Pterion Prep CraniPro VUMC Case Prep
2026-06-27

Case Prep: Thoracolumbar Burst Fracture Fixation

Case / Approach Snapshot

One-Liner

[Age]yo [M/F] with a [T_/L_] burst fracture [with/without neurological deficit] following [fall/MVC] planned for [posterior instrumented fusion ± decompression / anterior or combined reconstruction].

Figures, Imaging & Video

🎥 Operative video — search operative video on YouTube ▸ · The Neurosurgical Atlas ▸

🧭 Operative approach: Posterior thoracolumbar approach — detailed corridor setup, step-by-step technique & figures

Neurosurgical Atlas · AO Spine / Surgery Reference · Radiopaedia · PubMed Central — operative figures © linked; see media-sources.md

High-Yield Literature

Curated Image Set

Open-access figures are embedded from PubMed Central articles and kept unique to this guide.

Thoracolumbar Burst Fracture Fixation — Figure 7 Figure 7. Source: Can implant removal restore mobility after fracture of the thoracolumbar segment? A radiostereometric study — Acta Orthop. 2016 Jun 17;87(5):511–5. doi: 10.1080/17453674.2016.1197531; CC BY-NC.

Thoracolumbar Burst Fracture Fixation — Fig. 1 Fig. 1. a: at the time of injury, b: after posterior pedicle screw fixation, c: before implant removal, and d: at final observation Source: Vacuum phenomenon as a predictor of kyphosis after implant removal following posterior pedicle screw fixation without fusion for thoracolumbar burst fracture: a single-center retrospective study — BMC Musculoskeletal Disorders 2022; CC BY.

Thoracolumbar Burst Fracture Fixation — Fig. 2 Fig. 2. Kyphotic angle Source: Vacuum phenomenon as a predictor of kyphosis after implant removal following posterior pedicle screw fixation without fusion for thoracolumbar burst fracture: a single-center retrospective study — BMC Musculoskeletal Disorders 2022; CC BY.

Thoracolumbar Burst Fracture Fixation — Fig. 3 Fig. 3. Vacuum phenomenon Source: Vacuum phenomenon as a predictor of kyphosis after implant removal following posterior pedicle screw fixation without fusion for thoracolumbar burst fracture: a single-center retrospective study — BMC Musculoskeletal Disorders 2022; CC BY.

History of Present Illness

Imaging Review

CT thoracolumbar (reconstructions)

Labs

Neurological Examination

Surgical Planning

Case Logistics, OR Needs & Orders

Operative Decision (TLICS)

Approach

Position

Key Surgical Steps (Posterior) — Detailed

  1. Time-out and IONM baseline — confirm stable SSEP/MEP after the careful log-roll to prone; re-check signals after final positioning (unstable segment can shift with positioning)
  2. Fluoroscopic level localization — AP and lateral; count from the sacrum and from C2/ribs (thoracolumbar junction is error-prone); mark the fracture level and the planned instrumented levels
  3. Midline incision and subperiosteal exposure — expose the fractured level and the levels above and below to the tips of the transverse processes (thoracic) / bases of the transverse processes and pars (lumbar); preserve the facet capsules of levels NOT being fused
  4. Identify pedicle entry points at each level to be instrumented:
    • Thoracic: junction of the lateral pars, transverse process, and superior articular facet (straightforward or anatomic/Roy-Camille technique)
    • Lumbar: “eye of the pedicle” — junction of the transverse process midline, pars, and superior articular process; convergent trajectory
  5. Place pedicle screws above and below the fracture (and, when appropriate, at the fractured level for a more rigid construct and better reduction) using fluoroscopy or navigation; probe all four pedicle walls with a ball-tip feeler (medial wall = canal; inferior = exiting root) before tapping and inserting; triggered EMG to confirm no medial breach
  6. Reduction:
    • Postural reduction — extend the table/Jackson frame to restore lordosis and indirectly reduce the kyphosis
    • Rod-based reduction/ligamentotaxis — contour rods to the desired sagittal profile; seat and use distraction + lordosing maneuvers to restore vertebral body height and pull the retropulsed fragment forward via the intact PLL (ligamentotaxis); avoid over-distraction (can stretch the cord/worsen a kyphotic deformity into a translation)
  7. Decompression (only if neurological deficit and/or significant canal compromise):
    • Laminectomy at the fracture level (note laminar fractures are common — dura may be exposed/torn beneath, proceed cautiously)
    • For persistent ventral compression after ligamentotaxis: transpedicular reduction — remove a pedicle, place a tamp/impactor against the retropulsed fragment, and reduce it back into the vertebral body anteriorly (away from the cord)
    • Confirm thecal sac/conus/cauda is decompressed
  8. Final tightening — seat rods fully, lock all set screws; reassess sagittal alignment on fluoroscopy
  9. Inspect for dural tear (common with laminar fractures) — primary repair if accessible; if a ventral/inaccessible tear, dural sealant/muscle patch, consider lumbar drain
  10. Arthrodesis — decorticate the transverse processes/facets at the fused levels and lay autograft (local) + allograft for posterolateral fusion (± interbody/anterior support if anterior column is severely deficient)
  11. Final fluoroscopy (AP + lateral) — confirm screw position, rod contour, restoration of vertebral height and lordosis, fragment reduction
  12. Hemostasis, subfascial drain, layered watertight closure (especially if durotomy)

