Review Question - QID 215544

The patient is presenting with a thoracolumbar burst fracture (+2 points) with an incomplete spinal cord injury (+3 points) and a posterior ligamentous injury (+3 points) which necessitates surgical decompression and stabilization. Given that the spinal cord is present at the injured level and there is significant anterior cord compression, an L1 corpectomy through a lateral approach with a T12-L2 instrumented fusion is the best treatment option.

Thoracolumbar burst fractures are typically the result of an axial loading with a flexion moment resulting in a compressive force through the anterior and middle columns of the vertebral body. This can lead to retropulsion of bone fragments into the spinal canal leading to compression of the neural elements. Fracture stability is defined by an intact posterior ligamentous complex or a Thoracolumbar Injury Classification and Severity Score (TLICS) of 3 or lower. Fractures with significant neural compression from retropulsed vertebral body fragments and injuries above the conus medullaris are best treated with an anterior corpectomy and instrumented fusion.

Joaquim et al. performed a prospective study of 67 patients with thoracolumbar burst fractures to validate the thoracolumbar injury classification and severity score (TLICS) with regards to neurological outcome. They reported 37 patients with a TLICS score 3 and reported a neurologic improvement a final follow-up for patients with incomplete spinal cord injuries.

Patel et al. reviewed the TLICS classification system with three case examples. They concluded the TLICS classification is a highly reliable system with >90% interobserver agreement and guides treatment but is fraught with limitations, specifically patient-specific characteristics with ankylosing spondylitis.

Figure A is a sagittal CT of the lumbar spine with an L1 burst fracture and significant canal encroachment from retropulsion of vertebral body fragments and avulsion of the interspinous ligament from the T12 spinous process suggesting a PLC injury. Figure B is an axial CT of the abdomen depicting an L1 burst fracture with significant retropulsion and a right L1 lamina fracture.

Incorrect answers
Answer 1: Nonoperative treatment for this patient is not a viable option given the instability present from the PLC injury and the presence of an incomplete spinal cord injury.
Answer 2: Performing an in situ fusion would not address the kyphotic deformity at L1 and would not address the anterior-based compression from the encroaching vertebral body fragments. Posterior a lordotic and distraction-based correction could provide indirect decompression by ligamentotaxis.
Answer 3: Performing interbody fusion below the burst fracture would not address the neural compression and would be at high risk of subsidence given the degree of comminution in the vertebral body.
Answer 4: A L1 laminectomy would not address the deformity of the injury pattern, the instability of the injury pattern, or the anterior-based stenosis from the encroaching vertebral fragments. Stabilization and deformity correction should be performed in conjunction with decompression.