Review Question - QID 204

This patient is presenting with cauda equina syndrome following a lumbar burst fracture that was initially treated nonoperatively. Urgent anterior decompression with strut grafting is indicated followed by instrumented stabilization, which can be done with posterior instrumentation.

Treatment in most patients with thoracolumbar fractures who are neurologically intact is non-surgical. Surgery is indicated for unstable fracture patterns and/or neurologic deficits, especially if they are progressive. This includes CES, progressive neurological deficits, and evidence of injury to the posterior ligament complex (PLC).

Clohisy et al studied twenty-two patients with incomplete neurologic deficits after thoracolumbar junction fractures that were treated by anterior decompression and stabilization. In their series, no patients had any deterioration in neurologic function after surgery. The authors found that early anterior decompression for traumatic injuries at the thoracolumbar junction was associated with improved rates of neurologic recovery when compared to late decompression. Those who were treated within 48 hours of injury recovered more function then those who were treated at greater than 48 hours.

Krengel et al studied 14 patients who underwent stabilization for acute compression fractures at the thoracolumbar junction with neurologic deficits. 12 of the patients underwent initial posterior instrumentation and fusion, one of whom subsequently had an anterior decompression. Two patients had initial anterior decompression and fusion. Both patients later had posterior instrumentation and fusion to treat progressive deformity. Average neurologic improvement was 2.2 Frankel grades per patient, lower extremity motor index improved from an average of 7 to 44. Again, it was concluded that early surgical reduction, stabilization, and decompression is safe and improves neurologic recovery in comparison to historical controls treated by postural reduction or late surgical intervention.

Illustration A shows the postoperative radiographs of a combined anterior-posterior decompression and stabilization procedure.

Incorrect Answer:
Answers 1 & 2: Because this patient has acute symptoms of cauda equina syndrome, urgent decompression within 48 hours is indicated. Therefore EMG, steroids, and observation are not appropriate.
Answer 3: This patient has anterior retropulsed bone causing severe compression of the thecal sac. A posterior laminectomy would not provide adequate decompression, and an anterior decompression with a L4 corpectomy and strut grafting is the only way to ensure an adequate decompression.
Answer 4: Although one might argue posterior percutaneous pedicle screws instrumentation with distraction may provide indirect decompression through ligamentotaxis, due to the severity of the neurologic symptoms and degree of anterior compression, this approach would not be appropriate for this patient.