Thoraco-lumbar fractures with blunt traumatic aortic injury in adult patients: correlations and management

The Associative Pattern Between Segmental Arterial Damage and Complete Neurological Disorder After Spinal Cord Injury: A Case-Control Study

INTRODUCTION

The prevalence of vascular trauma surrounding the thoracic spine following Spinal Cord Injury (SCI) is unknown. The potential for neurologic recovery is uncertain in many cases; in some cases, neurologic assessment is not possible, for example, in severe head injury or early intubation, and detection of segmental artery injury may help as a predictive factor.

OBJECTIVE

To assess the prevalence of segmental vessel disruption in two groups, with and without neurologic deficit.

MATERIAL AND METHODS

This is a retrospective cohort study, with a group SCI American Spinal Injury Association (ASIA) E and a group SCI ASIA A. All patients had a high-energy thoracic or thoracolumbar fracture from T1 to L1. Patients were matched 1:1 (one ASIA A matched with one ASIA E) according to the fracture type, age, and level. The primary variable was the assessment of the presence/disruption of the segmental arteries, bilaterally, around the fracture. Analysis was performed twice by two independent surgeons in a blinded fashion.

RESULTS

Both groups had 2 type A, 8 type B, and 4 type C fractures. The right segmental artery was detected in 14/14 (100%) of the patients with ASIA E and in 3/14 (21%) or 2/14 (14%) of the patients with ASIA A, according to the observers, p=0.001. The left segmental artery was detectable in 13/14 (93%) or 14/14 (100%) of the patients ASIA E and in 3/14 (21%) of the patients ASIA A for both observers. All in all, 13/14 of the patients with ASIA A had at least one segmental artery undetectable. The sensibility varied between 78%to 92%, and the specificity from 82% to 100%. The Kappa Score varied between 0.55 and 0.78.

CONCLUSION

Segmental arteries disruption was common in the group ASIA A. This may help to predict the neurological status of patients with no complete neurological assessment or potential for recovery post-injury.

Endovascular Aortic Repair for Thoracic Aortic Compression Resulting From Chance Fracture of the Thoracic Spine

Blunt aortic injury is a serious condition with a high mortality rate. Although rare, blunt aortic injury associated with spinal fracture has also been reported, and appropriate management of aortic disease is key to a good outcome. This report is a case of a 78-year-old man who was found to have a transverse fracture (Chance fracture) in the ninth thoracic vertebra, with a sharp bone fragment compressing the thoracic aorta. Early spinal surgery was needed; however, there was concern about the possibility of bleeding from the aorta and surrounding small arteries associated with the bone fragment during spinal surgery. Therefore, thoracic endovascular aortic repair was performed before spinal surgery. The next day after thoracic endovascular aortic repair, posterior spinal instrumentation was performed, and the postoperative course was uneventful. Because aortic injury associated with vertebral fracture can lead to massive bleeding and spinal cord injury, endovascular repair before spinal surgery is reasonable.

Spinal injury with spinal ankylosing disorders as a primary cause of death: report of two cases

BACKGROUND

Spinal ankylosing disorders (SADs) refer to a group of conditions resulting in spontaneous or postsurgical ossification and fusion of the spinal segments. The spine becomes increasingly susceptible to injury over time such that even low-energy trauma can cause a spinal injury. We report two cases of SADs, associated with massive thoracic hemorrhage.

CASE PRESENTATION

The first patient was an 85-year-old male, who suffered from a vehicular crash. He was diagnosed with a fracture of the first lumbar vertebra, accompanied by SADs. Intubation was required, and thoracic drainage tubes were inserted. The patient underwent a massive transfusion and thoracotomy with packing. Despite prompt treatment, the hemorrhage from the vertebral fracture was uncontrolled, and the patient died 180 min after the injury. The second case features an 88-year-old male who fell from a height. He was diagnosed with flail chest, hemothorax, pneumothorax, and a fracture of the eighth thoracic vertebra with SADs. After intubation, four thoracic drainage tubes were placed, and a massive transfusion was conducted. He died after 3 days due to hypoxemia secondary to persistent bleeding of the vertebral fracture for 24 h.

CONCLUSIONS

The patients died of persistent thoracic hemorrhage, and the sources of bleeding were the fracture site of the spine fractures. Controlling spinal hemorrhage is difficult due to the absence of a bleeding artery, which is managed via trans-arterial embolization. This report emphasized that fracture of SADs could be a fatal disease that requires prompt intervention.

