Burst fracture

ext.conference

1. Case conference Ratchan Jariengprasert

2. CASE Patient profile : Thai elderly woman, 68 years old Chief complaint : ถูก MC เฉี่ยว ล้มศีรษะกระแทกพื้น 8/11/59 11.00 น.

3. Primary survey A : patent airway, C-spine not tender, can mobile B : normal breathing pattern, trachea in midline, normal breath sound, equal both, CCT negative C : hemodynamic stable, BP 200/100 mmHg, PR 80 bpm D : E4V5M6, pupil 3 mmRTLBE E : LW 6 cm at left temporal area, no other external bleeding, PCT negative

4. secondary survey A : none M : Underlying disease DM, HT P : ไม่เคยเข้านอน รพ. ไม่เคยผ่าตัดอะไรมาก่อน L : 17.00 E : ระหว่างเดินจูงจักรยานข้ามถนน รถMC เฉียว ล้มศีรษะกระแทก สลบ จำไม่เหตุการณ์ไม่ได้ อาเจียนสองครั้ง มีเลือดออกจากหูซ้าย มีแผลที่ศีรษะด้านซ้าย

5. physical examination GA : elderly woman, good consciousness HEENT : no pale conjunctiva, anicteric sclera head : LW 2 cm deep to subcutaneous with hepatoma 5 cm ear : bloody otorrhea Lt CVS : normal s1s2 no murmur, full regular pulse Lung : normal breath sound, equal both, no adventitious sound Abdomen : soft, not tender, no guarding, no rebound Extremity : no edema, no deformity, no external wound Neuro : motor power grade V all ext.

6. Diagnosis + management Severe head injury (high risk) r/o base of skull fracture Refer จากรพ.ด่านขุนทด consult neuro surgery CT brain non contrast pelvis AP, Chest x-ray

7. CT brain NC Left parieto-temporal bone fracture SAH along bilateral temporal sulci Admit observe neuro sign 2 day refer กลับด่านขุนทด

8. CC : ปวดขา ปวดหลัง ลุกนั่งแล้วปวด ลงมาเดินไม่ได้ PI : ตื่นดี ไม่ปวดหัว ไม่อ่อนแรง ไม่ชา ไม่มีปวดร้าวลงขา กลั้นปัสสาวะอุจจาระได้ ล้อหน้าจักรยานกระแทกขาขวา เจ็บด้านข้าง

9. thoracolumbar spine : midline back pain level L1L2 motor power grade V all, except Rt leg DTR 2+ all extremities, intact PPS PR : tight sphincter tone, perianal sensation intact Ext. - tender Rt leg, can flex/extend knee

10. A - alignment : 4 line ant/post. vertebral body/lamina/spinous no subluxation, no stepping, loss of kyphosis/lordosis spondylolithisis,retrolithisis B - bone : vertebral height, shape(square/wedge), density(osteolytic, osteoblastic lesion), homogenous end plate involve, subchondal sclerosis, marginal osteophyte C - cartilage : disc narrowing, vacuum disc, facet joint D - distance : interpedicular distance (เพิ่มขึ้นจากบนลงล่าง ให้เทียบกับอันล่าง ถ้ากว้างกว่าแปลว่า+) E - external soft tissue : paravertebral soft tissue, psoas muscle

11. Refer R/o compression fracture L1 Close isolated fracture of Right proximal 1/3 fibular on short leg slab

12. Admit Bed rest Pain control CT TL spine comminuted fracture of anterior and posterior vertebral body L1, 40% anterior height collapse of L1, burst fracture with fracture L1 spinous process no retropulsion of bone into spinal canal the rest of spine no visualised fracture and spondylolisthesis degenerative change of lumbar spine is seen

13. -??????- “Burst fracture”

14. Dennis three column classification

15. ▪ 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 ▪ spinous process ▪ posterior ligament complex (PLC):

16. The PLC serves as a posterior "tension band" of the spinal column and plays an important role in the stability of the spine. A torn PLC has a tendency not to heal and can lead to progressive kyphosis and collapse.

17. TL spine injury compression Fx stable/unstable burst Fx chance Fx (seat belt injury) flexion-distraction(ant, post) fracture dislocation

18. Burst fracture define : vertebral fx with compromise ant. + middle column mechanism : axial loading + flexion TL junction most vulnerable to traumatic injury maximum neural compression at moment of impact

19. Radiographs ◦ recommended views ▪ obtain radiographs of entire spine (concomitant spine fractures in 20%) ◦ AP shows ▪ widening of pedicles (>1 mm difference between the vertebrae above and below) ▪ coronal deformity ◦ lateral shows ▪ retropulsion of bone into canal ▪ loss of ant+post vertebral height ▪ kyphotic deformity

20. -the injury level interpedicular distance is more than average of the level above/below -suggest disruption of middle column and presence of burst Fx

21. Dennis classification burst fx 5 subtypes ◦ Type A: Fracture of both end-plates. ◦ Type B: Fracture of the superior end-plate. -common ◦ Type C: Fracture of the inferior end-plate. -rare ◦ Type D: Burst rotation. This fracture could be misdiagnosed as a fracture-dislocation. The he mechanism of this injury is a combination of axial load and rotation. ◦ Type E: Burst lateral flexion. This type of fracture differs from the lateral compression fracture in that it presents an increase of the interpediculate distance on anteroposterior roentgenogram

22. Thoracolumbar injury classification and severity score(TLICS) score < 4 : non surgical treatment score = 4/10 : non surgical treatment or surgical management score > 4 : surgical management *translation/rotation/distraction of post.side always involve PLC

23. CT features of PLC pathology are: • Widening of the interspinous space. • Avulsion fractures or transverse fractures of spinous processes or articular facets. • Widening or dislocation of facet joints. • Vertebral body translation or rotation. When the PLC is definitely injured on CT, it can already be scored as 3.

24. TLICS = 4-5 compression fracture + burst no neurodeficit +- PCL indeterminate/injury

25. Surgical treatment ◦ 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 ▪ > 30°kyphosis (controversial) ▪ > 50% loss of vertebral body height (controversial) ▪ > 50% canal compromise (controversial)

26. Nonsurgical treatment ◦ ambulation as tolerated with or without a thoracolumbosacral orthosis       ▪ indications ▪ patients that are neurologically intact and 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

27. Comparison comparison between operative and non operative for thoracolumbar burst fracture with no neurological deficit : There is no difference in kyphosis, residual back pain, cost of hospitalization and return to work between operative and non-operative approaches, but increased disability and complications with operative treatment.

28. Spine orthosis Jewett brace - prevent flex > extend Taylor brace - prevent extend > flex

29. Jewett brace symptomatic relief of compression fracture immobilisation after surgical stabilisation of TL fx limit flexion T6-L1 contraindication : instability type compression fx above T6 compression fx cause by osteoporosis

30. Bed rest 6 weeks TLSO until fracture union (3 months) prevent pressure sore breathing exercise exercise upper and lower extremities

31. Reference http://www.orthobullets.com/spine/2022/thoracolumbar-burst-fractures#5630 http://www.radiologyassistant.nl/en/p54885e620ee46/spine-injury-tlics-classification.html uptodate