Management of Lumbar Burst Fractures
Initial Assessment: Neurological Status Determines Management Pathway
The presence or absence of neurological deficits is the primary determinant of management strategy for lumbar burst fractures. 1, 2
For Neurologically Intact Patients
Treatment decisions should be made at the discretion of the treating provider, as evidence is conflicting regarding surgical versus nonoperative management. 1
- The Congress of Neurological Surgeons provides Grade Insufficient evidence for mandatory surgical intervention in neurologically intact patients with burst fractures 1
- Both surgical and nonoperative approaches can achieve acceptable outcomes in this population 3
Key fracture characteristics to guide decision-making include:
- Degree of vertebral body height loss (>40-50% suggests instability) 4
- Canal compromise (>50% traditionally considered for surgery) 5
- Kyphotic angulation (>30° suggests instability) 5
- Integrity of posterior elements and posterior ligamentous complex 3, 5
For Patients with Neurological Deficits
Surgical intervention is generally pursued to decompress neural elements, restore alignment, and stabilize the spine. 1, 2
- Immediate spine surgery consultation is mandatory for patients with neurological deficits 4
- Posterior decompression with instrumentation achieves significant neurological recovery in most patients with incomplete lesions 6
Nonoperative Management Protocol
For stable fractures in neurologically intact patients, external bracing with close outpatient follow-up within 1-2 weeks is recommended. 2, 3
- The decision to use external bracing is at the discretion of the treating physician, as evidence for specific brace types is inconclusive 3, 4
- Body-jacket cast immobilization for 6-8 weeks followed by thoracolumbosacral orthosis for 3 months has demonstrated effectiveness for stable L5 burst fractures 7
- Early mobilization (10-14 days post-injury) can be permitted with appropriate bracing 7
- Serial imaging is necessary to monitor for progressive deformity or delayed instability 2, 3
Warning signs requiring immediate return for evaluation include:
- New onset or worsening neurological symptoms 3
- Severe uncontrolled pain 3
- Inability to mobilize safely 3
Surgical Management: Evidence-Based Approach
Instrumentation Without Fusion is the Standard
Instrumentation without arthrodesis is the evidence-based standard for lumbar burst fractures requiring surgical intervention (Grade A recommendation). 1, 2
- Adding fusion to instrumented stabilization does not improve clinical or radiological outcomes 1, 2
- Fusion increases operative time and blood loss without benefit 1, 2
- Early mobilization is encouraged with instrumentation alone 2
Surgical Approach Selection
The posterior approach is most commonly used, with equivalent clinical and neurological outcomes compared to anterior or combined approaches (Grade B recommendation). 1, 2
- Anterior, posterior, or combined approaches may be utilized as the selection does not impact clinical or neurological outcomes 1
- The posterior approach offers surgeon familiarity and lower complication rates 2
- Anterior corpectomy may be considered for severe anterior column compromise with large anteriorly displaced fragments 8, 5
Open Versus Percutaneous Techniques
Both open and percutaneous pedicle screw techniques achieve equivalent clinical outcomes (Grade B recommendation). 1, 2
- Percutaneous instrumentation offers reduced blood loss and operative time 2
- Minimally invasive approaches allow for early mobilization and shorter hospital stays 5
Specific Surgical Techniques
Posterior short-segment fixation (one level above and below) with decompression is effective for most lumbar burst fractures with neurological deficits. 6, 9
- Posterior decompression with interlaminar fusion and short-segment fixation achieves excellent reduction of kyphosis and canal clearance 6
- Average operative time 72 minutes with blood loss 325 ml for posterior approach 6
- Neurological improvement occurs in the majority of patients with incomplete lesions (38/41 patients improved by at least one ASIA grade) 6
For severe anterior column destruction, minimally invasive corpectomy with cage reconstruction and posterior stabilization is an option. 5
- Direct lateral approach for corpectomy with titanium mesh cage followed by percutaneous pedicle screw fixation minimizes morbidity 5
- Blood loss less than 100 cc with discharge by postoperative day 2 in reported cases 5
Postoperative Management
CT with multiplanar reconstructions is the preferred imaging modality for assessing healing after surgical intervention. 2
- Radiological fusion is typically achieved within 6-8 months when fusion is performed 6
- No instrumentation failure should occur with appropriate technique 6
Common Pitfalls to Avoid
Do not assume all burst fractures require surgical intervention - the evidence does not support mandatory surgery for neurologically intact patients with burst fractures 1, 3
Do not routinely add fusion to instrumentation - this increases morbidity without improving outcomes (Grade A evidence against) 1, 2
Do not delay spine surgery consultation for patients with neurological deficits or severe structural compromise - these patients require expert evaluation within 1-2 weeks maximum 4
Do not fail to provide adequate patient education about warning signs - patients must understand when to seek immediate medical attention 3
Do not overlook the importance of close follow-up - monitoring for delayed instability or progression is critical in nonoperatively managed cases 2, 3