Springer - Publisher Connector

A multi-center phase II study and biomarker analysis of combined cetuximab and modified FOLFIRI as second-line treatment in patients with metastatic gastric cancer

Levels of insecticide resistance to deltamethrin, malathion, and temephos, and associated mechanisms in  mosquitoes from the Guadeloupe and Saint Martin islands (French West Indies)

Richard F. Keep

Hazel C. Jones

Lester R. Drewes

Brain barriers and brain fluid research in 2016: advances, challenges and controversies

Understanding Patterns of Social Support and Their Relationship to an ART Adherence Intervention Among Adults in Rural Southwestern Uganda

Henrik Boström

Henrik Linusson

Tuve Löfström

Ulf Johansson

Accelerating difficulty estimation for conformal regression forests

Johannes Naumann

Julian Grebe

Sonja Kaifel

Tomas Weinert

Catharina Sadaghiani

Roman Huber

Effects of hyperthermic baths on depression, sleep and heart rate variability in patients with depressive disorder: a randomized clinical pilot trial

María Magdalena Camou

Silvana Maubrigades

The Lingering Face of Gender Inequality in Latin America

Phase I trial to investigate the effect of renal impairment on isavuconazole pharmacokinetics

Time trends of mortality in patients with non-functioning pituitary adenoma: a Swedish nationwide study

