsS100B serum levels were significantly higher in patients with vertebral spine fractures (p=.01). In these patients, the mean S100B serum level was 0.75 μg/L (standard deviation [SD] 1.44, 95% confidence interval [CI] 0.24, 1.25). The mean S100B serum level in control group patients was 0.14 μg/L (SD 0.11, 95% CI 0.10, 0.19). The 10 patients with neurologic deficits had significantly higher S100B serum levels compared with the patients with vertebral fractures but without neurologic deficits (p=.02). The mean S100B serum level in these patients was 1.18 μg/L (SD 1.96). In the 26 patients with vertebral spine fractures but without neurologic injury, the mean S100B serum level was 0.42 μg/L (SD 0.91, 95% CI 0.08, 0.76). The analysis revealed no significant difference in NSE levels.ConclusionsWe observed a significant correlation not only between S100B serum levels and vertebral spine fractures but also between S100B serum levels and SCIs with neurologic deficit. These results may be meaningful in clinical practice and to future studies.     

Occurrence of massive gluteal muscle necrosis following transcatheter angiographic embolization (TAE) to control pelvic hemorrhage in 6 patients

BACKGROUND: An association between cervical fractures and thoracolumbar fractures after blunt trauma has long been assumed, but not adequately demonstrated. We sought to determine the actual association between these injuries in a large nationwide data set. METHODS: The National Trauma Databank (NTDB) was queried for victims of blunt vehicular trauma with at least minimal injury. An odds ratio was calculated for the association between cervical spine fractures and thoracolumbar fractures. RESULTS: Overall 190,183 NTDB patient records met the criteria of a motor vehicle crash with more than minimal injury. Of these 7.51% (14,292) had cervical spine fractures, 4.73% (8,996) had thoracic spine fractures, 5.93% (11,280) had lumbar spine fractures, and 9.79% (18,623) had either thoracic or lumbar fractures. Of patients with a cervical spine fracture, 13.06% (2,433) also had a thoracic or lumbar fracture, whereas among patients without cervical spine fracture only 6.91% (11,859) had a thoracolumbar fracture. The odds ratio (OR) for a thoracolumbar fracture in the presence of a cervical spine fracture was 2.02 (p < 0.0001) (95% confidence interval 1.9318-2.1201). CONCLUSION: These data confirm a strong association between cervical spine fractures and thoracolumbar fractures after blunt vehicular trauma, and support the practice of imaging the complete spine when a cervical fracture is identified.     

Patterns of collapse in thoracolumbar burst fractures

OBJECTIVE: Functional outcomes of neurologically intact patients with burst fractures may be dependent on final kyphosis at the end of treatment. Conservative treatment is indicated if an acceptable sagittal alignment of the spine can be anticipated. Thoracolumbar burst fractures are often grouped as a single entity where, in fact, anatomically distinct areas of the spine may behave differently owing to different biomechanical factors. The goal of this work was to evaluate differential behavior in terms of final kyphosis in anatomically distinct regions of the spine following stable burst fractures. METHODS: Prospective analysis of kyphosis in 60 patients treated conservatively for traumatic thoracolumbar burst fracture was conducted. Initial trauma supine radiographs were measured for initial kyphosis (Ki). Final kyphosis (Kf) in the upright patient was measured at the end of treatment. The Ki and Kf were plotted on a scatter graph; with use of linear regression analysis, a mathematical model was created to define a relationship between Ki and Kf based on anatomic level of the spine. RESULTS: The thoracolumbar spine behaved in two independent patterns with respect to Kf. Kf at the thoracolumbar junction (T11-L1) had a collapse pattern that could be approximated most accurately with the equation Kf = Ki + 0.5 Ki. At the midlumbar spine, L2-L3 level, a best-fit model for collapse was Kf = Ki + 4 degrees . CONCLUSION: In this cohort of patients, fractures that were categorized as "stable" and not requiring surgery were studied for the purpose of determining differential collapse patterns in anatomically distinct areas of the lumbar spine. We have demonstrated that the thoracolumbar junction and the midlumbar spine behave differently biomechanically and recommend that these two anatomic levels be studied independently for research purposes.     

“Outcome of thoracolumbar compression fractures following non-operative treatment”

Axial compressive/flexion moderate forces on the anterior spinal elements may cause vertebral compression fractures (VCF), compromising the anterior column of the spine, reducing vertebral body height and leading to characteristic wedge-shaped deformity. 60% to 75% of VCFs are located in the thoracolumbar junction (T12 – L2) due to mechanical forces upon the transition from the relatively fixed thoracic to the relatively mobile lumbar spine. Compression force spinal fractures vary in literature according to the classification system in use, resulting in controversial treatment options. Type A fracture patterns of AO classification are eligible for non-operative treatment provided the posterior complex is intact and there are no neurologic complications. That includes both simple compressive and burst fractures. The aim of this study is to investigate the long-term consequences of non-operative treated compressive thoracolumbar fractures regarding posttraumatic deformity, chronic back pain, and functional status. A retrospective study of 75 patients with stable (compressive and burst type A AO) spinal fractures of the thoracolumbar spine (T12-L2) without neurological symptoms and treated non-operatively was conducted. Post traumatic regional kyphosis, Visual Analogue Scale (VAS) and the Oswestry Disability Index (ODI) were used to evaluate deformity progression, pain and alteration of the quality of life during follow up. There was no significant correlation between magnitude of posttraumatic regional kyphosis, sex, pain score and disability index. Statistically significant correlation between patients age and disability index was revealed.     

