Fig. 12.1 Motorcycle accident with burst fracture of the first lumbar vertebral body and approx. 30° buckling
Fig. 12.2 Correction and stabilisation with a vertebral body replacement implant and bone cement
In general, concomitant neurological injuries are not commonly associated with recently acquired, traumatic vertebral body fractures that occur after accidents. Since these injuries are sufficiently stable, they can be conservatively treated, i.e. without surgery. Nonoperative vertebral fracture treatment includes an adapted medication regime to treat pain, a short-term period of physical rest and immobilization of the fracture with a corset or a plaster cast. Physiotherapy treatment is recommended at an early stage. The injured vertebral body usually heals after 2-3 months with good results.
Surgery is always necessary when acute vertebral fractures or dislocation fractures of the thoracic and lumbar spine are unstable or associated with concomitant neurological injuries. Combined bony injuries of one or more vertebral bodies (fractures), dislocations of vertebral joints (luxations) and discoligamentary injuries (rupture of discs and ligaments) often occur. In most cases, severe deformation with instability is seen. It is therefore important to restore the normal shape and function of the spine as best as possible. Immediate loading of the vertebral column (i.e. standing up soon after surgery) is a prerequisite for optimal healing and helps prevent long-term consequences.
The first example concerns a 50-year-old motorcyclist. He crashed at high speed with his motorbike while on holidays abroad and was seriously injured. After initial care at the accident site and transport to the nearest trauma hospital, it very quickly became clear that the pain in the area of the thoracic and lumbar spine was due to a burst fracture of the first lumbar vertebra (Fig. 12.1). An open fracture on the right lower leg as well as upper arm needed emergency surgery on the same day. The spine was temporarily immobilised with a plaster cast and stabilised externally.
After a few days, air ambulance services transported the patient home to the hospital of his choice for the treatment of the vertebral fracture.
Because the wedge-shaped malalignment of the first lumbar vertebral body increased despite plaster cast treatment, an operation was planned. Bone density measurement revealed that the patient’s bone quality was markedly reduced and therefore, bone cement reinforcement was needed.
The vertebral fracture is treated with a vertebral body replacement implant. The implant ensures sufficient stability, so plaster cast treatment can be discontinued (Fig. 12.2). The risk of breakage or unwanted screw loosening is minimised by reinforcing the implant construction with bone cement. The malalignment caused by the accident is corrected. Small incisions are made in the skin of the back (percutaneous) as well as the lateral side of the chest (thoracoscopy), so that aftercare is easier and the patient needs less pain medication.
Fig. 12.3 Incomplete upper L1 burst fracture with deformation after a fall from the roof
Fig. 12.4 Corrective surgery with short-range screw connection (T12-L1)
Fig. 12.5 Replacement of the defective disc with bone transplantation (green arrow)
Fig. 12.6 Stable healing after screw removal 1 year after the accident
This second example shows a 35-year-old father who fell from a height while doing some roofing work and sustained a fracture of the first lumbar vertebra (Fig. 12.3). The vertebral fracture did not cause any neurological problems. The patient declined the initially recommended 3-month treatment with a plaster corset, since he could not afford taking long periods of time off from his work or private life. As the sole breadwinner and father of two young children, this treatment was absolutely out of the question for him. A very short treatment period and rapid rehabilitation were very important.
The alternative is a spine operation for correcting the deformation and stabilisation. Since the patient is otherwise healthy and there were no further reasons for not undergoing the surgery, the procedure was planned for the next day. Bone fragments that constrict the spinal canal were removed along with the defective disc via a single posterior approach (Fig. 12.4 and Fig. 12.5). The deformation and buckling is corrected with four screws and held in position. The injured vertebral body (L1) is complete in its’ lower half, so that the screws have good hold and support in the intact bone.
The advantages of this method are that only a single access point is required with a very short instrumentation distance (T12-L1 monosegmental spondylodesis).
Rehabilitation begins on the first day after surgery. The patient gets up and receives physiotherapy treatment. One year later and once complete bone healing is seen in the X-ray examinations, the implants are removed again (Fig. 12.6).