Copyright 1996 by The Journal of Bone and Joint Surgery, Incorporated

Burst Fractures of the Second through Fifth Lumbar Vertebrae

CLINICAL AND RADIOGRAPHIC

RESULTS*

BY DAVID A. ANDREYCHIK, M.D.F. DIRK H. ALANDER, M.D.T KAROLYN M. SEN1CA, M.D.,

AND E. SHANNON STAUFFER, M.D., SPRINGFIELD, ILLINOIS

Investigation performed at the Southern Illinois University School of Medicine, Springfield

ABSTRACT: Fifty-five patients who had sustained

a burst fracture of the lumbar spine were followed for
a mean of seventy-nine months (range, twenty-four to
192 months) after the injury. Thirty patients had been
managed non-operatively with a short period of bed
rest followed by protected mobilization. The remaining
twenty-five patients had been managed operatively:
eight, with posterior arthrodesis with long-segment
hook-and-rod fixation; eight, with posterior arthrodesis
with short-segment transpedicular fixation; six, with
posterior arthrodesis and instrumentation followed by
anterior decompression and arthrodesis; and three,
with anterior decompression and arthrodesis.
Thirty-six patients had been neurological!} intact
at the time of presentation and had remained so
throughout the follow-up period. No neurological deterioration or symptoms of late spinal stenosis were
seen. Isolated partial single-nerve-root deficits resolved regardless of the method of treatment. Patients
who had had a complete single or a multiple-nerve-root
paralysis seemed to have benefited from anterior decompression.
Although the anatomical results as seen on the
most recent radiographs were superior for the group
that had been managed operatively with long posterior
fixation or anterior and posterior arthrodesis, the most
recent pain scores and the functional outcomes were
similar for all treatment groups. At the latest follow-up
evaluation, some loss of spinal alignment was noted in
the patients who had been managed with short transpedicular fixation; the alignment at the most recent
follow-up examination was comparable with that in
the patients who had been managed non-operatively.
For the patients who had had non-operative treatment, we were unable to predict the deformity at the
time of follow-up on the basis of the initial diagnostic radiographs. The clinical outcome was not related
*No benefits in any form have been received or will be received
from a commercial party related directly or indirectly to the subject
of this article. No funds were received in support of this study.
tGeisinger Clinic, 100 North Academy, Danville, Pennsylvania
17822.
^Dickson Diveley Midwest Orthopaedic Clinic, 4320 Wornall
Road, Suite 610, Kansas City, Missouri 64111.
Division of Orthopaedics and Rehabilitation, Southern Illinois
University School of Medicine, P.O. Box 19230, Springfield, Illinois
62794-9230.
1156

to the deformity at the latest follow-up evaluation.

On the basis of the results of our study, we recommend non-operative treatment for patients who do not
have neurological dysfunction or who have an isolated
partial nerve-root deficit at the time of presentation.
For patients who have a multiple-nerve-root paralysis,
anterior decompression is indicated.
There has been considerable controversy regarding what constitutes the best treatment for lumbar burst
fractures. Proponents of non-operative treatment have
claimed that, except in patients who have a larger residual kyphosis, the clinical outcome compares favorably
with that of operative treatment, without the attendant
risk of an operative procedure911'5-2627'3438454652. However,
advocates of stabilization procedures have cited better
restoration of anatomical alignment, more rapid mobilization, and improved neurological outcomes with operative intervention2'4'5-7'10121417'19-23-25'28'32-33'37'39-40-42'43'4748. A fear
of neurological deterioration, or the belief that operative realignment and arthrodesis prevent late symptomatic joint degeneration and spinal stenosis, has led
some authors to recommend operative rather than nonoperative treatment3'5'8'10-12-14-17-23-28-33-36'39'44'47-48'50'53.
Previous reports have documented conflicting results of non-operative treatment of patients who do
not have a neurological deficit1-11-'7-26-38-44-52. Denis et al.
reported high rates of failure in the form of severe deformity, an increasing neurological deficit, and incapacitating pain 17 . They concluded that patients who
had been managed operatively fared much better in
terms of pain, deformity, return to work, and neurological function. McEvoy and Bradford r e p o r t e d on
twenty-two patients who had initially been managed
non-operatively 44 . Although n o neurological deterioration was observed in neurologically normal patients,
there were six failures due to an increasing neurological deficit in partially paralyzed patients, increasing deformity, and persistent pain.
Despite these pessimistic reports, there is a growing
body of evidence that a burst fracture without a neurological deficit can be treated non-operatively, with only
rare neurological deterioration and with a good longterm clinical result. Weinstein et al.52, Chan et al.", and
Mumford et al.45 reported the results of non-operative
treatment of thoracolumbar and lumbar burst fractures.
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BURST F R A C T U R E S O F T H E S E C O N D T H R O U G H FIFTH LUMBAR V E R T E B R A E

TABLE I
DISTRIBUTION OF THE- FIFTY-FIVE PATIENTS AMONG THE FIVE TREATMENT GROUPS, ACCORDING TO THE LEVEL OF THE FRACTURE

Level
of Fracture

Group I:
Non-Op.
Treatment

L2
L3
L4
L5

12
8
5
5

Group II:
Posterior
Arthrodesis
(Long)