CASE REPORT Open Access
Asymmetrical pedicle subtraction
osteotomy for progressive kyphoscoliosis
caused by a pediatric Chance fracture: a
case report
Satoshi Suzuki, Nobuyuki Fujita, Tomohiro Hikata, Akio Iwanami, Ken Ishii, Masaya Nakamura,
Morio Matsumoto and Kota Watanabe*
Abstract
Background: Although most pediatric Chance fractures (PCFs) can be treated successfully with casting and bracing,
some PCFs cause progressive spinal deformities requiring surgical treatment. There are only few reports of asymmetrical
osteotomy for PCF-associated spinal deformities.
Case presentation: We here report a case of a 10-year-old girl who suffered an L2 Chance fracture from an asymmetrical
flexion-distraction force, accompanied by abdominal injuries. She was treated conservatively with a soft brace.
However, a progressive spinal deformity became evident, and 10 months after the injury, examination showed
segmental kyphoscoliosis with a Cobb angle of 36°, a kyphosis angle of 31°, and a coronal imbalance of 30 mm. Both
the coronal and sagittal deformities were successfully corrected by asymmetrical pedicle subtraction osteotomy.
Conclusions: Initial kyphosis and posterior ligament complex should be evaluated at some point when treating PCFs.
Asymmetrical pedicle subtraction osteotomy can be a useful surgical option when treating rigid kyphoscoliosis associated
with a PCF.
Keywords: Chance fracture, Flexion-distraction injury, Kyphoscoliosis, Asymmetrical pedicle subtraction osteotomy, Case
report
Background
Chance fractures, which are flexion-distraction injuries
of the spine, were defined by George Quentin Chance
in 1948 as a fracture line passing transversely through
the spinous process, laminae, and pedicle and then into
the vertebral body [1]. Chance fractures account for 5–
11% of the acute thoracolumbar spinal injuries in adults
[2, 3]. Although pediatric spinal injuries are more un-
usual, affecting only 0.3–4% of the pediatric population,
they have become more common due to mandatory
seat-belt laws [4–6]. Of these injuries, about 43–50%
consist of pediatric Chance fractures (PCFs) [5]. The
treatment of these fractures depends on the fracture
pattern as well as neurologic status [5]. Purely osseous
injuries with minimal deformity, and even those involving
ligamentous injuries, have been treated conservatively, and
these injuries have a good prognosis in pediatric patients
[7]. However, in some cases, surgery is required to correct a
kyphotic deformity or to halt neurological deterioration or
a progressive deformity [5, 7]. Surgeries to treat chronic,
rigid deformities caused by PCF are rare [8–10]. We here
report a case of a 10-year-old girl with rigid, chronic-phase
kyphoscoliosis caused by a PCF. The kyphoscoliosis was
successfully treated by asymmetrical pedicle subtraction
osteotomy (PSO) at the affected vertebra.
Case presentation
A 10-year-old girl was traveling in the back seat of a car,
wearing a 3-point restraint, when the car was involved
in a collision at an intersection. The girl was transported
to a nearby hospital, where she complained of abdominal
* Correspondence: kw197251@keio.jp
Department of Orthopaedic Surgery, Keio University School of Medicine, 35
Shinanomachi, Shinjyuku, Tokyo 160-8582, Japan
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Suzuki et al. Scoliosis and Spinal Disorders  (2017) 12:8 
DOI 10.1186/s13013-017-0115-1
and back pain. After clinical and radiographic examination,
the diagnoses were perforations in the duodenal and trans-
verse colon, a fracture of the right wrist, and an L2 Chance
fracture without neurologic deficit. Radiographs of the lum-
bar spine revealed local lumbar scoliosis at L1–L3 with a
Cobb angle of 18° in a supine position (Fig. 1). CT images
showed a horizontal split in the right L2 pedicle (Fig. 2b), a
collapse of the right anterior vertebral column (Fig. 2a, b),
and splitting of the L2 left transverse processes, the left L2
pedicle, and the middle of the L2 vertebral column (Fig. 2c),
resulting in asymmetrical kyphoscoliosis. The girl under-
went emergency surgery for the abdominal injury and wrist
fracture. The Chance fracture was treated conservatively
with 4 weeks of bed rest, after which the patient was
allowed to walk with a soft brace. However, the deformity
gradually deteriorated, and the girl was referred to our hos-
pital. Physical examination showed that her trunk was lean-
ing to the left side, and standing whole spine radiographs
revealed kyphoscoliosis at the thoracolumbar area with a
