Abstract
Background and Study Objective Complex traumatic lumbar spine fractures are difficult to manage and typically occur
in younger patients. Surgical immobilization for unstable fractures is an accepted
treatment but can lead to future adjacent-level disease. Furthermore, large variations
in fracture morphology create significant difficulties when attempting fixation. Therefore,
a surgical approach that considers both long-term outcomes and fracture type is of
utmost importance. We present a novel technique for percutaneous fixation without
interbody or posterolateral fusion in a young patient with bilateral pedicle dissociations
and an acute-onset incomplete neurologic deficit.
Case Description A 20-year-old man involved in a motorcycle accident presented with unilateral right
lower extremity paresis and sensory loss with intact rectal tone and no saddle anesthesia.
Lumbar computed tomography (CT) demonstrated L2 and L3 fractures associated with bilateral
pedicle dislocations. Lumbar magnetic resonance imaging showed draping of the conus
medullaris/cauda equina anteriorly over the kyphotic deformity at L2 with minimal
associated canal stenosis at L2 and L3. He was treated with emergent percutaneous
fixation of the fracture segment without interbody or posterolateral fusion. Decompression
was not performed because of the negligible amount of canal stenosis and high likelihood
of cerebrospinal fluid leakage due to dural tears from the fractures. Surgical fixation
of the L2 vertebra was achieved by cannulating the left pedicle with an oversized
tap while holding the right pedicle in place with a normal tap and then driving screws
into the left and right pedicles, respectively, thus reducing the free-floating fracture
segment. At 18 months after surgery, a follow-up CT demonstrated good cortication
across the prior pedicle fractures, and the instrumentation was removed without any
obvious signs of instability or disruption of the alignment at the thoracolumbar junction.
Conclusion We present a novel technique for percutaneous reduction and fixation of bilateral
pedicle fractures with significant dissociation from the vertebral body, associated
neural compression from the kyphotic deformity, and minimal spinal canal stenosis.
Furthermore, we argue that early fixation and reduction of the fracture prevented
irreversible neurologic compromise, and the absence of interbody or posterolateral
fusion ultimately preserved the spinal mobility of the patient once the hardware was
removed.
Keywords
bilateral pedicle dislocation - incomplete neurologic injury - percutaneous fixation
- spine trauma - unstable spine fracture
