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Spinal trauma and fracture classification

98 citationsUpdated Sep 2026

Overview

Spinal trauma encompasses fractures, dislocations, and fracture-dislocations that require immediate assessment in all multiply injured patients until proven otherwise [1]. While most injuries present without neurologic impairment, pain or tenderness from the occiput to the sacrum mandates investigation [1]. Approximately 10% to 15% of patients with severe head injuries have an associated cervical spine injury [1], and major trauma patients exhibit more complex spinal injuries with increased instability and multi-level fractures compared to non-major trauma counterparts [4]. The diagnostic workup relies on whole-body CT scans for bony assessment, while MRI is reserved for hemodynamically stable patients to visualize soft-tissue injuries, epidural bleeding, and spinal cord pathology [1]. Neurologic status is classified using the American Spinal Injury Association (ASIA) Impairment Scale, which stratifies injuries from complete (Grade A) to normal (Grade E) [1]. Incomplete injuries preserve some neurologic function below the level of injury and are associated with better outcomes than complete injuries [1].

Spinal stability is defined by the spine’s ability to maintain alignment and protect neural structures during physiologic loading [1]. Unstable injuries risk progressive deformity and neurologic compromise, often necessitating early stabilization and decompression [1]. For critically injured patients, early spinal fracture stabilization within 24 to 36 hours of injury is associated with fewer complications, shorter hospital stays, and reduced mechanical ventilation days [1]. The concept of spine damage control involves early posterior instrumentation of unstable thoracolumbar fractures in polytrauma patients, with delayed definitive surgery once physiologically stabilized [1]. Definitive management decisions are based on mechanical instability, neurologic impairment, and patient-specific factors [12]. Although spinal trauma remains a source of significant morbidity with decreased quality of life [15], standardized classification systems are essential for improving the understanding of clinical behavior and treatment decisions [2].

Specific populations and mechanisms present unique challenges. Patients with ankylosing spondylitis are at high risk for unstable spinal fractures and associated spinal cord injury, particularly in the cervical spine, even after minor injuries [10, 22]. Vertical deceleration injuries most commonly result in thoracic and lumbar spine fractures, especially at the thoracolumbar junction [21]. In near-hanging injuries, 19% of patients sustained an injury, with 5% involving cervical spine fractures, warranting liberal CT screening [39]. The incidence of multiple level cervical spine injuries was 24% in one cohort, likely reflecting increasingly elaborate investigations [14]. Pediatric thoracolumbar trauma classification currently relies primarily on adult studies, with limited high-level evidence for validity in pediatric populations [24]. Despite these complexities, the optimal surgical approach for specific thoracolumbar fractures remains a matter of controversy, warranting further clinical cohort studies to establish comprehensive protocols [168].

Anatomy & Pathophysiology

Bony Anatomy

The spine comprises 7 cervical, 12 thoracic, 5 lumbar, 5 fused sacral, and 4 or 5 fused coccygeal vertebrae [42]. Each vertebral body is a cylindrical mass of bone connected via pedicles to the posterior arch, which consists of the lamina and spinous process [42]. The spinal canal is formed anteriorly by the vertebral body, posteriorly by the lamina, and laterally by the pedicles [42]. Vertebral bodies primarily bear weight and transfer forces to the pelvis and hips, while posterior elements protect neural structures and function as a tension band [42].

The thoracic spine represents two transitional zones: from the highly mobile cervical spine into the rigid thoracic region, and then back to the more mobile lumbar spine [78]. This region is characterized by rigidity, forming a bony "cube" with the ribs and sternum that protects the heart and lungs [78]. The spinal canal is narrowest in the thoracic region [78]. Lumbar vertebral bodies are large, with a transverse diameter greater than the anterior-posterior diameter [85]. The sagittal orientation of lumbar facet joints allows flexion and extension while providing resistance to axial rotation and translation [85]. Due to the unique microarchitecture of cervical vertebrae, fractures occur much later in this region than in the thoracic or lumbar spine [46].

Spinal Cord Anatomy

Within the spinal cord, dorsal cells are primarily sensory and ventral cells are primarily motor [82]. The dorsal columns transfer vibration, deep pressure, and proprioception, while the lateral spinothalamic tract lies anterolaterally to transmit pain and temperature sensation [82]. The ventral spinothalamic tract transmits light touch, and efferent voluntary motor function is transmitted along the lateral corticospinal tracts [82]. Nerve fibers of the upper extremities are located deeper within the spinal column, with those related to the torso and lower extremities located sequentially more superficially [82].

At birth, the conus medullaris lies around the L3 level, but by adulthood it lies around the L1-L2 level [82]. Consequently, the neurologic level of the spinal cord does not necessarily correspond with the vertebral level [82]. In the cervical spine, nerve roots exit above the same-numbered pedicle, with the exception of the eighth nerve root which exits under the C7 pedicle [82]. From T1 distally, nerve roots exit the spine below the same-numbered pedicle [82].

Ligaments

The anterior longitudinal ligament is strong, thickest at the center of the vertebral body, and resists hyperextension [90]. The posterior longitudinal ligament is weaker than the anterior longitudinal ligament and extends from the occiput to the posterior sacrum [90]. It is hourglass-shaped, with wider sections located over the discs [90]. The ligamentum flavum is a strong yellow elastic ligament connecting the laminae that is constantly in tension [90]. The supraspinous ligament lies dorsal to the spinous processes and begins at C7 in continuity with the ligamentum nuchae [90]. The integrity of the posterior ligamentous complex has implications for operative versus non-operative treatment [90].

Biomechanics

Normal cervical alignment is approximately 15° of lordosis, while the thoracic spine generally ranges from 20° to 40° of kyphosis [79]. The lumbar spine has approximately 40° to 50° of lordosis [79]. Kyphotic segments (thoracic, sacral) are considered "primary" curvatures present in utero and at birth, whereas lordotic curvatures of the cervical and lumbar spine develop secondarily later in life to allow upright posture [79].

The functional spinal unit consists of two vertebrae, the disk between them, and the facet joints and their capsules [79]. Vertebral bodies bear 70% to 90% of the static axial load of the spine [79]. Facet joints support 10% to 20% of axial load in a standing, neutral alignment, but may bear up to 30% of the axial load in extension [79]. In flexion, facet joints may be burdened with up to 50% of the anterior shear load [79]. The intervertebral disk absorbs axial loads by deforming the nucleus pulposus, which redistributes forces radially to be resisted by the anulus fibrosus [79].

The high incidence of fractures at the thoracolumbar junction is due to its location at the biomechanical transition zone between the rigid thoracic rib cage and the more flexible lumbar spine [8]. The spinal canal in the thoracic spine is relatively narrow, increasing the risk of injury-associated compression and neurologic deficits [8].

Vascular Anatomy

The thoracic and lumbar levels are supplied by paired segmental arteries originating directly from the aorta [80]. The cervical spine derives its circulation primarily from the vertebral arteries, which typically enter the transverse foramen at the C6 level [80]. The vascular supply of the spinal cord is primarily from medullary branches of segmental spinal arteries that merge to feed the anterior spinal artery [80]. The anterior spinal artery is responsible for supplying approximately 80% of the vascular supply to the spinal cord [80].

