Burst Fractures

 

Cx burst 1Cx burst 2Cx burst

 

Definition

 

Injury to anterior and middle columns, with retropulsion +/- posterior column

 

Mechanism

 

Vertical compression

 

Epidemiology

 

10% cervical fractures

Most commonly C5/6

 

Pathology

 

Anterior & middle columns fail

- if severe, posterior ligament complex fails

 

Canal compromise / neurological injury

- retropulsed fragments

- typically one or two main retropulsed fragments

 

Neurology

 

More common than in upper cervical spine injuries

 

Clinical

 

Neck pain

 

Complete / incomplete cord lesion

 

American Spinal Injury Association (ASIA) Classification

- A (complete): no motor or sensory

- B (incomplete):  no motor, some sensory intact

- C (incomplete):  > 50% muscle groups strength < grade 3

- D (incomplete):  > 50% muscle groups strength > grade 3

- E (normal) motor and sensory

 

X-ray

 

AP

- widening between pedicles is hallmark on AP

 

Lateral

- > 50% anterior column loss of height

- loss of posterior vertebral height

 

CT

 

Cx burst sag CTCx burst coronal CTCx burst axial CT

 

MRI

 

Assess integrity of posterior column

Evaluate cord injury

 

Cx burst MRI 1C burst MRI

 

Cx burst MRI 2Cx burst MRI

MRI images demonstrating spinal cord injury and posterior ligamentous injury

 

Subaxial Injury Classification System / SLIC

 

Vaccaro et al Spine 2007

Injury Morphology   Discoligamentous complex   Neurological status  
No abnormality 0 Intact 0 Intact 0
Compression 1 Indeterminate (MRI change only) 1 Root injury 1
Burst 2 Disrupted 2 Complete cord injury 2
Distraction / facet perch 3     Incomplete cord injury 3
Rotation / facet dislocation 4     Persistent cord compression +1

 

SLIC 1 - 3 - neurologically intact, non operative

SLIC 4 - equivocal

SLIC > 5 - surgery

 

Reliability

 

Spitnale CORR 2020 - variable inter- and intra-observer reliability in the literature

 

AOSpine subaxial cervical spine injury classification

 

AOSpine Injury Classification

 

Neurological status:

N0 - neurologically intact

N1 - transient neurological deficit

N2 - radicular symptoms

N3 - incomplete spinal cord injuries

N4 - complete spinal cord injuries

NX - cannot be examined

 

Specific modifiers:

M1 - incomplete disruption of the posterior ligamentous complex

M2 - critical disk herniation

M3 - presence of comorbid spine conditions (osteoporosis, DISH, ossification of the PLL, AS)

M4 - vertebral artery injury

 

Reliability

 

Feuchtbaum et al Curr Rev Musculoskeletal Med 2016 - variable inter- and intra-observer reliability in the literature

 

Non operative Management

 

Indications

 

Wedge fractures

- < 50% height loss

- caused by flexion compression

- injury to anterior column only

Posterior column intact / nil instability / SLIC score 1 - 3

Minimal kyphosis

Nil neurology

 

Treatment

 

Collar for 6 weeks

 

Operative Management

 

Indications

 

Instability

Neurology

SLIC >5

 

Timing

 

Fehlings et al PLoS One 2012

- early (<24 hours) versus delayed (>24 hours) surgery

- 313 patients with acute cervical spinal cord injury

- improved neurological outcomes with decompression < 24 hours

 

Jug et al J Neurotrauma 2012

- surgical decompression < 8 hours versus 8-24 hours

- 42 patients with acute cervical spinal cord injury

- improvement of 2 ASIA grades in 46% patients treated < 8 hours

- improvement of 2 ASIA grades in 10% patients treated 8-24 hours

 

Steroids

 

Fehlings et al Global Spine J 2017

- evidence of modest improvements in motor functions with methylprednisone infusions within 8 hours

 

Technique

 

A. Anterior corpectomy & fusion with tricortical graft + plate

B. Anterior corpectomy & fusion with mesh cage + bone graft + plate

 

+/- Supplemental posterior fixation / cervical lateral mass screws

 

Cx burst ORIF 1Cx burst ORIF 2

Anterior corpectomy and tricortical graft

 

AO Surgery reference anterior cervical corpectomy

Vumedi anterior cervical corpectomy

 

Cx Mesh cage 1Cervical mesh cage 2