Documentation:FIB book/Spine/Thoracolumbar Brust Fracture

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Introduction

Burst fractures are a form of compression fracture caused by high-energy axial loading damage to the spine [1][2]​. This injury occurs when the vertebra fractures in several directions, hence the name, ‘burst’ ​[2]​. Retropulsion of fragments of the posterior vertebral body into the spinal canal can also be included in the definition ​[1][3][4]​.  

The thoracolumbar area has been shown to have the highest incidence of burst fractures ​[1][5]. This transition area is the most vulnerable due to the lack of stabilization from the ribs and thoracic muscles in that region ​​[6]. In addition, the curvature of the spine shifts from the anterior concave curvature of the thoracic region to the posterior concave curvature in the lumbar region while the movement of the spine shifts from the most stable thoracic segment to the most flexible lumbar segment ​[7]​[8]. In the thoracolumbar spine, the most common fracture mechanism is the burst fracture, accounting for approximately 15% of all spinal injuries ​[9]​.  

Burst fractures can be characterized as stable or unstable. A stable burst fracture is one in which there’s no neurologic injury, the angulation of the spine is less than 20 degrees, and the amount of spinal canal compromise is less than 50 % ​​[10]. A burst fracture that exceeds these criteria is considered unstable, and can occasionally be treated with bracing alone, but generally require surgery ​[10]​.  

The dynamic contact caused by burst fracture between the vertebral column and the spinal cord, often accompanied by failure or loss of bone and/or disc integrity, is the primary cause of traumatic spinal cord injury (SCI). The most frequent forms of vertebral fractures associated with SCI are burst fractures and fracture-dislocations, which together account for 30–40% of all vertebral fractures ​[11]​.

In a study conducted by Bensch et al., the most common burst fracture location observed of 152 patients was found to be in the thoracolumbar junction between levels T5 and T8 [1]​. Among all patients, the most common fracture causes were falls, traffic collisions, and sports ​[1]​. Neurological deficit was found to be highest among the cervical spine burst fracture patients and lowest among the thoracolumbar junction fracture patients, regardless of the type of accident ​[1]​.

Mechanism of Burst Fracture

Conventional Biomechanism Research

A burst fracture is often the result of a traumatic incident that causes bone compression, such as a vehicle accident or a hard fall ​[1][12][13]. The vertebral body shatters with sufficient energy to separate the bone pieces and jeopardize the vertebra's capacity to support the spine ​[1][2][4]. Bone fragments may also be dislodged into the spinal canal or foramen (exit path for a single nerve root), resulting in nerve compression and impaired function resulting in a high likelihood of neurological damage [1][2]​[3]​.  

In an experimental study in 1960, Roaf exposed a spinal column to compression stress, which resulted in the expulsion of the vertebral body's marrow ​​[14]. It was observed that when the pressure within the nucleus of the intervertebral disk rose, the endplates of the vertebrae deformed to be larger and eventually shattered ​[14]. This caused the nucleus material to infiltrate the vertebral body, increasing the pressure and causing the vertebral body to burst ​[14]​. One limitation of Roaf’s study was that forces to vertebral bodies were applied at a slow rate for simpler analysis, however, in reality, these types of fractures typically occur in fast, high-energy impacts [14].  

Similar findings and experimental force thresholds have been made by Perey and Willen in 1957 and 1984, respectively [15][16]​. Perey showed in experimental studies that fracture of the L1 vertebral endplates occurs when a static force averaging 7.6 kN is applied and that multiple fractures occur when a dynamic force of approximately 10-13.4 kN is applied [15][16] ​. In cadaveric experiments of the L1 vertebra from young subjects, under 40 years of age, Willen determined a dynamic axial loading of approximately 8 kN can cause initial fracture of the vertebrae while loading of 11 kN can result in crush fractures with the intrusion of the spinal canal [15]​​. Willen also observed various fracture patterns including vertebral disc rupture or dislocation, occlusion of the spinal canal, and pedicular or laminar fracture ​[15]. One significant limitation of cadaveric experiments described by Perey was the changes in the mechanical properties of the bone structure postmortem resulting in differing mechanical responses to loading [16]​​.  