The arteria medullaris magna (AMM), also known as the artery of Adamkiewicz, typically arises on the left side between the T8 and L1 level [80]. The AMM is the largest anterior segmental artery and is the primary blood supply to the lumbosacral spinal cord [87]. Injury to the AMM can result in spinal cord infarction [87]. The blood supply to the spinal cord is poorest at T4-T9, which is considered the critical vascular zone where interference with circulation is most likely to result in paraplegia [83].

Pathophysiology of Spinal Cord Injury

Spinal cord injury comprises compression, distraction, and shearing forces exerted directly on the spinal cord [26]. Trauma to the spinal cord causes dysfunction with nonprogressive loss of sensory and motor function distal to the injury [16]. The leading causes of spinal cord injury are motor vehicle accidents, gunshot wounds, falls, sports injuries, and water injuries [16].

Tetraplegia refers to loss or impairment of motor or sensory function in the cervical segments of the spinal cord with resulting impairment in the arms, trunk, legs, and pelvic organs [16]. Paraplegia refers to loss or impairment of motor or sensory function in the thoracic, lumbar, or sacral segments of the spinal cord [16]. A complete injury is defined as an injury with no spared motor or sensory function in the lowest sacral segments, while an incomplete injury is defined as an injury with partial preservation of sensory or motor function below the neurologic level, including the lowest sacral segments [16]. The diagnosis of complete spinal cord injury cannot be made until the period of spinal shock is over, as evidenced by the return of the bulbocavernosus reflex [16]. Patients with complete spinal cord injury who have recovered from spinal shock have a negligible chance for any useful motor return [16].

Anterior cord syndrome results from direct contusion to the anterior cord by bone fragments or damage to the anterior spinal artery [16]. Central cord syndrome results from trauma to the central gray matter, which has a higher metabolic requirement and is more susceptible to trauma and ischemia [16]. Brown-Séquard syndrome is caused by complete hemisection of the spinal cord, resulting in ipsilateral proprioceptive motor loss and contralateral loss of pain and temperature sensation [16].

Neurogenic shock is characterized by hypotension with bradycardia due to disruption of the sympathetic pathway within the spinal cord [36]. It is most common in patients who sustain a cervical or upper thoracic spinal cord injury [36]. Spinal stability refers to the ability of the spine to maintain its alignment and protect neural structures during normal physiologic loading [1]. Unstable spine injuries are at risk for progressive deformity and neurologic compromise [1].

Classification

General Principles and Assessment

Definitive management of subaxial cervical spine trauma relies on assessing mechanical instability, neurologic impairment, and patient-specific factors influencing outcome [12]. Standardized terminology regarding treatment decisions and prognosis is essential for understanding the clinical behavior of thoracic and lumbar fractures [2]. Neurologic status is graded using the ASIA scale: * ASIA A: Complete injury with no motor or sensory function preserved in sacral segments S4-S5 [1]. * ASIA B: Incomplete injury with sensory function, but not motor function, preserved below the neurologic level, including sacral segments S4-S5 [1]. * ASIA C: Incomplete injury with motor function preserved below the neurologic level, where more than half of key muscles below the neurologic level have a muscle grade <3 [1]. * ASIA D: Incomplete injury with motor function preserved below the neurologic level, where at least half of key muscles below the neurologic level have a muscle grade of ≥3 [1]. * ASIA E: Normal neurologic status with normal motor and sensory functions [1].

AO/OTA Thoracolumbar Classification

The AO/Orthopaedic Trauma Association classification system for spinal fractures, dislocations, and fracture-dislocations is based on an alphanumeric classification [1]. This system categorizes injuries using injury morphology (A-C), neurologic status (N), and two case-specific modifiers (M) [8]. It has largely replaced the contemporary TLICS and Denis classification scale [8]. The system classifies injuries based on morphologic patterns of fractures, neurologic status, and clinical modifiers [31].

Morphology: * Type A: Compression injuries [8]. These involve compression fractures [31]. * A0: Mechanically insignificant fractures of the spinous or transverse processes [8]. * A1: Single end plate involvement without posterior vertebral wall involvement [8]. * A2: Coronal split pincer-type fractures involving both endplates without posterior vertebral wall involvement [8]. * A3: Incomplete burst fractures involving a single end plate with any involvement of the posterior vertebral wall [8]. * A4: Complete burst fractures affecting both end plates with any involvement of the posterior vertebral wall [8]. * Type B: Tension band injuries [8]. These involve failure of the anterior or posterior tension band without gross translation [31]. * B1: Monosegmental osseous failure of the posterior tension band extending into the vertebral body, also defined as "chance fractures" in thoracolumbar injuries [8]. This is classically referred to as a "chance" fracture, involving failure from the spinous process through the pedicles and into the vertebral body [31]. * B2: Involvement of the posterior tension band (bony, capsuloligamentous or ligamentous) with or without osseous involvement [8]. This consists of an osseoligamentous injury that often propagates through an intervertebral level and disrupts the posterior tension band, with or without bony involvement [31]. * B3: Involvement of the anterior tension band with disruption of anterior bone/disk with tethering of posterior elements [8]. These are hyperextension injuries causing violation of the anterior tension band, more common in patients with an ankylosed spine [31]. * Type C: Displacement/translational injuries [8]. These include dislocation or rotational or displacement-type injuries [31]. Type C injuries do not have subtypes because they are unstable injuries that lead to surgical stabilization [31].

Neurologic Status: * N0: Intact neurology [8]. * N1: Transient deficits [8]. * N2: Symptoms of radiculopathy [8]. * N3: Cauda equina syndrome [8]. * N4: Complete spinal cord injury [8]. * NX: Undetermined neurology [8].

Modifiers: * M1: Possible injury to the tension band based on imaging [8]. * M2: Patient-specific comorbidities such as ankylosing spondylitis, rheumatologic conditions, or diffuse idiopathic skeletal hyperostosis [8].

TLICS (Thoracolumbar Injury Classification and Severity)

The Thoracolumbar Injury Classification and Severity Score (TLICS) defines injury based on three clinical characteristics: injury morphology, integrity of the posterior ligamentous complex, and neurologic status of the patient [35]. The TLICS severity score offers prognostic information and is helpful in medical decision making [35]. Initial application of the TLICS has shown good to excellent reliability and validity [35].

Scoring Criteria: * Morphology: Compression is assigned 1 point [8]; burst morphology is assigned +1 point [8]; translation/rotation morphology is assigned 3 points [8]; and distraction morphology is assigned 4 points [8]. * Posterior Ligamentous Complex: An intact complex is assigned 0 points [8]; suspected or indeterminate disruption is assigned 2 points [8]; and injury to the complex is assigned 3 points [8]. * Neurologic Status: Intact status is assigned 0 points [8]; nerve root injury is assigned 2 points [8]; complete cord or conus medullaris injury is assigned 2 points [8]; incomplete cord or conus medullaris injury is assigned 3 points [8]; and cauda equina injury is assigned 3 points [8].

