History of Present Illness: A 39 year-old woman who sustained major traumatic injuries presents for outpatient follow-up complaining of severe persistent midthoracic pain. She was struck by a falling tree while jogging three months prior, and suffered a pneumothorax, pulmonary contusions, fractures of the left lower extremity, and thoracic spine fractures. MRI and CT scans at that time revealed fractures of T8 and T9 [Figures 1(a) and (b) below], and she was treated in a rigid TLSO. She was subsequently discharged into an inpatient rehabilitation setting. Currently, she denies any new motor or sensory changes, nor bowel or bladder problems.
Past Medical, Social, and Family History: She reports no significant past medical or surgical history. She currently is not taking any medications and is a non-smoker. She also denies a personal or family history of cancer.
Physical Examination: Physical exam noted intact motor exam in all four extremities with 5/5 strength, with sensory exam intact to light touch and pin prick. Deep tendon reflexes were 3+ and symmetric. Rectal tone was normal.
Radiological Studies: She underwent further X-ray, CT and MRI studies of the thoracic spine [Figures 2(a), (b), and (c) below]. There evidence of osteopenia noted on the X-ray, and follow-up bone mineral density scan reveal a T-score of -1.6.
1. The initial management of the thoracic spine fractures [Figures 1(a) and (b)] would be:
2. Initial surgical interventions of the thoracic spine fractures [Figures 1(a) and (b)] would be:
3. Timing of surgical intervention for the initial spine fractures [Figures 1(a) and (b)]:
4. Current management of the thoracic spine fractures [Figures 2(a), (b), and (c)] would be:
5. Current surgical interventions of the thoracic spine fractures [Figures 2(a), (b), and (c)] would be:
6. Timing of surgical intervention for the current spine fractures [Figures 2(a), (b), and (c)]:
7. Should her osteopenia be treated prior to surgery?
8. Please provide any comments or suggestions regarding management of this case>
CT scan axial plane at the fracture level and bone densitometry
Patient should undergo a lateral corpectomy with an expandable titanium cage such as Vertespan supplemented with Antares or Vantage vertebral body screw/plate.
dear collegues: I think in first imaging we had a compression wedge fx With posterir element injuries, that disruption of bony and ligamentous element and there was an indication for surgical stabilization.
dear collegues: I think in first imaging we had a compression wedge fx With posterior element injuries, that disruption of bony and ligamentous element and there was an indication for surgical stabilization.
Interesting point in figures1 is a extraordinary kyphosis that is not match with the fractures' shape.And I'm curious about history of new accidet!Anterior Stabilization with strut and fixation.
it would be helpful to see T2 sagittal and axial images to assess canal compromise and ligamentous injury. it may be useful to see and extension film to see how much or her kyphosis reduces. although her osteopenia will factor on the fusion and quality of purchase with the instrumentation, i am not sure if waiting for her treatment is the correct thing. I am more concerned about the obvious progression and early myelopathy if her reflexes are pathological(??babinski/clonus present??
Interesting case which brings in management issue of osteopenia, medical, surgical (standard and minmally invasive aproaches)