Nonoperative Management of Isolated Thoracolumbar Flexion Distraction Injuries: A Single-Center Study.

BACKGROUND: Nonoperative management is an appealing option for purely transosseous thoracolumbar flexion-distraction injuries given the prospects of osseous healing and restoration of the posterior tension band complex. This study seeks to examine differences in outcomes following flexion-distraction injuries after operative and nonoperative management. METHODS: This study reviews all patients at a single Level 1 trauma center from 2004 to 2022 with AO Spine B1 thoracolumbar injuries treated operatively vs nonoperatively. Inclusion criteria were age greater than 16 years, computed tomography-confirmed transosseous flexion-distraction injuries, and at least 3 months of follow-up with available imaging. The primary outcome assessed was a change in local Cobb angles, with secondary outcomes consisting of complications, time to return to work, and need for subsequent operative fixation. RESULTS: Initial Cobb angles in the operative (n = 14) vs nonoperative group (n = 13) were -5° and -13°, respectively (P = 0.225), indicating kyphotic alignment in both cohorts. We noted a significant difference in Cobb angles between cohorts at first follow-up (2.6° and -13.9°, P = 0.015) and within the operative cohort from presentation to first follow-up (P = 0.029). At the second follow-up, there was no significant difference in Cobb angles between cohorts (3.6° and -12.6°, P = 0.07). No significant differences were noted in complication rates (P = 1), time to return to work (P = 0.193), or resolution of subjective back pain (P = 0.193). No crossover was noted. CONCLUSIONS: Nonoperative management of minimally displaced transosseous flexion-distraction injuries is a safe alternative to surgery. Patient factors, such as compliance with follow-up, and location of the injury should be factored into the surgeon's management recommendation. CLINICAL RELEVANCE: Overall, no significant differences in outcomes and complications were noted following nonoperative management of AO Spine B1 injuries, indicating the potential for these injuries to be managed conservatively.

A novel asymmetric horizontal splitting fracture of the lumbar spine: pediatric case report of a lateral bending, flexion and distraction fracture.

BACKGROUND: There are many lateral bending fracture cases presented in the literature that mostly involve facet dislocations or corpus collapse. In this report, we aim to describe a novel asymmetric lateral bending, flexion and distraction fracture, propose a mechanism, and delineate its clinical importance. CASE DESCRIPTION: A 13-year-old girl arrived at our trauma center 12 hours after a head-on truck collision. She had paraplegia, and her imaging revealed a spinal cord avulsion at the T10 level and a horizontal fracture at the L4 spinous process, left lamina, left pedicle, and left posterior-upper corner of the corpus, extending through the right lamina. Her posterior ligamentous complex, right facet joint, pedicle, and right side of the corpus were spared from the injury. The patient stated that she had been sitting on the right side of the back seat, turned toward her cousin in the middle. Her left leg was externally rotated and flexed on the seat while her right foot was on the floor at the time of the accident. The patient was managed conservatively with an orthosis. At follow-up, the patient was free of back pain and no lumbar kyphosis developed. CONCLUSION: The flexion-distraction injuries mostly require surgical stabilization according to TLICS classification, because of the instability. In this particular case, TLICS classification was not adequate for a treatment decision, and the conservative treatment came out to be a more than sufficient treatment option.

Temporary Monosegmental Fixation Using Multiaxial Percutaneous Pedicle Screws for Surgical Management of Bony Flexion-Distraction Injuries of the Thoracolumbar Spine: A Technical Note.

