Case Report
Direct Midline Posterior Corpectomy and Fusion of a Lumbar Burst Fracture with
Retrospondyloptosis
Arthur Carminucci, Rachid Assina, R. Nick Hernandez, Ira M. Goldstein
Key words
- Direct posterior corpectomy
- Lumbar burst fracture
- Retrospondyloptosis
Department of Neurological Surgery, Rutgers New Jersey
Medical School, Newark, New Jersey, USA
To whom correspondence should be addressed:
Arthur Carminucci, M.D.
[E-mail: carminas@njms.rutgers.edu]
Citation: World Neurosurg. (2017).
http://dx.doi.org/10.1016/j.wneu.2016.12.129
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2017 Elsevier Inc. All
rights reserved.
INTRODUCTION
Burst fractures of the lumbar spine
commonly occur secondary to high-impact
trauma.1 These fractures can result in
significant neurologic deficits and
instability of the spine. Although
unstable burst fractures with neurologic
deficit require surgery, the ideal surgical
approach remains debatable. A multitude
of surgical options are available to spine
surgeons, including the posterior
approach, the anterior approach, a
combination of anterior and posterior
approaches, or the lateral approach.1-8 In
addition, single-stage posterior ap-
proaches with 360
reconstruction have
been gaining popularity.9-11 The advan-
tages and disadvantages of each approach
vary. In choosing the appropriate
approach, the surgeon must take into
consideration the degree of deformity, the
extent of the neurologic injuries, and the
surrounding anatomy. We describe a
direct posterior lumbar corpectomy and
fusion of an L4 burst fracture with com-
plete posterior dislocation (retro-
spondyloptosis) and transection of the
spinal cord in a patient with severe
neurologic deficit.
WORLD NEUROSURGERY -: ---, MONTH 2017
- BACKGROUND: Traumatic burst fractures of the lumbar spine can result in
significant neurologic injury and mechanical instability. The ideal surgical
approach for the treatment of unstable lumbar spine burst fractures remains
debatable.
- CASE DESCRIPTION: A 37-year-old man presented with severe neurologic
injury including loss of motor function below the level of the iliopsoas muscles
bilaterally, saddle anesthesia, and absent rectal tone, after a fall from 18.28 m (60
ft). Computed tomography showed an L4 vertebral body comminuted burst
fracture with complete posterior translation of L4 over L5. The patient was taken
to the operating room for an L4 corpectomy and L2-S1 posterior fusion. The L4
vertebral body was visualized posterior to the posterior elements of L5 and
resected in a piecemeal fashion. Because the thecal sac had been completely
transected, a visible path down the L3-L4 and L4-L5 disk spaces was apparent,
allowing direct posterior discectomies at these levels and completion of the L4
segment resection. The use of a direct posterior approach resulted in minimal
blood loss, correction of sagittal alignment, and satisfactory outcomes compa-
rable with the standard posterior transpedicular approach. Construct stability
and solid bony fusion have been maintained for 4 years postoperatively.
- CONCLUSIONS: The use of a direct midline posterior corpectomy approach
may be considered for patients with lumbar burst fractures, high-grade neuro-
logic injury, and transection of the thecal sac.
CASE DESCRIPTION lacerations, a duodenal hematoma, and a
right pneumothorax requiring chest tube
Clinical History placement. A computed tomography scan
The patient was a 37-year-old man with no showed an L4 vertebral body comminuted
significant past medical history who pre- burst fracture with complete posterior
sented after a fall from a height of translation of L4 over L5 (retro-
approximately 18.28 m (60 ft). Physical spondyloptosis; Figure 1).
examination on arrival showed severe
palpable spinal deformity and complete
paraplegia below the level of the hip Operative Procedure
flexors. He was alert and oriented to per- The patient was brought to the operating
son, place, and time, and his motor room and after intubation, he was trans-
strength was 5/5 throughout the upper ferred to a Jackson spine operating table in
extremities and 0/5 throughout the lower the prone position. A midline incision was
extremities except for the hip flexors, performed and taken down to the level of
which were 2/5 bilaterally. Sensation to the spinous processes. Fluoroscopy was
pinprick was absent below the L4 sensory used to confirm the appropriate levels.
dermatome. In addition to saddle anes- Immediately evident was gross disruption
thesia and absent rectal tone, the patient’s of the soft tissues and significant defor-
plantar, knee, ankle, and bulbocavernosus mity of the spinal column secondary to his
reflexes were absent. The patient also had trauma (Figure 2A). The L4 vertebral body
multiple life-threatening injuries, was visualized posterior to the posterior
including pancreatic, splenic, and liver elements of L5. The laminae and
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ARTHUR CARMINUCCI ET AL.
