Stage Operation for Unstable Lumbar Spine Fracture- Dislocation with Incomplete Paraplegia: A Case Series

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1 C a s e R e p o r t J. of Advanced Spine Surgery Volume 2, Number 2, pp 60~65 Journal of Advanced Spine Surgery JASS Stage Operation for Unstable Lumbar Spine Fracture- Dislocation with Incomplete Paraplegia: A Case Series Sang-Hyuk Min, M.D., Young- Ho Park, M.D. Department of Othopedic Surgery, Dankook University College of Medicine, Cheonan, Korea Purpose: A surgical treatment has been preferred in patients with unstable lumbar spine fracture-dislocation with incomplete paraplegia as it does not cause further nerve injury by regenerating and maintaining the shape of the spinal canal via the accurate reduction of fracture, and prevents additional complications by preventing neurovascular injury that secondarily occurs. 1) However, the surgical treatment may be delayed or even impossible in patients with hemodynamic unstable state caused by an emergent concurrent injury. Accordingly, Stage operation was conducted on patients with unstable lumbar spine fracture-dislocation with incomplete paraplegia who had a difficulty in undergo immediate reduction and decompression due to hemodynamic unstable state caused by other concurrent injuries. Methods: Postural reduction and minimal invasive percutaneous pedicle screw fixation L1-4 were conducted as a first stage operation, and L2-3 partial laminectomy, discectomy, and posterior fusion were then conducted as a second stage operation by applying the concept of stage operation in the department of spinal surgery. Results: The first stage operation had a blood loss of 150cc and an operation time of 58 min. Compared to motor grade 3 shown in preoperative status, motor grade 4 was shown in L3 level or lower in a postoperative physical examination. The second stage operation was conducted two weeks later. It had an operation time of 90 min and a blood loss of 500cc. no neurologic change was further found. Conclusion: Stage operation was conducted on patients with hemodynamic unstable state. Postural reduction and minimal invasive percutaneous pedicle screw fixation were conducted as a first stage operation to achieve the immediate reduction and stability of fracture and dislocation and the improvement of neurologic deficits. Subsequently, decompression or fusion was conducted as a second stage operation under stable systemic status for through and accurate operation. Key Words: lumbar Fracture-dislocation, Stage operation, Minimally invasive, Hemodynamic unstable Introduction Due to recently increasing car accidents and industrial disasters, unstable lumbar spine fracture-dislocation increasingly occurs. As patients with unstable lumbar spine fracture-dislocation frequently accompany neurologic deficits, immediate decompression and fusion are required to achieve stability 1). However, immediate decompression and instrumentation are unavailable for patients with hemodynamic unstable state such as concurrent injury of internal organs and retroperitoneal hemorrhage among patients with lumbar spine fracturedislocation. Accordingly, the authors applied stage operation to patients who had poor systemic status and unstable lumbar spine fracture-dislocation with Corresponding author: Sang-Hyuk Min, M.D. Department of Orthopaedic Surgery, Dankook University College of Medicine, 16-5 Anseo-dong, Cheonan , Korea TEL: , FAX : osmin71@naver.com 60 Copyright 2012 Korean Society for the Advancement of Spine Surgery

2 incomplete paraplegia. As a first stage operation, postural reduction and minimal invasive percutaneous pedicle screw fixation were conducted to achieve the reduction and early stability of the neural tube. Subsequently, as a second stage operation, decompression and posterior fusion were conducted after the patient s systemic status was improved Case A 48-year-old male patient was transferred to the emergency department due to unstable fracture-dislocation of L2 through L3 vertebrae, trumatic-pseudoaneurysm, diaphragm rupture, and hemomediastinum that occurred by a fall at a height of 2 mm while working on June 28, He had initial Hb 12.3g/dl and 8.2g/dl one hour later. Thus, PRC 4500cc and FFP 2100cc transfusion were immediately conducted (Fig.1). The patient underwent a surgery for trumatic-pseudoaneurysm and diaphragm rupture in the department of thoracic surgery on the day of injury. He had a blood loss of 3600cc during the surgery. Thus, PRC 3000cc and PC 1000cc transfusion were conducted during the surgery. PRC 600cc and PC 500cc transfusion were conducted 3 days after the surgery. He showed Hb:10.2g/dl and Plt:52000/ul, and motor grade 3 at L3 Fig. 1. Initial simple Lumbar spine x-ray and computed tomography scan and MRI T2 sigital image demonstrate fracture-dislocation of L2 through L3 with facet fracture and severe canal compromise 61

spinal surgery. It had an operation time of 58 min and a blood loss of 150cc (Fig.2).

As a result, reduction of L2-3 facet joint and disc extrusion were observed (Fig.3).

