Emergency stabilisation by single-stage posterior transpedicular approach for treatment of unstable lumbar spine fracture with neurological injury

Abstract

Management of unstable thoracolumbar fractures remains controversial. Furthermore, when these are accompanied by related neurological injury, the choice of approach, decompression technique and timing of the intervention could have a neuroprotective effect. In terms of site, the lumbar spine represents only 1.2% of cases, yet fractures with severe instability and neurological injury call for attainment of the same goals, i.e., neurological stability and decompression. After suffering high-energy trauma as a result of an accidental fall, a young male patient presenting with unstable injury of the lumbar spine and neurological impairment compatible with incomplete cauda equina syndrome was treated with emergency stabilisation and decompression through single-stage posterior transpedicular approach. At one year of the intervention, the patient is making good progress, with absence of lumbar pain, isolated deficit in left ankle dorsiflexion with no need of orthosis or cane, adequate sphincter control and return to his previous activity. Patients who present with unstable injury of the lumbar spine and incomplete neurological involvement can benefit from emergency stabilisation and decompression treatment by posterior transpedicular approach, with improvement in neurological status and functional recovery.

Keywords: Emergency surgical treatment; Lumbar spine fracture; Neurological injury; Transpedicular decompression.

Fig. 1

Preoperative CT scans. (A) Axial view of stable compression fracture of T8. (B) Axial view of polyfragmentary fracture of L3 with >70% canal occupation. (C) Sagittal view of lumbar spine with loss of height of L3, lumbar kyphosis, severe injury, osseous elements and posterior ligamentous complex. Fracture of S5 and kyphosis sacro-coccyx (D) Sagittal view of 3D reconstruction.

Fig. 2

(A) Following screws were put two-levels up and below the L3, inferior L2/L3 and superior L3 facets were resected surrounding left L3 pedicle. The discs L2-L3 and L3-L4 were excised and through L3 left pedicle, the vertebral body L3 bone fragments were removed. Reconstruction was performed by insertion of titanium mesh filled with autologous bone from surgical field. First the mesh was introduced obliquely above the L3 root and then rotated in the intersomatic space. After the cage was placed and its positioned was confirmed by lateral and antero-posterior x-rays, compression was applied. Intraoperative views with appropriate position of implants and titanium cage in coronal and sagittal planes with recovery of lumbar lordosis. (B) Views in sagittal magnetic resonance (MR) projection of T1 and T2 sequences at three months post-operation with adequate decompression of neural elements. Picture compatible with encapsulated remnant cerebrospinal fluid due to initial dural tear.

Fig. 3

(A) Sagittal CT view at one year of the intervention. Appropriate position of the titanium cage and bony bridging across the cage were compatible with solid osseous fusion and preservation of lumbar lordosis. (B–C) The radiological study in upright position show adequate sagittal and coronal balance. The lumbar lordosis is proportional to pelvic incidence. (D) View of patient at one year in upright position. Extension deficit of left ankle persists but no cane or orthosis required for walking.