234

Relato de Caso

What is the importance of the spinal canal encroachment in the

management of thoracolumbar burst fracture without neurological
deficit? A review
Qual a importância da compressão do canal vertebral na decisão de conduta
da fratura em explosão toracolombar sem déficit neurológico? Revisão
Fabrizio Borges Scardino, M.D.1,
Alécio Cristino Evangelista Santos Barcelos, M.D.1,
Vanessa Bizarri da Silva2,
Paulo Augusto Silva Dumont, M.D.3,
José Marcus Rotta, M.D.1,
Ricardo Vieira Botelho, M.D., Ph.D.1

ABSTRACT The thoracolumbar fractures classifications did not directly

Introduction: The relevant features in the treatment
of thoracolumbar fractures vary in the literature. The
classical surgical indications of burst fractures are loss of
vertebral body height, kyphosis, neurological deficit and
canal encroachment. Recent papers have attributed less
importance to canal impingement as a surgical indicator in
intact patients, irrespectively of the degree of encroachment.
The several thoracolumbar fracture classifications have
prompted efforts to guide the surgical indications. We
analyzed the relevance attributed to the canal encroachment
by thoracolumbar fracture classifications in the management
of burst fractures without neurological deficit. Objective:
To evaluate the relevance attributed by the thoracolumbar
fractures classifications to the canal encroachment in the
management of burst fractures without posterior ligamentous
complex disruptions or neurological deficits. Methods: A
literature search was performed by tracking the related
articles of thoracolumbar fractures classifications from
Vaccaro’s to Holdsworth’s study. We analyzed the role of
canal impingement in the management of burst fractures
without posterior ligament complex injury or neurological
deficits in each classification. Results: Seven classifications
were included. Holdsworth considered the burst fractures as
stable, irrespectively of the amount of canal impingement or
neurological deficit. Denis considered that the burst fracture
carried a neurological instability criterion, therefore, in these
cases he suggested surgical treatment because of the risk
of new neurological damage. McAffee postulated that there
is no reliable predictor to correlate the severity of canal
encroachment with the risk of neurological damage. Ferguson
and Allen discussed the possibility of anterior decompression,
stabilization and anterior fusion of the spine in certain
cases of burst fractures. The classifications of McCormack,
Karaikovic and Gaines, Magerl and Vaccaro did not include
canal encroachment in their considerations. Conclusion:
consider the severity of canal encroachment in the treatment
decision making of burst fractures without neurological
damage. It is not possible to predict which patients will
deteriorate if not operated. It remains unclear what is the risk
of neurological deterioration in a SCE greater than 50%.
Keywords: Spinal trauma, burst fractures, canal encroach-
ment, neurological status, decision making, classifications.
SINOPSE
Introdução: As características relevantes no tratamento das
fraturas toracolombares variam na literatura. As indicações
cirúrgicas clássicas de fraturas tipo explosão são perda
de altura do corpo vertebral, cifose, déficit neurológico e
compressão do canal. Estudos recentes têm atribuído menos
importância à compressão do canal como um indicador
cirúrgico em pacientes neurologicamente intactos. As várias
classificações de fraturas toracolombares tentam orientar
a indicação cirúrgica. Analisamos a relevância atribuída
à compressão do canal pelas classificações de fraturas
toracolombares na conduta das fraturas explosão sem déficit
neurológico. Objetivo: Avaliar a relevância atribuída pelas
classificações de fraturas toracolombares à compressão do
canal na conduta da fratura explosão, sem lesão do complexo
ligamentar posterior ou déficit neurológico. Métodos:
Foi realizada uma revisão da literatura por “tracking”
dos artigos relacionados às classificações de fraturas
toracolombares a partir do artigo de Vaccaro até o de
Holdsworth. Analisamos o papel da compressão do canal na
conduta da fratura explosão sem lesão ligamentar posterior
ou déficit neurológico em cada classificação. Resultados:
Sete classificações foram incluídas. Holdsworth considerou
as fraturas explosão como estáveis, independentemente do
grau de compressão do canal ou déficit neurológico. Denis

1- Neurosurgeon, Department of Neurosurgery, Spine Surgery Section, Hospital do Servidor Público Estadual de São Paulo, São Paulo, Brazil
2- Physioterapist, Department of Neurosurgery, Spine Surgery Section, Hospital do Servidor Público Estadual de São Paulo, São Paulo, Brazil
3- In memorian

