Osteoporotic Burst Fracture
The patient is a 71-year-old priest who presents with a complaint of chronic pain. He has had progressive upper thoracic and neck pain for 2 months, and when asked, he denies any significant trauma.
His upper extremity power is normal. His lower extremities are a grade 5 power, and he is hyper-reflexive in patellar and achilles reflexes. There was sustained clonus bilaterally, and he has upgoing toes.
Figures 1-3 show anterior compression of T3 and T4, retropulsed bone into the spinal canal, and fractured posterior elements.
Figure 1. Sagittal CT
Figure 2. Sagittal CT
Figure 3. Sagittal CT
Sagittal MRI (Fig. 4) confirming bony changes and showing destruction of theT3-T4 disc.
Figure 4. Sagittal MRI
The patient was diagnosed wtih a burst fracture at T3 and a compression fracture at T4.
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The patient had posterior decompression and fusion with osteotomy; a transdiscal pedicle subtraction osteotomy.
This approach allowed for correction of the deformity, in addition to allowing for decompression and stabilization through a single approach.
He had complete pain relief post-operatively which status he enjoys now, 15 months after the surgery. He had post-operative weakness (grade 4) of the left quadriceps, which recovered by 3 months.
The patient made a full recovery of neurological function and has had excellent pain relief. He has resumed work.
Immediate post-operative sagittal CT (Fig. 5) showing T1-T9 posterior fusion with transdiscal osteotomy at T3 and T4
Figure 5. Post-operative sagittal CT
This patient with a T3 burst and T4 compression fracture and kyphosis presents numerous challenges.
What is the etiology of the patient's fractures? Reportedly there was no trauma. Does he have a pathological fracture from tumor or infection? The CT scan does not demonstrate overt osteopenia. The treating surgeon may consider a CT-guided biopsy to assess the etiology of the fracture.
Regardless of the etiology, a spinal canal decompression, correction of kyphosis, and fixation with fusion should be considered to treat the patient's myelopathy and instability.
T3 and T4 are among the most difficult levels to access surgically. The options are to approach anteriorly via a trans-sternal approach. However, with a ventral, mid-line approach the aortic arch may impede the exposure. In this case, the sagittal CT pre-operative scan shows the aorta does overlay the area of surgical interest.
A second surgical access option is a high right thoracotomy. With an incision in the right axilla area, it is possible to access T2-T5 from a lateral approach. A true orthogonal view of the area of pathology may be limited by this approach. Completing a two-level corpectomy and cage fixation without an orthogonal view of the area of interest could be difficult.
A posterolateral approach with a costotransversectomy of T3 and T4 with a vertebral column resection of T3 and a pedicle subtraction osteotomy of T4 would have been my choice of approach. The operation can be done with a single-stage surgery.
Pedicle screw fixation above and below the fracture levels should be accomplished first. Then a temporary rod could be used to avoid sudden spine subluxations. Then T3 and T4 laminectomies, costotransversectomies, pediculectomies and posterolateral corpectomy of T3 (VCR) with PSO of T4 could be done. If T4 is of poor bony quality, then a two-level posterior VCR could be performed. With such an approach, I would usually employ an expandable cage placed from a posterolateral approach. The combination of ventral cage expansion with posterior screw on rod compression and shortening will gradually correct the kyphosis.
Great care must be taken to avoid injury to the dura and spinal cord with such an approach. I typically utilize motor-evoked-potential monitoring and ensure that the anesthesiologist maintains a mean arterial pressure above 90 to assist with spinal cord perfusion during such an operation.
Ultimately, the case presented was treated with a posterolateral approach with a very nice correction of the kyphosis and decompression of the spinal canal. The surgeons chose not to place any anterior interbody cages, but I may consider filling in the open ventral disc spaces adjacent to the osteotomies with interbody fixation and fusion to ensure a solid construct.