In 1977, Kazarian and Graves studied the strength characteristics of isolated spinal segments in relation to strain rate due to mechanical loading[17]. Twelve thoracic vertebrae were subjected to compressive axial loading at 2100 inches/min, 21 inches/min, and 0.21 inches/min ​​[17]. It was experimentally observed that the ultimate load of the vertebral body was dependent on the strain rate and the location from which the spinal segment originated ​​[17]. Specifically, at a higher strain rate, a greater ultimate load was observed and the more inferior the vertebral specimen, the less likely the specimen was to fracture in experiments [17]​. Since this study was conducted on ex vivo specimen segments, the authors acknowledged the biomechanical effects in vivo due to the prestressed system through the presence of active muscles may differ from the results observed in these experiments ​[17]​.

Several reports based on clinical observations have postulated that axial burst fractures, which displace bone fragments into the spinal canal, are caused by internal pressure leading to burst fracture [3]​. The magnitude of vertebral bursting may depend on the rate of pressurization of the body, which may be related to the rate of load application ​[3]. The purpose of the study by Tran et al. in 1995 was to determine whether for the same impact direction and total energy delivered, occlusion of the spinal canal postvertebral fracture was related to the rate at which the impact was delivered ​[3]. The experimental results of this study produced compressive fractures with little spinal canal occlusion at the low loading rate of 400 milliseconds to peak load while burst fractures were observed with the significant intrusion of the spinal canal at the high loading rate of 20 milliseconds to peak load [3]​. This indicated that there is a greater likelihood of neurologic injury in fractures due to high loading rates compared to low loading rates ​​[3]. Additionally, it was shown that for comparable impact energy and loading direction, two unique fracture patterns can be produced [3]​. One limitation observed from this study is the use of calf lumbar spine specimens, however, this experiment did provide insights into the effect of loading rate on fracture pattern [3].  

Finite Element Models

Recently, researchers made use of finite element models to investigate the mechanisms of burst fracture as this approach alleviates limitations and ethical concerns surrounding animal and cadaver testing [18]. Guo and Li created a spinal finite element model of the thoracolumbar joint (T12-L1) segment and simulated the drop tower test with low (13J), intermediate (30J), and high energy (36J) ​[19]​. Intermediate and high energy impact caused burst fracture, propagating from the rear-end of the vertebral foramen along the circumferential direction ​[19]​. Also, the burst fracture happened faster and more severely under high energy impact and the cancellous bone failed faster than the cortical bone, which carried most of the pressure ​[19]​. Diotalevi et al. further investigated burst fracture damage to the spinal cord with a thoracolumbar joint (T11-L1) segment. They found that higher fragment retropulsion velocity was related to higher severity of spinal cord injury ​[20].

Future Research

A topic of controversy among researchers that will require further research has been the association between neurologic deficit and the final resting position of a bone fragment after injury ​​[13]. Biomechanical investigations have shown that the eventual position of bone fragments observed in post-trauma imaging may not correspond to the maximal temporary canal occlusion and cord compression that occurs during the dynamic event ​[4][13][21][22]. In a study by Vaccaro et al, it was shown that the post-injury sagittal-to-transverse diameter ratio of the canal, but not the individual canal diameters, was predictive of neurological damage in individuals with thoracolumbar burst fractures ​[23]. Meves and Avanzi later investigated whether the association between spinal canal compromise or injury severity was perhaps more predictive of neurologic deficit ​​[13]. The results of their study also suggested a greater statistical significance between the narrowing of the spinal column and the neurologic deficit of patients ​[13]​.

