Selection criteria and outcome of operative approaches for thoracolumbar burst fractures with and without neurological deficit

Abstract

Criteria for choosing operative techniques for the treatment of thoracolumbar burst fractures remain disputed, particularly in neurologically intact patients. A retrospective study of 25 patients with thoracolumbar burst fractures was performed to assess fracture characteristics, operative approaches, fixation, radiographic results, and neurological, functional, and pain outcomes. Anterior corpectomy, allograft strut, and plate fixation were performed in 14 patients with or without neurological deficit when vertebral compression or canal encroachment was at least 40% or kyphosis was 15 degrees or more with a stable posterior column. In nine cases, an anterior operation and a posterior segmental fixation were combined for similar deformity and three-column instability. Posterior transpedicular decompression, fixation, and fusion were used primarily for two symptomatic patients with less than 40% encroachment and at most 40% compression. Overall, 21 patients (84%) were walking and 18 (72%) were continent at follow-up evaluation (mean 16.3 months) versus eight (32%) and 11 (44%) at presentation, respectively. Preoperatively, 17 patients experienced neurological deficit; 16 improved and 12 increased one Frankel grade. No patient deteriorated. Prior employment or activity level was resumed by 19 patients (76%) and only four patients professed incapacity. Pain was eliminated after 18 procedures (72%), all anterior or combined approaches. Restoration of anatomical alignment (< 5 degrees) was achieved in 19 cases. No anterior construct failed and only one patient treated posteriorly had postoperative kyphosis progression. Operative morbidity occurred in three cases (12%). Satisfactory neurological and functional outcomes were achieved in a majority of patients with thoracolumbar burst fractures after correction of canal compromise, middle column compression, and attendant deformity. These results indicate that anterior decompression and a weight-bearing strut graft are critical to clinical success in patients with significant vertebral destruction.