Introduction

With a prevalence that increases with age, there are approximately 1.5 million vertebral compression fractures diagnosed in the United States annually, with treatment costs nearing three quarters of a billion dollars. Of those, an estimated 14.5% will have morphology of a pincer or split fracture. This is defined as a vertical fracture through the vertebral body, involving the superior and inferior end plates but sparing the anterior and posterior wall. Although not classically unstable, this particular fracture morphology is associated with an increased risk of displacement and painful nonunion that often requires surgical intervention (Alexandru & So, 2012; Gotzen et al., 1994; Krbec & Stulik, 1997; Reinhold et al., 2013).

Case Presentation

A 48-year-old man presented to the emergency department with polytrauma sustained in a rollover motor vehicle accident. Primary orthopaedic injuries included a right open tibia fracture and L5 pincer or split fracture (see Figures 1 and 2). Fortunately, the patient was otherwise neurovascularly intact, a relatively healthy nonsmoker, and independent with bowel and bladder functions. Given the nature of the tibial injury, requiring multiple surgeries during his 16-day hospital stay, with a plan for non-weight-bearing at the time of discharge, it was decided to trial conservative management for the lumbar pincer fracture.

Figure 1. Computed tomographic scan of the lumbar spine. Consecutive sagittal images with an arrow denoting pincer/split fracture of L5 vertebral body.

Figure 2. Weighted series MRI as noted. Note vertical orientation of the fracture on sagittal images. On the axial image, an arrow denotes pincer/split fracture of the vertebral body. (A) MRI sagittal STIR; (B) MRI sagittal T1; and (C) MRI axial T2. MRI = magnetic resonance imaging; STIR = short-TI inversion recovery.

Management

Prior to discharge, the patient was fitted for a custom thoracolumbosacral orthosis (TLSO) with thigh extension. Upright radiographs were obtained to ensure alignment and stability of fracture fragments. He was given instructions for strict brace wear when other than supine and neutral. He was subsequently discharged to a skilled nursing facility and was followed on an outpatient basis with serial radiographs (Alexandru & So, 2012; Gotzen et al., 1994; Krbec & Stulik, 1997; Reinhold et al., 2013).

The patient was seen in the outpatient clinic at 2- to 3-week intervals for the initial 8 weeks following discharge from the hospital. During this time, alignment remained stable but he had continued low back pain and no convincing radiographic evidence of healing. His tibia had fortunately healed nicely, and at 10-week follow-up, he was being allowed to progress weight-bearing. Despite reporting absolute compliance with brace and spine precautions, in the following weeks, he had further issues with ongoing back pain, severe enough to limit his progress in weight-bearing activities. He was becoming increasingly dependent on the use of oxycodone. He remained neurovascularly intact and so repeat computed tomography (CT) was performed to evaluate for healing (see Figure 3). With painful nonunion confirmed, notably given severity of patient-reported function limiting symptoms, consent was obtained to proceed with stabilization via expandable cage corpectomy and posterior spinal instrumentation and fusion (see Figure 4; Alexandru & So, 2012; Chen et al., 2017; Gotzen et al., 1994; Krbec & Stulik, 1997; Reinhold et al., 2013).

Figure 3. Follow-up computed tomographic scan. No evident interval bone formation to indicate healing of L5 pincer fracture.

Figure 4. Postoperative radiographs, anteroposterior (A) and lateral (B) images. Corpectomy cage and (B) posterior instrumentation stabilize the pincer fracture and adjacent segments.

Discussion

Compressive forces commonly seen in motor vehicle accidents, falls, and high-energy impact sports can cause significant injury to the spinal column. Radiographs are helpful in evaluating gross osseous abnormality and overall alignment, but advanced imaging, typically magnetic resonance imaging (MRI) or CT, is necessary for proper identification and classification of spinal fractures. Several classification systems exist, with the AO Spine Injury Classification system seemingly the most widely reported, with several independent studies in the past decade confirming reliability in thorough literature review and provider forums. It is important to note, although applicable and pertinent for initial diagnosis and management, interobserver variability can still be quite high and no classification system can reliably predict patient healing or the potential for progression in kyphosis, as is so often seen in the setting of associated compression-type fractures (Alexandru & So, 2012; Crim et al., 2022; Gotzen et al., 1994; Reinhold et al., 2013; Schnake et al., 2017; Vaccaro et al., 2013).

In managing spinal fractures, appropriate initial diagnosis of fracture type and stability, as well as prompt assessment of patient neurological status, is paramount in deciding on the need for early surgical intervention. Regular short-interval follow-up is necessary to assess stability in alignment, radiographic healing, anticipated improvements in pain, and reevaluation of neurological function. A persistence of symptoms, primarily back pain in regard to compression-type injuries, or a deterioration in neurological status may necessitate later surgical intervention despite appropriate conservative management. Special care and attention should be given to any patient with concomitant osteopenia/osteoporosis. For most stable injuries, conservative management with brace wear, spinal precautions, medications for associated symptoms, and time will be sufficient (Alexandru & So, 2012; Chen et al., 2017; Gotzen et al., 1994; Krbec & Stulik, 1997; Reinhold et al., 2013).

References