L3 Pathological Fracture During Softball Game
A 76-year-old man suddenly developed severe low back pain while batting at a softball game. He was found to have an L3 compression fracture.
There is tenderness to palpation in the lumbar region. Motor strength is 5/5 bilaterally, and the patient experiences severe pain with minimal exertion.
Initially, the patient was treated with a thoracolumbar orthosis (Body Jacket).
A CT-guided biopsy attempt was non-diagnostic. A search for a primary tumor was unremarkable.
Several weeks later, the patient had worsening low back pain, associated with numbness and burning pain down the legs.
Repeat imaging at this point showed increased thecal sac compression and progressive angulation of the lumbar spine.
Figure 1: Sagittal T2-weighted MRI showing L3 pathological fracture with retropulsion
Figure 2: Axial T2-weighted MRI showing a retropulsed fragment causing spinal stenosis.
The patient was diagnosed with an L3 compression fracture.
Suggest TreatmentIndicate how you would treat this patient by completing the following brief survey. Your response will be added to our survey results below.
The patient underwent a minimally invasive lateral retroperitoneal corpectomy with expandable cage and lateral plate placement.
Surgery was done through a direct lateral approach using a 3cm incision and a muscle splitting technique through the abdominal wall. Sequential dilators were inserted through the psoas, assisted by neuro-monitoring, to guide the minimally disruptive retractor. The L3-L4 disc was removed, followed by the L2-L3 disc.
The vertebral body of L3 was exposed while securing the segmental artery. The corpectomy was done using osteotomes and a high-speed drill. Bony fragments were removed until the dura was decompressed.
An expandable cage was inserted into the cavity and expanded into place. The residual cavity was filled with cellular bone matrix allograft. Vertebral augmentation with bone cement (PMMA) was done at L4. A lateral plate was then placed with 2 screws at each level.
Figure 3: Coronal CT scan reconstruction with expandable cage and lateral plate.
Figure 4: Sagittal CT scan reconstruction with expandable cage and lateral plate.
Figure 5: Axial CT scan axial showing lateral plate and L4 screw with PMMA augmentation
The patient reported resolution of his pain.
I would be very concerned about stability with an anterior-only approach in this case. Several factors contribute to my opinion.
- The patient is 76 years old.
- The patient has a pathological fracture.
- Fracture location is at the mid-lumbar spine.
The use of a minimally invasive approach is always attractive but not at the expense of a good outcome. This patient is 76 years old. The bone density is probably not great. A lateral plate with only one screw in each adjacent vertebral body in the mid-lumbar spine won't add much additional fixation. An expandable cage doesn't allow for much graft material so solid fusion will undoubtedly take a long time. The race between healing and fixation failure is on!
Additionally, there is no mention of why the fracture is "pathologic." Many questions are left unanswered in how to best manage this case. Is the fracture secondary to osteoporosis? Is it secondary to the tumor? Will adjunctive treatment (ie, radiation) be necessary? Unless there is acute need for decompression, which would be unlikely in a lumbar burst fracture, identifying the cause the pathologic fracture is the first step.
We would also need to know the patient's bone density. If stabilization is deemed necessary, I would favor a posterior approach with pedicle screw instrumentation. This could be supplemented with posterior corpectomy and reconstruction or possibly intraoperative vertebroplasty under direct visualization. Knowing the pathology and the bone density would help determine the best treatment.