Asymmetrical pedicle subtraction osteotomy for progressive kyphoscoliosis caused by a pediatric Chance fracture: a case report
© The Author(s). 2017
Received: 23 March 2016
Accepted: 27 February 2017
Published: 14 March 2017
Although most pediatric Chance fractures (PCFs) can be treated successfully with casting and bracing, some PCFs cause progressive spinal deformities requiring surgical treatment. There are only few reports of asymmetrical osteotomy for PCF-associated spinal deformities.
We here report a case of a 10-year-old girl who suffered an L2 Chance fracture from an asymmetrical flexion-distraction force, accompanied by abdominal injuries. She was treated conservatively with a soft brace. However, a progressive spinal deformity became evident, and 10 months after the injury, examination showed segmental kyphoscoliosis with a Cobb angle of 36°, a kyphosis angle of 31°, and a coronal imbalance of 30 mm. Both the coronal and sagittal deformities were successfully corrected by asymmetrical pedicle subtraction osteotomy.
Initial kyphosis and posterior ligament complex should be evaluated at some point when treating PCFs. Asymmetrical pedicle subtraction osteotomy can be a useful surgical option when treating rigid kyphoscoliosis associated with a PCF.
KeywordsChance fracture Flexion-distraction injury Kyphoscoliosis Asymmetrical pedicle subtraction osteotomy Case report
Chance fractures, which are flexion-distraction injuries of the spine, were defined by George Quentin Chance in 1948 as a fracture line passing transversely through the spinous process, laminae, and pedicle and then into the vertebral body . Chance fractures account for 5–11% of the acute thoracolumbar spinal injuries in adults [2, 3]. Although pediatric spinal injuries are more unusual, affecting only 0.3–4% of the pediatric population, they have become more common due to mandatory seat-belt laws [4–6]. Of these injuries, about 43–50% consist of pediatric Chance fractures (PCFs) . The treatment of these fractures depends on the fracture pattern as well as neurologic status . Purely osseous injuries with minimal deformity, and even those involving ligamentous injuries, have been treated conservatively, and these injuries have a good prognosis in pediatric patients . However, in some cases, surgery is required to correct a kyphotic deformity or to halt neurological deterioration or a progressive deformity [5, 7]. Surgeries to treat chronic, rigid deformities caused by PCF are rare [8–10]. We here report a case of a 10-year-old girl with rigid, chronic-phase kyphoscoliosis caused by a PCF. The kyphoscoliosis was successfully treated by asymmetrical pedicle subtraction osteotomy (PSO) at the affected vertebra.
In 1948, George Quentin Chance characterized a type of fracture with “horizontal splitting of the spine and neural arch .” Nicoll proposed the term “Chance fracture” in 1949 . Most cases are associated with a flexion-distraction injury obtained in a motor vehicle accident . In children, however, 2-point restraints and improperly used restraints have increased the incidence of PCFs at the lumbar spine, often at L2 or L3 . As a result of anatomical characteristics, Chance injuries are more likely to cause neurological issues in children than in adults: 15–43% of PCFs involve neurological deficits [7, 13, 14].
PCF post-traumatic deformities
Delayed displacement and progressive deformities have been reported after conservative therapy for PCF [7, 8, 13, 15, 16]. To summarize the reports, in Chance fractures, the threshold of kyphosis angle for surgical indication was ranged from 15° to 22°. However, taking standing radiographs for assessing initial kyphosis will be difficult in the situation of an acute spinal injury. Additionally, more attention will be paid for the possible concomitant injuries including abdominal viscera and vascular injuries at the time of injury. In our patient’s case, the initial lumbar scoliosis at L1–L3 was 18° in a supine position. Based only on the scoliosis, conservative treatment was a reasonable choice. Additionally, since treatments for abdominal injuries had the priority in this case, the delay in the evaluations for kyphosis angle and damages of posterior ligament complex were inevitable. The case report is therefore an important lesson of what can happen if an unstable asymmetrical Chance fracture is not well managed in the acute phase after trauma.
