L1 Burst Fracture: Bracing or Surgery?
Patient History
The patient is a 55-year-old male who was the rider in an ATV accident. He presented to the emergency room with severe lumbar pain, but no lower extremity symptoms.
Examination
He has type 2 diabetes mellitus. He weighs 130 kilograms (286 pounds). Neurologically, the patient is intact with no point tenderness in the lumbar spine.
Images
Below are the patient's initial lateral (Figure 1) and axial (Figure 2A, 2B) CT scans. Of note is a burst fracture of L1 with loss of height by 50% but no kyphosis. There is a little canal compromise by the retropulsed fragment. The posterior elements look intact.
Further below are the patient's initial lateral (Figures 3A-3C) and axial MR images. Of note is the adjacent discs look reasonable, and there is no evidence of posterior ligamentous injury. There is mild stenosis at this level and again, no kyphosis .
Figure 1
 Figure 2A |
 Figure 2B |
 Figure 3A |
 Figure 3B |
 Figure 3C |
Figure 4
Diagnosis
L1 burst fracture.
Suggest Treatment
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The patient was neurologically intact without evidence of posterior element injury. Consequently, he was initially managed nonoperatively in a TLSO jacket for 3 months. At 6 months, he continued to experience pain and surgery was offered.
Because the anterior column was so disrupted, an anterior L1 corpectomy was performed via a left thoracotomy with fusion at T12-L2 using PEEK cages, plating, autograft, and BMP.
Below are postoperative lateral (Figure 5A) and anterior (Figure 5B) images.
Figure 5A
Figure 5B
Outcome
At 6 months postoperative, the patient experienced some improvement in pain, but a degree of pain remains. He continues to be neurologically intact.
Case Discussion
The described clinical scenario is all too familiar. More and more we see older, aged, metabolically generous individuals, subjecting themselves to trauma under risky conditions.
I can just picture the front end of the ATV lifting off the ground, on a slow, gentle slope as the laws of gravity prevail. Having said that, this individual has sustained a serious but stable burst configuration spinal fracture.
I agree with the initial choice of treatment, especially supported by the patient's intact neurological condition. However, it is not surprising that this individual still had pain at 6 months. I suspect I would have waited at least a full year before proceeding with any other intervention on the basis of mechanical pain.
At one-year, I would repeat the investigations including an MRI scan and CT scan, paying particular attention to the marrow signal on the MRI, and to how well the fracture fragments consolidated on the CT scan. If the marrow signal normalized, and the fragments healed, I would proceed with an interbody reconstruction at T12-L1 and L1-L2 with femoral ring allograft.. If the abnormal marrow signal persisted, or the fragments did not coalesce, then I would proceed as described with a corpectomy and reconstruction.
Depending on how confident I am with the reconstruction, and my impression of the patient's compliance, I would, or would not include posterior stabilization and fusion. This is not a unique case and there is no one treatment path that would ensure ideal patient outcome.
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