Percutaneous Instrumentation of a Complex Lumbar Spine Fracture with Bilateral Pedicle Dissociation: Case Report and Technical Note

Abstract

Background and Study Objective Complex traumatic lumbar spine fractures are difficult to manage and typically occur in younger patients. Surgical immobilization for unstable fractures is an accepted treatment but can lead to future adjacent-level disease. Furthermore, large variations in fracture morphology create significant difficulties when attempting fixation. Therefore, a surgical approach that considers both long-term outcomes and fracture type is of utmost importance. We present a novel technique for percutaneous fixation without interbody or posterolateral fusion in a young patient with bilateral pedicle dissociations and an acute-onset incomplete neurologic deficit.

Case Description A 20-year-old man involved in a motorcycle accident presented with unilateral right lower extremity paresis and sensory loss with intact rectal tone and no saddle anesthesia. Lumbar computed tomography (CT) demonstrated L2 and L3 fractures associated with bilateral pedicle dislocations. Lumbar magnetic resonance imaging showed draping of the conus medullaris/cauda equina anteriorly over the kyphotic deformity at L2 with minimal associated canal stenosis at L2 and L3. He was treated with emergent percutaneous fixation of the fracture segment without interbody or posterolateral fusion. Decompression was not performed because of the negligible amount of canal stenosis and high likelihood of cerebrospinal fluid leakage due to dural tears from the fractures. Surgical fixation of the L2 vertebra was achieved by cannulating the left pedicle with an oversized tap while holding the right pedicle in place with a normal tap and then driving screws into the left and right pedicles, respectively, thus reducing the free-floating fracture segment. At 18 months after surgery, a follow-up CT demonstrated good cortication across the prior pedicle fractures, and the instrumentation was removed without any obvious signs of instability or disruption of the alignment at the thoracolumbar junction.

Conclusion We present a novel technique for percutaneous reduction and fixation of bilateral pedicle fractures with significant dissociation from the vertebral body, associated neural compression from the kyphotic deformity, and minimal spinal canal stenosis. Furthermore, we argue that early fixation and reduction of the fracture prevented irreversible neurologic compromise, and the absence of interbody or posterolateral fusion ultimately preserved the spinal mobility of the patient once the hardware was removed.

Keywords

bilateral pedicle dislocation - incomplete neurologic injury - percutaneous fixation - spine trauma - unstable spine fracture

• References

• 1 Grossbach AJ, Dahdaleh NS, Abel TJ, Woods GD, Dlouhy BJ, Hitchon PW. Flexion-distraction injuries of the thoracolumbar spine: open fusion versus percutaneous pedicle screw fixation. Neurosurg Focus 2013; 35 (02) E2
• 2 Kim BG, Dan JM, Shin DE. Treatment of thoracolumbar fracture. Asian Spine J 2015; 9 (01) 133-146
• 3 Epstein NE. Adjacent level disease following lumbar spine surgery: a review. Surg Neurol Int 2015; 6 (25) (Suppl. 24) S591-S599
• 4 Jacobs RR, Casey MP. Surgical management of thoracolumbar spinal injuries. General principles and controversial considerations. Clin Orthop Relat Res 1984; (189) 22-35
• 5 Verlaan JJ, Diekerhof CH, Buskens E. , et al. Surgical treatment of traumatic fractures of the thoracic and lumbar spine: a systematic review of the literature on techniques, complications, and outcome. Spine 2004; 29 (07) 803-814
• 6 Rajasekaran S, Kanna RM, Shetty AP. Management of thoracolumbar spine trauma: An overview. Indian J Orthop 2015; 49 (01) 72-82
• 7 Modi HN, Chung KJ, Seo IW. , et al. Two levels above and one level below pedicle screw fixation for the treatment of unstable thoracolumbar fracture with partial or intact neurology. J Orthop Surg 2009; 4: 28
• 8 Murtagh R, Castellvi AE. Motion preservation surgery in the spine. Neuroimaging Clin N Am 2014; 24 (02) 287-294
• 9 Cahill PJ, Marvil S, Cuddihy L. , et al. Autofusion in the immature spine treated with growing rods. Spine 2010; 35 (22) E1199-E1203
• 10 Han SH, Hyun SJ, Jahng TA, Kim KJ. Posterior osteosynthesis of a spontaneous bilateral pedicle fracture of the lumbar spine. J Neurosurg Spine 2016; 24 (03) 398-401