Treatment of PCFs
Outcomes of conservative therapy for PCFs are relatively good; however, some PCFs should be treated surgically to correct an initial kyphotic deformity or to prevent further neurological deterioration or a progressive deformity . Since the injury of PCFs is mainly the posterior osteoligamentous complex, reduction and stabilization with posterior instrumentation should be considered . When treating acute PCFs surgically, pedicle screw instrumentation, which extended one or two levels above and below the affected vertebra, seems to be a popular treatment . With a recent progress of spinal instrumentations, percutaneous pedicle screw fixation may have evolved as an alternative approach for PCFs [5, 20]. On the other hand, there are only a few reports of surgical treatment for chronic deformities due to PCFs, including combined anterior and posterior fusion surgery, transforaminal thoracic interbody fusion, and transpedicle wedge osteotomy and posterior fusion [8, 21, 22]. Asymmetrical PSO, which was first reported in 2012 by Sathya et al. , is not a novel technique; however, it seems to be rare rerated to a report of asymmetrical PSO for a chronic pediatric Chance fracture. Our patient’s spinal deformity was caused by a deformity of the fractured L2 vertebra, so we judged that short fusion with asymmetrical PSO was sufficient to correct the affected vertebra. Our osteotomy procedure included partial resection of the pedicle, vertebral body, and adjacent disc in an applied grade 4 osteotomy, according to the classification system of anatomically based spinal osteotomies proposed by Schwab et al. . In this case, we intended to fuse from T12 to L3 for the maintenance of spinal alignment after correction of scoliosis and kyphosis. The application of without fusion technique at L2/L3 fact joints and future removal of the spinal implants might be another option to preserve motion segment at L2/L3. However, we have removed posterior ligamentous complex at L2/L3 during the surgery and were afraid of the occurrence of distal junctional problem after removal of the implants.
Initial kyphosis and posterior ligament complex should be evaluated at some point when treating PCFs. Asymmetrical PSO is not a novel technique; however, there are only few reports of asymmetrical osteotomy for PCF-associated spinal deformities. Asymmetrical pedicle subtraction osteotomy can be a useful surgical option when treating rigid kyphoscoliosis associated with a PCF.
Pediatric Chance fracture
Pedicle subtraction osteotomy
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All authors read and approved the final manuscript. KW conceived the study, participated in the design of the study, helped to write the manuscript, and revised it critically. SS participated in its design and drafted the manuscript. NF, TH, AI, KI, and NM participated in the study design and helped to draft the manuscript. MM conceived, designed, and coordinated the study and drafted the final manuscript.
The authors declare that they have no competing interests.
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Written informed consent was obtained from the parents of the young patient for the publication of this case report and any accompanying images.
