Case 6: thoracic spine fracture

posted July 12, 1996

Resident: Ian Angel, MD
Attending Staff: Deepak Awasthi, MD

HISTORY: This 19 year old man was brought to the emergency room after sustaining a fall at his workplace and subsequent inability to move both lower extremities. The patient was started on the Solumedrol protocol by the EMT service. He was evaluted in the emergency room and found to have no other injuries.

EXAMINATION: Patient was awake and alert. Cranial nerves were intact. Good strength in both upper extremities. He was unable to move his legs. There was a sensory level to pinprick and light touch at approximately T10. The patient was able to appreciate light touch around the perianal and perineal region. He was able to feel the tug of the Foley catheter. The patient was also able to feel vibratory sensation in both lower extremities. He was able to discern position sensation on the right lower extremity, but not very well on the left lower extremity.

General exam was normal. Pulse in the 80's, BP 130/70, respirations normal, afebrile.

DIAGNOSTIC STUDIES: The initial studies obtained were plain x-rays of the cervical, thoracic and lumbar spine as well as a chest x-ray. Below is the plain lateral thoracic x-ray which shows a T8 burst fracture with retropulsion of bony fragments.

Below is an axial view of the thoracic CT scan (bone windows) at the level of the injury.

Note the vertebral body fracture as well as fractures of the posterior elements.

How will you proceed at this time? Any additional diagnostic studies? Management Options? 1. Nothing 2. Bracing 3. Anterior decompression and fusion/fixation 4. Posterior decompression and fusion/fixation 5. Anterior and Posterior approaches.

Please comment: dawast@lsuhsc.edu

Your comments will be tabulated and we will let you know how the readers of this page would approach this problem.

STEPS TAKEN AT LSU: We decided to take the patient to the OR on postinjury day #3. Through a transthoracic approach, a T8 corpectomy was performed and the spinal canal decompressed. The T8 vertebral body was essentially destroyed with bony fragments in the canal. After the decompression, multiple rib autografts were used to reconstruct the vertebral body space. Then fixation was provided with the Synthes anterolateral plate.

POSTOPERATIVE COURSE: Uneventful postoperative course. No change in the paraplegia. Increase ability to discern position sensation in both lower extremities. Transferred to rehab. Postoperative x-ray shows good alignment and good placement of the plate and screws- see below:

NOTE: Of 96 respondents to this case- 65% would approach this case posteriorly; 25% would approach it anteriorly; 8% anteriorly and posteriorly; and 2% would simply brace the patient

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