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What is the diagnosis?

This is a burst fracture of the 3rd lumbar vertebrae.  There is an inferior vertebral body fracture with a fracture plane across the posterior inferior corner with retropulsion.

What is the mechanism of injury?

Thoracolumbar spine injuries in younger patients require a significant amount of force. Thoracolumbar burst fractures are typically caused by an axial force with flexion [1]. Burst fractures are often comminuted and may disrupt both the anterior and middle columns, leading to retropulsion of the bone into the spinal cord.

• Pearl: Thoracolumbar burst fractures most commonly occur between T10 and L2 [2].

What physical exam findings are expected?

Patients will report pain over the affected vertebrae. Attempt to find the maximal point of tenderness. Perform a thorough neurovascular evaluation to evaluate for nerve injury. Given the high energy mechanism required for a lumbar burst fracture be sure to do a complete trauma assessment.

• Pearl: 30%–50% of the patients with thoracolumbar burst fractures remain neurologically intact [3].

Which imaging modalities can be used?

AP and lateral x-ray of the thoracic and lumbar spine is an appropriate initial screening test. However, they have insufficient sensitivity. A CT scan is the best test to evaluate for bony disruption [2, 4].CT is an appropriate test if the patient has a high force injury, presents with abnormal vital signs, or has neurological deficits [5]. MRI is the best test to evaluate for stability of the posterior ligamentus complex (supraspinous ligament, interspinous ligament, ligamentum flavum, and facet joint capsules), which is one of the primary determinants of fracture stability [6].

What is the management in the ED?

Management in the ED depends on the stability of the fracture. This is generally determined by the Denis three-column system (Image 2). The anterior column consists of the anterior longitudinal ligament and the anterior 2/3 of the vertebral body and annulus. The middle column comprises the posterior longitudinal ligament and the posterior 1/3 of the vertebral body and annulus. The posterior column comprises the pedicles, lamina, facets, ligamentum flavum, spinous process, and posterior ligament complex. Unstable fractures disrupt the middle column or the posterior ligament complex [7]. Depending on the stability of the fracture, the patient should be kept in spinal precautions until appropriate specialist evaluation. Unstable fractures or fractures with neurologic deficits will most likely necessitate an operation, while stable fractures can often be treated with a TLSO brace [8]. This decision should be made in conjunction with a spine specialist.

When do you consult a spine specialist?

All thoracolumbar burst fractures seen in the Emergency Room require an orthopedic or neurosurgical consultation depending on the clinician's institution.