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ORIGINAL ARTICLE
Year : 2021  |  Volume : 16  |  Issue : 4  |  Page : 692-694

Minimally invasive surgery for traumatic high-grade lateral spondylolisthesis of L1 with multiple spinal fractures: Closed reduction and internal fixation using percutaneous pedicle screws


Department of Orthopedics Surgery, Toyama Prefectural Central Hospital, Toyama, Japan

Date of Submission12-Mar-2021
Date of Acceptance04-May-2021
Date of Web Publication18-Dec-2021

Correspondence Address:
Dr. Takeshi Sasagawa
Department of Orthopedics Surgery, Toyama Prefectural Central Hospital, Toyama
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajns.AJNS_63_21

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  Abstract 

Background: Traumatic high grade lateral spondylolisthesis at the thoracolumbar junction is an extremely severe injury caused by high-energy trauma, commonly resulting in polytrauma. The treatment of this pathology is challenging, and even death following surgery has been reported. Therefore, it is necessary to focus on making surgical invasion minimal. Methods: A 53-year-old female fell from a height and presented with severe back pain and complete paralysis below L1. Computed tomography (CT) showed a Grade 4 traumatic lateral spondylolisthesis and severe comminution of L1, and mild compression fractures at T9 and L3. Results: First, we performed posterior surgery on the day of the injury to reduce the fracture and stabilize the spinal column using percutaneous pedicle screws (PPS). Twelve days later we resected the L1 vertebral body and inserted a cage with an iliac bone graft using an anterior approach. The estimated blood loss from posterior and anterior surgeries was 320ml and 200ml, respectively. Bony fusion was achieved as seen on CT at the 1-year follow-up. Conclusion: A 2-stage combined posterior-anterior approach using PPS can be performed less invasively, enabling adequate reduction, internal fixation, and anterior reconstruction for patients with high grade traumatic lateral spondylolisthesis without spinal shortening or facet interlocking.

Keywords: Combined posterior–anterior approach, lateral spondylolisthesis, minimally invasive surgery, percutaneous pedicle screws, thoracolumbar fracture


How to cite this article:
Sasagawa T. Minimally invasive surgery for traumatic high-grade lateral spondylolisthesis of L1 with multiple spinal fractures: Closed reduction and internal fixation using percutaneous pedicle screws. Asian J Neurosurg 2021;16:692-4

How to cite this URL:
Sasagawa T. Minimally invasive surgery for traumatic high-grade lateral spondylolisthesis of L1 with multiple spinal fractures: Closed reduction and internal fixation using percutaneous pedicle screws. Asian J Neurosurg [serial online] 2021 [cited 2022 May 26];16:692-4. Available from: https://www.asianjns.org/text.asp?2021/16/4/692/332821




  Introduction Top


Traumatic high-grade lateral spondylolisthesis at the thoracolumbar junction is an extremely severe injury caused by high-energy trauma, commonly resulting in polytrauma.[1],[2] The treatment of this pathology is challenging, and even death following surgery has been reported.[1] Therefore, it is necessary to focus on making surgical invasion minimal. Here, we report treatment of a case of traumatic high-grade lateral spondylolisthesis with multiple spinal fractures using percutaneous pedicle screws (PPS).


  Technical Note Top


A 53-year-old female fell from a height and presented with severe back pain and complete paralysis (Frankel A) below L1. Computed tomography (CT) showed a Grade 4 traumatic lateral spondylolisthesis and severe comminution of L1 and mild compression fractures at T9 and L3 [Figure 1]a,[Figure 1]b,[Figure 1]c. Other than the spinal injury, the patient had bilateral rib fractures and a pneumothorax [Figure 1]a and [Figure 1]b, and a thoracostomy tube was inserted. We planned a 2-stage posterior–anterior surgery. First, we performed posterior surgery on the day of the injury to reduce the fracture and stabilize the spinal column. Displacement of the fracture was reduced to Grade 3 spondylolisthesis by pushing the left thoracic cage to the right with the patient in the prone position. After placing PPS at T8 to L5, except for the fractured vertebrae (T9, L1, and L3), we reduced displacement of the fracture by assembling a 5.5 mm titanium rod from T8 to L5 bilaterally. Postoperative images demonstrated appropriate vertebral alignment [Figure 2]. Twelve days later, we resected the L1 vertebral body and inserted a cage with an iliac bone graft using an anterior approach [Figure 3]. The estimated blood loss from posterior and anterior surgeries was 320ml and 200ml, respectively. Bony fusion was achieved as seen on CT at the 1-year follow-up, and we removed the posterior instrumentation. Neurological improvement to Frankel C was evident.
Figure 1: Computed tomography at the initial visit to our hospital. (a) Coronal image. (b) Sagittal image. (c) 3D image

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Figure 2: Postoperative X-ray images after posterior surgery. (a) Frontal view. (b) Lateral view

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Figure 3: Postoperative images after anterior surgery. (a) Frontal view. (b) Lateral view. (c) Sagittal computed tomography image