A reduction-fixation system for unstable thoracolumbar burst fractures.

Thirty-three patients with unstable burst fractures of the lower thoracic and lumbar spine were treated with a reduction-fixation system. The new system is used both as a reduction and a fixation device for disorders of the lower thoracic and lumbar spine. In treatment of spinal fractures, it provides symmetric lordotic distraction to obtain the best possible reduction of intracanal fragments, and rigidly stabilizes the fractured vertebra while involving the minimum number of segments. All patients had a minimum follow-up of 24 months. Most patients in this series had a near-anatomic reduction of all three columns in the involved segment. The "indirect" neurologic decompression was successful in cases treated early after injury. The fixation was rigid enough to allow early mobilization and rehabilitation in a light orthosis within 1 week after surgery, and there was minimal loss of reduction during the follow-up period. The complications were minor. The reduction-fixation system achieved the surgical goals of posterior instrumentation for treatment of unstable thoracolumbar burst fractures.     

Decision-making in burst fractures of the thoracolumbar and lumbar spine

The most common site of injury to the spine is the thoracolumbar junction which is the mechanical transition junction between the rigid thoracic and the more flexible lumbar spine. The lumbar spine is another site which is more prone to injury. Absence of stabilizing articulations with the ribs, lordotic posture and more sagitally oriented facet joints are the most obvious explanations. Burst fractures of the spine account for 14% of all spinal injuries. Though common, thoracolumbar and lumbar burst fractures present a number of important treatment challenges. There has been substantial controversy related to the indications for nonoperative or operative management of these fractures. Disagreement also exists regarding the choice of the surgical approach. A large number of thoracolumbar and lumbar fractures can be treated conservatively while some fractures require surgery. Selecting an appropriate surgical option requires an in-depth understanding of the different methods of decompression, stabilization and/or fusion. Anterior surgery has the advantage of the greatest degree of canal decompression and offers the benefit of limiting the number of motion segments fused. These advantages come at the added cost of increased time for the surgery and the related morbidity of the surgical approach. Posterior surgery enjoys the advantage of being more familiar to the operating surgeons and can be an effective approach. However, the limitations of this approach include inadequate decompression, recurrence of the deformity and implant failure. Though many of the principles are the same, the treatment of low lumbar burst fractures requires some additional consideration due to the difficulty of approaching this region anteriorly. Avoiding complications of these surgeries are another important aspect and can be achieved by following an algorithmic approach to patient assessment, proper radiological examination and precision in decision-making regarding management. A detailed understanding of the mechanism of injury and their unique biomechanical propensities following various forms of treatment can help the spinal surgeon manage such patients effectively and prevent devastating complications.     

Effect of major axial skeleton trauma on preexisting lumbosacral spondylolisthesis.

The incidental occurrence of lumbar spine fractures in individuals with preexisting first degree lumbosacral isthmic spondylolisthesis may be looked upon as a simulated in vivo biomechanical experiment testing the stability of the lumbosacral subluxation. Among 200 patients with thoracolumbar spine fractures managed at the author's institution during the period of 1980-1989, five such cases were collected. All patients had a grade I isthmic spondylolisthesis at the L5-S1 level, and all sustained a burst fracture of the lumbar spine. In two patients, there was a previous history of low back pain and lumbosacral spondylolisthesis. In the other three patients, the olisthesis was judged to be old by a negative 99mTc-MDP bone scan, whereas the fractured vertebra showed intense uptake and/or by the negative operative findings at L5-S1 level during surgery. It was found that the incidence of lumbosacral spondylolisthesis in patients with thoracolumbar fractures was smaller than in the general population but the difference was not statistically significant (p = 0.213). In addition, it is concluded that mild lumbosacral spondylolisthesis can absorb considerable axial loading without an ascertainable evidence of damage.     

Low lumbar spinal fractures: management options

Fifty-four patients with low lumbar spinal fractures were retrospectively reviewed. Of these, there were 25 compression fractures, 21 burst fractures, three flexion-distraction fractures and five fracture-dislocations. Three patients had a complete neurological lesion, 17 sustained an incomplete neurological injury, and 34 were neurologically intact. Twenty-six patients were treated non-operatively and 28 underwent surgery. All patients were followed up for l-12 years. Forty-three patients (79.6%) have returned to their former employment or activity level. Four patients had experienced significant improvement but suffered from some limitation of activity. Five patients were unable to stand up and walk without support although they had some degree of improvement. Two remained completely paralyzed. There were no differences in neurologic function between patients treated non-operatively or operatively (P>0.05). The patients treated operatively had significantly less pain compared to the patients treated non-operatively (P<0.01). Because of the unique anatomy and biomechanics, fractures of the low lumbar spine are different from those in the remaining regions of spine. Most compression fractures are stable, and therefore conservative management is indicated. Surgery should be performed in those with burst fractures or flexion-distraction fractures, with severe spinal stenosis or kyphotic deformity, and fracture-dislocation.