Thoracolumbar Burst Fractures

Definition

  • Axial load failure of the anterior and middle columns, with a retropulsed posterior vertebral body fragment
  • Most occur at T12 to L2 after a fall from height or a motor vehicle crash

Classification

  • AO Spine describes A3 incomplete burst, A4 complete burst, B tension band injuries and C translation injuries
  • AO Spine adds neurology modifiers N0 to N4 and NX
  • TLICS scores morphology (compression 1, burst 2, translation or rotation 3, distraction 4), posterior ligamentous complex (intact 0, suspected 2, injured 3) and neurology (intact 0, root 2, complete cord or conus 2, incomplete cord or cauda equina 3)
  • A TLICS of 3 or less suggests nonoperative care, 4 is either and 5 or more suggests surgery

Assessment

  • ATLS survey, full neurological examination, ASIA grade, perianal sensation and bulbocavernosus reflex
  • Image the whole spine for noncontiguous fractures
  • CT defines canal compromise, kyphosis and posterior element fractures
  • MRI shows the posterior ligamentous complex and cord

Management

  • Neurologically intact with an intact ligamentous complex can be treated with early mobilisation, with or without a brace
  • Randomised trials in intact patients (Wood, Siebenga) show similar long term outcomes with and without surgery
  • Surgery is indicated for neurological deficit with canal compromise, posterior ligament injury or progressive kyphosis
  • Posterior short segment pedicle screws one level above and below is the usual construct
  • Long segment constructs suit osteoporotic bone and severe comminution
  • Anterior corpectomy with a cage allows direct decompression and column reconstruction
  • Consider early decompression in incomplete cord injury

Complications

  • Pressure injury, VTE and respiratory complications in the polytrauma patient
  • Progressive kyphosis and chronic back pain
  • Implant failure with short segment fixation of unstable burst fractures
  • Adjacent segment degeneration

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 15 October 2026.