Neurological L5 burst fracture: posterior decompression and lordotic fixation as treatment of choice

Abstract

Purpose We report our experience and literature review concerning surgical treatment of neurological burst fractures of the fifth lumbar vertebra. Materials and methods Nineteen patients with L5 neurological burst fractures were consecutively enrolled; 6 patients had complete motor deficits, and 12 had sphincter dysfunction. We performed 18 posterior and one combined approaches. To avoid kyphosis, posterior internal fixation was achieved by positioning patients on the operating table with hips and knees fully extended. At the latest follow-up (mean 22 months, range 10-66), neurological recovery, canal remodeling and L4-S1 angle were evaluated. Results Vertebral body replacement was difficult, which therefore resulted in an oblique position of the cage. Vertebral bodies still remained deformed, even though fixation allowed for an acceptable profile (22°, range 20-35). We observed three cases of paralysis, five complete, and three incomplete recoveries. In the remaining eight patients, sphincter impairment was the only finding. In 15 patients, pain was absent or occasional; in four individuals, it was continuous but not invalidating.Remodeling was visible by X-ray and/or CT, without significant secondary stenosis. Conclusions The L5 burst fractures are rare and mostly due to axial compression. Cauda and/or nerve root injuries are absolute indications for surgery. If an anterior approach is technically difficult, laminectomy can allow for decompression, and it can be easily combined with transpedicular screw fixation. Posterior instrumented fusion, also performed with the aim to restore sagittal profile, when associated with an accurate spinal canal exploration and decompression, may be looked at as an optimal treatment for neurological L5 burst fractures.

Minimally Invasive Temporary Posterior stabilization in Isolated Unstable L5 Burst Fracture with Predominant Radiculopathy: A Case Report

“…Previously described treatment modalities are summarized in Table 2 1,3,4,7,8,[10][11][12][13]16) . In 1992, Finn described conservative management in a series of seven patients with L5 burst fractures, which included immobilization in a cast for two months followed by mobilization with an orthosis for three months.…”

“…Mick et al achieved excellent results with conservative management in patients with intact neurology and canal compromise less than 50%, but recommended surgical intervention in patients with neurological . Previously described operative modalities include posterior decompression with instrumentation, corpectomy with cage reconstruction, laminotomy for the tapping of fracture fragments followed by percutaneous short segment pedicle fixation, MIS stabilization without direct decompression 3,4,7,8,[10][11][12][13]16) . With no fixed algorithm described, surgical intervention needs to be individualized depending on the clinical and radiological presentation.…”

Traumatic L5 Posterolateral Spondyloptosis: A Case Report and Review of the Literature

“…However, the relevance of their data to fracture dislocations is questionable because of the inherent ligamentous instability seen in three-column injuries. In fact, many authors advocate managing L5 burst fractures with posterior instrumentation alone, without anterior column reconstruction, given the inherent difficulties in performing a corpectomy / vertebrectomy at this level [ 7 ].…”

Frakturen der unteren Lendenwirbelsäule

“…Unabhängig vom Typ der Fraktur führt die konservative Behandlung typischerweise nicht zu einer Verschlechterung des neurologischen Status [5,7,8,14]. Andererseits ist eine Verbesserung eines neurologischen Defizits in 42 -87% durch eine chirurgische Therapie erzielt worden [7,9]. Dabei spielt auch die ventrale Dekompression eine Rolle [5].…”