Two-level burst fractures: clinical evaluation and treatment options

Two-level burst fractures are rare. In a series of 180 surgically treated spinal fracture-dislocations, seven had such injuries, with an incidence of 3.9%. Four had fracture sites without contiguity: C4-T12 (one), L1-L4 (one), L2-L4 (one), and L2-L5 (one); and three with contiguity: T12-L1 (one), L1-L2 (one), and L2-L3 (one). L2 was the most frequently involved site, accounting for four in seven. Falling from height was the most common mechanism of injury, accounting for four in seven. Five in seven patients (71%) sustained multiple injuries. Chest traumas and extremity fractures were the ones most frequently associated. All of these patients had incomplete neurologic deficits at initial presentation. In the four discontiguous bursts, the neurologic levels corresponded to the cephalic ones. Six patients had follow-up periods of more than 2 years. Transpediculate systems were used in five, and at follow-up, two had screw breakages. In this series, the average neurologic recovery was 1.3 grades on the Frankel scale. In conclusion, it is mandatory to have a thorough organ system review when such patients are first seen. Then each fracture site would be judged seperately as either a stable or unstable burst preoperatively. Every effort should be made to treat any unstable segment via anterior, posterior, or combined approaches.