A future topic of research proposed by Tran et al. was the potential for determining a “cut off loading rate” where any loading rate less than this would result in no spinal canal obstruction ​[3]​. There currently lacks an exact value or range of force that can indicate the occurrence of a thoracolumbar burst fracture. Future research could investigate such a range, starting from a smaller population, like 50th percentile male, to a larger population, covering more people. Another research interest discussed by Tran et al. was the effect of governing factors such as disc nucleus, fat, and marrow viscosity relating to the pressurization of the vertebrae causing fracture ​[3]. Building upon this hypothesis, Tran et al. also speculated whether changes in fat and marrow ratios due to age would alter the viscosity and therefore vertebrae fracture due to pressurization ​[3]​.  

Common limitations of finite element studies is they only looked at the thoracolumbar joint region, which may ignore the influence of other structures on the burst fracture mechanism. As such, validation and verification of finite element models is challenging. Further study could model a longer region of spine to study burst fracture and the interaction between bones and other components. Additionally, future development of finite element models to simulate complex interactions including large deformations and mechanical interactions resulting from fluid structure interactions of the spinal column and spinal cord could improve our understanding of this injury mechanism [18].

Diagnosis Methods

Multidetector Computed Tomography

Multidetector computed tomography (MDCT) is commonly used in vertebrae trauma diagnosis due to its high sensitivity, high specificity, and time-effectiveness [9]​[24]​. This technology allows the observation of bony materials in the targeted area from different planes and burst fractures in the spine can be identified and located by MDCT results ​​[9]. This assessment method is also non-invasive.

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) is another non-invasive tool used to assess the consequences of spinal burst fracture, emphasizing on the soft tissue aspect ​[25]​. It can provide the image of intervertebral disc, spinal ligament, and spinal cord ​[26]​. For instance, burst fracture in the spine could further lead to posterior ligamentous complex (PLC) injuries in the thoracic and lumbar spine, which would influence the severity of vertebral injury ​[27]. MRI outperforms computed topography (CT) in the diagnosis of PLC and the combination of MRI and CT is recommended [28]​[29]. Along with CT scans, MRI results help the surgeons to better understand the injury and make surgical decisions [30]​​.

Severity of Burst Fracture

There are several categorizating approaches for describing and guiding the treatment of burst fractures, including those of Denis, Magerl, and the Spine Trauma Study Group [31]​[32][33][34]​. The stable burst fracture was categorized by Holdsworth to describe a fracture where the following anatomy remained intact: the posterior ligament complex, consisting of the interspinous and supraspinous ligaments, the capsules of the lateral joints, and the ligamentum flavum. Whitesides identified the unstable burst fracture by noting that the spine is composed of two weight-bearing columns, an anterior and a posterior column. Complete destruction of the posterior column led to an unstable burst fracture ​[35]​. Whitesides identified this type of burst fracture as the most frequent reason for neural damage in the thoracolumbar area ​[35]​. One recent classification used clinically is the AO Spine Classification system as introduced below.

More recently, computed tomography (CT) imaging and biomechanical study of the spinal column have been used to better understand the mechanism of burst fractures and visualize the resulting damage ​[15][31][36][37][38]​. The use of CT imaging helps clinicians determine the resulting spinal stability, the likelihood of neurological involvement, and the best course of treatment by classifying column injuries according to the degree of disruption of the anterior and posterior vertebral elements, spinal ligaments, and intervertebral discs. Jelsma et al. proposed that the posterior-superior corner of the vertebral body is often the source of the bone fragment that might impinge on the spinal cord in wedge and burst fractures ​[37]​.  

AO Spine Classification System

AO Spine Classification system was developed for clinical diagnosis mainly based on the previously existing Magerl classification system ​[39]​. In this relatively new system, fractures are categorized into three types with different mechanisms, and type A fractures are caused by axial loading on anterior elements ​[39]. Burst fracture is listed in the thoracolumbar region and classified as Type A3 (incomplete) and Type A4 (complete), which are the two most severe Type A injuries ​[40]. The flow chart shown in Figure 1 describes the diagnosis process. However, Spiegl et al. proposed that the inclusion of more factors, like intervertebral disc condition, could further improve the ability of the AO Spine Classification system to guide treatment for surgeons ​​[41].

