What is the initial therapeutic regimen for a closed, burst fractured lumbar?

Initial Therapeutic Regimen for Closed, Burst Fractured Lumbar

For neurologically intact patients with thoracic and lumbar burst fractures, initial management can be either with or without external bracing as both approaches provide equivalent outcomes in terms of pain reduction and functional improvement. 1

Assessment and Classification

Before determining the therapeutic approach, proper assessment of fracture stability is essential:

• A burst fracture is considered unstable when there is:

  • Significant vertebral collapse
  • Substantial angulation
  • Significant canal compromise
  • Neurological deficit
  • Disruption of the disco-ligamentous complex 2

• Burst fractures without neurological deficit are considered relatively stable and can typically be managed non-operatively 2

Initial Therapeutic Algorithm

For Neurologically Intact Patients:

1. Non-operative management is recommended as first-line treatment 1, 3:

   • Short period of bed rest followed by protected mobilization
   • With or without external bracing (Grade B recommendation) 1
   • Pain management with appropriate analgesics

2. External bracing considerations:

   • Decision to use external bracing is at the discretion of the treating physician 1
   • No difference in final clinical and radiographic outcomes between patients treated with or without external bracing 1
   • Bracing is not associated with increased adverse events compared to no brace 1

3. Monitoring:

   • Regular radiographic follow-up to assess for progressive deformity
   • Clinical assessment for development of pain or neurological symptoms

For Patients with Neurological Deficits:

1. Surgical intervention is generally indicated 1, 2:
   • Immediate surgical decompression and stabilization 2
   • Choice of surgical approach (anterior, posterior, or combined) does not significantly impact clinical or neurological outcomes (Grade B recommendation) 1
   • Addition of arthrodesis to instrumented stabilization has not been shown to improve outcomes and adds to increased blood loss and operative time (Grade A recommendation) 1
   • Both open and percutaneous pedicle screw techniques show equivalent clinical outcomes (Grade B recommendation) 1

Special Considerations

1. Isolated partial single-nerve-root deficits:

   • May resolve regardless of treatment method 4

2. Complete single or multiple-nerve-root paralysis:

   • May benefit from anterior decompression 4

3. Degree of canal compromise:

   • Not directly correlated with neurological outcome in L5 burst fractures 5
   • Neurological injuries have promising prognosis after surgery 5

4. Stable fractures without neurological deficit:

   • Conservative treatment is recommended for stable fractures with less than 35° of kyphosis 6
   • No reported cases of neurological deterioration or symptoms of late spinal stenosis with non-operative management in neurologically intact patients 4, 3

Common Pitfalls to Avoid

1. Assuming all burst fractures require surgery:

   • Evidence shows that neurologically intact patients with burst fractures can be successfully managed non-operatively 1, 3

2. Prolonged immobilization:

   • Can lead to significant complications after 48-72 hours, including pressure sores and poor oral care leading to bacteremia 2

3. Relying solely on radiographic appearance:

   • Clinical outcome is not necessarily related to the deformity seen on follow-up imaging 4
   • Initial radiographs cannot reliably predict final deformity in non-operatively treated patients 4

4. Neglecting follow-up:

   • Regular monitoring is essential to detect any progressive deformity or late neurological deterioration

The evidence suggests that non-operative treatment is appropriate for burst fractures in neurologically intact patients, with equivalent outcomes whether using external bracing or not. The decision regarding surgical intervention should be guided by the presence of neurological deficits and the stability of the fracture.