Delayed diagnosis of blunt thoracic aortic injury due to thoracic vertebral fracture: A case report and literature review

Blunt vascular injury of the aorta combined with thoracolumbar fracture is rare. Delayed diagnosis may have a catastrophic outcome. We present a case of blunt thoracic aortic injury combined with a vertebral body fracture at T10 after a fall from height in which the diagnosis was delayed. After consultation with the vascular and spinal surgeons, we performed a thoracic endovascular aortic repair. When the patient's condition had stabilized, the fractures were reduced using posterior vertebral instrumentation. Prolonged compression of the thoracic aorta resulted in extensive necrosis of muscle tissues in the right lower leg. Fortunately, clinical and radiological examinations performed 7 months and 1 year later did not reveal any further damage. Cases of thoracic vertebral fracture with concomitant blunt thoracic aortic injury reported in the literature are reviewed. Thoracic endovascular aortic repair is a feasible, safe, and effective minimally invasive treatment for aortic injury when combined with thoracic vertebral fracture.

Large aortic pseudoaneurysm after fusion surgery for hyperextension-type lumbar fracture in diffuse idiopathic skeletal hyperostosis: illustrative case

BACKGROUND

This study aimed to report an aortic pseudoaneurysm, a rare but lethal complication, after a spinal fracture in ankylosing spine.

OBSERVATIONS

An 83-year-old obese woman presented with dementia and was nonambulatory after a fall. She was transported to the hospital, and imaging showed a hyperextension-type L1 fracture with diffuse idiopathic skeletal hyperostosis (DISH). After posterior fusion surgery using percutaneous pedicle screws, screw loosening was detected 10 days postoperatively. Fracture dislocation was reduced by changing to transdiscal screws and rodding while in the lateral position. However, the anterior opening persisted. Enhanced computed tomography performed at 6 weeks postoperatively showed a large aortic pseudoaneurysm extending into the vertebral fracture site without screw loosening. Neither endovascular aortic repair nor open surgery was applicable. The patient was transferred to a sanatorium and died of pneumonia 5 months postoperatively without aortic aneurysm rupture.

LESSONS

An aortic pseudoaneurysm can occur in hyperextension-type spinal fractures in DISH, even after fusion surgery, when the edge of the fracture is in contact with the aortic wall. The anterior opening dislocation should be reduced as much as possible.

Patterns of concomitant injury in thoracic spine fractures

Background

Thoracic spine fractures (TSFs) are rarely isolated injuries, and they tend to present with a characteristic set of vertebral and non-vertebral injuries based on mechanism of injury. There is limited research on the rates and distribution of injuries that occur concurrently with TSFs. The purpose of this study is to characterize the distributions of these injuries by region of the body and by mechanisms of injury, so that trauma and spine surgeons can efficiently evaluate and treat patients presenting with TSFs.

Methods

We retrospectively reviewed the trauma database records of 683 patients presenting with a TSFs at a single institution from 2015 to 2019. We recorded patient demographics, comorbidities, and associated injuries by body region. We characterized the TSFs using the AO classification system, as well as the presenting physical exam and treatment. All associated injuries among the TSF patients were classified into the following categories: head injury (HI), thoracic injury (TI), non-thoracic vertebral injury (NTVI), abdominal injury (AI), upper extremity injury (UEI), lower extremity injury (LEI), and spinal cord injury (SCI).

Results

The three leading causes of TSFs were mechanical falls (38.4%), falls from height (24.9%), and motor vehicle crashes (MVCs) (23.4%). Patients with a TSF from MVC were statistically more likely to have concomitant injuries of TI, NTVI, AI, HI, UEI, and LEI. TSFs from fall from height were statistically more likely to have TI, NTVI, and LEI. TSFs from mechanical falls had significantly lower rates of all injury locations, but still presented with high rates of additional injury. TSFs from motorcycle crashes (MCCs) presented with TI, AI, UEI, and LEI. There were high rates of treatment for TSFs, with surgery ranging from 5.3% to 20.0% and bracing from 52.3% to 65.7% depending on mechanism of injury.

Conclusions

TSFs after MVCs, mechanical falls, falls from height, and MCCs presented with a predictable pattern of injuries and were rarely an isolated injury. This cross-sectional data may help spine and trauma surgeons better understand patterns of injury associated with TSFs, with the hope of preventing missed injuries and better advising patients with TSFs on severity of injuries.

