Copyright

Burst
BY

1992

Fracture
CHARLES

IilteSti#{231}(ltiO?l

A.

M.D.t.

at the
.Southern

Burst

ABSTRACT:

bra is a rare injury.

who were treated

fracture

of the

We report
conservatively

orthosis

was

fifth

worn

for

had an injury

canal
could
neurological
spinal

not be
deficit;

canal

did

to the sacral

of

directly
related
that is, a large

not

necessarily

of

the

effectiveness

January

of the

spine

spine

of

2.2 per

and

by Denis
fractures

(Figs.
that

accident,

vertebra
neurological

were

treatment

in a body-jacket

by immobilization

burst

stable
deficits,

inand

cast

was

of one

years).

an

The

(anterior

and

modified

this

posterior)
classification

column.
He emphasized
were
disrupted.
the
However,
he reported

of only

specifically
bra:

one

four3.

fracture

of the
benefits

previously

Seven

in

dily

lumbar
vertebra,
for treatment.
published

fracture

included
fifth

fifth

of the

three
patients

lumbar
form

patients,
who

vertebra
have

been

had
and
received

sustained
were

other
a burst

treated

or will

from a commercial
party
related
directly
or indirectly
to the
this article.
No funds
were received
in support
of this study.
tSuite
C. 1(5)1 37th Street
North.
St. Petersburg.
Florida
Department
of Surgery.
Southern
Illinois
University
Medicine.
P.O. Box 19230. Springfield.
Illinois
62794.

398

vente-

the

Division

by

of Ortho-

subject

of

33713.
School

of

burst
fractures
of all fractures
of the

eighth
vertebra):

one,

and

back

or foraminal

from

the

ranged

study4.

from

each.
had

twelve

to

months).
patients
and

The
by a

water-skiing,

and

Five of the patients

had
another
fracture
of the

thoracic
one.

vertebra
bilateral

fracture

and two, of the

fracture
of the

of the

pain

ankle.

was

assessed

at regular

and computed
tomography
in order
to determine
the
wedge
at the

by osseous

The wedge
index was calculated
by measurement
of the height

nor

posterior

and

calculation

bodies

of the

by

of the
The

intervals.
scans
degree
of

fragments

or

in the standard
of both the ante-

fractured

lower

of anterior
compression.
from the cephalad

lumbar
vertebra
The development
arthrosis

ratio.

docuradic-

index and the degree

of lordosis
time of injury
and at follow-up

intervals.
fashion,

assessed

fractures
and
with involve-

two women:
the ages ranged
years (average,
thirty-five

compromise

disc material.
The
were determined

and

thoracolumbar

neurological
status
of each
patient
was
The development
of neurological
deficits.

pain,

spinal

excluded

bilateral

of the
of the

that met the criteria

columns,
as described

weight-lifting,
three

of the

the amount
was calculated

he received

seven
cent

(average,
thirty-six
by a fall in three

in one

Plain radiographs
were made
initially,

dealing

lumbar
and

ular

and he
We are

reports
fifth

to

587 frac-

l99(),

at the

of follow-up

crash

and

The
mented.

Denis

per

were

injuries:

lumbar

calcaneus:

to include
a third
(middle)
that if two of the three
columns
fracture
was inherently
unstable.
the case of only one patient
who

burst

report

included

:3N()

two

with

system.

(one,

second

distinguished
burst
in their two-column

classification

a burst
fracture
of the
not give recommendations

aware

Hardy

were

( 1.2

five men and

to forty-nine

duration

airplane

spine

had
did

column,

There
were
from twenty-two

associated

effective.
In 1953, Holdswonth
and
fractures
from fracture-dislocations

followed

1-A and 1-B). Compression

were
due to osteoporosis.

motor-vehicle

fractures
of the fifth lumbar
juries
that caused
minimum

the

December

of fractures

months
been caused

series,

and

treated

cent

seventy-two
injury
had

In our

Methods

spine).
All were true burst fractures
of involvement
of two of the three

vertebral

patient.

were

management.