Other Classification Systems and Reliability

Gertzbein: This classification correlates fracture type with mechanical instability and neurologic lesion [154]. Load Sharing Classification: This system correlates comminution and displacement with stability and implant failure [154]. The standard Cohen's kappa values for the Load Sharing Classification of spinal fractures can be rated as fair to moderate, indicating that the inter- and intraobserver reliability of the classification is fair [55]. CSOTF: The new classification system for chronic symptomatic osteoporotic thoracolumbar fracture (CSOTF) demonstrated excellent reliability in initial assessment [159]. MRI/CT Scoring: A novel scoring system using MRI and CT radiologic findings to differentiate malignant vertebral fractures from osteoporotic vertebral fractures in Chinese patients was efficient with high accuracy and good applicability [69].

Other Considerations

Epidemiology: Approximately 75% to 90% of spinal fractures occur in the thoracic and lumbar spine, with most occurring at the thoracolumbar junction (T10-L2) [35]. Around 50% of thoracolumbar fractures occur between T11 and L1 [8], while around 30% of thoracolumbar injuries occur between L2 and L5 [8]. Noncontiguous spinal injury may occur in up to 12% of patients once a thoracolumbar spine fracture has been detected [8]. Major trauma patients with spinal fractures have more complex injuries than non-major trauma counterparts, demonstrated by increased levels of instability and fractures at more than one level [4]. The incidence of multiple level injuries of the cervical spine was 24 per cent in a group of 105 patients, which is higher than previously reported [14].

Specific Populations: Ankylosing spondylitis (AS) patients are at high risk for spinal fractures and associated spinal cord injury, particularly in the cervical spine [22]. Specific characteristics of vertebral fractures in elderly men, including the number of fractures, fracture type, and degree of compression, are associated with low bone mineral density and osteoporosis [60].

Modified TLICS: The modified TLICS system is a practical tool for the classification and assessment of thoracolumbar fractures with guiding significance for clinical treatment [51]. The operation rate for the modified TLICS system was slightly lower than that of the standard TLICS system [51].

Clinical Presentation

General Assessment and Imaging

Whole-body CT scans have largely replaced conventional radiographs for the initial assessment of multiply injured patients [1]. Major trauma patients present with more complex spinal injuries than non-major trauma counterparts, characterized by increased instability and fractures at multiple levels [4]. Noncontiguous spinal injury occurs in up to 12% of patients with a detected thoracolumbar spine fracture [8], while 30% of thoracolumbar injuries occur between L2 and L5 [8]. The thoracic spinal canal is relatively narrow, increasing the risk of injury-associated compression and neurologic deficits [8]. In the cervical spine, multiple-level injuries occur in 10% to 20% of cases [36], with an incidence of 24% reported in a group of 105 patients [14]. CT of the cervical spine is replacing lateral radiography due to availability and greater processing speed [36]. Sagittal CT views detect 85% of cervical spine fractures, though CT may miss axial plane fractures such as type II odontoid fractures [36]. Even with adequate plain radiographs, an estimated 15% to 17% of cervical spine injuries are missed [50]. A three-view cervical spine series and CT scan have a negative predictive value greater than 99% for cervical spine clearance in certain instances [50]. Flexion-extension radiographs have low sensitivity in the acute setting and can be obtained 7 to 10 days after injury in patients with neck pain and a negative CT scan [50]. MRI should only be obtained for patients who are hemodynamically stable and adequately resuscitated [1]. MRI visualizes soft-tissue injuries to ligaments and intervertebral disks, epidural bleeding, dural tears, spinal cord contusions and lacerations, and intramedullary lesion expansion over time [1]. Abnormalities are found incidentally on MRI in 25% to 40% of patients, suggesting the modality may be oversensitive for cervical spine clearance [50].

Vertebral fracture is common on chest radiographs but is often ignored by radiologists [64]. Underdiagnosis of osteoporotic vertebral fractures is a common problem due to a lack of radiographic detection [47]. Patients with ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis have an increased risk of fractures and can experience neurologic deterioration secondary to development of epidural hematoma [50]. Spinal fractures in patients with ankylosing spondylitis can occur after minor injuries and are often unstable [10]. Nondisplaced fractures in patients with ankylosing spondylitis commonly occur and carry a high rate of delayed or missed diagnosis [50]. If conventional radiographs fail to delineate a spinal fracture in a patient with ankylosing spondylitis and persistent pain, an isotope bone scan is indicated [38].

Neurologic Assessment

It is crucial to document the time of the neurologic assessment because neurologic deterioration may occur [1]. Spinal cord injury is stratified into paraplegia (paralysis of the lower extremities) from thoracic and lumbar spine injuries, and quadriplegia (paralysis of all four extremities) from cervical spine injuries [1]. Incomplete injuries are associated with a better outcome versus complete injuries, where the prognosis is dismal [1]. The presence of sacral nerve function is critical because patients with incomplete injuries have the potential to recover normal neurologic function over a time span of up to 2 years even if paralysis is initially complete [16]. Spinal shock may last for as little as several hours or as long as several months in patients with complete spinal cord injury [16]. Male gender, having a spinal fracture, having a thoracic injury, and having complications were the major risk factors for a complete spinal cord injury [62].

The ASIA classification grades neurologic status as follows: ASIA grade A: Complete injury with no motor or sensory function preserved in sacral segments S4-S5 [1]. ASIA grade B: Incomplete injury where sensory function, but not motor function, is preserved below the neurologic level and includes sacral segments S4-S5 [1]. ASIA grade C: Incomplete injury where motor function is preserved below the neurologic level, and more than half of the key muscles below the neurologic level have a muscle grade <3 [1]. ASIA grade D: Incomplete injury where motor function is preserved below the neurologic level, and at least half of the key muscles below the neurologic level have a muscle grade of ≥3 [1].

Specific syndromes include: Anterior cord syndrome: Commonly results from direct contusion to the anterior cord by bone fragments or from damage to the anterior spinal artery [16]. Only posterior column function (proprioception and light touch) may be present depending on the extent of cord involvement [16]. Central cord syndrome: Often results from a minor injury such as a fall in an older patient with cervical spinal canal stenosis [16]. Most patients are able to walk despite severe paralysis of the upper extremity [16]. Brown-Séquard syndrome: Caused by complete hemisection of the spinal cord, classically by a stab wound [54]. It results in greater ipsilateral proprioceptive motor loss and greater contralateral loss of pain and temperature sensation two to three segments below [54]. Patients have an excellent prognosis and usually will be able to ambulate [54].

Classification Systems

The AO Spine classification categorizes thoracolumbar injuries as: AO Type A: Compression injuries [8]. AO Type B: Tension band injuries [8]. AO Type C: Displacement/translational injuries [8].