Introduction: The efficacy of minimally invasive surgeries for thoracolumbar flexion-distraction injuries (FDIs) has been reported, but those surgeries were monosegmental fusion surgeries of two adjacent vertebrae with bone grafts or temporary fixations using percutaneous pedicle screws (PPSs) that were at least bisegmental. Our idea was to fuse the fracture itself, not to fuse the fractured vertebra with an adjacent vertebra or to stabilize the fractured vertebra by bridging rostrally/caudally adjacent intact vertebrae, specifically when the displacement is minimal. This study aimed to present the surgical techniques of reduction and temporary monosegmental fixation of neurologically intact thoracolumbar bony FDIs using multiaxial PPSs, which can minimize the surgical invasiveness and preserve all motion segments, as well as report three cases treated with this procedure. Technical Note: When the fracture extended from the vertebral body to the spinous process at the same level, screws were placed into the fractured vertebra rostrally to the fracture along the rostral endplate, and the caudally adjacent vertebra was instrumented beyond the fracture line. When the fracture extended from the vertebral body to the spinous process of the rostrally adjacent vertebra, screws were placed into the fractured vertebra caudally to the fracture line, and the rostrally adjacent vertebra was instrumented. The kyphotic deformity was reduced through ligamentotaxis by using MPPSs in the rostral vertebra as rigid joysticks to apply direct buttress leverage to the rostral endplate. Intraoperative blood loss was minimal. The correction of kyphotic deformity and its durability were acceptable, and the segmental range of motion of the two affected vertebrae from flexion to extension was maintained after implant removal. Conclusions: This surgery can act as the least-invasive option for the management of thoracolumbar bony FDIs to allow early ambulation without external bracing and to preserve all the motion segments.

Comparison of the Outcomes between AO Type B2 Thoracolumbar Fracture with and without Disc Injury after Posterior Surgery.

OBJECTIVE: The type AO B2 thoracolumbar fracture is a kind of flexion-distraction injury and the effect of disc injury on treatment results of patients with B2 fracture remains unclear. The objective of the current study was to compare and analyze the outcomes in AO Type B2 thoracolumbar fracture patients with and without disc injuries in terms of the Cobb angle of kyphosis, the incidence of complication, and the rate of implant failure. METHODS: This is a retrospective study. Of the 486 patients with thoracolumbar fractures who underwent posterior fixation, 38 patients with AO type B2 injuries were included. All the patients were divided into two groups according to changes in the adjoining discs. Disc injury group A included 17 patients and no disc injury group included 21 patients. Clinical and radiologic parameters were evaluated before surgery, after surgery, and at follow-up. Clinical outcomes included visual analogue scale (VAS) scores, incidence of complications, and incidence of implant failure. Radiologic assessment was accomplished with the Cobb angle (CA), local kyphosis (LK), percentage of anterior vertebral height (AVBH%), intervertebral disc height, and intervertebral disc angle. Fisher's precision probability tests were employed and chi square test were used to compare categorical variables. Paired sample t tests and independent-sample t tests were used to compare continuous data. RESULTS: Disc injury mainly involved the cranial disc (15/19, 78.9%). The mean follow-up period for the patients was 30.2 ± 20.1 months. No neurologic deterioration was reported in the patients at the last follow-up. Radiological outcomes at the last follow-up showed significant differences in the CA (18.59° ± 13.74° vs 8.16° ± 9.99°, P = 0.008), LK (12.74° ± 8.00° vs 6.55° ± 4.89°, P = 0.006), and %AVBH (77.16% vs 90.83%, P = 0.01) between the two groups.Implant failure occurred after posterior fixation in five patients with disc injury who did not undergo interbody fusion during the initial surgery. Additionally, in the subgroup analysis, interbody fusion in the implant failure group were significantly different than in the no implant failure group (0% vs 75%, P = 0.009). CONCLUSIONS: AO B2 fracture patients with disc injury have higher risk of complications, especially implant failure after posterior surgery. Interbody fusion should be considered in AO type B2 fracture patients with disc injury.

Traumatic Spondylolisthesis of the Fourth Lumbar Vertebra Without Neurologic Deficit or Fracture of the Posterior Elements.