Of the 101 patients in those three series, only one had

neurological deterioration. All three groups of investigators reported acceptable clinical outcomes and the
lack of a relationship between the final anatomical result and the clinical symptoms.
A neurological deficit adds another component to
the process of making decisions regarding treatment.
No previous study, to our knowledge, has specifically
addressed the results of neurological injuries of the
cauda equina. Although neurological recovery has been
demonstrated after non-operative treatment of thoracolumbar fractures69153436'46, there is currently a trend to
treat these injuries more intensively. Several reports
have documented improved neurological function after
decompressive operative procedures722-3742.
The purpose of the present retrospective study was
to compare the long-term radiographic and functional
results of treatment of lumbar burst fractures with and
without operative decompression and arthrodesis.
Materials and Methods
Seventy-four consecutive patients in whom a lumbar
burst fracture at the second, third, fourth, or fifth lumbar
level had been treated at Southern Illinois University
School of Medicine between 1976 and 1992 were identified by a review of the records of the Orthopaedic
Spine Service. To be eligible for inclusion in the study,
the fracture had to have been non-pathological and
the patient had to have been followed for more than
two years. Of the seventy-four patients, two had died of
causes unrelated to the injury of the spine, six were
contacted but refused to participate in the study, and
eleven had been lost to follow-up. This left fifty-five
patients for the review.
There were forty-one male and fourteen female
patients. The mean age was thirty-one years (range,
fourteen to seventy-one years). The mechanisms of
injury included a motor-vehicle accident (twenty-nine
patients), a fall (seventeen patients), a motorcycle accident (four patients), a crush injury (four patients), and
a small-aircraft accident (one patient). Twenty-five fractures were at the second lumbar vertebra; seventeen,
at the third lumbar vertebra; eight, at the fourth lumbar vertebra; and five, at the fifth lumbar vertebra
(Table I). There were forty-five associated injuries in
twenty-three patients. Twenty-one patients had a fracVOL. 78-A, NO. 8, A U G U S T 1996

Group III:
Posterior
Arthrodesis
(Short)

Group IV:
Anterior and
Posterior
Arthrodesis

Group V:
Anterior
Arthrodesis
Only

ture of an extremity; six, a pelvic fracture; five, a closed

head injury; four, a chest injury; four, another injury of
the spine; three, a blunt abdominal injury; and two, a
burn. Of the four patients who had an additional injury of the spine, three had a compression fracture at
the first, third, or fourth lumbar level and the fourth
had a burst fracture at the first lumbar level. The physical and neurological status at the time of the injury
was assessed for each patient on the basis of the physical examination reports, the reported motor-trauma index4', and the grade according to the classification of
Frankel et al.27.
Thirty patients were managed non-operatively
(Group I). Twenty patients were managed with a body
cast and seven, with a custom-molded thoracolumbosacral orthosis; these patients were allowed out of bed
ten to fourteen days after the injury. The remaining
three patients were managed with more than four weeks
of bed rest because of an associated pelvic fracture.
Twenty-five patients were managed operatively (Table I). Sixteen had posterior instrumentation and arthrodesis: eight of them had long-segment (more than
two motion segments) hook-and-rod fixation (Group II),
and eight had short-segment (two motion segments)
transpedicular fixation (Group III). An additional six
patients (Group IV) had anterior and posterior arthrodesis. Three patients one who had a fracture at
the second lumbar level and two who had a fracture at
the fourth lumbar level had anterior decompression
and arthrodesis only (Group V). No anterior metallic
implants were used. Autogenous bone graft was used
for all arthrodeses. It is noteworthy that only one fracture caudad to the third lumbar level was treated with
instrumentation.
Both the initial and the follow-up radiographs were
reviewed. Of the fifty-five patients, forty-eight had complete radiographic data. Because of an institutional policy of destroying the radiographs of patients whose files
are inactive, the initial radiographs were not available
for the remaining seven patients. The initial radiographs
had been made with the patient supine because of the
acuteness of the injury. Radiographs at the follow-up
evaluation were made with the patient standing. Anteroposterior and lateral radiographs, with a distance
of forty-four inches (111.8 centimeters) from the x-ray
tube to the film cassette, were made for all patients.

1158

D. A. ANDREYCHIK, D. H. ALANDER, K. M. SENICA, AND E. S. STAUFFER

No radiographs were made with the spine in flexion or

extension.
The fractures were classified according to the system of Denis16, and measurements of kyphosis, compression, scoliosis, and the vertebral wedge index were
recorded. Kyphosis and scoliosis were measured with
the Cobb13 method, with the superior end plate of the
vertebra cephalad to the fracture and the inferior end
plate of the vertebra caudad to the fracture used as
references. Vertebral body compression was calculated
with the method of Willen et al.M. The wedge index was
expressed as a ratio of the anterior height of the body
to the posterior height, as measured on the lateral radiograph. The initial computerized tomography scans
that had been made before treatment were available
for review for thirty-seven of the fifty-five patients.
Compromise of the spinal canal was calculated with
the method of Mumford et al.45, with the intact vertebrae cephalad and caudad to the fracture used as references. The postoperative and follow-up computerized
tomography scans were also reviewed when they were
available. Magnetic resonance imaging was not routinely used in this population of patients, largely because of the time-period of the study. The success of
the arthrodesis and the subsequent fusion were not
specifically addressed for the groups that had been
managed operatively because of the inherent inaccuracy of plain radiographs in defining a solid fusion.
However, the instrumentation did not fail in any patient. Evidence of injury of a facet joint or another posterior element was also recorded. For consistency, all
radiographic measurements were made by one orthopaedic surgeon (D. A. A.) who had not been involved in
the initial treatment.
The most recent follow-up evaluation consisted of
an office visit, during which the patient responded to
a questionnaire regarding pain and functional status
and one of us (D. A. A., D. H. A., or K. M. S.) performed
a complete clinical and radiographic examination. This
assessment was performed at a mean of seventy-nine
months (range, twenty-four to 192 months) after the
injury. Each patient was assigned a pain score on the
basis of the frequency of pain and the use of medications. According to this scoring system, 0 indicates no
pain; 1 point, intermittent mild pain not necessitating
use of medication; 2 points, frequent mild pain necessitating occasional use of non-narcotic medication; 3
points, moderate pain necessitating frequent use of nonnarcotic medication; 4 points, severe pain necessitating
occasional use of narcotic medication; and 5 points, profound pain necessitating regular use of narcotic medication. If a patient needed a reconstructive procedure
because of pain or instability, the score immediately
before that operation was used for analysis.
The functional rating was based on a comparison of
the patient's occupational and recreational status before
the injury and that after it. According to this rating

