Journal of Spine & NeurosurgeryISSN: 2325-9701

Research Article, J Spine Neurosurg Vol: 5 Issue: 6

Nonunion of Traumatic Lumbar Fracture: Case Report

Zhang F, Xie J, Wang G*, Yang Y, Yang H and Jiang W
Department of Orthopaedics, The First Affiliated Hospital of Soochow University, Jiangsu Province 215006, China
Corresponding author : Dr. Genlin Wang
Department of Orthopaedics, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou, Jiangsu Province 215006, China
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+086-512-67780101
Fax: +086-512-65228072
E-mail: [email protected]
Received: August 13, 2016 Accepted: October 03, 2016 Published: October 16, 2016
Citation: Zhang F, Xie J, Wang G, Yang Y, Yang H, et al. (2016) Nonunion of Traumatic Lumbar Fracture: Case Report. J Spine Neurosurg 5:6. doi:10.4172/2325-9701.1000251

Abstract

Nonunion of flexion-distraction thoracolumbar fractures has few been described previously. The case report discussed a case of nonunion of traumatic lumbar fracture. A 30-year-old man suffered a traumatic L1-2 flexion-distraction fracture and no paraplegia. After complete bed rest 2 months, then hyperextension thoracolumbar cast 3 months, he still felt back pain when out-of-bed activity. X-ray images demonstrated the fracture was not united. At last, the patient underwent open reduction of the fracture nonunion and L1-2 posterior fusion using short segmental pedicle screw instrumentation with autogenous iliac crest graft. The patient gained an excellent functional restoration at 5 months after operation. This suggests that the disease entity may require surgical treatment as early as possible. Spinal fusion combined instrumentation fixation and bone graft may be the best treatment.

Keywords: Vertebral fracture; Ununited; Surgical treatment; Thoracolumbar spine

Keywords

Vertebral fracture; Ununited; Surgical treatment; Thoracolumbar spine

Introduction

Traumatic spine fracture nonunion mainly happens in fracture of the odontoid process [1,2]. To the authors’ knowledge, this is the first reported case of flexion-distraction thoracolumbar vertebral fracture nonunion. The authors present the unusual complication of a lumbar flexion-distraction fracture, and wish to increase awareness of the possibility of nonunion of flexion–distraction injuries of the spine.

Case Reports

A 36-year-old male construction worker fell from 4-m high, landing in a spine deep flexed position on his feet. He had immediate upper lumbar area pain and left ankle pain, but denied any neurologic symptoms. There was no associated loss of consciousness with this accident. He was transported to the hospital with spinal precautions by an ambulance after 2 hours. Physical examination revealed tenderness in the upper lumbar spine between the L1-L2 posterior spinous processes. Left ankle was found abnormity, distal tibia exposed and bleeding. Neurologic examination was normal. There were associated injuries of open dislocation of left ankle and craniocerebral injury. Initial spinal radiographs showed a near horizontal fracture extending across the arch of L2 vertebra, L2-L3 disci intervertebrales and anterior area of L3 vertebra (Figure 1).Computed tomography scan revealed distraction of the fractured L2-L3 (Figure 2). A sagittal view of T2-weighted magnetic resonance imaging demonstrated a laceration of the posterior elements at L2– L3 with high signal intensity consistent with hemorrhage and edema (Figure 3).
Figure 1: Initial spinal radiographs showed a near horizontal fracture extending across the arch of L2 vertebra, L2-L3 disci intervertebrales and anterior area of L3 vertebra.
Figure 2: Computed tomographic scan revealed distraction of the fractured L2-L3.
Figure 3: A sagittal view of T2-weighted magnetic resonance imaging demonstrated a laceration of the posterior elements at L2–L3 with high signal intensity consistent with hemorrhage and edema.
The patient’s left ankle was performed on emergent debridement, reduction and fixation with wire needle. Initially, the patient was treated with bed rest and analgesics. At 2 months after injury, lumbar radiographs showed the fracture line in the arch of L2 vertebra was clear, becoming increasingly sclerotic with time, no healing tendency (Figure 4). Then, he was placed in a hyperextension thoracolumbar cast for 3 months. After removed the cast, the patient felt back pain when he walked. At 5 months after injury, the fracture remained nonunion with pseudarthrosis formation at L2-L3, dynamic mobility was demonstrated by stress views in x-rays (Figure 5 and 6). An open reduction and posterior-lateral spinal fusion with segmental pedicle screw instrumentation were performed on the patient with nonunion of traumatic vertebral fracture. At 5 months after operation, radiographs revealed that the spine alignment was normal and the fracture line in the arch of L2 vertebra was blurred, satisfactory callus formation at the fracture site (Figure 7 and 8). And the patient had no back pain during daily activities. The pedicle screw instrumentation removed after operation 2 years and the fracture was union. (Figure 9 and 10).
Figure 4: At 2 months after injury, lumbar radiographs showed the fracture line in the arch of L2 vertebra was clear, becoming increasingly sclerotic with time, no healing tendency.
Figure 5: At 5 months after injury, Flexion/extension lateral radiographs revealed the fracture remained nonunion with pseudarthrosis formation at L2-L3.
Figure 7: At 5 months after operation, radiographs revealed that the spine alignment was normal and the fracture line in the arch of L2 vertebra was blurred, satisfactory callus formation at the fracture site.
Figure 9: The pedicle screw instrumentation removed after operation 2 years and the fracture was union.

Discussion

Traumatic spine fracture nonunion mainly happens in fracture of the odontoid process of axis [1,2]. Another, Delecrin et al. reported one patient with sacral nonunion treated with insertion of polyaxial screws [3]. However, up to now, there is no reported on nonunion of traumatic thoracolumbar fracture. The current study described a patient with lumbar flexion-distraction fracture, the fracture line extending across the arch of L2 vertebra, L2-L3 disci intervertebrales and anterior area of L3 vertebra. This fracture, belonging to Denis type Ⅳ Chance fracture, is an unstable spine fracture [4]. Yuan et al. biomechanically demonstrated the thoracolumbar junction is the spinal region which receives the greatest dynamic load, and therefore may predispose to fracture nonunion [5]. A rest in bed may provide insufficient immobilisation for this subtype of spine fracture. Thus, a rest in bed cannot eliminate shearing force at the fracture location. We cannot give the patient thoracolumbar cast fixation initially; this may be one of the fracture nonunion reasons. Another possible cause of nonunion includes relatively small bone fracture surfaces, mainly ligament and disc injuries. Finkelstein et al. prospectively study and believed conservative treatment cannot make ligaments injury healing well [6]. Burman et al. also believed that for flexion-distraction spine injury bone injury prognosis is better than ligaments injury [7]. For unstable spine fracture, especially main ligament injury, operation may be a better way. Although the patient later received a thorocalumbar cast fixation for 3 months, the fracture nonunion still to remain. This demonstrated spine fracture once developed nonunion, like limbs bone fractures nonunion, refractory to conservative treatments and not healing with time, they may be need operation of bone graft fusion and fixation to promote fracture union. Patients with ununited traumatic vertebral fracture are refractory to conservative treatments, like orther fractures, nonunion does not heal with time and will be a continued source of chronic pain and disability for the patient.

Conclusions

Traumatic thoracolumbar spine fracture, like limbs fractures, may develop nonunion. Nonunion of traumatic thoracolumbar spine fracture may be refractory to conservative treatments, so often need operative intervention. Spinal fusion combined instrumentation fixation and bone graft may be the best treatment for this kind of spine nonunion.

Conflicts of Interest

This work was supported by National Natural Science Foundation of China (No. 81271960). The authors have no conflicts of interest to declare in relation to this article.

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