Traumatic total axial reversal of the thoracic vertebral body

Abstract

IntroductionNumerous vertebral fracture patterns have been reported in the literature in the thoracic and thoracolumbar spine. These have been classified in different systems that take into account involvement of bone and soft tissue [1,9], injuries in different compartments such as the "three-column concept" of Denis [3], and displacement in the three dimensions [5,12]. The occurrence of some degree of rotation in the overall fracture pattern is a well-recognized factor of complications such as instability and neurological involvement. However, some fracture patterns still do not fit into any classification scheme [12]. We present the case of a patient who sustained severe trauma to the back that resulted in a very unusual and not previously reported pattern of injury. Unsuspected vascular complication resulted in severe evolution with fatal outcome. Case reportThe patient was a 52-year-old man who suffered a work-related accident in which he was struck from behind by a concrete tank that fell from a construction crane. He was admitted to the hospital as an emergency, with T7 complete paraplegia and in subacute respiratory distress. Chest radiographs showed bilateral haemothorax and anterolateral flail chest. Emergency lateral thoracic spine radiograph showed a 6-mm retrolisthesis of the T5 vertebral body over the T6 vertebra and an 11-mm retrolisthesis of T6 over T7 (Fig. 1). The anteroposterior (AP) view was rated normal with good alignment (Fig. 2). Only CT examination provided the basis for the diagnosis. CT scans revealed fractures of the T4, T5 and T6 pedicles, and showed that the T6 vertebral body was in a completely rotated position, with the posterior wall and broken pedicles being actually anterior, whereas the anterior aspect of the vertebral body was posterior, close to the dura (Figs. 3, 4) This suggested that the T6 vertebral body had undergone a complete 180°rotation around a vertical axis at the time of injury (Figs. 5, 6). Significant widening of the gap between the T6 and T7 facet joint was also present, with T6 posterior elements markedly displaced posteriorly, but the whole segment remained in gross alignment.In the intensive care unit, the patient remained a complete paraplegic. The clinical course was characterised by marked respiratory distress, Gram-negative pulmonary infection and severe urinary infection. A tracheostomy was needed on the 6th day, and all other surgery had to be delayed. The general status improved slowly in the intensive care unit, with chest drainage and antibiotics. MR imaging could be performed only after 1 month. It showed severe injury to the spinal cord and abnormal signal of the T6 and anterior part of T5 vertebral bodies (Fig. 7). No vascular abnormalities concerning the great vessels were suspected on the MR or CT studies. The segmental arteries at the level of the fractured vertebra could not be seen on these examinations.Instability due to rotation and the disruption of soft tissues was considered an indication for anterior surgery. The operation was Abstrac...