Figure 1. Preoperative images. (A) Sagittal computed tomography of the lumbar spine indicating L4
burst fracture with posterior dislocation of the vertebral body. In addition, there is complete
retrolisthesis of L3 with respect to L5. (B and C) Axial computed tomography showing severe burst
fracture of L4 with dislocation of the vertebral body posterior to the posterior elements of L5.
transverse processes of L2 to S1 bilaterally
were then exposed in the standard
fashion. Polyaxial pedicle screws were
placed at L2, L3, L5, and S1 bilaterally.
Reduction screws were placed at the level
of L5 bilaterally. Next, 2 titanium rods
were laid across the screw heads from L2
to S1 bilaterally. Locking caps were
fastened into place, with the L5 locking
caps used to reduce the rod, resulting in
reduction of the deformity and
subluxation (Figure 2B and C). A
distractor was applied between the screw
heads of L3 and L5, markedly opening
the intervertebral space between L3 and
L5. The L4 vertebral body was then
resected in a piecemeal fashion.
Additional bony elements of the L4 body
were removed from the spinal canal.
Because the thecal sac had been
completely transected, a visible path
down the L3-L4 and L4-L5 disk spaces
was apparent, allowing direct posterior
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POSTERIOR CORPECTOMY AND FUSION OF LUMBAR RETROSPONDYLOPTOSIS
discectomies at these levels and comple-
tion of the L4 segment resection
(Figure 2D). Care was taken to avoid
damage to any salvageable neural
elements while working across the spinal
canal. Lateral fluoroscopy confirmed that
good reduction of the subluxation had
been achieved. A trabecular metal
(Zimmer Spine, Minneapolis, Minnesota,
USA) lumbar corpectomy cage was
packed with local autograft bone and
advanced into position via a posterior
midline approach. The titanium rods
were then secured after compression of
the L3-L5 segment. Additional autograph
bone was applied adjacent to the cage to
achieve an L3 to L5 interbody fusion. A
paraspinal muscle patch was applied to
the dural defect along with encircling su-
ture ligature to repair the transected thecal
sac at the L3-L4 level. A high-speed drill
was used to decorticate the facets, spinous
processes, and lamina at L2, L3, L5, and
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2016.12.129
CASE REPORT
S1. Posterolateral arthodesis was then
performed from L2 to S1 using local
autograft bone. Estimated blood loss was
modest at 150 mL. The patient was trans-
ferred to the neurointensive care unit
intubated and in a stable condition.
Postoperative Outcome
Postoperative computed tomography and
plain radiography films showed proper
placement of hardware and good sagittal
alignment of the lumbar spinal column
(Figure 3A and B). The patient was
discharged in a stable condition and with
no signs or symptoms of cerebrospinal
fluid leak on postoperative day 10 to a
rehabilitation facility. Three months
later, the patient showed excellent
functional improvement and was able to
ambulate with a walker. On physical
examination, his lower extremity motor
examination was improved and his
iliopsoas, quadriceps, and hamstrings
muscles were 4þ/5 bilaterally. Initial
weakness in these muscle groups was
likely caused by traction on the cauda
equina secondary to translation of the L4
vertebral body across the spinal canal. As
expected, the patient’s lower extremity
distal muscle strength continued to be 0/
5. Lumbar radiographs indicated that
fusion was progressing well (Figure 3C).
Repeat radiographs at 4 years
postoperatively showed successful fusion
(Figure 3D).
DISCUSSION
Circumferential reconstruction of the
thoracolumbar spine can be achieved
through a combined anterior and posterior
approach or a combined lateral and poste-
rior approach. An anterior approach alone
or in combination with a posterior
approach for lumbar spine reconstruction
can achieve high fusion rates and correct
sagittal deformities in the setting of lumbar
burst fractures.1,3,7,12 An anterior approach
can facilitate direct corpectomy and cage
placement and allow for anterior plating,
which can increase the rate of fusion.13
Significant considerations against the
anterior approach are the need for an
access surgeon and the potential for
significant morbidities. A high incidence
of vascular injury (2%e15%) is associated
with an anterior approach secondary to
manipulation of the great vessels, most
 CASE REPORT
ARTHUR CARMINUCCI ET AL. POSTERIOR CORPECTOMY AND FUSION OF LUMBAR RETROSPONDYLOPTOSIS

reconstruction of thoracolumbar spinal tu-

mors.20 This technique has been further
adapted for the treatment of traumatic
burst fractures of the thoracic and lumbar
spine. A single-stage posterior approach
allows for effective decompression of the
neural elements and restoration of anterior
column height and provides good neuro-
logic outcomes. Lu et al.21 found patients
undergoing posterior transpedicular
corpectomy to have lower morbidity,
including less blood loss, decreased
operative time, and fewer complications
compared with patients undergoing
combined anterior/posterior corpectomies.
