Brief Communication Communication abrégée

Late neurologic deterioration after nonoperative treatment of a Chance fracture in an adolescent

Aaron Campbell, MD; David Yen, MD

njuries to the spine in children and and shattering of the pedicles, complete Chance fracture with late neurologic de- I adolescents are uncommon,1 and few disruption of the lamina of L3 with no terioration possibly due to progression reports on Chance-type fractures in this connection of the inferior articulation deformity. We carried out an L3 laminec- population exist.2 Differences between facets and the body.” The documented tomy, posterior segmental instrumenta- pediatric and adult spinal injuries have original diagnosis was that of an “L2–3 tion and fusion using cancellous iliac been noted,1 and the need for separate Chance fracture.” Treatment consisted of crest grafting from L1–4, as well as classification and treatment strategies for hyperextension on a Stryker frame for 3 an anterior release and fusion with iliac flexion-distraction injuries in children weeks with reported good correction of have been recognized.2,3 Still, there is lit- the deformity on the radiograph. This tle evidence to guide treatment and mini- was followed by immobilization for 3 mal data on long-term follow-up. We months in extension in a plaster body present the case of an adult in whom cast with reported maintenance of the neurologic symptoms developed many corrected alignment with slight kyphosis years after nonoperative treatment of a at the fracture site on on the radiographs. Chance fracture. At 2-year follow-up she was stated to be asymptomatic, fully active with no neuro- Case report logic symptoms and radiographs that were essentially unchanged. A 37-year-old woman complained of On examination at the time of her back pain radiating into both legs, associ- current presentation, she had a bilateral ated with leg weakness and numbness bi- high-stepping drop- gait. She was laterally, which had progressed slowly unsteady while walking and could only over several years to the point of signifi- travel 15 m before having to rest because cant disability and the need for narcotic of claudicant leg pain. Radiographs analgesia. At 15 years of age, she had sus- demonstrated anterior wedging of L3 tained a back injury in a motor vehicle with retrolisthesis of L3 on L4 (Fig. 1). collision. At that time she had hypoesthe- The kyphosis angle was 36° and horizon- sia in the L4 nerve root distribution in tal displacement was 44% as measured by her left leg that gradually resolved during the method of Denis and colleagues4 and her hospitalization. There was no motor Dupuis and associates,5 respectively. deficit. Radiographs were reported as Computed tomography showed a split in showing “a compression fracture of the the L3 spinous process and pars interar- anterior portion of the L3 vertebral body ticularis (Fig. 2), as well as severe central FIG. 1. Radiograph demonstrates ante- with a horizontal fracture line and sepa- spinal stenosis (Fig. 3). rior wedging of L3 with retrolisthesis of L3 ration of the posterior rim of the body A diagnosis was made of a remote on L4.

Department of Surgery, Queen’s University, Kingston, Ont. Accepted for publication Mar. 17, 2003. Correspondence to: Dr. David Yen, Douglas 5, Kingston General Hospital, 76 Stuart St., Kingston ON K7L 2V7; fax 613 548-2518; [email protected]

' 2003 Canadian Medical Association Can J Surg, Vol. 46, No. 5, October 2003 383 Campbell and Yen

crest strut bone graft and instrumenta- slightly wedged anteriorly.7 Later, How- population was “characteristically be- tion from L2–3 (Fig. 4). The radio- land and associates8 described a similar nign” and that late morbidity was not graphic findings were confirmed at “Chance fracture” that exited in the an- generally seen.1 Of the 7 “Chance-type” surgery, together with the discovery of a terior vertebral body and was associated fractures reported by Reid and col- fracture of the left transverse process. with the use of a lap belt. In 1968, Smith leagues,16 6 were treated with bedrest and Three months postoperatively, the poste- and Kaufer9 better defined the relation- postural reduction followed by applica- rior instrumentation from L1 was re- ship between lap belts and spinal injury tion of a body cast. Only 1 patient re- moved to provide better motion and the and postulated tension, created by forced quired operative treatment for progres- previous bone graft was augmented. extension about the belt as the mecha- sive refractory kyphosis. Six fractures There were no surgical complications. nism of injury. demonstrated satisfactory healing. In 1 At 9 months, the patient had signifi- With increased use of lap belts, associ- patient, a paraplegic, a slight kyphosis de- cant improvement in her back-specific ated lumbar spinal injuries become more veloped at the fracture site. Average pro- health status as measured by her score on common. Subsequent research elucidated gression in the kyphosis angle was 3°. the Roland–Morris Disability Question- various patterns of lumbar flexion-distrac- Similarly, Rumball and Jarvis3 re- naire6 (4 v. 21 preoperatively). She no tion injuries and their pathomechanics.9–12 viewed 10 cases of pediatric “Chance longer required narcotic analgesia and Further, the occurrence of “Chance-type” fracture.” Nine of these were treated had returned to horseback riding. Al- fractures among children and adolescents conservatively. One patient underwent though her walking and exercise toler- as well as the characteristics that distin- laminectomy for persistent ance had improved considerably, she still guish them from those of the adults were and eventually required fusion 5 years had a slow, unsteady drop-foot gait. reported.13–16 after the original injury. Although they The literature on flexion-distraction noted the uniqueness of these injuries in Discussion injuries in children and adolescents is the pediatric population and developed a restricted to a few small series and case classification system for these injuries, the In 1948, Chance7 reported 3 cases of reports. Although a few reports have authors did not comment on how such spinal fractures in which the fracture line described surgical treatment of these in- classification should guide treatment. extended transversely through the spin- juries1,9 and operative management was In reviewing 12 cases of flexion- ous process and neural arch to exit in the recommended for adolescent patients in distraction injuries in patients younger posterior-superior vertebral end plate. a recent review article,17 the majority of than 16 years, Glassman and associates2 These were believed to be flexion-type reported cases have been managed con- injuries, although the author could not servatively with generally good results. A explain why the vertebral body was only review of 42 children and adolescents with various spinal fractures noted that the natural history of spinal injury in this