Recebido em setembro 2010, aceito em setembro 2010

Scardino FB, Barcelos ACES, Silva VB, Dumont PAS, Rotta JM, Botelho RV - What is the importance of the spinal canal encroachment in the management of J Bras Neurocirurg 21 (4): 234-239, 2010
thoracolumbar burst fracture without neurological deficit? A review
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Relato de Caso

considerou que a fratura explosão determina instabilidade

neurológica, portanto, nestes casos ele sugeriu o tratamento
cirúrgico, devido ao risco de dano neurológico novo. McAffee
postulou que não existe preditor confiável para correlacionar
a gravidade da compressão do canal com o risco de dano
neurológico. Ferguson e Allen discutiram a possibilidade de
descompressão anterior, estabilização e fusão anterior da
coluna vertebral em determinados casos de fraturas explosão.
As classificações de McCormack, Karaikovic e Gaines,
Magerl e Vaccaro não incluíram a compressão do canal em
suas considerações. Conclusão: As classificações de fraturas
toracolombares não consideram, diretamente, a gravidade
da compressão do canal na decisão de conduta da fratura
tipo explosão, sem déficit neurológico. Não é possível prever
quais pacientes evoluirão com dano neurológico se não forem
operados. Ainda não está claro qual o risco de deterioração
neurológica em uma compressão do canal superior a 50%.
Palavras-chave: Trauma raquimedular, fraturas explosão,
compressão do canal, estado neurológico, decisão de conduta,
classificações.
Methods
A literature search was performed by tracking the related
articles of thoracolumbar fractures classifications, published in
English language, from Vaccaro’s study, the latest widespread
TLF classification, to Holdsworth’s study, which is considered
the first classification of the TLF treatment modern era. Only
the classical TLF classifications were included due to the fact
that they have been extensively evaluated and validated.
We analyzed the role of SCE in the treatment decision in
burst fractures caused by pure axial load mechanism (vertical
compression), without PLC injury or neurological deficits,
by discussing the treatment orientations of each classification
regarding to this kind of injury.

Results
Introduction
Seven TLF classifications were included in this review
The relevant features in the treatment of thoracolumbar spine 4,6,8,11,12,13,21
.
fractures (TLF) vary in the literature and result in different
management protocols20. The classical surgical indications The results regarding the management of burst fractures in
of TLF are loss of vertebral body height, kyphosis (which neurologically intact patients and the influence of SCE in the
denotes posterior column distraction), neurological deficit and management decision in these classifications are demonstrated
spinal canal encroachment (SCE)24. The severity of SCE has
been considered by many authors as an independent surgical in Table 1. None of the classifications included the severity of
indication criterion3,7,10,24. The canal impingement by bone canal encroachment in management decision in TLF.
fragment can potentially produce a neurological deficit, either
in an early or late phase.
Nevertheless, recent papers have attributed less importance to Table 1 – Recommended management and importance of the SCE in
SCE as a surgical indicator in intact patients, irrespectively of TLF classification
the degree of encroachment1,15,17,25.
Classification Recommended Importance of the canal
What might be the role of spinal canal encroachment in the management encroachment
management of TLF without posterior ligamentous complex 1 - Holdsworth Immobilization in plaster bed and NC
(PLC) injury or neurological deficits? turning case for 8 to 12 weeks

2 - Denis Surgery* **
The several TLF classifications have prompted during decades
efforts to guide the surgical indications. We analyzed the 3 - McAfee Body cast or orthosis NC

relevance attributed to the SCE by TLF classifications in the 4 - Ferguson & Allen Conservative treatment Anterior decompression,
treatment decision in stable burst fractures without neurological *** stabilization, in certain cases

deficit. 5 - Load Sharing NC NC

6 - Magerl NC NC

7 - Vaccaro Conservative treatment NC

Objective * Discuss with the patient the risk of neurological deterioration

** Defines middle column injuries as neurological instabilities
*** This lesion did not lead to further deformity or increasing neurological injury but the authors
discuss the possibility of anterior decompression, stabilization and anterior fusion in certain cases
To evaluate the relevance attributed by the modern TLF
NC: not considered
classifications to the SCE in the management of burst fractures
without PLC disruptions or neurological deficits.

Scardino FB, Barcelos ACES, Silva VB, Dumont PAS, Rotta JM, Botelho RV - What is the importance of the spinal canal encroachment in the management of J Bras Neurocirurg 21 (4): 234-239, 2010
thoracolumbar burst fracture without neurological deficit? A review
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Holdsworth8 was the first one to describe Burst fractures using new deficits in neurologically intact patients in the absence of
the two-column concept. Burst fractures were considered sta- PLC injury, in spite of their residual vertebral canal.
ble lesions, irrespectively of the amount of SCE or neurologi-
The fundamental question is if severe canal encroachment asso-
cal deficit.
ciated to mechanical incompetence of vertebral body could re-
sult in further compression and neurological damage (Figure 1).
Denis, McAffee and Ferguson & Allen used in their classifica-
tions the three-column concept introduced by Denis.

