Multilevel noncontiguous spinal fractures in adolescent idiopathic scoliosis: A report of three cases

Chris Yin Wei Chan; Kumar Shantanu Anand; Mun Keong Kwan

doi:10.4103/isj.isj_44_19

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CASE REPORT

Year : 2020 | Volume : 3 | Issue : 2 | Page : 250-253

Multilevel noncontiguous spinal fractures in adolescent idiopathic scoliosis: A report of three cases

Chris Yin Wei Chan¹, Kumar Shantanu Anand², Mun Keong Kwan¹
¹ Department of Orthopaedic Surgery, National Orthopaedic Centre of Excellence for Research and Learning (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
² Anand Hospital, Purnea, Bihar, India

Date of Submission	13-Jun-2019
Date of Acceptance	12-Aug-2019
Date of Web Publication	13-Jul-2020

Correspondence Address:
Prof. Mun Keong Kwan
Department of Orthopaedic Surgery, National Orthopaedic Centre of Excellence for Research and Learning (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpur.
Malaysia

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/isj.isj_44_19

Abstract

This is a report of three cases of patients with Adolescent Idiopathic Scoliosis who presented with multilevel noncontiguous fractures of the spine. Interestingly, the apical vertebrae of the scoliotic curve were involved in all these three cases. The first patient had a fracture at apical T7 of the main thoracic curve and a fracture dislocation at apical L1 at the compensatory lumbar curve. In the second patient, the fractures occurred at the apex of a lumbar major curve and the compensatory main thoracic curve at L2 and T8, respectively. In the third patient, one of the four fractures occurred over the apex of thoracic curve at T8. Therefore, when a patient with idiopathic scoliosis presents following a high-energy accident, a higher index of suspicion should be maintained to diagnose multilevel fractures, especially over the apical vertebrae. Minimally Invasive Stabilization technique is useful in the stabilization of multilevel noncontiguous spinal fractures in these patients.

Keywords: Adolescent idiopathic scoliosis, fracture, multilevel, noncontiguous, spinal

How to cite this article:
Chan CY, Anand KS, Kwan MK. Multilevel noncontiguous spinal fractures in adolescent idiopathic scoliosis: A report of three cases. Indian Spine J 2020;3:250-3

How to cite this URL:
Chan CY, Anand KS, Kwan MK. Multilevel noncontiguous spinal fractures in adolescent idiopathic scoliosis: A report of three cases. Indian Spine J [serial online] 2020 [cited 2020 Oct 25];3:250-3. Available from: https://www.isjonline.com/text.asp?2020/3/2/250/289652

Introduction

Noncontiguous fractures of the spinal column had been reported in the literature with an incidence as high as 15.4%.^[1],[2],[3] However, the outcome of noncontiguous fractures were comparable to single-level fractures.^[3] Most reports of fractures associated with scoliosis were in patients who had undergone posterior spinal fusion.^[4],[5] This was due to the stress at the junction of the fusion mass. To date, there were no reports of multiple noncontiguous spinal fractures in patients with idiopathic scoliosis who had not undergone spinal fusion. The purpose of this report was to document the pattern of multilevel noncontiguous fractures in patients with idiopathic scoliosis and to report the outcome of such injuries.

Case Report

This report included three patients with Adolescent Idiopathic Scoliosis (AIS) admitted from 2010 to 2015, who presented with multilevel noncontiguous fractures of the spine. [Table 1] summarizes the patients’ demographics and the injury pattern.

Table 1: Patients’ demographics and injury patterns of the three case reports

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Case 1

This was an 18-year-old girl with major depressive disorder. She was unaware of the diagnosis of AIS before the injury. She jumped from height and presented with fracture dislocation at L1 and stable burst fracture at T7 [Figure 1]. She had complete neurological deficit American Spinal Injury Association-A (ASIA-A) from L1 downward with severe lung contusion. She was planned for pedicle screw instrumentation at T10-L4, corpectomy at L1 with anterior column reconstruction with a titanium mesh cage at L1 through an open posterior approach and Minimally Invasive Stabilization technique (MISt) using percutaneous fixation for the T7 fracture. She had massive blood loss intraoperatively following the L1 corpectomy. She received eight packs of allogeneic blood transfusion with five cycles of disseminated intravascular coagulation regime. Decision was made not to proceed with the T7 stabilization due to hemodynamic instability. She was ventilated and nursed in the intensive care unit for five days. She did not have any wound complications. The T7 fracture was treated conservatively with an orthosis. She was discharged 24 days after trauma. At 18 months after trauma, the fractures had united [Figure 2]. No neurological recovery was observed.

