Chapter 219 Management of a Patient with Thoracolumbar Fracture with Complete Myelopathy and a 40-Degree Kyphotic Deformity
Operative or Recumbent Management
Operative Management
The 40-degree kyphotic deformity in a patient with a thoracolumbar fracture with complete myelopathy suggests that this patient has sustained a flexion-compression injury with wedging of the vertebral body. Because myelopathy is complete, decompression is not likely to improve the patient’s neurologic status.1 However, there is a very small possibility of recovery, which I believe supports strong consideration of decompression. Continued compression also may delay syringomyelia and/or pain following injury, again arguing for decompression and stabilization.
Because stabilization is the main goal of treatment, either a ventral or dorsal approach would be appropriate. Corpectomy and instrumentation may be performed, or a dorsal long- or short-segment pedicle screw construct may be used. The decision often is made based on the need for ventral column support. If there is substantial comminution of the vertebral body, significant spacing between the fragments, or inability to correct the kyphosis adequately, ventral column reconstruction or long-segment dorsal instrumentation will be required.2 If surgery is chosen, correction of deformity should be attempted. This may be accomplished either ventrally or dorsally. In my experience, there is minor loss of correction following either ventral or dorsal reconstruction. No correlation has yet been demonstrated between residual kyphosis and clinical outcome, including pain following treatment (including nonoperative management).3
Bracken M.B., Shepard M.J., Collins W.F.Jr., et al. Methylprednisolone or naloxone treatment after acute spinal cord injury: 1-year follow-up data. Results of the second National Acute Spinal Cord Injury Study. J Neurosurg. 1992;76(1):23-31.
Brown C.W., Gorup J.M., Chow G.H. Nonsurgical treatment of thoracic burst fractures. In: Zdeblick T.A., Benzel E.C., Anderson P.A., Stillerman C.B., editors. Controversies in spine surgery. St. Louis: Quality Medical; 1999:86-96.
Frankel H.L., Hancock D.O., Hyslop G., et al. The value of postural reduction in the initial management of closed injuries of the spine with paraplegia. Part I. Paraplegia. 1969;7:179-192.
Thomas K.C., Bailey C.S., Dvorak M.F., et al. Comparison of operative and nonoperative treatment for thoracolumbar burst fractures in patients without neurological deficit: a systematic review. J Neurosurg Spine. 2006;4(5):351-358.
1. Bracken M.B., Shepard M.J., Collins W.F.Jr., et al. Methylprednisolone or naloxone treatment after acute spinal cord injury: 1-year follow-up data. Results of the second National Acute Spinal Cord Injury Study. J Neurosurg. 1992;76(1):23-31.
2. Brown C.W., Gorup J.M., Chow G.H. Nonsurgical treatment of thoracic burst fractures. In: Zdeblick T.A., Benzel E.C., Anderson P.A., Stillerman C.B., editors. Controversies in spine surgery. St. Louis: Quality Medical; 1999:86-96.
3. Patel A.A., Dailey A., Brodke D.S., et al. Thoracolumbar spine trauma classification: the Thoracolumbar Injury Classification and Severity Score system and case examples. J Neurosurg Spine. 2009;10(3):201-206.
Recumbent Management
An acute fracture of the lower half of the thoracic spine or lumbar spine with an angulation of 40 degrees and a complete myelopathy is inherently unstable. Such an angular deformity with compromise of the spinal canal is associated with fracture of the vertebral body, and, more than likely, disruption of the posterior ligaments. Based on biomechanical and clinical data, criteria for instability in this case are satisfied.1–3 The medical condition of the patient permitting, appropriate management acutely will most likely consist of decompression, correction of deformity, and stabilization. Indeed, recently a large number of spinal implants advocated for the achievement of immediate stability have become available. The intent of such an approach has been early mobilization of the patient, a shorter hospital stay, and the achievement of neural decompression, reduction, and stabilization. These goals, however, have not always been achieved, rekindling an interest in nonoperative recumbent treatment. Such nonoperative management of thoracolumbar fractures is by no means novel. It initially was advocated in the 1940s with Guttman4
