What is the appropriate management of a lumbar burst fracture?

Management of Lumbar Burst Fractures

Primary Treatment Decision: Neurological Status Determines Management Strategy

For neurologically intact patients with lumbar burst fractures, both surgical and nonoperative management are acceptable options, as there is conflicting evidence that either approach improves clinical outcomes—the decision should be based on specific fracture characteristics and clinical judgment rather than a default to surgery. 1

Assessment of Stability and Surgical Indications

The critical determinants for surgical intervention include:

• Neurological deficit present: Surgery is generally pursued to decompress neural elements and stabilize the spine 2, 3
• Vertebral body collapse >50% of original height: This represents true instability requiring surgical consultation 2
• Posterior ligamentous complex disruption: Intact posterior elements indicate relative stability, while disruption suggests instability 2, 4
• Severe kyphotic deformity (>30°): This may warrant surgical stabilization 5

Canal stenosis alone in a neurologically intact patient does NOT define instability and does NOT automatically require surgery. 2 This is a critical pitfall—many clinicians assume canal compromise mandates operative intervention, but the evidence clearly shows neurologically intact patients with canal stenosis can be managed conservatively with equivalent functional outcomes. 2

Nonoperative Management Protocol

For stable fractures in neurologically intact patients:

• External bracing is optional: The Congress of Neurological Surgeons states that bracing decisions are at the discretion of the treating physician, as functional outcomes are equivalent with or without a brace (Grade B evidence) 1, 2
• Close outpatient follow-up within 1-2 weeks with a spine surgeon is mandatory 2, 6
• Serial imaging to monitor for progressive deformity or delayed instability 3
• Patient education on warning signs: New or worsening neurological symptoms, severe uncontrolled pain, or inability to mobilize safely require immediate return to emergency care 2

Surgical Management When Indicated

Approach Selection

The posterior approach is recommended as the primary surgical option for lumbar burst fractures requiring operative intervention, as it produces equivalent clinical and neurological outcomes to anterior or combined approaches while being more familiar to surgeons and having lower complication rates. 1, 3

• Anterior, posterior, or combined approaches all produce equivalent clinical and neurological outcomes (Grade B recommendation) 1
• The posterior approach offers surgeon familiarity and established safety profile 3
• Anterior approaches provide greater canal decompression but increase operative time and surgical morbidity 7

Instrumentation Strategy

Instrumentation without fusion is the evidence-based standard for lumbar burst fractures requiring surgical intervention (Grade A recommendation). 3

Key technical points:

• Short-segment posterior instrumentation with intermediate screws at the fractured level is advocated by current evidence 4
• Fusion does NOT improve clinical or radiological outcomes (Grade A evidence) but increases operative time and blood loss 3
• Both open and percutaneous pedicle screw techniques achieve equivalent clinical outcomes (Grade B recommendation), with percutaneous approaches offering reduced blood loss and operative time 2, 3
• Transpedicular corpectomy with cage placement via posterior-only approach is viable for severe burst fractures, avoiding anterior approach morbidity 8, 5

Vertebral Augmentation

• Cementoplasty (vertebroplasty) is an option for vertebral augmentation at the fractured level in selected patients, offering less operative morbidity and maintenance of lumbar mobility 9, 4

Adjunctive Medical Management

For patients with spinal cord injury:

• Methylprednisolone: Insufficient evidence to recommend routine use; complication profile should be carefully considered if administration is contemplated 1
• Mean arterial pressure maintenance >85 mmHg: Insufficient evidence for thoracolumbar injuries specifically, but clinicians may choose this target based on pooled spinal cord injury data 1

Postoperative Care

• Early mobilization is encouraged with instrumentation alone 3
• CT with multiplanar reconstructions is the preferred imaging modality for assessing healing 3
• Implant removal after stabilization may provide benefits, especially in younger patients 4

Common Pitfalls to Avoid

• Assuming all burst fractures require surgery: The evidence does not support mandatory surgical treatment for neurologically intact patients 1
• Equating canal stenosis with instability: Canal compromise alone does not define instability in neurologically intact patients 2
• Routinely adding fusion to instrumentation: This increases morbidity without improving outcomes 3
• Inadequate patient education: Failing to educate about warning signs for delayed neurological compromise is a critical error 2
• Insufficient follow-up: Close monitoring is essential to detect progressive deformity or delayed instability 3