Subtypes include: AO Type A2: Coronal split pincer-type fractures involving both endplates without any involvement of the posterior vertebral wall [8]. AO Type A3: Incomplete burst fractures involving a single end plate with any involvement of the posterior vertebral wall [8]. AO Type A4: Complete burst fractures affecting both end plates with any involvement of the posterior vertebral wall [8]. AO Type B1: Monosegmental osseous failure of the posterior tension band extending into the vertebral body, also defined as "chance fractures" [8]. AO Type C: Unstable injuries that lead to surgical stabilization and do not have subtypes [31].

Neurologic injury in the AO system is graded at the time of admission into N0 (intact), N1 (transient deficits), N2 (symptoms of radiculopathy), N3 (cauda equina), N4 (complete spinal cord), and NX (neurology undetermined) [8].

The Thoracolumbar Injury Classification and Severity (TLICS) scale assigns points based on morphology, integrity of the posterior ligamentous complex, and neurologic status [8]. Morphology: Compression is assigned 1 point, burst is assigned +1 point, translation/rotation is assigned 3 points, and distraction is assigned 4 points [8]. Posterior ligamentous complex: Intact is assigned 0 points, suspected/indeterminate disruption is assigned 2 points, and injury is assigned 3 points [8]. Neurologic status: Intact is assigned 0 points, nerve root injury is assigned 2 points, complete cord/conus medullaris injury is assigned 2 points, incomplete cord/conus medullaris injury is assigned 3 points, and cauda equina injury is assigned 3 points [8].

Cervical and occipital classifications include: Anderson and Montesano system: Classifies occipital condyle fractures into Type 1 (comminuted fractures from axial load), Type 2 (basilar skull fracture extending into the condyle), and Type 3 (avulsion fractures) [52]. Type 3 occipital condyle fractures account for 75% of cases and should raise clinical suspicion for an underlying occipitocervical dissociation [52]. Anderson and d’Alonzo classification: Categorizes axis fractures into Type 1 (avulsion of the tip of the odontoid), Type 2 (fractures through the waist of the odontoid process), and Type 3 (fractures extending into the C2 vertebral body) [52]. Levine and Edward classification: Categorizes traumatic spondylolisthesis of the axis into Type I (<3 mm displacement, no angulation), Type II (translation >3 mm plus angulation), Type IIA (angulation without significant translation), and Type III (Type 1 fractures with associated C2-3 facet joint injury) [52].

Inter- and intra-observer agreement for the main types of AO classifications for thoraco-lumbar spinal injuries was comparable to agreement for fractures of the trochanteric area of the proximal femur [19]. Including sub-types, agreement for evaluating thoraco-lumbar spinal injuries was significantly better than assessing fractures of the trochanteric area of the proximal femur [19]. The inter- and intraobserver reliability of the Load Sharing Classification for spinal fractures is rated as fair to moderate based on standard Cohen's kappa values [55]. The classification of pediatric thoracolumbar trauma is based primarily on adult studies, with little high-level evidence examining validity and accuracy in pediatric populations [24]. Pediatric spine injuries are rare and require an individualized approach due to unique injury patterns, plasticity of the spine, and difficulty of diagnosis [34].

Stability and Prognosis

Definitive management of subaxial cervical spine trauma is based on the assessment of mechanical instability, the presence or absence of neurologic impairment, and various patient factors that may influence outcome [12]. Patients with stable vertebral compression fractures without neurological deficit generally function well long-term, with no deformity progression after three months [20]. The functional outcome of thoracolumbar vertebrae fractures without neurological deficit was not significantly affected by the fracture type, severity, region, or treatment received [23]. Unlike compression fractures, the vertebral body with traumatic vertebral body bruise found in adult patients with nonosteoporotic spinal fractures of AO classification A or B types did not develop collapse [29]. Spinal trauma remains a source of significant morbidity with a pronounced decrease in quality of life [15]. Traumatic spine injuries can result in irreversible sensory, motor, or autonomic dysfunction and have a devastating impact on the functional abilities of patients [26]. Fracture-specific classification systems such as the thoracolumbar injury classification and severity score are valuable for clinical decision making and have prognostic value [26].

Investigations

Clinical Assessment and Neurologic Classification

Spinal cord injury is stratified into paraplegia, defined as paralysis of the lower extremities resulting from thoracic and lumbar spine injuries, and quadriplegia, defined as paralysis of all four extremities from cervical spine injuries [1]. The completeness of a spinal cord injury is determined by the presence or absence of sacral function [16].

Imaging Modalities

Plain radiography: Conventional imaging with anterior and posterior projections is insufficient for detecting all spinal fractures in multiply injured patients [73]. Radiographs, whether flexion-distraction or neutral, have limited utility in the acute setting due to high false-negative and false-positive rates [93]. In alert, asymptomatic patients without neck pain or distracting injury, who possess a normal neurological examination and complete range of motion, radiographic evaluation is not recommended; only clinical clearance is necessary [93]. Upright radiographs are useful in guiding management decisions for traumatic vertebral fractures [172]. Lateral radiographs in flexion and extension should be performed approximately 10 days after cervical spinal injury in patients with persistent pain or following transient neurological symptoms to demonstrate pathology such as spinous process fractures that are not visible on plain radiographs or MRI [169].

CT: Whole-body CT scans providing thin section images of the entire spine with two-dimensional and three-dimensional reconstructions have largely replaced conventional radiographs for the initial assessment of multiply injured patients [1]. CT is the method of choice in the investigation of spinal fractures after plain films have been taken [166]. It remains the most useful advanced imaging technique for spinal trauma due to inherent contrast provided by bone and unmatched spatial resolution [97]. Patients with neck tenderness and pain require multidetector CT (MDCT), which has a sensitivity of 97% to 100% [93]. However, CT may miss complex rotation fractures, making MRI warranted in such cases [173].

MRI: MRI is the modality of choice for evaluation of ligamentous and other soft tissue structures, disc, spinal cord, and occult osseous injuries [180]. It is helpful in patients with suspected spinal cord injury, epidural hematoma, or traumatic disc herniation [97]. Patients with presumed spinal cord injury should undergo MRI to determine the location and severity of the injury and to identify the cause of spinal cord compression [93]. Ligamentous injury of the cervical spine may not be clearly identifiable from MDCT images, but MRI images can reliably identify ligamentous injuries [93]. Patients presenting with a Glasgow Coma Scale of less than 15 and midline tenderness with neurological symptoms should be evaluated with MRI for possible ligamentous injury [93].

Classification Systems

AO Classification: AO Type B2 injuries involve injury of the posterior tension band (bony, capsuloligamentous or ligamentous) with or without osseous involvement [8]. AO Type B3 injuries involve injury of the anterior tension band with disruption of anterior bone/disk with tethering of posterior elements [8]. Neurologic injury in the AO thoracolumbar classification is graded at admission into N0 (intact), N1 (transient deficits), N2 (symptoms of radiculopathy), N3 (cauda equina), N4 (complete spinal cord), and NX (neurology undetermined) [8].