system, 0 indicates a return to the patient's pre-injury

occupation with no limitation; 1 point, a return to the
pre-injury occupation but minor occupational and recreational limitations; 2 points, a return to the pre-injury
occupation but major occupational and recreational
limitations; 3 points, a return to work but in a job that
is less strenuous than that before the injury; and 4 points,
an inability to perform productive work or to participate in recreational activities. The patient's employment
status before and after the injury was recorded with use
of a 0 to 5-point work-status scale, developed by the
United States Department of Training and Employment
Service51, to determine the effect of previous employment status on the functional outcome. According to
this scale, 1 point indicates heavy labor that involves
constant lifting of more than fifty pounds (22.7 kilograms); 2 points, moderately heavy labor that involves
constant lifting of more than twenty-five pounds (11.3
kilograms); 3 points, light labor that involves constant
lifting of less than ten pounds (4.5 kilograms); 4 points,
a sedentary job that involves sitting or standing without
lifting; and 5 points, unemployment.
Each patient was assigned to one of five treatment groups: Group I was managed with bed rest and
use of a cast; Group II, posterior arthrodesis with longsegment instrumentation; Group III, posterior arthrodesis with short-segment instrumentation; Group IV,
anterior and posterior arthrodesis; and Group V, anterior decompression and arthrodesis only. The initial
and most recently seen deformities of the lumbar spine
were compared among the treatment groups, and any
relationships among the method of treatment, the deformity and pain at the time of follow-up, and the functional outcome were analyzed. In the patients who had
been managed non-operatively, the initial and most recent radiographic patterns were compared to determine
whether the initial radiographic parameters had been
predictive of the radiographic deformity at the time of
follow-up. The effectiveness of the operative fixation in
obtaining and maintaining correction was also evaluated. The results for the operatively and non-operatively
treated groups were compared with regard to the most
recent radiographic, neurological, pain, and functional
outcomes.
A one-way analysis of variance with five levels
was used to compare the means of the five treatment
groups for each of the outcome measures. The Duncan
multiple-range follow-up tests were used to make pairwise comparisons. A result was considered significant
if the p value was less than 0.05.
Results
Neurological Outcome
Thirty-six patients had been neurologically intact at
the time of presentation; twenty-three had been managed non-operatively and thirteen had had posterior
arthrodesis. No neurological deterioration was observed
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.1159

BURST FRACTURES OF THE SECOND THROUGH FIFTH LUMBAR VERTEBRAE

TABLE II
DATA ON THE NINETEEN PATIENTS W H O H A D A NEUROLOGICAL DEFICIT AT THE TIME OF PRESENTATION

Grade 27
Case

Level of
Fracture

Treatment

Initial

At
Follow-up

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19

L2
L3
L3
L4
L5
L5
L5
L3
L2
L4
L2
L2
L2
L2
L2
L3
L3
L3
L4

Non-op.
Non-op.
Non-op.
Non-op.
Non-op.
Non-op.
Non-op.
Post, arthrodesis, short
Ant. arthrodesis
Ant. arthrodesis
Post, arthrodesis, long
Post, arthrodesis, long
Ant. and post, arthrodesis
Ant. and post, arthrodesis
Ant. and post, arthrodesis
Ant. and post, arthrodesis
Ant. and post, arthrodesis
Ant. and post, arthrodesis
Ant. arthrodesis

D
D
D
B
D
D
D
D
D
D
D
B
D
D
D
A
A
A
C

E
E
E
D
E
E
E
D
E
E
E
D
D
D
E
D
D
D
E

regardless of the method of treatment, and there were

no symptoms of spinal stenosis at the latest follow-up
evaluation.
Nineteen patients had had neurological loss at the
time of presentation (Table II). Of these patients, ten
had had an isolated single-nerve-root deficit: eight had
a partial paralysis and two, a complete paralysis. Seven
of these patients (six who had had a partial and one who
had had a complete paralysis) had been managed nonoperatively. All six patients who had had a partial paralysis treated non-operatively had complete motor
recovery, although minor sensory deficits persisted in
three. One patient (Case 4) who had been managed
non-operatively had had a complete unilateral paralysis
of the fourth lumbar nerve root; nearly complete recovery was noted at the time of follow-up (change in
motor-trauma index41, from 95 to 99). Another patient
(Case 8) who had had a partial paralysis had been managed with posterior arthrodesis. At the time of the injury, the left quadriceps had been noted to be grade 1
of 5. The patient had incomplete recovery at the latest
follow-up examination (change in motor-trauma index,
from 96 to 99). Two additional patients (Cases 9 and 10),
one who had had a partial paralysis and the other who
had had a complete single-nerve-root lesion, had had
anterior decompression and arthrodesis; both had complete recovery at the latest follow-up visit (change in
motor-trauma indices,from 95 to 100 and from 97 to 100).
Nine patients had had diffuse multiple-nerve-root
dysfunction. Two had been managed with posterior
arthrodesis and seven, with anterior and posterior arthrodesis or anterior decompression and arthrodesis
VOL. 78-A, NO. 8, AUGUST 1996