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  Discussion Top


Intraoperative blood loss during surgery for traumatic thoracolumbar fracture cannot be ignored, especially in the early acute phase of surgery.[3] Excessive intraoperative blood loss can worsen the general condition.[4] The use of PPS for fixation of traumatic thoracolumbar fracture has been found to result in less visible intraoperative blood loss than conventional open surgery.[5] However, to the best of our knowledge, all reported cases with traumatic high-grade lateral spondylolisthesis have been treated using open surgery.[1],[6],[7] Open reduction and internal fixation using spinal instrumentation are needed for traumatic high-grade lateral spondylolisthesis with spinal shortening or facet interlocking.[8],[9] Because the present case involved severe comminution of the vertebral body without spinal shortening, the fracture was easily reduced and stabilized by adapting the use of PPS to the rods. PPS, having extended threads on polyaxial screws, can function as reduction screws. Therefore, as with open surgery, we were able to reduce the dislocation successfully using PPS and a rod system. The present case involved polytrauma with thoracic injury. Early spine damage necessitated surgery to control further damage.[10] Using PPS, blood loss was small, even though long posterior stabilization from T8 to L5 was performed on the day of the injury. There were no complications or worsening of the patient's general condition postoperatively. Thus, ideal spine damage control was achieved using PPS.

There are some disadvantages to posterior surgery using PPS, such as difficulty in bone grafting. Anterior spinal reconstruction is needed for cases with severe comminution of the vertebral body.[11] Therefore, we grafted bone by inserting an expandable cage for anterior reconstruction. Because damage control was achieved by prior posterior stabilization, the amount of blood loss from the anterior approach was small. A 2-stage combined posterior–anterior approach using PPS can be performed less invasively, enabling adequate reduction, internal fixation, anterior cage and bone insertion, and fusion for patients with high-grade traumatic lateral spondylolisthesis without spinal shortening or facet interlocking.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Garg M, Kumar A, Sawarkar DP, Singh PK, Agarwal D, Kale SS, et al. Traumatic lateral spondyloptosis: Case series. World Neurosurg 2018;113:e166-71.  Back to cited text no. 1
    
2.
Mishra A, Agrawal D, Gupta D, Sinha S, Satyarthee GD, Singh PK. Traumatic spondyloptosis: A series of 20 patients. J Neurosurg Spine 2015;22:647-52.  Back to cited text no. 2
    
3.
Verlaan JJ, Diekerhof CH, Buskens E, van der Tweel I, Verbout AJ, Dhert WJ, et al. Surgical treatment of traumatic fractures of the thoracic and lumbar spine: A systematic review of the literature on techniques, complications, and outcome. Spine (Phila Pa 1976) 2004;29:803-14.  Back to cited text no. 3
    
4.
Kerwin AJ, Frykberg ER, Schinco MA, Griffen MM, Arce CA, Nguyen TQ, et al. The effect of early surgical treatment of traumatic spine injuries on patient mortality. J Trauma 2007;63:1308-13.  Back to cited text no. 4
    
5.
Sun XY, Zhang XN, Hai Y. Percutaneous versus traditional and paraspinal posterior open approaches for treatment of thoracolumbar fractures without neurologic deficit: A meta-analysis. Eur Spine J 2017;26:1418-31.  Back to cited text no. 5
    
6.
Howard BM, Holland CM, Krieger DA, Ahmad FU. Open reduction and posterior instrumented spinopelvic fixation for traumatic grade IV lateral spondylolisthesis of the thoracolumbar spine. Spine J 2015;15:1700-1.  Back to cited text no. 6
    
7.
Haddadi K, Hosseini SM, Khadem A, Hashemian MB. One-stage posterior only corpectomy and fusion in the treatment of a unique acute low lumbar l4 burst fracture without neurologic deficit: A case presentation. Asian J Neurosurg 2020;15:691-4.  Back to cited text no. 7
  [Full text]  
8.
Yadla S, Lebude B, Tender GC, Sharan AD, Harrop JS, Hilibrand AS, et al. Traumatic spondyloptosis of the thoracolumbar spine. J Neurosurg Spine 2008;9:145-51.  Back to cited text no. 8
    
9.
Reddy SJ, Al-Holou WN, Leveque JC, La Marca F, Park P. Traumatic lateral spondylolisthesis of the lumbar spine with a unilateral locked facet: Description of an unusual injury, probable mechanism, and management. J Neurosurg Spine 2008;9:576-80.  Back to cited text no. 9
    
10.
Stahel PF, Flierl MA, Moore EE, Smith WR, Beauchamp KM, Dwyer A. Advocating “spine damage control” as a safe and effective treatment modality for unstable thoracolumbar fractures in polytrauma patients: A hypothesis. J Trauma Manag Outcomes 2009;3:6.  Back to cited text no. 10
    
11.
McCormack T, Karaikovic E, Gaines RW. The load sharing classification of spine fractures. Spine (Phila Pa 1976) 1994;19:1741-4.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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