Burst Fractures in the Thoracolumbar Junction: What Do We Know About Their Treatment?

Dear Editor, The thoracic and lumbar spine (from T1 to L5) is the most common sites of traumatic spinal injuries, especially in the thoracolumbar transition (T11-L2), a junctional area between the mobile lumbar and the rigid thoracic spine (1, 2). The most common causes of trauma are motor vehicle accidents in younger adults and fall in older patients (3). About 160.000 of injuries occur every year in the US, with an important social and economical impact because of the productive years lost and its high morbidity, such as paraplegia, important disability and other associated organs lesions (3, 4). Classification of TL trauma is important to compare different treatment modalities as well as for scientific purposes. Historically, some classical schemes deserve comments. The concept of spinal stability based on the Denis three column model was widely accepted by the time it was proposed (5). In his model, an unstable spine was defined when the fracture compromised of both anterior and middle column, as occurs in burst fractures. Lately, in 1994, Magerl et al. proposed a comprehensive classification of thoracolumbar fractures that was used by the AO spine study group for many years. Due to its complexity and low reliability it was recently revised by Vaccaro et al. (6), who proposed a new AO Spine system, to improve morphological description. In this new system, TL trauma was grouped in three main morphological groups: type A) compression (failure of anterior structures under compression), type B) tension band disruption (anterior or posterior) and type C) displacement/ translation. Treatment of TL trauma consists basically of two options: conservative (with a brace or not) or surgical stabilization, to restore spinal alignment, decompress the spinal cord and nerve roots and also restore spinal stability. To guide treatment, injury morphology characteristics are of paramount importance. However, other variables may influence surgical treatment. In this context, a severity score known as Thoracolumbar Injury Classification System and Severity Score (TLICS) was proposed (7). This system considers the evaluation of injury morphology, neurological status and integrity of Posterior Ligamentous Complex (PLC) in the decision for the best treatment option. A score is obtained with the summation of each one of the three variables, and the final punctuation suggests the treatment: three or less points indicate that conservative treatment may be proposed, whereas with five points surgical treatment is recommended. Patients with four points may be managed both ways, according to surgeon’s preference and patients’ condition (other injuries, comorbidities, preferences, etc.) (7, 8).