Precision Management of Acute Traumatic Thoracolumbar Burst Fractures: Development of Radiographic Imaging Thresholds Specified by Presenting Neurologic Function and Clinical Comorbidity Status

Introduction: Our study investigates the management of acute traumatic thoracolumbar burst fractures, considering the influence of comorbidities and key factors on the choice between conservative and operative management.

Methods: A retrospective cohort of 61 patients with acute traumatic thoracolumbar burst fractures between 2020 and 2023 was analyzed, including comorbidities, traumatic causes, neurological status, fracture levels, radiographic measurements, and treatment methods using multivariate statistical analysis while controlling for demographics and fracture level.

Results: Our study found that patient’s with chronic kidney disease (stage 3 and above) (OR 1.67 95% CI 1.50-1.88), diabetes mellitus type 2 (OR 1.32 95% CI 1.12-1.48), congestive heart failure (OR 1.30 95% CI 1.25-1.37), and psychiatric medical history (OR 1.10 95% CI 1.05-1.10) resulted in a greater likelihood to be managed conservatively (p < 0.05 for all). Patients with less than 2 medical comorbidities and neurological deficit were more likely to undergo operative management (OR 2.58 95% CI 2.42-3.30) compared to those with more than 2 comorbidities. Multilevel fractures did not increase the likelihood for operative management (p=0.23). For every degree of kyphosis, the chances of operative management increased by 4.3% (p=0.003) and every millimeter of retropulsion by 12.9% (p=0.001). We found that when controlled for vertebral level, every 10 mm of interpeduncular diameter predicts operative management by 10% when compared to patients who were conservatively managed (p=0.02). Interestingly, of the 10 patients that were managed conservatively, but then requiring an operation, an epidural hematoma was found on MRI, 80% of the time. Additionally, the five patients who failed and required a revisional surgery had radiographic evidence of osteopenia or osteoporosis 100% of the time while the other 11 patients with radiographic evidence of osteopenia call or osteoporosis received osteoprotegrin analogues in the post operative period, and did not result in failure of initial management 100% of the time.

Conclusion : Neurosurgeons can make more informed decisions on managing vertebral burst fractures by considering comorbidities, neurological deficits, kyphosis, retropulsion, and interpeduncular diameter, based on the provided data.