and

1984

ment

in any

cast
of this

were

neurological
function.
There
was no early or late loss of
lordosis
between
the cephalad
end-plate
of the fourth
lumbar
vertebra
and the cephalad
aspect
of the sacrum,
and there
were no signs of progressive
collapse
of the
body

()fSliigerv.

in a body-jacket

determine

columbar
spine.
There
fifth lumbar
vertebra

spinal

loss

Departiiteitt

paedic
Surgery
at the Southern
Illinois
University
School
of Medicine.
Two hundred
and seventy-three
fractures
involved
the cervical
spine.
and 314 involved
the thora-

pain
sacral-

in a major

IL[.INOIS

Spriitgfield

Between

to the degree
of
compromise
of the

result

SPRINGFIELD.

at Medicine,

tunes

Two

the

M.D4.

Vertebra3

Materials

deficits
that
an occasional

compromise

poraieI

(4)P

immobilization

three
root.

Iii

amid Rehabilitation,

Sc/tool

verte-

had intermittent
radicular-type
of the fifth lumbar
or first
degree

.cirgert.

Lumbar

ofOrthopaedics
University

an additional

had mild lower lumbar

motor-root
within
one year. All patients
had

The

alit! Joini

F. S. STAUFFER.

cast that included

one
patients
were allowed
the injury. A thoraco-

patients
resolved

root.

Division

lumbar

No patient

nerve

AND

Illinois

months.

backache,
and two
in the distribution

vi Hone

J(ursulI

the cases ofseven

patients
by immobilization
for

six to eight weeks

in a body-jacket
lower extremity
to the knee. The
to walk ten to fourteen
days after
lumbosacral

i!i

of the Fifth

FINN.

performiteil

the

vertebra
ratio,

The
end-plate

and

the

greater

lordotic
of the

angle
fourth

and the cephalad

aspect
of the sacrum.
of late degeneration
of the disc space
of

lateral

TI-IE

the

facet

and

JOURNAL

(zygapophyseal

oblique

joints)

radiognaphs

()F

BONE

ANt)

of the

JOINT

was
lum-

SURGERY

BURST

Fi;.

for six to eight

in a body-jacket

FI,.
Figs.
follow-up
Fig.
Fig.
height

V(i)I..

FIFTH

LUMBAR

cast

2-A

that

ofthe

sagittal
alignment.
of the anterior

included

caudad

and

one

portion

middle

ofthe

with

lowenextremity

columbosacral
The patients

74-A,

NO.

3. MAR(II

1992

I-B
lumbar

columns.

spine

3() degrees

to the

and

the

sacrum.

of lordosis

knee.They

Fi;.

demonstrating

and

then

onthosis
for an additional
were allowed
to walk ten

and 2-B: Case

2. Lateral
radiographs
demonstrating
no loss of lordosis
or change
at thirty-six
months.
2-A: Initial
radiograph.
There
is 28 degrees
of lordosis
and a wedge
index
of 25/32 (0.78).
2-B: At the thirty-six-month
follow-up,
there
is 28 degrees
oflordosis
and a wedge
index
of the anterior
and posterior
columns
is most
likely
secondary
to a magnification
error.
2-A

399

VERTEBRA

Fi;.
radiographs

were made
during
follow-up.
patients
were
treated
by immobilization
weeks

THE

1-A

Figs. I-A and 1-B: Case 6. Anteroposterior

and lateral
a typical
burst
fracture
of the fifth lumbar
vertebra.
Fig. I-A: Anteroposterior
radiograph
showing
normal
Fig. I -B: Lateral
radiograph
demonstrating
involvement
of 24/30 (0.8). The posterior
column
is intact.

ban spine that

All seven

OF

FRACTURE

a wedge

wore

index

a thona-

three
months.
to fourteen
days

2-B
in the

of 27/34

wedge

(0.79).

index

The

from

difference

the

time

in the

of injury

measured

to

400

C. A. FINN

Figs. 3-A. 3-B. and

3-C: Case

2. Computed
cent compromise
was weakness
had resolved

onstrating
more
than
90 per
the only
neurological
deficit
hallucis
longus
that subsequently
up.