Acute traumatic spondylolisthesis in the lumbosacral spine is an uncommon injury. Traumatic dislocation of the fourth lumbar vertebra over the fifth lumbar vertebra (L4/L5) is extremely rare since few studies have been reported in the current literature. We report on a 53-year-old man, who had a motor vehicle accident and sustained an injury of the lumbar spine without neurological impairment. The radiographic evaluation disclosed an L4/L5 traumatic spondylolisthesis, classified as Meyerding grade III without any fracture of the posterior vertebral elements. To the best of our knowledge, this is the sixth case of L4 traumatic spondylolisthesis without concomitant fracture of the posterior vertebral elements and the third case without any neurological deficit among them. The patient underwent open reduction and posterior instrumentation. Intraoperatively, the posterior ligamentous complex, the capsules of the facet joints and also the disc were found torn, although facets, neural arch, and pedicles were intact. Following decompression and reduction of the spondylolisthesis without any neurologic complications, we performed pedicle screws and rods fixation from the third to the fifth lumbar vertebra (L3-L5). The patient had an uneventful recovery and returned to his previous activity three months after surgery. The four-year follow-up evaluation showed normal spinal alignment, successful pain-free fusion without neurologic complications. Flexion/distraction injury without simultaneous rotation at the L4/L5 segment during traffic accidents or the fall of a heavy object on the bent back accompanied with posterior ligament weakness is thought to be the probable mechanism for this type of injury. Concomitant neurologic impairment is associated with the majority of L4/L5 spondylolisthesis cases. Posterior decompression, reduction, and posterior instrumentation enhances bony fusion, improves the patient's neurologic status and restores the sagittal alignment.

Double-level noncontiguous thoracic Chance fractures treated with percutaneous stabilization: illustrative case.

BACKGROUND: Chance fractures are unstable due to horizontal extension of the injury, disrupting all three columns of the vertebra. Since being first described in 1948, Chance fractures have been commonly found at a single level near the thoracolumbar junction. Noncontiguous double-level Chance fractures that result from a single traumatic event are rarely reported in the literature. OBSERVATIONS: The authors report a case of an 18-year-old male who presented to the emergency department after a rollover motor vehicle accident. The patient complained of severe back pain when at rest and had no neurological deficits. Computed tomography revealed two unstable Chance fractures of bony subtype located at T6 and T11. The patient underwent percutaneous stabilization from T4 to T12. The postoperative assessment revealed continued 5/5 power bilaterally in all extremities, back pain, and the ability to ambulate with a walker. At 3 months after the operation, clinical assessment revealed no significant back pain and the ability to walk independently. Imaging confirmed stable fixation of the spine with no acute osseous or hardware complications. LESSONS: This report complements previous studies demonstrating support for more extensive stabilization for such unique fractures. Additionally, rapid radiological imaging is needed to identify the full injury and lead patients to appropriate treatment.

Delayed symptomatic spinal adhesive arachnoiditis after surgery for thoracolumbar flexion-distraction injury: A case report.

BACKGROUND: Adhesive arachnoiditis is an uncommon lesion caused by an inflammatory reaction in spinal nerves. Reports of substantial symptomatic thoracolumbar (TL) adhesive arachnoiditis after spinal surgery are rare. To the best of our knowledge, this is the first presentation of delayed adhesive arachnoiditis with cauda equina syndrome after decompression and fusion for a traumatic TL flexion-distraction injury. PRESENTATION OF CASE: A 51-year-old man presented to the emergency room with absence of lower extremity muscle power and partial sensation preservation below T12 after slipping. Magnetic resonance imaging (MRI) and computed tomography demonstrated a flexion-distraction injury at T12-L1 and unstable burst fracture at L1 with posterior fragment displacement and cauda equina compression. Emergency decompression, fracture reduction, and posterior fusion with pedicle screw instrumentation (T11-L2) were performed. After the surgical wound completely healed, the patient was transferred to the rehabilitation department. Three months after surgery, the patient complained of severe pain around the anal and testis area and had absent anal sensation and sphincter tone. We re-evaluated the spine MRI and diagnosed the patient with adhesive arachnoiditis in the previous injury site. After gabapentin was administered, the symptoms dramatically subsided. CONCLUSION: To the best of our knowledge, this is the first description of delayed spinal adhesive arachnoiditis after TL spinal surgery due to trauma. Developments in technology and resolution and the fact that titanium instrumentation produces less artifacts make MRI a useful tool to evaluate previously operated lesions. Gabapentin may be a good option in the treatment for delayed-onset postoperative adhesive arachnoiditis.

Chance Fracture in an Unbelted Rear Seat Passenger.

