Posterior Surgical Approach In Burst Type Fracture Of Upper Thoracic Vertebrae

and Complete Spinal Cord Injury (ASIA Impairment Scale A): A Case Report

1. Prakosa, Yudhistira
- Department of Neurosurgery, Faculty of Medicine, Universitas Padjadjaran/ Dr. Hasan Sadikin Gener
al Hospital, Bandung, West Java, Indonesia
Email: yudhistira.prakosa@gmail.com

2. Ihsan, Nikkita - Department of Neurosurgery, Faculty of Medicine, Universitas Padjadjaran/ Dr. Has
an Sadikin General Hospital, Bandung, West Java, Indonesia
Email: inikki07@gmail.com

3. Bosnia, Agus
- Department of Neurosurgery, Faculty of Medicine, Universitas Padjadjaran/ Dr. Hasan Sadikin Gener
al Hospital, Bandung, West Java, Indonesia
Email: bosniaagus@yahoo.co.id

4. Ompusunggu, Sevline Estethia

- Division of Spine and Peripheral Nerves, Department of Neurosurgery, Faculty of Medicine, Universit
as Padjadjaran/ Dr. Hasan Sadikin General Hospital, Bandung, West Java, Indonesia
- Department of Neurosurgery, Bandung Adventist Hospital, Bandung, West Java, Indonesia
Email: sevlineestethia@gmail.com

5. Dahlan, Rully Hanafi

- Division of Spine and Peripheral Nerves, Department of Neurosurgery, Faculty of Medicine, Universitas
Padjadjaran/ Dr. Hasan Sadikin General Hospital, Bandung, West Java, Indonesia
- Department of Neurosurgery, Bandung Adventist Hospital, Bandung, West Java, Indonesia
Email: rullyspinebandung@gmail.com

Corresponding Author:
Rully Hanafi Dahlan, M.D., Ph.D.
- Department of Neurosurgery, Faculty of Medicine, Universitas Padjadjaran/ Dr. Hasan Sadikin General
Hospital, Bandung, West Java, Indonesia
- Department of Neurosurgery, Bandung Adventist Hospital, Bandung, West Java, Indonesia
Email: rullyspinebandung@gmail.com
Abstract
Introduction: Burst fracture is a type of injury characterized by anterior vertebral body height
loss, posterior wall fracture, or retropulsion of bone fragments into the spinal canal, and account
for 14-17 percent of all spinal injuries. However, there are controversies regarding the specific
surgical treatment method.
Case report: A 32-year-old man sustained multiple injuries, including spinal cord injury,
vertebral fracture, and multiple rib fractures after his car crashed into a cliff. Neurological
examinations indicate a complete spinal cord injury below T4 with ASIA impairment scale A.
Later on, he developed a grade IV sacral pressure ulcer, urinary and fecal incontinence.
Necrotomy debridement, negative pressure wound therapy, laminectomy decompression and
posterior instrumentation were successfully performed.
Discussion: Studies reported that the posterior approach is more effective, shorter operation
times, lower costs, and less estimated blood loss, excellent results in spinal stability, anatomical
alignment, postoperative neurological improvement, low patient morbidity and no significant
differences in neurological status and complication rate than anterior or combined approach.
The functional outcome of the patient is primarily determined by the type of SCI (traumatic or
non-traumatic), the level, whether the injury is complete or incomplete, and whether surgery was
performed or not. The more severe the SCI, the less functional independence can be achieved.
Conclusion: The posterior approach is considered safe, has numerous advantages over the
anterior or combined approach, and there is no difference in neurological status or complication
rate. Numerous factors can complicate the outcome of a patient. Therefore, a multidisciplinary
approach is necessary.

Introduction
Burst fracture is a type of injury characterized by anterior vertebral body height loss,
posterior wall fracture, or retropulsion of bone fragments into the spinal canal, and account for
14-17 percent of all spinal injuries. 1-4 Many studies have shown good results with non-operative
treatment of burst fractures.5,6,7 However, there were a number of authors suggest that
symptomatic and unstable burst fractures require surgical treatment.8,9
There are controversies regarding the specific surgical treatment method. According to a
number of studies, when decompression of the spinal canal and stabilization of the segment are
the primary objectives, the anterior approach should be used. 10 However, some authors have
recommended posterior instrumentation with or without decompression due to the excellent
results in spinal stability, anatomical alignment, postoperative neurological improvement, and
low patient morbidity.11,12,13
Herein, we present a rather complex case of complete spinal cord injury due to thoracic
unstable burst fracture with significant canal compression treated by posterior approach with
long bilateral laminectomy and posterior instrumentation with pedicle screw and dual rods, and
pressure ulcer due to immobility which require complex decision-making and multidisciplinary
approach.

