Expert’s comment concerning Grand Rounds case entitled “Multiple revisions in a L2 burst fracture in a suicide jumper: a retrospective analysis of what went wrong” (by P. Gahr, S. K. Tschöke, D. Haschtmann, Christoph-E. Heyde)

Excerpt

This case description is a complex trauma case in a 35-year-old female patient. This patient had her index surgery performed at an outside facility and a first revision surgery 12 months later in the author’s department. The first time a purely posterior instrumentation from T12 to L3 was carried out in this multilevel fracture including T12, L1 and L2. While the L2 fracture was considered a complete burst fracture with 80% of canal compromise and consecutive paraplegia, the fractures of T12 and L1 were considered as stable fractures. When 12 months later the construct failed into kyphosis with new onset neurologic findings, a combined anterior and posterior surgery was done between L1 and L3 to reconstruct the anterior column with an expandable cage replacing L2, augmented with an anterior rod system. Simultaneously the posterior rod system was replaced by a fracture system. Seven months after the second operation, there was again a revision done with again a combined approach with posterior stabilization from T11 to L4 and an anterior support with a partial corpectomy of L1 and complete corpectomy of L2 replacing these defects by a long Mesh cage. Again 7 months later due to infection an additional surgery was necessary. More than 6 weeks later a final revision with a partial corpectomy of T12 was done. Therefore, this patient had five surgeries for a fracture, which seems in the CT reconstruction to be a fracture of T12, L1 as well as L2. L2 is a complete burst fracture with a significant posterior fragment, however, with a disruption of the posterior elements, which speaks rather for a B-injury than a simple A-injury. The vertebral body of L1 is not so sure a stable fracture, since at least in the CT reconstruction the vertebral body of L1 has a wedge configuration. Unfortunately there are no other X-rays available to understand this fracture, however, looking at the Fig. 2, where a posterior stabilization and reduction has been done it seems that the L1 vertebra is reduced, which speaks for the fact that there has also been a disruption between T12 and L1 for rendering this level unstable. …