Introduction

Defined as vertebral fracture with compromise of the anterior and middle

column
can be unstable because both anterior and middle columns are
involved
Mechanism
axial loading with flexion
at thoracolumbar junction there is fulcrum of increased motion
that makes spine more vulnerable to traumatic injury
Neurologic deficits
canal compromise often caused by retropulsion of bone
maximum canal occlusion and neural compression at moment of
impact
retropulsed fragments resorb over time and usually do not cause
progressive neurologic deterioration
Associated injuries
concomitant spine fractures in 20%

Anatomy

Denis three column system

clinical relevance
only moderately reliable in determining clinical degree of
stability
definitions
anterior column
anterior longitudinal ligament (ALL)
anterior 2/3 of vertebral body and annulus
middle column
posterior longitudinal ligament (PLL)
posterior 1/3 of vertebral body and annulus
posterior column
pedicles
lamina
facets
ligamentum flavum
spinous process
posterior ligament complex (PLC)
instability defined by
injury to middle column
as evidenced by widening of interpedicular
distance on AP radiograph
loss of height of posterior cortex of vertebral
body
disruption of posterior ligament complex combined
with anterior and middle column involvement
o Posterior Ligamentous Complex
considered to be a critical predictor of spinal fracture stability
 consists of
supraspinous ligament
interspinous ligament
ligamentum flavum
facet capsule
evaluation
determining the integrity of the PLC can be challenging
conditions where PLC is clearly ruptured
bony chance fracture
widening of interspinous distance
progressive kyphosis with nonoperative
treatment
facet diastasis
conditions where integrity of PLC is indeterminant
MRI shows signal intensity between spinous
process

Imaging

Radiographs

o recommended views

obtain radiographs of entire spine (concomitant spine fractures

in 20%)

o AP shows

widening of pedicles

coronal deformity

o lateral shows

retropulsion of bone into canal

kyphotic deformity

CT scan

o indications

fracture on plain film

neurologic deficit in lower extremity

inadequate plain films

MRI

o useful to evaluate for

 spinal cord or thecal sac compression by disk or osseous
material

cord edema or hemorrhage

injury posterior ligament complex

signal intensity in PLC is concerning for instability and may warrant

surgical intervention

Treatment

Nonoperative

o ambulation as tolerated with or without a thoracolumbosacral

orthosis

indications

patients that are neurologically intactand mechanically

stable

posterior ligament complex preserved

kyphosis < 30 (controversial)

vertebral body has lost < 50% of body height

(controversial)

TLICS score = 3 or lower

thoracolumbar orthosis

recent evidence shows no clear advantage of TLSO on

outcomes

if it provides symptomatic relief, may be beneficial for

patient

outcomes

retropulsed fragments resorb over time and usually do not

cause neurologic deterioration

Operative

o surgical decompression & spinal stabilization

indications

neurologic deficits with radiographic evidence of cord/thecal

 sac compression

both complete and incomplete spinal cord injuries

require decompression and stabilization to facilitate
rehabilitation

TLICS score = 5 or higher

unstable fracture pattern as defined by

injury to the Posterior Ligament Complex (PLC)

progressive kyphosis

> 30kyphosis (controversial)

> 50% loss of vertebral body height (controversial)

> 50% canal compromise (controversial)

Techniques

Anterior decompression and stabilization (with or without posterior

stabilization)

o indications

indicated when neurologic deficits caused by anterior compression

(bony retropulsion)

scientific data has not shown a benefit to early decompression and

stabilization

o technique

usually includes corpectomy and strut grafting followed by anterior

+/- posterior instrumentation

advantage is that you do not need to do a laminectomy which will

further destabilize the spine by compromising the posterior
supporting structures

Posterior Decompression and Fusion

o indications

unstable fracture pattern with no need for neurologic

decompression

complete neurologic injury (allows earlier rehab)

 o neural decompression

direct decompression

retropulsed bone can be removed via transpedicular

approach

indirect decompression

via ligamentotaxis may occur by restoring height and

sagittal alignment with posterior instrumentation

o arthrodesis

fusion should be performed with instrumentation

instrumentation should be under distraction to restore vertebral

body height and achieve indirect decompression

historically it was recommended to instrument three levels above

and two levels below

modern pedicle screws have changes this to one level

above and one level below

avoid laminectomy if possible as it will further destabilize the spine

by compromising the posterior supporting structures

Posterior Fusion Alone (no decompression)

o indications

progression kyphosis or clear injury to posterior ligament complex,

but with no significant neurologic compression

Complications

Pain

o most common

Progressive kyphosis

o common with unrecognized injury to PLL

Flat back

o leads to pain, a forward flexed posture, and easy fatigue

o post-traumatic syringomyelia