FIG. 4. Surgery consisted of an L3 laminectomy, posterior segmental in- FIG. 2. Computed tomography coronal strumentation and fusion with insertion reconstruction demonstrating a split in of cancellous iliac crest bone graft from the L3 spinous process and pars interar- FIG. 3. Axial computed tomography L1–4, plus an anterior release and fusion ticularis. shows severe central spinal stenosis. from L2–3.

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compared the outcomes of surgical versus neurologic deterioration and possibly late 9. Smith WS, Kaufer H. Patterns and mecha- nonsurgical therapy. Injuries were classified instability followed initially successful nisms of lumbar injuries associated with lap seat belts. J Bone Joint Surg Am 1969; as bony, ligamentous or combined, and nonoperative treatment. 51:239-54. this classification together with the pa- 10. Gumley G, Taylor TK, Ryan MD. Distrac- Competing interests: None declared. tient’s overall status determined treatment. tion fractures of the lumbar spine. J Bone Bracing was determined to be a viable Joint Surg Br 1982;64:520-5. treatment option not only for bony injuries References 11. Denis F. The three column spine and its significance in the classification of acute but also for some ligamentous and com- 1. Hubbard DD. Injuries of the spine in chil- thoracolumbar spinal injuries. Spine 1983; bined injuries. An initial kyphosis angle of dren and adolescents. Clin Orthop 1974; 8:817-31. less than 20° was considered to be a pre- 100:56-65. 12. Gerzbien SD, Court-Brown CM. Flexion dictor of good outcome with bracing. 2. Glassman SD, Johnson JR, Holt RT. Seat distraction injuries of the lumbar spine. To date there is little published evi- belt injuries in children. J Trauma 1992; Mechanism of injury and classification. Clin Orthop 1988;227:52-60. dence to guide the treatment of flexion- 33:882-6. 3. Rumball K, Jarvis J. injuries of 13. Holt BW. Spines and seat belts: mecha- distraction injuries of the lumbar spine in the spine in young children. J Bone Joint nisms of spinal injury in motor vehicle children and adolescents. Although some Surg Br 1992;74:571-4. crashes. Med J Aust 1976;2:411-3. authors believe the principles of adult 4. Denis F, Ruiz H, Searls K. Comparison 14. Argan PF, Dunkle DE, Winn DG. Injuries management can be applied to children between square-ended distraction rods to a sample of seat belted children evaluated in a hospital emergency room. J Trauma and adolescents,18 others have advocated and standard round-ended distraction rods in the treatment of thoracolumbar 1987;27:58-64. specific injury classification systems3 and spinal injuries. A statistical analysis. Clin 15. Vandersluis R. The seat belt syndrome. treatment strategies for the pediatric Orthop 1984;189:162-7. CMAJ 1987;137:1023-4. population.2 The literature consists of 5. Dupuis PR, Yong-Hing K, Cassidy JD, 16. Reid AB, Letts RM, Black GB. Paediatric only isolated case reports and a few small Kirkaldy-Willis WH. Radiologic diagnosis Chance fractures: association with intra- abdominal injuries and seat belt use. J studies with limited follow-up. One case of degenerative lumbar spinal instability. Spine 1985;10:262-76. Trauma 1990;30:384-91. of late instability after a missed diagnosis 6. Roland M, Fairbank J. The Roland–Mor- 17. Clark P, Letts M. Trauma to thoracic and 19 has been reported. To our knowledge, ris Disability Questionnaire and the Os- lumbar spine in the adolescent. Can J no cases of late neurologic deterioration westry Disability Questionnaire. Spine Surg 2001;44:337-45. or instability after treatment of a 2000;25:3115-24. 18. Triantafyllou SJ, Gertzbein SD. Flexion dis- “Chance-type” injury has been reported. 7. Chance GQ. Note on type of flexion fracture traction injuries of the thoracolumbar spine: of the spine. Br J Radiol 1948;21:452-3. a review. Orthopaedics 1992;15:357-64. Given the paucity of published out- 8. Howland WJ, Curry JL, Buffington CB. 19. Bouliane MJ, Moreau MJ, Mahood J. In- comes, we wish to contribute this case to Fulcrum injuries of the lumbar spine. stability resulting from a missed Chance the literature as an example in which JAMA 1965;193:240-1. fracture. Can J Surg 2001;44:61-2.

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