Denis4 suggested a specific classification for instability asso-

ciating mechanistic and neurologic features in spine trauma.
He considered that the burst fracture carries a neurological ins-
tability criterion, therefore, in these cases he suggested surgical
treatment due to the risk of neurological damage in previously
intact patients.

In contrast to Denis, McAffee et al12 and Ferguson & Allen6

used in their classifica¬tions the three-column concept introdu-
ced by Denis4.

Ferguson and Allen6 reported that burst fractures (vertical com-

pression lesions) did not lead to further deformity or increasing
neurologic injury. However, the authors discussed the possibi-
lity of anterior decompression, stabilization and anterior fusion
of the spine in certain cases.

The classifications of McCormack et al13, Magerl et al11 and

Vaccaro et al21 did not include SCE in their considerations.
Figura. 1. Artistic illustration of a stable burst fracture with severe canal encroa-
chment.

Holdsworth8 used the two-column concept: he described the

Discussion
There are characteristics of the burst TLF that are considered
classical indicators for surgery, such as loss of vertebral body
height, distraction or PLC lesion, neurological deficit and canal
encroachment3,7,10,16,24. Lesions of PLC and neurological deficits
are well established surgical indications21.
Severe vertebral body compressions (greater than 50%) indi-
rectly result in PLC distraction and are considered for surgery.
Despite some authors consider the severity of spine canal en-
croachment in vertical compression fractures as a surgical de-
terminant, others do not think so21,25.
Most of the classifications are based on the two-column
concept9. This concept is supported by the probability of late
deformity and/or kyphosis (mechanistic model)23. They do not
consider the risk of neurological damage in fractures defined
as stable. None of these classifications estimate the risk of late
spinal cord injury in traumatic canal encroachment, except
Denis4. This author discusses the surgical treatment for every
middle column lesion. In fact, most papers report low risk of
burst fracture as an injury caused by vertical compression me-
chanism that is stable and in which spontaneous fusion is expec-
ted. He did not discuss the risk for neurological deterioration.
Denis4, in 1983, introduced a grade system that defined burst
fractures as the second degree of instability (neurological ins-
tability), i.e., injuries with risk of neurological deterioration.
He reported late neurological deficit in 20.3% of conservative
burst fractures. Denis and his three-column concept had great
influence on the establishment of classical surgical indicators
at that time3,7,10.
Ferguson and Allen6 reported two types of canal encroachment
in burst injuries with ligamentar complex preservation, concen-
tric or plateau compression, although these did not result in in-
creased neurological injury or spine deformity.
However, McAffee et al12 state that there is not a completely
reliable predictor to evaluate the severity of canal encroachment
and the risk of neurological deficit.
According to Magerl et al11, in type A fractures (compression
fractures) the stability in compression may be intact, impaired,
or lost, depending on the extent of destruction of the vertebral

Scardino FB, Barcelos ACES, Silva VB, Dumont PAS, Rotta JM, Botelho RV - What is the importance of the spinal canal encroachment in the management of J Bras Neurocirurg 21 (4): 234-239, 2010
thoracolumbar burst fracture without neurological deficit? A review

