Traumatic coronal spondyloptosis of the spine: case report and review of the literature

Abstract

Background

Traumatic coronal spondyloptosis (TCS) describes complete coronal subluxation of a vertebral body relative to an adjacent segment secondary to high-energy trauma. TCS commonly associates with orthopedic, intraabdominal, and thoracic solid organ injury, nuancing overall management. Surgery is indicated for subluxation reduction, deformity correction, and stabilization. Thoracolumbar junctional TCS has a sparse description in the literature. As a complex deformity encounterable by spinal surgeons regularly managing spinal cord injury and spinal trauma, appropriate surgical management requires an understanding of the various operative approaches as well as available intraoperative technical adjuncts. We accordingly discuss our surgical technique for subluxation reduction, deformity correction, and stabilization, and review approaches employed for similar reported cases.

Case Description

We describe the case of a 36-year-old female presenting to Temple University Hospital after an automotive versus pedestrian injury. She demonstrated gross traumatic spinal deformity, secondary intraabdominal injuries, and was paraplegic on initial neurologic examination. After abdominal solid organ injury management and hemodynamic stabilization, the patient underwent standard pedicle screw fixation spanning the thoracolumbar junction from T9–L4, with complete coronal spondyloptosis correction achieved via manual caudal reduction after completion of a single-level unilateral facetectomy at T12–L1.

Conclusions

This complex traumatic spinal deformity underwent reduction and stabilization via techniques accessible to most spinal surgeons. Paraplegia on presentation obviated the need for intraoperative neuromonitoring and enabled muscle relaxant use to facilitate deformity correction. When requiring either neuromonitoring or a higher magnitude of distraction, we advise usage of distraction instrumentation and consideration of vertebrectomy for safe reduction. Understanding the variety of surgical options in the operative management of TCS is critical for safe and effective correction.

Highlight box.

Key findings

• Case description of a traumatic coronal spondyloptosis at the thoracolumbar junction after a high-speed motor vehicle accident requiring multidisciplinary management.

• An approach accessible to most spinal surgeons corrected the complex multiplanar deformity in combination with standard intraoperative adjuncts.

What is known and what is new?

• Traumatic spondyloptosis occurs after high-energy spinal trauma and describes complete subluxation of two adjacent vertebral bodies relative to one another. Sagittal spondyloptoses are reported, with surgical solutions including both anterior, posterior, and combination approaches described. Coronal spondyloptoses are sparsely reported, and information on corrective approaches if encountered are needed.

• This case report provides step-wise review of key management decisions in the care of a patient with coronal spondyloptosis, including consideration of associated polytrauma. A posterior-only technique accessible to most spinal surgeons regularly managing spinal trauma and spinal cord injury was suitable, and highlighted potential operative adjuncts for deformity correction guided by the patient’s neurologic status.

What is the implication, and what should change now?

• Neurologic status on presentation is critical, and guides subsequent multidisciplinary management and timing of surgical intervention.

• Paraplegia enables use of muscle relaxant and paralytic during intraoperative deformity reduction.

• Hemodynamic and abdominal solid organ management can optimize surgical correction of traumatic spondyloptosis in the setting of paraplegia.

Introduction

Vertebral column injuries most commonly arise secondary to high-energy trauma and carry significant morbidity (1-3). The thoracolumbar junction transitions the relatively rigid thoracic spine to the more mobile lumbar spine, placing this particular region vulnerable to injury. Excess biomechanical force past the typical spinal load-bearing capacity initiates a primary injury involving fracture of the bony elements, ligamentous complex damage, and with potential to compromise the spinal cord and/or nerve roots. Variation in the specific applied force vectors notably generate complex fracture patterns, with rates of paraplegia on presentation after thoracolumbar fracture-dislocations approaching 80% in reported series (3-11). Secondary injury typically follows due to posttraumatic alterations in spinal cord perfusion, neuronal metabolic demand, inflammation, and mechanical instability (12).

In the United States, approximately 17,000 new cases of traumatic spinal cord injury are estimated to occur each year, and nearly 250,000 individuals live with residual disability. Epidemiologic studies show a clear male predominance, typical age range between 20–40 years old, and an overall increasing annual incidence. Of note, a public health review assessing the lifetime cost-of-illness for spinal cord injury in the Canadian healthcare system estimated the financial burden at nearly $336,000 per patient, not including the hospitalization cost secondary to commonly associated comorbidities, such as stress ulcers formation, decubitus wounds, or urinary tract infections (12,13).

Acute injury management requires first an assessment of all sustained injuries from a multidisciplinary perspective. Indeed, comorbid orthopedic and abdominal solid organ injuries are commonplace.

