Management of T11 Hyperextension-Type 3-Column Chance Fracture
A T11 hyperextension-type 3-column Chance fracture requires urgent surgical stabilization due to extreme instability and high risk of neurological deterioration, even in patients presenting without initial neurological deficits. 1, 2
Immediate Assessment and Stabilization
Critical Initial Evaluation
- Assess neurological status immediately using standardized motor scoring (ASIA scale), as these injuries can present with deceptively mild or absent neurological findings initially but carry high risk of delayed paraplegia 1, 2
- Obtain advanced imaging urgently with MRI of the complete spine to evaluate the full extent of ligamentous disruption, disc injury, and spinal cord involvement, as plain radiographs and CT significantly underestimate injury severity in hyperextension 3-column injuries 1, 2
- Provide immediate pain control with appropriate analgesics before diagnostic workup 3, 4
Key Imaging Findings to Identify
- MRI will demonstrate disruption of anterior longitudinal ligament (ALL), posterior longitudinal ligament (PLL), ligamentum flavum, supraspinous and interspinous ligaments, and facet capsules 1
- Look for disc disruption and herniation, which can cause delayed spinal cord compression even after initial stabilization 2
- CT may show subtle endplate fractures, facet joint widening, spinous process deformity, and small fracture fragments in the spinal canal that indicate severe underlying instability 1
Definitive Management
Surgical Intervention (Strongly Recommended)
Proceed with urgent posterior spinal decompression, instrumentation, and fusion as the standard of care for this injury pattern 1, 2. The rationale includes:
- Three-column ligamentous injuries are extremely unstable despite potentially benign clinical presentation, with documented tendency to "fish mouth" and hyperextend intraoperatively 1
- High risk of delayed neurological deterioration has been documented, with cases of patients developing incomplete paraplegia up to 20 days post-injury from progressive disc herniation compressing the spinal cord 2
- Surgery should be performed as soon as possible (ideally within 24-48 hours) to prevent neurological complications and reduce mortality 3, 2
Surgical Technique Considerations
- Posterior approach with instrumentation spanning at least one level above and below the injury 1
- Intraoperative assessment will typically confirm complete disruption of posterior ligamentous complex 1
- Decompression of any canal compromise from fracture fragments or disc material 1, 2
Critical Pitfalls to Avoid
Do NOT Pursue Conservative Management
Nonoperative treatment is contraindicated for hyperextension 3-column injuries, even though some burst fractures can be managed conservatively 5. The key distinctions are:
- Hyperextension mechanism with complete ligamentous disruption creates fundamentally different biomechanics than compression burst fractures 1, 2
- The spine lacks any intact stabilizing column, unlike burst fractures where the posterior column may remain intact 5
- Risk of delayed paraplegia is unacceptably high with conservative management 2
Recognize the Deceptive Presentation
- Initial radiographs may appear normal or show only subtle findings 1
- Absence of neurological deficit does not indicate stability - these injuries can present with ASIA-D (near-normal) motor scores yet be profoundly unstable 1
- Lack of tenderness or step deformity on examination is misleading and does not rule out severe injury 1
Postoperative Management
Immediate Postoperative Care
- Provide appropriate pain management with multimodal analgesia 3
- Monitor neurological status closely for any deterioration 3
- Initiate early mobilization as tolerated after surgical stabilization to prevent complications from immobility 3
Rehabilitation Protocol
- Begin physical training and muscle strengthening early in the postoperative period 3, 6
- Continue balance training and fall prevention strategies long-term 3, 6