A clinical case study of long-term injury of the thoracic and lumbar spine

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Abstract


Overestimation of the efficacy of conservative treatment of spine injuries children often leads to unsatisfactory long-term results. The effective correction of post-traumatic spinal column deformities occurs in patients who undergo the operation in the early post-traumatic period. While choosing treatment strategies for children, higher reparative opportunities, which provide early fracture consolidation, including those in faulty positions, should be considered. This study presents a case of surgical treatment for uncomplicated injury of the thoracic and lumbar spine, with long-term compression fragmental fracture of the L1 vertebra body in a 12-year-old child. Due to the long-standing character of the injury right thoraco-frenotomy was conducted with partial L1 vertebral body and resection of the adjacent discs, deformity correction of the thoracic and lumbar spine with a transpedicular system, and ventral spondylodesis with an autograft. This extensive intervention was justified by the peculiarities in the vertebral body damage and the post-traumatic segmental kyphotic deformity that resulted from delayed medical treatment. An anterior approach was chosen to achieve immobilization at the site of the damage before correction using the transpedicular system. Surgical correction of long-term spinal injuries in children, with the use of a combined approach, is usually laborious and traumatic. The prevention of rigid post-traumatic spine deformities with the help of timely diagnostics and appropriate treatment, including surgery, should be a priority to prevent such cases.

Introduction

Due to the recent rise in the number of domestic and traffic injuries, there is an increase in the number of patients with spinal cord injuries [1-3], including children with vertebral fractures [2-5]. Further, the annual increase in the number of patients from this age group is a noteworthy trend. To date, the incidence of spinal injuires approaches 10% of all victims under the age of 18 years [6, 7]. The literature shows the unjustified exaggeration of conservative treatment possibilities for spinal injuries in children leading to unsatisfactory long-term outcomes [8,9].

In the case of children with conventional indications (compression fractures with reduced height of the anterior vertebral body by more than half, explosive fractures of vertebral bodies, and destruction of the capsular and ligamentous apparatus or articular disk in seat-belt injuries), surgical intervention is appropriate within the first week after injury [8,10]. In these cases, the best results from the correction of posttraumatic spinal deformities are achieved when patients undergo surgical intervention in the first few hours after the injury [9].

Aggressive surgical treatment in spinal cord injuries can result in poor outcomes due to inadequate decision-making [11,12]. One of the causes of complications is an incorrect assessment of the type of spinal injury and selection of surgical options for its treatment [10]. Mistakes in primary intervention in children and adolescents can further lead to the development of secondary deformities of the vertebral column, which requires further traumatic revision. The long-term existence of spinal deformity in a child is a risk factor for the development of psychosomatic disorders, sometimes delaying his social and physical development [13-15].

The apparent lack of reports in literature regarding surgical approaches in chronic vertebral injuries in a growing person’s body is our basis for presenting a case of a 12-year-old patient with a fractured first lumbar vertebral body.

Clinical case

On July 04, 2015, the parents of patient P, a male born in 2003, brought him to the Consultative and Diagnostic Department of the Saratov Research Institute of Traumatology and Orthopedics. At the time of presentation, the child complained of pain in the lumbar spine and fatigue. The pain was mostly stress-like in character and appeared on standing and sitting. His medical history showed that a year ago, a wooden advertisement billboard had fallen on him, after which he experienced pain in the lumbar spine that aggravated by motion. Being rural residents, the parents did not seek medical care. The child’s pain was significantly reduced 3 weeks after injury. During the beginning of the school year, the child noted an increase in pain severity when sitting, accompanied by fatigue. Over time, the frequency and severity of the pain increased. One year after the injury, the parents noticed that the child preferred to lie down, did not play outdoor games, and grew tired quickly during physical exertion; this prompted them to seek medical advice. Personal medical information is published with the written consent of the patient’s parents.

