Severe L5 Burst Fracture
The patient is a 23-year-old male who was involved in a motor vehicle accident. He presented with severe lower back pain, bowel and bladder incontinence, and no movement of his right foot.
The patient had diminished rectal tone, 0/5 motor strength in the right DF/EHL/PF, as well as diminished sensation in the foot. The trauma evaluation revealed no other injuries.
Lumbar spine CT demonstrated significant L5 burst fracture, with severe canal compromise and evidence of L4-L5 facet disruption.
Pre-operative sagittal (Fig. 1A) and axial CT (Fig. 1B) images demonstrated severe L5 fracture with canal stenosis.
Severe L5 vertebral body fracture with cauda equina syndrome
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- Given the patient’s acute deficits, he was urgently taken to the operating room (OR) for posterior decompression and instrumented fusion (L3-pelvis) using the freehand technique.
- There was a significant traumatic dural tear that was repaired primarily, and the vertebral body fragments were fully visible through the dural defect, with evidence of rootlet injuries.
- The patient was allowed to recover where he regained antigravity strength in the foot.
- He was taken back to the OR in a staged fashion, during the same hospitalization, for an anterior L5 vertebrectomy with cage reconstruction.
- Again, there were several ventral dural defects that were not amenable to primary repair.
- We placed an on-lay fat graft with a dural sealant before the cage was implanted.
- A screw at the caudal and rostral vertebral bodies was used as a buttress against the cage endcaps.
Post-operative CT and scout images demonstrated circumferential reconstruction (Figs. 2A, 2B, 2C).
The patient was discharged home after recovery. He had regained significant strength in the foot, and was ambulatory with a walker. He had regained bowel but not bladder function at time of discharge.
This case from Dr. Baaj reveals an L5 burst fracture causing a cauda equina syndrome. The patient has foot drop and bladder control problems.
I agree with Dr. Baaj that an urgent decompression and stabilization is needed. Dr. Baaj found a dural tear from the fracture, which is unusual after burst fractures. When I have encountered this issue, I typically employ a lumbar dural direct repair at the index surgery and sometimes also divert the CSF with a lumbar intradural temporary drain.
The fixation done by Dr. Baaj provides anterior column support and posterior stabilization using lumbosacral pedicle screws and iliac fixation. Such fixation is robust and unlikely to fail.
One other option is a posterior L3-S1 fixation with iliac fixation and transpedicular decompression to tamp the bone fragments ventrally without anterior column reconstruction. If it does not fuse, then a staged anterior column decompression can be performed at a later date.
However, trauma patients often are lost to follow up, so I agree with Dr. Baaj's approach of performing a L5 corpectomy at the index setting. Of note, a corpectomy of L5 is uncommon, and the use of a cage with built in lordosis is helpful to reconstruct the anterior column while avoiding a flat back.
The CT scan demonstrates a rotated, angulated, L5 bony fragment from the posterior superior portion of L5, nearly completely occluding the canal. The cuts provided are limited, but suggest L4-L5 facet dislocation on the left, as well as a L3 spinous process fracture. The patient (amazingly) is incomplete, suggesting there must be dural tears, which to some degree "decompressed" the thecal sac.
I agree with the need to operate, but would have done this in reverse order. Since almost all the compression is anteriorly from the L5 vertebral body, given the patient is incomplete and mechanically unstable anteriorly, I would have started with the anterior approach with a corpectomy, canal decompression, and strut fusion. This would have provided more immediate and significant decompression of the cauda equina and nerve roots than a laminectomy could/would do. I would not do this from a lateral or posterolateral approach, but a direct anterior (as was done here as the second operation). I would then, if the patient is stable enough, have turned him prone (not on an extension table) and fused him, as was done here, from L3 to the sacrum. I would assume there was a posterior (and perhaps anterior) dural tear. Unless the CSF, dura, or roots were visible through the lamina and trapped in the posterior defects, I would not have performed a laminectomy, but only an instrumented fusion.
Based on an adequate anterior decompression, there would be no need for a posterior decompression. If there were rootlets, or leaking CSF noted through the posterior elements, then I would have performed a laminectomy to repair the tear. Since there is no inherent stability of the anterior construct from L4 to the sacrum, if there were medical reasons not to perform an open procedure posteriorly at the time, I would have considered at least—for short-term stability—posterior percutaneous instrumentation to hold the anterior graft "in place."
Finally, though an expandable cage was used, and is increasingly used, I have some concerns about it since, as it is distracted, the graft placed in the cage does not remain opposed to the endplates, or leaves the center of the cage, and long-term the anterior fusion may not be so successful. Though the end result may not have been as lordotic, I would have used a bent Harms type cage with lordotic caps, filled with the corpectomy bone.
Overall, the end radiographs and clinical results appear excellent. However, there are theoretical, and I suggest anatomic, practical reasons to go anteriorly first.
I thank Drs. Mummaneni and Garfin for their thoughtful comments on this complex case.
Circumferential stabilization for a three-column injury at the lumbosacral junction likely provides the most biomechanically robust construct. Decompression of the canal, given the presenting neurology, is indicated. In the cervical and thoracic spine, a prompt direct decompression and excision of anterior bony fragments that act as a knuckle against the cord is the ideal approach. In the lower lumbar spine, a posterior decompressive laminectomy is typically adequate and allows for acceptable thecal sac decompression. Performing posterior stabilization first, as was done here, locks the vertebral bodies and allows for compression ventrally, albeit via expanding the cage against the adjacent bodies. My preference is to first “control” a highly unstable spine posteriorly, then augment the construct ventrally if needed.