Fracture dislocation of the lumbar spine without paraplegia. A case report

Traumatic Lumbar Spondylolisthesis: A Systematic Review and Case Series

STUDY DESIGN

Systematic review and case series.

OBJECTIVES

Any acute injury to the posterior elements of the lumbar spine resulting in listhesis is considered a traumatic spondylolisthesis. This rare injury caused by high-energy trauma is variably described in the literature as fracture-dislocation, where only case reports and series have been published. Our objectives were to propose evidence-based treatment recommendations and a new classification system for this injury.

METHODS

A systematic review of literature from PubMed, EMBASE, and Cochrane without time frame limitations was performed, which included 77 level IV and V articles and 9 patients as case series in the analysis.

RESULTS

A total of 125 cases were reviewed with mean age of 30.5 years. Half of the cases resulted from a vehicular accident. Back pain presented in 82%, while 50% had neurologic deficits. Operative treatment was performed in 93.6% (posterior decompression [PD] = 4%; posterior spinal fusion [PSF] = 43.2%; interbody fusion [IB] = 46.4%) with overall fusion rates of 74%. Binomial regression analysis for achieving solid fusion showed a 28.6× higher odds for IB compared to PSF (P = .008, r ² = 0.633). Subanalysis of cases with disc injuries revealed higher fusion outcomes for IB (87%) compared to PSF (46%; P = .006), while there were no significant differences for patients without disc injury. Pain and neurological symptoms improved significantly on final follow-up (P < .001). Overall complication rate was 22%.

CONCLUSION

Operative management with reduction, decompression for neurologic deficits, instrumentation, and fusion is recommended for traumatic spondylolisthesis. Interbody fusion is recommended to achieve better fusion outcomes especially with preoperatively identified disc lesions.

Complete thoracolumbar fracture-dislocation with intact neurologic function: Explanation of a novel cord saving mechanism

BACKGROUND

The thoracolumbar junction from T11 to L2 is a common site of injury in which fracture and dislocations are the most prevalent ones occurring at this location. Fracture dislocation is defined as failure of all three columns of the spine with gross displacement. Considering the significant violence necessary to produce fracture dislocations, these injuries are often associated with major neural deficit, with the majority of casualties becoming paraplegic immediately. Preservation of neurological function following complete fracture dislocation is quite rare entity.

OBJECTIVE

To represent the possibility of existence of a preservation mechanism for functional integrity of cord despite spinal gross fracture dislocation by reproducing the injury on a plastic model and simulating a corresponding model using 3DSlicer software, detailed description the pathomechanism of neurologic sparing.

CASE REPORT

A 19-year-old female who sustained severe thoracolumbar fracture dislocation but with normal neurology is presented. Despite the severity of the condition, the diagnosis was initially missed due to associated vital injuries.

RESULTS

Combined posterior and anterior surgery resulted in optimal coronal and sagittal alignment, as well as proper stabilization without any complication. At 9-year follow-up, the patient was found to be doing well.

CONCLUSION

The prognosis for complete recovery with preplanned surgical intervention in thoracolumbar injuries affecting all three columns but with normal neurologic function is promising based on images, plastic models and 3D simulated model based on digital images.

Traumatic lateral expulsion of the L-4 vertebral body from the spinal column

Traumatic lateral spondyloptosis is mostly a lateral shearing injury that must be tremendous enough to completely disrupt the strong musculoligamentous and bony structures. This injury has only been described at single levels in the lumbar spine. Lateral expulsion of a vertebral body from the spinal column due to 2-level adjacent spondyloptosis has not been previously reported.

This 16-year-old girl was referred to our center for the management of an extremely unusual L2–5 fracture-dislocation. Motor deficits were incomplete and sacral sensation was spared. Three-dimensional reconstructed CT scans revealed a fracture involving the superior L-4 vertebral body and endplate. There was also complete disruption of the L4–5 disc space. The majority of the L-4 vertebral body was expelled to the right of the spinal column, with the collapse of L-3 and a small remnant of the L-4 superior endplate onto L-5. Surgical management involved decompression, reduction, reconstruction of L-4 with a cage, and L1–ilium stabilization and fusion. Only a few attachments of the psoas muscles had to be divided to roll the L-4 vertebral body out posterolaterally, similar to the method of complete en bloc spondylectomy used in oncology. Neurological recovery has thus far included the resumption of normal bladder and bowel function, as well as ambulation with the use of a right leg brace.