The boy was asthenic but had normal bodily proportions. He moves without additional support but with his torso leaning forward. There was marked smoothing of the thoracic kyphosis and lumbar lordosis, but the spine was correctly positioned in the frontal axis. There were functional limitations in the lumbar spine’s range of motion, with flexion, extension, lateral tilt, and rotation at 25°, 15°, 25°, and 5°, respectively. The spinous process of L1 vertebra was visible. Kornev’s symptom was present at this level. CT examination revealed a clinoid deformation of the L1 vertebral body, which was unevenly sclerotic, with fragmented dorsal part. The height of the anterior column was primarily reduced and measured 9.2 × 11.4 × 18.2 mm. A kyphotic segmental deformity was observed at the level of the fracture. A deformation of the spinal canal was also noted with compression of the dural sac due to the displacement of a few fragments of the L1 vertebral body by up to 2.2 mm (Fig. 1). These findings indicated an incorrectly fused compression and comminuted fracture of the L1 vertebral body.

Based on the patient’s complaints, medical history, and the radiological findings, he was diagnosed with chronic uncomplicated injury of the thoracolumbar transition with an incorrectly fused compression and comminuted fracture of L1 vertebral body, pathological segmental kyphosis, and resistant pronounced vertebral pain syndrome. On July 08, 2015, the boy was hospitalized at the Institute’s Department of Traumatology and Orthopedics No. 3 (case history No. 3474). The following three-stage surgery was performed the following day: right thoraco-frenotomy with partial resection of the L1 vertebral body and adjacent intervertebral discs, correction of the thoracolumbar transition deformation using a transpedicular system (TPS), and ventral fusion with autologous bone. The three-stage surgery lasted 3 h and 20 min with an estimated blood loss of 200 mL.

Histopathological results

As a result of surgical intervention, we had an opportunity to evaluate the “quality” of bone resected from a 12-year-old child with a high level of homeostasis a year after injury. The L1 vertebral body with multiple fragments was delivered to the morphological laboratory.

The bone tissue of the vertebrae was fixed in 10% neutral formalin and then decalcified in a 12% nitric acid solution. The tissue was dehydrated in a battery of alcohols of increasing concentration and embedded in paraffin wax. Serial sections with a thickness of 5-7 microns were made from paraffin blocks, which were stained with hematoxylin and eosin using the main basic method after deparaffinization. Dehydrated and differentiated preparations were made in balsam under the cover glass.

The analysis of serial preparations of the vertebral body structures revealed a wide cortical layer with clearly delineated internal and external parts. To assess the bone’s “quality,” its microarchitecture (trabecular meshwork) and matrix structure were studied. A search for superficial and/or interstitial defects of mineralization and changes in parameters of bone formation (osteoid) was conducted. We investigated the status of various matrix elements, the parameters of the microarchitecture of the trabecular meshwork, trabecular thickness, and their separation and number; indicators reflecting the width of trabeculae, the distance between them, and the density of their allocation were also studied [16,17]. In areas of trabecular branching, we assessed the state of connection (nodes) and the ends of the trabeculae to study the topological properties of the trabecular meshwork and the extent of the so-called conjunctivity. In addition, we studied the peculiarities of mineralization (total, local, and interstitial), as well as the condition of osteoid formation.

We noted an increase in the density and “unusual pattern” of trabeculae on separate sites of the bone (perhaps, this was the former microfractures). In all fields of view, blood in intertrabecular spaces was observed. Blood marrow was intact.

Results of postoperative imaging

The patient’s condition after surgical treatment, which included correction of spinal deformity, partial resection of L1 vertebral body, corporodesis with autologous bone, and transpedicular fixation system at the level of spinal segments T11-L3, is shown in Fig. 2.

The position of the graft and metal structure is satisfactory. The result of the postoperative CT scan is shown in Fig. 1.

The patient’s postoperative period was normal. He could stand on the second day and was discharged for outpatient follow up on the 12th day. Dynamic observation at 3 and 6 months after surgery revealed a complete regression of vertebrogenic pain. A lag in body weight and growth compared with peers was not observed. There was no instability or loss of correction of the steel structures, and anterior bone block formation was noted.