TLICS Scale: The Thoracolumbar Injury Classification and Severity (TLICS) scale assigns 1 point for compression morphology, +1 for burst, 3 for translation/rotation, and 4 for distraction [8]. It assigns 0 points for an intact posterior ligamentous complex, 2 points for suspected/indeterminate disruption, and 3 points for injury [8]. The scale assigns 0 points for intact neurologic status, 2 points for nerve root or complete cord/conus medullaris injury, and 3 points for incomplete cord/conus medullaris or cauda equina injury [8].

AOSpine Classification: The AOSpine subaxial spine classification system accounts for morphological features of the fracture, facet involvement, neurologic status, and case-specific modifiers [102]. It divides cervical injuries into type A (compression), type B (tension band), type C (translation), and type F (facet) [102].

Epidemiology and Injury Patterns

Approximately 10% to 15% of all trauma patients with severe head injuries have an associated cervical spine injury [1]. Around 50% of thoracolumbar fractures occur between T11 and L1 and 30% of injuries occur between L2 and L5 [8]. Nineteen percent of near-hanging injury patients sustained an injury, and in 5% the injury was a cervical spine fracture [39]. An important proportion of patients over 60 years old evaluated with chest plus abdominal and pelvic CT scans present vertebral compression fractures [179].

Specific Injury Considerations

Patients with coexisting stiffening bone disease with a cervical fracture should undergo additional advanced imaging to find occult fractures and MRI to rule out epidural hematomas [102]. The four CT parameters most strongly associated with neurologic deficit in thoracolumbar burst fractures are AO classification, compression ratio of median sagittal diameter, anterior vertebral compression ratio, and distance from the posterior margin to the vertebral body above [182]. MRI showed that no loss of height occurred in discs adjacent to fractured vertebra and that there was no major alteration of the disc in terms of signal intensity and morphology in type A1 and A3 thoracolumbar fractures [170]. The combination of intensity change in the posterior wall on MRI and AVHR >75% on X-ray indicates a high probability of acute osteoporotic vertebral fracture [171].

Treatment

General Principles and Assessment

Multiple-level injuries occur in 10% to 20% of cases [36, 37]. The primary goal of treatment for spinal cord injury is stabilization [36, 37]. Adherence to advanced trauma life support protocols remains imperative for spinal trauma [36, 37]. Once initial resuscitation is complete, vasopressors are frequently required to help restore systemic vascular resistance in neurogenic shock [36, 37].

Classification Systems

The AO system categorizes injury morphology into three predefined categories: type A (compression injuries), type B (tension band injuries), and type C (displacement/translational injuries) [8]. Type A and Type B injuries are subclassified more granularly within the AO system [8]. Neurologic injury is graded at the time of admission into N0 (intact), N1 (transient deficits), N2 (symptoms of radiculopathy), N3 (cauda equina), N4 (complete spinal cord), and NX (neurology undetermined) [8]. Thoracolumbar case-specific modifier M1 is used to denote a possible injury to tension band based on imaging [8]. Thoracolumbar case-specific modifier M2 is used to designate patient specific comorbidities such as ankylosing spondylitis, rheumatologic conditions, and diffuse idiopathic skeletal hyperostosis [8]. Inter- and intra-observer agreement of thoraco-lumbar spinal injuries using the main types of AO classifications were comparable to agreement evaluating fractures of the trochanteric area of the proximal femur [19]. The operation rate for the modified TLICS system was slightly lower than that of the TLICS system [51].

Non-Operative

The treatment of most thoracolumbar fractures is nonsurgical [8]. Patients who are neurologically intact, have less than 25° kyphosis, less than 50% loss of vertebral height, less than 50% canal compromise, and an intact posterior ligamentous complex are the best candidates for nonsurgical treatment [8]. Nonsurgical treatment comprises hyperextension thoracolumbar orthosis or casting for 3 months [8]. In properly selected neurologically intact patients, stable thoracolumbar burst fractures are best treated nonoperatively, as long-term outcomes for pain and function were significantly better for the nonoperatively treated patients [66]. Non-operative treatment for stable thoracolumbar burst fractures demonstrates established clinical proficiency with excellent long-term outcomes and lower complication rates compared to instrumented approaches [165]. For patients with incomplete paralysis, early stabilization and mobilization should be weighed against surgical risks, while stable fractures are best treated non-operatively [177].

Conservative management of thoracolumbar and lumbar spine compression and burst fractures is of limited value in lumbar fractures and in burst type fractures with posterior column involvement [40]. Historically, thoracic injuries to the spine have always predominantly been treated non-operatively [128]. A primarily non-operative approach appears to be perfectly justified for type A2 and type A3 fractures of the thoracic spine [128]. Following non-operative treatment of thoracic type A fractures, tight follow-up reviews after 1, 2, 4, and 6 weeks are essential for recognizing early evidence of secondary vertebral collapse [128]. The risk of a clinically relevant deterioration of the fracture-related kyphotic deformity is increased in the thoracic spine region due to its physiological thoracic kyphosis [128]. Vertebroplasty delivered superior clinical and radiological outcomes over the first year from intervention when compared to conservative treatment of patients with osteoporotic compression fractures without neurological deficit [158]. Intoxicated patients may be able to have significant fractures requiring operative stabilisation excluded when clinical examination of the spine in the trauma bay is normal [174].

Operative

Indications: Surgical treatment is indicated for unstable fractures and/or patients with neurologic deficits [8]. Unstable injuries (types B and C), serial fractures, and injuries associated with symptoms of complete spinal cord injury have a better outcome after surgical management [128].

Surgical Approach / Technique: For patients with incomplete neurologic deficits and ongoing spinal cord compression from retropulsed fragments, anterior decompression and stabilization is typically required [8]. Adjunctive posterior stabilization may be necessary in injuries with posterior column involvement [8]. The early stabilization of patients with neurologic injuries facilitates early rehabilitation and improved outcomes [8]. Patients with unstable burst fractures that include failure of the posterior ligamentous complex, fracture-dislocations, and/or fractures with significant rotational displacement should undergo initial posterior stabilization [8]. If canal clearance from reduction and ligamentotaxis is not adequate, staged anterior decompression and reconstruction is warranted [8]. The goals of fracture treatment, including prevention of neurological damage, decompression, and stabilization, were achieved using fusion and Harrington instrumentation [156]. The effective use of the Williams plate in the correction of spinal fractures depended on the severity of the injury and the degree of the primary traumatic deformation of kyphosis [53]. The technique of a novel screw placement technique under navigation guidance is feasible, safe, and effective for treating traumatic thoracolumbar vertebral fractures [146]. Management of thoracolumbar fractures in France has progressed with increased use of percutaneous approaches (46% vs 28% in 2013) and posterior-only approaches (90% vs 83% in 2013) [176]. The authors do not recommend standalone kyphoplasty for all types of burst fractures, specifically recommending additional techniques like posterior instrumentation for A3.2 and A3.3 fractures [71]. The modified bone-disc-bone osteotomy (MBDBO) technique demonstrates stability of the correction effect and clinical efficacy and safety for treating kyphosis caused by old thoracolumbar vertebral fractures [163].

