Translate this page into:
Notice: Please configure GTranslate from WP-Admin -> Settings -> GTranslate to see it in action.
Transdural reduction of a bone fragment protruding into the spinal canal during surgical treatment of lumbar burst fracture: A case report
-
Received: ,
Accepted: ,
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Saruta W, Takahashi T, Kumabe T, Minami M, Kanematsu R, Ohtaki HS, et al. Transdural reduction of a bone fragment protruding into the spinal canal during surgical treatment of lumbar burst fracture: A case report. Surg Neurol Int 2021;12:406.
Abstract
Background:
There have been many reports on the clinical, radiographic, and surgical management of thoracolumbar burst fractures attributed to high-energy trauma. Interestingly, few reports have described how to extract bone fragments associated with these injuries protruding into the spinal canal contributing to significant neurological deficits.
Methods:
An 18-year-old male presented with a severe L3-level paraparesis (i.e., loss of motor/sensory function below L3 lower extremity hyporeflexia, and sphincter dysfunction: American Spinal Injury Association [ASIA] Impairment Scale B) following a high-speed crash. The computed tomography and magnetic resonance studies revealed a L3 burst fracture with bone fragments protruding into the spinal canal causing marked cauda equina compression. Following a L3-L4 laminectomy, and opening of the dorsal dura, the bone fragments were ventrally impacted into the fractured L3 vertebral body a pedicle/screw L1-L5 fusion was then completed.
Results:
One month later, the patient recovered to an ASIA Scale of C, (i.e., residual proximal 3/5 and distal 2/5 motor deficits, with partial sensory sparing).
Conclusion:
Transdural ventral impaction of protruded bone fragments attributed to high speed lumbar burst fractures contributing to significant cauda equina compression can be safely/effectively accomplished.
Keywords
Cauda equina injury
Lumbar burst fracture
Spinal fixation
Transdural decompression
INTRODUCTION
Lumbar burst fractures caused by high-energy trauma, can result in vertebral body bone fragments protruding into the spinal canal, resulting in significant cauda equina/root injuries.[3,5,7] Here, the authors showed that posterior transdural impaction of ventrally extruded lumbar vertebral bone fragments could be safely/effectively accomplished utilizing a L3-L4 laminectomy followed by a pedicle/screw/rod instrumented fusion.
MATERIALS AND METHODS
History and examination
An 18-year-old male fell from a height of 10 m resulting in an L3-level paraparesis (i.e., complete motor loss, partial sensory loss, and sphincter dysfunction: American Spinal Injury Association Impairment Scale B) [Table 1]. The magnetic resonance/computed tomography (MR/CT) studies showed the L3 vertebral body burst fracture fragments protruding into the spinal canal resulting in marked cauda equina compression [Figure 1a and b].


Operative procedure
Performing a L3-L4 laminectomy, revealed his dorsal dura was lacerated, with several damaged nerve rootlets herniating through the traumatic durotomy [Figure 2a]. Through the dorsal durotomy, the ventrally extruded L3 body bone fragments were impacted back into the fractured vertebral body [Figures 2b, 3a and b]. This was followed by a primary dorsal dural repair about 5 cm in length by stitch suture to the watertight. This was followed by percutaneous pedicle screw fixation from L1 to L5.


RESULTS
One month postoperatively, the patient’s proximal (3/5) and distal (2/5) motor strength improved along with bladder and bowel dysfunction completely. Further, the postoperative CT and MRI studies confirmed adequate canal decompression with just a slight residual ventral shift in the protruded bone fragments [Figure 4a and b].

DISCUSSION
Several studies have reported the removal of bone fragments protruding into the spinal canal in patients who have sustained lumbar burst fractures with resultant cauda equina syndromes.[1,2,4,6,8,9] Typically this was achieved utilizing either an anterior or posterior microscope-assisted approach, rather than through a traumatic dorsal durotomy [Table 2].

Advantages of posterior versus anterior approach
There are pros and cons for posterior versus anterior approaches to lumbar burst fractures with ventrally extruded/fractured bone fragments contributing to cauda equina syndrome. The posterior approach allows for ventral fragment removal (i.e., tamping down into the fractured vertebral body) while also facilitating direct dorsal dural repair.[2] Although the anterior approach allows for direct bone fragment removal/decompression, the major disadvantage is the difficulty in repairing the ventral dural defect.[6,9]
Dural injury due to lumbar vertebral burst fractures
Yoshiiwa et al. found that the cauda equina notch sign was a predictable MR finding of cauda equina entrapment (i.e., due to greenstick lamina fractures), but in many cases this is just found intraoperatively.[10] Here, the patient clearly had a greenstick laminar L3 fracture responsible for the dorsal dural injury.
Surgery
Minimally Invasive Surgical (MIS) Approaches: MIS surgical approaches are ineffective when dealing with dorsal dural injuries attributed to lumbar burst fractures. Chen et al. reported ventral packing of fractured fragments under endoscopy with vertebroplasty.[1] However, this risked inadequate decompression and neural damage when bilateral bone fragments extended in the spinal canal, while also making dorsal dural repair extremely more difficult.[1,8]
Transdural Approach to Impaction Vertebral Body Burst Fracture Fragments Contributing to Cauda Equina Compression.
One study discussed impaction of ventral vertebral body bone fragments utilizing a transdural approach in a case in which there was a traumatic dorsal durotomy.[7]
CONCLUSION
Transdural reduction of protruded lumbar bone fragments through a posterior traumatic durotomy following a L3 burst fracture was safely/effectively accomplished.
Ethical approval
This study was approved by the Medical Ethnic Board of Fujieda Heisei Memorial Hospital (approved number FHR2020-6).
Declaration of patient consent
Institutional Review Board (IRB) permission obtained for the study
Financial support and sponsorship
Nil
Conflict of Interest
The authors declare that they have no conflict of interest.
REFERENCES
- World Neurosurg. 2020;135:e209-20.Minimally invasive decompression and intracorporeal bone grafting combined with temporary percutaneous short-segment pedicle screw fixation for treatment of thoracolumbar burst gracture with neurological deficits.
- [Google Scholar]
- Orthop Traumatol. 2019;68:601-5.Bone fragment removal by posterior approach for delayed paralysis due to vertebral body rupture fracture.
- [Google Scholar]
- Medicine (Baltimore). 2017;96:e5936.Does the fracture fragment at the anterior column in thoracolumbar burst fractures get enough attention?
- [Google Scholar]
- Spine (Phila Pa 1976). 2010;35:295-302.Three-column reconstruction through single posterior approach for the treatment of unstable thoracolumbar fracture.
- [Google Scholar]
- Spine (Phila Pa 1976). 2012;37:321-9.The epidemiology of traumatic spinal cord injury in British Columbia, Canada.
- [Google Scholar]
- Orthop Surg. 2015;7:185-6.Anterior reconstruction via a relatively noninvasive retroperitoneal approach for lumbar burst fracture.
- [Google Scholar]
- Spinal Cord Ser Cases. 2017;3:2016-8.Dural penetration caused by a vertebral bone fragment in a lumbar burst fracture: A case report.
- [Google Scholar]
- Medicine (Baltimore). 2017;96:e8640.Transforaminal endoscopy in lumbar burst fracture: A case report.
- [Google Scholar]
- Spine (Phila Pa 1976). 2011;36:e498-504.Anterior Z-plate and titanic mesh fixation for acute burst thoracolumbar fracture.
- [Google Scholar]
- Asian Spine J. 2014;8:339-45.Predictable imaging signs of cauda equina entrapment in thoracolumbar and lumbar burst fractures with greenstick lamina fractures.
- [Google Scholar]