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Abstract
STUDY DESIGN Systematic Review. OBJECTIVE To determine whether early spinal stabilization in thoracolumbar spine trauma decreases morbidity and mortality. SUMMARY OF BACKGROUND DATA The role of early spinal stabilization through surgical means may have a number of benefits. These include reduced morbidity and mortality because of more rapid mobilization afforded by spinal column stabilization and a reduction in the incidence and severity of sepsis and respiratory failure. There are several potential disadvantages of early surgery. The most strongly debated is the potential that the additional physiologic injury may result in an unintended increase in morbidity and mortality caused by worsening of existing injuries, such as with pulmonary or intracranial trauma. This problem may be compounded by increased hemorrhage and resulting hypotension. Operating in the presence of missed or underestimated associated injuries or under less-than-ideal conditions relative to the complexity of the surgery and resources required is also a potential disadvantage. METHODS A systematic review of the English-language literature was undertaken for articles published between January 1990 and December 2008. Electronic databases and reference lists of key articles were searched to identify published studies examining the timing of thoracolumbar fracture fixation. Two independent reviewers assessed the strength of literature using the Grading of Recommendations Assessment, Development, and Evaluation criteria, assessing quality, quantity, and consistency of results. Disagreements were resolved by consensus. RESULTS A total of 68 articles were initially screened, and 9 ultimately met the predetermined inclusion criteria. These studies demonstrated that early stabilization of thoracic fractures reduced the mean number of days on a ventilator, the number of days in intensive care unit and in hospital, and reduced respiratory morbidity compared with late stabilization. This effect, other than the length of hospital stay, was not seen with stabilization of lumbar fractures. There is not enough evidence to determine the effect of the timing of stabilization on mortality in thoracolumbar fractures. CONCLUSION Ideally, patients with unstable thoracic fractures should undergo early (<72 hours) stabilization of their injury to reduce morbidity and, possibly, mortality.
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Furlan JC, Noonan V, Cadotte DW, Fehlings MG. Timing of decompressive surgery of spinal cord after traumatic spinal cord injury: an evidence-based examination of pre-clinical and clinical studies. J Neurotrauma 2010; 28:1371-99. [PMID: 20001726 DOI: 10.1089/neu.2009.1147] [Citation(s) in RCA: 217] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
While the recommendations for spine surgery in specific cases of acute traumatic spinal cord injury (SCI) are well recognized, there is considerable uncertainty regarding the role of the timing of surgical decompression of the spinal cord in the management of patients with SCI. Given this, we sought to critically review the literature regarding the pre-clinical and clinical evidence on the potential impact of timing of surgical decompression of the spinal cord on outcomes after traumatic SCI. The primary literature search was performed using MEDLINE, CINAHL, EMBASE, and Cochrane databases. A secondary search strategy incorporated articles referenced in prior meta-analyses and systematic and nonsystematic review articles. Two reviewers independently assessed every study with regard to eligibility, level of evidence, and study quality. Of 198 abstracts of pre-clinical studies, 19 experimental studies using animal SCI models fulfilled our inclusion and exclusion criteria. Despite some discrepancies in the results of those pre-clinical studies, there is evidence for a biological rationale to support early decompression of the spinal cord. Of 153 abstracts of clinical studies, 22 fulfilled the inclusion and exclusion criteria. While the vast majority of the clinical studies were level-4 evidence, there were two studies of level-2b evidence. The quality assessment scores varied from 7 to 25 with a mean value of 12.41. While 2 of 22 clinical studies assessed feasibility and safety, 20 clinical studies examined efficacy of early surgical intervention to stabilize and align the spine and to decompress the spinal cord; the most common definitions of early operation used 24 and 72 h after SCI as timelines. A number of studies indicated that patients who undergo early surgical decompression can have similar outcomes to patients who received a delayed decompressive operation. However, there is evidence to suggest that early surgical intervention is safe and feasible and that it can improve clinical and neurological outcomes and reduce health care costs. Based on the current clinical evidence using a Delphi process, an expert panel recommended that early surgical intervention should be considered in all patients from 8 to 24 h following acute traumatic SCI.
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Affiliation(s)
- Julio C Furlan
- Department of Genetics and Development, Toronto Western Research Institute, University Health Network, Toronto, Ontario, Canada
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Tisot RA, Avanzi O. Laminar fractures as a severity marker in burst fractures of the thoracolumbar spine. J Orthop Surg (Hong Kong) 2009; 17:261-4. [PMID: 20065359 DOI: 10.1177/230949900901700302] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To assess the correlation between the presence of lamina fractures, narrowing of the spinal canal, and the severity of injury. METHODS Records of 146 men and 44 women aged 13 to 84 (mean, 39) years diagnosed with burst fractures of the thoracolumbar spine were retrospectively reviewed. The laminar fractures and narrowing of the spinal canal were measured using computed tomography. The severity of injury was determined using the Injury Severity Score (ISS) and the New Injury Severity Score (NISS). The ISS and NISS of patients with and without laminar fractures were compared. The sensitivity and specificity of ISS, NISS, and narrowing of the spinal canal in association with laminar fractures were also compared. RESULTS 92 (48%) of the patients had laminar fractures. The mean narrowing of the spinal canal was more severe in patients with laminar fractures than those without (47% vs 28%, p<0.001). Patients with laminar fractures had a significantly higher mean ISS (17 vs 12, p<0.001) and NISS (19 vs 13, p<0.001). Narrowing of the spinal canal is more sensitive and specific than the ISS and NISS when correlating laminar fractures. CONCLUSION In patients with burst fractures of the thoracolumbar spine, the presence of laminar fractures indicates a more severe injury.
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Affiliation(s)
- Rodrigo A Tisot
- Department of Orthopaedics and Traumatology, Faculdade de Ciencias Medicas, Irmandade da Santa Casa de Misericordia de Sao Paulo, Brasil.
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Abstract
INTRODUCTION Polytrauma patients represent the ultimate challenge to trauma care and the optimisation of their care is a major focus of clinical and basic science research. A universally accepted definition for polytrauma is vital for comparing datasets and conducting multicentre trials. The purpose of this review is to identify and evaluate the published definitions of the term "polytrauma". MATERIALS AND METHODS A literature search was conducted for the time period January 1950-August 2008. The Medline, Embase and Cochrane Library databases were searched using the keyword "polytrauma". Articles were evaluated without language exclusion for the occurrence of the word "polytrauma" in the text and the presence of a subsequent definition. Relevant online resources and medical dictionaries were also reviewed. RESULTS A total of 1,665 publications used the term polytrauma, 47 of which included a definition of the term. The available definitions can be divided into eight groups according to the crux of the definition. No uniformly used consensus definition exists. None of the existing definitions were found to be validated or supported by evidence higher than Level 4. CONCLUSION This review identified the lack of a validated or consensus definition of the term polytrauma. The international trauma community should consider establishing a consensus definition for polytrauma, which could be validated prospectively and serve as a basis for future research.
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Affiliation(s)
- Nerida Butcher
- Department of Traumatology, Division of Surgery, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
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Schmidt OI, Gahr RH, Gosse A, Heyde CE. ATLS(R) and damage control in spine trauma. World J Emerg Surg 2009; 4:9. [PMID: 19257904 PMCID: PMC2660300 DOI: 10.1186/1749-7922-4-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2008] [Accepted: 03/03/2009] [Indexed: 02/07/2023] Open
Abstract
Substantial inflammatory disturbances following major trauma have been found throughout the posttraumatic course of polytraumatized patients, which was confirmed in experimental models of trauma and in vitro settings. As a consequence, the principle of damage control surgery (DCS) has developed over the last two decades and has been successfully introduced in the treatment of severely injured patients. The aim of damage control surgery and orthopaedics (DCO) is to limit additional iatrogenic trauma in the vulnerable phase following major injury. Considering traumatic brain and acute lung injury, implants for quick stabilization like external fixators as well as decided surgical approaches with minimized potential for additional surgery-related impairment of the patient's immunologic state have been developed and used widely. It is obvious, that a similar approach should be undertaken in the case of spinal trauma in the polytraumatized patient. Yet, few data on damage control spine surgery are published to so far, controlled trials are missing and spinal injury is addressed only secondarily in the broadly used ATLS(R) polytrauma algorithm. This article reviews the literature on spine trauma assessment and treatment in the polytrauma setting, gives hints on how to assess the spine trauma patient regarding to the ATLS(R) protocol and recommendations on therapeutic strategies in spinal injury in the polytraumatized patient.