Figure 1. AO Spine injury classification flow chart for thoracolumbar region [40].

AIS Score

Abbreviated Injury Scale (AIS) is a widely used index indicating the severity of injury. According to the AIS dictionary updated in 2008, AIS scores associated with thoracic and lumbar spine injuries are summarized in Table 1 ​[42]​. Burst fracture is only specified when there is no cord injury involved and the AIS score ranges from 2-3, depending on the extent of compression in the vertebrae. Once the spinal cord is involved with some kind of spinal fracture, the type of fracture does not change the AIS score. Where there is cord contusion with fracture, AIS score ranges from 3-5, depending on the nerve function. If the injury involves cord laceration, AIS score of the injury is 5.  

Table 1: AIS scores for thoracic and lumbar spine (T1-L5) injuries related to fracture [42]. NFS = not further specified
Injury description AIS Score
Burst fracture (NFS) without cord injury 2
minor compression (loss of anterior height ≤20%) 2
major compression (loss of anterior height >20%) 3
Cord contusion with fracture  
with transient neurological sign 3
with incomplete cord syndrome 4
with complete cord syndrome 5
Cord laceration with fracture 5

Prognosis

The outcome of a spinal burst fracture can vary depending on the location of the burst fracture and whether it is considered stable or unstable. The consequences of a burst fracture in the spine may lead to nerve injury and severe pain.  If the spinal cord is injured, symptoms of a burst fracture, specifically in the thoracolumbar region, include moderate to severe back pain made worse by movement, numbness, tingling, and weakness, as well as an inability to correctly empty the bowel or bladder ​[1][10]​.  

Current treatment varies but has a universal focus on limiting neurological damage, rehabilitation from the start, restabilizing and ensuring fusion of the spine, and allowing the patient to return to their daily lives [8]​. Treatment is chosen by the doctor, depending on the stability of the injury, including whether there is neurological damage and the angle of the spine after injury ​[10]​. Mechanical stability refers to the integrity of the posterior ligamentous complex and whether the angulation of the spine is more than 20 degrees [8] [10]​. The neurological status is referred to the ASIA (American Spinal Injury Association), a scale from A to E, with A meaning complete neurological deficit, and E meaning no neurological compromise ​[8]​. For instances of severe neurological damage (level A), surgery will only be considered if there is an indication of a change in the neurological status, if not a focus will be put on bed rest and rehabilitation ​[8].

Non-Surgical Treatments

Type A, compression fractures not requiring surgery can be treated with bed rest, braces, and physiotherapy ​[8]​. However, there are varying opinions on the best course of non-surgical treatment timelines for thoracolumbar burst fractures ​[8]. For compression fractures without neurological deficits, bed rest typically ranges from 8-12 weeks, however, some clinicians suggest shorter bed rest periods of 4-6 weeks [8]. Bracing and physical therapy is often required to regain strength and full mobility ​[8]​.

In instances where only a body cast is needed, there is a good probability of full recovery ​[43]. In a study conducted by Rava et al., 64 patients who had suffered a thoracolumbar burst spinal fracture were followed through treatment with body casts and showed positive clinical results of recovery ​[43]​. After a two-year follow-up, which included bracing, orthosis and physical therapy, the mean result of ODI (Oswestry Disability Index) was 10.34 % and Short Form 36 Health Survey was above 80% in all areas including vitality, physical functioning, bodily pain, general health perceptions, physical functions, emotional functions, and mental health ​[43]. The ODI scores the level of function in daily activities, with 0-20% indicating minimal disability ​[44]​. The SF36 is a standard set of 36 questions that are centered around determining the patient’s quality of life through physical and mental health scores ​[45]​.  

