T5 Burst Fracture from MVA
Can the patient ever return to farming?
The patient is a 52-year-old female. Six months before presenting in the clinic, she was involved in a motor vehicle accident (MVA). She now can’t work her farm because of her back pain.
The patient is neurologically intact. There is point tenderness to palpation over T5.
To deal with her back pain, the patient has tried:
- pain medicine
- physical therapy
- epidural steroid injections
Figure 1: Sagittal x-ray showing T5 burst fracture with kyphotic angulation at that level.
Figure 2: Coned down view showing T5 burst fracture.
Figure 3: T2-weighted MRI showing burst fracture with retropulsion of bone into spinal canal, coming up to and touching the spinal cord. This also shows incidental small fracture at T12.
The patient was diagnosed with a T5 burst fracture.
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The patient underwent a T5 MIS lateral extra-cavitary with anterior reconstruction and posterior instrumentation. The anterior reconstruction was done using the patient’s own rib.
She was in the hospital for 2 days following surgery, and she had only 100cc of blood loss during surgery. The MIS approach allowed for minimal disruption of normal anatomy.
Figure 4: AP x-ray 6 months post-operative
Figure 5: Sagittal x-ray 6 months post-operative
The patient is now 8 years post-op. She continues to work 14 hours a day on her farm, and she says, “After 14 hours on my tractor, my back starts hurting a little bit.”
This case of an unfortunate but not so unlucky 52-year-old female who suffered a potentially devastating T5 burst fracture. The most important factor upon reviewing this case is the fact that it occurred 8 years ago. Spine surgery instrumentation and approach access has been continuously evolving.
Canal decompression and spinal stabilization appear to have been addressed with this procedure. Both objectives could be reached with minimally invasive techniques. Upon review of the post-operative images, there is still some kyphosis. The use of the rib as autograft provides little significant structural support. The lack of anterior column support increases the dependence on the posterior instrumentation.
The objectives not addressed in the management of this patient, that could have been done today through minimally invasive spine surgery:
- Reconstruction of the anterior column and anterior column support
- Sagittal balance
- Anterior instrumentation
- Single small incision (2.5")
- Rib reconstruction
If this patient presented today, I believe the best procedure would entail a lateral retropleural T5 corpectomy with T4-T5 and T5-T6 discectomies, expandable cage placement with cellular bone matrix allograft, lateral plate and screws. With this procedure, the rib may be reconstructed. If the pleura has not been violated there is no need for a chest tube. When there are small pleural tears, a medium bore drain can be placed during closure and removed after valsalva maneuvers.