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Affiliation(s)
- Oliver I Schmidt
- Klinikum St. Georg gGmbH, Trauma Centre, Dept. of Trauma and Orthopaedic Surgery, Delitzscher Strasse 141, 04129 Leipzig, Germany
| | - Ralf H Gahr
- Klinikum St. Georg gGmbH, Trauma Centre, Dept. of Trauma and Orthopaedic Surgery, Delitzscher Strasse 141, 04129 Leipzig, Germany
| | - Andreas Gosse
- Klinikum St. Georg gGmbH, Trauma Centre, Dept. of Trauma and Orthopaedic Surgery, Delitzscher Strasse 141, 04129 Leipzig, Germany
| | - Christoph E Heyde
- Leipzig University, Department of Orthopaedic Surgery, Spine Unit, Liebigstrasse 20, 04103 Leipzig, Germany
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Best practice determination of timing of spinal fracture fixation as defined by analysis of the National Trauma Data Bank. ACTA ACUST UNITED AC 2008; 65:824-30; discussion 830-1. [PMID: 18849798 DOI: 10.1097/ta.0b013e318182af7b] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND To examine the efficacy of early versus late spinal fracture fixation, we reviewed National Trauma Data Bank (NTDB) records to identify the breakpoint in reported timing of operative fixation. Using this breakpoint we then analyzed outcome for those treated early versus late, hypothesizing that the early group would experience better outcome as reflected by resource utilization and complications. METHODS The NTDB was queried for patients with any level spinal fracture that required surgical stabilization. Histogram analysis of the postinjury day of initial operative fixation was used to determine the point at which the majority of operative procedures had been performed, thereby defining early (E) and late (L) groups. Patients in E were matched to a cohort from L with similar age, Injury Severity Score, and Glasgow Coma Scale. Outcome data included hospital length of stay, intensive care unit length of stay, ventilator days, charges, incidence of complications, and mortality. The groups were compared using Student's t test for continuous variables and Fisher's exact test for categorical variables, accepting p < or = 0.05 as significant. RESULTS Of 16,812 patients who underwent operative fixation, 59% were completed within 3 days of injury and formed E. The 374 L patients whose dataset was complete enough to allow analysis were matched to 497 E patients. There was no significant difference in the presence of spinal cord injury between E and L (51 vs. 48%; p = 0.3735). Complications were significantly higher in L (30% vs. 17.5%; p < 0.0001) yet mortality was similar in both groups (2.0% vs.1.9%; p > 0.05). CONCLUSIONS NTDB records indicate that the majority of patients with spinal fractures undergo operative fixation within 3 days, and that these patients had less complications and required less resources. Use of a national data bank to compare groups with similar injury severity and presenting physiology can validate best practice and define opportunities for improvement in care.
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Schinkel C, Frangen TM, Kmetic A, Andress HJ, Muhr G. [Spinal fractures in multiply injured patients: an analysis of the German Trauma Society's Trauma Register]. Unfallchirurg 2008; 110:946-52. [PMID: 17989949 DOI: 10.1007/s00113-007-1351-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Spinal trauma is frequently found in multiply injured patients. To gain more insight into the epidemiology and the clinical course of this entity, we analyzed the relevant data held in the German Trauma Registry (German Trauma Society, DGU). The Registry provides prospective, standardized and anonymous documentation on severely injured patients at different predetermined time points from the site of the accident until they are discharged from hospital. METHODS Out of 8,057 patients whose details are recorded in the German Trauma Registry, 772 (approximately 10%) with severe spine trauma (AIS>/=3) patients were identified. Far more men (72%) than women (28%) had such spinal injuries. The mean age of the patients with severe spine injury was 37+/-17 years; their mean Injury Severity Score (ISS) was 29+/-15 (range 9-75) points. RESULTS The age group 15-54 years was the largest (80%). Motor vehicle accidents (MVA) were the most frequent cause of severe spine trauma (49%), followed by falls from a great height (20%). About half of all severe spine injuries were not suspected in the prehospital setting. Symptoms of incomplete paraplegia were found in 20% of the patients and symptoms of complete paraplegia, in 27%. Patients with injuries to the thoracic spine more often had a lengthy average stay in the intensive care unit, because they were accompanied by thoracic trauma significantly more often than were injuries to the other spinal segments (96% vs 37%). Patients who underwent spinal surgery at an early stage (70% operated on <72 h after their injuries were sustained) showed a tendency to shorter periods ventilatory support and did not remain in the intensive care unit or indeed in the hospital as long as the other patients. Seventy-eight percent of the patients had survived for 90 days after sustaining their injuries. CONCLUSION Almost 10% of all documented cases of patients with severe injuries in the German Trauma Registry had severe spinal injuries. These injuries were frequently not recognized or their extent underestimated in the preclinical setting. About 70% underwent spine stabilization within 72 h after being injured. These results support previous findings suggesting that early stabilization of vertebral fractures might be beneficial in multiply injured patients.
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Affiliation(s)
- C Schinkel
- Chirurgische Klinik und Poliklinik, BG-Kliniken Bergmannsheil,Ruhr-Universität Bochum, Bürkle-de-la-Camp-Platz 1, Bochum, Germany.
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Traumatic thoracic and lumbar spinal fractures: operative or nonoperative treatment: comparison of two treatment strategies by means of surgeon equipoise. Spine (Phila Pa 1976) 2008; 33:1006-17. [PMID: 18427323 DOI: 10.1097/brs.0b013e31816c8b32] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A center parallel cohort study with blinded inclusion based on clinical equipoise. OBJECTIVE To compare outcomes of nonoperative and operative treatment strategies in terms of quality of life and neurologic and functional status. SUMMARY OF BACKGROUND DATA Despite a considerable body of literature, sound evidence regarding the optimal treatment for traumatic thoracic and lumbar spine fractures is lacking. METHODS Medical records of patients hospitalized for traumatic spinal fractures between 1991 and 2002 were identified in 2 trauma centers in the same country with established and different treatment strategies. Eligibility was retrospectively assessed for each case by a panel of orthopaedic surgeons who were representative of the 2 medical centers, and who were blinded to the treatment actually administered. Patients were included in the study when there was disagreement on the suggested treatment method. Thus, 2 comparable groups were identified undergoing nonoperative or operative treatment. Outcome assessment and comparison across groups focused on quality of life, residual pain, neurologic recovery, and employment in the middle-long-term follow-up. RESULTS Discordance in regards to choice of treatment was identified in 190 (95 treated nonoperative, 95 operative) of 636 potentially eligible patients. Patients were comparable regarding baseline characteristics, except for a somewhat higher proportion of males and neurologic impairment in the operative group. Seventeen percent of the nonoperative and 21% of the operative group developed complications and 3 patients displayed neurologic deterioration for which a treatment change was considered necessary. Follow-up was complete in 79%; mean follow-up time was 6.2 years with a minimum of 2 years. Pain scores, disability indexes, and general health outcome were comparable at follow-up. Compared with matched population norms, outcomes were poorer regardless of treatment method. Neurologic recovery was better in the operative group, but this difference did not reach statistical significance. Multivariate regression analyses revealed that female gender and neurologic impairment were independent predictors of poor functional outcome. Eighty-eight and 83% of the nonoperatively and operatively treated patients were employed at some point after a rehabilitation period. CONCLUSION Overall outcome of nonoperative and operative treatment in middle-long-term follow up is comparable, although there seems to be a difference in neurologic recovery patterns. Studies on the cost-effectiveness of treatment options and the patterns of recovery within 2 years after injury would assist in guideline development and stimulate interest for future research.
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Abstract
STUDY DESIGN Retrospective study, prospectively gathered databases. OBJECTIVE To assess abdominal comorbidities, missed injuries, and complications associated with thoracolumbar flexion-distraction injuries (FDI). SUMMARY OF BACKGROUND DATA From 1989 to 2003, 153 patients with flexion-distraction type injuries were identified. Predominant injury mechanisms consisted of motor vehicle crashes, falls, and motorcycle crashes. METHODS Spinal injuries were categorized by region, injury pattern, American Spinal Injury Association grade, and motor score. Diagnostic methods, delayed diagnoses, and complications were recorded and compared with variables of spinal injury, abdominal injury, and neurologic outcome. Treatment variables included nonoperative care, posterior surgery alone, anterior surgery alone, or combination treatment. Primary outcomes were neurologic status, unintended secondary procedures, complications, and kyphosis angle. RESULTS Spinal cord injury (SCI) was found in 37 of 151 patients (25%). SCI was correlated with high-grade posterior element dissociation. Intra-abdominal injury (IAI) was found in 46 of 151 of patients (30%). There was a statistically significant correlation between presence of FDI and IAI in the lumbar (L2-L4) region. There was a 3.9% incidence of delayed diagnosis of FDI and a 0.9% incidence of delayed diagnosis of IAI. Presence of a "lapbelt-sign" had a positive predictive value of 0.69 and a negative predictive value of 0.91 for IAI. Presence of a lumbar injury due to a motor vehicle crash in the presence of a lapbelt sign was positively associated with IAI. There was no increase in complications in the subpopulation of patients with concurrent SCI and FDI. CONCLUSION Both IAI and SCI remain commonly associated with FDI of the thoracolumbar spinal column. The presence of an abdominal wall contusion (lapbelt sign) is a strong indicator of IAI. Adherence to an established trauma algorithm can minimize the risk of delayed diagnosis. Disruption of an established work-up paradigm, however, can lead to potentially life and spinal cord threatening complications.
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The effect of early surgical treatment of traumatic spine injuries on patient mortality. ACTA ACUST UNITED AC 2008; 63:1308-13. [PMID: 18212654 DOI: 10.1097/ta.0b013e31815b8361] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The ideal timing of spinal fixation is controversial. A recent study showed that early spine fixation reduced morbidity and resource utilization. We previously noted a trend toward higher mortality in patients undergoing early spinal fixation. This study was done to analyze whether the timing of spinal fixation had a significant effect on mortality. METHODS The registry of our Level I trauma program was queried for all patients with at least one spinal vertebral injury. Anatomic and physiologic variables included age, initial Glasgow Coma Scale score, systolic blood pressure, heart rate, and Injury Severity Score. Outcome was evaluated in terms of ventilator days, intensive care unit length of stay, hospital length of stay (HLOS), and mortality. Patients were stratified by day of spinal operative fixation as early when done within 48 hours and late when done after 48 hours. Data were analyzed using chi and an unpaired t test, accepting p < 0.05 as significant. RESULTS Three hundred sixty-one patients between January 1988 and February 2003 required operative spinal fixation (158 early, within 48 hours vs. 203 late, beyond 48 hours). There was no significant difference between the two groups except mortality, which was significantly higher in the early group (7.6 vs. 2.5%; p = 0.0257), and HLOS, which was significantly shorter in the early group (14.42 vs. 17.64 days; p = 0.025). CONCLUSION Spinal fixation within 48 hours after vertebral fractures and dislocations appears to increase mortality despite similar anatomic and physiologic parameters in the later operative group. Incomplete resuscitation of patients before surgery may have contributed to this result. The shorter HLOS may have been because of the higher number of early deaths. Prospective studies to identify the optimal timing of spinal fixation and the reason for these outcome differences are warranted.
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Damage control of multiple injuries headed by cervical spinal cord injury. Chin J Traumatol 2008; 11:45-8. [PMID: 18230292 DOI: 10.1016/s1008-1275(08)60010-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To explore the strategy of damage control in clinical treatment of multiple injuries headed by cervical spinal cord injury. METHODS A retrospective analysis was performed in 32 patients. Cervical fractures associated with tetraplegia occurred in 18 patients, traumatic intervertebral disk hernia associated with tetraplegia in 2 patients, and cervical fractures and dislocation associated with tetraplegia in 12 patients. Seventeen cases were combined with craniocerebral injury, 7 combined with pulmonary contusion, multi-fractures of rib or hemopneumothorax, 2 combined with pelvic fracture and other 8 combined with fracture of limbs. The neural function was assessed by the American Spinal Injury Association (ASIA) scale. RESULTS Thirty-one patients were followed up for an average of 14 months. Of them, 10 got complete recovery, 13 obtained improvement of more than one ASIA grade, 8 did not improve, and 1 died. CONCLUSIONS For the emergency treatment of multiple injuries headed by cervical spinal cord injury, the damage control strategy is the principle to follow. The final operations are preferably performed within 5 to 10 days after injury so as to raise the successful rate of remedy.
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Hierholzer C, Bühren V, Woltmann A. Operative Timing and Management of Spinal Injuries in Multiply Injured Patients. Eur J Trauma Emerg Surg 2007; 33:488-500. [DOI: 10.1007/s00068-007-7127-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2007] [Accepted: 09/04/2007] [Indexed: 10/22/2022]
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El Saman A, Laurer H, Maier B, Wyen H, Mack M, Marzi I. Diagnosis, Timing and Treatment of Cervical Spine Injuries in Polytraumatized Patients. Eur J Trauma Emerg Surg 2007; 33:501-11. [DOI: 10.1007/s00068-007-7125-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2007] [Accepted: 09/02/2007] [Indexed: 12/17/2022]
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Frangen TM, Ruppert S, Muhr G, Schinkel C. [Respiratory failure in thoracic spine injuries. Does the timing of dorsal stabilization have any effect on the clinical course in multiply injured patients?]. DER ORTHOPADE 2007; 36:365-71. [PMID: 17262180 DOI: 10.1007/s00132-007-1049-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Proper timing of stabilization for spinal injuries is discussed controversially. Whereas early repair of long bone fractures is known to reduce complications, few studies exist that investigate this issue in acute spinal trauma. In particular, the importance of coexisting lung injuries has to be determined, as it might influence clinical course and outcome. MATERIAL AND METHODS We investigated retrospectively 30 severely injured patients who were stabilized dorsally for fractures of the thoracic and upper lumbar spine. The mean Injury Severity Score (ISS) was 41 points. Patients were divided into two groups: group I: acute trauma/stabilization <72 h and group II: acute trauma/stabilization >72 h. All patients in groups I and II presented radiological or clinical signs of lung contusion. RESULTS The average duration of the procedures in group I was 199 min (115-312 min) and in group II 139 min (98-269 min). Intraoperative blood loss and P(a)O(2)/F(i)O(2)-ratio did not differ significantly between the two groups. The overall in ICU and hospital stay was significantly shorter in group I: 16 days (1-78 days) versus 24 days (7-86 days) in the late group II. Postoperative respirator therapy was necessary in group I for 15 days (0-79 days) and in group II for 19 days (4-31 days). The mortality rate was 10% in this series. CONCLUSION Our data provide further evidence that early stabilization of spinal injuries is safe in severely injured patients, does not impair perioperative lung function, and results in a reduced overall ICU and hospital stay. Further prospective randomized investigations are warranted to prove these results.
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Affiliation(s)
- Thomas M Frangen
- Chirurgische Klinik und Poliklinik, BG-Kliniken Bergmannsheil, Ruhr-Universität, Bürkle-de-la-Camp-Platz 1, 44789 Bochum, Deutschland.
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Wild MH, Glees M, Plieschnegger C, Wenda K. Five-year follow-up examination after purely minimally invasive posterior stabilization of thoracolumbar fractures: a comparison of minimally invasive percutaneously and conventionally open treated patients. Arch Orthop Trauma Surg 2007; 127:335-43. [PMID: 17165033 DOI: 10.1007/s00402-006-0264-9] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2006] [Indexed: 10/23/2022]
Abstract
INTRODUCTION It is well known that during posterior stabilization of the spinal column conventionally open methods are predominantly used. However, in this study a minimally invasive method was chosen to decrease the morbidity of the operative access and to protect the paravertebral musculature, which serves as an important spine-stabilizing factor during posterior stabilization. The aims of this retrospective non-randomized case-control study were to compare the clinical and radiological results of minimally invasive on the one hand and conventionally open posterior surgery on the other with each other and to measure the loss of correction after purely posterior stabilization. METHODS Twenty-one consecutive non-randomized patients with thoracolumbar vertebral body fractures, which had been stabilized posteriorly without any intervertebral body fusion between 1996 and 1997, and without any neurological symptoms, were examined retrospectively more than 5 years after trauma. Eleven patients had been treated conventionally open and 10 patients minimally invasive. As methods of evaluation, the intra- and postoperative amount of blood loss, the X-ray time, the Hannover-Spine-Score, the SF-36 Health Questionnaire and radiological assessment of the bisegmental wedge and vertebral body angle were made use of. RESULTS The blood loss was significantly lower among those patients who had been operated in a minimally invasive way. The operating time, the time of X-ray exposure and the loss of correction were identical in both groups. The first year after implant removal, the loss of correction was the highest with 2.1 degrees for the body angle and 6.86 degrees for the bisegmental wedge angle. Neither in the Hannover-Spine-Score nor in the SF-36 Health Questionnaire did both groups show a difference. A correlation between the loss of correction and the clinical results could not be demonstrated. CONCLUSION The minimally invasive posterior stabilization leads to lower blood loss in comparison to the conventionally open method and can be carried out without any special effort limited to A-fractures without any neurological symptoms.
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Affiliation(s)
- Michael H Wild
- Klinik für Unfall- und Handchirurgie, Heinrich Heine Universitätsklinikum, Moorenstrasse 5, 40225 Düsseldorf, Germany.
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Vieweg U. Vertebral body replacement system Synex in unstable burst fractures of the thoracic and lumbar spine. J Orthop Traumatol 2007; 8:64-70. [PMID: 27519889 DOI: 10.1007/s10195-007-0166-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2007] [Accepted: 03/01/2007] [Indexed: 11/28/2022] Open
Abstract
A prospective longitudinal study was performed to evaluate the vertebral body replacement system Synex associated with posterior fixation in unstable burst fractures of the lumbar and thoracic spine. Within 24 months, we treated 28 patients (average age, 41 years; range, 22-64 years; 14 women, 14 men) with acute unstable burst fractures without osteoporosis of the thoracolumbar region (n=16) and the thoracic (n=3) as well as the lumbar (n=9) spine in two stages (primary dorsal transpedicular stabilization and secondary vertebral body replacement). The complications were analyzed and the postoperative follow-up result was evaluated regarding stability, bone fusion, correction loss, pain and neurological status. One patient showed a transient irritation of the lumbosacral plexus and one patient had a superficial wound infection (complication rate, 7.1%). At the follow-up examination (mean follow-up, 13 months) only in two cases a minimal loss of correction (<5°) was measured. Radiologically, 27 patients showed secure bone fusions and all patients had stability of the osteosynthesis. Most of the patients stated no or just slight pain at follow-up. Only two patients with pain to a medium degree had to take painkillers. The vertebral body replacement system Synex seems to be a good alternative for vertebral body replacement in unstable burst fractures of the thoracic and lumbar spine since at present follow-up it shows a high rate of bone fusion and minimal loss of correction.
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Affiliation(s)
- U Vieweg
- Department of Spine Surgery, Leopoldina Hospital Schweinfurt, Gustav-Adolf-Street 8, D-97422, Schweinfurt, Germany.
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Schinkel C, Greiner-Perth R, Schwienhorst-Pawlowsky G, Frangen TM, Muhr G, Böhm H. [Does timing of thoracic spine stabilization influence perioperative lung function after trauma?]. DER ORTHOPADE 2007; 35:331-6. [PMID: 16322967 DOI: 10.1007/s00132-005-0898-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Proper timing of stabilization for spine injuries is discussed controversially. Whereas early repair of long bone fractures is known to reduce complications. PATIENTS AND METHODS We investigated retrospectively 48 patients who were stabilized in a ventrodorsal approach for fractures of the thoracic spine. Patients were divided into three groups. All patients in groups I and II presented radiological or clinical signs of lung contusion. Patients were stabilized in the prone position via single-step dorsal stabilization with internal transpedicular fixation and ventral fusion with titanium cage or autologous bone graft using a minimally invasive video-assisted thoracotomy. RESULTS The average duration of the procedures in group I was 213+/-40 min, in group II 250+/-75 min, and in group III 255+/-65 min (p: n.s.). Intraoperative blood loss did not differ significantly between the three groups. The PaO(2)/FiO(2) ratio improved in groups I and III, whereas in group II an significant impairment of lung function occurred perioperatively. Postoperative ICU stay was comparable in groups I and II (I: 10+/-5 days; II: 9+/-7 days); overall ICU stay tended to be shorter in group I versus II. The postoperative dependence on ventilator support did not differ significantly among the three groups. The mortality rate was 0% in this series. CONCLUSION Our data provide further evidence that early stabilization of combined thoracic and thoracic spine injuries is safe, does not alter perioperative lung function, and results in a reduced overall ICU stay.
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Affiliation(s)
- C Schinkel
- Chirurgische Klinik, BG Kliniken Bergmannsheil, Ruhr-Universität, Bochum.
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Moon MS, Choi WT, Sun DH, Chae JW, Ryu JS, Chang H, Lin JF. Instrumented ligamentotaxis and stabilization of compression and burst fractures of dorsolumbar and mid-lumbar spines. Indian J Orthop 2007; 41:346-53. [PMID: 21139790 PMCID: PMC2989514 DOI: 10.4103/0019-5413.36999] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Controversy continues regarding the best treatment for compression and burst fractures. The axial distraction reduction utilizing the technique employing the long straight rod or curved short rod without derotation to reduce fracture are practised together with short segment posterolateral fusion (PLF). Effects of the early postoperative mobilization without posterolateral fusion on reduction maintenance and fracture consolidation were not evaluated so far. The present prospective study is designed to assess the effectiveness of i) reduction and restoration of sagittal alignment, ii) no posterolateral fusion on the reduced, fractured vertebral body and injured disc, iii) fracture consolidation and iv) the fate of the unfused cephalad and caudal injured motion segments of the fractured vertebra. MATERIALS AND METHODS The study includes 15 Denis burst and two Denis type D compression fractures between T(12) and L(3). The lordotic distraction technique was used for ligamentotaxis utilizing the contoured short rods and pedicle screw fixator. Three vertebrae including the fractured one were fixed. The patients after surgery were braced for ten weeks with activity restriction for 2-4 weeks. The patients were evaluated for change in vertebral body height, sagittal curve, reduction of retropulsion, improvement in neural deficit. The unfused motion segments, residual postoperative pain and bone and metal failure were also evaluated. RESULTS The preoperative and postreduction percentile vertebral heights at, zero (immediate postoperative), at three, six and 12 months followup were 62.4, 94.8, 94.6, 94.5 and 94.5%, respectively. The percentages of the intracanal fragment retropulsion at preoperative, and postoperative at zero, 3, 6 and 12 months followup were 59.0, 36.2,, 36.0, 32.3, and 13.6% respectively. The preoperative and postreduction percentile loss of the canal dimension and at zero, three, six and 12 months were 52.1, 45.0, 44.0, 41.0 and 29% respectively suggesting that the under-reduced fragment was being resorbed gradually by a remodeling process. The mean initial kyphosis of 33° became mean 2° immediately after reduction and mean 3° at the final followup. The fractured vertebral bodies consolidated in an average period of ten weeks (range 8-14 weeks). The restored disc heights were relatively well maintained throughout the observation period. All paraparetic patients recovered neurologically. There were no postoperative complications. CONCLUSION Instrument-aided ligamentotaxis for compression and burst fractures utilizing the short contoured rod derotation technique and the instrumented stabilization of the fractured spine are found to be effective procedures which contribute to the fractured vertebral body consolidation without recollapse and maintain the motion segment function.
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Affiliation(s)
- Myung-Sang Moon
- Department of Orthopedic Surgery, Sun General Hospital, Daejeon, Korea,Correspondence: Dr. Myung-Sang Moon, Department of Orthopedic Surgery, Sun General Hospital, 10-7 Mok-dong, Chung-ku, Daejeon, Korea (South), E-mail:
| | - Won-Tae Choi
- Department of Orthopedic Surgery, Sun General Hospital, Daejeon, Korea
| | - Doo-Hoon Sun
- Department of Orthopedic Surgery, Sun General Hospital, Daejeon, Korea
| | - Jong-Woo Chae
- Department of Orthopedic Surgery, Sun General Hospital, Daejeon, Korea
| | - Jong-Seon Ryu
- Department of Orthopedic Surgery, Sun General Hospital, Daejeon, Korea
| | - Han Chang
- Department of Orthopedic Surgery, Sun General Hospital, Daejeon, Korea
| | - Jin-Fu Lin
- Department of Spine Surgery, Taipei Hospital, D.O.H, Taipei, Taiwan
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Schmidt OI, Strasser S, Kaufmann V, Strasser E, Gahr RH. Role of early minimal-invasive spine fixation in acute thoracic and lumbar spine trauma. Indian J Orthop 2007; 41:374-80. [PMID: 21139794 PMCID: PMC2989516 DOI: 10.4103/0019-5413.37003] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
UNLABELLED Polytraumatized patients following a severe trauma suffer from substantial disturbances of the immune system. Secondary organ dysfunction syndromes due to early hyperinflammation and late immunparalysis contribute to adverse outcome. Consequently the principle of damage control surgery / orthopedics developed in the last two decades to limit secondary iatrogenic insult in these patients. New percutaneous internal fixators provide implants for a damage control approach of spinal trauma in polytraumatized patients. The goal of this study is to evaluate the feasibility of minimal-invasive instrumentation in the setting of minor and major trauma and to discuss the potential benefits and drawbacks of this procedure. MATERIALS AND METHODS The present study is a prospective analysis of 76 consecutive patients (mean age 53.3 years) with thoracolumbar spine fractures following major or minor trauma from August 2003 to January 2007 who were subjected to minimal-invasive dorsal instrumentation using CD Horizon(®) Sextant™ Rod Insertion System and Longitude™ Rod Insertion System (Medtronic(®) Sofamor Danek). Perioperative and postoperative outcome measures including e.g. local and systemic complications were assessed and discussed. RESULTS Forty-nine patients (64.5%) suffered from minor trauma (Injury Severity Score <16). Polytraumatized patients (n=27; 35.5%) had associated chest (n=20) and traumatic brain injuries (n=22). For mono- and bisegmental dorsal instrumentation the Sextant™ was used in 60 patients, whereas in 16 longer ranging instrumentations the (prototype) Longitude™ system was implanted. Operation time was substantially lower than in conventional approach at minimum 22.5 min for Sextant and 36.2 min for Longitude™, respectively. Geriatric patients with high perioperative risk according to ASA classification benefited from the less invasive approach and lack of approach-related complications including no substantial blood loss. CONCLUSION Low rate of approach-related complications in association with short operation time and virtually no blood loss is beneficial in the setting of polytraumatized patients regarding damage control orthopedics, as well as in geriatric patients with high perioperative risk. The minimal-invasive instrumentation of the spine is associated with beneficial outcome in a selected patient population.
