Thoracolumbar Burst Fracture without Neurological Deficit: Review of Controversies and Current Evidence of Treatment

Tanasansomboon, Teerachat; Kittipibul, Thanachaporn; Limthongkul, Worawat; Yingsakmongkol, Wicharn; Kotheeranurak, Vit; Singhatanadgige, Weerasak

doi:10.1016/j.wneu.2022.03.061

Cited by 21 publications

(12 citation statements)

References 54 publications

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“…If PLC damage is found during the assessment of TL burst fractures, surgical therapy is typically advised. 13 , 14 ) As a result, the early detection of PLC injuries on CT scans would have significant clinical value to enable early decision making and establish the best surgical strategy especially in cases where the presence of PLC injury cannot be accurately assessed on MRI or MRI is not practical in polytrauma scenario. Although the use of a fat-suppressed MRI sequence or STIR has been recommended to identify damages to PLC components, 9 , 15 , 16 ) prioritizing CT scans over MRI is reasonable for acute trauma assessment due to a quick turnaround time and the ability to describe whole-body polytrauma, fracture morphology, and spinal alignment at once even in an unstable clinical scenario.…”

Section: Discussionmentioning

confidence: 99%

Evaluation of Posterior Ligamentous Complex Injury in Thoracolumbar Burst Fractures: Correlation Analysis of CT and MRI Findings

Yoshikawa¹,

Nishimura

Nagashima

et al. 2023

Neurol. Med. Chir.(Tokyo)

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The goal of this study is to perform correlation analysis of Computed tomography (CT) and magnetic resonance imaging (MRI) results in posterior ligament complex (PLC) injury and define the morphological traits of thoracolumbar (TL) burst fractures connected to PLC injury. Forty patients with surgically repaired TL burst fractures between January 2013 and December 2020 were retrospectively analyzed. The patients were split into two groups for comparison based on MRI (Group P: patients with a confirmed or suspected PLC injury; Group N: patients with PLC injury denied). The radiographic morphological examination based on CT scans and clinical evaluation was performed and compared between two groups. The thoracolumbar injury classification and severity score (TLICS), the load sharing classification (LSC) scores, and the number of patients with neurological impairments were considerably greater in Group P. Loss of height of the fracture (loss height), local kyphosis of the fracture (local kyphosis), and supraspinous distance were significantly higher in Group P and significantly associated with PLC injuries indicating severe vertebral body destruction and traumatic kyphosis in multivariate logistic analysis [odds ratio: 1.90, 1.06, and 1.13, respectively]. Cutoff value for local kyphosis obtained from the receiver operating characteristic curve was 18.8. If local kyphosis is greater than 18.8 degrees on CT scans, we should take into account the probability of the highly damaged burst fracture associated with PLC injury. In this situation, we should carefully assess MRI to identify the spinal cord injury or spinal cord compression in addition to PLC injury because these instances likely present with neurological abnormalities.

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Section: Discussionmentioning

confidence: 99%

Evaluation of Posterior Ligamentous Complex Injury in Thoracolumbar Burst Fractures: Correlation Analysis of CT and MRI Findings

Yoshikawa¹,

Nishimura

Nagashima

et al. 2023

Neurol. Med. Chir.(Tokyo)

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“…2 Therefore, for TL burst fractures with intact neurology, it is generally agreed that the degree of bony instability and the integrity of the posterior ligamentous complex (PLC) are the two critical determinants in decisionmaking. 3 Nevertheless, the lack of agreed-on criteria for bony instability or PLC injury may explain why decision-making in TL burst fractures has been controversial. 4,5 The criteria used to indicate bony instability have changed across various classification systems over the years.…”

Section: Introductionmentioning

confidence: 99%

The Influence of Comminution and Posterior Ligamentous Complex Integrity on Treatment Decision Making in Thoracolumbar Burst Fractures Without Neurologic Deficit?