Motor-Trauma Index41
At
Initial
Follow-up
99
98
99
95
96
96
99
96
95
97
78
50
90
88
71
58
63
51
64

100
100
100
99
100
100
100
99
100
100
100
74
95
99
100
65
80
63
100

alone. Of the two patients who had been managed posteriorly, one (Case 11) had complete motor recovery
(change in motor-trauma index, from 78 to 100). This
patient had diffuse weakness of both lower extremities,
although there was some motor function of all muscle
groups. Soon after placement of Harrington instrumentation, there was a rapid return of motor function, making an anticipated anterior procedure unnecessary. The
second patient (Case 12) had had a complete motor
paralysis (grade B, as defined by Frankel et al.27) secondary to a fracture of the second lumbar vertebra. She
was subsequently managed with Harrington instrumentation, but despite a strong recommendation for an anterior procedure she refused to have.it. She had partial
recovery (change in motor-trauma index, from 50 to 74)
but, at the latest follow-up evaluation, no motor or sensory function was observed distal to the quadriceps. At
the time of writing, she was able to walk about the
community with use of an ankle-foot orthosis.
The remaining seven patients who had had multiplenerve-root dysfunction at the time of presentation had
had anterior and posterior arthrodesis or anterior decompression and arthrodesis alone. Three of these patients had had grade-D status27; one (Case 15) of the three
had complete recovery (change in motor-trauma index,
from 71 to 100), and two (Cases 13 and 14) had partial
recovery (change in motor-trauma indices, from 90 to 95
and from 88 to 99). Sensory deficits persisted in all three
patients. Four patients had had nearly complete motor
paralysis (grade C in one and grade A in three). The
patient who had had grade-C paralysis (Case 19) had
complete motor recovery (change in motor-trauma in-

1160

D. A. ANDREYCHIK, D. H. ALANDER, K. M. SENICA, AND E. S. STAUFFER

TABLE III
DATA ON KYPHOSIS AND COMPRESSION, ACCORDING TO THE TYPE OF TREATMENT*

L2 fracture
No. of patients
Kyphosis (degrees)
Initial
At follow-up
Change
Compression (per cent)
Initial
At follow-up
Change
L3 fracture
No. of patients
Kyphosis (degrees)
Initial
At follow-up
Change
Compression (per cent)
Initial
At follow-up
Change
L4 fracture
No. of patients
Kyphosis (degrees)
Initial
At follow-up
Change
Compression (per cent)
Initial
At follow-up
Change
L5 fracture
No. of patients
Kyphosis (degrees)
Initial
At follow-up
Change
Compression (per cent)
Initial
At follow-up
Change

Group 1:
Non-Op.
Treatment

Group II:
Post. Arthrodesis
(Long)

Group III:
Post. Arthrodesis

(Short) t

Group IV:
Ant. and Post.
Arthrodesis

12

3 (-5 to +12)
12 (5 to 26)
9 (0 to 21)

18 (6 to 40)
15 (7 to 30)
-2 (-10 to +15)

29 (10 to 52)
37 (1.4 to 63)
8 (0 to 27)

54 (33 to 90)
27 (21 to 41)
-27 (-49 to +1)

NA
30

13 (6 to 19)
13 (6 to 21)
0 (-5 to +19)

NA
60

56 (52 to 58)
40 (31 to 61)
-16 (-25 to+9)

-2 (-19 to +17)
8 (-5 to +26)
10 (2 to 17)

5 (-15 to +13)
10 (-6 to+21)
5 (-16 to +22)

32 (24 to 43)
39 (24 to 66)
7 (0 to 25)

48 (44 to 54)
43 (32 to 59)
-5 (-17 to +7)

-24 (-42 to -9)

-12 (-22 to +5)
12 (5 to 22)

40 (30 to 56)
44 (30 to 63)
4 (-11 to +20)
0

5
5
0

33 (9 to 46)
47 (36 to 63)
14 (1 to 22)
5

7 (5 to 8)
9 (5 to 14)
2 (0 to 6)

52
33
-19
0

-25 (0 to -35)
-15 (-26 to +10)
10 (4 to 15)
47 (34 to 58)
51 (33 to 69)
4 ( 0 to 11)

*The values are given as the mean, with the range in parentheses.
tNA = not available.

dex, from 64 to 100), and the remaining three (Cases 16,

17, and 18) all had incomplete recovery (motor-trauma
indices at the time of follow-up, 65, 80, and 63). One of
these patients used an ankle-foot orthosis bilaterally for
walking about the community. The other two used a
wheelchair although both had enough strength in the
lower extremities for transfers. Of the nine patients who
had had multiple-nerve-root involvement, four had had
bowel and bladder dysfunction at the time of presentation. Three of the four attained normal function after
anterior decompression and arthrodesis.
Radiographic Evaluation
The initial kyphosis and initial compression associated with fractures at the second and third lumbar levels were compared between the group that had been

managed non-operatively and the groups that had been

managed with posterior arthrodesis, to determine if
there had been a bias toward performing an operation
for fractures associated with a larger initial deformity
(Table III). Only fractures at these two levels were included, as only one fracture caudad to the third lumbar
level had been stabilized with instrumentation.
The mean initial kyphosis was 2 degrees (range, -19
to +17 degrees) for the patients who had been managed
non-operatively (Group I), compared with 10 degrees
(range, -15 to +40 degrees) for the patients who had had
posterior stabilization (Groups II and III). The mean
initial compression was 29 per cent (range, 10 to 52 per
cent) for Group I, compared with 50 per cent (range, 33
to 90 per cent) for Groups II and III. Both of these
differences were significant (p = 0.05 and 0.0006).
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B U R S T F R A C T U R E S OF T H E S E C O N D T H R O U G H FIFTH LUMBAR V E R T E B R A E

