Traumatic T3 Burst Fracture

History

This case study reports on a 31-year-old female who sustained a traumatic spine injury during a rollover motor vehicle accident. She was driving a pickup truck while restrained in her seat traveling at an intermediate speed. Her boyfriend, seated in the passenger seat, was bouncing a basketball off the windscreen when it inadvertently hit her in the face subsequently causing her to veer the truck from the road over an embankment where it rolled several times.

She was immediately paralyzed and did not lose consciousness. This otherwise healthy woman, a non-smoker, worked as a waitress.

Examination

In the emergency room, her vital signs were stable. She was assessed by the trauma service and, apart from the spinal injury had no other injuries.

The patient’s Glasgow Coma Score was 15, T4 complete bilateral sensory and motor loss, and American Spinal Cord Injury Association (ASIA) A. Initial lab work was ok. She had initial CT scanning.

Pre-Treatment Imaging

The lateral thoracic CT scan showed a traumatic T3 burst fracture. As demonstrated in Figure 1 (below), there is a 3-column injury with complete retropulsion of the T3 vertebral body into the spinal canal.

Figure 1. Lateral thoracic CT scan shows traumatic T3 burst fracture and a 3-column injury with complete retropulsion of the T3 vertebral body into the spinal canal.

The axial thoracic CT scan showed a complex T3 burst fracture filling the spinal canal. (Figure 2, below)

Figure 2. Axial thoracic CT scan shows complex T3 burst fracture filling the spinal canal.

Hypothetical question:

• Is there a role for MRI scanning in this scenario?

The sagittal MR image of the T3 burst fracture showed spinal cord compression, which was expected. Of interest, there is extensive edema in the T2 vertebra as well suggesting that it (T2) was injured too. (Figure 3, below)

Figure 3. Sagittal MRI of T3 burst fracture shows cord compression and extensive edema in the T2 vertebra as well, suggesting the T2 level was injured as well.

Diagnosis

T3 burst fracture

Selected Treatment

A posterior T2-T3 transpedicular extracavitary vertebrectomy, cage placement and posterior instrumented fusion was the selected treatment.

Surgeon’s Commentary

The important points in this case:

First, the T2 vertebra was injured intraoperatively and easily removed with a posterior bilateral transpedicular approach. No nerve roots were sacrificed in order to place an expandable cage.

Second, the reduction was easily achieved once the corpectomies were done with Gardner-Wells tongs and in line traction. Surprisingly, even though this was upper thoracic spine traction, with skull tongs, 30-lb weight facilitated an open reduction once the corpectomies were completed.

Finally, 5.5mm diameter lumbar pedicle screws were placed into C7 and T1. No transitional rods were used, and a cervical screw system was not utilized. This reduced the number of cervical levels that required instrumentation and made it easier to assemble the final construct.

Intraoperative Imaging

T3 is a silent area, so routine fluoroscopic imaging other than anteroposterior (AP) films was of limited use. Stereotactic navigation was not available.

Figure 4. Lateral cervical spine.

Figure 5. Anterior cervicothoracic spine.

Figure 6. Lateral intraoperative x-ray shows T2-T3 cage construct with C7-T5 pedicle screw instrumentation.

Figure 7. C7 5.5mm lumbar pedicle screws.

Post-Operative Imaging

Figure 8. Post-operative axial CT scan; T3 level shows cage placement.

Figure 9. Post-operative sagittal reconstructed CT scan shows canal decompression and cage placement.

Figure 10. Post-operative MR image shows canal decompression; somewhat obscured by metal artifact.

The operative time was 5 hours. Estimated blood loss was 500cc. The patient was neurologically unchanged and transferred to a rehabilitation facility 5 days after surgery.

Outcome

At 6 months status post, the patient was pain free and ambulatory. There was no change in her neurological status, but she was independent and pain free.

Lateral and AP x-rays taken 6 months postop demonstrated satisfactory alignment and no instrumentation failure. (Figure 11, below)

Figure 11. Six month postop lateral cervical/thoracic and AP thoracic x-rays show satisfactory alignment and no hardware failure.

Peer Case Discussion

Neel Anand, MD

Professor of Orthopaedic Surgery
Director of Spine Trauma

Cedars-Sinai Spine Center

The author discusses the management of a T3 burst fracture post-MVA with complete neurological impairment. The story is extremely unfortunate but a reflection of the fast-paced life we lead. The patient was properly evaluated, and the fracture clearly identified.

Personally, I may not have insisted on an MRI, as this is clearly a three-column injury. As regard the finding of edema in T2, I find this to be quite common and would rely on the CT scan to assess if T2 was fractured. If there were fractures seen on CT, then yes, I would include it in the corpectomy along with T3. If no real fractures were seen on CT scan imaging, I would have been more inclined to limit the corpectomy to T3.

I also agree with the comment about radiology and the difficulty seeing this area. Navigation is being increasingly used for surgeries like this, but I do agree that it is not necessary in the hands of an experienced surgeon. The surgery was executed well, and the post-operative films show an excellent reconstruction.

I would assume that the patient is a wheelchair ambulator given that she was completely paralyzed. The clinical outcome is truly excellent, given the unfortunate circumstances. The resilience of the human body to tragedy and in overcoming the significant disability is best exemplified by this patient.