Thoracolumbar junction translation injury in a patient with ankylosing spondylitis, a case report

Abstract

Introduction

The thoracic spine is stable because of kyphotic alignment, rib cage, and costovertebral joints. Any compression or kyphosis in the thoracic spine always causes spinal cord injury.

Clinical case

A 47-year-old male with complaints of back pain 1 day prior to admission, after he sustained a motorbike crush and landed on his back. The pain, radiates to both limbs, associated with severe spasms, numbness, and weakness in his lower extremities, however no incontinence. No other associated injuries were reported.

25 years ago he had a history of tuberculosis of the spine with progressive deformity of the back, he was treated medically without surgery.

On examinations: Gibbus at T11-L1, with hyper-pigmented post-inflammatory skin and an easily palpable spine, power 1/5 right and 2/5 left lower limbs, Sensation and bulbocarvenosus reflex were intact. Upper limbs were neurologically intact.

All laboratory investigations including FBP, ESR, Electrolytes, renal and liver function tests were all within normal range.

After radiological imaging, a final diagnosis of Spinal Cord Injury, ASIA C. AO classification type T12-L1:C/T9-L1:A4/N3/M2 was made.

He was kept on a thoracolumbar corset 6 weeks after being initiated on spine protocol. He was discharged 8 weeks this time patient had no back pain but no improvement was noted neurologically.

After a year of thoracolumbar corset and physiotherapy, he reported no more back pain, no numbness to lower limbs, and power 3/5 right and 4/5 left lower limbs, with intact sensation. However, no changes were observed radiologically.

Clinical discussion

Due to the instability of fracture-dislocation, surgical treatment is recommended to realign the spine but for this case with back deformity and fractured vertebra bodies, it is best not to temper with reduction and fixation as it would further worsen the neurological deficit of the patient, during maneuvers while doing the reduction.

Conclusion

Fracture-dislocation of the thoracic spine can impact the physical and mental well-being of the patients. Surgical fixation and instrumentation are ideal but in cases where surgical intervention would further impair the neurological function of the patient conservative management is the goal.

Highlights

• •thoracic spinal fracture-dislocation is usually accompanied by complete neurological dysfunction and multiple costal fractures
• •47years male patient with a complete anteroposterior dislocation of the thoracic vertebral following a trivial injury
• •25years history of Ankylosing spondylitis secondary to Tb-spine
• •Treated conservatively with thoracolumbar corset

1. Introduction

The thoracic spine is stable because of kyphotic alignment, rib cage, and costovertebral joints. The spinal canal is narrow; there is little free space between the cord and the osseous ring [1]. The thoracic spinal cord also has a relatively sparse blood supply [2]. Therefore, any compression or kyphosis in the thoracic spine always causes spinal cord injury which is usually severe in the upper thoracic spine [3].

There are only a few cases of severe thoracic spinal fracture-dislocation without neurological symptoms in the literature. Only a powerful force can cause fracture-dislocation of the thoracic spine concomitant with life-threatening injuries [4]. Severe upper thoracic spinal fracture-dislocation is usually accompanied by complete neurological dysfunction and multiple costal fractures, but a few patients with thoracic spinal fracture-dislocation present non-neurological symptoms, and patients with thoracic spinal fracture-dislocation without neurological symptoms and costal fractures are frighteningly rare [3,5]. Here, we report a patient with a back deformity that existed 25 years ago due to TB of the spine, currently with multiple level vertebral body fractures, Spinal Cord Injury, ASIA C. AO classification type T12-L1:C/T9-L1:A4/N3/M2, who was managed conservatively with a thoracolumbar corset as surgery would have worsened his neurological status. This case report has been reported in line with the SCARE criteria [6].

2. Case

A 47-year-old male was admitted to the orthopaedic department with complaints of back pain 1 day prior to admission, after he sustained a motorbike crush and landed by his back. Soon after the incident, he experienced back pain, radiating to both limbs, associated with severe spasms, numbness and weakness to his lower extremities, however no incontinence. No any other associated injuries were reported.

Furthermore, 25 years ago he had a history of tuberculosis of the spine with progressive deformity of the back (gibbus formation and kyphosis), he was only kept on anti-TBs medications for a year without surgical correction of the back deformity. However, he had no neurological deficits. No any other history of chronic diseases.

On examination; He was fully conscious, with a GCS 15/15, afebrile, not pale, not jaundiced, and no lower limb oedema. Vitals; Temp = 36.5, BP = 110/70, PR = 60, Spo2 = 99 RA, RBG = 7 mmol/l, RR = 16c/min.

Local examinations: Gibbus formation at the thoracic level with hyper-pigmented post-inflammatory skin and an easily palpable spine (Fig. 1).

Fig. 1.

Preexisting beck deformity.

Gibbus formation at the thoracic level with hyper-pigmented post-inflammatory skin and an easily palpable spine.

Neurological examination; Power to the right lower limbs was 1/5, to the left lower limb was 2/5, Sensation and bulbocarvenosus reflex were intact. Upper limbs were neurologically intact. (American Spinal Injury Association) classification – ASIA C.

All laboratory investigations including FBP, ESR, Electrolytes, renal and liver function tests were all within normal range.

X-ray revealed: ankylosing spondylitis with calcified ligaments holding the vertebral column; laterally, anteriorly, and posteriorly, with 100 % dislocation at T11/T12 (Fig. 2).

Fig. 2.

Initial plain radiography.