The primary goals of spinal surgery are preservation of neurologic function, restoration of spinal alignment, and prevention of further spinal deformity or neurologic compromise via decompression of any affected neural elements, subluxation reduction, and instrumented fusion. Correction of spinal instability expedites adjuvant treatments after spinal cord injury, such as rehabilitative therapy, given risks of significant in-hospital immobilization time.

The surgical approaches for spondyloptosis require understanding inciting mechanisms, typically secondary to late-stage degenerative changes or trauma. Planning reconstruction requires a thorough patient neurologic assessment, cross-sectional radiographic evaluation [e.g., computed tomography (CT), magnetic resonance imaging (MRI)] for multiplanar anatomic visualization of the completely subluxed vertebral body, identification of exact spinal location, consideration of complex fracture patterns, relevant comorbid injuries, and patient-specific factors impacting surgical risk. Anterior approaches via vertebrectomy or spondylectomy require abdominal exposure, traversing across potential coexisting injuries, and may provide incomplete standalone stabilization. Posterior pedicle screw and rod fixation, alone or in conjunction with an anterior approach, represent commonly employed techniques by spinal surgeons for other indications and can allow for a controlled, step-wise deformity correction.

We herein review previously described surgical approaches to TCS, and describe our unique case of a thoracolumbar junctional TCS at T12–L1. The patient presented after a high-speed motor vehicle accident, a commonly cited etiology for traumatic spinal cord injury, was paraplegic on arrival, and required a multi-level posterior instrumented fusion with intraoperative manual reduction for deformity correction, realignment, and spinal fixation. The patient notably also sustained multiple systemic, solid abdominal organ, and orthopedic injuries, highlighting practical management challenges and considerations in this context. We present this article in accordance with the CARE reporting checklist (available at https://jss.amegroups.com/article/view/10.21037/jss-25-74/rc).

Case presentation

A 36-year-old female presented to the emergency department of Temple University Hospital as a pedestrian struck by a high-speed motor vehicle. Upon initial trauma evaluation, she had a Glasgow Coma Scale (GCS) score of 15, and vital signs were notable for hypotension and tachycardia. The initial trauma survey revealed a thoracolumbar step-off, paraplegic neurologic exam, absent sensation below T12, and absent rectal tone, consistent with an American Spinal Injury Association (ASIA) Grade A injury. Spinal CT demonstrated a fracture-dislocation at the thoracolumbar junction, with coronal spondyloptosis of T12 on L1 (Figure 1). Further imaging revealed pancreatic transection, retroperitoneal hematoma, and contusions of the liver, kidney, and lung. She was maintained on strict spinal precautions and required emergent exploratory laparotomy secondary to worsening hypotension and her known intra-abdominal injuries. The displaced superior L1 endplate in the left upper abdominal quadrant was palpable. Although spinal reduction was considered at this time, multidisciplinary discussion advocated for deferred management to allow for medical and hemodynamic optimization, control of retroperitoneal hemorrhage, and to allow for prone positioning.

Figure 1.

Coronal orientation of complete subluxation between T12 and L1 utilizing various radiographic imaging techniques. (A) Computed tomographic scan; (B) 3D reconstruction; (C) magnetic resonance T2-weighted imaging; (D) magnetic resonance short tau inversion recovery (STIR) sequence.

The patient was managed in the surgical intensive care unit, with mean arterial pressure maintained above 85 mmHg per institutional acute spinal cord injury protocol. MRI of the thoracic and lumbar spine demonstrated three-column structural failure, with deformation and stretch of the spinal cord between the subluxed segments (Figure 1).

After medical and hemodynamic stabilization, the patient underwent surgical correction. ASIA A spinal cord injury enabled paralytic and muscle relaxant use for deformity reduction and precluded the need for intraoperative neuromonitoring. Due to the potential for great vessel injury or significant blood loss, a trauma surgeon, perfusionist, and an autologous red blood cell salvage machine (Cell Saver, Haemonetics, Braintree, MA, USA) were available throughout the procedure. A pelvic corset was applied prior to patient positioning in anticipation of lower extremity traction. Prone positioning on a flat spine table enabled intraoperative CT (BrainLab Airo^®, Munich, Germany).