body. The stability in flexion may be intact, or it may be redu-
ced due to the impaired compressive resistance of the vertebral
body. However, stability in flexion is never completely lost sin-
ce, by definition, PLC must be intact in type A injuries. Really
stable injuries only occur in type A. Burst fractures are defined
as type A3. Complete burst fractures (A3.3) are unstable in fle-
xion-compression and may result in additional loss of vertebral
body height. The spinal canal is often extremely narrowed by
posterior wall fragments. They did not propose a specific treat-
ment for burst fractures without neurological injury.
McCormack et al described the Load Sharing Classification
(LSC)13. They identified three factors involved in mechanical
failures after posterior fixation of vertebral fractures: amount
of damaged vertebral body, the spread of the segments in the
fracture site and the amount of corrected traumatic kyphosis.
However, they did not consider the amount of SCE in surgical
decision.
Although late neurological damage has not been valued by most
of classifications, many authors describe it after conservative
treatment of burst fractures4,14,19,24. Mumford et al reported 1
case of neurological deficit out of 41 patients with mean canal
encroachment of only 37%14.
The natural history of thoracolumbar burst fractures in 54
patients treated conservatively showed good results. Fractures
with anterior column compression and spinal canal narrowing
exceeding 50% were in a large extent complicated by intractable
low back pain, neurological damage and signs of instability 24.
Many authors consider canal encroachment greater than 50% as
surgical criterion3,7,10,16,22.
The analysis of the prospective studies comparing surgical ver-
sus conservative treatment can clarify the role of SCE in the
TLF.There are three prospective studies comparing conservati-
ve and surgical managements.
In 2001, Shen et al compared the results of nonoperative
treatment versus short-segment posterior fixation using pedicle
screws and concluded that the operative treatment provides
partial kyphosis correction and earlier pain relief, but the
functional outcome at 2 years is similar. Early activity to the
point of pain tolerance can be safely allowed. The mean canal
compression was of 34% in the conservative group18.
In 2003, Wood et al. reported that operative treatment of
stable thoracolumbar burst fracture in neurologically intact
patients provided no major long-term advantage compared
to a non-operative treatment25. However, in the group treated
nonoperatively, the average degree of anteroposterior canal
compromise on presentation was only 34% (5% to 75%).
The author did not present the results for each degree of canal
compression, therefore, it is difficult to conclude the risk of
canal impingement in burst fractures treated nonoperatively.
Scardino FB, Barcelos ACES, Silva VB, Dumont PAS, Rotta JM, Botelho RV - What is the importance of the spinal canal encroachment in the management of
thoracolumbar burst fracture without neurological deficit? A review
237
Relato de Caso
In 2006, Siebenga et al. published a prospective study
comparing conservative and surgical treatment of patients
with TLF (T10-L4)19. In the conservative treatment group, one
out of 15 patients evolved with conus syndrome and urinary
dysfunction. Recently, isolated sphincter involvement has been
valued as neurological deficit in TLF2.
The role of spinal canal compression cannot be neglected, main-
ly associated with a mechanical incompetent fragmented verte-
bral body. Vertebral body occupying the canal places neural
structures at risk5. Despite some descriptions indicating that late
neurological deterioration gradually occurs and can be reverted
after surgical treatment19, there are cases without recovery once
neural deficit is installed.
Not all burst fractures should be operated on. Probably most of
them should be submitted to a conservative treatment and those
patients with high risk of neurological deterioration should be
recommended for surgery to prevent new damage.
There are serious reasons to stimulate the search for the best and
worst cases for conservative treatment, mainly delineating trials
to observe the mechanical and neurological behavior of spinal
canal encroachment greater than 50% in patients submitted to
conservative treatment. In these ones, the results would have the
potential for avoiding unnecessary neurological deficits.
Conclusions
TLF classifications did not directly consider the severity of
SCE in the treatment decision making of burst fractures wi-
thout neurological damage. Most of the burst fractures treated
conservatively presented good outcomes, although the majori-
ty had canal encroachment lower than 50%. Many studies do
not describe the characteristics of the fractures that resulted
in late neurological deficits. Thus it is not possible to predict
which patients will deteriorate if not operated on: it remains
unclear what is the risk of neurological deterioration in a SCE
greater than 50%.
