Successful L3 Kyphoplasty & L2–L4 Spinal Fusion with Fixation for L3 Burst Fracture

Chief Complaints

A 77-year-old female patient with a body mass index (BMI) of 21 presented to the Neurosurgery Department at PACE Hospitals, Hitech City, Hyderabad, with complaints of severe back pain following a fall at home 2 months prior. She reported difficulty in walking and pain present even at rest. There was no associated history of paresthesias, bowel or bladder disturbances. Prior to the fall, she had no significant neurological deficits.

The patient had no known history of diabetes mellitus, hypertension, cardiac illness, renal disease, thyroid disorders, tuberculosis, or any major previous surgical interventions. There was no history of bowel or bladder dysfunction or other significant comorbidities.

On general examination, the patient was moderately built and nourished, conscious, coherent, oriented and hemodynamically stable. Neurological examination revealed power 4/4 in both lower limbs with normal sensation, intact cranial nerves, and absent cerebellar signs. Reflexes were normal, and there were no signs of meningitis. Cardiovascular and respiratory system examination was normal, with normal heart sounds and bilateral air entry. There were no focal neurological deficits, bowel or bladder involvement, or other systemic abnormalities noted.

Upon admission to PACE Hospitals, the patient underwent a comprehensive clinical evaluation along with a detailed review of her medical history and preoperative investigations conducted by the Neurosurgery team.

Laboratory investigations revealed microcytic hypochromic anemia with normal leukocyte counts, while renal and liver function tests, serum electrolytes, coagulation profile, and blood sugar levels were within normal limits. Chest X-ray showed normal heart size and clear lung fields.

Neuroimaging, including X-ray of the lumbar spine, demonstrated L3 burst fracture with L2–L3 disc prolapse causing canal stenosis. Findings included multilevel degenerative changes, vertebral body collapse at L3, and posterior element compression contributing to spinal canal narrowing and nerve root impingement, correlating with the patient’s severe back pain and difficulty walking.

Based on the confirmed diagnosis, the patient was advised to undergo L3 burst fracture with L2–L3 disc prolapse and lumbar canal stenosis treatment in Hyderabad, India under the expert care of the Neurosurgery Department.

After a detailed consultation with Dr. U. L. Sandeep Varma (Consultant Neurosurgeon), and cross-consultation with Dr Seshi Vardhan Janjirala (Consultant Cardiologist), a comprehensive evaluation was conducted focusing on the patient’s presentation of severe back pain and difficulty walking following a fall.

Clinical examination, laboratory investigations including complete blood picture, renal and liver function tests, serum electrolytes, coagulation profile, viral markers, urine analysis, chest X-ray, and 2D echocardiography were reviewed. Findings confirmed an L3 burst fracture with L2–L3 disc prolapse causing canal stenosis, with multilevel degenerative changes and posterior element compression, while no major cardiopulmonary contraindications were noted for surgery.

It was determined that L3 Kyphoplasty, L2–L4 Posterolateral Spinal Fusion and Fixation, and L2 Laminectomy with L2–L3 Discectomy under general anesthesia were the most appropriate interventions to stabilize the spine, decompress the spinal canal, relieve nerve compression, alleviate pain, restore mobility, and prevent further neurological deterioration.

The patient and family were counseled in detail regarding the diagnosis, surgical procedure, postoperative care, physiotherapy, medication adherence, and the importance of regular follow-up to optimize recovery and functional outcomes.

Following the decision, the patient was scheduled to undergo an L3 Kyphoplasty, L2–L4 Posterolateral Spinal Fusion and Fixation, L2 Laminectomy, and L2–L3 Discectomy Surgery in Hyderabad at PACE Hospitals under the expert supervision of the Neurosurgery Department. 

The procedure involved the following steps:

• Patient Positioning and Anaesthesia: The patient was placed in a prone position on the operating table after the administration of general anaesthesia. The surgical site was prepared and draped under strict aseptic precautions to ensure a sterile operating environment.

• Exposure and Pedicle Screw Fixation: A vertical midline incision was made over the lumbar spine. The incision was deepened, and the paraspinal muscles were carefully separated to expose the lamina, spinous processes, and transverse processes. Bilateral pedicle screw fixation was performed from L2 to L4 using cannulated pedicle screws under fluoroscopic guidance.

• L3 Kyphoplasty and Vertebral Stabilisation: Kyphoplasty of the fractured L3 vertebral body was performed bilaterally under X-ray guidance. Bone cement was injected through the pedicle screw system to strengthen the vertebral body and enhance spinal stability. The fixation construct was completed using titanium rods bilaterally.

• Laminectomy, Discectomy, and Neural Decompression: An L2 laminectomy was performed, and the ligamentum flavum was excised to decompress the spinal canal. Subsequently, an L2–L3 discectomy was carried out to remove the prolapsed disc material causing canal stenosis. Adequate decompression of the neural elements was confirmed, and the dura was noted to be freely pulsatile at the end of the procedure.

• Posterolateral Fusion and Wound Closure: Posterolateral spinal fusion from L2 to L4 was performed using autologous bone graft to promote long-term spinal stability and fusion. Hemostasis was secured, and the wound was closed in layers over a surgical drain and epidural catheter. The patient tolerated the procedure well and was transferred to the intensive care unit for postoperative monitoring.

Postoperatively, the patient was monitored in the Intensive Care Unit (ICU) overnight and later shifted to the room after stabilization. The drain and urinary catheter were removed on the second postoperative day, and supervised ambulation was initiated. Postoperative X-rays showed satisfactory implant alignment, the surgical wound remained healthy, and physiotherapy was continued during recovery. The patient was discharged in stable condition with improved mobility and neurological status.

Upon discharge, the patient was discharged with treatment aimed at postoperative pain control, prevention of infection, management of nerve-related symptoms, gastric protection, bowel regulation, nutritional supplementation, and enhancement of bone healing and recovery following spinal surgery. Continued osteoporosis treatment was advised to promote vertebral healing and improve bone strength. 

The patient was advised to continue prescribed medications, comply with physiotherapy and rehabilitation exercises, and gradually increase walking as tolerated. She was instructed to avoid strenuous activities, lifting heavy weights, and sitting on the floor during the recovery period. Wound care was advised, and she was permitted to take a bath while ensuring proper wound hygiene. 

The patient was instructed to contact the emergency ward at PACE Hospitals if she develops fever, worsening weakness, discharge from the surgical wound, severe back pain, difficulty walking, or any new neurological symptoms.

The patient was advised to return for follow-up with the Neurosurgeon in Hyderabad at PACE Hospitals after 10 days for postoperative review, wound inspection, and staple removal. Further follow-up visits were advised to assess neurological recovery, spinal stability, wound healing, and progress with physiotherapy. Compliance with rehabilitation measures and prescribed medications was strongly recommended.

This case highlights an L3 burst fracture with associated L2–L3 disc prolapse causing spinal canal stenosis, resulting in severe back pain and difficulty walking following a fall. The patient underwent successful L3 kyphoplasty, L2–L4 posterolateral spinal fusion and fixation, L2 laminectomy, and L2–L3 discectomy. She had an uneventful postoperative recovery with satisfactory implant alignment, healthy wound healing, and improved ambulation. The patient was discharged in stable condition with planned follow-up and continuation of physiotherapy for functional recovery.