A midline posterior incision with subperiosteal dissection was performed to expose the T9–L4 levels. Tears within the supraspinous and interspinous ligaments were noted, as well as within the ligamentum flavum (Figure 2). The paraspinal musculature showed severe contusions. The thecal sac showed oblique stretch between T12 and L1, with multiple small dural tears and slight cerebrospinal fluid (CSF) egress. Penetrating towel clamps were then placed on the T12 and L1 spinous processes for spinal stabilization during pedicle screw placement. Pedicle screws were then inserted at T12 and L1 on the left side via freehand approach. A temporary rod was then instrumented between the left T12 and L1 pedicle screws. A right-sided T12–L1 partial facetectomy with removal of the L1 superior articulating process was then performed. The temporary rod was then removed, and a combination of craniocaudal manual reduction and horizontal translation achieved near-complete deformity reduction. The remainder of the pedicle screws from T9–L4 were now inserted. Intraoperative CT scan confirmed proper screw position. Titanium rod implantation allowed for long-segment fixation from T9–L4. Additional parallel rods were placed spanning the level of the dislocation at T12–L1, with connectors inserted for cross-linkage to the main construct. Fusion was completed with bony decortication, and placement of both autologous bone graft and demineralized bone matrix (Figure 3). Paralytic and muscle relaxant enabled relatively easy manipulation of the spondyloptotic segment. All the above steps have been concisely described in our operative workflow (Figure 4). All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent for publication of this case report and accompanying images was not obtained from the patient or the relatives after all possible attempts were made.

Figure 2.

Intraoperative photograph demonstrating traumatic coronal spondyloptosis between T12 and L1. Spondyloptosis level is demarcated with asterisk. Note significant ligamentous injury and paraspinal muscular contusions.

Figure 3.

Post-operative imaging showing instrumentation utilizing various orientations and radiographic imaging techniques. (A) Coronal computed tomographic scan; (B) sagittal computed tomographic scan; (C) anterior-posterior X-ray projection showing final construct.

Figure 4.

Operative workflow. Stepwise workflow for correction of traumatic thoracolumbar spondyloptotic deformity.

Literature search

A literature search for case series and case reports regarding traumatic spondyloptosis was conducted on PubMed and Embase using the following keywords: thoracolumbar fracture dislocation, traumatic spondyloptosis, thoracolumbar injury classification and severity score TLICS score, ASIA score, spinal disorders, and trauma. From our search, 234 articles were initially identified. Articles were selected using inclusion criteria such as injury involving the thoracic and lumbar spine, fixation across the thoracolumbar junction, traumatic etiology, displaced fracture, and ASIA grading scale use. Exclusion criteria included: cervical spinal involvement, and patient mortality prior to surgery. Thirty-two cases of traumatic spondyloptosis spanning or adjacent to the thoracolumbar junction were identified (Table 1).

Table 1. Literature review of reported traumatic spondyloptoses ordered by decreasing acuity of ASIA grade.

