1Emory School of Medicine, Atlanta, Georgia, USA
2Department of Neurosurgery, Emory School of Medicine, Atlanta, Georgia, USA
3Department of Surgery, Emory School of Medicine, Atlanta, Georgia, USA
Correspondence to Dr Faiz U Ahmad, firstname.lastname@example.org
A 29-year-old man was brought to our level one trauma hospital after a motor vehicle accident, during which he was ejected from the vehicle during the crash. He lost consciousness on impact but was alert and oriented on arrival at the hospital, and was able to move all four extremities during the initial trauma assessment.
Multiple injuries were noted on presentation, including an extensive degloving injury with anorectal dissociation. The patient was taken for an emergent exploratory laparotomy shortly after admission and his abdomen was left open with a temporary covering for 2 days due to abdominal compartment syndrome. Subsequent surgeries included bilateral chest-tube placement, end-sigmoid colostomy, anorectal reconstruction, closed reduction of a tibial fracture and tracheostomy.
On hospital day 3, the patient’s neurological status deteriorated to a Glasgow Coma Scale of 3 T, with reactive pupils but no cough or gag reflex on examination. A head CT showed diffuse cerebral oedema due to a traumatic brain injury. On hospital day 7, he developed sepsis with renal failure and increased need for respiratory and blood pressure support. At that time, he was found to have necrotising fasciitis, and required multiple operative debridements of the devitalised skin and soft tissue.
At the time of admission, CT imaging of the spine demonstrated an acute, oblique fracture through the body of the T4 and bilateral widening of the facet joints at T4/5, with posterior displacement of the fracture causing spinal cord compression (figure 1), consistent with an AO/Magerl Type B2.2.2 injury. Owing to the patient’s other injuries and haemodynamic instability, no further imaging could be obtained to assess injury to the spinal cord and ligamentous structures.
On admission, sensation and motor function were intact in all four extremities, but after the patient’s mental status declined secondary to traumatic brain injury, spinal cord function was difficult to monitor. When his condition improved, he had full strength in his upper extremities and was able to follow commands in his lower extremities. There was no loss of sensation detectable on examination. Spinal cord function appeared to be preserved although this was difficult to assess due to his other injuries.
On hospital day 9, the patient’s neurological status began to improve and he no longer required pressors for haemodynamic stability. Over the next 3 weeks, he was frequently brought to the operating room for wound irrigation and debridements with revisions of his abdominal closure. During that time, his vital signs and renal function slowly improved and he was extubated on hospital day 25.
Owing to the patient’s numerous injuries and haemodynamic instability, immediate management of the thoracic spine fracture consisted of a thoraco-lumbar-sacral orthosis (TLSO) brace, though the brace had to be frequently removed for wound care. One month into the hospitalisation, with his condition better stabilised, attention returned to the vertebral fracture and options for management. The constellation of features found on CT was consistent with an unstable chance fracture, which required surgical stabilisation.
Though the patient’s condition was improving, he was not a good candidate for open surgery due to necrotising fasciitis, and extensive loss of skin and subcutaneous tissue. This resulted in a large area of exposed muscle over the lower thoracolumbar spine (figure 2). In light of this, surgical stabilisation was achieved using a minimally invasive approach, with percutaneous placement of pedicle screws from T2–T7 with bilateral titanium rods (figure 3). The pedicle screws were 5 mm by 40 mm in size and were made by DePuy-Synthes (Raynam, Massachusetts, USA).
The decision to instrument down to the T7 level was due to difficulty in distinguishing the T4-6 levels on fluoroscopy after the T4 fracture was reduced, and the inability to cannulate and instrument the T4 pedicles. Therefore, we erred on the side of caution to provide an extra level of instrumentation and support. The patient tolerated the procedure well and postoperative imaging demonstrated accurate placement of hardware and effective reduction and fixation of the chance fracture (figure 4).
Outcome and follow-up
In the weeks following surgery, the patient continued to improve and received several skin grafts to the areas of exposed subcutaneous tissue. He was transferred from the intensive care unit to a regular floor, and was subsequently discharged to an acute rehabilitation facility. His total length of hospital stay was 12 weeks.
His motor strength and lower extremity function improved tremendously with extensive physical therapy, and at his most recent follow-up appointment (14 months) he was able to walk independently and perform all basic activities of daily life. Radiographs taken after surgery demonstrated accurate hardware placement and normal alignment of the thoracic spine (figure 4). Follow-up photographs (figure 5) demonstrated well-healed surgical incisions and well-incorporated skin grafts covering the previously exposed soft tissue over the thorax and gluteus.
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