Asian Spine Journal

Asian Spine Journal

Review Article Treatment
Asian Spine J 2015;9(1):133-146 of thoracolumbar fracture 133
• http://dx.doi.org/10.4184/asj.2015.9.1.133

Treatment of Thoracolumbar Fracture

Byung-Guk Kim1, Jin-Myoung Dan1, Dong-Eun Shin2
1
Department of Orthopaedic Surgery, CHA Gumi Medical Center, School of Medicine, CHA University, Gumi, Korea
2
Department of Orthopaedic Surgery, CHA Bundang Medical Center, CHA University, Seongnam, Korea

The most common fractures of the spine are associated with the thoracolumbar junction. The goals of treatment of thoracolumbar
fracture are leading to early mobilization and rehabilitation by restoring mechanical stability of fracture and inducing neurologic re-
covery, thereby enabling patients to return to the workplace. However, it is still debatable about the treatment methods. Neurologic
injury should be identified by thorough physical examination for motor and sensory nerve system in order to determine the appropri-
ate treatment. The mechanical stability of fracture also should be evaluated by plain radiographs and computed tomography. In some
cases, magnetic resonance imaging is required to evaluate soft tissue injury involving neurologic structure or posterior ligament com-
plex. Based on these physical examinations and imaging studies, fracture stability is evaluated and it is determined whether to use
the conservative or operative treatment. The development of instruments have led to more interests on the operative treatment which
saves mobile segments without fusion and on instrumentation through minimal invasive approach in recent years. It is still controver-
sial for the use of these treatments because there have not been verified evidences yet. However, the morbidity of patients can be de-
creased and good clinical and radiologic outcomes can be achieved if the recent operative treatments are used carefully considering
the fracture pattern and the injury severity.

Keywords: Thoracolumbar spine; Fracture; Treatment; Minimally invasive surgery

Introduction patients involve in a severe trauma, the complications,

such as paralysis and deformity, may occur after that ac-
Ninety percent of all spine fractures are related to the cident. Even if the patients do not experience any com-
thoracolumbar region [1]. Especially, the majority of tho- plications, there could be limits of daily activities or diffi-
racolumbar injuries occur at the T11 to L2 level, which is culty to return to work due to chronic pain [6]. Therefore,
the biomechanically weak for stress [2]. the appropriate treatment for the thoracolumbar fracture
The causes of thoracolumbar fracture are different de- is important.
pending on patient’s age. In younger patients, fracture is The primary goal of treatment of the thoracolumbar
more likely to occur due to a high-energy trauma, such as fracture is keeping patients alive, protecting from the
motor vehicle accident, motorcycle accident, and falling further neural damage, obtaining the stability by recon-
injury. However, in elderly, even falls from standing posi- structing anatomical alignment of spinal columns and re-
tion to ground can cause fractures due to osteoporosis turning patients to workplace through early mobilization
and decreased cognition [3,4]. Twenty to forty percent of and rehabilitation. These fundamental principles have not
fractures are associated with neurologic injuries [5]. If the been changed for decades. However, it has been ongoing

Received Aug 12, 2014; Accepted Aug 24, 2014

Corresponding author: Jin-Myoung Dan
Department of Orthopaedic Surgery, CHA Gumi Medical Center, School of Medicine, CHA University,
12 Sinsi-ro 10gil, Gumi-si, Kyungsangbuk-do, Republic of Korea
Tel: +82-54-450-9869, FAX: +82-54-450-9899, E-mail: [email protected]

ASJ
Copyright Ⓒ 2015 by Korean Society of Spine Surgery
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Asian Spine Journal • pISSN 1976-1902 eISSN 1976-7846 • www.asianspinejournal.org
 134 Byung-Guk Kim et al. Asian Spine J 2015;9(1):133-146

controversy in determining treatment methods until now. logic exam should be performed again after spinal shock
is over. Then, if the paralysis persists even in the second
Discussion neurologic exam, it means that there is little chance of
neurologic recovery resulting from surgical decompres-
1. Stability of thoracolumbar fracture sion [26]. Therefore, the goal of operative treatment is
limited to not the recovery of neurologic injury but the
Fracture stability is an important factor in determining restoration of spinal alignments and fracture stabilization
the treatment of thoracolumbar fracture. Fracture stabil- [21,27]. On the other hand, there is a report that anterior
ity is comprised of mechanical stability and neurological decompression is required in order to prevent syringomy-
stability. Denis [7] classified instability in the thoraco- elia and maintain the proper dynamics of cerebrospinal
lumbar spine into three subgroups: mechanical instability fluid flow [28].
(first degree), neurological instability (second degree),
and the combined mechanical and neurologic instability 2. Classification of thoracolumbar fractures
(third degree).
The mechanical stability of thoracolumbar spine is Since the classification of thoracolumbar fractures was
evaluated by whether posterior ligament complex (PLC), introduced by Boehler 75 years ago, various classification
which is composed of supraspinous ligament, interspi- systems have been suggested until now. These classifica-
nous ligament, ligametum flavum, and facet capsule, is tion systems have been developed to help in better com-
damaged or not [8-10]. On plain radiographs, decrease munication among doctors, determining treatment plan
of 50 percent in vertebral body height, increase of inter- and evaluating the prognosis.
spinous distance, and greater than 30 to 35 degrees of Denis [7] proposed three column theory based on two
kyphotic deformity are suggestive of PLC injury [11-13]. column theory of Holdsworth [8]. He emphasized the
Computed tomography (CT) is the most appropriate ex- biomechanical importance of middle column and insisted
amination for assessing diastasis of facet joint, related to that fractures with middle column injury are unstable.
PLC injury [14,15]. Magnetic resonance imaging (MRI) Moreover, according to the fracture morphology and in-
is regarded as a significant examination in determining jury mechanisms, he classified thoracolumbar fractures
the treatment plan because it can evaluate PLC injury di- into 4 categories: compression fracture, burst fracture,
rectly [16-18]. PLC injury shows high signal intensity on flexion-distraction injury (seat-belt injury), and fracture-
fat suppression T2-weighted MR images. Many studies dislocation. His classification system is significant because
reported that MRI has a high sensitivity and specificity it is simple and introduces the concept of neurological
for detecting PLC injury, as a result of comparing MRI injury. However, it has also some limitations: it is difficult
findings and intraoperative findings [16-20]. to distinguish stable burst fractures and unstable burst
Neurological symptom caused by involvement of single fractures [29], and its inter-observer reliability is low [30].
nerve root is classified as Frankel Grade E [21]. Except McAfee et al. [12] emphasized that PLC is an impor-
for that, the thoracolumbar fracture with complete or tant structure for fracture stability, based on CT findings.
incomplete neurologic deficit caused by spinal canal in- Also, they subdivided the middle column injury and
volvement is classified as an unstable fracture regardless proposed that the middle column fails by three different
of the instability from fracture itself or posterior element forces such as axial compression, axial distraction, and
injury. Although the fracture accompanied with neuro- translation. According to this injury mechanism, they
logic injuries is not an absolute indication for operative divided thoracolumbar fractures into 6 categories: wedge
treatment [22-25], the operative treatment is mostly compression fracture, stable burst fracture, unstable burst
performed for patients with incomplete neurologic defi- fracture, Chance fracture, flexion-distraction injury and
cit because it prevents further progression of neurologic translational injury. However, this classification system
injury, helps neurological recovery and makes early mo- has not been widely used because its reliability and valid-
bilization possible by achieving the stability of fracture. ity are not verified yet [29].
However, if patients have Frankel A paralysis caused by AO classification [31] classified thoracolumbar frac-
the fracture with complete neurologic injury, the neuro- tures into 3 groups, such as compression group, dis-
 Asian Spine Journal Treatment of thoracolumbar fracture 135