TABLE IV
DATA WITH REGARD TO CORRECTION OF THE KYPHOSIS, ACCORDING TO THE TYPE OF INSTRUMENTION*

Group III:
Post. Arthrodesis (Short)
Fixateur Internet
Steffee Plates
(N = 5)
(N = 3)

Group II:
Post. Arthrodesis
(Long)
(N = 8)
Initial kyphosis
Correction obtained
Correction lost with
instrumentation in place
Correction lost after
removal of instrumentation
Total loss of correction
Total change in kyphosis

18 (6 to 40)
9 (0 to 20)
9 (3 to 14)

1 (-15 to +10)
19 (15 to 27)
23 (11 to 38)

5 (5 to 13)
13 (11 to 16)
13 (7 to 18)

6 (5 to 7)

-2 (-10 to +15)

4 (-16 to +22)

19 (12 to 26)
6 (-1 to +14)

Group IV:
Ant. and Post.
Arthrodesis
(N = 6)
12 (5 to 19)
17 (8 to 25)
18 (9 to 25)

1 (-5 to +19)

*The values are given as the mean, in degrees, with the range in parentheses. The mean duration of follow-up for all patients was eighty-six
months.
tFour of the five patients who were managed with the fixateur interne had the device removed at a mean of eleven months postoperatively.

The degree of kyphosis immediately after the injury and preoperatively was compared with that at the
latest follow-up evaluation. The mean increase in kyphosis during treatment was 10 degrees (range, 0 to 21
degrees) for the patients who had been managed nonoperatively (Group I) compared with - 2 degrees (range,
-10 to +15 degrees) for those who had been managed
with a long hook-and-rod system (Group II), 5 degrees
(range, -16 to +22 degrees) for those who had been
treated with a short transpedicular construct (Group
III), and 0 degrees (range, -5 to +19 degrees) for those
who had been managed with anterior and posterior
arthrodesis (Group IV). The increase in kyphosis for
the patients who had been managed non-operatively
and for those who had been treated with short transpedicular fixation was similar. Both values were significantly greater than those for the patients who had been
managed with either long posterior arthrodesis or anterior and posterior arthrodesis (p = 0.005).
The change in vertebral body compression averaged
8 per cent (range, 0 to 27 per cent) for the group that
had been managed non-operatively, -27 per cent (range,
-49 to +1 per cent) for the group that had been treated
with long posterior arthrodesis, -5 per cent (range, -17
to +7 per cent) for the group that had had short posterior arthrodesis, and -10 per cent (range, -25 to +20
per cent) for the group that had had anterior and posterior arthrodesis. The difference between the group
that had been managed non-operatively and the groups
that had been treated operatively was significant (p =
0.0004). The change in kyphosis did not correspond to
the change in compression in the group that had been
managed with short fixation.
The initial radiographic measurements, including
the type of fracture according to the classification of
Denis16, the location of the fracture, the initial kyphosis,
the initial compression, the initial vertebral wedge index, and the presence of radiographically identifiable
injury of the posterior elements, were analyzed with
regard to progressive deformity in the form of increased
VOL. 78-A, NO. 8, A U G U S T 1996

kyphosis. Sixteen fractures were classified as Denis type

A and fourteen, as type B. Only one type-B fracture was
caudad to the third lumbar level, indicating a predilection of type-A fractures for the more caudad lumbar
segments. With the numbers available, the level of the
fracture (p = 0.47), the initial kyphosis (p = 0.27), the
initial compression (p = 0.07), and disruption of the posterior elements (p = 0.10) demonstrated no relationship
to increased kyphosis. The only significant relationship
was between Denis type-A fractures and progressive
kyphosis (mean increase, 12 degrees [range, 2 to 22 degrees], compared with 7 degrees [range, 0 to 15 degrees]
for the type-B fractures; p = 0.02). The initial compression associated with the type-A fractures was greater
than that associated with the type-B fractures (38 compared with 28 per cent). This wedge compression remained constant and did not account for the increase in
kyphosis seen at the time of follow-up.
The effectiveness of the various types of operative
treatment in achieving and maintaining correction of
the deformity was assessed (Table IV). With the numbers available, the mean values for the initial kyphosis
and the initial compression were not significantly different (p = 0.10 and 0.94) among the treatment groups.
For the patients who had had long posterior arthrodesis (Group II), short posterior arthrodesis (Group
III), and anterior and posterior arthrodesis (Group IV),
the mean initial kyphosis was 18 degrees (range, 6 to
40 degrees), 5 degrees (range, -15 to +13 degrees), and
12 degrees (range, 5 to 19 degrees), respectively. The
mean initial compression was 54 per cent (range, 33 to
90 per cent), 48 per cent (range, 44 to 54 per cent), and
50 per cent (range, 30 to 58 per cent). With the numbers available, no significant differences were observed
among the groups with respect to correction obtained
and correction lost throughout the follow-up period
(p = 0.15 and 0.09). For the patients who had had long
posterior arthrodesis (Group II), the mean correction
was 9 degrees (range, 0 to 20 degrees) and the mean
correction lost was 9 degrees (range, 3 to 14 degrees).