Critical Anatomy & Structures at Risk

  1. Conus medullaris / cauda equina / spinal cord (level-dependent) — retropulsed fragment, manipulation
  2. Pedicle walls (medial breach → neural; screw accuracy)
  3. Segmental vessels, great vessels (anterior approach), artery of Adamkiewicz (T8-L1 left)
  4. Dura (laminar/posterior element fractures — dural tears common in burst with laminar fracture)

Equipment

Monitoring

Anesthesia

Potential Complications

  1. Neurological worsening (reduction, retropulsion manipulation)
  2. Dural tear/CSF leak (laminar fracture — common; repair)
  3. Hardware failure/pseudarthrosis, loss of correction/kyphosis
  4. Screw malposition, infection, adjacent segment issues, ileus

Operative Note Template

Preoperative Diagnosis: [T_/L_] burst fracture [with retropulsion and canal compromise] [with incomplete/complete neurological deficit — ASIA __]

Postoperative Diagnosis: Same

Procedure: [T_-T_/L_] posterior instrumented fusion with pedicle screw fixation [and laminectomy/decompression at ___] [with transpedicular fragment reduction] [with posterolateral arthrodesis] for thoracolumbar burst fracture

Surgeon / Assistant: Anesthesia: General endotracheal EBL / Fluids / Blood products: Specimens: None Drains: Subfascial drain Implants: Pedicle screws and rods [system/sizes], bone graft (local autograft + allograft) Complications: None

Indications: The patient is a [age]yo [M/F] who sustained a [T_/L_] burst fracture after [mechanism], with [retropulsion and _% canal compromise], [PLC disruption on MRI], and [neurological exam — ASIA __ / intact]. The TLICS score was [], indicating operative management. After discussion of risks, benefits, and alternatives, the patient/family elected to proceed.

Description of Procedure: After consent and a time-out, general endotracheal anesthesia was induced and neuromonitoring (SSEP/MEP/EMG) established with stable baselines. The patient was carefully log-rolled prone onto a Jackson table with the abdomen free; pressure points and eyes were padded; signals were re-confirmed stable after positioning. The back was prepped and draped, and antibiotics were administered.

A midline incision was made and subperiosteal dissection exposed the posterior elements from [level] to [level], preserving the facet capsules of adjacent un-fused levels. The fracture level and instrumented levels were confirmed by fluoroscopy. Pedicle screws were placed at [levels] using [fluoroscopic/navigation] guidance; all pedicle walls were probed intact and triggered-EMG thresholds were acceptable.

[The table was extended and contoured rods were used to achieve postural and ligamentotaxis reduction, restoring vertebral body height and segmental lordosis.] [A laminectomy was performed at ___ for decompression; the dura was inspected — (intact / a laminar-fracture dural tear was repaired primarily / sealed with graft and sealant). Transpedicular reduction of the retropulsed fragment was performed, restoring the canal.] The rods were seated and all set screws locked. Final fluoroscopy confirmed satisfactory screw position, alignment, vertebral height, and fragment reduction. The transverse processes and facets were decorticated and graft was applied for posterolateral arthrodesis.

Hemostasis was obtained, a subfascial drain placed, and the wound closed in layers. Neuromonitoring remained stable throughout. The patient was returned supine, awakened, and moving [all extremities at baseline / per deficit], and transferred to the [ICU/PACU] in stable condition.

Postoperative Plan

Chief-Level Case Review

Use these as the senior-level mental model for Thoracolumbar Burst Fracture Fixation:

Common Pimp Questions

Use these to pressure-test preparation for Thoracolumbar Burst Fracture Fixation:

  1. What neurologic level and root are responsible for the presenting deficit?
  2. What is the decompression target and how will you know it is adequately decompressed?
  3. What instability, deformity, bone-quality, or fusion variable changes the construct?
  4. What vascular, visceral, dural, or neural structure is the main structure at risk?
  5. What postop brace, drain, mobilization, MAP, antibiotic, and DVT plan should be ordered?

Attending Preference Variables

Items that commonly vary by surgeon or institution: