PMC5351051_01
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)
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Fig1
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.
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
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Fig2
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.
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)
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Fig3
Physical examination showed that her trunk was leaning 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).
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)
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Fig4
CT images revealed that the fractures had fused (Fig. 4a).    
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)
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Fig5
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 between the L1 and L3 pedicle screws on the left side while monitoring motor-evoked potentials (Fig. 5a). 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). 
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)
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Fig6
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).