traction group, and rotation group, considering injury compression alone or flexion forces and shows wedge
mechanism, fracture morphology, and mechanical stabil- deformities of vertebral body on radiologic examination.
ity. Each group was further subdivided into subgroups of Middle and posterior column of spine are preserved and
from A1 to C3. In other words, as the level of subgroup classified as a stable fracture. Patients with compression
is higher and moves A to C, it represents more severe fractures mostly received the conservative treatment be-
degree of injury and more unstable fractures. Although cause they rarely show neurologic deficits.
this AO classification tried to suggest the comprehensive As a conservative treatment, a thoracolumbosacral
classification including all different types of fractures, it orthosis (TLSO) brace is applied for 8 to 12 weeks and
showed only moderate intraobserver and interobserver medications are also prescribed for pain [39,40]. Accord-
reliability due to its complexity [29,30,32]. This classifi- ing to recent prospective randomized study [41], the out-
cation system could not propose the concrete definition come was better when bracing with physical therapy was
of fracture stability and also did not include neurologic performed. Severe pain is usually improved within 3 to 6
damage. weeks. However, if the pain of fracture site is alleviated to
In order to overcome disadvantages of previous classi- a certain extent regardless of time period, as much as the
fication systems based on injury mechanism and fracture patient can sit down without severe pain, walking is rec-
pattern, Vaccaro et al. [9] suggested new classification, ommended wearing the brace. After that, the patient can
called thoracolumbar injury severity score (TLISS). gradually return to daily life, considering the level of pain.
They evaluated thoracolumbar fractures using this clas- The prognosis of conservative treatment generally seems
sification based on plain radiographs, CT and/or MRI, to be good but a small number of patients may experience
in terms of mechanism of injury, integrity of the PLC persistent pain after the fracture is completely healed [42-
and patient’s neurologic status. In addition, these three 45]. These clinical outcomes are not always corresponded
categories for injury were subdivided and scored. The to radiologic ones. However, if the kyphotic angle is
total score was determined by summing up the scores greater than 30 degrees or a decrease of height of vertebral
from each three categories and used to guide treatment. body is greater than 50%, PLC injury is suspected and the
If the total score is 3 points, the conservative treatment operative treatment is recommended. Additionally, if the
is recommended. However, if it is 4 points, the conserva- injury is occurred in three contiguous vertebral bodies, it
tive or operative treatment may be chosen by surgeon’s is also regarded as an unstable compression fracture and
preference. If that score is greater than 5 points, the op- the operative treatment is required [46]. Usually, spinal
erative treatment is suggested. This TLISS showed fair fusion is performed as an operative treatment and in
to substantial (kappa, 0.24–0.724) intraobserver and this procedure, the posterior approach is preferred than
interobserver reliability in several studies [33-35]. How- the anterior approach because most of the compression
ever, many surgeons tended to classify the same type of fractures do not have an involvement of the spinal canal.
injury differently because this classification classified Short segment or long segment fusion may be chosen de-
fractures based on the mechanism of injury. To improve pending on the situation. Nowadays, satisfactory results
this drawback, Vaccaro et al. [36] proposed the modified are reported by conducting short segment instrumenta-
classification, called thoracolumbar injury classification tion without fusion [47]. The operative treatment is also
and severity score (TLCIS). In this classification, its in- required for coronal split fractures or pincer fractures,
terobserver reliability was improved by characterizing the classified as AO 2.2 or 2.3, because nonunion or pseudo-
fractures based on the fracture morphology instead of the arthrosis can occur due to the intrusion of disc material
mechanism of injury [34,37]. Oner et al. [38] insisted that into the fracture site [31,48]. Occasionally, the anterior
this TLCIS is the most effective classification system for fusion using the anterior approach is required if there is
the treatment of thoracolumar fractures. severe bone void in the vertebral body after the fracture or
the reduction is needed due to old fractures.
3. Compression fracture
4. Burst fracture
Fifty percent of thoracolumbar fractures are compres-
sion fractures. Compression fractures are caused by axial A burst fracture is caused by axial compression and ac-
 136 Byung-Guk Kim et al. Asian Spine J 2015;9(1):133-146

