J Korean Orthop Assoc.  2013 Aug;48(4):308-313.

The Fate of Neglected Three Column Injuries of the Thoracolumbar Spine

• Suh SP
• Kim CW
• Kang CN

Abstract

In a thoracolumbar fracture, accurate diagnosis of spinal stability is necessary in deciding on appropriate treatment options and for prevention of complications that can subsequently occur. In various reports for spinal stability, rupture of the posterior ligament complex is generally accepted as a very important factor of spinal stabiliby. In cases of conservative treatment for unstable thoracolumbar fractures, the progressive kyphotic deformity can cause chronic pain and functional disability, and neurologic deterioration in severe cases. Therefore, the concept of surgical treatment for unstable thoracolumbar fracture has been well established. We report on two cases of neglected three column injury in the thoracolumbar spine, which were treated conservatively due to misdiagnosis at other hospitals, and finally underwent delayed operation in our hospital because of chronic back pain and progressive kyphotic deformity.

Keyword

thoracolumbar spine; three column injury; conservative treatment; surgical treatment

MeSH Terms

Back Pain
Chronic Pain
Congenital Abnormalities
Diagnostic Errors
Ligaments
Rupture
Spine

Figure

• 

  Figure 1 Initial anteroposterior (A) and lateral (B) views of the thoracolumbar spine taken in the emergency room in another hospital, shows approximately 15% collapse (B, arrows) of anterior body height of T12, L1 with a slightly widening (A, circle) of interspinous distance between T11 and T12.

• 

  Figure 2 T2 fat suppression image of initial magnetic resonance imaging shows high signal intensity of T8 body, T12 body, L1 body, interspinous ligament and supraspinous ligament between T11 and T12.

• 

  Figure 3 Serial thoracolumbar lateral radiographs show progressive collapse of T12 body height, increased T11 and T12 interspinous distance and increased kyphotic deformity. (A) Two weeks; (B) Six weeks; (C) Three months; (D) Ten months.

• 

  Figure 4 T2 fat suppression image of magnetic resonance, taken at 10 months after injury, shows high signal intensity of T12 body with widening of interspinous distance between T11 and T12.

• 

  Figure 5 Plain radiograph of the thoracolumbar spine, taken in our hospital at 14 months after injury, shows approximately 80% collapsed anterior body height of T12 with kyphotic deformity of 40 degrees and significant interspinous widening (arrow) between T11 and T12.

• 

  Figure 6 Plain anteroposterior (A) and lateral (B) radiographs taken at two weeks after the anterior operation show the state of anterior interbody fusion with a mesh cage and anterior instrumentations from T11 to L1. Thoracolumbar kyphosis was corrected from 40 degrees to 23 degrees (B).

• 

  Figure 7 Anteroposterior (A) and lateral (B) view of the thoracolumbar spine, taken at six month after injury, shows approximately 70% collapsed anterior body height of T12 and kyphotic deformity of 45 degrees with widening of interspinous distance (arrows in A, B) between T11 and T12.

• 

  Figure 8 T2 fat suppression image of magnetic resonance, taken at six months after injury, shows high signal intensity of T12 body and a mild degree of spinal canal encroachment with disruption of supraspinous, interspinous ligament, and ligamentum flavum between T11 and T12.

• 

  Figure 9 Sagittal (A) and axial (B) images of computed tomography scan show the collapsed anterior body (A) of T12 and facet joint dislocation (B) of T11-T12 with kyphotic deformity (A).

• 

  Figure 10 Plain anteroposterior (A) and lateral (B) radiographs taken at one week after the operation shows the state of anterior interbody fusion with mesh cage from T11 to L1, and posterolateral fusion with transpedicular fixation from T9 to L2.

Reference

1. Nicoll EA. Fractures of the dorso-lumbar spine. J Bone Joint Surg Br. 1949; 31B:376–394.

2. Holdsworth F. Fractures, dislocations, and fracture-dislocations of the spine. J Bone Joint Surg Am. 1970; 52:1534–1551.

3. Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine (Phila Pa 1976). 1983; 8:817–831.

4. McAfee PC, Yuan HA, Fredrickson BE, Lubicky JP. The value of computed tomography in thoracolumbar fractures. An analysis of one hundred consecutive cases and a new classification. J Bone Joint Surg Am. 1983; 65:461–473.

5. Vaccaro AR, Lehman RA Jr, Hurlbert RJ, et al. A new classification of thoracolumbar injuries: the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status. . Spine (Phila Pa 1976). 2005; 30:2325–2333.

6. Vaccaro AR, Lee JY, Schweitzer KM Jr, et al. Assessment of injury to the posterior ligamentous complex in thoracolumbar spine trauma. Spine J. 2006; 6:524–528.

7. Daffner RH, Deeb ZL, Goldberg AL, Kandabarow A, Rothfus WE. The radiologic assessment of post-traumatic vertebral stability. Skeletal Radiol. 1990; 19:103–108.

8. Lee HM, Kim DJ, Kim HS, Suk KS, Kim NH, Park SY. Reliability of MRI to detect posterior ligament complex injury in thoracolumbar spinal fractures. J Korean Soc Spine Surg. 2000; 7:70–76.

9. Pizones J, Izquierdo E, Alvarez P, et al. Impact of magnetic resonance imaging on decision making for thoracolumbar traumatic fracture diagnosis and treatment. Eur Spine J. 2011; 20:Suppl 3. 390–396.