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High Thoracic Pathological Fractures

Case Report

History
This 60M had a 2 month history of posterior thoracic pain, easily controlled with simple analgesia, but persistent. He had no neurological symptoms and was otherwise healthy. Physical examination elicited no neurological deficits. A CT scan of the chest elicited vertebral body anomalies at the T2-3 level. He was also noted to have rib lesions but no visceral metastases. Relevant imaging is shown below:
?posterior

Pre-Operative Posterior Image

?fracture?

Pre-Operative Lateral Image

Management
Despite the fact that the patient had not had radiotherapy, was neurologically intact and the pathology was a radiosensitive lesion, because of the 50% subluxation it was felt likely that with subsequent therapy this man was at a high risk of paraplegia with progressive collapse, kyphosis and subluxation at T2-3. Consequently surgical decompression and stabilization was advised.

Surgery was performed on a Jackson operating table. Lateral fluoroscopy could not visualize the region of interest. A T2-3 corpectomy was effected via a posterior bipedicular approach. The subluxation was reduced by distraction and by readjustment of head position in the Mayfield holder. T4 was found to be involved with tumor and was also removed. Stabilization was then achieved with methylmethacrylate countersunk into the endplates of T1 and T5 and pedicle screw fixation using titanium fixed M8 CD Horizon screws into C7, T1, T5, T6 and T7. Total operating time 5 hours. Patient was discharged from hospital on Day 7 postop. No complications. This is shown in the following images:

?thecal

(Above) The wide decompression showing the thecal sac and T2 and T3 roots.
?distraction?

(Above): Reduction being effected initially with distraction between T1 and T5.
?operative

(Above): The final construct after placement of bone cement and with all screws in place.
?final

Post-Operative Image

?bone
Post-Operative Image

?screw
Post-Operative Image

?axial
Post-Operative Image
(Above): Four postoperative images showing the completed construct,
vertebral body reconstruction and C7 and T6 pedicle screw placements.

 

Discussion
It is essential that pathological fracture dislocations are considered for surgical intervention, even in neurologically intact patients that have radiosensitive lesions as these cases have a propensity to progress their instability. Reconstruction of all 3 columns is essential and strong fixation is required. Pedicle screw constructs achieve this and a posterior circumferential decompression and fusion achieves what would be difficult from an anterior approach which may or may not be followed by posterior surgery.

Updated on: 02/01/10
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