Traumatic thoracic spine spondyloptosis treated with spondylectomy and fusion.

BACKGROUND: There are multiple surgical treatment options for traumatic thoracic spine spondyloptosis, a three-column spinal injury typically attributed to high-energy trauma. CASE DESCRIPTION: A 20-year-old male presented with back deformity attributed to a fall. On neurological examination, he had complete spinal cord injury below the T6 level. Magnetic resonance and computed tomography imaging documented a T8 vertebral fracture and complete T7/T8 spondyloptosis. Six days following admission, he underwent a single posterior procedure consisting of a T8 spondylectomy and instrumented fusion from T5 to T11. The patient was mobilized in a wheelchair on the 3rd postoperative day and was discharged on the 11th day following admission. Three months later, the surgical construct was fused and the patient's neurological status remained unchanged.
CONCLUSION: Here we present a patient who following a fall sustained a T7/T8 spondyloptosis resulting in paraplegia treated with a single posterior T8 spondylectomy with T5-T11 instrumented fusion.

INTRODUCTION

Traumatic thoracic spine spondyloptosis (TTS) is a three-column spinal injury that typically results in paralysis.[14] Due to the thoracic rib cage and its connection with sternum, TTS is typically attributed to very high-energy trauma.[3] Surgery typically requires both reduction and fusion of the deformity. Different treatment options for TTS include intraoperative axilla-pelvic distraction and fusion, in situ fixation and fusion, or corpectomy with cage placement.[1247] Here we present a case of T7/T8 TTS surgically treated with a total of T8 spondylectomy and T5–T11 posterior instrumented fusion.

CASE REPORT

A 20-year-old male was admitted with paraplegia after a 9-m fall. He initially underwent emergent bilateral chest tube placement for a hemothorax. As he was paraplegic with a T6 sensory level, computed tomography thoracic studies were performed. These revealed a T8 body fracture and T7/T8 spondyloptosis [Figures 1 and 2]. Six days later, he underwent reduction of the spondyloptotic T7/8 deformity, total T8 spondylectomy with discectomy of T7/T8 and T8/T9, and instrumented fusion and bilateral pedicular screw fixation from T5 to T11 [Figure 3]. The accompanying dura laceration was not repaired (circumferential rupture of the cord and dura were noted). A sub-fascial drain was placed and was removed on the third postoperative day; there was no secondary cerebrospinal fluid fistula. The patient was mobilized in a wheelchair on the 3rd postoperative day and discharged the 11th day following admission. Three months later, the fusion construct was intact, but the patient's neurological status remained unchanged (e.g., complete paraplegia).

Figure 1

Photograph revealing severe stepping and deformity of back on the prone position

Figure 2

Preoperative axial (a), sagittal (b), and three-dimensional (c) reconstruction computed tomography revealing a T8 body fracture with spondyloptosis of T7 on T8 concomitant with severe deformity

Figure 3

Intraoperative illustrations before (a) and after (b) spondylectomy showing complete release of the spine after T8 removal and also cross section of the cord and dura (*). Also we can see intraoperative illustration showing spinal curve after instrumentation (c). Postoperative sagittal reconstructed (d) computed tomography revealing good realignment of the spine with instrumented fusion between T5, T6, T7, T9, T10, and T11

DISCUSSION

Surgical treatment of TTS is very complex problem and requires a multidisciplinary approach. Injury to great arteries of thoracic cage and other vital organs can complicate management. With complete cord disruption, as in the case presented, delayed surgery helps reduce perioperative surgical complications and life-threatening events (e.g., aortic or vena cava injuries).

Rahimizadeh and Rahimizadeh reported a patient with a retro-spondyloptosis of T2 requiring total spondylectomy, intraoperative distraction, and T1–T3 fusion.[5] Farooque et al. presented a patient with spondyloptosis at the T9/T10 level treated with in situ fixation/fusion.[1] Sandquist et al. presented a T12/L1 spondyloptosis treated with spondylectomy of L1 and T8 to L4 instrumented fusion.[6] Here in a patient with T/7/T8 spondylopstosis, we performed a T8 spondylectomy and fused T5–T11 (e.g. relatively short fusion construct).

Goals of surgery for TTS in patients with complete spinal cord injuries include minimizing major displacement during the reduction of displaced vertebrae to avoid great thoracic vessel injuries. Although some authors report success using axilla-pelvic distraction for deformity reduction, these procedures increase risks/complications.[2] Where only one vertebra is removed (e.g., spondylectomy) and accompanied by pedicle/screw fixation/fusion, excessive traction and its complications are avoided. This procedure, also called “shortening of the spinal column,” can reduce the surgical time without impacting neurological outcomes (e.g., already a complete spinal cord injury). Furthermore, if the dura is lacerated and there is full cord transection, there is no need for dural repair.

CONCLUSION

Here we presented a patient with a TTS attributed to T7/T8 spondyloptosis and a complete spinal cord injury requiring T8 spondylectomy and T5–T11 pedicle screw instrumented fusion.

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Conflicts of interest

There are no conflicts of interest.