Key-words: Combined posterior–anterior approach - lateral spondylolisthesis - minimally invasive
surgery - percutaneous pedicle screws - thoracolumbar fracture
Introduction
Traumatic high-grade lateral spondylolisthesis at the thoracolumbar junction is an
extremely severe injury caused by high-energy trauma, commonly resulting in polytrauma.[[1 ]],[[2 ]] The treatment of this pathology is challenging, and even death following surgery
has been reported.[[1 ]] Therefore, it is necessary to focus on making surgical invasion minimal. Here,
we report treatment of a case of traumatic high-grade lateral spondylolisthesis with
multiple spinal fractures using percutaneous pedicle screws (PPS).
Technical Note
A 53-year-old female fell from a height and presented with severe back pain and complete
paralysis (Frankel A) below L1. Computed tomography (CT) showed a Grade 4 traumatic
lateral spondylolisthesis and severe comminution of L1 and mild compression fractures
at T9 and L3 [[Figure 1 ]]a,[[Figure 1 ]]b,[[Figure 1 ]]c. Other than the spinal injury, the patient had bilateral rib fractures and a pneumothorax
[[Figure 1 ]]a and [[Figure 1 ]]b, and a thoracostomy tube was inserted. We planned a 2-stage posterior–anterior
surgery. First, we performed posterior surgery on the day of the injury to reduce
the fracture and stabilize the spinal column. Displacement of the fracture was reduced
to Grade 3 spondylolisthesis by pushing the left thoracic cage to the right with the
patient in the prone position. After placing PPS at T8 to L5, except for the fractured
vertebrae (T9, L1, and L3), we reduced displacement of the fracture by assembling
a 5.5 mm titanium rod from T8 to L5 bilaterally. Postoperative images demonstrated
appropriate vertebral alignment [[Figure 2 ]]. Twelve days later, we resected the L1 vertebral body and inserted a cage with
an iliac bone graft using an anterior approach [[Figure 3 ]]. The estimated blood loss from posterior and anterior surgeries was 320ml and 200ml,
respectively. Bony fusion was achieved as seen on CT at the 1-year follow-up, and
we removed the posterior instrumentation. Neurological improvement to Frankel C was
evident.
Figure 1: Computed tomography at the initial visit to our hospital. (a) Coronal image. (b)
Sagittal image. (c) 3D image
Figure 2: Postoperative X-ray images after posterior surgery. (a) Frontal view. (b) Lateral
view
Figure 3: Postoperative images after anterior surgery. (a) Frontal view. (b) Lateral view.
(c) Sagittal computed tomography image
Discussion
Intraoperative blood loss during surgery for traumatic thoracolumbar fracture cannot
be ignored, especially in the early acute phase of surgery.[[3 ]] Excessive intraoperative blood loss can worsen the general condition.[[4 ]] The use of PPS for fixation of traumatic thoracolumbar fracture has been found
to result in less visible intraoperative blood loss than conventional open surgery.[[5 ]] However, to the best of our knowledge, all reported cases with traumatic high-grade
lateral spondylolisthesis have been treated using open surgery.[[1 ]],[[6 ]],[[7 ]] Open reduction and internal fixation using spinal instrumentation are needed for
traumatic high-grade lateral spondylolisthesis with spinal shortening or facet interlocking.[[8 ]],[[9 ]] Because the present case involved severe comminution of the vertebral body without
spinal shortening, the fracture was easily reduced and stabilized by adapting the
use of PPS to the rods. PPS, having extended threads on polyaxial screws, can function
as reduction screws. Therefore, as with open surgery, we were able to reduce the dislocation
successfully using PPS and a rod system. The present case involved polytrauma with
thoracic injury. Early spine damage necessitated surgery to control further damage.[[10 ]] Using PPS, blood loss was small, even though long posterior stabilization from
T8 to L5 was performed on the day of the injury. There were no complications or worsening
of the patient's general condition postoperatively. Thus, ideal spine damage control
was achieved using PPS.
There are some disadvantages to posterior surgery using PPS, such as difficulty in
bone grafting. Anterior spinal reconstruction is needed for cases with severe comminution
of the vertebral body.[[11 ]] Therefore, we grafted bone by inserting an expandable cage for anterior reconstruction.
Because damage control was achieved by prior posterior stabilization, the amount of
blood loss from the anterior approach was small. A 2-stage combined posterior–anterior
approach using PPS can be performed less invasively, enabling adequate reduction,
internal fixation, anterior cage and bone insertion, and fusion for patients with
high-grade traumatic lateral spondylolisthesis without spinal shortening or facet
interlocking.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms.
In the form, the patient has given her consent for her images and other clinical information
to be reported in the journal. The patient understands that her name and initials
will not be published and due efforts will be made to conceal identity, but anonymity
cannot be guaranteed.