Discussion

The restoration of the shape of vertebra and its function with conservative treatment after spinal injury in children is rare. In addition, the spine of a child cannot be regarded as a smaller version of the adult spine. When planning intervention, it is essential to consider age-specific sizes and orientations of the arches and facets in space. Experimental and clinical studies have shown [18] that the specific biological response of a growing spine to rigid pedicle fixation allows the use of the latter in children. In general, the forces of growth do not exceed the holding force of segmental pedicle screws in the actively growing spine, and the longitudinal growth of the vertebrae occurs even within the zone of fixation. Such a biological response of the immature spinal column to the segmental pedicle system is probably one of the reasons for the favorable clinical results with its use in children within the early period after injury. Further, conducting regular monitoring is necessary to exclude late complications after spinal fusion. It is essential to consider the high reparative ability of the spine in children that results in early consolidation of the fractures, even in abnormal positions.

In the early period after injury, the optimal treatment for patient P would have been transpedicular fixation with short segments. However, a surgical approach was selected due to the presence of vertebral body deformation and posttraumatic kyphotic segmental deformation caused by delayed medical attention. The ventral phase of the operation was necessary to raise the deformed area before performing a correction using the TPS [3]. The weight of a small child is sufficient for supporting the properties of the TPS, and quick remodeling of the autograft helps to avoid the need in MESH implants. In addition, according to the literature, the best material to ensure the formation of a strong ventral bone block in pediatric patients is autologous bone [9].

Conclusion

Given that such spinal injuries in children are often conservatively treated at present, the description of this case can be of interest for practical medicine. Surgical interventions with a multi-stage approach for chronic spinal injuries in children are frequently time-consuming and are accompanied by significant surgical trauma; therefore, it is crucial to prevent posttraumatic spine deformities by timely diagnosis and adequate treatment including surgical methods.

Funding information and conflicts of interest

The work was conducted as part of the research that was approved in FSBI Saratov Research Institute of Traumatology and Orthopedics.

The authors declare no potential conflicts of interest related to the publication of this article.

Vladimir V Zaretskov

Saratov Scientific and Research Institute of Traumatology and Orthopedics

Author for correspondence.
Email: fake@eco-vector.com

Russian Federation MD, PhD, professor, leading research associate. Saratov Scientific and Research Institute of Traumatology and Orthopedics.

Vladislav B Arsenievich

Saratov Scientific and Research Institute of Traumatology and Orthopedics

Email: fake@eco-vector.com

Russian Federation MD, PhD, chief of the department of traumatology and orthopedics No 3. Saratov Scientific and Research Institute of Traumatology and Orthopedics.

Sergey V Likhachev

Saratov Scientific and Research Institute of Traumatology and Orthopedics

Email: Likha4@mail.ru

Russian Federation MD, PhD, orthopedic and trauma surgeon. Saratov Scientific and Research Institute of Traumatology and Orthopedics

Alexey E Shul’ga

Saratov Scientific and Research Institute of Traumatology and Orthopedics

Email: fake@eco-vector.com

Russian Federation MD, PhD, senior research associate. Saratov Scientific and Research Institute of Traumatology and Orthopedics.

Sergey V Stepukhovich

Saratov Scientific and Research Institute of Traumatology and Orthopedics

Email: fake@eco-vector.com

Russian Federation MD, PhD, orthopedic and trauma surgeon. Saratov Scientific and Research Institute of Traumatology and Orthopedics.

Nina V Bogomolova

Saratov Scientific and Research Institute of Traumatology and Orthopedics

Email: fake@eco-vector.com

Russian Federation MD, PhD, professor, corresponding member of RANS, AMS. Saratov Scientific and Research Institute of Traumatology and Orthopedics.

