Impaction fracture of the lumbar vertebrae with dural tear

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✓ The authors describe a lumbar spine fracture that is characterized on anteroposterior x-ray views by separation of the pedicular shadows. It is almost invariably associated with posterior interlaminar herniation of the cauda equina through a dorsal dural split, and anterolateral entrapment or amputation of the nerve root. The fracture is unstable and requires internal fixation and fusion at the time of neurolysis. Fractures meeting these criteria should be explored as soon as the patient's condition permits. Myelography is usually unnecessary and may be contraindicated in some cases. The postulated mechanism of injury is hyperextension with vertical impaction and rupture of the ring made up of the lamina, pedicle, and vertebral body. The ring is fractured in several places in a manner similar to that seen in “Jefferson fracture” of C-1. The special anatomical relationships of the thoracolumbar junction and the plane of the lumbar facets are also discussed.

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Address reprint requests to: Carole A. Miller, M.D., Department of Surgery, The Ohio State University, 410 West 10th Street, Columbus, Ohio 43210.

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Headings

Figures

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    The pathognomonic finding is separation of the pedicular shadows, as indicated by the arrows. Comminution of the vertebral body and bone misalignment may also be present.

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    Computerized tomography scan showing a pure hyperextension injury. Scans by kind permission of Edward Reifel, M.D., Seattle, Washington. Left: Fragmentation of the vertebral body and a fracture through the base of both pedicles are visible. The fracture extends through the pedicle on the left and through the left lamina at the base of the spinous process. This is the point of nerve root herniation (arrows). Right: Scan showing a fracture at the base of both pedicles into the body of the vertebra (arrows). Fracture at the base of the spinous process again seen.

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    Demonstration of a laminar spreader between T-12 and L-2. Once the dissection of muscle and ligaments is complete and the spinous processes above and below the lesion are freed, the laminar spreader can be placed and often allows reduction of posterior-element fragments without excessive dissection at the fracture site.

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    Black paper has been inserted into the facets of the thoracic and lumbar spine. In the thoracic spine, the plane of the facets is near the coronal plane of the body; in the lumbar spine, the plane is nearly sagittal. There is an abrupt change of plane between the T11–12 articulation and the T12-L1 articulation from coronal to sagittal. The upper point permits movement in all planes, but at the lower point motion is primarily for flexion-extension. The facets permit flexion and extension, but as sliding joints they also permit downward force to be delivered by the inferior articular facets against the pars interarticularis.

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    Anatomical mechanical factors in impaction fracture of the lumbar vertebrae with dural rent. For details see above.

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