Cobb angle of 36° at L1–L3 (Fig. 3a), a kyphosis angle of
31° at L1–L3 (Fig. 3b), and a coronal imbalance of 30 mm
(the distance between the C7 plumb line and the center of
the sacrum) to the left (Fig. 3c). The kyphotic angle
decreased to 2.4° over a bolster (Fig. 3d). MR images did
not show any soft tissue injury or spinal cord damage when
she was transferred to our hospital (data not shown). CT
images revealed that the fractures had fused (Fig. 4a).
Ten months after the injury, we performed correction
and fusion surgery using asymmetrical PSO at L2. After
exposing the posterior elements through a posterior mid-
line approach, we placed pedicle screws bilaterally at T12,
L1, and L3 and at the right L2 pedicle. We next removed
the upper one third of the elongated left L2 pedicle, the
left upper and posterior portion of the vertebra, and the
L1/L2 intervertebral disc (Fig. 5a). After local bone graft
into L1/L2 disc space, we applied compression force be-
tween the L1 and L3 pedicle screws on the left side while18°
L3
L1
LR
Fig. 1 Radiographs at the time of injury. Radiographs obtained
immediately after the injury revealed an L2 fracture with local lumbar
scoliosis at L1–L3 of 18° (AP view)
L2
a
R L
b
c
L2
L2
Fig. 2 CT images at the time of injury. CT images revealed a Chance-
type injury with an associated L2 compression fracture of the right
vertebral body (a), a horizontal split of the right L2 pedicle (b), and the
splitting and distraction of the left L2 transverse processes, left L2 pedicle,
and the L2 middle column (c), resulting in asymmetrical kyphoscoliosis
Suzuki et al. Scoliosis and Spinal Disorders  (2017) 12:8 Page 2 of 6
monitoring motor-evoked potentials (Fig. 5a). The facet
joints of T12/L1 and L2/L3 and transverse processes of
T12, L1, L2, and L3 were decorticated. The remaining
local bone graft was placed along the decorticated bones.
The intraoperative time was 91 min; the estimated blood
loss was 220 ml (Fig. 5b).
The scoliosis was corrected from 36° to 1° and the
kyphosis from 31° to 1° (Fig. 6a, b). At the 2-year follow-
up, radiographs showed excellent coronal balance, no
instrument failure or loss of correction, and osseous
continuity between the vertebrae (Fig. 6c).
Discussion
In 1948, George Quentin Chance characterized a type of
fracture with “horizontal splitting of the spine and neural
arch [1].” Nicoll proposed the term “Chance fracture” in
1949 [11]. Most cases are associated with a flexion-
distraction injury obtained in a motor vehicle accident
[12]. In children, however, 2-point restraints and improp-
erly used restraints have increased the incidence of PCFs
at the lumbar spine, often at L2 or L3 [7]. As a result of
anatomical characteristics, Chance injuries are more likely
to cause neurological issues in children than in adults:
15–43% of PCFs involve neurological deficits [7, 13, 14].
PCF post-traumatic deformities
Delayed displacement and progressive deformities
have been reported after conservative therapy for PCF
[7, 8, 13, 15, 16]. To summarize the reports, in Chance frac-
tures, the threshold of kyphosis angle for surgical indication
was ranged from 15° to 22°. However, taking standing ra-
diographs for assessing initial kyphosis will be difficult in
the situation of an acute spinal injury. Additionally, more
attention will be paid for the possible concomitant injuries
Fig. 3 Radiographs at the time of surgery. Lumbar radiographs revealed segmental kyphoscoliosis with a Cobb angle of 36° (a) and a kyphosis
angle of 31° (b). A standing AP view of the entire spine showed a 30-mm leftward shift of the C7-central sacral vertical line (c). The kyphotic angle
decreased to 2.4° on a lateral radiograph over a bolster (d)
a
b
Fig. 4 CT images at the time of surgery. A reconstructed three-dimensional CT image showing kyphoscoliosis due to the affected L2 vertebra (a).
CT images revealed an opening of bilateral Y-shaped cartilage (b)
Suzuki et al. Scoliosis and Spinal Disorders  (2017) 12:8 Page 3 of 6
including abdominal viscera and vascular injuries at the
time of injury. In our patient’s case, the initial lumbar scoli-
osis at L1–L3 was 18° in a supine position. Based only on
the scoliosis, conservative treatment was a reasonable
choice. Additionally, since treatments for abdominal injur-
ies had the priority in this case, the delay in the evaluations
for kyphosis angle and damages of posterior ligament com-
plex were inevitable. The case report is therefore an import-
ant lesson of what can happen if an unstable asymmetrical
Chance fracture is not well managed in the acute phase