companied with retropulsed bone fragments into spinal neurological injury, the spinal canal involvement of frac-
canal. Not only fracture of posterior cortex of vertebral tured fragments itself cannot be the indication for surgi-
body but also retropulsion of the fractured fragments cal decompression [39]. It is because the degree of spinal
into the spinal canal and an increase of inter-pedicular canal involvement on imaging studies, which is taken
distance are presented on radiologic examinations [39]. after injury, is not able to reflect the impact on nerves at
Unlike compression fractures, neurologic injury and the time of injury [57] and also remodeling of the spinal
posterior column injury can occur more frequently. The canal may occur as time passes after either conservative
posterior column is destroyed by compression, lateral or operative treatment is completed. Dai [58] reported
flexion, or torsion. In addition, subluxation of the facet, that there is no difference in the canal remodeling be-
displaced lamina fracture, and disruption of posterior tween the conservative and the operative treatment.
ligament may be accompanied with it. As Mumford et al. [59] reported, the canal remodeling
The indicators for treatment of burst fractures are also occurred with the conservative treatment even though
the mechanical and neurological stability of fractures nearly 66% of spinal canal was involved. The remodeling
which are mentioned earlier. The conservative treatment was completed within one year in most cases. Accord-
using orthosis is mostly recommended for stable burst ingly, the conservative treatment can be used for burst
fractures but the operative treatment is required for un- fractures without neurologic compromise regardless of
stable burst fractures. degree of spinal canal involvement of fracture fragments
if there is any progressive neurologic deficit. According
1) Nonoperative treatment to prior studies, when burst fractures without neurologic
The conservative treatment for burst fractures is per- symptoms were treated by the conservative treatment,
formed based on physical examinations and imaging functional outcomes were not different from those of the
studies. In radiologic studies, more than 50% decrease operative treatment. They reported that the conservative
of vertebral body and less than 30 degrees of traumatic treatment was even better in terms of cost and complica-
kyphosis are regarded as mechanically stable findings for tions [60-63].
the conservative treatment [49,50]. MRI is used to evalu- Therefore, the conservative treatment should be con-
ate PLC injury and has high sensitivity and specificity. sidered first in managing mechanically and neurologi-
In many studies, the operative treatment was conducted cally stable burst fractures. Tezer et al. [42] described that
if there was PLC injury on MRI. However, according the conservative treatment is appropriate for patients who
to the prospective study by Alanay et al. [51], although do not have neurologic deficit and PLC injury and have
there was not PLC injury, PLC could not prevent the loss less than 50% of the vertebral height loss and less than 25
of fracture reduction when the fracture was treated by degrees of traumatic kyphosis.
cast immobilization after the reduction of burst fracture. In the conservative treatment, hyperextension cast or
Therefore, even though PLC injury is not observed, the TLSO is applied for 8 to 12 weeks, considering patient’s
conservative treatment should be performed when it is pain. Wood et al. [64] reported that there was no differ-
considered that there is no instability taking into account ence in the results of treatment of burst fractures without
plain radiographs and CT findings. neurological injury between cast and orthosis treatment.
When there is the neurologic injury, treatment should Also, Cantor et al. [50] and Tropiano et al. [65] reported
be performed considering the location of fracture and the that they could achieve satisfactory results by early
retropulsed bone fragments into the spinal canal. While ambulation wearing cast or TLSO. Long-term bed rest
less than 40% of canal narrowing can cause neurologic in- may cause embolization, pressure ulcer and pulmonary
jury at upper thoracic level, more than 90% of canal nar- complication, and exacerbate patient’s general condition.
rowing may not cause it at lower lumbar level [52-54]. As Thus, it is suggested to start the early ambulation as much
the retropulsed bone fragments into the spinal canal are as possible. If the patient starts the ambulation after wear-
larger, the chance of neurologic injury can be more com- ing cast or orthosis, follow-up standing radiographs are
mon [55,56]. However, the size of this retropulsed bone required 1 to 2 weeks later. In most patients, kyphosis of
fragment is rarely related to the severity of neurological fractures progresses over time and frequently returns to
injury. Thus, if burst fractures are not accompanied with the degree of kyphosis at the time of injury. However, this
 Asian Spine Journal Treatment of thoracolumbar fracture 137

is not associated with patients’ clinical manifestation. The approach can be used to minimize the loss of motion
conservative treatment can be continued if there are no segment and achieve the rigid fixation if the patient has
greater than 10 degrees of obvious increase of kyphotic neurological injury or the loss of anterior support due
angle or the pain during the conservative treatment [66]. to severe comminution of the vertebral body. However,
the anterior approach has some disadvantages: it may
2) Operative treatment result in visceral injury and it is an unfamiliar approach
The operative treatment for burst fractures is generally to many surgeons. Also, there is the risk of bleeding and
performed when there is neurological or mechanical pulmonary complications. For these disadvantages, it is
instability and its goal is decompression of spinal canal less commonly used than the posterior approach.
and nerve root for neurological recovery, restoration and
maintenance of vertebral height and spinal alignment, (2) Posterior approach
rigid fixation for early ambulation and rehabilitation, and Posterior approach is usually used for the treatment of
prevention of progressive neurological injury and ky- burst fractures without neurologic deficit. However, even
photic deformity. It is controversial depending on the de- though there is neurological injury, posterior approach
gree of fracture and neurological injury but the surgery is can be used for the purpose of the decompression of the
generally conducted with posterior, anterior or anterior- spinal canal depending on the mechanism or the pat-
posterior approaches. tern of fracture. The decompression can be achieved by
indirect reduction using ligamentotaxis or direct decom-
(1) Anterior approach pression (Fig. 1). The reduction using ligamentotaxis is
If nerve compression due to disc or fractured fragments successful if it is completed within 3 days after the injury
was shown on imaging studies in burst fractures with [40]. The increase of vertebral canal after the indirect
incomplete neurologic injury, it can be an indication for reduction is averagely less than 20% but may sometimes
anterior decompression. The nerve compression in burst increase up to 50% depending on situation [64,72,73].
fractures usually occurs in anterior aspect of the spinal However, if the canal encroachment of bone fragments
canal due to retropulsion of fracture fragments. Thus, an- is greater than 67%, it is not effective because annulus is
terior decompression is superior to remove the fragments destroyed in many cases [74]. If the surgery is delayed or
or soft tissues which compress the neural structures. Af- the indirect decompression is difficult due to severe canal
ter this anterior decompression is completed, the anterior compromise, the direct reduction [75] with the transpe-
reconstruction is performed using plate or rod with bone dicular approach or direct decompression [76] with lami-
graft. Kaneda et al. [67] treated 150 patients with thoraco- nectomy can be performed.
lumbar burst fractures and neurological deficits by ante- The pedicle screw fixation is the most commonly
rior decompression and fusion, and followed up them for used for the fixation of fractures with the posterior ap-
8 years. As a result of it, they reported 93% of fusion rate proach. This pedicle screw has an advantage of being able
and 72% of complete recovery of bladder function. In ad- to fix three columns of spine. Due to the development
dition, 95% of patients showed neurologic recovery more of instruments, strength of the screws is improved and
than Frankel Grade 1. The anterior approach not only de- the use of short segment fixation, which fixes the above
compresses the neural contents more efficiently and but and below segment of fracture site, has been increasing.
also provides the superior mechanical stability. Hitchon However, there were studies that the failure rate of this
et al. [68] reported that the anterior approach was more short segment fixation was 20% to 50% and the loss of
advantageous in the correction and the maintenance of reduction was 50% to 90% [77-80]. McCormack et al. [81]
each deformity than the posterior approach. Sasso et al. suggested load sharing classification (LSC) in order to
[69] also reported that the average of sagittal plane cor- predict the prognosis of short segment fixation using pos-
rection was 8.1° with the anterior approach but it was terior approach. This classification divided spine fractures
1.8° with the posterior approach. In some biomechanical into 3 categories according to the amount of damaged
studies, anterior approach offered superior mechanical vertebral body, the spread of the fragments in the frac-
stability than the posterior approach [70,71]. Therefore, ture site and the amount of corrected traumatic kyphosis;
the reconstruction of vertebral body with the anterior then, each category was scored from 1 to 3 according to
 138 Byung-Guk Kim et al. Asian Spine J 2015;9(1):133-146