1162

D. A. ANDREYCHIK, D. H. ALANDER, K. M. SENICA, AND E. S. STAUFFER

For the patients who had had short posterior arthrodesis (Group III), the mean correction was 15 degrees
(range, 11 to 27 degrees) and the mean correction lost
was 19 degrees (range, 7 to 38 degrees). For the patients who had had anterior and posterior arthrodesis
(Group IV), the mean correction was 17 degrees (range,
8 to 25 degrees) and the mean correction lost was 18
degrees (range, 9 to 25 degrees). Although transpedicular fixation and anterior and posterior arthrodesis displayed the greatest capacity for correction, all constructs
tended to collapse toward the preoperative deformity.
The radiographs of the three patients who had had anterior arthrodesis only were excluded from the analysis,
as only one of these patients had complete radiographic
data.
The initial computerized tomography scans were analyzed for twenty-one of the thirty patients in Group I,
none of the eight in Group II, all eight in Group III, all
six in Group IV, and two of the three in Group V. The
mean reduction in the cross-sectional size of the canal
was 43 per cent (range, 10 to 90 per cent) for Group I,
68 per cent (range, 50 to 90 per cent) for Group III, and
87 per cent (range, 75 to 90 per cent) for Group IV. In
Group V, both patients for whom computerized tomography scans were available had a 90 per cent reduction
in the cross-sectional size of the canal.
Follow-up computerized tomography scans were interpreted for two patients (one fracture at the second
lumbar level and one at the third lumbar level) who had
been managed non-operatively. Both patients had partial resorption of the fragments in the canal. The patient
who had had a fracture at the second lumbar level had
an initial reduction of 44 per cent in the cross-sectional
size of the canal; forty-four months after the injury, the
canal had increased to 90 per cent of its expected size.
The patient who had had a fracture at the third lumbar
level had an initial reduction of 40 per cent in the crosssectional size of the canal; fifty months after the injury,
the canal had increased to 80 per cent of its expected
size.
Immediate postoperative scans were available and
were reviewed for four of the eight patients who had
been managed with a short transpedicular construct
(Group III); all four had had a fracture at the third
lumbar level. The increase in the cross-sectional size of
the canal at the level of the injury was unpredictable;
the mean initial decrease was 78 per cent (range, 60 to
90 per cent), and the mean postoperative size was 62 per
cent (range, 50 to 90 per cent).
Pain and Functional Results
At the latest follow-up evaluation, the pain scores
were a mean of 1.50 points for Group I, 1.13 points
for Group II, 1.38 points for Group III, 1.17 points
for Group IV, and 1.33 points for Group V; with the
numbers available, these differences were not significant (p = 0.78). No relationship was demonstrated be-

tween the pain score and the level of the fracture, the
kyphosis at the time of follow-up, the compression at
the time of follow-up, the change in the kyphosis, or the
change in the compression (p = 0.27,0.15,0.23,0.09, and
0.09, respectively). The only variable that had a significant relationship (p = 0.03) to the pain score was the
type16 of fracture. The pain score was a mean of 1.76
points for type-A fractures, 1.33 points for type-B, and
1.00 for type-D. Although we could not determine a
significant difference with the numbers available, there
was a trend for higher pain scores in association with
the fractures at the more caudad lumbar segments (a
mean of 1.33, 1.18, 1.50, and 2.20 points in association
with fractures at the second, third, fourth, and fifth lumbar levels, respectively).
Most of the thirty patients who had been managed
non-operatively had mild or moderate pain. Only three
of these patients were pain-free (a pain score of 0
points). Seventeen patients had intermittent mild pain
(a pain score of 1 point); three, frequent mild pain (a
score of 2 points); five, moderate pain (a score of 3
points); one, severe pain (a score of 4 points); and one,
profound pain (a score of 5 points). The patient who had
a score of 4 points was a nineteen-year-old woman who
had sustained a burst fracture at the fourth lumbar level
as a result of a motor-vehicle accident. She did well (a
pain score of 1 point) for two and one-half years, until
she was involved in another motor-vehicle accident. After the second accident, she had persistent back pain
although she remained employed. She eventually had
anterior and posterior arthrodesis for relief of pain
associated with instability at a level cephalad to the
fracture. Eight months postoperatively, she had only
intermittent mild discomfort (a pain score of 1 point).
The patient who had a pain score of 5 points was a
twenty-nine-year-old man who had sustained a fracture
at the second lumbar level secondary to a work-related
injury. He reported profound pain and eventually, at
twelve months, had anterior and posterior arthrodesis
for the pain as well as disc degeneration and instability
(13 degrees on flexion and extension). Seven years after
the operation, the pattern of pain remained unchanged
and the patient was totally disabled.
In the operative groups, three patients had no pain;
fifteen, intermittent mild pain; five, frequent mild pain;
and two, moderate pain.
For the patients who did not have neurological
dysfunction, the functional outcome at the time of the
most recent follow-up was analyzed with respect to the
patient's age, the level of the fracture, the kyphosis
and compression at the time of follow-up, and the patient's pre-injury occupation. With the numbers available, no significant relationships were found. Of the
thirty patients who had been managed non-operatively,
ten had performed heavy labor before the injury, six
had performed moderately heavy labor, three had performed light labor, nine had been sedentary, and two
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BURST FRACTURES OF THE SECOND THROUGH FIFTH LUMBAR VERTEBRAE