Author (ref.)	N	Injury level	Trauma mechanism	Age (years)/gender	Neurological status on presentation	Associated traumatic comorbidities	Time from injury to surgical intervention	Surgical intervention
Garg et al. (14)	2	T12–L1	Motor vehicle accident	50/M	ASIA A	None	13.5 days	Pedicle screws: T10–T12, L2–L3
								Corpectomy: L1
		L1–L2	Mechanical fall	18/M	ASIA A	None	7 days	Pedicle screws: T12–L1, L3–L4
								Corpectomy: L2
Zhao et al. (4)	1	T12–L1	Mechanical fall	44/M	ASIA A	Pulmonary contusions and hemothorax	<24 hours	Pedicle screws: T12–L3
								Laminectomy: T12, L1
Morel et al. (5)	1	T12–L1	Motor vehicle accident	24/F	ASIA A	Retroperitoneal hematoma	<24 hours	Pedicle screws: T11–L2
								Laminectomy: T11–12
								Facet resection: T12–L1
Mishra et al. (15)	11	T12–L1	Motor vehicle accident	45/M	ASIA A	Retroperitoneal hematoma	2–3 weeks	Laminectomy: L2–L3
		L1–L2	Mechanical fall	25/M	ASIA A	None	<48 hours	Pedicle screws: T11–T12, L1–L2
								Laminectomy: L1–L2
		T12–L1	Mechanical fall	20/M	ASIA A	None	<48 hours	Pedicle screws: T10–T11, L1–L2
								Laminectomy:
								T12–L1
		T11–T12	Mechanical fall	29/M	ASIA A	Renal laceration	2–3 weeks	Corpectomy
		T9, L1–L2	Mechanical fall	18/M	ASIA A	None	<48 hours	Pedicle screws: T12–L1, L3–L4
								Corpectomy: L2
		T12–L1	Mechanical fall	35/M	ASIA A	None	<48 hours	Pedicle screws: T11–T12, L2–L3
								Laminectomy: T11–L3
								Corpectomy: L1
		L1–L2	Motor vehicle accident	30/M	ASIA A	Pneumothorax	2–3 weeks	Pedicle screws: T12–L1, L3–L4
		L1–L2	Mechanical fall	40/M	ASIA A	None	<48 hours	Pedicle screws: T11–L2
		T12–L1	Motor vehicle accident	25/M	ASIA A	Traumatic brain injury	4 weeks	Pedicle screws: T11–L2
								Laminectomy: L1
								Corpectomy: L1
		L1–L2	Crushing accident	35/M	ASIA A	None	<48 hours	Pedicle screws: T11–T12, L3–L4
		T12–L1	Mechanical fall	22/F	ASIA A	None	<48 hours	Pedicle screws: T11–L2
Chandrashekhara et al. (16)	2	T12–L1	Mechanical fall	20/M	ASIA A	Na	NA	Pedicle screws: T11, L2
		T11–T12	Mechanical fall	27/M	ASIA A	Na	NA	Pedicle screws: T10–T12, L2
Costachescu et al. (17)	1	T11–T12	Motor vehicle accident	16/M	ASIA A	Hemothorax and pulmonary contusion	21 days	Pedicle screws: T9–T11, L2
Setiawan et al. (18)	1	T12–L1	Motor vehicle accident	21/M	ASIA A	Renal contusion	<24 hours	Pedicle screws: T10–L2
								Laminectomy: T12–L1
Agrawal et al. (19)	4	L1–L2	Mechanical fall	18/M	ASIA A	None	13.5 days	Pedicle screws: T12–L3
								Corpectomy: L2
		T12–L1	Mechanical fall	15/M	ASIA A	Hemothorax and rib fracture	13.5 days	Pedicle screws: T12–L1
								Corpectomy: L1
		L1–L2	Motor vehicle accident	18/M	ASIA A	None	13.5 days	Pedicle screws: T12–L4
								Corpectomy: L2
		T11–T12	Mechanical fall	18/M	ASIA A	None	13.5 days	Pedicle screws: T9–L2
Jindong et al. (20)	1	L2	Mechanical fall	56/M	ASIA A	Hemopneumothorax	16 hours	Pedicle screws: T12–L4
								Corpectomy: L4
Yadla et al. (3)	1	L1–L2	Motor vehicle accident	21/M	ASIA C	Pneumothorax and splenic and renal lacerations	NA	Pedicle screws: T10–T12, L2–L3
								Laminectomy: T11–L3
								Corpectomy: L1
Hsieh et al. (8)	1	T12–L1	Bicycle accident	50/M	ASIA D	Pulmonary contusions and hemothorax	<24 hours	Pedicle screws: T10–T11, L2–L3
Koruga et al. (21)	1	L1–L2	Motor vehicle accident	48/M	ASIA D	Traumatic brain injury	NA	Pedicle screws: T12–L4
Rahimizadeh et al. (22)	1	T11–L2	Mechanical fall	19/F	ASIA E	Small intestine perforation and hepatic hematoma	14 days	Pedicle screws: T12–L5
								Corpectomy: L2
Akay et al. (6)	1	T12–L1	Motor vehicle accident	21/M	ASIA E	None	<24 hours	Pedicle screws: T11–T12, L2–L3
								Laminectomy: L1
Phadnis et al. (9)	1	L1–L2	Motor vehicle accident	21/M	ASIA E	None	2 days	Pedicle screws: T12–L1, L3–L4
								Laminectomy: L1–L2
Guzel et al. (23)	1	L1–L2	Mechanical fall	3/M	ASIA E	None	NA	None
Zeng et al. (24)	1	L1–L2	Mechanical fall and crushing accident	38/M	ASIA E	None	3 days	Pedicle screws: T12–L5

ASIA, America Spinal Injury Association; F, female; M, male; NA, not applicable.

The most common presenting mechanism was mechanical fall (56%, 18/32 cases), followed by motor vehicle accidents (39%, 13/32 cases). The male-to-female ratio was 28:4, and on presentation 75% (24/32 cases) of patients had complete spinal cord injury (ASIA A), 12% (4/32 cases) had incomplete spinal cord injury (ASIA B–D), and 12% (4/32 cases) had no neurologic deficit (ASIA E). Complete paraplegia likely occurs at a higher rate than reported given the tendency to report patients with no neurologic deficit presenting with this fracture pattern. Despite the majority of cases meeting ASIA A classification, only 16% (5/32 cases) of those patients underwent surgery within 24 hours. Time from injury to surgical intervention varied greatly amongst cases and was most likely affected by comorbidities requiring optimization prior to spinal surgery. Fifty percent of reported injuries (17/32 ASIA A cases) involved the coronal plane, highlighting the importance of this case report and discussion for surgeons routinely managing spinal cord injury.