Implant Selection: The long-term results of short segmental fixation with and without fusion for burst fractures of the thoracolumbar and lumbar spine were comparable [33]. This study presented evidence of successful treatment of non-fusion short-segment posterior fixation for a certain type of thoracolumbar and lumbar burst fractures [167].

Polytrauma and Damage Control

The concept of spine damage control has been proposed using early posterior instrumentation of unstable thoracolumbar fractures in patients with polytrauma [1]. Spine damage control involves delayed definitive surgery occurring once patients are fully resuscitated and physiologically stabilized [1]. An increasing body of literature has reported fewer complications and shorter hospital stays with fewer days of mechanical ventilation when spinal fractures are stabilized early in critically injured patients, within 24 to 36 hours of injury [1]. Spinal cord injuries of the cervical and thoracolumbar region are associated with significant morbidity and mortality [26]. Stabilization and treatment of these injuries in the acute setting are important and impact the long-term functional outcome of patient [26]. Both surgical and nonsurgical treatments play an important role in the stabilization and optimization of traumatic spine fractures [26].

Special Populations

Spinal fractures in patients with ankylosing spondylitis (AS) can occur after minor injuries and are often unstable, requiring surgery [10]. If conventional radiographs fail to delineate a spinal fracture in a patient with persistent pain, an isotope bone scan is indicated [38]. Fractures caused by low-energy trauma in AS may prove challenging to diagnose, with diagnostic delays occurring in 19% to 60% of cases [123]. Multidetector computed tomography is the diagnostic reference standard for AS spinal fractures, although the images may be difficult to interpret [123]. In non-displaced AS fractures, magnetic resonance imaging may be helpful, with T2-weighted STIR images showing oedema at the fracture site as high signal and T1-weighted images allowing an evaluation of the fracture line [123]. Bracing is challenging in patients with an unyielding kyphotic deformity, making spinal stabilisation in a brace inadequate in most AS patients [123]. Conventional open surgery for AS spinal fractures has been criticized based on its high post-operative morbidity rate of up to 51% [123]. Pedicle screw loosening is common in AS patients due to limited bone stock, with a frequency of up to 15% [123]. Immune response impairments in patients with AS translate into a 14% infection rate [123]. Although immediate postoperative outcomes for spine trauma patients with AS and diffuse idiopathic skeletal hyperostosis (DISH) were comparable with those of unaffected individuals, tailored management strategies are needed [77].

The incidence of spinal cord injury is approximately 54 cases per one million people in the United States [32]. Depending on the severity of trauma, the average healthcare costs and living expenses for spinal cord injury can range from about $350,000 to $1.1 million in the first year [32]. Approximately 400,000 people have spinal cord damage in the United States, and the incidence is about 10,000 per year [16]. The leading causes of spinal cord injury are motor vehicle accidents, gunshot wounds, falls, sports (especially diving) injuries, and water injuries [16]. With the benefits of an organized program of medical care, the life expectancy of survivors of spinal cord injury is now approaching normal [16]. Spinal trauma remains a source of significant morbidity with a pronounced decrease in quality of life despite progress in management [15]. Quality of life decreased in patients who sustained incident vertebral and non-vertebral fractures [75]. Outcome is particularly affected by multiple fractures in the thoracolumbar and lumbar regions and by failure to prevent kyphosis [161].

Complications

Spinal Cord Injury: Spinal cord injury is associated with high morbidity and mortality [32]. The average healthcare costs and living expenses for spinal cord injury can range from about $350,000 to $1.1 million in the first year [32]. Male gender, having a spinal fracture, having a thoracic injury, and having complications were the major risk factors for a complete injury [62]. Patients with ankylosing spondylitis are at high risk for spinal fractures and associated spinal cord injury, particularly in the cervical spine [22]. The incidence of extension injury to the cervical spine complicated by damage to the spinal cord shows a marked increase with age, with 84 per cent occurring during and after the fifth decade [74].

Other Considerations: An increasing body of literature has reported fewer complications, shorter hospital stays, and fewer days of mechanical ventilation with early stabilization of spinal fractures in critically injured patients within 24 to 36 hours of injury [1]. Health-related quality of life is affected several years after short segment posterior instrumentation of thoracolumbar fractures without neurological deficit [65]. The incidence of subsequent vertebral fracture in patients aged 70 years and older was significantly higher than in patients aged under 70 years of age [76]. The natural history of thoracolumbar burst fractures without neurology would appear to be benign [57].

Recovery

Neurologic Prognosis and Assessment: Incomplete spinal cord injuries are associated with a better outcome compared to complete injuries, where the prognosis is dismal [1]. The American Spinal Injury Association (ASIA) Impairment Scale classifies spinal cord injuries into complete (Grade A) or incomplete (Grades B–D), with Grade E reflecting normal neurologic status [1]. ASIA Grade A is defined as no motor or sensory function preserved in sacral segments S4–S5 [1]. ASIA Grade B is defined as sensory function, but not motor function, preserved below the neurologic level and including sacral segments S4–S5 [1]. ASIA Grade C is defined as motor function preserved below the neurologic level, with more than half of the key muscles below the neurologic level having a muscle grade <3 [1]. ASIA Grade D is defined as motor function preserved below the neurologic level, with at least half of the key muscles below the neurologic level having a muscle grade of ≥3 [1]. The time of neurologic assessment must be documented because neurologic deterioration may occur [1].

Long-Term Functional Outcomes: The long-term reduction of health-related quality of life in women with vertebral fracture emerged clearly in a seven-year follow-up study [150]. The natural history of thoracolumbar burst fractures without neurology appears to be benign [57]. At long-term follow-up (sixteen to twenty-two years), patients with a stable burst fracture treated nonoperatively reported less pain and better function compared with those who were treated surgically [136].

Deformity Progression and Healing: A study clarified the natural history of the progression pattern of vertebral deformities in radiographic prevalent vertebral fractures in elderly individuals [61]. Patients treated with long segmental stabilization for unstable midthoracic spine fractures had a significantly lower rate of sequential vertebral body fractures during follow-up [164]. A fracture in a fused and instrumented lumbar segment healed without incident and had no adverse effect on the patient's ultimate outcome [41].

Pediatric and Special Populations: Appropriate early diagnosis, management, and long-term follow-up are imperative for pediatric thoracolumbar spine trauma due to the potential for substantial healing and remodeling as well as the risk of late deformity and neurologic injury [162]. Although immediate postoperative outcomes for spine trauma patients with ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis were comparable with those of unaffected individuals, tailored management strategies are needed [77].

