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

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Thoracolumbar burst fractures are severe fractures of the thoracic-lumbar junction, caused mainly due to accidents and are associated with pain and numbness.

Medically reviewed by

Dr. Anuj Gupta

Published At May 4, 2023
Reviewed AtNovember 2, 2023

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

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.

Frequently Asked Questions

1.

What Is the Etiology of a Thoracolumbar Burst Fracture?

A thoracolumbar burst fracture typically occurs due to high-energy trauma, such as a motor vehicle accident or a fall from a significant height. The primary etiology involves axial compression forces on the spine, leading to the vertebrae's anterior and middle columns being crushed. This often results in a burst fracture where bone fragments displace into the spinal canal, potentially causing spinal cord injury. Such injuries can also result from sports accidents, industrial mishaps, or other traumatic events that subject the thoracolumbar spine to excessive force. 

2.

How to Treat Burst Fracture?

Treatment for a burst fracture depends on its severity and associated symptoms. In general, options include:
- Conservative Management: Mild cases may be treated non-surgically with bed rest, bracing, and pain management.
- Surgical Intervention: Severe fractures or those causing neurological deficits often require surgery to stabilize the spine, which may involve spinal fusion and hardware placement.
- Pain Management: Pain relief measures, including medication and physical therapy, are commonly incorporated into the treatment plan.
- Rehabilitation: Post-treatment rehabilitation focuses on regaining mobility and function through physical therapy.

3.

Is It Possible for Spinal Fractures to Heal Naturally Without Surgical Intervention?

Spinal fractures can sometimes heal without surgery, particularly if the fracture is stable and does not cause neurological deficits or significant deformity. The approach to treatment depends on the type and severity of the fracture. Here are some key points:
- Conservative Management: Many stable spinal fractures can be managed conservatively. This typically involves a combination of bed rest, bracing to immobilize the spine, and pain management with medications. The body's natural healing processes can mend the bone over time.
- Monitoring: Regular monitoring by a healthcare provider through imaging studies like X-rays or CT scans is essential to assess the healing progress and ensure the fracture remains stable.
- Physical Therapy: Physical therapy may be recommended to help with pain relief and to regain strength, mobility, and function after the fracture has started to heal.
- Time: Healing times can vary, but many spinal fractures will show significant improvement within several weeks to a few months.

4.

Is Walking Safe With a Back Fracture, or Should It Be Avoided?

Whether a person can walk with a fractured back depends on the severity and stability of the fracture. In some cases, walking might be possible with stable fractures, but it can be painful and limited. Unstable fractures may lead to paralysis or weakness, making walking unsafe. Seeking immediate medical evaluation and following professional guidance is essential to determine the ability to walk and ensure the best action for the situation.

5.

How to Cure a Thoracic Burst Fracture?

Treatment for a thoracic burst fracture typically involves:
- Medical Evaluation: Seek immediate medical attention for an accurate diagnosis and assessment of the fracture's severity.
- Stabilization: Stable fractures may be treated non-surgically with bracing and pain management. Unstable fractures often require surgical intervention to stabilize the spine.
- Pain Management: Medications and physical therapy can help manage pain and promote mobility.
- Rehabilitation: Post-treatment rehabilitation is important to regain strength, mobility, and function.
- Long-term Care: Regular follow-up and monitoring may be necessary to address complications and ensure the best recovery.
 

6.

How Severe Is a Thoracic Vertebra Fracture?

The seriousness of a fractured thoracic vertebrae varies based on the type, location, and severity. Unstable fractures with spinal cord involvement are more serious and can lead to paralysis. Treatment and timely medical evaluation are critical for the best outcome.

7.

What is the Typical Healing Duration for a Burst Fractured Vertebra?

The time it takes for a burst fracture of a vertebra to heal varies but generally ranges from several months to over a year. Non-surgical management involves bracing and physical therapy, extending the healing timeline. Surgical intervention can expedite healing but still requires several months for recovery. Individual factors, including age and overall health, influence the healing duration, and regular monitoring is essential to assess progress. Patience and adherence to medical advice are crucial for the best outcome.

8.

What Is the Level of Pain Associated With a Burst Fracture?

A burst fracture can be very painful, but the level of pain experienced varies depending on factors like the severity of the fracture, its location, and the individual's pain tolerance. In general:
- Acute Pain: Initially, a burst fracture can cause intense, sharp pain, especially if it results in spinal cord or nerve compression.
- Chronic Pain: Some individuals experience chronic pain even after the fracture heals, particularly if there is residual damage to the spinal cord or nerves.
- Pain Management: Pain can be managed with medications, physical therapy, and other treatments to improve comfort and function.
- Individual Variation: Pain perception varies from person to person, and the degree of pain can differ in each case.

9.

What Is the Maximum Duration of Recovery for Fractures?

The recovery time for fractures can vary significantly based on several factors, including the type of fracture, its location, and an individual's overall health. Some fractures may have longer recovery times than others:
- Simple Fractures: Simple fractures with minimal displacement may heal in several weeks to a few months with proper treatment.
- Complex or Compound Fractures: More complex fractures, especially those involving multiple bones or open fractures with soft tissue damage, can require several months to over a year to recover fully.
- Spinal Fractures: Spinal fractures, particularly those that involve the vertebrae, may have longer recovery times, often taking several months or more, depending on the severity.
- Individual Factors: An individual's age, overall health, and compliance with treatment can also influence the recovery duration.

10.

What Is the Shortest Possible Healing Duration for a Fracture?

The fastest time for a fracture to heal depends on factors like the type and location of the fracture, an individual's age and overall health, and the effectiveness of the treatment. Simple fractures may heal in as little as a few weeks, while more complex fractures can take several months.

11.

Are There Specific Dietary Choices That Promote Faster Bone Healing?

There is no specific food that can drastically accelerate bone healing, but a balanced diet rich in nutrients like calcium, vitamin D, protein, and vitamin C can support the healing process. These nutrients are essential for bone health and repair.

12.

Which Type of Bone Fracture Presents the Most Challenging Healing Process?

The hardest bone break to heal is often considered a comminuted fracture, where the bone shatters into multiple pieces. Such fractures require extensive surgical intervention and may still result in long and challenging recovery periods due to the complexity of restoring the bone's structure.
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Dr. Anuj Gupta
Dr. Anuj Gupta

Spine Surgery

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