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Conservative Treatment of Burst Fractures of the Thoracolumbar and Lumbar Spine

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Conservative Treatment of Burst Fractures of the Thoracolumbar and Lumbar Spine Paraplegia 31 (1993) 58-67 © 1993 International Medical Society of Paraplegia Conservative treatment of burst fractures of the thoracolumbar and lumbar spine H Kinoshita MD,! Y Nagata MD,! H Ueda MD,2 K Kishi MD3 2 1 Director, Kosei Hospital, Hiroshima, Japan; Chugoku Rosai Hospital, Hiroshima, 3 Japan; Department of Orthopaedic Surgery, Hiroshima University School of Medicine, Hiroshima, Japan. Twenty-three patients with burst fracture of the thoracolumbar and lumbar spine were treated nonoperatively. Among these 23 patients, 13 had a neurological deficit and 10 patients did not have such a deficit. Union of burst fractures occurred with conservative treatment in 22 out of 23 patients, but late operation was necessary in only one patient, who had an increasing kyphotic deformation. Of the 13 patients with neurological deficit, 8 showed full recovery and none had neurological deterioration. It was observed by CT scans that the narrowing of the spinal canals was progressively relieved by natural remodelling of the fragments retropulsed into the spinal canal. Keywords: burst fracture of thoracolumbar and lumbar spine; conservative treatment; follow up study; remodelling of fragments. Patients and methods were observed. Rectal and perianal sensa­ tion, voluntary anal sphincter control, anal By CT scans, 23 patients with a burst wink, urinary sensation and voluntary void­ fracture of the thoracolumbar or lumbar ing were periodically observed. Regarding spine were observed from 1981 to 1988 with motor paralysis, with the use of Daniels' vertebral bone fragments retropulsed into muscle testing technique of manual exam­ the spinal canal. The course of bone injuries ination,l the functions of all the muscle of 10 cases without neurological deficit was groups controlling the hip, knee, ankle, and observed by xray examinations and CT toes were evaluated and expressed as 5 scans. A long term follow up was made (normal), 4 (good), 3 (fair), 2 (poor), 1 using CT scans on the clinical course of ( trace), or O. paralysis, on the morphological changes of Concerning the bony injury, the heights the vertebral bodies and on the spinal canals of the anterior and posterior aspect of the of 13 patients with a neurological deficit. vertebral bodies were measured using con­ The series consisted of 11 males and 2 ventional lateral view xray films, and the females in the age range 15-63 years (aver­ kyphotic angle was calculated by Cobb's age 42.3 years). Of those 13 patients, 12 fell method. from a height and one was struck by a heavy The area of the spinal canal and the bone object. fragments within the spinal canal were The fractured vertebral bodies were T12 measured with a planimeter, and the degree in 2 patients, L1 in 6, L2 in 2, L3 in 1 and L4 of canal obstruction was expressed as a in 2 patients. percentage. The patients were treated by being flat on their bed for 8-10 weeks, and then being gradually mobilized while the spine was Results supported by a brace. Sensory loss and notably sacral sparing Sensory changes In all of the patients, varying levels of Correspondence: 86-2 Ichiida, Kurose-cho, Kamo-gun, anaesthesia, hypoaesthesia, and paraesthe­ Hiroshima-ken 724-06, Japan. sia were observed below the inguinal region. Paraplegia 31 (1993) 58-67 Thoracolumbar and lumbar burst fractures 59 At follow up, full recovery of sensory sacral sparin�, within from 3 days to 4� power was observed in 3 patients, with months after InJury,. and voluntary urination partial recovery in 9. H ypoaesthesia of S 1-2 became possible. During the follow up, in patient 3 recovered, but there was no patient 4 continued to complain of urgency change in anaesthesia of S3, 4, 5. and incontinence, patient 5 of dysuria, and Hypoaesthesia below L4 in the left leg of patient 6 of stress incontinence (Table III). patient 11 recovered, but there was no Complete paralysis of bladder function per­ change in anaesthesia below L4 of right leg sisted in only the following patient:- (Table I). Patient 3 is a 38 year old male who fell from a height sustaining a burst fracture of L1 vertebral body. At the time of the initial examination, hypoaesthesia of Sl-2 seg­ Motor paralysis There was no motor paralysis in patients 7,9 ment, anaesthesia of S3-5, and toe weak­ and 12. Complete recovery from motor ness were observed. The Achilles tendon araly is was observed during the follow up reflex and anal wink were absent. The p � sphincters were patulous and urinary sensa­ III