Intramural hematoma with intramural blood pool associated with vertebral compression fracture

Although intramural blood pools due to intercostal arteries in intramural hematoma have been reported as a traumatic aortic injury, the precise mechanism is unclear. We present the case of an elderly patient who presented with an intramural blood pool due to an intercostal artery prolapse in an intramural hematoma associated with a compression fracture of the thoracic vertebra after a fall. <Learning objective: It is possible to treat intramural blood pool due to intercostal artery prolapse in an intramural hematoma associated with thoracic vertebral compression and intramural blood pool in an intramural hematoma as a traumatic aortic injury with medications.>.

Aortic Impingement in Displaced Traumatic Spine Fracture with Complete Spinal Cord Transection: A Case Report

Aortic impingement associated with traumatic thoracic spinal fractures is a rare and potentially lethal complication that creates management challenges in an already complex clinical problem. Traumatic aortic injury is one of the leading causes of death in blunt trauma. Magerl divided thoracic and lumbar fractures into 3 categories; the primary focus of this report, type C fractures, describes rotational injury and is one of the less common types, especially associated with aortic impingement as such. In this case, a young man was admitted following a near-fatal fall resulting in blunt force trauma to the midthoracic region. Emergency CT revealed a type C complete transection at the level of T11 and a grade I aortic injury. Definitive fixation of the spinal injury was delayed in favor of preventing further vascular injury by prioritizing the securing of hemodynamic stability. In traumatic thoracolumbar injuries, blunt traumatic aortic injury is often managed conservatively. However, blunt thoracic aortic injury is one of the leading causes of death from trauma, and each case requires its own case-by-case multidisciplinary management. In this occasion, management of the vascular insult was paramount to ensuring patient survival and favorable outcome.

Thoracic Spine Fractures with Blunt Aortic Injury: Incidence, Risk Factors, and Characteristics

Background: The coexistence of thoracic fractures and blunt aortic injury (BAI) is potentially catastrophic and easy to be missed in acute trauma settings. Data regarding patients with thoracic fractures complicated with BAI are limited. Methods: The authors conducted a prospective, observational, single-center study including patients with thoracic burst fractures. A multivariate logistic regression model was developed to determine the risk factors of aortic injury. Results: In total, 124 patients with burst fractures of the thoracic spine were included. The incidence of BAI was 11.3% (14/124) in patients with thoracic burst fractures. Among these patients, 11 patients with BAI were missed diagnoses. The main risk factors of BAI were as follows: Injury severity score (OR 1.184; 95% CI, 1.072–1.308; p = 0.001), mechanism of injury, such as crush (OR 10.474; 95% CI, 1.905–57.579; p = 0.007), flail chest (OR = 4.917; 95% CI, 1.122–21.545; p = 0.035), and neurological deficit (OR = 8.299; 95% CI, 0.999–68.933; p = 0.05). Conclusions: BAI (incidence 11.3%) is common in patients with burst fractures of the thoracic spine and is an easily missed diagnosis. We must maintain a high suspicion of injury for BAI when patients with thoracic burst fractures present with these high-risk factors.

Rare association of traumatic diaphragmatic hernia with spinal cord injury: A case report

Introduction and importance

The traumatic diaphragmatic hernia could be missed in the background of spinal fractures due to neurological weakness. We report the first case of the management of thoracolumbar fracture-dislocation associated with diaphragmatic injury.

Presentation of case

53-year-old male transferred from local hospital following fallen from a motorbike on the 4th day after the injury. He was paraplegic from L1 below with sacral root involvement. Further imaging showed fracture-dislocation of the vertebral body at the T12-L1 level and anterior displacement of T11 on T12. The left-sided diaphragmatic hernia was detected by chest x-ray with bowel shadows in the left hemithorax. Emergency laparotomy and diaphragmatic repair followed by a posterior spinal exploration and pedicle screw fixation were done. Early mobilization was done after spinal fixation and the patient is successfully continuing rehabilitation.

Clinical discussion

Thoracolumbar fracture-dislocation associated with the traumatic diaphragmatic hernia is rare. Clinical diagnosis of associated visceral injuries could be delayed due to the neurological deficit of the patient. An initial concern was to repair the life-threatening diaphragmatic hernia. Even current studies showed improved neurological function from early spinal surgery, spinal fixation had to delay as surgery needs a prone position.

Conclusion

Early identification and management of traumatic diaphragmatic hernia are life-saving and allows early surgical intervention for the spine. Early reduction and fixation are associated with improved neurological function and will allow early mobilization and reduce hospital and ICU stay.

•

Traumatic Diaphragmatic hernia is a life-threatening condition which may not presented with classical features in the presence of spinal cord injury.

•

Careful clinical and radiological assessment is necessary to detect this condition in the presence of neurological weakness.

