T3 Burst Fracture after Motor Vehicle Accident
A 32-year-old woman presented to the emergency room after a rollover motor vehicle accident. She was instantly paralyzed in her lower extremities. She had no sensation below the clavicles, and she had severe neck pain.
On examination, she had no lower extremity movements (ASIA A) with a complete sensory level at T2-T3. Reflexes were depressed. She had no anal tone or bladder sensation.
Figures 1-3 show a complex T3 burst fracture with almost complete retropulsion of the T3 vertebral body into the spinal canal. There is a severe kyphotic deformity at this level, and the canal is obliterated.
Figure 4: Sagittal T2-weighted MRI scan of the cervicothoracic spine. Note the edema in the T2 body .
The patient was diagnosed with a T3 burst fracture.
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The patient underwent posterior single-stage reconstruction and stabilization.
After initial exposure, a transpedicular vertebrectomy of T2 and T3 was effected. T2 was included because of the edema in the vertebra on the MRI scan.
Pedicle screws were placed at C7, T1, T4, T5, and T6. To allow for reduction and also to preserve lower cervical levels, 6.5 mm screws were placed at each level. Using a temporary reduction rod and traction through Gardner Wells tongs to 70 lb, the deformity was corrected.
An expandable cage was placed posteriorly from T1-T4 and packed with local autograft.
The case was performed with AP fluoroscopy only. No navigation system was used.
She had no new deficit post-operatively and was not braced.
Figures 5A and 5B: Initial AP (left) and lateral (right) x-rays taken intraoperatively after positioning
Figures 6A and 6B: Final intraoperative AP (left) and lateral (right) x-rays
Figures 7A and 7B: C7 6.5 mm x 25 mm pedicle screw placement
Figures 8A and 8B: T1 pedicle screw placement (left) and T2-T3 level showing decompression (right)
Figures 9A and 9B: Reconstructed post-operative sagittal (left) and coronal MRI (right) scans showing complete reduction
Figure 10: Post-operative cervical spine x-ray
Figure 11: Post-operative lateral cervical spine x-ray
Figure 12: Post-operative lateral thoracic spine x-ray
The patient had no neurological recovery, but her pain settled. Three months post-operatively, her x-rays were satisfactory, as seen in the above section.
This is a really interesting, challenging case with a severe burst fracture at T3 and complete paraplegia. It appears that besides the clearly apparent burst fracture at T3, there probably is a fracture at T2 also. An axial CT of T2 might confirm the same.
Given the high thoracic level of the fracture and the considerable moribidity associated with an anterior approach at T2 and T3, I would agree with the author on approaching this posteriorly. If the patient had neurological preservation or incomplete injury, then personally, I would probably approach this in the traditional anterior fashion in order to avoid any manipulation of the cord whatsoever. Given the fact the patient had a complete spinal cord injury and the main goal was providing stabilization, the posterior approach is a sound and reasonable option.
The author has obtained an excellent re-alignment and stabilization and should be commended for the same.