Thoraco-lumbar flexion-distraction injury in a competitive gymnast: a case report.

CASE REPORT A seventeen-year-old female gymnast developed progressive thoraco-lumbar back pain over a five-month period. There was no radiation of the pain and no neurological symptoms. The patient reported that five months prior to the initial assessment she completed a landing during training during which her lumbar spine was forced into forward flexion. With this landing she sustained an un-displaced fracture of her right calcaneous. The patient was able to return to training after several months, though she reported gradually increasing thoraco-lumbar back pain and was eventually unable to resume training due to back pain. Physical exam revealed normal spinal alignment with a full range of spine motion. Pain was reproduced with spine extension at the thoraco-lumbar junction. With forward flexion, a palpable locally painful inter-spinous gap was evident at the T12-L1 level. The neurological examination was normal. Plain lateral radiographs of the lumbar spine were normal. Dynamic flexion and extension lateral radiographs revealed inter-spinous widening and segmental kyphosis at the T12-L1 inter-space on flexion, while extension resulted in 3mm of retrolisthesis between T12 and L1 indicative of abnormal segmental motion. A CT scan, with three-dimensional reconstructions, revealed a 50% subluxation of the T12-L1 facets bilaterally. (Figs. 1A–C). A bone scan showed increased uptake at the T12-L1 level on the right side. An MRI showed disruption of the annulus of the T12-L1 disc with posterior displacement of the nucleus. There was protrusion of the T12-L1 disc into the spinal canal with effacement of the CSF at the T12-L1 level. There was a mild focal kyphosis at the T12-L1 level. (Figs. 1D–F). The diagnosis was that of a flexion distraction injury with persistent subluxation of the T12-L1 facets, and disc disruption. Given the degree of subluxation, the associated ligamentous injury, and disruption of the disc, and the patient’s expectations, we recommended surgical stabilization. Due to the MRI evidence of disc disruption and the anticipated high loading of the spine, an anterior and posterior arthrodesis was the preferred option. A posterior T12-L1 trans-foraminal inter-body fusion utilizing Motech titanium cages and posterior Moss-Miami (DePuy-Spine Raynham, MA), instrumentation and a right iliac crest bone graft was performed. Following a four-day hospital stay, the patient wore a Jewitt thoraco-lumbar orthosis for six weeks. Physical rehabilitation was carried out under the guidance of a physiotherapist. Activities were restricted until two months following surgery. Rehabilitation involved a gradual re-introduction of the patient’s training program over a period of six to eight weeks following which the patient was able to resume her full intense training regime. Six months following surgery, the patient was able to compete at an international level and did so successfully. Follow-up radiographs at one year post-operatively revealed satisfactory fusion at the T12-L1 inter-space (Fig. 2). Clinical follow-up at 44 months following surgery confirmed an excellent result with continued participation in competitive gymnastics.