[gm1973]

#20282

Dear Dr Corenman

First of all may I say how wonderfully generous it is of you to take time to respond to patients and pain sufferers through your website.

This is my case. Sorry it is a bit long. I was a fit and active, healthy male, early 40s. 6 months ago I had a skiing accident. I fell and tried to stop myself by digging my skis into the snow. I hit a bump that was much harder than I expected with straight rigid legs. I instantly felt a shock running up through my legs and back. There was instant acute pain and I even thought to myself, I hope I haven’t just broken my back because of the impact. However I was able to get up and could carry on, albeit with severe knife-like pain and spasms. I did not go to hospital as I thought it was just spasms since I had had an episode of back spasms several years earlier and it felt similar. I went to see my home doctor a week later who gave me a physical exam but did not think there was a fracture since there did not appear to be neurological deficit and I had control of my bowels/bladder. I was prescribed muscle relaxers and painkillers. Two weeks later, still in pain and spasm, I returned to the cinic and was seen by a different doctor. This time I also pointed out that I could feel a bony protrusion in the middle of my back. I had noticed this several days earlier. I do not recall it being present straight after the injury. I had another physical exam and again the conclusion was continued muscle spasms, so I was given more painkillers but also recommended physiotherapy. No x-rays were taken or requested.

I seemed to get some temporary relief from physio which included massage, stretching and taping. The physio thought I had some pelvic rotation and a tender floating rib. Then about six weeks after the injury I started to get the most horrific crushing pain running around my rib cage on the right side when sitting down. It felt like the ribs were being locked in a vice and pulled downwards. The pain extended around the flank into the front abdominal area. I also had some electric-like tingling sensations down my right hand side which I think may have been nerve irritation. This lasted several weeks. It also felt like the muscle that covers the area between the top of the pelvis and the bottom of the ribs had been pulled back. The right side of my torso now looks more concave than the left hand side. By this time, sitting for any length of time was becoming unbearable. I have had an ultrasound on my abdomen which was all clear but I have not had an EMG.

At about 11 weeks after the accident, I finally got my doctors to refer me to an orthopedic specialist. When I described the accident, he instantly suspected a wedge fracture and sent me for an MRI scan. The MRI did indeed reveal a fracture at T12 level. The loss of anterior height was approximately 50% and posterior height was largely maintained. The fracture also looks uneven as if it is crushed more on one side than the other. There is some retropulsion of bone into the canal but the fluid around the cord is intact. The spinous process appears more prominent at this level and to me it looks like there may be some rotation of several verterbrae. My specialist told me that if I had presented with this injury on day 1 he would have stabilised me with instrumentation and bracing. As I had ‘self-mobilised’ my options were: do nothing and see how things progress; have kyphoplasty or have the instrumentation.

I opted for the kyphoplasty since it seemed a less major type of surgery and I knew that it works better the earlier it is performed although by the time it was done it was already 14 weeks since the accident. There was ‘some’ deformity correction achieved but due to the retropulsed fragment, my specialist said he didn’t want to be too agressive for fear of making me worse. He also said he could only approach the verterbra from the left since the right was rather messy.

At my post-op follow-up I was told I had some kyphosis and was told to do 6 months physiotherapy. I work hard in the gym on core strenghtening and stretching. I am fairly straight but there is a rounding in the middle of my back. (It looks like the erector muscles are prominent). I feel good when I exercise or walk (or lie down!) but I still have a lot of discomfort, mainly from sitting still. The protrusion in the middle of my back is still there and that is probably what bothers me the most. It feels like the spinous process is protruding at an angle and it is at just the level you would put your back when sitting in a chair so it is extremely uncomfortable to the point that I am always shifting position and feeling it. It also feels to me like it is not in complete vertical alignment, like it is slightly to the left and I still have some pain and tenderness along my ribs and right side.

Is it possible that I could have some post-traumatic kypho-scoliosis?
Can anything be done to correct the bony protrusion? That is the most bothersome.
Is the discomfort in my flank and ribs related to nerve damage or could it be stenosis? Or could there be damage to the facet joints?
Do I have any more options now? is it too late for further surgery?

I intend to see my specialist again soon in any case.

Thank you for your time

[Donald Corenman, MD, DC]

#20284

It sounds by your description that you had a burst fracture of T12; “There is some retropulsion of bone into the canal”. This is somewhat a common fracture from your mechanism of injury. A burst fracture means that the vertebral body has broken apart like a barrel made of staves and held together with metal bands would do so if dropped from a height (the barrel would “burst” apart).