3 level or lower as intubation state. Postural reduction and minimal invasive percutaneous pedicle screw fixation L1-4 were conducted as a first stage operation to minimize the deterioration of the systemic status in the department of spinal surgery. It had an operation time of 58 min and a blood loss of 150cc (Fig.2). After the first stage operation, motor grade 4 was shown at the L3 or lower, showing the recovery of neurologic deficits. Follow-up CT and MRI were conducted prior to a second stage operation. As a result, reduction of L2-3 facet joint and disc extrusion were observed (Fig.3). L2-3 partial laminectomy, discectomy, and posterior fusion were conducted as a second stage operation 2 weeks after the first stage operation (Fig. 4). It had an operation time of 90 min and a blood loss of 500cc during the operation. After the second stage operation, neurology was some improved. Discussion Fig. 2. First stage operation was done a method of postural reduction and minimally invasive percutaneous pedicle screw fixation Surgical or conservative treatments are conducted to achieve the reduction and stability of unstable thoracolumbar spine fracture-dislocation. It is, however, still controversial over the indications and advantages of each treatment method. Holdsworth 2-4) reported that anatomical reduction of fracture was achieved and spinal canal shape was regenerated and maintained by conducting internal fixation and bone graft after early open reduction, thereby preventing deformity that secondarily occurs and reducing additional complications without further neurologic deficits. Although many studies reported that bed rest and conservative treatment based on body position showed neurologic recovery similar to that Fig. 3. (A) Postoperative(two weeks after first stage operation) reconstruction CT demonstrate correction of sagittal balance with facet joint reduction (B) postoperative(two weeks after first stage operation) MRI sagittal and axial image demonstrate canal encroachment of herniated disc with soft tissue Fig. 4. Second stage operation was done a method of partial laminectomy, discectomy and posterior fusion L2-3 level 62

$shown in surgical treatment in a long-term follow-up, 5,6) surgical treatment has been gradually preferred due to its advantages of anatomical reduction of fracture, decompression of compression$ The reason for that is that if the operation is delayed, physical changes that increase other risks might occur due to physical burdening during the operation compared to early operation.

The reason for that is that if the operation is delayed, physical changes that increase other risks might occur due to physical burdening during the operation compared to early operation.

4 shown in surgical treatment in a long-term follow-up, 5,6) surgical treatment has been gradually preferred due to its advantages of anatomical reduction of fracture, decompression of compression neuropathy, decreased deformity, recovery of nerve function, and early rehabilitation. 7) As for time for operation, Dickson et al. 8) suggested early operation. The reason for that is that if the operation is delayed, physical changes that increase other risks might occur due to physical burdening during the operation compared to early operation. They explained that early operation can decompress spinal or nerve muscle compression with neurologic deficits, thereby increasing the possibility of neurologic recovery, and improving fast recovery due to no delay between the injury and operation. Whiteside et al. 9) and Jacob et al. 7) suggested that anterior decompression and fusion should be conducted after achieving posterior stability via internal fixation in the case of the injury of both anterior body and posterior ligament. In this case report, although it is difficult to conclude that operation itself contributed to the recovery of neurologic deficits, early reduction of fracturedislocation is likely to be helpful for the recovery of neurologic deficits by regenerating and maintaining the shape of the spinal canal. In addition, it could prevent further neurologic deficits by preventing deformity that secondarily occurs. Stage operation, in which early stability using the external fixator is provided to minimize neurovascular injury and to assist wound treatment, and accurate reduction and internal fixation are subsequently conducted, has been commonly conducted on patients with open comminuted fracture. Thus, the same stage operation could be applied to unstable lumbar spine fracture-dislocation patients with hemodynamic unstable state. A 56-year-old female patient was transferred to Fig. 6. First stage operation was done a method of postural reduction and minimally invasive percutaneous pedicle screw fixation Fig. 5. Initial simple Lumbar spine x-ray and MRI T2 image demonstrate severely displaced fracture-dislocation of L3 through L4 vertebrae 63

