Definition
Fractures of the lumbar vertebrae, most commonly occurring after high-energy trauma (e.g., motor vehicle accidents, falls)
Frequently involve the thoracolumbar junction (L1–L2)
Management depends on stability and neurological status
Epidemiology
Thoracolumbar region accounts for a large proportion of spinal fractures
Younger patients → high-energy trauma
Elderly patients → osteoporotic compression fractures
More common in males (trauma-related)
Etiology / Mechanism
Axial load → compression or burst fractures
Flexion → wedge (compression) fractures
Flexion-distraction → Chance fracture (seatbelt injury)
Rotation/shear → fracture-dislocation (highly unstable)
Classification
1. Denis Three-Column Theory
Anterior column: anterior longitudinal ligament (ALL) + anterior vertebral body
Middle column: posterior vertebral body + posterior longitudinal ligament (PLL)
Posterior column: pedicles, lamina, facet joints, posterior ligaments
Injury to ≥2 columns = instability
2. AO Spine Classification (Practical Use)
Type A (Compression)
A1: wedge compression
A3/A4: burst fractures
Type B (Tension Band Injury)
Posterior ligamentous complex (PLC) disruption
Includes Chance fractures
Type C (Translation/Rotation)
Most unstable injuries
High risk of neurological compromise
Clinical Presentation
Localised low back pain (most common)
Muscle spasm and reduced mobility
Neurological deficits (more common in burst/dislocation injuries):
Radiculopathy
Cauda equina syndrome
Frequently associated with polytrauma (abdominal, long bone injuries)
Imaging
X-ray
Initial assessment
Vertebral height loss
Kyphotic deformity
CT (Gold Standard)
Defines fracture pattern
Identifies retropulsed fragments
Assesses canal compromise
MRI
Essential for posterior ligamentous complex (PLC) evaluation
Detects disc injury
Assesses neural elements (cord/cauda equina)
Helps differentiate osteoporotic vs pathological fractures
Diagnosis
Based on clinical findings + imaging
Key elements:
Stability assessment (Denis columns / PLC integrity)
Neurological examination (mandatory)
Treatment
Nonoperative Management
Indications:
Stable fractures
No neurological deficit
Intact PLC
Management:
Bracing (TLSO)
Analgesia
Early mobilisation
Operative Management
Indications:
Unstable fractures
Neurological deficit
PLC injury
Progressive deformity
Surgical Options
Posterior instrumentation (most common)
Decompression
If neural compression present
Anterior reconstruction
In cases of severe vertebral body loss
Complications
Neurological injury
Progressive kyphosis
Nonunion
Chronic pain
Post-traumatic deformity
Prognosis
Stable fractures → generally favourable
Burst fractures with neurological deficit → variable outcomes
PLC injury → indicator of poor mechanical stability
Pits & Pearls
Thoracolumbar junction = highest risk region
Burst fracture ≠ automatic indication for surgery
MRI is critical for detecting PLC injury
Always assess canal compromise in burst fractures
High-energy trauma → maintain suspicion for associated injuries
Pitfalls
Relying solely on X-ray → missed PLC injury
Misjudging fracture stability
Failing to distinguish osteoporotic vs malignant fractures
Incomplete neurological examination
Missing intra-abdominal injuries in Chance fractures
TLICS (Thoracolumbar Injury Classification and Severity Score)
A validated scoring system used to guide management decisions in thoracolumbar (including lumbar) fractures.
1. Injury Morphology
Compression fracture → 1 point
Burst fracture → 2 points
Translation / rotation → 3 points
Distraction → 4 points
2. Posterior Ligamentous Complex (PLC) Integrity
Intact → 0 points
Suspected / indeterminate → 2 points
Disrupted → 3 points
Best assessed with MRI
3. Neurological Status
Intact → 0 points
Nerve root injury → 2 points
Complete spinal cord injury → 2 points
Incomplete spinal cord injury → 3 points
Cauda equina syndrome → 3 points
Scoring Interpretation
≤3 points → Nonoperative management
4 points → Either option (clinical judgement)
≥5 points → Surgical management
Clinical Application
Integrates:
Mechanical stability (morphology)
Soft tissue integrity (PLC)
Neurological status
Helps standardise decision-making beyond subjective assessment
Pits & Pearls (TLICS-specific)
PLC status is the “tie-breaker” in many borderline cases
A neurologically intact burst fracture may still be treated nonoperatively if stable
MRI is critical when PLC injury is suspected
TLICS ≥5 → strong surgical indication
Ignoring PLC injury → underestimating instability
Over-reliance on CT without MRI
Misclassifying neurological status
Treating the score blindly without clinical context