Surgical Treatments

In instances where there is neurological damage and mechanical instability, surgery will be performed at the earliest time possible, allowing for a greater chance of a full recovery ​[10]​. Surgery can be performed either anteriorly or posteriorly to stabilize the spine with screws and rods ​[10]. If fragments of the spine are pressing on the spinal cord, they can either be moved around in a posterior approach or removed and replaced with a bone strut in an anterior approach [10]​. Following surgery patients can expect to wear body casts and follow a similar procedure as those who receive a non-surgical treatment ​[10]​. In instances where there was severe neurological damage, recovery depends heavily on what time the surgery was performed and how severe the initial injury was ​[10]​. Continued physical therapy will be suggested in hopes of the level of injury not worsening ​[10]​. The effects of injuries with neurological damage are dependent on where the injury occurred.  

Conclusion

Burst fractures of the thoracolumbar region typically occur in young individuals often due to vehicle accidents or high-energy impact falls. While much research has been conducted over the past half a century into the injury mechanism of burst fractures, there is still uncertainty regarding injury threshold criteria, the level of associated neurological deficit, and severity classification systems. In recent years, advanced technologies such as finite element analysis have been utilized by researchers to work to better understand this injury mechanism through simulations.

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 Bensch, Frank V.; Koivikko, Mika P.; Kiuru, Martti J.; Koskinen, Seppo K. (2006). "The incidence and distribution of burst fractures". Emergency Radiology. 12 (3): 124–129. doi:10.1007/S0010140-005-0457-5.
  2. ↑ 2.0 2.1 2.2 2.3 Holdsworth, F. W. (1963). "Fractures, Dislocations, and Fracture-Dislocations of the Spine". The Journal of Bone and Joint Surgery. British volume. 45-B (1): 6–20. doi:10.1302/0301-620X.45B1.6.
  3. ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 Tran, N. T.; Watson, N. A.; Tencer, A. F.; Ching, R. P.; Anderson, P. A. (1995). "Mechanism of the burst fracture in the thoracolumbar spine: the effect of loading rate". Spine. 20 (18): 1984–1988. doi:10.1097/00007632-199509150-00004.
  4. ↑ 4.0 4.1 4.2 Wilcox, Ruth K; Boerger, Thomas O; Allen, David J; Barton, David C; Limb, David; Dickson, Robert A; Hall, Richard M (2003). "A Dynamic Study of Thoracolumbar Burst Fractures". The Journal of Bone & Joint Surgery. 85 (11): 2184–2189. doi:10.2106/00004623-200311000-00020.
  5. ↑ Devilee, R.; Sanders, R.; de Lange, S. (1995). "Treatment of fractures and dislocations of the thoracic and lumbar spine by fusion and Harrington instrumentation". Archives of Orthopaedic and Trauma Surgery. 114 (2): 100–102. doi:10.1007/BF00422835.
  6. ↑ de Assunção Filho, Carlos Alberto Almeida; Veloso, Rafael Parizzi; Meves, Robert; Bergamaschi, João Paulo; Caffaro, Maria Fernanda Silber; Avanzi, Osmar (2012). "Thoracolumbar Burst Fracture: Radiographic Evaluation on Differences Between Magerl's A and B". Acta ortopedica brasileira. 20 (4): 240–242. doi:10.1590/S1413-78522012000400010.