Investigation of Preoperative Traction Followed by Percutaneous Kyphoplasty Combined with Percutaneous Cement Discoplasty for the Treatment of Severe Thoracolumbar Osteoporotic Vertebral Compression Fractures

Objective

To evaluate the feasibility, clinical efficacy and imaging results of preoperative traction (PT) followed by percutaneous kyphoplasty (PKP) combined with percutaneous cement discoplasty (PCD) for treating severe thoracolumbar osteoporotic vertebral compression fractures (OVCFs).

Methods

A total of 13 patients with severe thoracolumbar OVCFs treated by PT followed by PKP combined with PCD were enrolled. General information, PT time, operation time, postoperative hospital stay, perioperative complications, visual analog scale (VAS) score, Oswestry disability index (ODI) score, local kyphosis angle, intervertebral angle (IVA), anterior vertebral height (AVH) and posterior vertebral height (PVH) were recorded.

Results

The average VAS score at admission was 7.4±3.5, decreased to 4.3±1.7 after PT and 2.3±0.7 three days after operation, and 1.5±0.9 at last follow-up. The average ODI score was 73.7±21.4 before operation, decreased to 26.6±9.3 three days after operation and 13.7±7.1 at last follow-up. Compared to VAS and ODI scores at admission, these at the third day after operation and last follow-up were significantly different. At admission, the IVA was 3.4°±6.8°, the disc height was 5.7±1.2mm, the AVH was 10.7±3.2mm, and the PVH was 25.7±4.2 mm, which, after PT, changed to 8.1°±7.3°, 8.6±2.6mm, 18.5±2.8mm, and 26.2±7.1mm, respectively, and the differences were significant. The average kyphotic angle was 43.4°±17.8° at admission, and decreased to 26.3°±6.7° after PT, 17.5°±8.4° three days after operation and 19.1°±10.3° at last follow-up, and the differences were significant.

Conclusion

PT followed by PKP combined with PCD for the treatment of severe thoracolumbar OVCFs was an effective and simple procedure with satisfactory short-term clinical outcomes by relieving pain and improving kyphosis.

Endovascular repair of a distal thoracic aortic transection in association with traumatic burst fracture

We present an endovascular repair of aortic transection at distal thoracic level due to traumatic burst fracture. The association of blunt aortic transections and thoracic burst fractures is very rare. Contemporary preferred treatment approach is endovascular aortic repair, because of low mortality rates. The aortic repair procedure should be performed before spinal stabilization surgery. In this case report, we present a 49-year-old male patient with blunt traumatic descending thoracic aortic transection, treated by endovascular aortic repair. In conclusion, the emergent endovascular repair is a preferable method to treat the traumatic distal thoracic aortic transection.

Aortic Fistulas: Pathophysiologic Features, Imaging Findings, and Diagnostic Pitfalls

Fistulas between the aorta and surrounding organs are extremely rare but can be fatal if they are not identified and treated promptly. Most of these fistulas are associated with a history of trauma or vascular intervention. However, spontaneous aortic fistulas (AoFs) can develop in patients with weakened vasculature, which can be due to advanced atherosclerotic disease, collagen-vascular disease, vasculitides, and/or hematogenous infections. The clinical features of AoFs are often nonspecific, with patients presenting with bleeding manifestations, back or abdominal pain, fever, and shock. Confirmation with invasive endoscopy is often impractical in the acute setting. Imaging plays an important role in the management of AoFs, and multiphasic multidetector CT angiography is the initial imaging examination of choice. Obvious signs of AoF include intravenous contrast material extravasation into the fistulizing hollow organ, tract visualization, and aortic graft migration into the adjacent structure. However, nonspecific indirect signs such as loss of fat planes and ectopic foci of gas are seen more commonly. These indirect signs can be confused with other entities such as infection and postoperative changes. Management may involve complex and staged surgical procedures, depending on the patient's clinical status, site of the fistula, presence of infection, and anticipated tissue friability. As endovascular interventions become more common, radiologists will need to have a high index of suspicion for this entity in patients who have a history of aneurysms, vascular repair, or trauma and present with bleeding. Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. ^©RSNA, 2021.

Clinical effect of a novel transpedicular reducer for reduction and bone grafting combined with pedicle screw fixation for thoracolumbar burst fractures

BACKGROUND

Short-segment transpedicular screw fixation is a common method for the treatment of thoracolumbar burst fractures (TBFs),but this technique has many problems. Therefore,the purpose of this article is to observe and evaluate the clinical efficacy of a novel transpedicular reducer that we designed for fractured vertebral body reduction and bone grafting in the treatment of TBFs.