Chance fracture occurs from flexion-distraction injury in motor vehicle road crash usually when the patient is on a seat belt. It is often associated with intra-abdominal injuries. We managed a 22-year old female unbelted rear seat passenger of a bus which was involved in a lone accident. We highlighted the possible mechanism of chance fracture in an unbelted passenger and satisfactory spinal stability on conservative care with neither internal nor external fixation.

A Case Report: Upper Thoracic Chance Fracture with Monoplegia An Unusual Presentation!

INTRODUCTION: Chance fractures, the horizontal splitting vertebral fractures caused by flexion distraction mechanism, are inherently unstable fractures. These fractures can land up with significant visceral injuries. There are most commonly seen at thoracolumbar junction or in lumbar spine due to their high mobility. These fractures are extremely rare in the thoracic spine due to the rigidity of thoracic spine rendered by attachment of ribs. Furthermore, the level of injury makes neurological complications even graver. CASE REPORT: We present a case of a road traffic accident with right lower limb monoplegia. On careful examination, a thin transverse fracture line was noticed in D5 vertebral body, and magnetic resonance imaging revealed posterior ligamentous disruption extending in line with the transverse fracture line in D5 vertebral body which confirmed the diagnosis of a Chance fracture. Fracture was stabilized by pedicle screw fixation from D4 to D7 level, and decompression was done at D5 level. By the end of 7 months, patient regained Grade 4 power in the right hip and knee joints, with Grade 5 power in the right ankle and great toe. CONCLUSION: Chance fractures in thoracic region are extremely rare. A clinician should have a high index of suspicion as these fractures can be notorious when it comes to presentation on plain X-ray. These being inherently unstable fractures, posterior instrumented stabilization with decompression in patients with neurodeficit gives good results.

Purely Ligamentous Flexion-Distraction Injury in a Five-Year-Old Child Treated with Surgical Management.

Chance fractures by definition are a type of flexion-distraction injury with concomitant vertebral body fracture. Although uncommon in the pediatric population, they are associated with motor vehicle accidents and typically involve the thoraco-lumbar spine. Injury occurs when the spine rotates about a fixed axis, such as a lap belt. Our case reports the management of a five-year-old girl involved in a head-on collision who suffered a purely ligamentous flexion-distraction injury (Chance-type injury, without bone involvement) at the L2-L3 vertebral level. Previously these injuries were managed conservatively with serial casting; however, we present a case in which surgical management was used. A five-year-old girl sustained multiple injuries after being involved in a high-speed motor vehicle accident. At presentation, there was obvious abdominal bruising with a seat-belt sign and marked kyphosis of the spine with severe tenderness at the L2-L3 level. She required immediate exploratory laparotomy for her intraabdominal injuries. After stabilization, an orthopedic consult was deemed necessary. She was found to have occipital-cervical injury with mild anterolisthesis of C2 on C3 and disruption of the apical ligament. There was evidence of bilateral dislocation of the L2-L3 facet joints with marked disruption of the posterior ligaments and a hematoma sack. She required open reduction and internal fixation with an L2-L3 laminectomy, pedicle screw and rod placement. The kyphotic deformity was reduced using a compression device and stable alignment was achieved intraoperatively. This was a rare and difficult case with limited evidence on the appropriate management of such an injury. Due to the severe instability of her injury, a surgical approach was taken. At two years postoperative, the patient is neurologically intact and pain free. Imaging revealed stable alignment of her lumbar hardware. Ultimately, this has resulted in an excellent outcome at the current follow-up.

Asymmetrical pedicle subtraction osteotomy for progressive kyphoscoliosis caused by a pediatric Chance fracture: a case report.

BACKGROUND: Although most pediatric Chance fractures (PCFs) can be treated successfully with casting and bracing, some PCFs cause progressive spinal deformities requiring surgical treatment. There are only few reports of asymmetrical osteotomy for PCF-associated spinal deformities. CASE PRESENTATION: We here report a case of a 10-year-old girl who suffered an L2 Chance fracture from an asymmetrical flexion-distraction force, accompanied by abdominal injuries. She was treated conservatively with a soft brace. However, a progressive spinal deformity became evident, and 10 months after the injury, examination showed segmental kyphoscoliosis with a Cobb angle of 36°, a kyphosis angle of 31°, and a coronal imbalance of 30 mm. Both the coronal and sagittal deformities were successfully corrected by asymmetrical pedicle subtraction osteotomy. CONCLUSIONS: Initial kyphosis and posterior ligament complex should be evaluated at some point when treating PCFs. Asymmetrical pedicle subtraction osteotomy can be a useful surgical option when treating rigid kyphoscoliosis associated with a PCF.