  7. ↑ Drake, Richard L.; Vogl, Wayne; Mitchell, Adam W. M.; Gray, Henry (2015). Gray’s Anatomy for Students, 3rd Edition. ISBN 9780702051319.
  8. ↑ 8.0 8.1 8.2 8.3 8.4 8.5 8.6 8.7 8.8 Cahueque, Mario; Cobar, Andrés; Zuñiga, Carlos; Caldera, Gustavo (Dec. 2016). "Management of burst fractures in the thoracolumbar spine". Journal of Orthopaedics. 13 (4): 278–281. doi:10.1016/J.JOR.2016.06.007. Check date values in: |date= (help)
  9. ↑ 9.0 9.1 9.2 Bensch, Frank V.; Koivikko, Mika P.; Kiuru, Martti J.; Koskinen, Seppo K. (2006). "The incidence and distribution of burst fractures". Emergency Radiology. 12 (3): 124–129. doi:10.1007/S0010140-005-0457-5.
  10. ↑ 10.00 10.01 10.02 10.03 10.04 10.05 10.06 10.07 10.08 10.09 10.10 Zdeblick, Thomas (Mar.4, 2016). "Burst Fractures: Treatment and Recovery". Spine Universe. Check date values in: |date= (help)
  11. ↑ Sekhon, L.H.; Fehlings, M.G. (2001). "Epidemiology, demographics, and pathophysiology of acute spinal cord injury". Spine. 26 (24S): S2–S12. doi:10.1097/00007632-200112151-00002. ISSN 0362-2436.
  12. ↑ Zdeblick, Thomas (Mar 14, 2019). "Burst Fractures: Defined and Diagnosed". Spine Universe.
  13. ↑ 13.0 13.1 13.2 13.3 13.4 Meves, Robert; Avanzi, Osmar (2006). "Correlation among canal compromise, neurologic deficit, and injury severity in thoracolumbar burst fractures". Spine. 31 (18): 2137–2141. doi:10.1097/01.BRS.0000231730.34754.9E.
  14. ↑ 14.0 14.1 14.2 14.3 Roaf, Robert (1960). "A Study of the Mechanics of Spinal Injuries". The Journal of Bone and Joint Surgery. British volume. 42-B (4): 810–823. doi:10.1302/0301-620X.42B4.810.
  15. ↑ 15.0 15.1 15.2 15.3 15.4 Willen, J; Lindahl, S; Irstam, L; Aldman, B; Nordwall, A (1984). "The Thoracolumbar Crush Fracture An Experimental Study on Instant Axial Dynamic Loading". Spine. 9 (6): 624–631. doi:10.1097/00007632-198409000-00014. ISSN 0362-2436.
  16. ↑ 16.0 16.1 16.2 Perey, Olof (1957). "Fracture of the vertebral end-plate in the lumbar spine; an experimental biochemical investigation". Acta Orthopaedica Scandinavica. 25: 1–101. doi:10.3109/ORT.1957.28.SUPPL-25.01.
  17. ↑ 17.0 17.1 17.2 17.3 17.4 Kazarian, L.; Graves, G.A. (1977). "Compressive strength characteristics of the human vertebral centrum". Spine. 2 (1): 1–14. doi:10.1097/00007632-197703000-00001. ISSN 0362-2436.
  18. ↑ 18.0 18.1 Persson, Cecilia; Summers, Jon L.; Hall, Richard M. (2011). "Modelling of Spinal Cord Biomechanics: In Vitro and Computational Approaches". Studies in Mechanobiology, Tissue Engineering and Biomaterials. 3: 181–201. doi:10.1007/8415_2010_38.
  19. ↑ 19.0 19.1 19.2 Guo, Li-Xin; Li, Wu-Jie. "A biomechanical investigation of thoracolumbar burst fracture under vertical impact loads using finite element method". Clinical Biomechanics. 68: 29–36. doi:10.1016/j.clinbiomech.2019.05.018.
  20. ↑ Diotalevi, Lucien; Bailly, Nicolas; Wagnac, Éric; Mac-Thiong, Jean-Marc; Goulet, Julien; Petit, Yvan (2020). "Dynamics of spinal cord compression with different patterns of thoracolumbar burst fractures: Numerical simulations using finite element modelling". Clinical Biomechanics. 72: 186–194. doi:10.1016/j.clinbiomech.2019.12.023. ISSN 0268-0033.
