Multilevel Noncontiguous Spinal Fractures: Surgical Approach towards Clinical Characteristics

Abstract

Study DesignThe study retrospectively investigated 15 cases with multilevel noncontiguous spinal fractures (MNSF).PurposeTo clarify the evaluation of true diagnosis and to plane the surgical treatment.Overview of LiteratureMNSF are defined as fractures of the vertebral column at more than one level. High-energy injuries caused MNSF, with an incidence ranging from 1.6% to 16.7%. MNSF may be misdiagnosed due to lack of detailed neurological and radiological examinations.MethodsPatients with metabolic, rheumatologic diseases and neoplasms were excluded. Despite the presence of a spinal fracture associated clearly with the clinical picture, all patients were scanned within spinal column by direct X-rays, computed tomography and magnetic resonance imaging. When there were ≥5 intact vertebrae between two fractured vertebral segments, each fracture region was managed with a separated stabilization. In cases with ≤4 intact segments between two fractured levels, both fractures were fixed with the same rod and screw system.ResultsThere were 32 vertebra fractures in 15 patients. Eleven (73.3%) patients were male and age ranged from 20 to 64 years (35.9±13.7 years). Eleven cases were the American Spinal Injury Association (ASIA) E, 3 were ASIA A, and one was ASIA D. Ten of the 15 (66.7%) patients returned to previous social status without additional deficit or morbidity. The remaining 5 (33.3%) patients had mild or moderate improvement after surgery.ConclusionsThe spinal column should always be scanned to rule out a secondary or tertiary vertebra fracture in vertebral fractures associated with high-energy trauma. In MNSF, each fracture should be separately evaluated for decision of surgery and planned approach needs particular care. In MNSF with ≤4 intact vertebra in between, stabilization of one segment should prompt the involvement of the secondary fracture into the system.

A multilevel noncontiguous spinal fracture with cervical and thoracic spinal cord injury

“…MNSF with multilevel spinal cord injury, a special type of multilevel spinal injury, most frequently occurs in high-velocity traffic accidents or falls from height [1] , [2] . Delayed diagnosis of a second fracture has been reported in between 23.1% to 83.3% of cases, with delays ranging from 2.8 to 52.6 days [2] , [4] . In traumatic lacerations of the dura or of dura tears, 18–36% were associated with spine injuries.…”

“…The most common fracture pattern related to dura tears is fracture-dislocation associated with complete spinal cord injuries [5] . The current standard treatment of MNSF with traumatic dura tears includes early detection, ridged internal fixation plus decompression and dura repair, with results showing improvements in outcomes and reduction of deformity [4] , [5] .…”

“…The MRI classification for this patient was pattern 2 using the Kanna RM et al system: a spine subaxial cervical injury classification type A0 combined with an AO Spine TL injury classification type C3, i.e., this was the most severe injury. A complete examination and full investigation is important for reducing the risk of a missed diagnosis as well as prevention of secondary damage to neurological structures related to clinical outcomes [4] . In this patient choose conservative treatment on cervical problem despite some neurological deficit because after we classified by AO Spine subaxial cervical injury, it was type A0 (included only lamina or spinous process fracture in cervical spine) and MRI scan showed no spinal cord compression, minimal displaced of C5 spinous process without rupture of posterior ligamentous complex (stable stability).…”

Clinical Features and Treatment Outcomes of Acute Multiple Thoracic and Lumbar Spinal Fractures : A Comparison of Continuous and Noncontinuous Fractures

“…Regarding the pathogenesis of noncontinuous fracture, some authors have claimed that a concentration of force might result in a severe vertebral fracture in one area and secondary, less severe fracture(s) in another area due to the action of secondary force [7,22]. Therefore, it was presumed that relatively stable fracture(s) occur in the other vertebrae because the force is dispersed to various spine regions [7].…”

“…Multiple vertebral fractures are most often caused by highenergy injuries including complicated traffic accidents or falls from large heights [22]. Henderson et al [7] in 1991 and Korres et al [13] in 2003 also reported that traffic accidents were the most common cause of multiple vertebral fractures.…”