Brace or Surgery
- Neurologically intact patient
- Less than 40% height loss
- Less than 10 degrees of kyphosis on upright imaging
- Other factors - body habitus
- Circumstances of accident
- Mumford et al
- 41 patients with thoracolumbar burst fxs w/o neurologic deficit were treated conservatively.
- At injury, canal compromise averaged 37% at 2-year follow-up, 2/3 resolution of fragments occluding canal.
- Outcome evaluation: 49% patients reported excellent outcome relative to pain and function.
- Progression of body collapse on imaging averaged 8%.
- 1 patient developed neurologic deterioration prompting surgery. All other patients remained intact.
- Cantor et al.
- 18 Neurologically intact patients without PLC disruption were treated with early ambulation and bracing.
- Kyphosis was 19 degrees at time of injury and 20 degrees at follow-up.
- VB height loss was 36% on presentation, maximum change of 5% on follow-up.
- At follow-up, 15 patients rated their pain as little or none, and 17 patients had little or no restriction of activity.
- CT scan 1 year after injury in 8 patients showed > 50% resorption of retropulsed bone.
- No patient had deterioration of neurologic function.
Surgical Results in Thoracolumbar Burst Fractures
- Studies comparing anterior and posterior surgery have equivalent neurological outcomes.
- There is a tendency for less kyphosis and better pain and function outcomes with anterior surgery.
- Reduced degenerative changes resulting from saving motion segments with anterior procedures has not been proved.
Technique Pearls for Posterior Instrumentation
- More instability or deformity or poor bone quality = more failure with short segment posterior instrumentation.
- More points of fixation
- May require anterior column support
Inappropriate Screw Placement
- Nerve damage
- Vascular or visceral complications
- Late onset discomfort or pain
- Secondary to pseudoarthrosis, hardware failure
Entry Point Lumbar Pedicle Screws
- Start out by marking the entry points with K-wires or short pins using the fluoroscopy in the AP direction.
- The correct positioning and orientation can be verified by adjusting the fluoroscopy to where the K-wire is a "point," which lies clearly within the pedicle.
- The integrity of five walls is essential to insert the screw.
- Most important are medial and inferior due to presence of spinal cord and nerve root, respectively.
- Avoid the medial half of the superior facet and its caudal projection.
- Scrutinize intraoperative x-rays --> true A/P at each level.
- Utilize intraoperative CT scan.