Aly,

Dandurand,

Dvorak

et al. 2024

Global Spine Journal

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Study Design A prospective study. Objective to evaluate the impact of vertebral body comminution and Posterior Ligamentous Complex (PLC) integrity on the treatment recommendations of thoracolumbar fractures among an expert panel of 22 spine surgeons. Methods A review of 183 prospectively collected thoracolumbar burst fracture computed tomography (CT) scans by an expert panel of 22 trauma spine surgeons to assess vertebral body comminution and PLC integrity. This study is a sub-study of a prospective observational study of thoracolumbar burst fractures (Spine TL A3/A4). Each expert was asked to grade the degree of comminution and certainty about the PLC disruption from 0 to 100, with 0 representing the intact vertebral body or intact PLC and 100 representing complete comminution or complete PLC disruption, respectively. Results ≥45% comminution had a 74% chance of having surgery recommended, while <25% comminution had an 86.3% chance of non-surgical treatment. A comminution from 25 to 45% had a 57% chance of non-surgical management. ≥55% PLC injury certainity had a 97% chance of having surgery, and ≥45-55% PLC injury certainty had a 65%. <20% PLC injury had a 64% chance of having non-operative treatment. A 20 to 45% PLC injury certainity had a 56% chance of non-surgical management. There was fair inter-rater agreement on the degree of comminution (ICC .57 [95% CI 0.52-.63]) and the PLC integrity (ICC .42 [95% CI 0.37-.48]). Conclusion The study concludes that vetebral comminution and PLC integrity are major dterminant in decision making of thoracolumbar fractures without neurological deficit. However, more objective, reliable, and accurate methods of assessment of these variables are warranted.

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“…Thoracolumbar (TL) 'burst type' fractures account for 45% of all major thoracolumbar injuries. [1][2][3][4] Despite being a frequent pathology, which is regularly seen and managed by spine surgeons, there is still no consensus on the indications for surgical treatment in cases without neurologic involvement. The current literature offers mixed and inconclusive results with various recommendations and multiple treatment algorithms.…”

Section: Introductionmentioning

confidence: 99%

Using Equipoise to Determine the Radiographic Characteristics Leading to Agreement on Best Treatment for Thoracolumbar Burst Fractures Without Neurologic Deficits

Dandurand,

Dvorak,

Hazenbiller

et al. 2024

Global Spine Journal

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Study Design Retrospective analysis of prospectively collected data. Objectives Our goal was to assess radiographic characteristics associated with agreement and disagreement in treatment recommendation in thoracolumbar (TL) burst fractures. Methods A panel of 22 AO Spine Knowledge Forum Trauma experts reviewed 183 cases and were asked to: (1) classify the fracture; (2) assess degree of certainty of PLC disruption; (3) assess degree of comminution; and (4) make a treatment recommendation. Equipoise threshold used was 77% (77:23 distribution of uncertainty or 17 vs 5 experts). Two groups were created: consensus vs equipoise. Results Of the 183 cases reviewed, the experts reached full consensus in only 8 cases (4.4%). Eighty-one cases (44.3%) were included in the agreement group and 102 cases (55.7%) in the equipoise group. A3/A4 fractures were more common in the equipoise group (92.0% vs 83.7%, P < .001). The agreement group had higher degree of certainty of PLC disruption [35.8% (SD 34.2) vs 27.6 (SD 27.3), P < .001] and more common use of the M1 modifier (44.3% vs 38.3%, P < .001). Overall, the degree of comminution was slightly higher in the equipoise group [47.8 (SD 20.5) vs 45.7 (SD 23.4), P < .001]. Conclusions The agreement group had a higher degree of certainty of PLC injury and more common use of M1 modifier (more type B fractures). The equipoise group had more A3/A4 type fractures. Future studies are required to identify the role of comminution in decision making as degree of comminution was slightly higher in the equipoise group.

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Thoracolumbar Burst Fracture without Neurological Deficit: Review of Controversies and Current Evidence of Treatment

Cited by 21 publications

References 54 publications

Evaluation of Posterior Ligamentous Complex Injury in Thoracolumbar Burst Fractures: Correlation Analysis of CT and MRI Findings

Evaluation of Posterior Ligamentous Complex Injury in Thoracolumbar Burst Fractures: Correlation Analysis of CT and MRI Findings

The Influence of Comminution and Posterior Ligamentous Complex Integrity on Treatment Decision Making in Thoracolumbar Burst Fractures Without Neurologic Deficit?

Using Equipoise to Determine the Radiographic Characteristics Leading to Agreement on Best Treatment for Thoracolumbar Burst Fractures Without Neurologic Deficits

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