the degree. When the total score is more than 6 points, fracture site, or the anterior reconstruction with the ante-
they insisted that the long segment fixation, which fixes rior approach are required.
at least more than two segments of above and below the The posterior short segment fixation can be performed
by open or percutaneous method and supported by
transpedicular cancellous bone grafting, vertebroplasty
[82-84] using calcium sulfate, polymethyl methacrylate or
kyphoplasty [85-88] using calciumphosphate for anterior
structural support. The transpedicular cancellous bone
grafting showed successful results in short-term follow-
up but, in long-term follow-up, there was no difference
from the short segment fixation without bone graft and
it could not prevent the loss of reduction and the failure
A B of instruments [89,90]. However, Toyone et al. [91,92]
reported that there was no reduction loss and degen-
erative change in disc of adjacent segment in their 10-
year follow-up using hydroxyapatite ceramic instead of
cancellous bone grafting. Verlaan et al. [88] described
that posterior short segment fixation with kyphoplasty
is a feasible and safe treatment based on their 6-year
follow-up results of 20 patients who have burst fracture
with AO type A3 or B2 type, LSC scoring equal or higher
than 6 points and without neurologic deficit. Addition-
ally, inserting additional pedicle screws at the level of the
fracture site can help to provide better kyphosis correc-
tion with saving motion segments and offers improved
C D biomechanical stability [82,93,94].
The fixation of burst fractures by posterior approach
is generally conducted with posterolateral fusion or pos-
terior fusion. However, Dai et al. [95] and Ni et al. [96]
reported good results by using open or percutaneous
pedicle screw fixation only without fusion in patients who
have the thoracolumbar burst fractures with LSC scoring
equal to or less than 6 points.

(3) Combined anterior-posterior approach

Combined anterior-posterior approach can be indicated
when PLC injury is accompanied with incomplete neu-
rological injury due to canal encroachment of fracture
fragments or neurological symptoms persist after the
E
surgery using posterior approach or fixed kyphotic de-
Fig. 1. A 42-year-old male patient with falling injury. Conus medullaris formities occur more than two weeks after the injury
syndrome was diagnosed with symptoms including loss of perianal
[97]. The fixation with anterior-posterior approach can
sensation, bladder and bowel dysfunction at the time of injury. (A)
Burst fractures at L1 on sagittal computed tomography (CT) scan at the provide more improved stability for all range of mo-
time of injury. (B) Around 50% of canal involvement by retropulsed tion in spine, comparing to the fixation with anterior or
bony fragments on axial CT scan at the time of injury. (C, D) Plain posterior approach alone [98]. However, this approach
radiographs after indirect reduction and instrumented fusion with
posterior approach. (E) Postoperative axial CT scans showing canal has more bleeding risk and longer operation time, in ad-
decompression by indirect reduction. dition, it has not been proven yet that the clinical and
 Asian Spine Journal Treatment of thoracolumbar fracture 139

radiological outcomes of this approach is more superior or exacerbation of neurologic condition may be induced
than the fixation with anterior or posterior approach [104] (Fig. 2). PLC injury may be missed because the
alone [99]. Nowadays, the interbody fusion using poste- displacement of posterior structure caused by distraction
rior approach has been developed and used to stabilize force at the time of injury can be reduced spontaneously.
the vertebral body, instead of Anterior-Posterior ap- In this case, PLC injury should be suspected by confirm-
proach [100,101]. ing swelling or tenderness on spinous process and evalu-
ate more precisely using MRI.
5. Flexion-distraction injury Fusion with posterior instrumentation is preferred
in most cases as the operative treatment. This operative
Flexion-distraction injury, or so-called Chance injury, method providing compressive and tension band effect
occurs by primary distractive forces on the spine. The resists effectively to the distractive forces. The vertebral
axis of rotation is located within or in front of anterior body is not seriously damaged in flexion-distraction inju-
vertebral body. Thus, the distractive forces are loaded on ry; thus, it is mostly treated by the short segment fixation.
a posterior column and a middle column, and distractive However, recently, only posterior instrumentation
or compressive forces are loaded on an anterior column. without fusion is often used for the treatment. Because
This injury generally occurs in high energy motor vehicle there is no fusion process, it can be conducted by per-
accident when wearing only lap belt without shoulder cutaneous screw fixation. Kim et al. [105] performed
belt. Abdominal injuries are also accompanied with 30% open short segment pedicle screw fixation to 11 patients
of those patients. It accounts for 1% to 16 % of all tho- who have flexion-distraction injury without neurologi-
racolumbar fractures and occur most commonly in the cal injury and reported satisfactory sagittal alignments
thoracolumbar junction. The neurological injury is found in more than 18 months follow-up. Grossbach et al.
in 25% of patients [102,103]. If only bone injury occurs [106] compared and analyzed the clinical and radio-
without ligament injury, it is unstable during the acute logical outcomes between open posterior instrumenta-
phase but it will be stabilized with bone union as time tion with posterolateral fusion group and percutane-
elapsed. Thus, the brace treatment is possible if only bony ous pedicle screw fixation group. As a result of it, they
structure is damaged without displacement. However, if reported that percutaneous method was effective as like
PLC was disrupted, the conservative treatment is not rec- open method.
ommended because progression of kyphosis, nonunion,

A B C D
Fig. 2. A 31-year-old male patient who sustained seat belt injury from motor vehicle accident. (A) A wedge deformity at T12 and an in-
creased interspinous distance on sagittal computed tomography scan (arrow). (B) Posterior ligament complex injury on T2 fat suppression
sagittal magnetic resonance imaging (arrow head). (C, D) Anteroposterior and lateral radiograph images of flexion distraction injury after
the indirect reduction and posterior instrumented fusion using the posterior approach.
 140 Byung-Guk Kim et al. Asian Spine J 2015;9(1):133-146

6. Fracture-dislocation injury more attention for diagnosis. Lateral translation and

anteroposterior translation of spine may be observed by
Fracture-dislocation injury in thoracolumbar region is anteroposterior radiographs and lateral radiographs, re-
caused by various combinations of shear, torsion, distrac- spectively. CT is useful for the evaluation for bone injury
tion, flexion and extension forces and is very unstable and facet. MRI is used for determining the degree of disc,
injury because three columns, including anterior, middle ligament and spinal canal injury.
and posterior column, are damaged. This is a high energy Mostly, the reduction and the instrumented fusion
injury and 75% of it is accompanied with neurological using posterior approach are prefered for this injury. Al-
injury [107]. The conservative treatment is not recom- though the anterior approach is rarely used, if anterior
mended for it because there are not only fractures but column support is not enough or canal decompression is
also various degrees of ligament and disc injury. It would required after posterior sugery, the interbody fusion [108]
be diagnosed if there is unilateral or bilateral facet frac- using posterior approach or the anterior reconstruction
ture, subluxation or dislocation. If there is only subtle can be performed [66] (Fig. 3).
facet subluxation without neurological injury, it requires