Key Evidence

• [L5] Although the ideal classification for thoracic and lumbar fractures does not exist, standardization of terminology as related to treatment decisions and prognosis is key to an improved understanding of the clinical behavior of these injuries. [2] (10.5435/00124635-200209000-00008)
• [L5] A complete classification scheme for thoracolumbar fractures that incorporates the mechanism of injury, a description of osseous and ligamentous destruction, and the degree of neurologic damage is still lacking. [3] (10.5435/00124635-199511000-00005)
• [L3] Major trauma patients differ from non-major trauma counterparts and have more complex spinal injuries, demonstrated by increased levels of instability and fractures at more than one level. [4] (10.1302/0301-620x.97b2.34392)
• [L3] A reliable classification for assessing the stability of a healed vertebra was developed. [5] (10.1186/s12891-020-03386-z)
• [L3] In C type fractures, correct surgical indication must be evaluated on an individual basis. [6] (10.1016/j.injury.2016.07.052)
• [L4] Injuries of the first and second cervical vertebrae commonly occurred together, and injuries involving the upper and lower cervical spine in the same individual occurred in 9 per cent of patients with fractures of C1 and C2. [7] (10.1016/0020-1383(92)90123-a)
• [Case_report] Spinal fractures in patients with AS can occur after minor injuries and are often unstable, requiring surgery. [10] (10.1016/j.otsr.2012.09.018)
• [L5] Definitive management (surgical or nonsurgical) is based on the assessment of the mechanical instability of the injury, the presence or absence of neurologic impairment, and various patient factors that may influence outcome. [12] (10.5435/00124635-200602000-00003)
• [L3] Twenty-five out of 1000 patients presented with a vertebral fracture, with over two-thirds treated surgically and a 6.3% complication rate. [13] (10.1186/s13018-022-03147-9)
• [L4] The incidence of multiple level injuries of the cervical spine was 24 per cent in this group of 105 patients, which is higher than previously reported, probably due to increasingly elaborate investigations. [14] (10.1016/0020-1383(85)90013-0)
• [L3] Despite progress in management, spinal trauma remains a source of significant morbidity with a pronounced decrease in quality of life. [15] (10.1016/j.otsr.2014.11.012)
• [L5] Diagnosis of cervical spine injuries is a three-step process involving risk assessment, imaging, and classification. [18] (10.1302/2058-5241.3.170076)
• [L3] Using the main types of AO classifications, inter- and intra-observer agreement of thoraco-lumbar spinal injuries were comparable to agreement evaluating fractures of the trochanteric area of the proximal femur; including sub-types, agreement evaluating thoraco-lumbar spinal injuries was significantly better than assessing fractures of the trochanteric area of the proximal femur. [19] (10.1016/j.injury.2015.11.016)
• [L4] Patients with stable vertebral compression fractures without neurological deficit generally function well long-term, with no deformity progression after three months. [20] (10.2106/00004623-198870090-00007)
• [L4] The most common injuries were fractures of the thoracic and lumbar spine (83.0 per cent) especially of the thoracolumbar junction. [21] (10.1016/s0020-1383(96)00083-6)
• [L4] AS patients are at high risk for spinal fractures and associated SCI, particularly in the cervical spine. [22] (10.1186/s13018-026-06871-8)
• [L3] The functional outcome was not significantly affected by the fracture type, severity, region or treatment received. [23] (10.1016/0020-1383(95)00074-j)
• [L4] The classification of pediatric thoracolumbar trauma is based primarily on adult studies and there is little high-level evidence examining validity and accuracy in pediatric populations. [24] (10.2106/jbjs.rvw.24.00045)
• [L3] Unlike compression fractures, the vertebral body with traumatic VBB found in adult patients with nonosteoporotic spinal fractures of AO classification A or B types did not develop collapse. [29] (10.1186/s12891-022-05405-7)
• [L5] [31] (10.1097/corr.0000000000001086)
• [L2] The long-term results of short segmental fixation with and without fusion for burst fractures of the thoracolumbar and lumbar spine were comparable. [33] (10.2106/jbjs.m.01486)
• [L4] Pediatric spine injuries are rare and require an individualized approach due to unique injury patterns, plasticity of the spine, and difficulty of diagnosis. [34] (10.1016/j.injury.2005.06.021)
• [L5] [35] (10.5435/00124635-201002000-00001)
• [L4] If conventional radiographs fail to delineate a spinal fracture in a patient with persistent pain an isotope bone scan is indicated. [38] (10.1016/0020-1383(91)90118-x)
• [L4] Nineteen percent of patients sustained an injury, and in 5% the injury was a cervical spine fracture; therefore, liberal screening using CT scans is warranted. [39] (10.1016/j.injury.2005.12.013)
• [L4] It is of limited value in lumbar fractures and in burst type fractures with posterior column involvement. [40] (10.1007/s00402-008-0780-x)
• [L4] The fracture healed without incident and had no adverse effect on the patient's ultimate outcome. [41] (10.1097/blo.0b013e3180315082)
• [L5] Due to the unique microarchitecture of the cervical vertebrae, fractures occur much later in this region than they do in the thoracic or lumbar spine. [46] (10.1186/s13018-022-03105-5)
• [L3] Underdiagnosis of osteoporotic vertebral fractures is a common problem due to a lack of radiographic detection. [47] (10.1016/j.injury.2018.10.006)
• [L3] The modified TLICS system is a practical tool for the classification and assessment of thoracolumbar fractures with guiding significance for clinical treatment, and the operation rate was slightly lower than that of the TLICS system. [51] (10.1186/s13018-023-03958-4)
• [L4] The effective use of the Williams plate in the correction of spinal fractures depended on the severity of the injury and the degree of the primary traumatic deformation of kyphosis. [53] (10.1016/0020-1383(88)90004-6)
• [L4] The standard Cohen's kappa values for the Load Sharing Classification of spinal fractures can be rated as fair to moderate, indicating that the inter- and intraobserver reliability of the classification is fair. [55] (10.1016/j.injury.2011.05.013)
• [L4] The natural history of thoracolumbar burst fractures without neurology would appear to be benign. [57] (10.1302/0301-620x.98b1.36121)
• [L3] Specific characteristics of vertebral fractures in elderly men, including the number of fractures, fracture type, and degree of compression, are associated with low bone mineral density and osteoporosis. [60] (10.1302/0301-620x.97b8.35032)
• [L2] This study clarified the natural history of the progression pattern of vertebral deformities in radiographic prevalent vertebral fractures in elderly individuals. [61] (10.1186/s12891-024-07254-y)
• [L4] Male gender, having a spinal fracture, having a thoracic injury, and having complications were the major risk factors for a complete injury. [62] (10.1371/journal.pone.0084733)
• [L4] Vertebral fracture is common on chest radiographs but it is often ignored by radiologists. [64] (10.1186/s12891-018-2171-y)
• [L3] Health-related quality of life is affected several years after short segment posterior instrumentation of thoracolumbar fractures without neurological deficit. [65] (10.1016/j.injury.2013.06.012)
• [L1] In properly selected neurologically intact patients, stable thoracolumbar burst fractures are best treated nonoperatively, as long-term outcomes for pain and function were significantly better for the nonoperatively treated patients. [66] (10.2106/jbjs.n.01092)