Similarly, Sasani and Ozer11 reported low
mean blood loss (approximately 600 mL)
and short operative times. One potential
disadvantage of the posterior approach in
the setting of acute trauma is the
possibility of construct failure, therefore
requiring revision surgery. Hofstetter
et al.10 found that 18% of acute traumatic
Figure 2. Intraoperative photographs. (A) Gross deformity of the lumbar spine evident on exposure. burst fractures required revision when
Severe disruption of the soft tissues and L4 posterior elements (white arrow), as well as significant posterior circumferential reconstruction
damage to the neural elements (black arrow). (B) Partial resection of the subluxed L4 vertebral body
(white arrow) and its posterior elements exposing the transected thecal sac (black arrow). (C) Pedicle
was performed. The posterior
screw fixation restoring alignment of vertebral column with the L4 comminuted burst fracture. (D) transpedicular approach allows only a
Postcorpectomy of the L4 vertebral body and adjacent disc spaces via direct posterior approach (L4 narrow exposure of the anterior column,
space labeled by black arrow). and therefore, a limited reconstruction of
the anterior column can be attained. The
narrow space between the exiting nerve
commonly the iliac arteries.14-18 In cases of disadvantage of posterior fixation is the root and the thecal sac allows placement of
posteriorly displaced burst fractures, a potential need for long segment fixation only narrow cages, and in particular
posterior approach is beneficial in to provide adequate stability.19 expandable cages, making the application
decompressing the spinal cord, removing Single-stage posterior transpedicular ap- of an adequate volume of graft against the
encroaching bony fragments, and proaches have been successfully used end plate more challenging. The decrease
improving neurologic deficits.6 A for circumferential decompression and in contact area between the cage and the

Figure 3. Postoperative images. (A and B) Postoperative lumbar progressing bony fusion. (D) Lumbar radiographs at 4 years
radiographs showing L4 interbody and posterior pedicle screws fixation. postoperatively showing successful bony fusion.
(C) Repeat radiographs at 3 months showing stable construct and

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ARTHUR CARMINUCCI ET AL.
end plate, especially in the setting of a
short construct, increases the potential
for biomechanical instability and
pseudoarthrosis.3
We have described a modified posterior
corpectomy in which circumferential
reconstruction was performed via a direct
posterior approach across the thecal sac.
Because of the significant retropulsion of
the L4 vertebral body, a posterior
approach was necessary to remove the
disrupted bony fragments and decompress
the thecal sac. The subsequent transection
of the thecal sac by the L4 body allowed
the vertebral body and discs to be directly
visualized, facilitating direct discectomies
and vertebrectomy through the thecal sac.
In this case, the exposure obtained
through a transdural approach allowed for
adequate placement of a large interverte-
bral cage. Although placement of an
intervertebral cage could be considered
through an anterior approach followed by
posterior decompression and fusion, in
this case, because of the patient’s multiple
intra-abdominal injuries and retroperito-
neal hematoma, an anterior approach
would have put the patient at significant
risk for major organ and vascular injury.
Construct stability and solid bony fusion
were achieved without additional need for
anterior circumferential fixation. To our
knowledge, this is the first report of direct
transdural corpectomy and interbody
fusion in the setting of significantly ret-
ropulsed burst fracture. The use of a direct
midline posterior corpectomy approach
may be considered for patients with lum-
bar burst fractures, high-grade neurologic
injury, and transection of the thecal sac.
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Conflict of interest statement: The authors declare that the
article content was composed in the absence of any
commercial or financial relationships that could be construed
as a potential conflict of interest.
Received 8 August 2016; accepted 29 December 2016
Citation: World Neurosurg. (2017).
http://dx.doi.org/10.1016/j.wneu.2016.12.129
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2017 Elsevier Inc. All
rights reserved.