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Affiliation(s)
- Oliver I Schmidt
- Trauma Centre, St.Georg, Klinikum Sankt Georg, Delitzscher Strasse 141, 04129 Leipzig, Germany,Correspondence: Dr. Oliver I Schmidt, Trauma Centre “St. Georg”, Klinikum Sankt Georg, Delitzscher Strasse 141, 04129 Leipzig, Germany. E-mail:
| | - Sergej Strasser
- Department of Neurology, Klinikum Sankt Georg, Delitzscher Strasse 141, 04129 Leipzig, Germany
| | - Victoria Kaufmann
- Trauma Centre, St.Georg, Klinikum Sankt Georg, Delitzscher Strasse 141, 04129 Leipzig, Germany
| | - Ewald Strasser
- Trauma Centre, St.Georg, Klinikum Sankt Georg, Delitzscher Strasse 141, 04129 Leipzig, Germany
| | - Ralf H Gahr
- Trauma Centre, St.Georg, Klinikum Sankt Georg, Delitzscher Strasse 141, 04129 Leipzig, Germany
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Rutges JPHJ, Oner FC, Leenen LPH. Timing of thoracic and lumbar fracture fixation in spinal injuries: a systematic review of neurological and clinical outcome. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2006; 16:579-87. [PMID: 17109106 PMCID: PMC2213541 DOI: 10.1007/s00586-006-0224-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2006] [Revised: 08/09/2006] [Accepted: 09/05/2006] [Indexed: 12/16/2022]
Abstract
A systematic review of all available evidence on the timing of surgical fixation for thoracic and lumbar fractures with respect to clinical and neurological outcome was designed. The purpose of this review is to clarify some of the controversy about the timing of surgical fracture fixation in spinal trauma. Better neurological outcome, shorter hospital stay and fewer complications have been reported after early fracture fixation. But there are also studies showing no difference in neurological outcome when compared to late treatment. Mortality is another controversial point since a recent report of higher mortality in early treated patients. A systematic review of the literature was preformed. Ten articles were included. Early fracture fixation is associated with less complications, shorter hospital and ICU stay. The effect of early treatment on the neurological outcome remains unclear due to the contradictory results of the included studies. Early thoracic and lumbar fracture fixation results in improvement of clinical outcome, but the effect on neurological outcome remains controversial.
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71
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Meves R, Avanzi O. Correlation among canal compromise, neurologic deficit, and injury severity in thoracolumbar burst fractures. Spine (Phila Pa 1976) 2006; 31:2137-41. [PMID: 16915102 DOI: 10.1097/01.brs.0000231730.34754.9e] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Review the association between injury severity, narrowing of the spinal canal, and neurologic deficit in thoracolumbar burst fractures. OBJECTIVE To determine which variable has a stronger association with neurologic deficit: spinal canal compromise or injury severity. SUMMARY OF BACKGROUND DATA Literature has not reached a consensus regarding the cause of neurologic deficits in these fractures. Some believe it to be the spinal canal compromise and others the energy of trauma. METHODS A review of the clinical data and axial computerized tomography of 184 patients was performed. The injury severity was determined by subtracting neurologic data from the Injury Severity Score and New Injury Severity Score (ISSM and NISSM) to avoid the bias of overestimating neurologic lesions. RESULTS Patients with neurologic deficit presented higher canal compromise (52% vs. 34%), higher Injury Severity Score (24 vs. 11), New Injury Severity Score (26 vs. 13), ISSM (10 vs. 7), and NISSM (11 vs. 8, respectively). A positive correlation was found among these scores and the spinal canal compromise (P < 0.005; r < 0.35). In the current methodology, logistic regression proved narrowing of the spinal canal to be the only independent variable associated with neurologic deficit. CONCLUSIONS Narrowing of the spinal canal has a stronger association with neurologic deficit than injury severity in thoracolumbar burst fractures.
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Affiliation(s)
- Robert Meves
- Orthopedics Department, Santa Casa School of Medicine of São Paulo, Brazil.
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Steib JP, Aoui M, Mitulescu A, Bogorin I, Chiffolot X, Cognet JM, Simon P. Thoracolumbar fractures surgically treated by "in situ contouring". EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2006; 15:1823-32. [PMID: 16823556 DOI: 10.1007/s00586-006-0161-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2005] [Revised: 03/01/2006] [Accepted: 05/10/2006] [Indexed: 10/24/2022]
Abstract
This is a retrospective study on a series of 70 patients with thoracolumbar fractures (TL), surgically treated by the in situ bending technique (ISB). Its purpose is to show the performances and limits of the ISB technique for the early correction of post-traumatic spine deformities as well as to estimate the overall outcome in this series and to discuss the indications for anterior grafting. Although the management of limbs fractures is a cleared issue today, spine fractures management is still a matter of debate. Surgical treatment progresses fast, while indications, the fixation techniques, fracture reduction options, and associated grafting are still blurry. Seventy patients with TL fractures, mean age 40.3 years (20-80) were treated by posterior fusion with a standard construct and deformity reduction by means of the ISB technique. Mean follow-up was 30.7 months (12-78). Pre- and post-operative deformity was evaluated and the relative deformity as defined by Farcy's sagittal index (SIF) was analyzed. Thirty-eight patients underwent anterior interbody grafting. The pre-operative SIF decreased from 16.98 to 1.62 degrees (15.36 degrees decrease). Eighty percent of patients were normo- or hyper-corrected. The loss of correction during the follow-up occurred within the disc (SIF: -2.24 degrees , vertebral kyphosis 0.94 degrees , p<0.001), and was lower in patients who underwent secondary anterior grafting (-5.21 degrees vs.-1.18 degrees , p=0.002). Clinical outcome is good (Oswestry=29.75) and seems to be better in cases of double approach (20.71 vs. 37.,4, p=0.001). Sepsis occurred in ten cases, and two patients experienced construct dismounting. One patient had a retroperitoneal hematoma that required embolization. Seventy-one percent of operated patients went back to their previous work after surgery. Spine fractures deserve an efficient treatment. The ISB technique improves post traumatic kyphosis. This results is maintained at long term if the posterior fusion is associated with anterior grafting in cases where the correction within the disc exceeds 50% of the total correction.
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Affiliation(s)
- Jean-Paul Steib
- Service de Chirurgie Orthopédique, du Rachis et de Traumatologie du Sport, Chirurgie B, Hôpitaux Universitaires de Strasbourg, BP 426, 67091, Strasbourg Cedex, France.
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Harris MB, Sethi RK. The initial assessment and management of the multiple-trauma patient with an associated spine injury. Spine (Phila Pa 1976) 2006; 31:S9-15; discussion S36. [PMID: 16685243 DOI: 10.1097/01.brs.0000217924.56853.0d] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Review and summary of the relevant literature from multiple disciplines. OBJECTIVE Provide the readership with evidence-based guidelines on the initial assessment and treatment of the multiple-trauma patient with an associated spinal column injury. SUMMARY OF BACKGROUND DATA Early operative stabilization of the isolated spinal column injury has decreased hospital and intensive care unit length of stay. Early intervention has not provided consistently improved neurologic outcomes. The timing of spinal column stabilization in the multiple-trauma patient continues to be a source of discussion. METHODS Review of published English literature from 1990 to present using key words: spinal trauma, multiple-trauma with spinal injury; timing of spinal injury treatment; spinal fracture management; and Advanced Trauma Life Support. CONCLUSIONS The treatment of the poly-trauma patient with an associated spinal column injury requires strict adherence to Advanced Trauma Life Support principles. Once life and limb-threatening injuries have been identified and addressed, spinal column assessment and neurologic protection must be maintained at the highest priority. Early spinal stabilization can be performed safely in the multiple-trauma patient in medical centers, in which medical and ancillary staff is available on a 24-hour basis and is familiar with these procedures.