• [L4] Large well-controlled prospective studies are needed to draw up guidelines for less invasive procedures in spine trauma. [68] (10.1016/j.otsr.2012.09.014)
• [L3] This novel scoring system using MRI and CT radiologic findings to differentiate malignant vertebral fractures from osteoporotic vertebral fractures in Chinese patients was efficient with high accuracy and good applicability. [69] (10.1186/s12891-018-2331-0)
• [Letter] The authors clarify that they do not recommend standalone kyphoplasty for all types of burst fractures, specifically recommending additional techniques like posterior instrumentation for A3.2 and A3.3 fractures. [71] (10.1016/j.injury.2011.02.008)
• [Paper] Posterior monosegmental fixation is an adequate and satisfactory procedure for specific types of thoracolumbar spine fractures, particularly when the vertebral body is intact. [72] (10.1016/j.injury.2005.06.019)
• [L4] However, conventional imaging with anterior and posterior projections seems to be insufficient in detecting all of the spinal fractures. [73] (10.1016/0020-1383(93)90152-v)
• [L4] The incidence of extension injury to the cervical spine complicated by damage to the spinal cord shows a marked increase with age, with 84 per cent occurring during and after the fifth decade. [74] (10.1016/0020-1383(87)90002-7)
• [L2] Quality of life decreased in patients who sustained incident vertebral and non-vertebral fractures. [75] (10.1186/1471-2474-3-11)
• [L3] The incidence of subsequent vertebral fracture in patients aged 70 years and older was significantly higher than in patients aged under 70 years of age. [76] (10.1186/s12891-019-2534-z)
• [L3] Although immediate postoperative outcomes were comparable with those of unaffected individuals, these findings underscore the need for tailored management strategies for spine trauma patients with AS and DISH. [77] (10.5435/jaaos-d-25-00785)
• [L4] [123] (10.1016/j.otsr.2017.07.023)
• [Paper] [128] (10.1055/a-1144-3846)
• [L1] While early analysis (four years) revealed few significant differences between the two groups, at long-term follow-up (sixteen to twenty-two years), those with a stable burst fracture who were treated nonoperatively reported less pain and better function compared with those who were treated surgically. [136] (10.2106/jbjs.n.00226)
• [L3] The technique is feasible, safe, and effective for treating traumatic thoracolumbar vertebral fractures. [146] (10.1186/s12891-025-09071-3)
• [L2] The long-term reduction of HRQOL in women with vertebral fracture emerged clearly in this study. [150] (10.1186/1471-2474-10-135)
• [L4] The Gertzbein classification correlates fracture type with mechanical instability and neurologic lesion, while the load sharing classification correlates comminution and displacement with stability and implant failure. [154] (10.1097/01.blo.0000068187.83581.5d)
• [L4] The goals of fracture treatment, including prevention of neurological damage, decompression, and stabilization, were achieved. [156] (10.1007/bf00422835)
• [L3] Vertebroplasty delivered superior clinical and radiological outcomes over the first year from intervention when compared to conservative treatment of patients with osteoporotic compression fractures without neurological deficit. [158] (10.1007/s00264-017-3409-2)
• [L4] The new classification system for CSOTF demonstrated excellent reliability in this initial assessment. [159] (10.1186/s13018-020-01882-5)
• [L4] Outcome is particularly affected by multiple fractures in the thoracolumbar and lumbar regions and by failure to prevent kyphosis. [161] (10.1302/0301-620x.98b9.37786)
• [L5] Appropriate early diagnosis, management, and long-term follow-up are imperative due to the potential for substantial healing and remodeling as well as the risk of late deformity and neurologic injury. [162] (10.5435/00124635-201312000-00001)
• [L4] The study demonstrates the stability of the correction effect and the clinical efficacy and safety of this modified technique for treating kyphosis caused by old thoracolumbar vertebral fractures. [163] (10.1186/s13018-026-06867-4)
• [L3] Patients treated with long segmental stabilization had a significantly lower rate of sequential vertebral body fractures during follow-up. [164] (10.1186/s12891-021-04049-3)
• [L5] Non-operative treatment for stable thoracolumbar burst fractures and uninstrumented fusion for low-grade lytic spondylolisthesis demonstrate established clinical proficiency with excellent long-term outcomes and lower complication rates compared to instrumented approaches. [165] (10.1302/0301-620x.98b1.37508)
• [L4] CT is the method of choice in the investigation of spinal fractures after plain films have been taken. [166] (10.1016/0020-1383(87)90134-3)
• [L5] This study presented evidence of successful treatment of non-fusion short-segment posterior fixation for a certain type of thoracolumbar and lumbar burst fractures. [167] (10.2106/jbjs.n.00751)
• [L5] The optimal surgical approach for specific thoracolumbar fractures remains a matter of controversy, warranting multiple clinical cohort studies to establish a comprehensive surgical protocol. [168] (10.5435/00124635-200807000-00008)
• [L4] Lateral radiographs in flexion and extension should be performed about 10 days after cervical spinal injury in patients with persistent pain or following transient neurological symptoms, as they can demonstrate pathology such as spinous process fractures that are not visible on plain radiographs or MRI. [169] (10.1007/bf00572919)
• [L4] MRI showed that no loss of height occurred in discs adjacent to fractured vertebra and that there was no major alteration of the disc in terms of signal intensity and morphology. [170] (10.1016/j.otsr.2015.08.008)
• [L2] The combination of intensity change in the posterior wall on MRI and AVHR >75% on X-ray indicates a high probability of acute fracture. [171] (10.1186/s13018-014-0096-1)
• [L3] Upright radiographs are useful in guiding traumatic vertebral fracture management decisions. [172] (10.1186/s12891-022-05243-7)
• [L4] CT may miss complex rotation fractures, making MRI warranted in such cases. [173] (10.1016/s0020-1383(99)00235-1)
• [L3] Intoxicated patients may be able to have significant fractures (requiring operative stabilisation) excluded when clinical examination of the spine in the trauma bay is normal. [174] (10.1016/j.injury.2004.09.033)
• [L4] Management of thoracolumbar fractures has progressed in France with increased use of percutaneous approaches (46% vs 28% in 2013) and posterior-only approaches (90% vs 83% in 2013). [176] (10.1016/j.otsr.2020.02.023)
• [L5] For patients with incomplete paralysis, early stabilization and mobilization should be weighed against surgical risks, while stable fractures are best treated non-operatively. [177] (10.2106/00004623-198466070-00032)
• [L3] An important proportion of patients over 60 years old evaluated with chest plus abdominal and pelvic CT scans present vertebral compression fractures. [179] (10.1007/s00402-019-03177-9)
• [L5] MRI is the modality of choice for evaluation of ligamentous and other soft tissue structures, disc, spinal cord, and occult osseous injuries. [180] (10.1186/s12891-016-1169-6)
• [L3] The four CT parameters most strongly associated with neurologic deficit in thoracolumbar burst fractures are AO classification, compression ratio of median sagittal diameter, anterior vertebral compression ratio, and distance from the posterior margin to the vertebral body above. [182] (10.1186/s13018-016-0448-0)

See Also

• Cauda equina syndrome
• Osteoporotic vertebral fracture

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