Case Report
A month ago, a 32-year-old man sustained multiple injuries, including spinal cord injury,
vertebral fracture, and multiple rib fractures after his car crashed into a cliff. After the incident,
he was transported to nearest hospital’s emergency unit. He complained of weakness in both of
his lower extremities in addition to severe back pain and left lower chest pain, especially when
breathing. Clinical examinations revealed that he was alert, breathing normally, and exhibiting
remarkable vital signs. Neurological examinations showed weakness in both lower extremities
with zero motor strength, bilateral anesthesia below level T4, loss of perianal sensation,
absence of voluntary anal contraction, absence of great toe extension, and absence of
bulbocavernous reflex. These results indicate a complete spinal cord injury below T4 with ASIA
impairment scale A. The patient was then hospitalized and treated for two weeks. Chest and
thoracolumbar X-rays revealed fragmented burst fractures at vertebral body levels T3 and T4,
8th and 10th left rib fractures, and no spinal malalignment (Fig. 1). After two weeks of
admission, he developed a grade IV sacral pressure ulcer, urinary and fecal incontinence, and
no motor or sensory improvement. He was therefore referred to our hospital.

Figure 1. Chest and thoracolumbal x-ray showed fragmented burst fractures at vertebral body levels T3
and T4, 8th and 10th left rib fractures, and no spinal malalignment.
 At our emergency unit, neurological examinations revealed persistent weakness in both
lower extremities with zero muscle strength, spasticity, but no clonus, and a widening of the
sacral pressure ulcer. A non-contrast cervicothoracic CT scan and three-dimension
reconstructed CT-scan (3D-CT) revealed a fragmented burst fracture at vertebral body levels T3
and T4, with intervertebral disc narrowing at levels T3-T4 and T4-T5, as well as significant canal
stenosis (Fig. 2). The anterior vertebral body T3-T5 height loss was determined to be 66.43
percent, 62.70 percent, and 55.19 percent, in that order. The posterior vertebral body T3-T5
height loss was measured to be 56.3%, 63.82 %, and 48.1%, respectively. The height of the
intervertebral disc at T1-T2, T2-T3, T3-T4, and T4-T5 was measured to be 2,223, 2,193, 1,563,
and 2,214 mm, respectively. The kyphotic angle and Cobb's angle were each measured at 0.7
and 3.1 degrees (Fig. 3). On otherwise normal laboratory results, slight hypoalbuminemia and
hyponatremia were detected. The patient was then consulted to neurosurgery and plastic
surgery department.

Figure 2. A non-contrast cervicothoracic CT scan revealed a fragmented burst fracture at vertebral body
levels T3 and T4, with intervertebral disc narrowing at levels T3-T4 and T4-T5, as well as significant canal
stenosis. Three-dimension reconstructed CT-scan (3D-CT) revealed a fragmented burst fracture at
vertebral body levels T3 and T4, with intervertebral disc narrowing at levels T3-T4 and T4-T5.

Plastic surgery planned to perform necrotomy debridement and negative pressure

wound therapy (Fig 4). Our department planned bilateral T3-T5 laminectomy, insertion of
pedicle screws, and placement of dual rods for posterior stabilization (Fig. 5). The two surgeries
were performed concurrently on the same day, with necrotomy debridement and negative
pressure wound therapy performed first (Fig. 4). Afterwards, we performed level identification
and incisional marking (Fig. 5).
 Figure 3. The anterior vertebral body T3-T5 height loss was determined to be 66.43 percent, 62.70
percent, and 55.19 percent, in that order. The posterior vertebral body T3-T5 height loss was measured to
be 56.3%, 63.82 %, and 48.1%, respectively. The height of the intervertebral disc at T1-T2, T2-T3, T3-T4,
and T4-T5 (right) was measured to be 2,223, 2,193, 1,563, and 2,214 mm respectively. The kyphotic
angle and Cobb's angle were each measured at 0.7 and 3.1 degrees.