AP and lateral plain radiography of the thoracolumbar spine, showing ankylosing spondylitis with calcified ligaments holding the vertebral column; laterally, anteriorly, and posteriorly, with 100 % dislocation at T11/T12.

CT scan revealed; severe burst fracture involving T9, T10, T11, T12, and L1 with 100 % anterolisthesis of T12/L1 (Fig. 3).

Fig. 3.

Initial CT scan image.

The sagittal view image shows a severe burst fracture involving T9, T10, T11, T12, and L1 with 100 % anterolisthesis of T12/L1.

A radiological diagnosis of Translation injury at T12/L1, with Burst fractures of vertebral bodies of T9 to L1, was made.

Final diagnosis of Spinal Cord Injury, ASIA C. AO classification type T12-L1:C/T9-L1:A4/N3/M2 was made.

Despite these multiple-level vertebra fractures, the patient was treated conservatively and kept on a Thoracolumbar corset (Fig. 4), because we outweighed the risks vs benefits, as our patient had incomplete spinal cord injury with power right lower limb1/5 and 2/5 left lower limb and sensation was intact, with such back deformity (gibbus and kyphosis) that was present 25 years ago prior this recent injury, any surgical manipulation would have worsened his neurological function, therefore he was kept on thoracolumbar corset 6 weeks after being initiated on spine protocol, i.e., bed rest with 2 hourly turnings, catheterization, oral hygiene, low molecular heparin, amitriptyline and pregabalin for neuropathic pain, spasmolytics(tizanidine), strong analgesics(meloxicam), and rehabilitation with physiotherapy and occupational therapy.

Fig. 4.

Fabricated thoracolumbar corset.

He was then discharged 8 weeks later with instruction to adhere wearing the thoracolumbar corset, medications pregabalin and tizanidine, also instructed to attend monthly clinic follow-ups, however, this time patient had no back pain but no improvement was noted neurologically.

On the follow-up visit after a year of thoracolumbar corset and physiotherapy, the patient reported no more back pain, no numbness to lower limbs, and power to the right lower limb was 3/5, and left lower limb was 4/5, with intact sensation. However, no changes were observed radiologically (Fig. 5, Fig. 6).

Fig. 5.

A year follow of plain radiography.

AP and lateral plain radiography of the thoracolumbar spine, showing calcified ligaments holding the vertebral column; laterally, anteriorly, and posteriorly, with grade 4 anterolisthesis at T11/T12.

Fig. 6.

A year CT follow-up.

The sagittal view image shows a severe burst fracture involving T9, T10, T11, T12, and L1 with 100 % anterolisthesis of T12/L1.

3. Discussion

Fracture-dislocation of the thoracic spine is a common result of high-velocity motor accidents or crash injuries. Such spinal injury is the most unstable type with failure of all three columns. Dural tears and paraplegia often accompany such injuries [7]. Neural injury is caused by bone fragments and/or encroachment of the spinal canal due to translational displacement [1,8,9]. Classification of fracture-dislocations of the thoracic spine has been accomplished according to different mechanisms [10]. Magerl considered slice fractures to be more dangerous than rotational shear oblique fractures about spinal cord compression because of the shear in the sagittal direction [3]. It is critical for clinical practitioners to diagnose a patient with fracture-dislocation of the thoracic spine with no paraplegia or severe neurological deficits, as inappropriate maneuvering of the spine may lead to dangerous impairments of the spinal cord. Due to the instability of fracture-dislocation, surgical treatment is recommended to realign the spine and prevent secondary injury to the spinal cord [4,5,7,11]. In this case, surgical treatment was not done as we outweighed the risks vs benefits, as our patient had incomplete spinal cord injury with power right lower limb1/5 and 2/5 left lower limb and sensation was intact, with such back deformity (gibbus and kyphosis) that was present 25 years ago prior this recent injury, any surgical manipulation would have worsened his neurological function. Conservative management was applied to this rare thoracolumbar fracture dislocation patient who was kept on a thoracolumbar corset also another treatment modality is continuous halo-femoral traction to reduce the dislocation was an optional treatment for this patient but was not applied [7,12].

4. Conclusion

Fracture-dislocation of the thoracic spine can impact to physical and mental well-being of patients. For patients with severe neurological deficits, it is necessary to provide them with proper management, after thorough examination and investigations. For cases with previous deformities like ours, though surgery is usually mandatory for such cases, for the case of neurological deficits and high cost of surgical intervention, it is best not to temper with reduction and fixation as it would further worsen the neurological deficit of the patient during the maneuver while doing the reduction. In addition, conservative management with bracing should also go hand in hand with proper nursing care, specifically with bed turning, oral and genital hygiene, physiotherapy, occupational therapy, psychological support, and oral medications such as ant-pain, antispasmodics, and prophylactic DVT management. All these should aim to prevent complications such as pressure sores, urinary tract infections, depression, etc.

Ethical approval

The ethical approval was obtained from author institutions.

Funding

This case study did not receive any specific funding.

Author contribution

Dr. Daniel Rovelt Mwanga prepared the case and the literature behind the case.

Dr. Peter Magembe Mrimba, Dr. Mathias Switbert Ncheye, Dr. Godlisten Samwel Kawiche, Dr. Honest Herman Massawe, reviewed each step and also did grammar and spelling checks during care report writing

Dr. Faiton Ndesanjo Mandari, Main Supervisor and Main reviewer of this case study.

Guarantor

Dr. Daniel Rovelt Mwanga is the guarantor of this work

Research registration number

N/A

Informed consent

The informed consent was obtained and signed by patient.

Conflict of interest statement

None declared.