There is a possibility that you might have had a flexion-distraction fracture. This type of fracture involves not only injury to the bone of the vertebra but also the posterior ligaments (intraspinous, supraspinous and facet capsules). These posterior ligaments prevent the vertebra from falling into kyphosis (bending forward in what is called a tension band) with a “wedge fracture” like you describe. If these ligaments are torn, there is nothing to prevent the spine from falling forward and the kyphosis that is generated is relatively severe (greater than 25 degrees).

If you have significant kyphosis (you use the “Cobb technique” to measure-greater than 25 degrees), then you probably need to consider a surgical repair to straighten out the spine. The”kyphoplasty” is generally not the technique to use to repair these fractures as the cement is incapable of correcting the angulation and fixes the fracture so that healing bone edges may not fully join together.

Find out what your kyphosis of the T11-L1 levels measures. If you have further questions, please let me know if I can help.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

[gm1973]

#20962

Dear Dr. Corenman

I would like to thank you for your time in reading and replying to my previous message.

In the last couple of months, I have been referred to another specialist and had a new CT scan.
The standing segmental kyphosis is about 32 degrees. Is that the same thing as cobb angle? Apparently I am not particularly out of balance sagitally but I do notice the more rounded shape of my mid-back. I find I get progressively fatigued during the day and frequently have to lie down.

The T12 is crushed into a trapezoid. The crush and kyphosis is more marked on the right versus the left. There is also marked degenerative change at L2/3 but also L1/2 and L3/4. Given the more widespread change, the specialist would prefer to avoid surgery since it should also include those levels and would be extensive.
I am curious what type of surgery that would be or what you might consider? From our conversations, I think the suggestion for the repair of T12 would be osteotomy or corpectomy of T12 with cage reconstruction done via transpedicular approach. I was a little surprised by that since I thought you would have to approach this level through the ribs. As for the lumbar region, what would have to be done in that area? I understand degenerative changes are common from age 30 onwards but I was shocked to see the black on the scans and the reduced disc space. I am aware that some changes have developed over years but is it also possible for trauma to produce a drastic change or acceleration in the degeneration?

Finally, do you have any opinion on how successful surgeries of this type are? I worry that I might be able to get by now but what about later life? So would I be better off doing something now and going through the recovery while I am still young and strong enough to do so?

Thank you again for your generosity and time.

[Donald Corenman, MD, DC]

#20970

The “kyphosis” measuring 32 degrees (measured by the Cobb methods) is substantial and in my opinion, needs to be fixed surgically.

The junction between the thoracic and the lumbar spines should be “straight” but your fracture has deformed the spine to a 32 degree angulation. This means the lumbar spine has to compensate for this angulation by bending backwards (extension) by another 32 degrees. This increases facet pressure and can cause early wear and lower back pain.

The fracture angulation will also generally be painful with standing and loading (lifting).

The surgical repair is common as these fractures are relatively common and generally can be approached only from the back of the spine. Approach depends upon forced extension X-rays as to how much the fracture will “straighten out”. This is done by having you lie on an X-ray table with a bolster under your fracture and having the tech press down on your chest and pelvis to look for correction.

If this is a T12 fracture, generally there would be pedicle screws in T10 through L1 to develop enough “hold” to keep the level straight while it heals.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

[gm1973]

#20993

Dear Dr

Thank you for your reply. You make it sound so routine and simple, where do I sign up?!

Seriously though, the injury was in February and the T12 has now healed. There is some cement in the bone and it is now a fixed, rigid deformity. Does that make a difference to the type of procedure and the complexity?
I feel like I would like to have this corrected but I am currently being advised against it because any treatment should also include the degenerative lower levels, down to L3 or L4, so that would be more extensive surgery. Would that involve just screws or would those levels have to be fused as well?

[Donald Corenman, MD, DC]

#21029

The angulation generally can be corrected significantly with a T10-L1 fusion. This of course really depends upon fracture configuration and the stiffness of the deformity. Generally, I have been able to correct these deformities to a minimum of 15 degrees of kyphosis in a stiff spine if not fully straight in a supple spine.

The lower vertebra, if not painful (and most likely are not painful) should be left alone. If you had significant lower back pain prior to the injury, a work-up needs to be completed of the lower vertebra to determine if any of those are pain generators.

I would just think about converting the “bent spine” to a more straightened one to reduce pressure on the vertebra above and below.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

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