  1. Норкин И.А., Баратов А.В., Федонников А.С., и др. Значимость анализа медико-социальных параметров травм позвоночника в организации специализированной медицинской помощи // Хирургия позвоночника. - 2014. - № 3. - С. 95-100. [Norkin IA, Baratov AV, Fedonnikov AS, et al. The importance of analysis of medical and social parameters of traumatic spine injuries for organization of specialized medical care. Spine Surgery. 2014;3:95-100. (In Russ).]. doi: 10.14531/ss2014.3.95-100.
  2. Виссарионов С.В., Баиндурашвили А.Г., Кокушин Д.Н., и др. Организация помощи детям с нестабильными и осложненными переломами позвоночника в Санкт-Петербурге // Хирургия позвоночника. - 2014. - № 4. - С. 146-150. [Vissarionov SV, Baindurashvili AG, Kokushin DN, et al. Organization of medical care to children with unstable and complicated vertebral fractures in St Petersburg. Spine Surgery. 2014; 4:146-150. (In Russ).].
  3. Зарецков В.В., Норкин И.А., Арсениевич В.Б., и др. Хирургическое лечение повреждений и заболеваний позвоночника: практическое руководство для врачей. - Рыбинск, 2007. - 110 с. [Zareckov VV, Norkin IA, Arsenievich VB, et al. Khirurgicheskoe lechenie povrezhdenij i zabolevanij pozvonochnika. Prakticheskoe rukovodstvo dlya vrachej. Rybinsk; 2007;110 p. (In Russ).].
  4. Sayama C, et al. A review of pediatric lumbar spine trauma. Neurosurgical focus. 2014;37(1):E6. doi: 10.3171/2014.5.focus1490.
  5. Rush JK, Kelly DM, Astur N, et al. Associated injures in children and adolescents with spinal trauma. J Pediatr Orthop. 2013;33:393-397. doi: 10.1097/bpo.0b013e318279c7cb.
  6. Grigoriou E, Dormans JP. Pediatric Spine Trauma. The Growing Spine. Springer Berlin Heidelberg; 2016:359-381. doi: 10.1007/978-3-662-48284-1-21.
  7. Рерих В.В., Борзых К.О., Рахматиллаев Ш.Н. Хирургическое лечение взрывных переломов грудных и поясничных повонков, сопровождающихся сужением повоночного канала // Хирургия позвоночника. - 2007. - № 2. - С 8-15. [Rerikh VV, Borzykh KO, Rakhmatillaev SHN. Surgical treatment of burst fractures of the thoracic and lumbar spine accompanied with spinal canal narrowing. Spine Surgery. 2007;2:8-15. (In Russ).].
  8. Виссарионов С.В., Баиндурашвили А.Г., Мушкин А.Ю., и др. Хирургическое лечение взрывных переломов тел позвонков грудного и поясничного отделов у детей // Травматология и ортопедия России. - 2006. - № 1 (39). - С. 10-15. [Vissarionov SV., Baindurashvili AG, Mushkin AY, et al. The surgical treatment of burst compression fractures of thoracic and lumbar parts of spine in children. Traumatology and orthopedics of Russia. 2006;39(1):10-15. (In Russ).].
  9. Onen MR, Naderi S. Pediatric Spine Trauma. J Spine. 2015;4(2). doi: 10.4172/2165-7939.1000211.
  10. Шульга А.Е., Зарецков В.В., Островский В.В., и др. К вопросу о причинах развития вторичных посттравматических деформаций грудного и поясничного отделов позвоночника // Саратовский научно-медицинский журнал. - 2015. - Т. 11. - № 4. - С. 570-575. [Shulga AE, Zareckov VV, Ostrovskij VV, et al. Towards the causes of secondary post-traumatic deformations of thoracic and lumbar spine. Saratov Journal of Medical Scientific Research. 2015;11(4):570-575. (In Russ).].
  11. Бердюгин К.А., Чертков А.К., Штадлер Д.И., Бердюгина О.В. О неудовлетворительных исходах транспедикулярной фиксации позвоночника // Хирургия позвоночника. - 2010. - № 4. - С. 19-24. [Berdyugin KA, Chertkov AK, Shtadler DI, Berdyugina OV. On Unsatisfactory Outcomes of Transpedicular Fixation. Spine Surgery. 2010;4:19-24. (In Russ).].