Fig. 3-A: Transverse

of the

canal

and

after

the

injury

of injuries

cut showing

foraminal

Two
deficits.

this

lower

on one

was

side.

Another

patient

extensor

hallucis

by the one-year
of the spinal

shown

on

remaining
icits. three
spinal
puted

because

lumbar
(3+

motor-root
of 5) of the

(Case

2) had

weakness

that

subsequently

longus

tomographic

who had
3, 6, and

Of

scans.

of the

spinal

of function
of the
penineal
sensation.
Initial
ces ranging

and

the indices

were

not

of the

anterior

five

on com5) had no

and

changed

did not
control

all had

normal

wedge
mdiAt the most

little:

the range

0.82).
On the basis
of these
anterior
collapse
of the yen-

demonstrated

involvement
of hone.

I).

bladder.

had

with

3-B

demonstrating
retropulsion

defof the

present
and
maintained

evaluation
revealed
to 0.97 (average,
0.85).

was 0.66 to 0.97 (average,

indices.
signs of progressive
body

(Table

were
not
All patients

bowel

radiographic
from 0.75

follow-up.

canal

deficits
patient.

reconstruction
columns,

had
cent,

the

no lumbar
motor-root
7) had compromise

FIC.
Sagittal
and middle

(4

follow-up.
Both
patients
canal of more than 90 per

computed

patients
(Cases

Sacnal
root
develop
in any

tebral

contnaindicated

canal
of 50 per cent or more,
as shown
tomography
scans. and two (Cases
I and

occlusion

recent

90 per cent compromise

longus
and plantan
flexors
bilaterally.
patient
had completely
recovered
cx(4 of 5) of the extensor
hallucis
longus

of 5) of the
resolved
compromise

tomography
scan demof the spinal
column:
(4 of 5) of the extensor
at the one-year
follow-

extremity.

of the seven
patients
had
One
(Case
4) had weakness

extensor
hallucis
At OflC year, the
cept for weakness

as

than

E. 5. STAUFFER

encroachment.

unless

of the

more

AND

in any

patient.

Also.

FtC;.

3-C

Transverse
scan made
one year after
able compromise
of the canal
but the
deficit
at this time.

THE

JOURNAL

OF

the injury.
There
patient
had no

BONE

AND

JOINT

is considerneurological

SURGERY

BURST

FRACTURE

OF

FIFTH

THE

TABLE
DATA

Sex,
Case

Duration

Age

of

Follow-up

Status

M. 49
M. 23

33
47

Intact
Weakness
extensor
resolved

3
4

F.49
M. 43

12
16

M, 25
F, 35
M. 22

72
36

Intact
Bilat. weakness
(3#{247}15)
of
extensor
hallucis
longus
and plantar
flexors;
resolved,
except
weak
(4/5) extensor
hallucis
longus
on one side
Intact

6
7
*Lordotic

substantial
(Figs.

the

loss oflordosis
2-A

end-plate
aspect
enage,

between

and

2-B).

of the fourth

The

fourth

vertebra

did not occur

during

angle

lumban

between
vertebra

Evaluation

the cephalad

74-A,

(avwas

of londosis
(average,
27 degrees)
(Table I).
by computed
tomography
revealed
that

FIG. 4-A
Figs. 4-A,
changes
of
Fig. 4-A:
fifth lumbar
Fig. 4-B:
Fig. 4-C:

(Degrees)

Initial

Follow-up

0.94
0.78

0.94
0.79

29
28

25
28

None
>90%

0.96
0.77

0.95
0.66

18
34

15
30

>90%

0.97
0.8
0.75

0.97
0.74

35
30

35

0.72

28

26

28

60%

None
50%
>90%

sacrum.

cephalad

of the sacrum
ranged
from 18 to 35 degrees
29 degrees).
At the latest follow-up,
the range

15 to 35 degrees

the

follow-up

the
and

and

Lordosis

Follow-up

(4/5) of
hallucis
longus:

lumbar

e Index

Estimated
Compromise
on Computed
Tomog.
Scans

Initial

Intact
Intact

36

angle

Wedg

(Mos.)

401

VERTEBRA

PATIENTS

THE

Neurological

(Yrs.)

VOL.

ON

LUMBAR

five of the seven

patients
had occlusion
of the spinal
canal and encroachment
of the fonamen
of at least 50 pen
cent; three
of the five (Cases
2, 4, and 7) had compromise
of more
than 90 per cent (Figs. 3-A , 3-B, and 3-C). The
remaining
two patients
(Cases
1 and 5) had no evidence
of occlusion
of the spinal
canal on of fonaminal
encroachment

FIG. 4-B

on computed

tomography.

FIG. 4-C

4-B. and 4-C: Case

7. Lateral
and oblique
radiographs
showing
a burst
fracture
of the fifth lumbar
vertebra
with degenerative
the facets
and disc space.
The radiographs
were
made
thirty-six
months
after the injury.
Lateral
radiograph
demonstrating
degeneration
of the disc space,
with narrowing
between
the fourth
and fifth vertebrae
and
vertebra
and the sacrum.
Left oblique
radiograph
demonstrating
degenerated
facetjoints
at the level of the fifth lumbar
vertebra
and the sacrum.
Right
oblique
radiograph
demonstrating
degenerated
facet joints
at the level of the fifth lumbar
vertebra
and the sacrum.

NO.

3. MARCH

1992

the

402

C. A.

At

the

most

recent

follow-up,

two

of the

FINN

AND

seven

E.

pa-

All seven

patient
thought
that the
an operative
decompression.
patients

ing the period

7). hypentrophic
veloped

reported

occasional

of follow-up.
facet joints

at later

follow-up

pain

was

logically
ative

dun-

In two patients
(Cases
4 and
and a degenerated
disc deintervals

(Figs.

4-A,

4-B,

neurological

have

been

very

few

reports

in the

vertebra.

as did

discussed
the treatment.
reports
have specifically
fifth lumbar
vertebra3.
Fredrickson
patients

who

had

Denis,

but

was
status

fracture,

any

and

neither

Little

of the

associated

fifth

the

lumbar

An

Court-Brown

on the
of the

operation

lumbar
the

vertebra

had

neuroof neuno-

neurological

and

Gentzbein,

in 1987,

patients
vertebra.

who
They

of

and
complaints

in the

vertebra

the

that,

two

90 pen
two
was

this, no
patients

for the

most

All patients

patients
seem

had
minor

mild
when

or

radicular

pain.

loss of lordosis
the

sacrum.

between

This

the

connespon-

no appreciable
vertebral
body

progression
of coloccurred.
The angles

of lumbar

and

index

loss

londosis
the

initial

these
is not

the

wedge

evaluation

and

changed

the time

little

of follow-up.

results.
we believe
that anthnodesis
necessary
to prevent
the loss of

of the
lumbar

who have a burst fracture

of the fifth humthe presence
of another
fracture
of the
always
be considered.
Three
of our seven

at the

other

level.

There

was

one

compression

tune of the eighth

thonacic
vertebra
and
fractures
of the second
lumbar
vertebra.
on

slight
these

had a burst
treated
two

neurological
concurrent

injuries,
fractures

with
did

frac-

two burst-type
Because
of the

only lower
root deficits,
not contribute
substan-

tially to the ultimate

clinical
outcome.
Therefore,
in the
interpretation
of the results.
these
concomitant
fractures
were ignored.
In conclusion,
in our patients
who had a burst
frac-

despite

of instrumentation

Our

of them.

than

for another
of the canal

ded to the fact that

lapse of the anterior

tune of the fifth lumbar

stabilized
the fracture

in one

back

and

was a loss of londosis

between
the fourth
and the sacrum
in all three
patients.

use

more

follow-up.