Perhaps this type of fracture has not been previously described because many patients would be expected to succumb to vascular or visceral injury. The authors believe this is the first case report of double lateral spondyloptosis at adjacent levels, resulting in expulsion of the vertebral body from the spinal column.

Traumatic spondylolisthesis of the lumbar spine: a report of three cases

Traumatic spondylolisthesis of the lumbar spine is uncommon and can result in canal narrowing and spinal cord injury. Early decompression promotes recovery of neurological function. We report 3 such cases: one in the lumbosacral joint and 2 in the lumbar spine. The former patient had an open fracture-dislocation and underwent (delayed) posterior decompression and instrumentation without interbody fusion. The connecting rods broke at 3 years and the patient had a residual neurological deficit. We recommend early decompression with posterior instrumentation and interbody fusion for maximum recovery of neurological function and stability of the spine.

Traumatic spondyloptosis of the thoracolumbar spine

Object

Traumatic Grade V thoracolumbar spondylolisthesis, or traumatic spondyloptosis (severe translation injuries), are uncommon spinal injuries. To the best of the authors' knowledge, this article represents the first reported case series of these unique spinal lesions.

Methods

The authors undertook a retrospective review of a tertiary care regional spinal cord injury patient population treated over a 10-year period (1997–2007). They analyzed data regarding age, sex, mechanism of injury, neurological status, and treatment.

Results

Five patients were identified (3 men and 2 women) with ages ranging from 17 to 44 years. All patients had sustained high-energy closed spinal injuries: 3 motor vehicle accidents, 1 injured in a building collapse, and 1 hurt by a fallen steel beam. Four patients, all with sagittal-plane spondyloptosis, had a complete neurological deficit (American Spinal Injury Association [ASIA] Grade A), and 1, with coronal-plane spondyloptosis, presented with an incomplete neurological deficit (ASIA Grade C). Four patients had sustained concurrent multisystem trauma. All patients underwent surgery: an isolated posterior fusion in 2 and combined posterior-anterior fusion in 3. Only the patient with an incomplete neurological deficit (coronal-plane spondyloptosis) recovered neurological function postoperatively.

Conclusions

Traumatic thoracolumbar junction spondyloptosis is rare. Surgical reconstruction and stabilization allow for early mobilization and rehabilitation. In the present series, a patient with coronal-plane spondyloptosis presented with preserved neurological function. This may be due to the result of differences in resultant neurological compression due to displacement mechanics compared with sagittally displaced injuries.

Dramatic neurological recovery with delayed correction of traumatic lumbar spondyloptosis

✓The authors describe a 36-year-old woman with traumatic lateral spondyloptosis at L-2 and complete cauda equina injury who experienced a remarkable recovery after delayed treatment. To the authors' knowledge, this is the first case of traumatic spondyloptosis at L2–3 described in the English literature. A review of previous cases of lumbar spondyloptosis suggests that the degree of anatomical injury found at surgery is a better predictor of patient outcome than fracture severity assessed radiologically. Concomitant multisystem injury is common with spine disruptions of this magnitude and may mask clinical neurological function. Even when delayed, operative decompression of these severe lesions should be considered because dramatic neurological recovery is possible.

Traumatic noncontiguous double fracture-dislocation of the lumbosacral spine

BACKGROUND CONTEXT

To our knowledge, the presence of noncontiguous fracture-dislocation of the lumbosacral spine occurring at two levels has not been reported. The etiology, evaluation, and treatment of the unusual injury is presented.

PURPOSE

To notify spinal traumatologists about the possibility of this unusual injury.

STUDY DESIGN

A case report of an unusual noncontiguous double fracture-dislocation of the lumbosacral spine.

METHODS

A 26-year-old man was involved in a motor vehicle accident where his car fell over a bridge and plummeted approximately 300 feet before hitting the ground. The patient was transported to a major medical center where he was found to be conscious, and amazingly, his only major injury was fracture-dislocations of L2-L3 and L5-S1. His preoperative neurologic status showed a partial paraparesis to all motor groups of the lower extremities bilaterally.

