Thoracolumbar fractures without neurological impairment: A review of diagnosis and treatment

Overview

This review, published in EFORT Open Reviews in 2016, looks at thoracolumbar fractures in patients without neurological impairment. These injuries are common and usually result from traffic accidents and falls from a height. No unified protocol for managing them has been established. The authors examine the role of imaging, the value of classification systems and the evidence for conservative and surgical treatment.

Diagnostic imaging

Plain radiographs and CT are usually enough to assess stable injuries such as compression fractures and mild burst fractures. CT is routine in patients with multiple injuries. MRI shows soft-tissue and ligament damage that CT can miss, and adding it can change both the fracture classification and the treatment decision. However, MRI may overestimate injury to the posterior ligamentous complex and lead to overtreatment of stable lesions. The authors conclude that MRI is not mandatory for every fracture.

Classification

Several systems have been used, including the Denis three-column concept, the AO-Magerl classification and the load-sharing classification. A later severity system combined fracture morphology, ligament integrity and neurological status. It was criticised for underestimating some comminuted burst fractures, and it was eventually merged with the AO system into the AOSpine classification. According to the review, no current system captures every factor that influences outcome.

Conservative and surgical treatment

Conservative treatment is proposed for stable fractures without significant disruption of the posterior bone and ligaments. No immobilisation protocol has proven superior. Randomised trials found no benefit of bracing compared with no brace at all. Close outpatient follow-up is essential, and surgery should be considered if deformity or pain increases. Surgery is indicated for unstable burst fractures with ligament injury, flexion-distraction injuries and fracture-dislocations. Posterior approaches carry fewer complications than anterior or combined approaches. Percutaneous techniques give good results, especially in patients with multiple injuries, who may benefit from early stabilisation.

Clinical implications

Meta-analyses and a Cochrane review found insufficient evidence that surgery is superior to non-operative care for neurologically intact burst fractures. Long-term follow-up of a randomised study even favoured non-operative treatment for pain and function. Treatment should therefore be individualised. When surgery is chosen, less invasive posterior techniques are preferred.