European Spine Journal

, Volume 18, Issue 2, pp 282–287 | Cite as

Reverse and pseudoreverse cortical sign in thoracolumbar burst fracture: radiologic description and distinction—a propos of three cases

  • Vincent Arlet
  • Douglas G. Orndorff
  • Jay Jagannathan
  • Aaron Dumont
Original Article


In thoracolumbar burst fracture the “reverse cortical sign” is a known entity that corresponds to a fragment of the posterior wall that has been flipped 180° with the cancellous surface of the fragment facing posteriorly in the canal and the cortical surface (posterior wall) facing anteriorly. The identification of such reverse cortical fragment is crucial as ligamentotaxis is classically contraindicated as the posterior longitudinal ligament is ruptured. Recognition of such a flipped cortical fragment has relied so far on the axial CT. The advent of CT scans with sagittal reconstruction has allowed us to better describe such entities that have received little attention in the literature. The goal of this report was therefore to describe the appearance of the reverse cortical sign and its likes as they can appear on axial CT scans, sagittal reconstructions and MRI. During 1-year practice at our institution we had to treat three patients with thoracolumbar burst fracture associated with what looked like a reverse cortical sign on the axial CT scans. Further analysis of the sagittal reconstruction CT could differentiate the true reverse cortical sign from a new entity that we coined “the pseudoreverse cortical sign” as observed in two out of the three cases. In the pseudo reverse cortical sign what appears to be a flipped piece of posterior vertebral body is actually part of the superior or inferior endplate that is depressed into the comminuted vertebral body. In such cases the posterior longitudinal ligament appears to be in continuity and therefore such fracture can theoretically be treated with posterior ligamentotaxis as evidenced in one of our case. Careful analysis of the CT scan and specifically the sagittal reconstruction and MRI can differentiate two separate entities that may correspond to a different severity injury.


Reverse cortical sign Burst fracture Spine Ligamentotaxis 


Conflict of interest statement

In preparation of this manuscript the authors have no competing interests or financial interest to disclose.


  1. 1.
    Aebi M, Etter C et al (1988) The internal skeletal fixation system. A new treatment of thoracolumbar fractures and other spinal disorders. Clin Orthop Relat Res 227:30–43PubMedGoogle Scholar
  2. 2.
    Kaneda K, Taneichi H et al (1997) Anterior decompression and stabilization with the Kaneda device for thoracolumbar burst fractures associated with neurological deficits. J Bone Joint Surg Am 79(1):69–83PubMedGoogle Scholar
  3. 3.
    Kirkpatrick JS (2003) Thoracolumbar fracture management: anterior approach. J Am Acad Orthop Surg 11(5):355–363PubMedGoogle Scholar
  4. 4.
    McDonough PW, Davis R et al (2004) The management of acute thoracolumbar burst fractures with anterior corpectomy and Z-plate fixation. Spine 29(17):1901–1908 (discussion 1909). doi: 10.1097/01.brs.0000137059.03557.1d PubMedCrossRefGoogle Scholar
  5. 5.
    Marre B (2007) Thoracic and lumbar spine trauma. In: Aebi M, Arlet V, Webb JK (eds) AOSpine manual. Thieme 2007, New York, pp 165–192Google Scholar
  6. 6.
    Mikles MR, Stchur RP et al (2004) Posterior instrumentation for thoracolumbar fractures. J Am Acad Orthop Surg 12(6):424–435PubMedGoogle Scholar
  7. 7.
    Meves R, Avanzi O (2006) Correlation among canal compromise, neurologic deficit, and injury severity in thoracolumbar burst fractures. Spine 31(18):2137–2141. doi: 10.1097/01.brs.0000231730.34754.9e PubMedCrossRefGoogle Scholar
  8. 8.
    Roy-Camille R (1992) Posterior screw plate fixation in thoracolumbar injuries. Instr Course Lect 41:157–163PubMedGoogle Scholar
  9. 9.
    Vaccaro AR, Lehman RA Jr et al (2005) A new classification of thoracolumbar injuries: the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status. Spine 30(20):2325–2333. doi: 10.1097/01.brs.0000182986.43345.cb PubMedCrossRefGoogle Scholar
  10. 10.
    Whang PG, Vaccaro AR (2007) Thoracolumbar fracture: posterior instrumentation using distraction and ligamentotaxis reduction. J Am Acad Orthop Surg 15(11):695–701PubMedGoogle Scholar
  11. 11.
    Wood KB, Bohn D et al (2005) Anterior versus posterior treatment of stable thoracolumbar burst fractures without neurologic deficit: a prospective, randomized study. J Spinal Disord Tech 18:S15–S23. doi: 10.1097/01.bsd.0000132287.65702.8a PubMedCrossRefGoogle Scholar
  12. 12.
    Yazici M, Gulman B et al (1995) Sagittal contour restoration and canal clearance in burst fractures of the thoracolumbar junction (T12-L1): the efficacy of timing of the surgery. J Orthop Trauma 9(6):491–498. doi: 10.1097/00005131-199509060-00006 PubMedCrossRefGoogle Scholar
  13. 13.
    Zdeblick TA, Phillips FM (2003) Interbody cage devices. Spine 28(Suppl 15):S2–S7. doi: 10.1097/00007632-200308011-00002 PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2008

Authors and Affiliations

  • Vincent Arlet
    • 1
    • 2
  • Douglas G. Orndorff
    • 1
  • Jay Jagannathan
    • 2
  • Aaron Dumont
    • 2
  1. 1.Division of Spine Surgery, Department of Orthopaedic SurgeryUniversity of Virginia Health Sciences SystemCharlottesvilleUSA
  2. 2.Department of Neurological SurgeryUniversity of Virginia Health Sciences SystemCharlottesvilleUSA

Personalised recommendations