SpineUniverse Case Study Library

L3 Pathological Fracture During Softball Game

History

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.

Examination

There is tenderness to palpation in the lumbar region. Motor strength is 5/5 bilaterally, and the patient experiences severe pain with minimal exertion.

Initial Treatment

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.

Pre-treatment Images

Fig 1 Cardona Pre-op Sagittal T2-weighted MRI

Figure 1: Sagittal T2-weighted MRI showing L3 pathological fracture with retropulsion

 

Fig 2 Cardona Pre-op Axial T2-weighted MRIFigure 2: Axial T2-weighted MRI showing a retropulsed fragment causing spinal stenosis.

Diagnosis

The patient was diagnosed with an L3 compression fracture.

Suggest Treatment

Indicate how you would treat this patient by completing the following brief survey. Your response will be added to our survey results below.

 

Selected Treatment

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.

Post-treatment Images

Fig 3 Cardona Post-op Coronal CT ScanFigure 3: Coronal CT scan reconstruction with expandable cage and lateral plate.

 

Fig 4 Cardona Post-op Sagittal CT ScanFigure 4: Sagittal CT scan reconstruction with expandable cage and lateral plate.

 

Fig 5 Cardona Post-op Axial CT ScanFigure 5: Axial CT scan axial showing lateral plate and L4 screw with PMMA augmentation

Outcome

The patient reported resolution of his pain.

Case Discussion

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.

Community Case Discussion (3 comments)

SpineUniverse invites spine professionals to share their thoughts on this case.


An easier and perhaps safer approach would be anterior corpectomy, fusion with cage and or allogranft and fixation. If bone quality is poor, supplemental pedical screws could be placed.

three things i would look forward to
a role of anterior decompression with fixationthan MISS
what about osteoporosis what you plan to do
what is the biopsy report more likely this could be due to osteoporosis even then in s uch cases there is 25% chance of missing a malignant lesion

I had some case like this, in old patients, My treatment option, with good results in long follow up, was: posterior decompression + PMMA injection+ short transpedicular fixation.

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