  21. ↑ Panjabi, MM; Kifune, M; Wen, L; Arand, M; Oxland, TR; Lin, R; Yoon, WS; Vasavada, A (1995). "Dynamic canal encroachment during thoracolumbar burst". Journal of Spinal Disorders. 8 (1): 39–48. doi:10.1097/00002517-199502000-00006. eISSN 1531-2305. ISSN 1531-2305 0895-0385, 1531-2305 Check |issn= value (help).
  22. ↑ Wilcox, RK; Boerger, TO; Hall, RM; Barton, DC; Limb, D; Dickson, RA (2002). "Measurement of canal occlusion during the thoracolumbar burst fracture process". Journal of Biomechanics. 35 (3): 381–384. doi:10.1016/S0021-9290(01)00180-4. ISSN 0021-9290.
  23. ↑ Vaccaro, Alexander R.; Nachwalter, Richard S.; Klein, Gregg R.; Sewards, J. Milo; Albert, Todd J.; Garfin, Steven R. (2001). "The significance of thoracolumbar spinal canal size in spinal cord injury patients". Spine. 26 (4): 371–376. doi:10.1097/00007632-200102150-00013. ISSN 0362-2436.
  24. ↑ Raza, Mushahid; Elkhodair, Samer; Zaheer, Asif; Yousaf, Sohail. "Safe cervical spine clearance in adult obtunded blunt trauma patients on the basis of a normal multidetector CT scan—A meta-analysis and cohort study". Injury. 44 (11): 1589–1595. doi:10.1016/J.INJURY.2013.06.005.
  25. ↑ Pizones, Javier; Castillo, Ernesto (2013). "Assessment of acute thoracolumbar fractures: Challenges in multidetector computed tomography and added". Seminars in Musculoskeletal Radiology. 17 (4): 389–395. doi:10.1055/S-0033-1356468/ID/JR00751-46.
  26. ↑ Vaccaro, Alexander R.; Falatyn, Stephen P.; Flanders, Adam E.; Balderston, Richard A.; Northrup, Bruce E.; Cotler, Jerome M. (1999). "Magnetic resonance evaluation of the intervertebral disc, spinal ligaments, and spinal cord before and after closed traction reduction of cervical spine dislocations". Spine. 24 (12): 1210–1217. doi:10.1097/00007632-199906150-00007.
  27. ↑ Machino, Masaaki; Yukawa, Yasutsugu; Ito, Keigo; Kanbara, Shunsuke; Morita, Daigo; Kato, Fumihiko (2013). "Posterior Ligamentous Complex Injuries Are Related to Fracture Severity and Neurological Damage in Patients with Acute Thoracic and Lumbar Burst Fractures". Yonsei Medical Journal. 54 (4): 1020. doi:10.3349/ymj.2013.54.4.1020. ISSN 0513-5796.
  28. ↑ Aly, Mohamed M.; Al-Shoaibi, Abdulbaset M.; Aljuzair, Ali H.; Issa, Tariq Ziad; Vaccaro, Alexander R. (2022). "A Proposal for a Standardized Imaging Algorithm to Improve the Accuracy and Reliability for the Diagnosis of Thoracolumbar Posterior Ligamentous Complex Injury in Computed Tomography and Magnetic Resonance Imaging". Global Spine Journal. doi:10.1177/21925682221129220.
  29. ↑ Lee, Joon Y.; Vaccaro, Alexander R.; Schweitzer, Karl M.; Lim, Moe R.; Baron, Eli M.; Rampersaud, Raja; Öner, F.C.; ...; Harris, Mitchel B. (2007). "Assessment of injury to the thoracolumbar posterior ligamentous complex in the setting of normal-appearing plain". The Spine Journal. 7 (4): 422–427. doi:10.1016/j.spinee.2006.07.014. ISSN 1529-9430.CS1 maint: numeric names: authors list (link)
  30. ↑ Wood, Kirkham B.; Li, Weishi; Lebl, Darren S.; Ploumis, Avraam (2014). "Management of thoracolumbar spine fractures". The Spine Journal. 14 (1): 145–164. doi:10.1016/j.spinee.2012.10.041. ISSN 1529-9430.
  31. ↑ 31.0 31.1 Denis, Francis (1983). "The three column spine and its significance in the classification of acute thoracolumbar spinal injuries". Spine. 8 (8): 817–831. doi:10.1097/00007632-198311000-00003. ISSN 0362-2436.