These

the back. There

lumbar
vertebra

authors
concluded
that
appropriate
for fractures

loss.
for

patients
had a fracture
at another
level of the spine; none
had an associated
neurological
injury or any neurological

The authors
no benefit.
reported

deficits

no progressive

lordosis.
In patients
bar vertebra,
spine
should

sacrum.

status

after the decompression.

internal
fixation
added

with
three
fifth lumbar

the

early

the amount
of
severity
of the

scans.
Despite
and only two

backache,

of pain

was

lumbar

Given
spine

conservative!y,with
no major
complications.
The
patient,
who
had had posterior
decompression,
fixation,
and anthrodesis,
had persistent
pain in

the

patients

motor-root

pain.

for

neurological
was reserved

between
and the

at the one-year

an occasional

between

was

had had
arthro-

to

lumbar

There

vertebra.

of the four patients

and postenolatena!

in

found
that

their
experience
fracture
of the
patients
other
internal

Three

resolved

persistence

to the amount
of compromise
canal that was seen on computed

fourth

improvement

had

non-open-

the potential
for severe
damage
to the cauda
equina
from
the fragments
of bone in the spinal
canal are considered.
Furthermore.
we have
no indication
that an operative
procedure
would
have
lessened
the prevalence
of the

in four

and was based

the stability

injuries.

scans.
Three
decompression,

patients
was
also reported

deficit.

injuries,

in the
neuno-

compression
of the lumbar
pain. No patient
met any of

no relationship
of the spinal
canal

radicular-type

author

the results

individualized
of the patient.

logical
loss corresponded
of the fonamen
or spinal

from

minor

pant,
had

two previous
fractures
of the

performed
because
of progressive
or substantial
logical
loss. The authors
stated
that the degree

desis

had

fourth

a fracture

The treatment
neurological

literature

burst fractures
Osebold
et a!.
fracture
of the

To our knowledge,
addressed
burst

et a!., in 1982,neported

tomography
laminectomy.

been progressive
and anthrodesis

were
were

indication

cent occlusion
of the spinal
canal,
and
patients,
at least 50 per cent compromise

of the fifth lumbar

vertebra.
of fractures
of the thonacolum-

little has been mentioned

about
the fifth lumbar
vertebra2424.
on one patient
who had a burst

lumbar

The

seen
on computed
tomographic
patient
had a sacral
root deficit,

regarding
burst
fractures
Even
in the many reports

fifth

was

root

have

for operation.

criteria

There
compromise

minor

chosen.

these

and

Discussion

ban spine,
involving
reported

only

was

had substantial
considerable

arthrodesis.

There

with

patients
who
root, causing

4-C).
The
remaining
five patients
had no identifiable
radiographic
evidence
of degeneration
of the lumbar
spine at subsequent
follow-up
visits. None of the patients
thought
that the pain was sufficient
to warrant
an openative

stable,
treatment

operation
would
Late
decompression

suffi-

backache

STAUFFER

In our series,
since
the burst
fractures
lordotic
area of the spine
and the patients

tients
had some
degree
of radiculan
pain in the distnibution of the fifth lumbar
on the first sacnal
nerve.
These
were the same two patients
who had lumbar
motor-root
deficits.
Neither
cient to warrant

S.

The

a conservative
regimen
seemed
at the lumbosacra!
junction.

patients

did

amount
of londosis
not progress
during

not

vertebra,
immobilization
in a cast
and provided
a good clinical
result.
deteriorate

neurologically,

on collapse
follow-up.

of the

vertebral

and

the

body

did

References
1.

Court-Brown,

2.

Denis,
817-831,

C. M.,

Francis:

The

and
three

Gertzbein,
column

S. D.: The
spine

and

management
its

significance

ofburst
in

fractures
the

of the

classification

fifth
of

lumbar
acute

vertebra.

Spine.

thoracolumbar

12: 308-312,
spinal

1987.

injuries.

Spine.

JOINT

SURGERY

1983.
THE

JOURNAL

OF

BONE

AND

8:

BURST
3.

Fredrickson,

B. E.; Yuan,

Sirg.,

1088-1094.

64-A:

4.

Holdsworth,

F. W.:

5.

Holdsworth,

F. W., and

35-B(4):
6.

R. R.; Asher,

Kaufer,
McAfee,

9.

Nykamp,

Snider,
1980.

Hayes,

of a case.

J. Bone

Osebold,

W. R.; Weinstein,
E. S.: Treatment

Daniel

Ruge

Stauffer,

and

New

E. S.: Fractures
York,Churchill

StaufTer,

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