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Traumatic thoracic spinal fracture dislocation with minimal or no cord injury

Report of four cases and review of the literature

Scott Shapiro, Todd Abel and Richard B. Rodgers

Object. Thoracic fracture dislocations reportedly lead to complete paraplegia in 80% of cases. It is rare for these dislocations not to cause neurological deficits, as evidenced by the mere 11 well-documented neurologically intact cases in the English-language literature.

Methods. The authors report four cases of thoracic fracture dislocation that remained neurologically intact and discuss 11 other previously published well-documented cases.

Overall there were 10 men and five women with a mean age of 34 years (range 17–66 years). Mechanisms of injury included car crash in six, motorcycle crash in seven, plane crash in one, and fall from a horse in one. On admission, neurological deficits were absent in 11 patients, intercostal neuralgia was present in two, and mild lower-extremity weakness/numbness was demonstrated in two. All suffered significant thoracic pain, with 14 patients having sustained rib fractures and eight a hemothorax. The levels of dislocation were T3–4 in two, T5–6 in four, T6–7 in four, T7–8 in two, T8–9 in one, and T9–10 in two. All suffered some degree of lateral translation (mean 12 mm, range 3–27 mm). There were six cases of well-documented anterior subluxation in addition to translation (mean 12 mm, range 4–23 mm), and all involved some degree of fracture imploding of one vertebral body (VB) into an adjacent VB. There were six cases of burst fracture with translation (mean kyphotic angle 38°, range 28–50°). Bilateral pedicle shear fractures were present in all 15 cases at the site of subluxation, thus separating the anterior from the posterior elements and preserving the spinal canal. Only two of the 15 patients suffered complete spondylolisthesis. Five patients underwent successful nonoperative management with prolonged bed rest; at follow-up examination, neurological status remained normal in all five, lesions were radiographically unchanged in three, and there was less subluxation but not anatomical alignment in two. Ten patients underwent successful internal fixation via anterior approaches (two cases), posterior approaches (five cases), and combined approaches (three cases). Neurological status either improved to normal or remained normal except in one case with persistent intercostal neuralgia. Surgery resulted in no change in alignment in three, improved but not anatomical alignment in 11, and normal alignment in one patient. All patients ambulated unassisted by 6 months.

Conclusions. In cases in which bilateral pedicle fractures occur at the site of significant thoracic subluxation and/or translation, preservation of the spinal canal and spinal cord neurological function can rarely occur when both the lamina and spinal cord do not dislocate along with the anterior VBs. In these instances, perfect anatomical reduction may require forces that unnecessarily put neurological function at risk and the results appear to justify internal fixation with some or no reduction of deformity.

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Jeffrey F. Lastfogel, Thomas J. Altstadt, Richard B. Rodgers and Eric M. Horn

Recent studies have demonstrated excellent results in treating isthmic spondylolisthesis via an anterior lumbar interbody fusion (ALIF). The authors describe 3 patients with isthmic spondylolisthesis at L5–S1 who experienced sacral fractures after insertion of a unique, stand-alone anterior interbody fixation device.

Three consecutive patients at a single institution were treated for Grade I spondylolisthesis at L5–S1 via a standalone ALIF with insertion of a novel biomechanical interbody device. This device is made of polyetheretherketone and has an integrated system for internal fixation into the vertebral bodies. In each patient a bone morphogenetic protein–soaked sponge was placed for the fusion. The indications for treatment in each patient were back and radicular pain that had been unsuccessfully treated with conservative measures.

All 3 patients had reduction of their spondylolisthesis and resolution of their unilateral radiculopathies immediately postoperatively. Within 1 month of surgery, all 3 patients had failure of the device and recurrence of their symptoms. In each case the failure was due to fracture of the anterior portion of the S-1 body. Each patient underwent reduction and pedicle screw fixation at L5–S1. In all cases, there was successful reduction in their recurrent spondylolisthesis and resolution of their radiculopathies.

Treatment of Grade I isthmic spondylolisthesis at L5–S1 with stand-alone ALIF and fixation can lead to sacral fracture from high stress loads at that level in the spine, and consideration should be made either for supplemental pedicle screw fixation or a completely posterior approach.

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Shaheryar F. Ansari, Richard B. Rodgers and Daniel H. Fulkerson

Congenital scoliosis from laterally located hemivertebrae at the lumbosacral junction has been described previously. However, dorsally located midline hemivertebrae at this location have not been reported. The authors describe the presentation, treatment, and outcomes of 2 patients (1 male and 1 female) with this rare malformation. All clinical and radiographic records were reviewed. Outcomes were recorded using survey instruments (Oswestry Disability Index and the 36-Item Short Form Health Survey). Radiographic assessment of bony fusion was performed using CT scanning 1 year after surgery.

Both patients presented with back and leg pain, urinary hesitancy/incontinence, difficulty sitting and lying down, waddling gait, and restriction of movement. Imaging showed a wedge-shaped dorsal deformity that stretched the nerve roots and compressed the canal. Both patients underwent resection of the hemivertebra with posterolateral instrumented fusion from L-2 to the pelvis. The female patient had a low-lying conus and underwent sectioning of the filum terminale. Both patients showed improvement in the ability to sit and lie flat and in bowel and bladder function after surgery. The authors describe their experience with 2 patients with similar, rare congenital bony deformities at the lumbosacral junction. To their knowledge, similar cases have not been previously reported.