What are the potential complications and management strategies for an L2 burst fracture?

L2 Burst Fracture Complications and Management

L2 burst fractures require multidisciplinary management with careful attention to neurological status, spinal stability, and prevention of secondary complications to optimize morbidity, mortality, and quality of life outcomes.

Potential Complications

Immediate Complications

• Neurological deficits:
  • Paraplegia or paraparesis due to spinal cord compression 1
  • Radiculopathy from nerve root compression (particularly L2 nerve root) 1
  • Cauda equina syndrome

Early Post-Injury Complications

• Spinal instability leading to progressive kyphotic deformity 1, 2
• Vertebral body re-collapse after initial treatment (14.9% of cases) 2
• Canal compromise from posterior wall fragments 1
• Pain and functional disability, particularly in elderly and osteoporotic patients 3

Late Complications

• Progressive kyphosis with loss of correction 1, 2
• Hardware failure requiring revision surgery 1, 4
• Adjacent segment degeneration
• Chronic pain and disability
• Subsequent fragility fractures in osteoporotic patients 5

Risk Factors for Complications

Independent predictors for vertebral body re-collapse after posterior instrumented fusion include:

• Age >43 years (strongest predictor) 2
• Preoperative body height loss >54% 2
• Osteoporosis as underlying condition 3
• High-energy trauma mechanism 2

Management Strategies

Initial Assessment and Stabilization

• Multidisciplinary approach involving orthopaedic surgeons, neurosurgeons, and rehabilitation specialists 5
• Comprehensive neurological examination to identify deficits
• Appropriate imaging:
  • CT scan to assess fracture pattern and canal compromise
  • MRI to evaluate ligamentous injury and neural compression

Non-Surgical Management

For stable fractures without neurological deficit:

• Pain management:

  • Calcitonin for 4 weeks in acute osteoporotic compression fractures (Level II evidence) 5
  • L2 nerve root blocks for pain relief (option for L3/L4 fractures, may be applicable to L2) 5

• Bracing (inconclusive evidence for effectiveness) 5

• Prevention of subsequent fractures:

  • Ibandronate or strontium ranelate in osteoporotic patients 5
  • Calcium and vitamin D supplementation

Surgical Management

Indications for surgery include:

• Neurological deficit
• Significant canal compromise
• Unstable fracture pattern
• Progressive kyphotic deformity
• Failure of conservative treatment

Surgical Options:

1. Posterior approach:

   • Pedicle screw fixation (typically 2 levels above and below the fracture) 4
   • Indirect decompression through ligamentotaxis

2. Anterior approach:

   • Corpectomy and cage placement for severe burst fractures 6, 4
   • Provides direct decompression of neural elements
   • Restores anterior column support

3. Combined approaches:

   • Posterior stabilization followed by anterior corpectomy and cage placement 4
   • Provides optimal correction of kyphosis and maintenance of correction
   • Higher complication rate due to double approach morbidity

4. Minimally invasive options:

   • Transpsoas L2 corpectomy with percutaneous pedicle screw fixation 3
   • Particularly beneficial in elderly or medically frail patients
   • Reduced blood loss (35mL vs. traditional approaches)
   • Shorter hospital stay (discharge within 36 hours)

Complications of Surgical Treatment

• Approach-related complications:

  • Vascular injury during anterior approach 6
  • Infection (requiring multiple debridements) 1
  • Postoperative paraparesis 1

• Hardware-related complications:

  • Loss of correction at instrumented levels 1, 2
  • Screw loosening in osteoporotic bone
  • Rod breakage

Post-Treatment Care

• Rehabilitation program to restore mobility and function
• Regular radiographic follow-up to detect early re-collapse or hardware failure
• Osteoporosis management to prevent subsequent fractures 5
• Pain management strategies for chronic pain

Special Considerations

Elderly Patients

• Higher risk of complications due to osteoporosis and comorbidities 3
• Consider minimally invasive approaches to reduce surgical morbidity 3
• Balance between adequate stabilization and minimizing surgical stress

Osteoporotic Fractures

• Higher risk of implant failure and re-collapse 2
• Consider augmentation techniques (cement, expandable cages) 3
• Aggressive medical management of osteoporosis 5

Pitfalls and Caveats

• Underestimating instability can lead to progressive deformity and neurological deterioration
• Inadequate fixation length may result in construct failure, particularly in osteoporotic patients
• Delayed treatment of neurological deficits may lead to permanent neurological damage
• Failure to address osteoporosis increases risk of subsequent fractures and hardware failure
• Overly aggressive surgery in elderly or medically frail patients may increase morbidity and mortality

By understanding these complications and implementing appropriate management strategies, clinicians can optimize outcomes for patients with L2 burst fractures.