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Affiliation(s)
- Mitchel B Harris
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA 02115, USA.
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Rampersaud YR, Annand N, Dekutoski MB. Use of minimally invasive surgical techniques in the management of thoracolumbar trauma: current concepts. Spine (Phila Pa 1976) 2006; 31:S96-102; discussion S104. [PMID: 16685244 DOI: 10.1097/01.brs.0000218250.51148.5b] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Literature review and expert opinion. OBJECTIVE To provide an overview of the current concepts of minimally invasive surgical (MIS) techniques for the management of thoracolumbar (TL) spinal trauma. SUMMARY OF BACKGROUND DATA Current surgical treatment of thoracolumbar trauma typically involves open placement of spinal instrumentation with fusion. Conventional open spinal exposures can be associated with significant muscle morbidity that can lead to subsequent paraspinal muscular atrophy, scarring, decreased extensor strength and endurance, as well as pain. This approach-related morbidity is the main impetus for application MIS techniques to spinal procedures including trauma. METHODS A review of the relevant English literature was performed. RESULTS The current rationale, clinical applications, outcomes, and limitation of MIS management of TL injuries are summarized. CONCLUSION The application of MIS techniques to spinal trauma is theoretically sound. However, the indications and technology are currently in evolution. Although very limited information is available, the results of current MIS techniques for the management of TL trauma are encouraging.
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Affiliation(s)
- Y Raja Rampersaud
- Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada.
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MCHENRY TIMOTHYP, MIRZA SOHAILK, WANG JINGJING, WADE CHARLESE, OʼKEEFE GRANTE, DAILEY ANDREWT, SCHREIBER MARTINA, CHAPMAN JENSR. RISK FACTORS FOR RESPIRATORY FAILURE FOLLOWING OPERATIVE STABILIZATION OF THORACIC AND LUMBAR SPINE FRACTURES. J Bone Joint Surg Am 2006. [DOI: 10.2106/00004623-200605000-00010] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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McHenry TP, Mirza SK, Wang J, Wade CE, O'Keefe GE, Dailey AT, Schreiber MA, Chapman JR. Risk factors for respiratory failure following operative stabilization of thoracic and lumbar spine fractures. J Bone Joint Surg Am 2006; 88:997-1005. [PMID: 16651574 DOI: 10.2106/jbjs.e.00560] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Respiratory failure is a serious complication that can adversely affect the hospital course and survival of multiply injured patients. Some studies have suggested that delayed surgical stabilization of spine fractures may increase the incidence of respiratory complications. However, the authors of these studies analyzed small sets of patients and did not assess the independent effects of multiple risk factors. METHODS A retrospective cohort study was conducted at a regional level-I trauma center to identify risk factors for respiratory failure in patients with surgically treated thoracic and lumbar spine fractures. Demographic, diagnostic, and procedural variables were identified. The incidence of respiratory failure was determined in an adult respiratory distress syndrome registry maintained concurrently at the same institution. Univariate and multivariate analyses were used to determine independent risk factors for respiratory failure. An algorithm was formulated to predict respiratory failure. RESULTS Respiratory failure developed in 140 of the 1032 patients in the study cohort. Patients with respiratory failure were older; had a higher mean Injury Severity Score (ISS) and Charlson Comorbidity Index Score; had greater incidences of pneumothorax, pulmonary contusion, and thoracic level injury; had a lower mean Glasgow Coma Score (GCS); were more likely to have had a posterior surgical approach; and had a longer mean time from admission to surgical stabilization than the patients without respiratory failure (p < 0.05). Multivariate analysis identified five independent risk factors for respiratory failure: an age of more than thirty-five years, an ISS of > 25 points, a GCS of < or = 12 points, blunt chest injury, and surgical stabilization performed more than two days after admission. An algorithm was created to determine, on the basis of the number of preoperative predictors present, the relative risk of respiratory failure when surgery was delayed for more than two days. CONCLUSIONS Independent risk factors for respiratory failure were identified in an analysis of a large cohort of patients who had undergone operative stabilization of thoracic and lumbar spine fractures. Early operative stabilization of these fractures, the only risk factor that can be controlled by the physician, may decrease the risk of respiratory failure in multiply injured patients.
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Heyde CE, Ertel W, Kayser R. [Management of spine injuries in polytraumatized patients]. DER ORTHOPADE 2005; 34:889-905. [PMID: 16096745 DOI: 10.1007/s00132-005-0847-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The management of spine injuries in polytraumatized patients remains a great challenge for the diagnostic procedures and institution of appropriate treatment by integrating spinal trauma treatment into the whole treatment concept as well as following the treatment steps for the injured spine itself. The established concept of "damage control" and criteria regarding the optimal time and manner for operative treatment of the injured spine in the polytrauma setting is presented and discussed.
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Affiliation(s)
- C E Heyde
- Zentrum für spezielle Chirurgie des Bewegungsapparates, Klinik für Unfall- und Wiederherstellungschirurgie, Charité, Campus Benjamin Franklin, Universitätsmedizin, Hindenburgdamm 30, 12200 Berlin, Germany.
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Abstract
✓ Appropriate timing for surgical intervention following destabilizing cervical or thoracic spine trauma remains controversial. Clinical investigators have failed to provide convincing evidence that the timing of surgery significantly affects neurological outcome in most situations. Nevertheless, early surgical stabilization of the injured spine has been shown to provide significant nonneurological benefits such as more rapid patient mobilization, facilitation of treating associated injuries, reduction in rates of pulmonary and pressure sore complications, reduction in duration of intensive care unit and hospital stays, and a decrease in overall medical costs.
The findings of basic science studies have improved our understanding of the molecular and cellular events surrounding initial and secondary spinal cord injury (SCI), and analysis of these findings suggests that the early postinjury period may present a unique opportunity for meaningful intervention. This possibility has been supported by results obtained in animal studies that demonstrate the potential for improving functional outcome when surgical intervention is performed within a few hours following experimental SCI. Despite the absence of significant neurological recovery in most clinical studies, the results of most recent clinical studies strongly support the overall clinical benefits of early surgical intervention, particularly in the setting of unstable thoracic spinal column injury with associated SCI. Based on the best available scientific and clinical evidence, the authors report that it is therefore recommended that surgical stabilization be performed in as timely a fashion as possible, particularly for unstable thoracic spine trauma, within the constraints of the patient's overall medical condition and availability of appropriate resources.
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Affiliation(s)
- Todd J Albert
- Department of Orthopaedic Surgery, Thomas Jefferson University, Rothman Institute of Orthopaedic Surgery, Philadelphia, Pennsylvania 19107-1216, USA.