METHODS

From July 2018 to November 2020, 70 cases of TBFs were included. Thirty-five patients were treated with the novel transpedicular reducer for reduction and bone grafting combined with pedicle screw fixation (observation group), and 35 patients were treated with short-segment transpedicular screw fixation (control group). Before the operation, after reduction, and 3 days, 3 months,and 12 months after the operation, the two groups were assessed, and compared with respect to the anterior and middle heights of the injured vertebrae, the ratios of the anterior and middle heights of the injured vertebral body to the respective heights of the adjacent uninjured vertebral bodies (AVBHr and MVBHr, respectively), and the Cobb angle of the patients. We compared the pain VAS score and quality of life GQOL-74 score at the last follow-up. Finally,we evaluated the distribution of bone grafts and bone healing 12 months after the operation.

RESULTS

The anterior height, middle height, AVBHr, MVBHr, and Cobb angle of the injured vertebral body in the observation after reduction, and 3 days, 3 months and 12 months post-operatively were compared with those of the injured vertebral body before operation. All of these parameters were improved, and the difference was statistically significant (p < 0.05). These parameters in the observation group at the above time points were significantly better than thoes in the control group at the corresponding time points (p < 0.05). The VAS scores at the last follow-up were significantly better than those of the control group (p < 0.05), but the GQOL-74 score differences were not statistically significant (p > 0.05). The observation group showed no obvious defects on CT at 12 months after the operation, and the bone healing was good.

CONCLUSION

The novel transpedicular reducer for reduction and bone grafting combined with pedicle screw fixation for TBFs has good clinical efficacy.

Intercostal artery rupture associated with thoracic spinal hyperextension injury caused by a minor trauma: A case report

Diffuse idiopathic skeletal hyperostosis is associated with hyperextension injury of the spine caused by a minor trauma and may often be diagnosed late, thus preventing effective treatment. To date, there have been no reported cases of segmental arterial injury associated with a hyperextension injury caused by a minor trauma in super-elderly patients with diffuse idiopathic skeletal hyperostosis. Herein, we present the findings and treatment provided for a 92-year-old woman with a right massive hemothorax and 12th thoracic vertebral fracture. The patient was diagnosed with diffuse idiopathic skeletal hyperostosis. Bleeding stopped naturally, and we successfully treated the patient using posterior fixation with percutaneous pedicle screws. At 6 months post-surgery, there was no complication, instrumentation failure, or correction loss, and she could walk independently using a cane. To our knowledge, this is the first report of intercostal artery rupture and massive hemothorax associated with diffuse idiopathic skeletal hyperostosis fracture caused by a minor trauma. It is notable that diffuse idiopathic skeletal hyperostosis following a minor trauma in such elderly patients may cause segmental arterial rupture associated with spinal burst fracture and hyperextension injury.

Neurologically Asymptomatic Lumbar Traumatic Dislocation With Vascular Compression in a Patient With Ankylosing Spondylitis: Case Report

BACKGROUND

Ankylosing spondylitis (AS) is associated with high rates of severe thoracolumbar fractures, in many cases with neurological deficits. It is currently a point of debate as to whether the optimal surgical treatment is posterior fixation and fusion or combined approaches. Vascular injuries in this kind of fracture are a challenging issue to solve in the management of these patients.

METHODS

We are reporting the case of a 65-year-old man who presented an L4 traumatic fracture-dislocation. He had a long history of symptomatic AS. No neurological deficits were detected during the initial exploration. During the preoperative work-up, a lumbar spine computed tomography (CT) scan was taken with vascular reconstruction of the abdominal vessels. It confirmed the compression of the abdominal aorta, which had caused more than 90% stenosis. A posterior approach, an open reduction, and fixation with pedicle screws were performed, without hemodynamic or neurological changes. A postoperative angiography demonstrated a complete recovery of the vessel caliber, without contrast leaks.

RESULTS

After a 2-year follow-up, the patient was pain free and the CT scan revealed bone fusion.

CONCLUSIONS

The vascular structures involved in severe thoracolumbar fractures present a dangerous situation that should be considered in the choice of the surgical approach. The posterior approach alone may be a good option in the absence of vascular damage. However, due to risk of vessel rupture during the fracture reduction, vascular surgeons must take part in the surgery.

LEVEL OF EVIDENCE

5.

CLINICAL RELEVANCE

The article provides help for surgeons who have to treat severe fractures in the context of ankylosing spondylitis.