SpineThoracolumbar Spine/Thoracolumbar Spine

Burst Fractures

A spinal burst fracture involves disruption of both the anterior and middle columns of the vertebral body under axial-compression load. Retropulsion of posterior wall fragments into the spinal canal is typical and may cause neurological injury through direct compression or secondary deformity. The thoracolumbar junction (T11–L2) is most often affected because it transitions from rigid thoracic to mobile lumbar segments. Common mechanisms include falls from height and motor-vehicle accidents.

Assoc. Prof. Ali Koc· Sakarya University Training and Research Hospital
Apr 20, 2026

 Clinical Features

  • Sudden severe back pain and limited motion

  • Possible neurologic deficit (paresthesia, weakness, paralysis)

  • Local tenderness, paraspinal spasm, step deformity, or widened interspinous gap → posterior-ligamentous injury

  • Always perform complete trauma survey to rule out associated injuries

  • Neurological exam must include sensory, motor, reflex, and bulbocavernosus reflex evaluation

💡 Absence of bulbocavernosus reflex = spinal shock; hyperactive response = complete cord injury.

Imaging

X-ray (AP + Lateral)Loss of vertebral-body height, widened interpedicular distance, sagittal malalignment, spinous-process gap

CT scanDefines bony detail, canal compromise, facet/pedicle/lamina fractures; essential for classification

MRIVisualizes posterior-ligamentous complex (PLC), spinal-cord edema, epidural hematoma, disc or soft-tissue injury; guides non-operative decision

Classification & Decision Making

  • AO / Magerl Classification for fracture morphology

  • TLICS (Thoracolumbar Injury Classification and Severity Score) guides management
    ≤ 3 points: Conservative
    4–5 points: Surgeon discretion
    ≥ 6 points: Surgical stabilization

Conservative Treatment

Indications

  • Neurologically intact

  • Kyphosis < 35°

  • Vertebral-height loss < 50 %

  • PLC intact

  • Medically unfit for surgery

Protocol

  • Bed rest 4–12 weeks ± hyperextension brace

  • Early mobilization under brace

  • Serial X-rays (2 wk → 1 mo → 2 mo → 3 mo)

  • Stop brace once alignment and pain stable

Surgical Treatment

Indications Goals: 

Unstable fracture, 

progressive neural deficit,

kyphosis > 35°,

height loss > 50%

canal decompression,

anterior/posterior column reconstruction

spinal stabilization

Approaches

  • Posterior instrumentation → shorter time, less blood loss, good outcomes

  • Anterior reconstruction → better kyphosis correction, less hardware failure

  • Combined approach → selected cases with severe retropulsion

  • Short vs long segment fixation: intermediate screw in the fractured body improves stability and fusion

  • Minimally invasive (percutaneous pedicle screws) shows promising results for selected patients

Clinical Pearls

💡 Intermediate screws through the fractured vertebra enhance construct rigidity and fusion rate.
💡 Posterior-ligamentous complex integrity is key determinant for non-operative management.
💡 Early mobilization in brace reduces pulmonary and thrombotic complications.

References

  1. Dai LY et al. Conservative treatment of thoracolumbar burst fractures: long-term follow-up with load sharing classification. Spine (Phila Pa 1976). 2008;33:2536–2544.

  2. Cahueque M et al. Management of thoracolumbar burst fractures. J Orthop. 2016;13:278–281.

  3. Rockwood & Green’s Fractures in Adults, 10th ed.

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