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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Chance GQ. Note on a type of flexion fracture of the spine. Br J Radiol. 1948;21:452–3.View ArticlePubMedGoogle Scholar
- Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine. 1983;8:817–31.View ArticlePubMedGoogle Scholar
- Gumley G, Taylor TK, Ryan MD. Distraction fractures of the lumbar spine. J Bone Joint Surg (Br). 1982;64:520–25.Google Scholar
- Campbell DJ, Sprouse 2nd LR, Smith LA, Kelley JE, Carr MG. Injuries in pediatric patients with seatbelt contusions. Am Surg. 2003;69:1095–99.PubMedGoogle Scholar
- Le TV, Baaj AA, Deukmedjian A, Uribe JS, Vale FL. Chance fractures in the pediatric population. J Neurosurg Pediatr. 2011;8:189–97.View ArticlePubMedGoogle Scholar
- Lutz N, Nance ML, Kallan MJ, Arbogast KB, Durbin DR, Winston FK. Incidence and clinical significance of abdominal wall bruising in restrained children involved in motor vehicle crashes. J Pediatr Surg. 2004;39:972–75.View ArticlePubMedGoogle Scholar
- Glassman SD, Johnson JR, Holt RT. Seatbelt injuries in children. J Trauma. 1992;33:882–6.View ArticlePubMedGoogle Scholar
- Campbell A, Yen D. Late neurologic deterioration after nonoperative treatment of a Chance fracture in an adolescent. Can J Surg. 2003;46:383–5.PubMedPubMed CentralGoogle Scholar
- Keene JS, Lash EG, Kling Jr TF. Undetected posttraumatic instability of “stable” thoracolumbar fractures. J Orthop Trauma. 1988;2:202–11.View ArticlePubMedGoogle Scholar
- Reid AB, Letts RM, Black GB. Paediatric Chance fractures: association with intraabdominal injuries and seat belt use. J Trauma. 1990;30:384–91.View ArticlePubMedGoogle Scholar
- Nicoll EA. Fractures of the dorso-lumbar spine. J Bone Joint Surg (Br). 1949;31:376–94.Google Scholar
- Louman-Gardiner K, Mulpuri K, Perdios A, Tredwell S, Cripton PA. Pediatric lumbar Chance fractures in British Columbia: chart review and analysis of the use of shoulder restraints in MVAs. Accid Anal Prev. 2008;40:1424–9.View ArticlePubMedGoogle Scholar
- Arkader A, Warner Jr WC, Tolo VT, Sponseller PD, Skaggs DL. Pediatric Chance fractures: a multicenter perspective. J Pediatr Orthop. 2011;31:741–4.View ArticlePubMedGoogle Scholar
- Rumball K, Jarvis J. Seat-belt injuries of the spine in young children. J Bone Joint Surg (Br). 1992;74:571–4.View ArticleGoogle Scholar
- Bouliane MJ, Moreau MJ, Mahood J. Instability resulting from a missed Chance fracture. Can J Surg. 2001;44:61–2.PubMedPubMed CentralGoogle Scholar
- Reilly CW. Pediatric spine trauma. J Bone Joint Surg Am. 2007;89 Suppl 1:98–107.PubMedGoogle Scholar
- Vaccaro AR, Silber JS. Post-traumatic spinal deformity. Spine. 2001;26:S111–8.View ArticlePubMedGoogle Scholar
- Wood KB, Li W, Lebl DR, Ploumis A. Management of thoracolumbar spine fractures. Spine J. 2014;14:145–64.View ArticlePubMedGoogle Scholar
- Daniels AH, Sobel AD, Eberson CP. Pediatric thoracolumbar spine trauma. J Am Acad Orthop Surg. 2013;21:707–16.PubMedGoogle Scholar
- Phan K, Rao PJ, Mobbs RJ. Percutaneous versus open pedicle screw fixation for treatment of thoracolumbar fractures: systematic review and meta-analysis of comparative studies. Clin Neurol Neurosurg. 2015;135:85–92.View ArticlePubMedGoogle Scholar
- Huang RC, Meredith DS, Taunk R. Transforaminal thoracic interbody fusion (TTIF) for treatment of a chronic Chance injury. HSS J. 2010;6:26–9.View ArticlePubMedGoogle Scholar
- Okuyama K, Sasaki H, Kido T, Chiba M. A chronic flexion-distraction injury with a “fistulous wither” on the split spinous process of the L1 vertebra—a case report of a modified transpedicle wedge osteotomy. Eur Orthop Traumatol. 2013;4:253–7.View ArticlePubMedPubMed CentralGoogle Scholar
- Thambiraj S, Boszczyk BM. Asymmetric osteotomy of the spine for coronal imbalance: a technical report. Eur Spine J. 2012;21:S225–9.View ArticlePubMedGoogle Scholar
- Schwab F, Blondel B, Chay E, Demakakos J, Lenke L, Tropiano P, et al. The comprehensive anatomical spinal osteotomy classification. Neurosurgery. 2014;74:112–20.View ArticlePubMedGoogle Scholar