  12. Hempfing A, Zenner J, et al. Restoration of sagittal balance in treatment of thoracic and lumbar vertebral fractures. Orthopade. 2011;40(8):690-702.
  13. Пятакова Г.В., Виссарионов С.В., Овечкина А.В. Психологические факторы риска психосоматических нарушений у детей с идиопатическим сколиозом // Хирургия позвоночника. - 2015. - Т. 12. - № 1. - С. 21-26. [Pyatakova GV, Vissarionov SV, Ovechkina AV. Psychological risk factors of psychosomatic disorders in children with idiopathic scoliosis.Spine Surgery. 2015;12(1):21-26. (In Russ).].
  14. Зарецков В.В., Арсениевич В.Б., Рубашкин С.А. Хирургическая коррекция сколиотической деформации в условиях продолжающегося роста больного //Хирургия позвоночника. - 2007. - № 3. - С. 36-38. [Zaretskov VV, Arsenievich VB, Rubashkin SA. Surgical correction of scoliotic deformation in a patient with continuing growth. Spine Surgery. 2007;3:36-38. (In Russ).].
  15. Норкин И.А., Шемятенков В.Н., Зарецков В.В., и др. Особенности психофизиологического статуса детей и подростков со сколиозом на разных этапах лечения // Хирургия повоночника. - 2006. - № 4. - С. 8-12. [Norkin IA, Shemyatenkov VN, Zaretskov VV, et al. Peculiarities of Psychophysiology of Children and Adolescents with Scoliosis at Different Stages of Treatment. Spine Surgery. 2006;(4):8-12. (In Russ).].
  16. Денисов-Никольский Ю.И., Миронов С.П., Омельяненко Н.П., Матвейчук И.В. Морфофункциональные характеристики кости как органа // Актуальные проблемы теоретической и клинической остеоартрологии. - 2005. - С. 15-35 [Denisov-Nikolskij YI, Mironov SP, Omelyanenko NP, Matvejchuk IV. Morfofunkcionalnye kharakteristiki kosti kak organa. In: Aktualnye problemy teoreticheskoj i klinicheskoj osteoartrologii. 2005. P. 15-35. (In Russ).].
  17. Богомолова Н.В., Норкин И.А., Шульга А.Е., и др. Репаративный остеогенез позвонков в разные сроки после травмы // Сб. «Травматология и ортопедия в России: традиции и инновации». - Саратов, 2015. С. 48-50 [Bogomolova NV, Norkin IA, Shulga AE, et al. Reparativnyj osteogenez pozvonkov v raznye sroki posle travmy. In Sb. “Travmatologiya i ortopediya v Rossii: tradicii i innovacii”. Saratov; 2015, P. 48-50 (In Russ).].
  18. Ким В.Д., и др. Влияние сегментарной транспедикулярной фиксации на активно растущий позвоночник: длительное экспериментальное исследование // Хирургия позвоночника. - 2005. - № 1. - С. 105-111. [Kim VD, et al. The Effect of Segmental Pedicle Screw Instrumentation on Actively Growing Spine: A Long-term Experimental Study. Spine Surgery. 2005;1:105-111. (In Russ).].

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CrossRef     2 citations

  • Korshunova GA, Shul'ga AE, Zaretskov VV, Smol'kin AA. Functional state of spinal cord and its radices in patients with thoracic and lumbar spine injuries. Zhurnal nevrologii i psikhiatrii im. S.S. Korsakova. 2019;119(2):44. doi: 10.17116/jnevro201911902144
  • Shul’ga AE, Zaretskov VV, Korshunova GA, Smol'kin AA, Sumin DY. Surgical treatment of gross posttraumatic deformations in thoracic spine. Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2017;5(3):80. doi: 10.17816/PTORS5380-87

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Copyright (c) 2016 Zaretskov V.V., Arsenievich V.B., Likhachev S.V., Shul’ga A.E., Stepukhovich S.V., Bogomolova N.V.

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