5 the emergency room due to fracture-dislocation of L3 through L4 caused by a car accident. She had hemodynamic unstable state showing Hb:8.2 g/dl and BP:90/50 mmhg. A physical examination showed hip flexor G1, knee extensor G1, and motor Grade 0 at the L4 level or lower (Fig.5). The patient underwent stage operation. Postural reduction and minimal invasive percutaneous pedicle screw fixation L2-5 were conducted as a first stage operation (operation time: 30 min, intraoperative blood loss: 30cc) (Fig.6). After the first stage operation, hip flexor G3 and knee extensor G3 were shown, confirming the recovery of the neurologic deficits. No scheduled second stage operation was conducted due to the surgery refusal by the patient. However, the immediate recovery and stability of the neural tube was maintained via the first stage operation. In this case report, reduction was conducted using the polyaxial screw, which resulted in the insufficient recovery of sagittal balance. However, with the recent development of various minimally invasive instruments, more accurate reduction and sagittal balance recovery are expected to be achieved. Reduction and fixation via an early surgical treatment could be helpful for the recovery of neurologic deficits in patients with unstable lumbar spine fracturedislocation with incomplete paraplegia. This method could be also helpful for preventing neurovascular injury that secondarily occurs in the treatment of emergent concurrent injuries and during nursing including postural change. As shown in this case report, the following advantages can be obtained by applying stage operation to patients with unstable lumbar spine fracture-dislocation who have a difficulty in undergoing immediate open reduction and decompression or posterior internal fixation due to hemodynamic unstable state: First stage operation is conducted to achieve dislocation reduction and the recovery of the neural tube using minimally invasive percutaneous pedicle screw rather than conventional open pedicle screw fixation for fracture-dislocation. As a result, additional blood loss and the deterioration of neurologic deficits caused by the operation can be minimized. 10) References 1. Cheng-Ta H.,Guann-juh C. Complete fracture-dislocation of the thoracolumbar spine without paraplegia. Am. Journal of emergency medicine. 2008;26:633.e Holdsworth FW. Early Treatment of Paaraplegia from Fractures of the Thoraco-lumbar Spine. J Bone and Joint Surg. 1953;35B: Holdsworth FW. Early Treatment of Paaraplegia from Fractures of the Thoraco-lumbar Spine. J Bone and Joint Surg. 1963;45B:6-20, 4. Holdsworth FW. Early Treatment of Paaraplegia from Fractures of the Thoraco-lumbar Spine. J Bone and Joint Surg. 1970;52A: Cantor JB, Lebwohl NH, Garvey T and Eismont FJ. Nonoperative management of stable thoracolumbar burst fractures with early ambulation and bracing. Spine J. 1993;1: Weinstein JN, Collato P and Lehmann TR. Thoracolumbar burst fractures treated conservatively. A Long-term follow up. Spine J. 1988;13: Jacobs RR, Asden MA and Snider RK. Thoracolumbar spinal injuries. A comparative study of recumbent and operative treatment in 100 patients. Spine J. 1982;5: Dickson JH, Harrington PR, Erwin WD. Results of reduction and stabilization of severely fractured thoracic and lumbar spine. J Bone and Joint surg. 1978;60A: Whitesides TE Jr., Shah SGA. On the management of unstable fractures of the thoracolumbar spine:rationale for use of anterior decompression and fusion and posterior stabilization. Spine J. 1976;1: Kim DY, Lee SH, Chung SK, et al. Comparision of multifidus muscle atrophy and trunk extension muscle strength: percutaneous versus open pedicle screw fixation. Spine J. 2005;32:

6 불완전마비를동반한불안정성요추부골절 - 탈구환자에서의단계적수술 민상혁, 박영호단국대학교의과대학정형외과학교실 서론 : 불완전마비를동반한불안정성요추부골절-탈구환자에서수술적치료는골절의정확한정복을도모하여척수강의형태를재생시켜이를유지함으로써더이상의신경손상을주지않고이차적으로발생하는신경혈관손상을예방하여추가적인합병증을줄일수있어선호되고있다. 1) 하지만환자가응급을요하는동반손상으로인하여혈역학적으로불안정한경우수술적치료가지연되거나불가능한경우가발생할수있다. 이런환자에게단계적수술의개념을적용하였다. 재료및방법 : 단계적수술의개념을적용하여일차적수술로체위정복술및요추 1-4번간최소침습경피적척추경나사못고정술시행하였으며, 이단계수술로 2-3번간부분적후궁절제술, 디스크제거술및후방골유합술을시행하였다. 결과 : 일차적수술중수술시간 58분수술중출혈량 150cc 였으며, 수술전과비교하여수술후임상검사상요추 3번이하로 motor grade 3에서 4로호전되는양상보였다. 2주후이차적수술을행하였으며수술시간은 90분, 수술중출혈량 500cc 였으며이후의신경학적변화는관찰되지않았다. 결론 : 혈역학적으로불안정한상태의환자에서단계적수술의개념을적용하여일차적수술로체위정복술및최소침습경피적척추경나사못고정술을시행하여골절및탈구의즉각적인정복및안정성을얻어신경증상의회복에도움을줄것으로생각되며전신상태가안정된상태에서이차적수술로감압술이나골유합술등을시행함으로써보다철저하고정확한수술이가능하였다. 색인단어 : 요추골절 - 탈구, 단계적수술, 최소침습적, 혈역학적불안정 65

Posterior Instrumentation of Thoracolumbar Fracture

Posterior Instrumentation of Thoracolumbar Fracture Jin-Young Lee, MD, and Gab-Lae Kim, MD Department of Orthopedic Surgery, Hallym University College of Medicine, Seoul, Korea Abstract The thoracolumbar