Thoracolumbar Burst Fractures - Causes, Symptoms, Diagnosis, and Management

Introduction

The vertebral column or the spinal cord consists of twelve thoracics, seven cervical, five lumbar, and five sacral vertebrae. The sacrum and coccyx vertebrae are fused. The thoracolumbar area is the region between the rigid thoracic vertebrae and the flexible lumbar vertebrae. This area is highly susceptible to fractures, and a burst fracture disrupts the vertebral body endplate and posterior vertebral body cortex, involving the anterior and middle column of the spine. Burst fractures are severe fractures that apply great force on the spinal cord, which may even crush the vertebrae, pushing the bony fragments into the spinal canal, and may be associated with nerve involvement leading to partial or complete paralysis.

What Are Thoracolumbar Burst Fractures?

Thoracolumbar burst fractures are fractures at the junction of the thoracic and lumbar spine, which are severe and may be associated with neurological involvement. If the fracture involves only the front of the spine, it becomes wedge shape and is called a compression fracture, and if the vertebrae are crushed in all directions, it is called a burst fracture. The neurological involvement depends on the amount of force during the injury and the extent of damage to the spinal canal. Most fractures occur in the T9 (thoracic vertebra) to L2 (lumbar vertebra) area and the lumbar spine.

What Are the Types of Thoracolumbar Burst Fractures?

Different types of columnar fractures are grouped based on column involvement and mechanism of injury. According to Denis's classification, thoracolumbar injuries are classified as follows:

• Compression Injuries: Fracture of the anterior column of the spinal cord, with the intact middle column, associated with involvement of superior or inferior endplates or both.

• Burst Injuries: Fracture of the anterior and middle column, the posterior column may or may not be involved, associated with involvement of superior or inferior endplates, or both.

• Flexion-Distraction Injuries: It is also called seat-belt type fractures; these are fractures involving all three columns of the spinal cord; with flexion and distraction mechanism

• Fracture-Dislocation Injuries: These involve all three columns of the spinal cord; the mechanism is variable, like shear, compression, tension, and rotation

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What Are the Causes of Thoracolumbar Burst Fractures?

• Thoracolumbar fractures are seen mainly in individuals below 35 years of age. It is primarily caused due to vehicle accidents, falls from great heights, or occupational injuries. The fulcrum of increased motion at the thoracolumbar junction makes it more susceptible to injuries and fractures.

• A previous history of spinal cord injury, osteoporosis, and tumors.

• Conus-medullaris syndrome and spinal stenosis are some other causes that may make the individual vulnerable to thoracolumbar fractures.

What Are the Signs and Symptoms of Thoracolumbar Burst Fractures?

Signs and symptoms include:

• Skin abrasions, bleeding, bruises, and damage to the soft tissues.

• Severe swelling and pain in the back, which radiates to the legs.

• Inability to move the legs or walk.

• Tingling or burning sensation along the affected area.

• In some cases, there may be numbness or complete loss of sensation.

• Inability to empty the bowel or bladder properly.

How Are Thoracolumbar Burst Fractures Diagnosed?

Thoracolumbar fractures need immediate care and management by an orthopedic specialist or a neurosurgeon. A complete history of the patient is taken, followed by a physical examination to check the injuries, bruises, and swelling; surrounding structures like the chest, stomach, and legs are also examined to determine the strength, range of motion, and coordination of arms and legs. Testing of muscle tone and nerves to confirm neurological involvement. Palpation shows localized tenderness and fluid collection. Radiological diagnosis includes:

• X-ray: Both anterior-posterior and lateral views to determine the damage caused to the vertebral column and the involvement of the other bones. Spinal dislocation, kyphosis, scoliosis, or the overall alignment of the spinal cord, can be assessed. Bony spurs, bone erosions, and disc space narrowing can also be noted by the X-rays.

• Computed Tomography (CT Scan): A combination of X-rays and computer technology produces a detailed image of the bones, surrounding muscles, and organs.

• Magnetic Resonance Imaging (MRI): It is a procedure that uses large magnets and radio frequencies to produce a detailed view and gives an accurate picture of the structures damaged during the injury. It shows the presence of spinal cord compression or enlargement, associated edema, and hematoma.

• CT Myelography: It is a procedure in which a contrast material is injected to evaluate the spinal cord, spinal lining, and nerve roots. This is advised in patients who cannot go for MRI scan.

How Are Thoracolumbar Burst Fractures Managed?

Immediate hospitalization is necessary for the accurate diagnosis and treatment of thoracolumbar fractures.

• Non-operative or conservative treatment is indicated for mechanically stable injuries without neurological involvement. It includes postural reduction by bed rest for 8 to 12 weeks, followed by slight assisted mobilization use of a thoracolumbar corset, and rehabilitation. In the case of compression fractures, physical therapy, and braces are considered to be the most effective method of management. Thoracic lumbosacral orthosis (TLSO) is recommended; it is a customized brace worn over an undershirt, which prevents further compression and provides symptomatic relief. It is advised for around two to three months and monitored once every two weeks, followed by physical therapy. External stabilization may not be required if there is no further subluxation.

• Complex fractures that cannot be treated conservatively or compression fractures and burst fractures with impaired mechanical strength and neurological involvement require surgical intervention. It includes decompression surgery, which removes the bone or the fragments that compress the spinal cord and the nerve roots, which provides relief from the pressure. Spinal fusion surgery is recommended in some cases, which involves the removal of loose bony fragments and fusion of the remaining vertebrae, and immobilization through screws and implants. Rehabilitation therapy is carried out after four to six weeks.

What Are the Complications of Thoracolumbar Burst Fractures?

Complications of thoracolumbar fractures include

• Pressure sores and blood clots in the pelvic region and legs due to long periods of immobility or bed rest.

• Long periods of inactivity of leg muscles can lead to deep vein thrombosis, which may progress to pulmonary embolism.

• Bowel or bladder dysfunction.

Complications of the surgery include

• Bleeding and infection at the surgical site.

• Non-union or failure of the surgery.

• Progressive forward rounding of the back (kyphosis) or failure in the spinal fusion (pseudoarthrosis).

• Iatrogenic neurological injury caused due to over-manipulation during surgery.

Conclusion

Thoracolumbar burst fractures are fractures of the thoracic-lumbar region and may or may not be associated with neurological involvement. It is caused mainly due to vehicle accidents or falls from heights and is associated with severe pain, swelling, and loss of movement. These fractures are treated conservatively, and complex fractures with nerve involvement are treated by spinal fusion or decompression surgery.