Figure 4. Image showed that necrotomy debridement and negative pressure wound therapy were being
performed successfully.

Intraoperatively, we discovered intact ligaments, spinous processes, and laminae. We

inserted pedicle screws from levels T2 to T6, performed bilateral laminectomy from levels T3 to
T5, observed the dura to be intact, pale, and pulsating, and then placed dual rods (Fig. 5). The
surgical procedures were successful. The patient's back pain was significantly reduced after
surgery. However, neurological examinations revealed no improvement in motor or sensory
function.
 Figure 5. Image showed level identification process and incisional marking. Intraoperatively image
showed intact ligaments, spinous processes, and laminae. Pedicle screws were inserted from levels T2 to
T6 and dual rods were placed. Bilateral laminectomy was performed from levels T3 to T5. the dura was
intact, pale, and pulsatile. The surgery was performed successfully.

Discussion
The burst fracture is a type of injury characterized by anterior vertebral body height loss,
posterior wall fracture, or retropulsion of bone fragments into the spinal canal. 3 Acute back pain,
restricted motion, and neurological deficits such as motor or sensory changes and sphincter
disturbances are the clinical manifestations of burst fractures. Widening of the interspinous and
interlaminar distances, translation of more than 2 mm, kyphosis of more than 20°, dislocation,
height loss of more than 50 percent, and articular process fractures are radiographic indicators
of vertebral instability.14,15 Many studies have shown good results with non-operative treatment
of burst fractures.5,6,7 However, there were a number of authors suggest that symptomatic and
unstable burst fractures require surgical treatment.8,9
In this case, the fractured segment was unstable, as evidenced by the development of
complete neurological injury, marked anterior and posterior vertebral body height loss, and
significant canal stenosis. Consequently, we chose surgical approach. According to a number of
studies, when decompression of the spinal canal and stabilization of the segment are the
primary objectives, the anterior approach should be used. 10 However, we chose the posterior
approach over the anterior or combined approaches due to a number of factors. Some studies
reported that the posterior approach is more effective, shorter operation times, lower costs, and
less estimated blood loss, excellent results in spinal stability, anatomical alignment,
postoperative neurological improvement, low patient morbidity and no significant differences in
neurological status and complication rate than anterior or combined approach.11-13,16
The posterior approach procedure includes laminectomy and pedicle screw and rod
instrumentation for stabilization. Laminectomy decompression was performed in order to
decompress the spinal canal from the vertebral body that was retropulsed. The cranial and
caudal vertebrae of the involved segment comprise the fixated vertebral segment in the
stabilization procedure in which the pedicle screw and rod are attached. 17,18 In this case, we
inserted the pedicle screws from T2 to T6 vertebrae, including the fractured level. We
considered it safe since the ligaments, spinous processes, and laminae are intact. Under C-arm
guidance, we inserted the pedicle screw into the pedicle and vertebral body successfully.
Although these methods are widely utilized, complications may still arise. It includes
instrumentation failures such as loosening, breaking, dislodging, or detaching of pedicle screws
from the rod, as well as pseudoarthrosis, CSF leakage, infection, wound breakdown, and
bleeding.19 In our case, it was complicated by the presence of a pressure ulcer due to
immobility. This pressure ulcer must be properly treated, as it could be a source of infection for
a bedridden patient and could worsen the outcome of the patient. We aimed that by
decompressing the canal, the patient's motor functions would improve and the patient would be
able to regain mobility as soon as possible. However, his back pain was the only symptom that
showed improvement. There was no improvement in his motor, sensory, or vegetative functions.
The functional outcome of the patient is primarily determined by the type of SCI (traumatic or
non-traumatic), the level, whether the injury is complete or incomplete, and whether surgery was
performed or not. The more severe the SCI, the less functional independence can be
achieved.20,21,22
Conclusion
The management of spinal cord injuries caused by burst fractures in patients with acute
spinal trauma requires complex decision-making. Whether the patient should be treated
conservatively or surgically was the subject of debate. The posterior approach is considered
safe, has numerous advantages over the anterior or combined approach, and there is no
difference in neurological status or complication rate. Numerous factors can complicate the
outcome of a patient, as was the case here with the pressure ulcer, therefore a multidisciplinary
approach is necessary.
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