Percutaneous Instrumentation Without Arthrodesis for Thoracolumbar Flexion-Distraction Injuries: A Review of the Literature.

Background: Flexion-distraction injuries (FDI) represent 5% to 15% of traumatic thoracolumbar fractures. Treatment depends on the extent of ligamentous involvement: osseous/Magerl type B2 injuries can be managed conservatively, while ligamentous/Magerl type B1 injuries undergo stabilization with arthrodesis. Minimally invasive surgery without arthrodesis can achieve similar outcomes to open procedures. This has been studied for burst fractures; however, its role in FDI is unclear. Objective: To conduct a systematic review of the literature that examined minimally invasive surgery instrumentation without arthrodesis for traumatic FDI of the thoracolumbar spine. Methods: Four electronic databases were searched, and articles were screened using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines for patients with traumatic FDI of the thoracolumbar spine treated with percutaneous techniques without arthrodesis and had postoperative follow-up. Results: Seven studies with 44 patients met inclusion criteria. There were 19 patients with osseous FDI and 25 with ligamentous FDI. When reported, patients (n = 39) were neurologically intact preoperatively and at follow-up. Osseous FDI patients underwent instrumentation at 2 levels, while ligamentous injuries at approximately 4 levels. Complication rate was 2.3%. All patients had at least 6 mo of follow-up and demonstrated healing on follow-up imaging. Conclusion: Percutaneous instrumentation without arthrodesis represents a low-risk intermediate between conservative management and open instrumented fusion. This "internal bracing" can be used in osseous and ligamentous FDIs. Neurologically intact patients who do not require decompression and those that may not tolerate or fail conservative management may be candidates. The current level of evidence cannot provide official recommendations and future studies are required to investigate long-term safety and efficacy.

Management of severe traumatic flexion-distraction injuries in a multisystem trauma patient: A case report.

STUDY DESIGN: Case report and relevant literature review. OBJECTIVE: To discuss the management of severe flexion-distraction injury of the subaxial cervical spine in a multisystem trauma patient. SUMMARY OF BACKGROUND DATA: Traumatic cervical spine injury from flexion-distraction injury can cause significant instability requiring extensive instrumentation complicated by vascular and soft tissue injuries. METHODS: The medical record of a patient who suffered traumatic flexion-distraction injury was reviewed for relevant clinical and radiology data. A literature review on the management of traumatic cervical injuries was performed using the PubMed database. RESULTS: We report a case of 21-year-old woman who suffered a C5-C6 flexion-distraction injury. After she underwent anterior cervical discectomy and fusion (ACDF), her care was transferred to the senior author (S.K.) due to the severity of the distraction. The patient returned to the OR the next day and underwent removal of implants at C5 and corpectomy with anterior and posterior instrumentation. CONCLUSION: There are many ways to manage a flexion-distraction injury of the cervical spine. In a polytrauma patient, the surgical strategy can become complex. We present a surgical option with an acceptable outcome.

Posterior vertebral injury; is this a burst fracture or a flexion-distraction injury?

In thoracolumbar spinal fractures with posterior column injury for applying proper management, it is important to distinguish a flexion-distraction injury (FDI) from a three column burst fracture (BF) as in clinical examination, both may have a similar significant tenderness on direct spinal palpation. Careful attention to the comprehensive clinical examination and detailed imaging features are essential in making an accurate diagnosis and thus appropriate treatment.

Pediatric thoracic spine injuries: a single-institution experience.

OBJECTIVE: The objective of our study was to determine the incidence of various fractures of the thoracic spine in pediatric patients. CONCLUSION: Simple compression and process-only fractures were the most common types of fractures and all other fracture types were infrequent. Distraction injury was unexpectedly more common in the nonjunctional thoracic spine than in the junctional thoracic spine.