1Clifton W, 2Tavanaiepour D, 2Rahmathulla G
1Mayo Clinic Florida, Jacksonville, FL, USA; 2UF Health Jacksonville, Jacksonville, FL, USA
In the last decade, there have been several proposed classification systems for traumatic thoracolumbar fractures (TLF). Most recently published are the AO Spine Classification System and the Thoraco-Lumbar Injury Classification System (TLICS). There has been a paucity of high-level evidence to link these classification system subtypes with clinical outcomes and/or management strategies. Previously, post-traumatic burst fractures or two column injuries identified on CT scan have been deemed stable injuries. The addition of MRI evaluation for concomitant ligamentous injuries has been widely debated without high-level evidence. In this report, we present a case of an apparent minor burst fracture at L1, AO-A3 that presented with delayed paraplegia four weeks later.
Timeline: A 28 y/o male was admitted after a MVC with low back pain and orthopedic fractures. The admission CT scan of his lumbar spine showed a slight posterior superior endplate fracture at L1 (AO-A3) that was nondisplaced without posterior element displacement or disc space widening. The fracture was deemed stable and he was placed in a TLSO. A MRI was deferred at the time due to an emergent orthopedic procedure. The patient remained in the hospital for four weeks with immobilization due to his orthopedic procedures. He did not complain of any neurologic symptoms and was voiding independently.
Diagnostic: When he was finally mobilized it was realized that he had severe leg weakness both proximally and distally with severe paresthesias. An MRI showed complete ligamentous disruption and translation of the vertebral bodies, AO L1/2 type C2 (L1 type A3). There was marked edema in the conus that extended up into the thoracic spinal cord concerning for ischemic injury secondary to severe compression.
Therapeutic: The patient underwent emergent open decompression at L1-2 and pedicle screw fixation at T12-L2. The displaced segment was carefully reduced under fluoroscopic guidance using rod distraction.
Results: The patient did not recover motor function of his legs during his last follow-up at two months. His sensory symptoms improved. He was still able to void independently.
Discussion: The most recent classification systems for TLF have attempted to produce algorithms that assist in determining the need for secondary imaging (MRI) and surgical intervention. However, there is little high-level evidence supporting these classification systems and their significance in these areas. In this case, a seemingly stable AO-A3 injury was discovered to be an AO-C2 after the MRI was obtained post mobilization. This case indicates the importance of having a low threshold for acquiring additional MR imaging in patients with incomplete burst fractures to determine ligamentous instability and preventing neurologic compromise. Further outcomes-based studies using these classification systems should be performed to understand their significance in the management of patients with acute traumatic thoracolumbar fractures.
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