A B C

E F
Fig. 3. A 47-year-old male patient with fracture-dislocation injury. (A) Lateral translation of L3 compared to L2 on anteroposterior
radiographs (arrow) right after the injury. (B) Posterior translation of L3 to L2 on sagittal computed tomography (CT) scan right after
the injury. (C) Bony fragment within the spinal canal on preoperative axial CT scan. (D) Bony fragments were not reduced after
the reduction and posterior instrumented fusion (arrow head). (E, F) Anteroposterior and lateral radiographs after removal of bony
fragments and fusion with cages through the anterior approach.
 Asian Spine Journal Treatment of thoracolumbar fracture 141

Conclusions References
Thoracolumbar fractures have been classified into com- 1. DeWald RL. Burst fractures of the thoracic and lum-
pression fracture, burst fracture, flexion-distraction bar spine. Clin Orthop Relat Res 1984;(189):150-61.
injury and fracture-dislocation injury, depending on 2. Gertzbein SD. Scoliosis Research Society. Multicenter
injury mechanism and fracture morphology. Each in- spine fracture study. Spine (Phila Pa 1976) 1992;17:
jury is also subdivided into stable fracture and unstable 528-40.
fracture, according to the presence of neurologic injury, 3. Rockwood CA, Green DP, Bucholz RW. Rockwood
soft tissue injury and bone injury. The conservative and Green’s fractures in adults. Philadelphia: Lippin-
treatment is recommended for stable fractures but the cott Williams & Wilkins; 2006.
operative treatment is needed for unstable fractures. 4. Kim DH, Silber JS, Albert TJ. Osteoporotic vertebral
In radiologic studies, more than 50% of vertebral body compression fractures. Instr Course Lect 2003;52:
height loss, more than 30 degrees of traumatic kypho- 541-50.
sis, more than 50% of canal enchroachment, facet frac- 5. Hsu JM, Joseph T, Ellis AM. Thoracolumbar fracture
ture, subluxation or dislocation are regarded as unstable in blunt trauma patients: guidelines for diagnosis and
findings; in addition, PLC injury is also regarded as an imaging. Injury 2003;34:426-33.
unstable finding on MRI. Abnormal findings in neu- 6. McLain RF. Functional outcomes after surgery for
rologic examinations at the time of injury also imply spinal fractures: return to work and activity. Spine
the spinal instability. By the evaluation of the stability (Phila Pa 1976) 2004;29:470-7.
of spinal column based on detailed physical examina- 7. Denis F. The three column spine and its significance
tions and imaging studies, if it is unstable, the operative in the classification of acute thoracolumbar spinal
treatment using anterior, posterior or combined anteri- injuries. Spine (Phila Pa 1976) 1983;8:817-31.
or-posterior approach is performed. For the operative 8. Holdsworth F. Fractures, dislocations, and fracture-
treatment, the instrumented fusion has been conven- dislocations of the spine. J Bone Joint Surg Am
tionally performed following the fracture reduction; 1970;52:1534-51.
however, according to fracture patterns and degrees, 9. Vaccaro AR, Zeiller SC, Hulbert RJ, et al. The thora-
posterior instrumentation without fusion following columbar injury severity score: a proposed treatment
indirect reduction have been increasing in recent years. algorithm. J Spinal Disord Tech 2005;18:209-15.
The instrumentation can be achieved through percuta- 10. Terk MR, Hume-Neal M, Fraipont M, Ahmadi J, Col-
neous fixation. The requirement for the operative treat- letti PM. Injury of the posterior ligament complex in
ment using anterior approach has been decreased along patients with acute spinal trauma: evaluation by MR
with the development of pedicle screws and posterior imaging. AJR Am J Roentgenol 1997;168:1481-6.
operation techniques for canal decompression and an- 11. Benson DR, Burkus JK, Montesano PX, Sutherland
terior reconstruction such as transpedicular bone graft, TB, McLain RF. Unstable thoracolumbar and lumbar
cement augmentation or interbody fusion. The princi- burst fractures treated with the AO fixateur interne. J
pals which obtain mechanical and neurological stability Spinal Disord 1992;5:335-43.
of spine have not been changed, however, the surgical 12. McAfee PC, Yuan HA, Fredrickson BE, Lubicky JP.
methods have been diversified. Accordingly, the sur- The value of computed tomography in thoracolum-
geons should make sure of the indications, advantages bar fractures. An analysis of one hundred consecu-
and disadvantages of each operative treatment in deter- tive cases and a new classification. J Bone Joint Surg
mining the treatment plan. Am 1983;65:461-73.
13. Reid DC, Hu R, Davis LA, Saboe LA. The nonopera-
Conflict of Interest tive treatment of burst fractures of the thoracolumbar
junction. J Trauma 1988;28:1188-94.
No potential conflict of interest relevant to this article 14. Schweitzer KM, Vaccaro AR, Harrop JS, et al. Inter-
was reported rater reliability of identifying indicators of posterior
ligamentous complex disruption when plain films are
 142 Byung-Guk Kim et al. Asian Spine J 2015;9(1):133-146