after trauma.
Treatment of PCFs
Outcomes of conservative therapy for PCFs are relatively
good; however, some PCFs should be treated surgically to
correct an initial kyphotic deformity or to prevent
further neurological deterioration or a progressive
deformity [17]. Since the injury of PCFs is mainly the
L2
L R
L R
ba
Fig. 5 Intraoperative findings. The deformity was corrected by L1/L2 intervertebral disc resection and osteotomy of the upper one third of the
elongated L2 pedicle and vertebral body, followed by compression to the left side and distraction to the right side (a). An intraoperative photograph
just after the correction is shown in (b)
1.2°
1.5°
a b c
RL L R
Fig. 6 Postoperative radiographs and CT images. Postoperative radiographs revealed that the L1–L3 scoliosis was corrected to 1.2° (a) and the
kyphosis to 1.5° (b). A radiograph and CT image obtained at the 2-year follow-up showed good global coronal balance with no instrument failure
or loss of correction (c)
Suzuki et al. Scoliosis and Spinal Disorders  (2017) 12:8 Page 4 of 6
posterior osteoligamentous complex, reduction and
stabilization with posterior instrumentation should be
considered [18]. When treating acute PCFs surgically,
pedicle screw instrumentation, which extended one or
two levels above and below the affected vertebra, seems
to be a popular treatment [19]. With a recent progress
of spinal instrumentations, percutaneous pedicle screw
fixation may have evolved as an alternative approach
for PCFs [5, 20]. On the other hand, there are only a
few reports of surgical treatment for chronic deform-
ities due to PCFs, including combined anterior and pos-
terior fusion surgery, transforaminal thoracic interbody
fusion, and transpedicle wedge osteotomy and posterior
fusion [8, 21, 22]. Asymmetrical PSO, which was first
reported in 2012 by Sathya et al. [23], is not a novel
technique; however, it seems to be rare rerated to a
report of asymmetrical PSO for a chronic pediatric
Chance fracture. Our patient’s spinal deformity was
caused by a deformity of the fractured L2 vertebra, so
we judged that short fusion with asymmetrical PSO was
sufficient to correct the affected vertebra. Our osteot-
omy procedure included partial resection of the pedicle,
vertebral body, and adjacent disc in an applied grade 4
osteotomy, according to the classification system of
anatomically based spinal osteotomies proposed by
Schwab et al. [24]. In this case, we intended to fuse
from T12 to L3 for the maintenance of spinal align-
ment after correction of scoliosis and kyphosis. The ap-
plication of without fusion technique at L2/L3 fact
joints and future removal of the spinal implants might
be another option to preserve motion segment at L2/
L3. However, we have removed posterior ligamentous
complex at L2/L3 during the surgery and were afraid of
the occurrence of distal junctional problem after removal
of the implants.
Conclusions
Initial kyphosis and posterior ligament complex should be
evaluated at some point when treating PCFs. Asymmet-
rical PSO is not a novel technique; however, there are only
few reports of asymmetrical osteotomy for PCF-associated
spinal deformities. Asymmetrical pedicle subtraction oste-
otomy can be a useful surgical option when treating rigid
kyphoscoliosis associated with a PCF.
Abbreviations
CT: Computed tomography; MR: Magnetic resonance; PCF: Pediatric Chance
fracture; PSO: Pedicle subtraction osteotomy
Acknowledgements
Not applicable
Funding
Not applicable
Availability of data and materials
This article is distributed under the terms of the Creative Commons
Attribution 4.0 International License (http://creativecommons.org/licenses/by/
4.0/), which permits unrestricted use, distribution, and reproduction in any
medium, provided you give appropriate credit to the original authors and
the source, provide a link to the Creative Commons license, and indicate if
changes were made. The Creative Commons Public Domain Dedication
waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
data made available in this article, unless otherwise stated.
Authors’ contributions
All authors read and approved the final manuscript. KW conceived the study,
participated in the design of the study, helped to write the manuscript, and
revised it critically. SS participated in its design and drafted the manuscript.
NF, TH, AI, KI, and NM participated in the study design and helped to draft
the manuscript. MM conceived, designed, and coordinated the study and
drafted the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