Figure 1: Case 1. Preoperative computed tomography scans showing the preexisting scoliosis with fractures at T7 and L1

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Figure 2: Case 1. Postoperative whole spine radiograph and postoperative computed tomography scans at 12 months showing union with no loosening of implants

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Case 2

A 26-year-old gentleman, known case of AIS, had T8 compression and L2 burst fractures following a motor vehicle accident. He did not have any neurological deficit. He also had olecranon fracture and bilateral lungs contusion. He underwent MISt at T7-T9 and T12-L3 using fluoroscopic-guided percutaneous pedicle screws [Figure 3]. Postoperatively, he recovered well with no complications. He was discharged 10 days after trauma. During the latest follow-up, 14 months after trauma, the fractures had united.

Figure 3: Case 2. Preoperative computed tomography scans showing the noncontiguous fractures with preexisting scoliosis. Figure on the right shows the postoperative radiograph

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Case 3

A 45-year-old gentleman presented following a motor vehicle accident. He sustained multiple level fractures at T8, T11, L1, and L3. He did not sustain any neurological injury. He also had a hemothorax on the right side that was managed conservatively. He underwent long construct MISt from T7 to L4 using fluoroscopic-guided percutaneous pedicle screws [Figure 4]. He was discharged eight days after operation. Union of the fractures was confirmed by computed tomography after six months. Implant was removed at 18 months after trauma. After implant removal, no progression of the kyphosis or scoliosis was observed. Dynamic films of the whole spine showed the mobility of the lumbar spine was preserved.

Figure 4: Case 3. Preoperative computed tomography scans, postoperative radiographs, and radiographs after implant removal at 18 months after operation

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Discussion

Patients with idiopathic scoliosis have an altered spinal alignment in the sagittal, coronal, and axial planes. This might change the way a load is being distributed when it is applied to a scoliotic spine. There had been previous reports on the association of osteoporosis or osteopenia with scoliosis. Sadat-Ali et al.^[6] reported significant higher bone mineral density (BMD) in normal girls compared with girls with scoliosis. A similar finding was reported by Cheng et al.,^[7] whereby the 14 girls with osteopenic AIS who were followed up longitudinally showed persistent and significantly lower BMD.

Whether the low BMD predisposes the scoliotic spine to fractures is unknown. There had been no previous documentation of fractures or multilevel noncontiguous spinal fractures in patients with idiopathic scoliosis who had not undergone spinal fusion. In our report, two of the three patients had been previously diagnosed with scoliosis. The third patient, that is, Case 1 was not aware of the diagnosis of scoliosis before the accident.

Interestingly, the apical vertebrae of the scoliotic curve was fractured in all these three cases. The first patient had a fracture at T7 of the main thoracic curve and a fracture dislocation at L1 at the compensatory lumbar curve. In the second patient, the fractures occurred at the apex of a lumbar major curve and the compensatory main thoracic curve at L2 and T8, respectively. In the third patient, one of the fractures occurred over the apex of thoracic curve at T8.

The management of multilevel noncontiguous spinal fractures remains controversial. Mehmet et al.^[8] proposed separate stabilization when there were more than four intervening segments between the fractures. In our cases, Case 1 had to undergo open surgery due to the severity of the fracture dislocation. The second fracture in this patient was treated with an orthosis due to hemodynamic instability developed during the fixation of the fracture dislocation. Cases 2 and 3 were treated with MISt with percutaneous pedicle screws. In Case 2, two separate fixations were performed because there were five intervening segments between the fractures, whereas in Case 3, a single long construct was preferred because of the proximity of the intervening fracture segments. This new surgical technique, MISt was particularly useful in these noncontiguous fractures.

However, whether patients with idiopathic scoliosis are at higher risk for multilevel fractures cannot be concluded from this report. Perhaps when a patient with idiopathic scoliosis presents following a high-energy accident, a higher index of suspicion should be maintained to diagnose multilevel fractures.

Conclusion

In conclusion, this is a report of three cases of idiopathic scoliosis that presented with multilevel noncontiguous spinal fractures where all the apical vertebrae over the apex of the deformity were fractured. MISt is useful in the stabilization of multilevel noncontiguous spinal fractures in such patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There were no conflicts of interest.

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