Thoracolumbar Vertebral

Fractures
(Wedge Compression Fracture,
Burst Fracture and Chance
Fracture)
Prepared by,
Sun KJ
Outline
Relevant Anatomy
Classification and Etiology
Presentation
Imaging and Investigations
TLICS
Management
Prognosis
Reference
Relevant Anatomy Denis Three Column
Concept
Anterior Column:
1. Anterior longitudinal ligament
2. Anterior 2/3 of vertebral body and intervertebral disc
Middle Column:
1. Posterior 1/3 of vertebral body and intervertebral disc
2. Posterior longitudinal ligament
Posterior Column
1. Pedicles
2. Lamina
3. Facets
4. Spinous process
5. Posterior ligamentous complex (PLC)
Classification and Etiology
Wedge Compression Fracture: Single column, stable anterior fracture
Burst Fracture: Two columns, anterior and middle fracture, can be
unstable
Chance Fracture: Three columns, unstable fracture

Traumatic - Various mechanism of force loading ( flexion-

compression, axial-compression, flexion-distraction, rotational)
Pathologic - Osteoporosis, Tumour/Cancer or Infection
Osteoporotic Vertebral Compression Fracture
Most common pathologic fracture, affects up to 25% of elderly over
70 years old, 50% over 80 years old.
Prognosis: 1-year mortality 15%, 2-year mortality 20% (equivalent
to hip fracture)
P/w: Pain that is localized to fracture site but might wrap around the
dermatome
Physical exam: Focal tenderness, local kyphosis
Normally no neurology but nerve root deficits might occur if there is
severe foraminal stenosis
Osteoporotic Vertebral Compression Fracture
Radiograph: Loss of vertebral height by 20% or at least 4mm

Indications for CT: Neurologic deficits, inadequate plain films

MRI is useful for: acute vs chronic nature, ligamentous injury, spinal

cord compression, cord oedema or hemorrhage
Osteoporotic Vertebral Compression Fracture
Management:
Non operative: Observation, Bracing and Medical treatment
Indications for non operative treatment: PLL intact

Operative: Kyphoplasty
Indications: Severe pain after 6 weeks of conservative management
Complications: Extravasation of PMMA into spinal canal

Surgical decompression and stabilization

Indications: PLL injury, unstable spine or progressive neurologic deficits
TLSO Brace
Thoracolumbar Burst Fracture
High-energy axial loading spinal trauma. Mostly happens at
thoracolumbar junction T11 L2.
Neurologic deficits: Canal compromise caused by retropulsion of
bone. Maximum damage at the moment of impact. Rarely
progressive.
Ask for whole spine imaging: Concomitant spine fractures 20%
Always ask for CT or MRI: To look for canal compromise
Long term prognosis: Pain + Progressive Kyphosis
Thoracolumbar Burst Fracture
X ray AP: Interpedicular widening, coronal deformity

X ray Lateral: Loss of vertebral height, retropulsion of bone, kyphotic

deformity

CT: burst vertebra on axial CT

MRI: Spinal cord compression, oedema, haemorrhage and PLC injury

Retropulsed vertebra and Interpedicular widening
Thoracolumbar Injury Classification System
(TLICS)
Thoracolumbar Burst Fracture
Non operative: Ambulation as tolerated and TLSO
Outcomes: Retropulsed fragments resorb over time and usually do not
cause neurological deterioration

Operative: Surgical decompression and spinal stabilization

Either anterior or posterior approach, direct or indirect decompression
Avoid laminectomy if possible
Need to consider complications of surgery
Post op X ray will be shown later
Chance Fracture
Flexion-distraction injury (seatbelt injury)
Anterior column fails under compression
Middle and posterior columns fail under tension

Associated injuries: High risk of gastrointestinal involvement 50%

Prognosis: Pain, Deformity and Post traumatic Syringomyelia

Chance Fracture
X ray AP: Empty box sign, interpedicular widening

X ray Lateral: Transverse fracture across transverse process, lamina

and articular process, widening of interspinous process, fanning of
spinous process, widening of facet joints

MRI: Important to evaluate posterior elements

CT: Important to evaluate bony retropulsion into spinal canal

Chance Fracture
Non Operative: Immobilization in cast or TLSO
Indications: Neurologically intact with stable fracture pattern
Complications: Non union

Operative: Surgical decompression and stabilization

Indications: Neurologic deficits or unstable fracture
Approach: Anterior or posterior. Most likely needs instrumentation
and fusion.
Case Study
61 years old, Male

Underlying HPT

MOI: Alleged fall from roof top about 20 feet. Landed in sitting
position

PT: Low back pain, reduced sensation over bilateral lower limbs,
unable to ambulate
 Diagnosis: L1 burst fracture with incomplete neurology

Management:
CRIB
Analgesics
Post case under EMOT for Laminectomy L1 + PSIF T11 - L3
For spine rehab post op
Reference
Orthobullets
Radiopaedia
Radiology assistant
Medscape
Thank you!