SpineUniverse Case Study Library

Traumatic L1 Vertebral Body Fracture

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History

A 29-year-old Caucasian female presents with vertebral body fracture at L1 following a motor vehicle collision. She reports severe mid-back pain.

Examination

The evaluation for head, cervical, thoracic or visceral injury was negative. The patient sustained minor soft-tissue injuries. She is neurologically intact.

Pre-treatment Imaging

L1 vertebral body fracture with kyphosis

Figure 1. L1 vertebral body fracture with kyphosis

L1 vertebral body fracture with kyphosisFigure 2. L1 vertebral body fracture with kyphotic deformity

minimal spinal canal narrowing, L1 vertebral body fractureFigure 3. Minimal spinal canal narrowing

L1 posterior elements intactFigure 4. L1 posterior elements intact

 

Diagnosis

  • L1 vertebral body fracture
  • Two-column injury at the thoracolumbar junction
  • Kyphotic deformity

Suggest Treatment

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Selected Treatment

A minimally invasive approach was utilized for internal fixation from T11 through L3 using CD HORIZON® LONGITUDE® Multi-level Percutaneous Fixation System with onlay laminar bone grafts to facilitate fusion at T12 through L3.

Intra-operative Image

intra-operative, Longitude fixation

Figure 5


Surgeons’ Treatment Rationale
The decision to offer the patient operative management versus bracing was based upon concerns regarding compliance and the literature, including results of recent meta-analysis that demonstrate improvement in kyphosis at the fracture site in patients treated operatively.1 While kyphosis in these patients has not been proven in the literature to influence long-term pain, it was also our concern that given the patient's very young age, she was at risk for developing a significant deformity over her lifetime.

With regards to the choice to use CD HORIZON® LONGITUDE® as our fixation system, we prefer a percutaneous approach when possible. One of the limitations of most percutaneous fixation systems has been traversing extended implant constructs across multiple levels. The CD HORIZON® LONGITUDE® system permits individual contouring of the rod for percutaneous passage across the thoracolumbar junction, critical in these types of injuries.

Reference
1 Gnanenthiran SR, Adie S, Harris IA. Nonoperative versus Operative Treatment for Thoracolumbar Burst Fractures Without Neurologic Deficit: A Meta-analysis. 2012. Clin Orthop Relat Res. Feb;470(2):567-77.

Medtronic Technology Featured
CD HORIZON® LONGITUDE® Multi-level Percutaneous Fixation System

Outcome

Fusion was evidenced at four months after surgery. The patient had mild mid back pain. She returned surgery to have the instrumentation removed, and post-operatively, has no pain and remains neurologically intact.

CT scans prior to removal of instrumentation shows bony fusion along the laminae and T12-L2 spinous processes (Figs. 6 and 9, red circles).

ct scan, T12-L1

Figure 6. T12-L1

CT scan, L2Figure 7. L2

CT scan, T12Figure 8. T12

L1-L2 postop vertebral body fractureFigure 9. L1-L2

L3 postop vertebral body fractureFigure 10. L3

T11 postop vertebral body fractureFigure 11. T11

X-ray after removal of instrumentation shows spinous process fusion T12-L1 (Fig. 12, red circle).

T12-L1 postop vertebral body fracture, instrumentation removedFigure 12

Note to patients
As you read this please keep in mind that all treatment and outcome results are specific to the individual patient. Results may vary. There are some risks associated with minimally invasive spine surgery, including transitioning to a conventional open procedure, neurological damage, damage to the surrounding soft tissue. In addition, instrument malfunction such as bending, fragmentation, loosening, and/or breakage (whole or partial) may occur. Please consult your physician for a complete list of indications, warnings, precautions, adverse events, clinical results, and other important medical information.

This therapy is not for everyone. Please consult your physician. A prescription is required. For further information, please call MEDTRONIC at (800)876-3133.

 

 

Discussion

This is a 29-year old female who was involved in a motor vehicle accident with a fracture at L1. The patient is reportedly neurologically intact and complains of severe thoracolumbar pain. The work-up indicated that all other systems were atraumatic.

The question comes down to surgical vs. non-surgical treatment. There is noted to be fracture deformity, and a question of stability under load is on the table. Neurological injury is an indication for surgery but there is no neurological impairment here. Canal compromise of greater than 50% is an indication for surgery by some surgeons and there is no mention of canal stenosis.

In regard to kyphotic angulation, there is debate as to the amount of acceptable kyphosis after TLSO treatment. Some authors state that any residual kyphosis under 30 degrees is acceptable in the thoracolumbar junction. There are papers that indicate that 20 to 25 degrees need surgical attention.

In my experience, fractures over 25 degrees should be surgically stabilized and fractures under 20 degrees never need surgery if the fracture kyphosis does not progress with brace treatment.

If you examine the widening of the spinous processes between T12 and L1 noted on the sagittal CT scan, the posterior column (interspinous, supraspinous ligaments and facet capsules) has been disrupted. This fracture is most likely a flexion-distraction fracture, which has inherent instability under load. The posterior column injury associated with the anterior column fracture will normally induce progressive kyphosis utilizing brace treatment, even with a well-fitting extension TLSO.

The “percutaneous” instrumentation has nicely reduced the kyphosis angulation, and a fusion has stabilized the fracture. Percutaneous systems work well if the fracture is surgically stabilized within two to three days of the trauma. If the fracture is resistant to reduction, however, it is my opinion that an open instrumentation with cantilever rod reduction will allow greater forces to be generated to align the vertebra.

Many do not remember the “rod long/fuse short” period that occurred in the 1970s and early 1980s. The philosophy at that time was only fuse the involved injured segments and then later, take out the instrumentation. This technique was discontinued after we realized that instrumenting and immobilizing levels that were later allowed to mobilize created significant motion segment pain.

Authors' Response

Joshua M. Ammerman, MD
Matthew D. Ammerman, MD

It is our opinion that since the fracture was at the thoracolumbar junction, where the very rigid thoracic spine transitions to the more mobile lumbar spine, simple immobilization and instrumentation from T12-L1 had a high risk of instrument failure. Therefore, a longer construction was necessary to guard against failure in this young and active individual. 

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