J Korean Neurosurg Soc.  2021 Nov;64(6):944-949. 10.3340/jkns.2021.0080.

Are “Unstable” Burst Fractures Really Unstable?

• Woo JH
• Lee HW
• Choi HJ
• Kwon YM

• KMID: 2521984
• DOI: http://doi.org/10.3340/jkns.2021.0080

Abstract

Objective
: The stability is an important factor to decide the treatment plan in thoracolumbar burst fracture patients. Patients with an unstable burst fracture generally need operative management. Decrease in vertebral body height, local kyphosis, involvement of posterior column, and/or canal compromise are considered important factors to determine the treatment plan. On the other hand, in thoracolumbar injury classification system (TLICS), surgery is recommended in patients with TLICS of more than 5 points. The purpose of this study was to apply the TLICS score in patients with thoracolumbar burst fractures and to distinguish the differences of treatment plan on burst fracture.
Methods
: All patients, diagnosed as a thoracolumbar burst fracture between January 2006 and February 2019 were included in this study. Unstable thoracolumbar burst fracture was defined as burst fracture with neurologic deficit, three-column injury, kyphosis over 30 degrees, decrease of anterior body height over 40 percent and canal comprise more than 50%. TLICS score was measured with morphology, neurological involvement and posterior ligamentous complex integrity. The existence of instability was compared with TLICS score.
Results
: Total 233 patients (131 men, 102 women) were included in this study. In Denis classification, 51 patients (21.9%) diagnosed as stable burst fracture while 182 patients (78.1%) had unstable burst fracture. According to TLICS, 72 patients (30.9%) scored less than 4, while 161 patients (69.1%) scored 4 or more. All the patients with stable burst fracture scored 2 in TLICS. Twenty-one patients (9.0) scored 2 in TLICS but diagnosed as unstable burst fracture. Thirteen patients had over 40% of vertebra body compression, four patients had more than 50% of canal compromise, three patients had both body compression over 40% and kyphosis over 30 degrees, one patients had both body compression and canal compromise. Fifteen patients presented kyphosis over 30 degrees, and three (20%) of them scored 2 in TLICS. Seventy-three patients presented vertebral body compression over 40% and 17 (23.3%) of them scored 2 in TLICS. Fifty-three patients presented spinal canal compromise more than 50%, and five (9.4%) of them scored 2 in TLICS.
Conclusion
: Although the instability of thoracolumbar burst fracture was regarded as a critical factor for operability, therapeutic strategies by TLICS do not exactly match with the concept of instability. According to the concept of TLICS, it should be reconsidered whether the unstable burst fracture truly unstable to do operation.

Keyword

Spinal injuries; Spinal fractures; Classification

Figure

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  Fig. 1. Plain X-ray, computed tomography (CT) and magnetic resonance image (MRI) of a 36-year-old male patient with a L2 burst fracture without neurological deficits. Radiologic measure of parameters. In plain X-ray lateral view, compression ratio of vertebral height was calculated by [1 – 2b / (a + c)], as the ratio of the fractured front vertebral body height to the mean of the adjacent upper and lower vertebral frontal body. He showed 55% of compression ratio. Kyphotic angle was measured by Cobb’s angle, between the superior end plate of the vertebra above and the inferior vertebra below the fractured level. He showed 9.2° of kyphosis (A). Spinal canal compromise was measured in axial image of CT scan by [1– d/e]. He showed 47% of spinal canal compromise (B). MRI of injured level present no signs of posterior ligamentous complex damage (C). His thoracolumbar injury classification system score was 2 (morphology, 2; posterior ligamentous complex, 0; neurology, 0). He underwent posterior decompression and pedicle screw fixation.

Reference

References

1. Alpantaki K, Bano A, Pasku D, Mavrogenis AF, Papagelopoulos PJ, Sapkas GS, et al. Thoracolumbar burst fractures: a systematic review of management. Orthopedics. 33:422–429. 2010.

2. Cantor JB, Lebwohl NH, Garvey T, Eismont FJ. Nonoperative management of stable thoracolumbar burst fractures with early ambulation and bracing. Spine (Phila Pa 1976). 18:971–976. 1993.

3. Dai LY, Jiang SD, Wang XY, Jiang LS. A review of the management of thoracolumbar burst fractures. Surg Neurol. 67:221–231. discussion 231. 2007.

4. Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine (Phila Pa 1976). 8:817–831. 1983.

5. Denis F, Armstrong GW, Searls K, Matta L. Acute thoracolumbar burst fractures in the absence of neurologic deficit. A comparison between operative and nonoperative treatment. Clin Orthop Relat Res. 189:142–149. 1984.

6. Holdsworth F. Fractures, dislocations, and fracture-dislocations of the spine. J Bone Joint Surg Am. 52:1534–1551. 1970.

7. Joaquim AF, Daubs MD, Lawrence BD, Brodke DS, Cendes F, Tedeschi H, et al. Retrospective evaluation of the validity of the thoracolumbar injury classification system in 458 consecutively treated patients. Spine J. 13:1760–1765. 2013.

8. Kelly RP, Whitesides TE Jr. Treatment of lumbodorsal fracture-dislocations. Ann Surg. 167:705–717. 1968.

9. Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S. A comprehensive classification of thoracic and lumbar injuries. Eur Spine J. 3:184–201. 1994.

10. Mattei TA, Hanovnikian J, Dinh DH. Progressive kyphotic deformity in comminuted burst fractures treated non-operatively: the Achilles tendon of the thoracolumbar injury classification and severity score (TLICS). Eur Spine J. 23:2255–2262. 2014.

11. McAfee PC, Yuan HA, Lasda NA. The unstable burst fracture. Spine (Phila Pa 1976). 7:365–373. 1982.

12. McCormack T, Karaikovic E, Gaines RW. The load sharing classification of spine fractures. Spine (Phila Pa 1976). 19:1741–1744. 1994.

13. Reid AB, Letts RM, Black GB. Pediatric chance fractures: association with intra-abdominal injuries and seatbelt use. J Trauma. 30:384–391. 1990.

14. Stadhouder A, Buskens E, Vergroesen DA, Fidler MW, de Nies F, Oner FC. Nonoperative treatment of thoracic and lumbar spine fractures: a prospective randomized study of different treatment options. J Orthop Trauma. 23:588–594. 2009.

15. Vaccaro AR, Lehman RA Jr, Hurlbert RJ, Anderson PA, Harris M, Hedlund R, et al. A new classification of thoracolumbar injuries: the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status. Spine (Phila Pa 1976). 30:2325–2333. 2005.

16. Wood K, Buttermann G, Mehbod A, Garvey T, Jhanjee R, Sechriest V. Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit. A prospective, randomized study. J Bone Joint Surg Am. 85:773–781. 2003.