indeterminate in thoracolumbar injuries. J Orthop of the thoracic and lumbar spine in adults: a 23- to
Sci 2007;12:437-42. 41-year follow-up. Spine J 2007;7:701-7.
15. Lee JY, Vaccaro AR, Schweitzer KM Jr, et al. Assess- 26. Bohlman HH, Freehafer A, Dejak J. The results of
ment of injury to the thoracolumbar posterior liga- treatment of acute injuries of the upper thoracic spine
mentous complex in the setting of normal-appearing with paralysis. J Bone Joint Surg Am 1985;67:360-9.
plain radiography. Spine J 2007;7:422-7. 27. Pneumaticos SG, Triantafyllopoulos GK, Giannoudis
16. Brightman RP, Miller CA, Rea GL, Chakeres DW, PV. Advances made in the treatment of thoracolum-
Hunt WE. Magnetic resonance imaging of trauma bar fractures: current trends and future directions.
to the thoracic and lumbar spine. The importance of Injury 2013;44:703-12.
the posterior longitudinal ligament. Spine (Phila Pa 28. Bains RS, Althausen PL, Gitlin GN, Gupta MC, Ben-
1976) 1992;17:541-50. son DR. The role of acute decompression and resto-
17. Emery SE, Pathria MN, Wilber RG, Masaryk T, ration of spinal alignment in the prevention of post-
Bohlman HH. Magnetic resonance imaging of post- traumatic syringomyelia: case report and review of
traumatic spinal ligament injury. J Spinal Disord recent literature. Spine (Phila Pa 1976) 2001;26:E399-
1989;2:229-33. 402.
18. Petersilge CA, Pathria MN, Emery SE, Masaryk TJ. 29. Bono CM, Vaccaro AR, Hurlbert RJ, et al. Validat-
Thoracolumbar burst fractures: evaluation with MR ing a newly proposed classification system for tho-
imaging. Radiology 1995;194:49-54. racolumbar spine trauma: looking to the future of
19. Lee HM, Kim HS, Kim DJ, Suk KS, Park JO, Kim the thoracolumbar injury classification and severity
NH. Reliability of magnetic resonance imaging in score. J Orthop Trauma 2006;20:567-72.
detecting posterior ligament complex injury in tho- 30. Wood KB, Khanna G, Vaccaro AR, Arnold PM, Har-
racolumbar spinal fractures. Spine (Phila Pa 1976) ris MB, Mehbod AA. Assessment of two thoracolum-
2000;25:2079-84. bar fracture classification systems as used by multiple
20. Haba H, Taneichi H, Kotani Y, et al. Diagnostic ac- surgeons. J Bone Joint Surg Am 2005;87:1423-9.
curacy of magnetic resonance imaging for detecting 31. Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S.
posterior ligamentous complex injury associated A comprehensive classification of thoracic and lum-
with thoracic and lumbar fractures. J Neurosurg bar injuries. Eur Spine J 1994;3:184-201.
2003;99:20-6. 32. Mirza SK, Mirza AJ, Chapman JR, Anderson PA.
21. Vaccaro AR, Lim MR, Hurlbert RJ, et al. Surgical Classifications of thoracic and lumbar fractures: ra-
decision making for unstable thoracolumbar spine tionale and supporting data. J Am Acad Orthop Surg
injuries: results of a consensus panel review by the 2002;10:364-77.
Spine Trauma Study Group. J Spinal Disord Tech 33. Raja Rampersaud Y, Fisher C, Wilsey J, et al. Agree-
2006;19:1-10. ment between orthopedic surgeons and neurosur-
22. Andreychik DA, Alander DH, Senica KM, Stauffer geons regarding a new algorithm for the treatment
ES. Burst fractures of the second through fifth lum- of thoracolumbar injuries: a multicenter reliability
bar vertebrae. Clinical and radiographic results. J study. J Spinal Disord Tech 2006;19:477-82.
Bone Joint Surg Am 1996;78:1156-66. 34. Harrop JS, Vaccaro AR, Hurlbert RJ, et al. Intrarater
23. Dai LY, Jiang LS, Jiang SD. Conservative treatment of and interrater reliability and validity in the assess-
thoracolumbar burst fractures: a long-term follow-up ment of the mechanism of injury and integrity of the
results with special reference to the load sharing clas- posterior ligamentous complex: a novel injury sever-
sification. Spine (Phila Pa 1976) 2008;33:2536-44. ity scoring system for thoracolumbar injuries. In-
24. Knight RQ, Stornelli DP, Chan DP, Devanny JR, Jack- vited submission from the Joint Section Meeting On
son KV. Comparison of operative versus nonopera- Disorders of the Spine and Peripheral Nerves, March
tive treatment of lumbar burst fractures. Clin Orthop 2005. J Neurosurg Spine 2006;4:118-22.
Relat Res 1993;(293):112-21. 35. Patel AA, Vaccaro AR, Albert TJ, et al. The adoption
25. Moller A, Hasserius R, Redlund-Johnell I, Ohlin A, of a new classification system: time-dependent varia-
Karlsson MK. Nonoperatively treated burst fractures tion in interobserver reliability of the thoracolumbar
 Asian Spine Journal Treatment of thoracolumbar fracture 143

injury severity score classification system. Spine 48. De Boeck H, Opdecam P. Split coronal fractures of
(Phila Pa 1976) 2007;32:E105-10. the lumbar spine. Treatment by posterior internal
36. Vaccaro AR, Lehman RA Jr, Hurlbert RJ, et al. A new fixation and transpedicular bone grafting. Int Or-
classification of thoracolumbar injuries: the impor- thop 1999;23:87-90.
tance of injury morphology, the integrity of the pos- 49. Krompinger WJ, Fredrickson BE, Mino DE, Yuan
terior ligamentous complex, and neurologic status. HA. Conservative treatment of fractures of the
Spine (Phila Pa 1976) 2005;30:2325-33. thoracic and lumbar spine. Orthop Clin North Am
37. Whang PG, Vaccaro AR, Poelstra KA, et al. The influ- 1986;17:161-70.
ence of fracture mechanism and morphology on the 50. Cantor JB, Lebwohl NH, Garvey T, Eismont FJ. Non-
reliability and validity of two novel thoracolumbar operative management of stable thoracolumbar burst
injury classification systems. Spine (Phila Pa 1976) fractures with early ambulation and bracing. Spine
2007;32:791-5. (Phila Pa 1976) 1993;18:971-6.
38. Oner FC, van Gils AP, Dhert WJ, Verbout AJ. MRI 51. Alanay A, Yazici M, Acaroglu E, Turhan E, Cila A,
findings of thoracolumbar spine fractures: a categori- Surat A. Course of nonsurgical management of burst
sation based on MRI examinations of 100 fractures. fractures with intact posterior ligamentous complex:
Skeletal Radiol 1999;28:433-43. an MRI study. Spine (Phila Pa 1976) 2004;29:2425-
39. Canale ST, Beaty JH, Campbell WC. Campbell’s op- 31.
erative orthopaedics. St. Louis, MO: Mosby; 2012. 52. Weinstein JN, Collalto P, Lehmann TR. Thoracolum-
40. Vaccaro AR, Kim DH, Brodke DS, et al. Diagnosis bar “burst” fractures treated conservatively: a long-
and management of thoracolumbar spine fractures. J term follow-up. Spine (Phila Pa 1976) 1988;13:33-8.
Bone Joint Surg Am 2003;85:2456-70. 53. Shuman WP, Rogers JV, Sickler ME, et al. Thoraco-
41. Stadhouder A, Buskens E, Vergroesen DA, Fidler lumbar burst fractures: CT dimensions of the spinal
MW, de Nies F, Oner FC. Nonoperative treatment of canal relative to postsurgical improvement. AJR Am
thoracic and lumbar spine fractures: a prospective J Roentgenol 1985;145:337-41.
randomized study of different treatment options. J 54. Meves R, Avanzi O. Correlation among canal com-
Orthop Trauma 2009;23:588-94. promise, neurologic deficit, and injury severity in
42. Tezer M, Erturer RE, Ozturk C, Ozturk I, Kuzgun U. thoracolumbar burst fractures. Spine (Phila Pa 1976)
Conservative treatment of fractures of the thoraco- 2006;31:2137-41.
lumbar spine. Int Orthop 2005;29:78-82. 55. Mohanty SP, Venkatram N. Does neurological re-
43. Post RB, Keizer HJ, Leferink VJ, van der Sluis CK. covery in thoracolumbar and lumbar burst fractures
Functional outcome 5 years after non-operative depend on the extent of canal compromise? Spinal
treatment of type A spinal fractures. Eur Spine J Cord 2002;40:295-9.
2006;15:472-8. 56. van Middendorp JJ, Goss B, Williams RP, Schuetz M.
44. Post RB, van der Sluis CK, Leferink VJ, Dijkstra PU, Is there a difference between narrowing of the spinal
ten Duis HJ. Nonoperatively treated type A spinal canal and neurological deficits comparing Denis and
fractures: mid-term versus long-term functional out- Magerl classifications? Spinal Cord 2011;49:855.
come. Int Orthop 2009;33:1055-60. 57. Limb D, Shaw DL, Dickson RA. Neurological injury
45. Butler JS, Walsh A, O’Byrne J. Functional outcome of in thoracolumbar burst fractures. J Bone Joint Surg
burst fractures of the first lumbar vertebra managed Br 1995;77:774-7.
surgically and conservatively. Int Orthop 2005;29:51- 58. Dai LY. Remodeling of the spinal canal after tho-
4. racolumbar burst fractures. Clin Orthop Relat Res
46. Rea GL, Zerick WR. The treatment of thoracolum- 2001;(382):119-23.
bar fractures: one point of view. J Spinal Disord 59. Mumford J, Weinstein JN, Spratt KF, Goel VK. Tho-
1995;8:368-82. racolumbar burst fractures. The clinical efficacy and
47. Khare S, Sharma V. Surgical outcome of posterior outcome of nonoperative management. Spine (Phila
short segment trans-pedicle screw fixation for thora- Pa 1976) 1993;18:955-70.
columbar fractures. J Orthop 2013;10:162-7. 60. Yi L, Jingping B, Gele J, Baoleri X, Taixiang W. Op-
 144 Byung-Guk Kim et al. Asian Spine J 2015;9(1):133-146