Written informed consent was obtained from the parents of the young patient
for the publication of this case report and any accompanying images.
Ethics approval and consent to participate
This study was approved by the Scientific Review Board at our hospital and was
conducted in accordance with the World Medical Association Declaration of
Helsinki.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Received: 23 March 2016 Accepted: 27 February 2017
References
1. Chance GQ. Note on a type of flexion fracture of the spine. Br J Radiol.
1948;21:452–3.
2. Denis F. The three column spine and its significance in the classification of
acute thoracolumbar spinal injuries. Spine. 1983;8:817–31.
3. Gumley G, Taylor TK, Ryan MD. Distraction fractures of the lumbar spine.
J Bone Joint Surg (Br). 1982;64:520–25.
4. Campbell DJ, Sprouse 2nd LR, Smith LA, Kelley JE, Carr MG. Injuries in
pediatric patients with seatbelt contusions. Am Surg. 2003;69:1095–99.
5. Le TV, Baaj AA, Deukmedjian A, Uribe JS, Vale FL. Chance fractures in the
pediatric population. J Neurosurg Pediatr. 2011;8:189–97.
6. Lutz N, Nance ML, Kallan MJ, Arbogast KB, Durbin DR, Winston FK. Incidence
and clinical significance of abdominal wall bruising in restrained children
involved in motor vehicle crashes. J Pediatr Surg. 2004;39:972–75.
7. Glassman SD, Johnson JR, Holt RT. Seatbelt injuries in children. J Trauma.
1992;33:882–6.
8. Campbell A, Yen D. Late neurologic deterioration after nonoperative
treatment of a Chance fracture in an adolescent. Can J Surg. 2003;46:383–5.
9. Keene JS, Lash EG, Kling Jr TF. Undetected posttraumatic instability of
“stable” thoracolumbar fractures. J Orthop Trauma. 1988;2:202–11.
10. Reid AB, Letts RM, Black GB. Paediatric Chance fractures: association with
intraabdominal injuries and seat belt use. J Trauma. 1990;30:384–91.
11. Nicoll EA. Fractures of the dorso-lumbar spine. J Bone Joint Surg (Br).
1949;31:376–94.
12. Louman-Gardiner K, Mulpuri K, Perdios A, Tredwell S, Cripton PA. Pediatric
lumbar Chance fractures in British Columbia: chart review and analysis of
the use of shoulder restraints in MVAs. Accid Anal Prev. 2008;40:1424–9.
13. Arkader A, Warner Jr WC, Tolo VT, Sponseller PD, Skaggs DL. Pediatric
Chance fractures: a multicenter perspective. J Pediatr Orthop. 2011;31:741–4.
14. Rumball K, Jarvis J. Seat-belt injuries of the spine in young children. J Bone
Joint Surg (Br). 1992;74:571–4.
15. Bouliane MJ, Moreau MJ, Mahood J. Instability resulting from a missed
Chance fracture. Can J Surg. 2001;44:61–2.
16. Reilly CW. Pediatric spine trauma. J Bone Joint Surg Am. 2007;89 Suppl 1:98–107.
Suzuki et al. Scoliosis and Spinal Disorders  (2017) 12:8 Page 5 of 6
17. Vaccaro AR, Silber JS. Post-traumatic spinal deformity. Spine. 2001;26:S111–8.
18. Wood KB, Li W, Lebl DR, Ploumis A. Management of thoracolumbar spine
fractures. Spine J. 2014;14:145–64.
19. Daniels AH, Sobel AD, Eberson CP. Pediatric thoracolumbar spine trauma.
J Am Acad Orthop Surg. 2013;21:707–16.
20. Phan K, Rao PJ, Mobbs RJ. Percutaneous versus open pedicle screw fixation
for treatment of thoracolumbar fractures: systematic review and meta-
analysis of comparative studies. Clin Neurol Neurosurg. 2015;135:85–92.
21. Huang RC, Meredith DS, Taunk R. Transforaminal thoracic interbody fusion
(TTIF) for treatment of a chronic Chance injury. HSS J. 2010;6:26–9.
22. Okuyama K, Sasaki H, Kido T, Chiba M. A chronic flexion-distraction injury
with a “fistulous wither” on the split spinous process of the L1 vertebra—a
case report of a modified transpedicle wedge osteotomy. Eur Orthop
Traumatol. 2013;4:253–7.
23. Thambiraj S, Boszczyk BM. Asymmetric osteotomy of the spine for coronal
imbalance: a technical report. Eur Spine J. 2012;21:S225–9.
24. Schwab F, Blondel B, Chay E, Demakakos J, Lenke L, Tropiano P, et al. The
comprehensive anatomical spinal osteotomy classification. Neurosurgery.
2014;74:112–20.
•  We accept pre-submission inquiries 
•  Our selector tool helps you to find the most relevant journal
•  We provide round the clock customer support 
•  Convenient online submission
•  Thorough peer review
•  Inclusion in PubMed and all major indexing services 
•  Maximum visibility for your research
Submit your manuscript at
www.biomedcentral.com/submit
Submit your next manuscript to BioMed Central 
and we will help you at every step:
Suzuki et al. Scoliosis and Spinal Disorders  (2017) 12:8 Page 6 of 6


Asymmetrical pedicle subtraction osteotomy for progressive kyphoscoliosis caused by a pediatric Chance fracture: a case report

Not a member yet