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Kerwin AJ, Frykberg ER, Schinco MA, Griffen MM, Murphy T, Tepas JJ. The effect of early spine fixation on non-neurologic outcome. ACTA ACUST UNITED AC 2005; 58:15-21. [PMID: 15674144 DOI: 10.1097/01.ta.0000154182.35386.7e] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION It has been shown that spinal fracture fixation within 3 days can reduce the incidence of pneumonia, length of stay, number of ventilator days, and hospital charges. Our institutional protocol calls for surgical stabilization of spinal fractures within 3 days of admission. We hypothesized that compliance with an early spinal fracture fixation protocol (within 3 days of admission) would improve non-neurologic outcome in patients with spinal fractures. METHODS The trauma registry was queried for the period January 1988 through October 2001 to identify patients with spinal fractures requiring surgical stabilization. Patients were analyzed to determine the compliance with our protocol and to determine whether early spinal fixation can reduce the incidence of pneumonia, reduce length of stay, and reduce mortality. RESULTS 1,741 patients with spinal fractures were identified. 299 (17.2%) required surgical stabilization. 174 (58.2%) had surgical stabilization within 3 days while 125 (41.8%) had surgical stabilization greater than 3 days from admission. There were no significant differences between the two groups with regards to age (37.9 versus 42.5), admission GCS (14.1 versus 13.9), or ISS (22 versus 20.8). The incidence of pneumonia was similar in both groups (21.8 versus 25.6%). The mortality was higher in the early group as compared with the late group (6.9 versus 2.5%), although it did not reach statistical significance. The hospital length of stay was significantly shorter (14.3 versus 21.1) for patients who had early spine fixation, however there was no statistically significant difference between the two groups with regards to intensive care unit length of stay (7.2 versus 7.9) or number of ventilator days (5.02 versus 1.9). Patients who were severely injured (ISS > 25) also had a significantly shorter hospital length of stay (19.6 versus 29.1) if they underwent early spinal fixation. Patients with thoracic spine injury and associated spinal cord injury had a significantly shorter HLOS (10.1 versus 30.5), ICULOS (2.3 versus 13.1), and lower incidence of pneumonia (6.5 versus 33.3%). CONCLUSIONS Reasonable compliance with an early spinal fracture fixation protocol produced some outcome improvements in non-neurologic outcome. Early spine stabilization reduced hospital length of stay in all patients. Patients with thoracic spine trauma and a spinal cord injury had the greatest benefit in reduction of morbidity, HLOS and ICULOS from early stabilization. There was a trend toward poorer outcome in some groups with early spine stabilization. A rigid protocol requiring early surgical spine stabilization in all patients does not appear justified. Although early spine stabilization should be performed whenever possible to reduce hospital length of stay, the timing of this procedure should be individualized to allow patients with the most severe physiologic derangements to be optimized preoperatively.
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Affiliation(s)
- Andrew J Kerwin
- University of Florida Health Science Center-Jacksonville, Department of Surgery, Division of Trauma and Critical Care, Jacksonville, Florida 32209, USA.
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Pape HC, Hildebrand F, Krettek C. [Decision making and and priorities for surgical treatment during and after shock trauma room treatment]. Unfallchirurg 2005; 107:927-36. [PMID: 15452656 DOI: 10.1007/s00113-004-0848-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Concepts for optimal surgical treatment of the patient with blunt multiple injuries are being evaluated on the basis of the current literature. METHODS Clinical trials were systematically collected (Medline, Cochrane and hand searches) and classified into evidence levels (1 to 5 according to the Oxford system). RESULTS The posttraumatic clinical course is divided into four different periods: acute-, primary-, secondary- und tertiary period. The first and second period are important for life saving surgery and the stabilization of major fractures. After the cardiorespiratory systems have been stabilized, the following priorities have been formulated: head, face, spine, abdomen, extremities. To restrict the degree of operative burden on the patient it appears to be necessary to limit the duration of initial surgery to less than 6 hours. In patients at high risk to develop posttraumatic complications-"borderline patients"-it appears safer to perform only temporary fixation of major fractures. CONCLUSIONS Three different factors determine the clinical course after polytrauma: Trauma represents the first hit, followed by the therapy-induced burden (second hit). In addition, the third hit is represented by the individual response. An evaluation of the clinical status by immunologic monitoring can be performed in order to assess the patient's status.
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Affiliation(s)
- H C Pape
- Unfallchirurgische Klinik, Medizinische Hochschule Hannover.
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Folman Y, Gepstein R. Secondary neurologic deficit due to unrecognized spine instability in multitrauma casualties: a report of three cases. J Orthop Trauma 2004; 18:450-4. [PMID: 15289693 DOI: 10.1097/00005131-200408000-00011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
We present three cases of major multiple injuries in which delayed diagnosis of spinal instability resulted in neurologic deficit. The spinal injuries, once diagnosed, were treated by urgent surgical stabilization, which resulted in prompt and full recovery. A set of recommendations is proposed to prevent these potentially disastrous consequences.
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Affiliation(s)
- Yoram Folman
- Department of Orthopaedic Surgery, Hillel-Yaffe Hospital, Hadera, Israel.
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Abstract
The concept of "damage control" surgery was originally developed for massive abdominal trauma and also successfully applied to the management of lone bone injuries. More recently this has been extended to severely injured patients with spine injuries. This paper provided an overview of how damage control principles can be applied to multitrauma patients with spine injuries, to patients with isolated spine injuries and to spine injuries with and without neurology. The role of neuroimaging in acute spine trauma and controversies in the pharmaceutical approach to spine injuries are discussed. Additional prospective controlled trials are required to delineate the role and timing of damage control surgery in acute spine injury. With improved neuroimaging early spinal damage control surgery will be formally established in the management of spine trauma.
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Affiliation(s)
- Thomas Kossmann
- Department of Trauma Surgery, The Alfred Hospital/Monash University, Commercial Road, Melbourne, Vic. 3004, Australia.
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83
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Dai LY, Yao WF, Cui YM, Zhou Q. Thoracolumbar fractures in patients with multiple injuries: diagnosis and treatment-a review of 147 cases. ACTA ACUST UNITED AC 2004; 56:348-55. [PMID: 14960979 DOI: 10.1097/01.ta.0000035089.51187.43] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The initial evaluation and treatment of patients with multiple injuries are challenging. However, little is known about thoracolumbar fractures in patients with multiple injuries. We aimed to determine the incidence of missed injuries of the thoracolumbar spine in patients with multiple injuries, to examine the reasons for the delay in diagnosis, and to study the selection of treatment options in the management and timing of surgical intervention. METHODS One hundred forty-seven consecutive patients with acute thoracolumbar fractures and multiple trauma at the authors' hospital between 1988 and 1997 were retrospectively reviewed. The incidence of missed injuries of the thoracolumbar spine and the reasons for the delay in diagnosis were determined. All these patients were observed for a minimum of 3 years after surgery, except four who died during their hospital stay. RESULTS Delayed diagnosis of thoracolumbar fractures was made in 28 patients (19%). There was an increased incidence of pulmonary complications (p < 0.01) and increased length of hospital stay (p < 0.05) in patients treated nonoperatively compared with patients treated operatively. Although no significant differences in the recovery rate of neurologic function (p > 0.05) were noted between the groups, the surgical patients had highly significantly less pain compared with the nonoperative patients (p < 0.01). The relationship between the timing of thoracolumbar surgery and complications failed to show statistical significance (p > 0.05). Neither the severity of injury nor the timing of surgery had any significant effect on the recovery rate (p > 0.05). CONCLUSION Patients with blunt trauma caused by high-energy impact injuries are much more likely to have thoracolumbar fractures even if injuries elsewhere have been noted. Further radiographic studies of the thoracolumbar spine should be performed if there is any question related to a thorough and systematic examination. Choice of treatment options of thoracolumbar fractures in patients with multiple injuries is not different from that in patients with no associated injuries to other systems. Appropriate timing of thoracolumbar fracture fixation in patients with multiple injuries should not be dependent on a rigid protocol.
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Affiliation(s)
- Li-Yang Dai
- Department of Orthopaedic Surgery, Xinhua Hospital, Shang-hai Second Medical University, Shanghai, China.
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84
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Chipman JG, Deuser WE, Beilman GJ. Early surgery for thoracolumbar spine injuries decreases complications. ACTA ACUST UNITED AC 2004; 56:52-7. [PMID: 14749565 DOI: 10.1097/01.ta.0000108630.34225.85] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The proper timing for surgical fracture repair is controversial. Early repair of long bone and cervical fractures reduces complications and is safe. Few studies exist to compare time to surgery with outcomes in thoracolumbar (TL) spine injuries. METHODS Patients with TL spine injuries were identified from the trauma registry and divided into two cohorts on the basis of Injury Severity Score (ISS). Cohorts were compared for infectious, respiratory, and total complications in patients who had early (<72 hours from injury) versus late (>72 hours from injury) surgical repair. A retrospective chart review was performed on High ISS patients (> or =15) to identify differences in resuscitation needs and neurologic, respiratory, and infectious complications. RESULTS Early surgery, Low ISS patients were younger, received fewer anterior repairs, and had shorter hospitalizations. Early patients in the High ISS cohort had significantly fewer total complications and shorter hospital and intensive care unit lengths of stay. Resuscitative requirements were similar for both surgery groups. More late surgery patients required ventilator support for noninfectious reasons. There was no difference in admission or postoperative neurologic status or the incidence of head injury. CONCLUSION Early surgery in severely injured patients with thoracolumbar spine trauma was associated with fewer complications and shorter hospital and intensive care unit lengths of stay, required less ventilator support for noninfectious reasons, and did not increase neurologic deficits.