erative versus non-operative treatment for thoraco- 71. Gurwitz GS, Dawson JM, McNamara MJ, Federspiel
lumbar burst fractures without neurological deficit. CF, Spengler DM. Biomechanical analysis of three
Cochrane Database Syst Rev 2006;(4):CD005079. surgical approaches for lumbar burst fractures us-
61. Thomas KC, Bailey CS, Dvorak MF, Kwon B, Fisher C. ing short-segment instrumentation. Spine (Phila Pa
Comparison of operative and nonoperative treatment 1976) 1993;18:977-82.
for thoracolumbar burst fractures in patients without 72. Sjostrom L, Karlstrom G, Pech P, Rauschning W. In-
neurological deficit: a systematic review. J Neurosurg direct spinal canal decompression in burst fractures
Spine 2006;4:351-8. treated with pedicle screw instrumentation. Spine
62. Abudou M, Chen X, Kong X, Wu T. Surgical versus (Phila Pa 1976) 1996;21:113-23.
non-surgical treatment for thoracolumbar burst frac- 73. Crutcher JP Jr, Anderson PA, King HA, Montesano
tures without neurological deficit. Cochrane Data- PX. Indirect spinal canal decompression in patients
base Syst Rev 2013;6:CD005079. with thoracolumbar burst fractures treated by poste-
63. Gnanenthiran SR, Adie S, Harris IA. Nonoperative rior distraction rods. J Spinal Disord 1991;4:39-48.
versus operative treatment for thoracolumbar burst 74. Gertzbein SD, Crowe PJ, Fazl M, Schwartz M, Rowed
fractures without neurologic deficit: a meta-analysis. D. Canal clearance in burst fractures using the AO
Clin Orthop Relat Res 2012;470:567-77. internal fixator. Spine (Phila Pa 1976) 1992;17:558-
64. Wood K, Buttermann G, Mehbod A, Garvey T, Jhan- 60.
jee R, Sechriest V. Operative compared with nonop- 75. Kaya RA, Aydin Y. Modified transpedicular approach
erative treatment of a thoracolumbar burst fracture for the surgical treatment of severe thoracolumbar or
without neurological deficit. A prospective, random- lumbar burst fractures. Spine J 2004;4:208-17.
ized study. J Bone Joint Surg Am 2003;85:773-81. 76. Kong W, Sun Y, Hu J, Xu J. Modified posterior de-
65. Tropiano P, Huang RC, Louis CA, Poitout DG, Louis compression for the management of thoracolumbar
RP. Functional and radiographic outcome of tho- burst fractures with canal encroachment. J Spinal
racolumbar and lumbar burst fractures managed Disord Tech 2010;23:302-9.
by closed orthopaedic reduction and casting. Spine 77. Carl AL, Tromanhauser SG, Roger DJ. Pedicle screw
(Phila Pa 1976) 2003;28:2459-65. instrumentation for thoracolumbar burst fractures
66. Wood KB, Li W, Lebl DR, Ploumis A. Management of and fracture-dislocations. Spine (Phila Pa 1976)
thoracolumbar spine fractures. Spine J 2014;14:145- 1992;17:S317-24.
64. 78. Ebelke DK, Asher MA, Neff JR, Kraker DP. Survivor-
67. Kaneda K, Taneichi H, Abumi K, Hashimoto T, Satoh ship analysis of VSP spine instrumentation in the
S, Fujiya M. Anterior decompression and stabiliza- treatment of thoracolumbar and lumbar burst frac-
tion with the Kaneda device for thoracolumbar burst tures. Spine (Phila Pa 1976) 1991;16:S428-32.
fractures associated with neurological deficits. J Bone 79. McLain RF, Sparling E, Benson DR. Early failure of
Joint Surg Am 1997;79:69-83. short-segment pedicle instrumentation for thoraco-
68. Hitchon PW, Torner J, Eichholz KM, Beeler SN. lumbar fractures. A preliminary report. J Bone Joint
Comparison of anterolateral and posterior approach- Surg Am 1993;75:162-7.
es in the management of thoracolumbar burst frac- 80. McNamara MJ, Stephens GC, Spengler DM. Trans-
tures. J Neurosurg Spine 2006;5:117-25. pedicular short-segment fusions for treatment of
69. Sasso RC, Renkens K, Hanson D, Reilly T, McGuire lumbar burst fractures. J Spinal Disord 1992;5:183-7.
RA Jr, Best NM. Unstable thoracolumbar burst frac- 81. McCormack T, Karaikovic E, Gaines RW. The load
tures: anterior-only versus short-segment posterior sharing classification of spine fractures. Spine (Phila
fixation. J Spinal Disord Tech 2006;19:242-8. Pa 1976) 1994;19:1741-4.
70. Shono Y, McAfee PC, Cunningham BW. Experimen- 82. Chen C, Lv G, Xu B, Zhang X, Ma X. Posterior short-
tal study of thoracolumbar burst fractures. A radio- segment instrumentation and limited segmental de-
graphic and biomechanical analysis of anterior and compression supplemented with vertebroplasty with
posterior instrumentation systems. Spine (Phila Pa calcium sulphate and intermediate screws for thoraco-
1976) 1994;19:1711-22. lumbar burst fractures. Eur Spine J 2014;23:1548-57.
 Asian Spine Journal Treatment of thoracolumbar fracture 145