Prospective studies of burst fractures with severe SCE and with
no neurological damage can clarify the real role of SCE in this
type of fracture.
J Bras Neurocirurg 21 (4): 234-239, 2010
238
References
1. Alanay A, Acaroglu E, Yazici M, Oznur A, Surat A. Short-
segment pedicle instrumentation of thoracolumbar burst
fractures. Does transpedicular intracorporeal grafting prevent
early failure? Spine. 2001; 26:213-7.
2. Chou D, Hartl R, Sonntag VK. Conus medullaris syndrome
without lower-extremity involvement in L-1 burst fractures:
report of four cases. J Neurosurg Spine. 2006; 4(3):265-9.
3. Davies WE, Morris JH, Hill V. An analysis of conservative (non-
surgical) management of thoracolumbar fractures and fracture-
dislocations with neural damage. J Bone Joint Surg. 1980; 62-
A:1324-8.
4. Denis F. The three column spine and its significance in the
classification of acute thoracolumbar spinal injuries. Spine.
1983; 8(8):817-31.
5. Denis F, Armstrong GWD, Searls K, Matta L. Acute
thoracolumbar burst fractures in the absence of neurologic
deficit: a comparison between operative and nonoperative
treatment. Clin Orthop. 1984; 189:142–9.
6. Ferguson RL, Allen BL Jr. A mechanistic classification of
thoracolumbar spine fractures. Clin Orthop. 1984; 189:77-88.
7. Hitchon PW, Torner JC, Haddad SF, Follett KA.. Management
options in thoracolumbar burst fractures. Surg Neurol. 1998;
49:619-27.
8. Holdsworth F. Fractures, dislocations and fracture-dislocations
of the spine. J Bone Joint Surg Am. 1970; 52:1534–51.
9. Kelly RP, Whitesides TE Jr. Treatment of lumbodorsal fracture-
dislocations. Ann Surg. 1968; 167:705-17.
10. Kraemer WJ, Schemitsch EH, Lever J, McBroom RJ, McKee
MD, Waddell JP. Functional outcome of thoracolumbar burst
fractures without neurological deficit. J Orthop Trauma. 1996;
10(8):541-4.
11. Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S. A
comprehensive classification of thoracic and lumbar injuries.
Eur Spine J. 1994; 3:184-201.
12. McAfee PC, Yuan HA, Fredrickson BE, Lubicky JP. The value of
computed tomography in thoracolumbar fractures. An analysis
of one hundred consecutive cases and a new classification. J
Bone Joint Surg AM. 1983; 65:461-73.
13. McCormack T, Karaikovic E, Gaines RW. The load-sharing
classification of spine fractures. Spine. 1994; 19:1741–4.
14. Mumford J, Weinstein JN, Spratt KF, Goel VK. Thoracolumbar
burst fractures. The clinical efficacy and outcome of nonoperative
management. Spine. 1993; 18:955–70.
15. Oner FC, van Gils AP, Faber JA, Dhert WJ, Verbout AJ. Some
complications of common treatment schemes of thoracolumbar
spine fractures can be predicted with magnetic resonance
imaging: prospective study of 53 patients with 71 fractures.
Spine. 2002; 27(6):629–36.
Scardino FB, Barcelos ACES, Silva VB, Dumont PAS, Rotta JM, Botelho RV - What is the importance of the spinal canal encroachment in the management of
thoracolumbar burst fracture without neurological deficit? A review
Relato de Caso
16. Romero J, Vilar G, Bravo P. Fractures of the dorsolumbar spine
with neurological lesions. A comparison of different treatments.
Int Orthop. 1994; 18:157-63.
17. Sanderson PL, Fraser RD, Hall DJ, Cain CM, Osti OL, Potter
GR. Short segment fixation of thoracolumbar burst fractures
without fusion. Eur Spine J. 1999; 8:495-500.
18. Shen WJ, Liu TJ, Shen YS. Nonoperative treatment versus
posterior fixation for thoracolumbar junction burst fractures
without neurologic deficit. Spine. 2001; 26(9):1038-45.
19. Siebenga J, Leferink VJ, Segers MJ, Elzinga MJ, Bakker FC,
Haarman HJ, et al. Treatment of traumatic thoracolumbar
spine fractures: a multicenter prospective randomized study
of operative versus nonsurgical treatment. Spine. 2006;
31(25):2881-90.
20. Thomas KC, Bailey CS, Dvorak MF, Kwon B, Fisher C.
Comparison of operative and nonoperative treatment for
thoracolumbar burst fractures in patients without neurological
deficit: a systematic review. J Neurosurg Spine. 2006; 4:351-8.
21. Vaccaro AR, Lehman RA Jr., Hurlbert J, Anderson PA, Harris
M, Hedlund R, et al. A New Classification of thoracolumbar
Injuries. The importance of injury morphology, the integrity
of the posterior ligamentous complex, and neurologic status.
Spine. 2005; 30(20):2325-33.
22. Wang ST, Ma HL, Liu CL, Yu WK, Chang MC, Chen TH. Is
fusion necessary for surgically treated burst fractures of the
thoracolumbar and lumbar spine? Spine. 2006; 31(23):2646-52.
23. Whitesides TE Jr. Traumatic Kyphosis of the thoracolumbar
spine. Clin Orthop. 1977; 128:78-92.
24. Willen J, Anderson J, Toomoka K, Singer K. The natural history
of burst fractures at the thoracolumbar junction. J Spinal Disord.
1990; 3(1):39-46.
25. Wood KB, Bohn D, Mehbod A. Anterior versus posterior
treatment of stable thoracolumbar burst fractures without
neurologic deficit: a prospective, randomized study. J Spinal
Disord Tech. 2005; 18 Suppl:S15-23.
Corresponding Author
Fabrizio Borges Scardino
Rua Fortaleza, 961
Itapuã – Vila Velha
Espírito Santo – Brazil
CEP: 29101-575
E-mail: fabrizioscardino@gmail.com
J Bras Neurocirurg 21 (4): 234-239, 2010