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Affiliation(s)
- Jeffrey G Chipman
- Department of Surgery, University of Minnesota, Minneapolis, 55455, USA
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85
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Abstract
OBJECT OF STUDY The literature regarding surgical treatment's impact on patient function after spinal fracture is sparse. Some authors have speculated that operative injury--the dissection of paraspinous muscle tissue, damage to spinal motion segments, implantation of spinal devices--may impair functional recovery in spine trauma patients. Nonoperative care has produced satisfactory results in some hands, but results are difficult to reproduce, treatment is resource-intensive, and functional outcomes are poorly documented. This study reports return to work and functional recovery in a 5-year follow-up of severely injured patients treated with segmental spinal instrumentation. MATERIALS AND METHODS Seventy consecutive patients treated with Cotrel Dubousset instrumentation for unstable thoracic, thoracolumbar, and lumbar spine fractures were followed-up. All had high-energy trauma and were admitted directly to a level 1 university trauma center; 38% were polytraumatized; and 56% had neurologic injuries. Indications for surgery included: (1) segmental instability; (2) incomplete or progressive neurologic injuries with residual spinal canal compromise; (3) concomitant injuries precluding cast treatment; and (4) polytrauma. Two patients died and six were lost to follow-up, leaving 62 (91%) for assessment at a mean 5-year follow-up (range 2-8 y). Clinical outcome has been reported. Functional recovery was assessed based on return to work, level of work, and level of daily activity. RESULTS Despite the severity of spinal and concomitant injuries, 70% of patients returned to full-time work and another 8% were considered capable: 54% to their previous level of employment without restrictions and 16% to full-time, but lighter, jobs. Twenty-two percent were working part-time or not at all, and 8% were unemployed despite unrestricted functional status. Work status correlated directly with neurologic impairment (P < 0.00005) and was not related to level of injury, hardware failure, extent of surgical dissection, or construct pattern. Of patients with limitations, 18% were limited by pain and 27% by neurologic injury. CONCLUSION Neurologic injury had a greater impact on functional outcome than any other variable. Patients limited by pain were more often impaired by residual radicular and neuropathic symptoms than by back pain. Impairment was not related to the extent of either the surgical incision or the instrumentation. Patients with persistent back pain generally had an identifiable and correctable mechanical problem-sagittal imbalance, pseudarthrosis, or persistent instability--as the underlying cause. Our series of trauma patients was predominantly young and male. Among this cohort, individual characteristics of occupation (often physical laborers and craftsmen) and judgment (criminal convictions and incarceration) may have restricted opportunities for re-employment in 40% of the entire study group.
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Affiliation(s)
- Robert F McLain
- Section of Spine Surgery, The Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
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86
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Cohen WA, Giauque AP, Hallam DK, Linnau KF, Mann FA. Evidence-based approach to use of MR imaging in acute spinal trauma. Eur J Radiol 2003; 48:49-60. [PMID: 14511860 DOI: 10.1016/s0720-048x(03)00201-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
MR imaging directly shows integrity of spinal cord, and provides sensitive assessments of structurally important soft tissue investments of the vertebral column. High-resolution images should be acquired in at least two planes, with T1 and fluid sensitive sequences. In the acute and subacute settings, MR may be used to assess integrity of intervertebral discs prior to closed reduction of inter-facetal dislocations, to discriminate between neurological deficits due to intra-substance hemorrhage or edema, and to determine the status of spinal ligaments as an adjunct to 'clearing' the spine.
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Affiliation(s)
- Wendy A Cohen
- Harborview Medical Center, Seattle, WA 98109-2499, USA.
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87
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Abstract
The surgeon who treats patients with spine trauma must be able to apply a variety of management techniques to achieve optimal care of the patient. The anterior surgical approach is appropriate for some thoracolumbar burst fractures in patients with neurologic deficit and without posterior ligamentous injury. Surgery is most often indicated for patients with incomplete deficit, especially those with a large retropulsed fragment, marked canal compromise, severe anterior comminution, or kyphosis <30 degrees. This approach provides excellent visualization of the anterior aspect of the dura mater for decompression. Reconstruction of the anterior body defect can be done with autograft, allograft, or a cage. Supplementation of the graft with anterior internal fixation helps prevent kyphosis. Clinical results demonstrate improved neurologic function in most patients as well as low pseudarthrosis rates. In patients with incomplete deficit, improvement in neurologic function usually can be expected with few complications.
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Affiliation(s)
- John S Kirkpatrick
- Division of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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88
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Yue JJ, Sossan A, Selgrath C, Deutsch LS, Wilkens K, Testaiuti M, Gabriel JP. The treatment of unstable thoracic spine fractures with transpedicular screw instrumentation: a 3-year consecutive series. Spine (Phila Pa 1976) 2002; 27:2782-7. [PMID: 12486347 DOI: 10.1097/00007632-200212150-00008] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN The treatment of unstable thoracic spine fractures remains controversial. Theoretical biomechanical advantages of transpedicular screw fixation include three-column control of vertebral segments and fixation of a vertebral segment in the absence of intact posterior elements. Additionally, pedicle screw constructs may obviate the need for neural canal dissection and potential neural element impingement by intracanal instrumentation. A 3-year consecutive series was performed to evaluate the use of transpedicular screw fixation in the treatment of unstable thoracic spine injuries. OBJECTIVE This study was performed to evaluate the efficacy of transpedicular screw fixation in the upper, middle, and lower thoracic spine. SUMMARY OF BACKGROUND DATA The use of rod/hook and rod/wiring techniques has been evaluated in the treatment of thoracic spine injuries. To date, a study evaluating the safety and efficacy of pedicle screw instrumentation in the upper, middle, and lower thoracic spine has not been reported. METHODS Thirty-two patients with 79 individual vertebral injury levels (T2-L1) treated with transpedicular spinal stabilization and bone fusion were evaluated during a 3-year consecutive series from 1998 to 2001. Patient charts, operative reports, preoperative and postoperative radiographs, computed tomography scans, and postoperative follow-up examinations and radiographs were reviewed from the time of surgery to final follow-up assessment. Radiographic measurements included: sagittal index, Gardner segmental kyphotic deformity, and compression percentage. RESULTS A total of 252 pedicle screws were placed, of which 222 were placed in segments T2-L1. Clinical examination and plain radiographs were used to determine the presence of a solid fusion. Fracture healing and radiographic stabilization occurred at an average of 4.8 months after the initial operation. There were no reported cases of hardware failure, loss of reduction, or painful hardware removal. Two hundred fifty-two transpedicular screws were successfully placed without intraoperative complications. The mean preoperative sagittal index was 13.9 degrees, whereas the mean follow-up was 5.25 degrees (P < 0.001). The mean final correction of sagittal index achieved was 8.65 degrees, or a 62.2% improvement. The mean Gardner segmental kyphotic angle was 15.9 degrees, whereas the mean follow-up angle was 10.6 degrees (P < 0.0005). The mean compression percentage was 35.4, and at follow-up was 27.4 (P < 0.07). CONCLUSIONS In carefully selected instances, pedicle screw fixation of upper, middle, and lower thoracic and upper thoracolumbar spinal injuries is a reliable and safe method of posterior spinal stabilization. Transpedicular screw fixation may offer superior three-column control in the absence of posterior element integrity and obviates the need for intracanal placement of hardware. Transpedicular instrumentation provides rigid fixation for upper, middle, and lower unstable thoracic spine injuries and produces early pain-free fusion results. These results provide evidence that with appropriate preoperative radiographic evaluation of pedicular size and orientation using computed tomography as well as radiograph assessment, transpedicular instrumentation is a safe and effective alternative in the treatment of unstable thoracic (T2-L1) spinal injuries.
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Affiliation(s)
- James J Yue
- Yale University School of Medicine, Department of Orthopaedic Surgery, New Haven, Connecticut 06520, USA.
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89
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Abstract
The management of patients with spinal trauma is based on the following goals: (1) the preservation of life; (2) preserving and maximising the neurological function; and (3) providing a stable, painless vertebral column. There have been advances in both non operative as well operative modalities of treatment of patients with spinal injuries. These advances have led to renewed interest in the management of a spinally injured patient. However, despite these advances controversies exist regarding the classification of these fractures, the use of pharmacological intervention, the timing of surgical intervention and indeed the use of surgical intervention itself in the management of these fractures. Most of these controversies surround the treatment of thoracic and lumbar fractures. The purpose of this article is to provide an over view of the therapy options available in the treatment of these fractures. The article shall also look at some of the controversies surrounding the management of these fractures.
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Affiliation(s)
- Jayesh M Trivedi
- Robert Jones and Agnes Hunt, Orthopaedic Hospital, Twmpath Lane, Gobowen, Oswestry SY10 7AG, UK.
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90
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