The neurologically intact patient with TLICS 4 or 5 burst fracture should be given a trial of nonoperative management

Abstract

Thoracolumbar burst fracture treatment in neurologically intact patients is controversial with many classification systems to help guide management. Thoracolumbar Injury Classification and Severity score (TLICS) provides a framework, but evidence is limited, and recommendations are primarily based on expert opinion. In this retrospective cohort study, data was reviewed for patients with thoracolumbar burst fractures at a Level-1 Trauma Center in New England from 2013 to 2018. Neurologically intact patients without subluxation/dislocation on supine computed tomography were included. Multimodal pain control and early mobilization were encouraged. Patients that failed to mobilize due to pain were treated with operative stabilization. Outcome measures include degree of kyphosis, visual analog scale pain scores, and neurological function. Thirty-one patients with thoracolumbar burst fractures with TLICS scores of 4 or 5 were identified, of which 21 were treated nonoperatively. Kyphosis at final follow-up was 26.4 degrees for the nonoperative cohort versus 13.5 degrees for the operative group (P < .001). Nonoperative patients tended towards shorter hospital lengths-of-stay (3.0 vs 7.1 days, P = .085) and lower final pain scores (2.0 vs 4.0, P = .147) compared to the operative group. Two patients (6%) developed radicular pain with mobilization, which resolved after surgical intervention. No patients experienced decline in neurologic function. A trial of mobilization for neurologically intact TLICS grade 4 and 5 thoracolumbar burst fractures is a safe and reasonable treatment option that resulted in successful nonoperative management of 21 out of 31 (68%) patients.

Figure 1.

Flow chart depicting pathway for nonoperative management of neurologically intact thoracolumbar burst fractures.

Figure 2.

(A–H) Images A to C are selected parasagittal, coronal, and axial CT cuts demonstrating an L1 burst fracture with extension to the T12–L1 facet joints and T12 spinous process. Images D and E are selected parasagittal and axial MRI sequences revealing disruption of the posterior ligamentous complex with ligamentum flavum injury (white arrow). Image F is the initial upright lateral radiograph which shows the degree of kyphosis and interspinous distances at time of admission. Images G and H are upright radiographs taken at 6 weeks and 5 months respectively indicating slight progression of kyphosis and interspinous splaying.

Figure 3.

(A–D) Images A and B show selected parasagittal and axial CT images demonstrating an L2 burst fracture with indeterminate posterior ligamentous complex injury. Images C and D are initial postop and final postop lateral radiographs, respectively.