Thoracic & Lumbosacral Trauma | Fractures

Thoracic & Lumbosacral Trauma | Fractures, sagittal ct of an l4 burst fracture
Sagittal CT of an L4 burst fracture. Image by James Heilman, MD, Wikimedia Commons, CC BY-SA 4.0.

Overview

  • Commonest at the thoracolumbar junction, between stiff thoracic and mobile lumbar spine
  • ATLS assessment with whole spine imaging, as noncontiguous injuries are common
  • AO Spine grades morphology, neurology and modifiers, TLICS guides treatment
  • Stable burst fractures without deficit mobilise early, with or without a brace
  • Surgery for deficit, posterior ligament disruption, translation or progressive deformity

Western Health Orthopaedic Registrar presentation – Thoracolumbar Spine Trauma by Dr Amy Gibbens

Classification

Denis

  • Anterior, middle and posterior columns, with injury to two or more implying instability

AO Spine

TypeDescription
ACompression. A3 incomplete burst of one endplate, A4 complete burst of both
BTension band failure. B1 bony Chance, B3 anterior hyperextension injury
CDisplacement or translation

Original publication Vaccaro AR, Oner C, Kepler CK, Dvorak M, Schnake K, Bellabarba C, Reinhold M, Aarabi B, Kandziora F, Chapman J, Shanmuganathan R, Fehlings M, Vialle L. AOSpine thoracolumbar spine injury classification system: fracture description, neurological status, and key modifiers. Spine (Phila Pa 1976). 2013;38(23):2028-37.

  • Neurology N0 to N4 and NX, with posterior ligament and comorbidity modifiers

TLICS

Scores morphology, neurology and posterior ligamentous complex integrity

Total scoreManagement
3 or lessNon-operative
4Indeterminate
5 or moreSurgery

Original publication Vaccaro AR, Lehman Ra Jr, Hurlbert RJ, Anderson PA, Harris M, Hedlund R, Harrop J, Dvorak M, Wood K, Fehlings MG, Fisher C, Zeiller SC, Anderson DG, Bono CM, Stock GH, Brown AK, Kuklo T, Oner FC. A new classification of thoracolumbar injuries: the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status. Spine (Phila Pa 1976). 2005;30(20):2325-33.

Denis sacral zones

ZoneDescription
ILateral to the foramina, occasional L5 root injury
IIThrough the foramina, sacral root injury
IIIMedial into the canal, highest rate of bowel, bladder and sexual dysfunction

Original publication Denis F, Davis S, Comfort T. Sacral fractures: an important problem. Retrospective analysis of 236 cases. Clin Orthop Relat Res. 1988;227:67-81.

Management

  • Intact burst fractures with intact posterior ligaments do as well non-operatively as with fusion
  • Bracing shows no clear benefit over mobilisation without a brace
  • Canal compromise alone is no indication, as retropulsed fragments remodel
  • Surgery for deficit, ligamentous disruption, progressive kyphosis or translation
  • Bony Chance fractures may heal in a hyperextension cast or brace
  • Ligamentous Chance injuries need posterior compression instrumentation and fusion
  • Seat belt sign suggests hollow viscus injury
  • Keep MAP above about 85 mmHg, without routine high-dose methylprednisolone
  • U and H sacral fractures cause spinopelvic dissociation, treated with lumbopelvic fixation or iliosacral screws

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.