Discussion

The thoracolumbar junction is subject to biomechanical stress during routine activity, and high-energy trauma imparts a high mechanical load with potential for destabilization. In a series of 412 thoracolumbar injuries reviewed by Denis et al., nearly 20% of the cohort had fracture-dislocations. The widely-used thoracolumbar injury classification and severity (TLICS) score classifies lateral spondyloptosis as a severely unstable injury requiring operative management (2). Coronal displacement represents a rare variant manifestation of traumatic spondyloptosis, requiring shear and rotation in addition to a severe flexion-extension force.

Treatment of coronal spondyloptosis at the thoracolumbar junction with associated acute neurologic deficit, spinal cord compression, and spinal misalignment requires surgical intervention in conjunction with appropriate multidisciplinary treatment of traumatic comorbidities. Planning a surgical approach requires multiplanar assessment of the spinal deformity, potential to salvage the disrupted vertebral segment, feasibility of the optimal construct length, and patient neurologic status.

We present the case of a 36-year-old female presenting after a motor vehicle accident with a T12 ASIA A spinal cord injury and surgical correction with a posterior approach accessible to most spinal surgeons. Asymptomatic patients and those with incomplete spinal cord injury require neuromonitoring. Deformity correction past that attainable with manual reduction alone requires distraction instrumentation.

The principles of thoracolumbar fracture-dislocation management are, in general, fracture reduction, spinal realignment, and stabilization (2,3). This enables early mobilization and rehabilitation, regardless of neurological status (25). Timing of intervention, however, depends on both the neurological status on presentation and the presence of associated injuries. These can include damage to the lung, ribs, abdominal solid organs, and the presence of intra-abdominal hemorrhage. These additional factors require medical and hemodynamic stabilization prior to surgery. Indeed, in eligible patients, Kerwin et al. found a shorter hospital length of stay after early stabilization (<3 days of injury) in polytrauma patients with spinal fractures, with a decreased incidence of pneumonia, albeit with increased perioperative mortality (26). Konieczny et al. demonstrate significantly higher mortality after early spinal stabilization in polytrauma patients with thoracic fractures compared to those undergoing delayed surgery (>3 days after injury) (25). However, delineation of the innate heterogeneity of polytrauma patients must be undertaken to enable individualized assessments on optimal spinal fixation timing.

Most published cases of traumatic thoracolumbar spondyloptosis are in the sagittal plane, with TCS very rarely reported (4-12). For sagittal deformity, the majority of cases required a single stage posterior thoracolumbar pedicle screw fixation for reduction (3). Partial corpectomy/vertebrectomy of the affected vertebral segments was required in select cases, while other patients required a combined anterior-posterior approach to augment fusion. Construct length typically involves 2–3 levels cranial and caudal of the affected vertebral segments. Temporary rod placement avoids secondary cord injury during instrumentation. Decompression at the affected levels may be considered if imaging demonstrates cord injury, mass lesion, or focal severe stenosis. If a large magnitude of correction is warranted, spinal anchors may be placed and distraction instrumentation can be utilized.

All of the reported cases demonstrated adequate bony fusion on follow up, and for at-risk patients an anterior approach for additional instrumentation may reduce any theoretical risk of non-union in this patient population (3-12). As previously mentioned, the anterior approach not unexpectedly has variable safety and feasibility considerations commensurate with associated traumatic comorbidities. Intrinsic limitations to an anterior-only approach are failure of fracture reduction, given the limited ability to generate sufficient traction, and requirement to traverse associated abdominal injuries.

Conclusions

Traumatic coronal spondyloptosis requires multidisciplinary management, meticulous pre-operative planning, and step-wise surgical execution. Even with a complete spinal cord injury, early surgical fixation enables streamlined hospital admission, and facilitates adjuvant spinal cord injury management. Deformity correction must consider the role of neuromonitoring, construct length, temporary rod placement to prevent secondary neurologic injury, decompression in the presence of concomitant space-occupying lesion, feasibility of manual reduction, and need for distraction instrumentation. We present here the case of a 36-year-old female with a multiplanar thoracolumbar junctional spondyloptosis at T12–L1 and complete spinal cord injury with deformity correction through a posterior approach, assisted by muscle relaxation given her neurologic status. Despite the relative rarity, fracture type complexity, and presence of significant traumatic comorbidities, the patient tolerated the surgery well without any perioperative complications, and with a technique accessible to most spinal surgeons.

Supplementary

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Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent for publication of this case report and accompanying images was not obtained from the patient or the relatives after all possible attempts were made.