History & Physical: A 23-year-old male was involved in a rollover injury sustained when his open air all-terrain-vehicle flipped over while advancing up a steep incline. He noted a severe episode of lower back pain, but denied any loss of consciousness, motor or sensory function, or bowel or bladder dysfunction. The physical examination noted intact motor function with decreased sensation to pinprick and light touch over the right lateral thigh. Rectal tone was intact and downward Babinski as well as no clonus was elicited in the lower extremities.
Imaging: CT images note a L2 burst fracture with approximately 80% canal compromise along with bilateral interarticular and left laminar fractures with contrast extravasation at the L2-L3 level. MRI studies showed disruption of the supraspinal and ligamentum flavum.
1. The diagnosis of this L2 injury is most likely:
2. The treatment option of choice in this patient is:
3. The optimal surgical option offered to this patient would be:
4. The optimal surgical approach to a bony decompression of this lesion would be:
5. The optimal bone placement for spinal fusion to be offered to this patient would be:
6. The optimal spinal instrumentation option offered to this patient would be:
7. Please provide any comments or suggestions regarding management of this case:
"I would carry out decompressive laminectomy (L2-3), repair of dural tear and insertion of pedicle screws (at least 1 level above and below)."
"The spinal cords need to be decompressed. I believe this will provide the most stable result. The patient being young and active will hopefully heal quickly and have a good load bearing construct."
"I would be concerned about post-op CSF fisula, especially from anterior. I would still accomplish the decompression (and spine reconstruction graft / instrumentation) from anterolateral but would be prepared to deal with dural tear by perhaps not removing 100% of fragment/PLL and using fibrin glue and placing a lumbar subarachnoid drain if I saw CSF. I would either augment the anterior strut graft / instrumentation with percutaneous pedicle screws only (short level construct) or (if open) pedicle screw short construct AND posterolateral fusion. Being young and (assumingly) healthy, I don't think a posterior graft is absolutely necessary like the posterior stabilization is (due to posterior ligamentous disruption)."
"We did immediate to make fast mobilization."
"Posterior exploration necessary for possible neural entrapment, followed by transpedicular decompression and posterior fusion."