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|LETTER TO EDITOR
|Year : 2016 | Volume
| Issue : 6 | Page : 1369-1371
Rotational translational injury at the thoracolumbar junction
Manjul Tripathi, K. V. L. Narasinga Rao, Vikas Vazhayil, Dwarakanath Srinivas, Somanna Sampath
Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
|Date of Web Publication||11-Nov-2016|
Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Tripathi M, Rao KN, Vazhayil V, Srinivas D, Sampath S. Rotational translational injury at the thoracolumbar junction. Neurol India 2016;64:1369-71
Rotational translational fractures are, without an argument, the most unstable injuries at the thoracolumbar junction (TLJ). A 30-year-old male presented with a history of pain in the back following a fall from a height of 12 feet. A gibbus was noticed on the lower back. Patient was neurologically intact except for bilateral sluggish ankle jerks (American Spine Injury Association [ASIA] scale D). Radiology revealed lateral translation and vertical ptosis of T12 over L1 segment suggestive of Holdsworth slice fracture at the T12-L1 junction. Associated injuries were fracture of both the transverse processes and a communited fracture at the superior articular surface of L1 vertebra, with bilateral facet joint dislocation and pedicle fracture of T12 [Figure 1]a,[Figure 1]b,[Figure 1]c,[Figure 1]d,[Figure 1]e and an intact neural canal and disrupted posterior ligamentous complex [Figure 1]f and [Figure 1]g.
|Figure 1: Preoperative images, (a) Thoracolumbar computed tomography (CT) scan anteroposterior view showing rotational translation injury at T12-L1 junction with vertical settling of T12 over L1 vertebrae; (b and c) reconstructed images suggestive of horizontal displacement with vertical settling; (d) CT scan, axial view showing comminuted fracture of lateral half of L1 vertebral body; (e) CT Scan axial view showing D12 and L1 vertebral bodies at the same level attributed to vertical settling; (f and g) magnetic resonance imaging, T1 and T2 images suggestive of severe musculo-ligamentous injury at fracture site|
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Initially, the patient was approached by a right extrapleural retroperitoneal approach and an L1 corpectomy, alignment, and T12-L1 fixation with autologous bone graft was planned. The procedure was abandoned during the first surgery after the L1 corpectomy because a proper reduction and alignment could not be achieved due to the severe horizontal and vertical displacement of the vertebral segment [Figure 2]a and [Figure 2]b. After 3 days, the patient was reoperated and a T12-L2 fusion with transpedicular screws and Steffi plates was done [Figure 2]c and [Figure 2]d. Radiographs performed 2 months after the surgery revealed fracture of the right lower transpedicular screw and extrusion of the Steffi plate [Figure 3]a. The patient was re-explored with removal of the implant followed by a right extrapleural retroperitoneal approach and T12-L2 fusion with interbody cage placement. Following this, posterior T11-L2 fusion was performed (third surgery) [Figure 3]b,[Figure 3]c,[Figure 3]d. At the 3-year follow up, the patient had increased kyphotic angulation for which a long segment fusion (T11-L5 transpedicular screw and plate fixation) was done (fourth surgery) [Figure 3]e. A repeat scan showed a nonprogressive kyphotic deformity with preserved neurological status [Figure 3]f. At a 6-year follow up, the patient was neurologically stable.
|Figure 2: (a) Postoperative X-ray, (following first surgery) (a and b) anteroposterior and lateral views suggestive of partial reduction with alignment; (following second surgery), (c and d) X-ray anteroposterior view suggestive of T12-L1 posterior fixation|
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|Figure 3: (a) Follow-up X-ray (lateral view) suggestive of implant failure; (b and c) follow-up X-ray (following third surgery) showing implant repositioning with interbody cage and T12-L2 Steffi plate fixation; (d) follow-up X-ray TL spine showing increased kyphotic angulation; (e and f) anteroposterior and lateral views showing long segment T11-L5 fusion with persistent kyphotic deformity (following fourth surgery)|
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Arbeitsgemeinschaft für Osteosynthesefragen (AO) type C3 injury is the second least common injury pattern in the thoracolumbar spine (1.11%). The majority of type C injuries are the most unstable injuries with the highest incidence of neurological deficits. As per the guidelines laid by the Spine Trauma Study Group (STSG), three important variables should be considered in deciding the management option, i.e., (1) injury morphology; (2) neurological status of the patient, and (3) integrity of the posterior ligamentous complex. Independent of the neurological status and integrity of the posterior ligamentous complex of the patient, all patients with translational injuries should be managed initially with a posterior approach for realignment and stabilization, followed by anterior decompression and stabilization if necessary. The rationale for the same lies in the fact that, in patients with rotational-translational injury, in general, it is very difficult to reduce the spine from the anterior aspect. In retrospect, authors agree to this statement because proper alignment could not be achieved with an anterior approach in our case as well.
The indications for the posterior approach are distraction or translational morphology without neural compression, or when neural compression is relieved by reduction; an isolated nerve root deficit with intact posterior ligaments; an intact neurological status with disrupted posterior ligaments; and, complete neurological injury with intact/ disrupted posterior ligaments. It also highlights the importance of routine screening of all patients with a history of possible spine injury. This type of injury is particularly dangerous in a neurologically intact patient as the degree of instability may be overlooked and patient may rapidly deteriorate during routine care and mobilization. A sensitive issue in neurologically intact patients with such a significant injury is the positioning of the patient on the operating table, which should be done while the patient is awake. At present, such injuries should be managed with posterior stabilization followed by anterior approach for decompression and alignment.
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[Figure 1], [Figure 2], [Figure 3]