had been unemployed. Of the twenty-eight patients who

had been employed at the time of the injury, twenty-five
(89 per cent) returned to their pre-injury occupational
status, although ten had minor and two had major limitations (a functional score of 1 and 2 points, respectively). One patient, who had a functional score of 3
points, needed to change to a less strenuous occupation. Two patients were disabled as a result of pain: the
twenty-nine-year-old man described previously as well
as a forty-eight-year-old man who had sustained a fracture at the fifth lumbar level and was unable to return
to work because of moderate pain; these patients had a
pain score of 5 and 3 points, respectively.
Of the twenty-five patients who had been managed
operatively, seven had performed heavy labor before
the injury, six had performed moderately heavy labor,
three had engaged in light labor, five had been sedentary, and four had been unemployed. Of the twenty-one
patients who had been employed at the time of the
injury, three were disabled secondary to neurological
dysfunction. Of the eighteen remaining patients, sixteen
returned to their pre-injury work status, one was employed in a less strenuous job, and one was unemployed
secondary to moderate activity-related back pain. Of
the entire group of twenty-five patients, fifteen had no
functional impairment and four had minor functional
limitations.

1163

of severe neurological deficits and the potential for neurological recovery when such a deficit is present.
In patients who do not have a neurological deficit,
the long-term clinical results of non-operative treatment
have been comparable with those of operative treatm e n t u 1.15,26.27,38.45,46.52 Although operative stabilization has
been previously shown to improve the alignment of the
spinel,2A10,12,14,,7-20,22,23,2832,33,36,39,47,48,535

^ g

a n a

t 0 m i c a l TCSUlt h a S

never been shown to be related to the final neurological

or clinical outcome1115'27-34'45-4652.
In the past, the spectrum of non-operative treatment has ranged from prolonged periods of strict bed
rest to early protected mobilization1115-27'34-38-45'46. A variable amount of bed rest ranging from two to twelve
weeks has been advocated. With a current trend toward
less costly, shortened hospitalizations, prolonged bed
rest is becoming a less popular treatment method. It is
our contention that most lumbar burst fractures possess
adequate inherent stability to allow early protected mobilization. We currently manage patients who have a
lumbar burst fracture with bed rest for three, four, or
five days followed by application of a cast and mobilization; the patients are generally discharged from the
hospital within a week after the injury. The duration of
this treatment regimen compares favorably with that of
hospitalization for patients who have been managed
operatively.

Burst fractures of the lumbar spine have unique

biomechanical and neurological features as compared
with burst fractures in other regions of the spine. Decisions with regard to stability and treatment are different
than those made when there is a more cephalad fracture of the vertebral column. In the lumbar spine, the
body's center of gravity falls at or posterior to the vertebral axis1. Slight flexion decreases the lordosis and
places the axial load force-of-injury vector through the
vertebral body. This dictates the specific pattern of injury as well as the tendency for progressive deformity.
Pure axial load injuries are more common in this spinal
region16-24. Because of the relative stability provided by
the posterior elements, the risk of neurological deterioration is iow1'1U5'263"'38'45<52.

Composite series of thoracolumbar and lumbar

burst fractures have had conflicting results with regard
to the efficacy of non-operative treatment17'38-44-45'52. Two
recent reports dealt exclusively with the lumbar spine111.
Chan et al.11 evaluated twenty neurologically intact patients who had had non-operative treatment for a lumbar burst fracture. Eighteen patients (90 per cent) had
a good or excellent result, and no neurological deterioration or incapacitating back pain was noted. An et
al.1 reported the results of treatment of twenty burst
fractures at the third, fourth, and fifth lumbar levels.
The patients who had been managed non-operatively
had less pain than those who had been managed with
arthrodesis of four or five spinal segments. The neurological and functional outcomes were similar for the
neurologically intact patients regardless of the method
of treatment.

From a neurological standpoint, the content and

size of the neural canal distinguish the lumbar area
from other regions. The cauda equina alone occupies
the spinal canal at and caudad to the second lumbar
level. Unlike in the spinal cord or the conus medullaris, neurological dysfunction in this area simulates a
peripheral-nerve injury with the potential for spontaneous recovery. Additionally, the dimensions of the
spinal canal are wider here than in any other region
and, indeed, there have been several reports of decreases of as much as 90 per cent in the cross-sectional
area of the canal in the absence of a neurological deficit62635. These features help to explain the infrequency

Our findings are consistent with those of Weinstein

et al.52, Mumford et al.45, An et al.1, and Chan et al.11. We
did not find neurological deterioration in our patients
who had been managed non-operatively and, despite a
larger ultimate deformity in this group, the pain and
functional scores at the latest follow-up evaluation were
not significantly different than those for the groups that
had been treated operatively. Quite unexpectedly, the
pain scores for the patients who had had a long posterior arthrodesis (to the fourth or fifth lumbar level)
were similar to those for the other groups, despite a
mean duration of follow-up of more than ten years. The
only factor that was related to the pain score at the