patIents 1, 3, 5, 10 and 13 with muscle strength restored to the normal level. tion was absent. Motor function was com­ In patients 2, 4, 6 and 8 motor power pletely restored 3 months later, and he controllIng. the foot has been partially re­ could stand on his tiptoes. At the time of stored, but as toe motion is impaired, these follow up made 6� years later, the Achilles patients are walking with the use of one tendon reflex was restored, but the anal cane. In patient II, motor paralysis of the reflex was completely absent and recovery right knee, ankle and toes did not improve, from bladder and bowel paralysis did not but paralysis of the left knee and ankle occur. The kyphotic angle which was 10° at improved and that patient has returned to the time of initial examination was 8° 5 work, walking with a right leg brace and one months later. Thereafter there was no cane (Table I). change in the kyphotic angle nor in the Recovery of neurological function was height of the vertebral body. He complains evaluated with the use of Frankel's scale of slight back pain, but no medication is (Table II). 2 One patient improved from necessary. This patient is now working in a grade C to grade D, and 5 from grade D to steel works. grade E. In spite of the recovery made in mot<?r and sensory functions in 4 patients, the Improvement was not sufficient to ad­ Bone injury union vance into the next grade. In all of the patients except one, bony Muscles innervated by the spinal cord of the crushed vertebral body was com­ segment found at the time of the initial pleted within 4 months and the spinal examination, with paraesthesiae or hypo­ column became stable. The kyphotic angle of 13 patients with a aesthesia as sensory disorders all recovered. neu ological deficit averaged 12.4° (0-30°) Of those whose muscle strength was 0 at the � at tIme of the initial examination, and was time of the initial examination, only patient 3.2° during bed rest. It was 6.6° with the 2 showed recovery, and patients 4,8, and 11 commencement of mobilisation with a did not show recovery. Recovery of motor brace, 9.2° 6 months thereafter, and 10.4° function was observed up to the sixth month one year later. No change was observed after injury; no significant recovery was thereafter. observed after 6 months. Bony fragments which had retropulsed into the spinal canal occupied 55% -29.2% of the spinal canal. Bladder paralysis No correlation could be demonstrated At the time of the initial examination between the degree of spinal canal com­ ur�nary retention was observed in 7 patients: promise as measured by CT scans and the unnary sensation was restored in 6 with resulting neurological disturbance. 0\ 0 ;:,:" c ;:s-"" Table I Degree of spinal compromise and neurological function at admission and at follow up s· � Subject Age/ Site of Spinal canal Sensory loss Motor paralysis Sensory Motor recovery Back Frankel's Walking :2. Sex injury compromise at admission at admission recovery at follow up pain scale Admission Follow up R L R L 1 60/M TI2 33.9% 0% Bilateral Ankle 3 3 Full Full + D-E Below L4 Toe 2 2 Hyp 2 49/M TI2 41.2% 9.9% Bilateral below Knee 3 2 Full Knee 3 4 D-D Cane L1 parae Ankle 0 0 Ankle 1 3 L5 hyp Toe 0 0 Toe 0 3 3 38/M L11 36.0% 15.0% Bilateral Ankle 5 5 Sl-2 full Full + D-E Sl-2 hyp Toe 2 2 S3-5 no change S3-5 anae 4 43/M L1 33.6% 15.2% Bilateral below Knee 3 3 Improve Knee 4 4 D-D Cane L1 hyp Ankle 3 0 Ankle 3 0 Toe 0 0 Toe 0 0 5 15/F L1 41.3% 21.0% Bilateral below Ankle 3 3 Improve Full + D-E L1 hyp Toe 3 3 6 63/F L1 37.3% 0% Bilateral below Hip 2 2 Improve Hip 4 4 D-D Cane L5 hyp Knee 1 1 Knee 2 2 Ankle 0 1 Ankle 0 1 Toe 0 0 Toe 0 0 ;p.... {; 7 24/M L1 50.4% 7.4% Bilateral only Improve No deterioration E-E '" ", L4L5 hyp £ . ... 8 49/M L1 37.3% 0% Bilateral below Knee 3 3 Improve Knee 4 4 D-D Cane .... �..... L4 hyp Ankle 0 0 Ankle 0 0 'CO Toe 0 0 Toe 0 0 'CO 2: Vl 9 60/M L2 29.2% 10.0% R below L2 hyp Improve No deterioration + E-E 00 I L- 0-, ..... ;;,0..., -§ c[ '" "" .... ...... \0 \0 � V1 00 I 0'> -.-J Table I (cant) Subject Agel Site of Spinal canal Sensory loss Motor paralysis Sensory Motor recovery Back Frankel's Walking Sex injury compromise at admission at admission recovery at follow up pain scale Admission Follow up 10 241M L2 0% 0% R- Ankle 3 Full Full D-E L below L3 hyp Toe 2 11 45/M L3 55.0% 12.2% R below L4 anaeHip 3 3 R no change Hip 4 4 + C-D Cane L below L4 hyp Knee 0 3 L improve Knee 0 4 Orthosis Ankle 0 2 Ankle 0 4 Toe 0 2 Toe 0 4 <::>;:l 12 271M L4 49.5% 13.3% R- Improve No deterioration E-E ";:s <::> L below L4 hyp l2" 2l 13 53/M L4 46.2% 14.6% Bilateral Ankle 2 2 Improve Full + D-E Cl'" I':> Below L4 hyp Toe 1 1 ..., I':> ;=: I':>.
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