RESULTS

The patient underwent a posterior reduction, instrumentation, and fusion from L1 to S1 with autogenous bone graft and segmental pedicle screw instrumentation. One week postoperatively, he underwent an anterior spinal fusion of L5/S1. Postoperatively, his neurologic status improved allowing him to be ambulatory, with a normal lumbosacral alignment being well-maintained.

CONCLUSIONS

Noncontiguous double fracture-dislocation of the lumbosacral spine is an unusual injury, which results from a very high-energy trauma. Prompt recognition of the injuries, reduction of the fracture-dislocations, and posterior stabilization is recommended for neural decompression, spinal alignment, and long-term stabilization.

Complete L1-L2 lateral dislocation without fracture and neurologic deficit in a child

Spinal injuries in the infantile age group are relatively rare, mainly due to anatomical and biomechanical features of the pediatric spine. With its hypermobile character, pediatric spine can withstand trauma without fracture, and the elastic nature of the young spine allows easy slippage between segments, especially under the age of 8. Clinically, a few of the cases present with subluxation only, which seldom involve the lumbar level. We report an extremely rare case of traumatic complete upper lumbar lateral lystesis in a 3-year-old boy. The patient was treated conservatively and followed up for 2 years with some degree of correction.

Treatment of L5-S1 Spondyloptosis With Single-Stage Surgery Through the Posterior Approach-Case Report-

A 21-year-old male patient with L5-S1 spondyloptosis was treated by total L-5 laminectomy with foraminotomy and posterior fusion through the posterior approach. His complaints of severe low back pain and limited spine mobility were resolved. No new deficits occurred. The surgical management of spondyloptosis includes one-, two-, or three-stage operations with posterior, anterior, or combined approaches. Careful posterior decompression and posterior fusion without reduction may be adequate for the treatment of L5-S1 spondyloptosis.

Lower lumbar hyperextension fracture without paraplegia

Lumbar shear injuries are a rare injury with few cases documented in the literature. They are the result of hyperextension combined with anteroposterior shearing forces. Those with near-complete displacement are usually associated with significant neurologic deficit. Presented here is a case of L4-L5 fracture-dislocation with no neurologic loss.

Fracture and lateral dislocation of the T12-L1 vertebrae without neurological deficit--case report

A 21-year-old man suffered T12-L1 vertebrae fracture and lateral dislocation without neurological deficit. Computed tomography and magnetic resonance imaging demonstrated the fracture and lateral dislocation of the thoracolumbar spine. The injured spine was realigned with rods and screws, and bony fusion of the affected vertebrae was performed. Patients with thoracolumbar fracture-dislocation without neurological deficit may suffer unintended neurological injury secondary to maneuvers that cause further dislocation of the spine. Severe spinal injury without neurological deficit should be evaluated in detail, especially with spinal computed tomography. Internal fixation and reduction are recommended if the patient's condition is suitable for surgery.

Adjacent fracture-dislocations of the lumbosacral spine: case report

OBJECTIVE AND IMPORTANCE

Traumatic fracture-dislocations of the lumbosacral junction are rare, with all previously reported cases involving fracture-dislocations at a single level. No cases of multiple fracture-dislocations of contiguous spinal segments in the lumbosacral spine have been reported. A case of traumatic adjacent fracture-dislocations of the fifth lumbar segment is presented.

CLINICAL PRESENTATION

An 18-year-old male patient sustained open lumbar spinal trauma after a motor vehicle accident. A neurological examination revealed an L4 level. Radiographic evaluation of the spine revealed a three-column injury at L5 with spondyloptosis of the L5 vertebral body. Aorto-ilio-femoral angiography revealed no evidence of vascular injury.

INTERVENTION

The patient was treated with a combined anterior and posterior approach in a two-stage operation. Six months postoperatively, he was neurologically unchanged; however, he was able to walk with the aid of a cane. Plain films revealed normal alignment of the lumbosacral spine.

CONCLUSION

The management of traumatic lumbosacral fracture-dislocations requires careful consideration of retroperitoneal structures and possible exploration of the iliac vessels in addition to spinal reconstruction.