Discussion

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D. A. ANDREYCHIK, D. H. ALANDER. K. M. SENICA, AND E. S. STAUFFER

time of follow-up was a type-A fracture, although there

was a trend toward more pain with the more caudad
levels of fracture. The relationship between the type of
fracture and the pain score is difficult to explain, but
type-A fractures may result in disruption of two motion segments rather than one. Also, activity-related
stresses are concentrated toward the more caudad lumbar segments.
We were unable to predict the deformity at the time
of follow-up from the initial radiographic measurements. Neither the initial kyphosis, compression, and
wedge index nor the presence or absence of radiographically identifiable disruption of the posterior elements demonstrated any relationship to the deformity
at the time of follow-up. However, type-A fractures
were associated with almost twice as much progressive
deformity as type-B fractures (12 compared with 7 degrees). This finding was somewhat unexpected, as most
type-A fractures were clustered in the more caudad
segments, an area caudad to the apex of the lordosis,
where less progressive deformity would be expected.
With the numbers available, the relationship between
the vertebral body compression and the kyphosis at the
time of follow-up was not significant.
We believe that the inability to predict the deformity
at the time of follow-up from the initial radiographs is
related to the intervertebral disc spaces. The discs in the
lumbar spine are larger and assume a more structural
role than those in other regions of the spine. As initial
plain radiographs, usually made with the patient supine,
fail to document the extent of damage to the intervertebral disc, anatomical predictions made on the basis of
the initial osseous measurements are unreliable. Denis16
type-A fractures theoretically result in more extensive
damage to the disc inferiorly, which may explain this
finding. The role of the intervertebral disc in the production of the deformity is further supported by the data
on our patients who had had posterior spinal arthrodesis (Groups II and III). Despite reasonable correction
of the sagittal alignment (9 and 16 degrees for hookand-rod and transpedicular fixation, respectively) and a
decrease in vertebral body compression postoperatively,
all constructs tended to settle through the involved disc
spaces toward the immediate post-injury position. At
the time of follow-up, the anatomical results of the short
(two-motion-segment) fixation were not significantly
better than those of the non-operative treatment. Even
the patients who had had anterior and posterior arthrodesis had an increase in kyphosis at the latest follow-up
evaluation, despite having had a mean correction of 17
degrees at the time of the operation. We attribute this
increase to the fact that the anterior strut had not been
placed securely from end plate to end plate. The only
way to reconcile an increase in kyphosis without an
increase in the percentage of vertebral body compression is to attribute the increasing angular deformity to
the disc space. All of the instrumentation systems that

were used could partially restore the osseous anatomy

and provide a stable environment for bone-healing. Ultimately, however, no system, regardless of its rigidity,
could compensate for the defect created by the damaged discs. Reports of the results of posterior instrumentation in other series'0121419'222839'47 have documented a loss
of correction over time similar to that in the current
study.
The over-all comparable clinical results between the
group that had been managed non-operatively and
those managed operatively, coupled with the variable
anatomical results of posterior arthrodesis, call into
question the role of prophylactic internal fixation in
patients who have a lumbar burst fracture in the absence of a neurological deficit.
A neurological deficit at the time of presentation
introduces another factor into the treatment equation.
Although previously debated by some6'9-15,27'46, the role of
decompression and realignment as a means of augmenting neurological recovery has been supported in the
recent literature7'212337'4248. We are unaware of any studies
that have specifically addressed neurological recovery
in patients who have an isolated traumatic lesion of
the cauda equina. All ten of our patients who had had
a single-nerve-root paralysis had substantial improvement, although two (one managed non-operatively and
the other managed with posterior arthrodesis) had incomplete recovery. Both patients had had a complete
nerve-root paralysis at the time of presentation. The
patients who had had a partial single-nerve-root deficit
recovered, regardless of the method of treatment. Nine
patients had had a multiple-nerve-root paralysis at the
time of presentation, and it is for such patients that
decompressive procedures appear to be beneficial in
restoring motor, bowel, and bladder function.
Although the results of anterior decompression appear encouraging, interpretation of the data is hampered by several factors. No study of which we are
aware, including the current one, has been prospective
and controlled, making it difficult to determine if the
treatment is actually altering the natural history of the
neurological lesion. Additionally, neurological recovery
in patients who have an incomplete lesion has been
reported not only after posterior stabilization procedures11012 but also during the course of non-operative
treatment6'915'27'34'46. Further complicating the picture are
the poor relationships between the initial compromise
of the canal and the initial neurological deficit6293549 and
between the anatomical result and neurological recovery at the time of follow-up62746. Despite the paucity of
controlled studies and the seemingly poor relationship
between the anatomy of the spinal canal and neurological function, it is our impression, on the basis of our
data and those in the literature, that a multiple-nerveroot deficit secondary to a lumbar burst fracture should
be treated with anterior decompression.
By nature of its design, a study such as the current
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BURST FRACTURES OF THE SECOND THROUGH FIFTH LUMBAR VERTEBRAE

one contains inherent scientific flaws. Our data represent a consecutive series spanning a sixteen-year timeperiod. Many of the variables that were evaluated, such
as the specific treatment plan, were not controlled. It
could be argued, for example, that the fractures that
were treated operatively were more severe than those
that were treated non-operatively and that the similarity in the clinical results was more a reflection of the
anatomy of the fracture than of the method of treatment. We contend that the method of treatment is more
reflective of the time-period of the study than of a specific bias in the treatment. We did not address the issue
of a preferred operative approach, as our intention was
to examine the long-term radiographic and functional
results. Very few magnetic resonance imaging scans
were available, which may have influenced our decisions with regard to treatment. The lack of magnetic

1165

resonance imaging was due to the time-period that the

study covered and to the limited availability of this modality throughout much of the study period,
Despite these limitations, we believe that the findings of our comparison of non-operative and operative
treatment are indicative of the long-term functional and
radiographic results of fractures of the lumbar spine. On
the basis of these results, we conclude that, in the absence of a neurological deficit or in the presence of a
partial single-nerve-root paralysis, patients who have a
lumbar burst fracture can be managed with early protected mobilization. This treatment method results in a
neurological, clinical, and functional outcome comparable with that of other forms of treatment. Decompressive procedures appear to be indicated in patients who
have a complete single-nerve-root or a multiple-nerveroot lower-extremity paralysis.

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