  32. ↑ Magerl, F.; Aebi, M.; Gertzbein, S.D.; Harms, J.; Nazarian, S. (1994). "A comprehensive classification of thoracic and lumbar injuries". European Spine Journal. 3 (4): 184–201. doi:10.1007/BF02221591.
  33. ↑ Lee, Joon Y.; Vaccaro, Alexander R.; Lim, Moe R.; Öner, F. C.; Hulbert, R. John; Hedlund, Rune; Fehlings, Michael G.; ...; Baron, Eli M. (2005). "Thoracolumbar injury classification and severity score: A new paradigm for the treatment of thoracolumbar spine trauma". Journal of Orthopaedic Science. 10 (6): 671–675. doi:10.1007/S00776-005-0956-Y.CS1 maint: numeric names: authors list (link)
  34. ↑ Aebi, Max (2010). "Classification of thoracolumbar fractures and dislocations". European Spine Journal. 19 (S1): S2–S7. doi:10.1007/S00586-009-1114-6.
  35. ↑ 35.0 35.1 Whitesides, Thomas E. (1977). "Traumatic kyphosis of the thoracolumbar spine". Clinical orthopaedics and related research. 128: 78–92. doi:10.1097/00003086-197710000-00011.
  36. ↑ Denis, Francis (1984). "Spinal instability as defined by the three-column spine concept in acute spinal trauma". Clinical orthopaedics and related research. 189: 65–76. doi:10.1097/00003086-198410000-00008.
  37. ↑ 37.0 37.1 Jelsma, Richard K.; Kirsch, Peter T.; Rice, John F.; Jelsma, Lawrence F. (1982). "The radiographic description of thoracolumbar fractures". Surgical Neurology. 18 (4): 230–236. doi:10.1016/0090-3019(82)90328-7.
  38. ↑ McAfee, PC; Yuan, HA; Fredrickson, BE; Lubicky, JP (1983). "The value of computed tomography in thoracolumbar fractures. An analysis of one hundred consecutive cases and a new classification". The Journal of bone and joint surgery. American volume. 65 (4): 461–473. ISSN 0021-9355.
  39. ↑ 39.0 39.1 Reinhold, Maximilian; Audigé, Laurent; Schnake, Klaus John; Bellabarba, Carlo; Dai, Li-Yang; Oner, F. Cumhur (2013). "AO spine injury classification system: a revision proposal for the thoracic and lumbar spine". European Spine Journal. 22 (10): 2184–2201. doi:10.1007/s00586-013-2738-0.
  40. ↑ 40.0 40.1 "AO Spine Thoracolumbar Injury Classification System Pocket Card" (PDF). AO Foundation. Retrieved 06/11/2022. Check date values in: |access-date= (help)
  41. ↑ Spiegl, U. J.; Josten, C.; Devitt, B.M.; Heyde, C.E. (2017). "Incomplete burst fractures of the thoracolumbar spine: a review of literature". European Spine Journal. 26 (12): 3187–3198. doi:10.1007/s00586-017-5126-3.
  42. ↑ 42.0 42.1 Gennarelli, Thomas A.; Wodzin, Elaine (eds.). "Abbreviated Injury Scale 2005 Update 2008" (PDF). Retrieved 06/11/2022. Check date values in: |access-date= (help)
  43. ↑ 43.0 43.1 43.2 Rava, Alessandro; Fusini, Federico; Cinnella, Pasquale; Massè, Alessandro; Girardo, Massimo (2019). "Is cast an option in the treatment of thoracolumbar vertebral fractures?". Journal of Craniovertebral Junction & Spine. 10 (1): 51–56. doi:10.4103/JCVJS.JCVJS_8_19.
  44. ↑ Mehra, A; Baker, D; Disney, S; Pynsent, PB (2008). "Oswestry Disability Index Scoring Made Easy". The Annals of The Royal College of Surgeons of England. 90 (6): 497–499. doi:10.1308/003588408X300984.
  45. ↑ Ware, J. E. (2000). "SF-36 Health Survey Update". Spine. 25 (24): 3130–3139. doi:10.1097/00007632-200012150-00008. ISSN 0362-2436.
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