Abstract
Introduction
The case report evaluates the clinical and radiological success of early reposition, posterior decompression, posterolateral fusion and stabilization by titanium pedicle screws and rods, performed within six hours after injury in young patient with C-type second lumbar vertebrae (L2) fracture.
Material and Methods
22 years old male patient presented in our Clinic with C-type L2 fracture after accident on work site when a part of truck engine felt on his back. The severity of injury was determined using the ASIA (American Spinal Injury Association) scale. Preoperative ASIA impairment scale was evaluated as grade C, with L2 as the most caudal segment with normal motor function. ASIA muscle grading was grade ⅖ evaluated bilaterally on knee extensors, ankle dorsiflexors, long toe extensors and ankle plantar flexors. Patient had voluntary anal contraction and normal anal sensation. ASIA sensory pin prick and light touch scores were in the normal range. Concomitant injuries included transverse process fractures of first, third and fourth lumbar vertebrae (L1, L3, L4) with dislocation, bilateral pneumothorax, fracture of eighth rib on right side and right-sided pulmonary contusion. MSCT showed multifragmentary fracture of anterior and posterior elements of L2 with dislocation and luxation. Preoperative treatment included corticosteroid therapy according to NASCIS III protocol and was continued 3 days postoperatively. Surgery was performed within 6 hours after injury. Reposition of lumbar luxation, posterior decompression, stabilization by titanium pedicle screws and rods and posterolateral fusion with autologous bone graft was done. Postoperatively patient wore a thoracolumbar orthosis for 12 weeks. Physical therapy started second day after surgery and was continued for 12 weeks.
Results
Patient underwent neurological and radiological evaluation 3 days and 12 weeks postoperatively. MSCT and MR imaging were performed. 3 days postoperatively ASIA impairment scale was grade D, showing neurological recovery on lower limbs with muscle grading ⅘ on knee extensors, ankle dorsiflexors, long toe extensors and ankle plantar flexors. 12 weeks postoperatively ASIA impairment scale remained D but complete motor recovery was noticed on knee extensors and long toe extensors bilaterally. Radiological examinations showed residual dislocation in L1/L2 segment with faset joints subluxation and right-sided foraminal stenosis. 12 weeks postoperatively patient was walking independently with residual motor deficit seen on ankle dorsiflexors and ankle plantar flexors on both legs.
Conclusion
In young patient with C-type lumbar fracture and incomplete neurological deficit open reposition, posterior decompression, posterolateral fusion and instrumented stabilization is a safe and effective procedure. It is important to involve corticosteroid therapy and to perform a surgery in early phase after traumatic incident. Our results showed that there is a great possibility of neurological recovery if the surgery is performed within 6 hours after injury.