83. Liao JC, Fan KF, Keorochana G, Chen WJ, Chen LH. lumbar motion without resulting in post-traumatic
Transpedicular grafting after short-segment pedicle disc degeneration: a 10-year follow-up study. Spine
instrumentation for thoracolumbar burst fracture: (Phila Pa 1976) 2013;38:1482-90.
calcium sulfate cement versus autogenous iliac bone 93. Guven O, Kocaoglu B, Bezer M, Aydin N, Nalban-
graft. Spine (Phila Pa 1976) 2010;35:1482-8. toglu U. The use of screw at the fracture level in the
84. Shen YX, Zhang P, Zhao JG, et al. Pedicle screw in- treatment of thoracolumbar burst fractures. J Spinal
strumentation plus augmentation vertebroplasty us- Disord Tech 2009;22:417-21.
ing calcium sulfate for thoracolumbar burst fractures 94. Mahar A, Kim C, Wedemeyer M, et al. Short-
without neurologic deficits. Orthop Surg 2011;3:1-6. segment fixation of lumbar burst fractures using
85. Rahamimov N, Mulla H, Shani A, Freiman S. Percu- pedicle fixation at the level of the fracture. Spine
taneous augmented instrumentation of unstable tho- (Phila Pa 1976) 2007;32:1503-7.
racolumbar burst fractures. Eur Spine J 2012;21:850- 95. Dai LY, Jiang LS, Jiang SD. Posterior short-segment
4. fixation with or without fusion for thoracolumbar
86. Korovessis P, Repantis T, Petsinis G, Iliopoulos P, burst fractures. a five to seven-year prospective ran-
Hadjipavlou A. Direct reduction of thoracolumbar domized study. J Bone Joint Surg Am 2009;91:1033-
burst fractures by means of balloon kyphoplasty with 41.
calcium phosphate and stabilization with pedicle- 96. Ni WF, Huang YX, Chi YL, et al. Percutaneous
screw instrumentation and fusion. Spine (Phila Pa pedicle screw fixation for neurologic intact thoraco-
1976) 2008;33:E100-8. lumbar burst fractures. J Spinal Disord Tech 2010;
87. Marco RA, Kushwaha VP. Thoracolumbar burst frac- 23:530-7.
tures treated with posterior decompression and ped- 97. Alpantaki K, Bano A, Pasku D, et al. Thoracolumbar
icle screw instrumentation supplemented with bal- burst fractures: a systematic review of management.
loon-assisted vertebroplasty and calcium phosphate Orthopedics 2010;33:422-9.
reconstruction. J Bone Joint Surg Am 2009;91:20-8. 98. Wilke HJ, Kemmerich V, Claes LE, Arand M. Com-
88. Verlaan JJ, Dhert WJ, Verbout AJ, Oner FC. Balloon bined anteroposterior spinal fixation provides su-
vertebroplasty in combination with pedicle screw perior stabilisation to a single anterior or posterior
instrumentation: a novel technique to treat thoracic procedure. J Bone Joint Surg Br 2001;83:609-17.
and lumbar burst fractures. Spine (Phila Pa 1976) 99. Danisa OA, Shaffrey CI, Jane JA, et al. Surgical ap-
2005;30:E73-9. proaches for the correction of unstable thoracolum-
89. Alanay A, Acaroglu E, Yazici M, Oznur A, Surat A. bar burst fractures: a retrospective analysis of treat-
Short-segment pedicle instrumentation of thoraco- ment outcomes. J Neurosurg 1995;83:977-83.
lumbar burst fractures: does transpedicular intracor- 100. Schmid R, Krappinger D, Blauth M, Kathrein A.
poreal grafting prevent early failure? Spine (Phila Pa Mid-term results of PLIF/TLIF in trauma. Eur
1976) 2001;26:213-7. Spine J 2011;20:395-402.
90. Knop C, Fabian HF, Bastian L, Blauth M. Late results 101. Schmid R, Krappinger D, Seykora P, Blauth M,
of thoracolumbar fractures after posterior instru- Kathrein A. PLIF in thoracolumbar trauma: tech-
mentation and transpedicular bone grafting. Spine nique and radiological results. Eur Spine J 2010;19:
(Phila Pa 1976) 2001;26:88-99. 1079-86.
91. Toyone T, Tanaka T, Kato D, Kaneyama R, Otsuka M. 102. Anderson PA, Rivara FP, Maier RV, Drake C. The
The treatment of acute thoracolumbar burst fractures epidemiology of seatbelt-associated injuries. J Trau-
with transpedicular intracorporeal hydroxyapatite ma 1991;31:60-7.
grafting following indirect reduction and pedicle 103. Chapman JR, Agel J, Jurkovich GJ, Bellabarba C.
screw fixation: a prospective study. Spine (Phila Pa Thoracolumbar flexion-distraction injuries: associ-
1976) 2006;31:E208-14. ated morbidity and neurological outcomes. Spine
92. Toyone T, Ozawa T, Inada K, et al. Short-segment (Phila Pa 1976) 2008;33:648-57.
fixation without fusion for thoracolumbar burst frac- 104. Liu YJ, Chang MC, Wang ST, Yu WK, Liu CL, Chen
tures with neurological deficit can preserve thoraco TH. Flexion-distraction injury of the thoracolum-
 146 Byung-Guk Kim et al. Asian Spine J 2015;9(1):133-146

bar spine. Injury 2003;34:920-3. cus 2013;35:E2.

105. Kim YM, Kim DS, Choi ES, et al. Nonfusion meth- 107. Herkowitz HN, Garfin SR, Eismont FJ, Bell GR,
od in thoracolumbar and lumbar spinal fractures. Balderston RA. Rothman-Simeone the spine: expert
Spine (Phila Pa 1976) 2011;36:170-6. consult. London: Elsevier Health Sciences; 2011.
106. Grossbach AJ, Dahdaleh NS, Abel TJ, Woods GD, 108. Hao D, Wang W, Duan K, et al. Two-year follow-up
Dlouhy BJ, Hitchon PW. Flexion-distraction inju- evaluation of surgical treatment for thoracolumbar
ries of the thoracolumbar spine: open fusion versus fracture-dislocation. Spine (Phila Pa 1976) 2014;39:
percutaneous pedicle screw fixation. Neurosurg Fo- E1284-90.