Burst Fractures: Treatment and Recovery
A stable burst fracture may be treated without surgery. In general, a stable burst fracture is one in which there is no neurologic injury, in which the angulation of the spine is less than 20 degrees and in which the amount of spinal canal compromise is less than 50 percent. In these patients, treatment with a brace may lead to an excellent result. In general a molded turtle shell type brace (TLSO) or a body cast is required for the treatment of a burst fracture. This brace is usually worn for eight to twelve weeks in order to ensure adequate healing.
Occasionally, a fracture that was thought to be stable and treated in a brace may begin to angulate while in the brace. This may necessitate a later decision to perform surgery. All burst fractures require some type of treatment.
There is no burst fracture that heals well with simple observation. In rare instances, an unstable burst fracture may elect to be treated without surgery. This is usually due to extenuating circumstances, such as, severe injury to the head, chest or abdomen. If that is the case, the patient is usually treated at bed rest, flat until early healing has begun. They may then be converted to a brace or to have late surgery.
A burst fracture is considered unstable if neurologic injury is present, angulation of the spine is greater than 20 degrees, there is subluxation or dislocation of the spine, or there is greater than 50 percent spinal canal compromise. Unstable burst fractures usually do better with early surgery. As mentioned, occasionally an unstable burst fracture can be treated with bracing alone. Without neurologic deficit, but with an unstable spine, a posterior procedure may be performed.
Surgery for burst fractures may be performed from either an anterior (front) or posterior (back) approach. This means that the surgeon makes an incision in the back of the spine in order to place rods, screws and hooks in order to hold the spine in place. In general, a reduction maneuver is performed to straighten the spine and a fusion is performed with bone graft to help those injured vertebral elements heal together. The rods, screws and hooks are used to hold the spine in place and to maintain the reduction.
On occasion, fragments that are partially pressing on the spinal canal may be moved into a better position via the posterior approach. This can be done through laminectomy, costotransversectomy (lateral, side approach to the thoracic spine) or transpedicular (through or across the vertebral pedicle) resection.
In each of the approaches, the surgeon comes from the side of the spinal canal in an attempt to remove or push forward the offending bony fragments. For some patients with neurologic deficit, an anterior approach to the spine may be beneficial. In this procedure, a flank incision is made on the side of the patient's chest. The spine is approached from the side so that fragments can be removed from the spinal canal without disturbing the spinal cord. In this procedure the vertebral body that is fractured is completely removed and replaced with a bone strut. The surgeon will then apply a titanium plate holding the bone strut in place, maintaining the reduction of the spine and obtaining the stability of the spine. This is considered an anterior corpectomy and plating.
Occasionally, both an anterior approach and a posterior approach may be necessary. This is usually in severe fractures where there is subluxation or dislocation of the spinal elements. After any of these stabilization procedures some type of bracing is required for eight to ten weeks following surgery.
With nonsurgical treatment, most patients are kept in the hospital for one or two days to have their brace fit. X-rays are then checked in the standing position to make sure that the spine remains stable while in the brace.
Patients can expect to require pain medications for three to four weeks while treating their fracture in a brace. In general, non-narcotic medications can be utilized beginning after week four.
When the brace is removed at eight to ten weeks, physical therapy is usually instituted to help return strength to the trunk and lower extremities.
Following spinal surgery for a burst fracture most patients will remain in the hospital for three to five days. They will usually be fit with a brace once their incisions have become less painful and they have recovered from the surgical approach.
Patients are usually allowed to walk within one or two days of surgery with the help of a physical therapist.
Subsequent x-rays are taken in the surgeon's office to follow the position of the spine and to assess the degree of healing. Once the brace is discontinued physical therapy is instituted to help with trunk strength and lower extremity strength. The amount of recovery following a burst fracture is usually dependent on the neurologic injury. Most patients who do not have neurologic injury can make a near complete recovery with return to most of the activities of their life. With incomplete neurologic deficit often recovery will occur with appropriate surgical treatment. These patients too may expect to make an excellent recovery. However, with permanent neurologic injury, recovery is limited. The degree of recovery may depend on the timing of surgery, the degree of spinal canal compromise and the stability of the spine. The most important factor in how much neurologic recovery occurs is how severe the original injury was.
The results of the treatment of a burst fracture today are far superior to what they were even twenty years ago prior to the institution of specific spinal procedures.