Treatment of unstable lumbar spine fracture with neurologica
Management of unstable thoracolumbar fractures remains controversial. Furthermore, when these are accompanied by related neurological injury, the choice of approach, decompression technique and timing of the intervention could have a neuroprotective effect. In terms of site, the lumbar spine represents only 1.2% of cases, yet fractures with severe instability and neurological injury call for attainment of the same goals, i.e., neurological stability and decompression.

A 23-year-old male, received by the emergency ward after experiencing an accidental fall from the fourth floor, was conscious on arrival, co-operative and somewhat confused (Glasgow14). On initial examination, he complained of lumbar pain and loss of strength in the lower limbs, with evidence of distal flaccid paralysis in lower limbs, thermoalgesic and proprioceptive hypoesthesia below level L2, and absence of anal and bulbocavernosus reflexes, with osteotendinous reflexes present and bilateral flexor cutaneous-plantar reflex.
The computed tomography (CT) scan showed multifragmentary fracture of the L3 body, middle column injury with the occupation of 70% of the medullary canal, and injury of the complete ligamentous complex (Type C translation injury, according to the AOSpine Classification System). In addition, stable compression fracture of T8 and polyfragmentary fracture of S5 and coccyx were also in evidence. The findings were compatible with incomplete cauda equina syndrome.

Under general anaesthesia and antibiotic prophylaxis, with the patient in prone decubitus position and the lower limbs extended to maximise lumbar lordosis, a posterior approach of the lumbar spine was performed. We found which confirmed a complete tear of the L3-L4 and L4-L5 ligamentous complex, laceration of dura mater, and partial injury of lumbar spinal nerve roots. Reconstruction of the posterior tension band, with bilateral pedicle screw fixation at L1-L2 and L4-L5 and posterolateral arthrodesis with autologous bone, were performed. Direct decompression of the L3 body was achieved by means of left TPA and reconstruction of the anterior column, by the placement of titanium mesh cage with autologous bone graft obtained from the surgical field. Due to the severity of the injury of the dura mater, this was reconstructed by suture and ovine patch graft.

The patient made favorable progress after the intervention with progressive improvement in motor and sensory function, though he required intermittent bladder catheterization for a few months. The postoperative MR scan showed evidence of adequate decompression of neural elements.

In conclusion, patients who present with an unstable injury of the lumbar spine and incomplete neurological involvement can benefit from emergency stabilization and decompression treatment by posterior TPA, with improvement in neurological status and functional recovery.