Fractures and fractures-dislocations of the lumbar spine. A retrospective study of 70 patients

Minimally invasive stabilization for thoracolumbar and lumbar fractures: a comparative study with short segment open Schanz screw constructs

Background

Analysis was performed of two patient cohorts who underwent fixation without fusion for unstable thoracolumbar and lumbar fractures: (I) minimally invasive surgery (MIS) group using combined monoaxial-polyaxial pedicle screws inserted percutaneously; (II) open surgery (OS) group using Schanz screw constructs. Our aim was to compare radiographic and clinical indices of the 'gold standard' of open Schanz screw to MIS monoaxial-polyaxial screw constructs.

Methods

There were 13 patients in the MIS group and 19 in the OS group. Primary outcomes were the correction of fracture angulation and percentage loss of reduction until fracture union. Patient demographics, fracture classification, perioperative data and complications were also collected.

Results

There was no significant difference in cohorts when comparing demographics and fracture classification. Operative time was 50 minutes less and haemoglobin drop was 9 g/L less in the MIS group. Radiation exposure was significantly higher in the MIS group. Pre-operatively, the mean kyphotic angle was 22° in the MIS and 16° in the OS group. Both groups achieved similar on-table correction. On immediate postoperative erect radiographs, the MIS group lost 15% of correction vs. 55% in the OS group. At final follow-up, both groups had a further loss of position, but significantly higher in the OS group (28% vs. 96%).

Conclusions

Combined polyaxial-monoaxial screw MIS constructs demonstrate favorable radiological and clinical outcomes for treatment of unstable thoracolumbar and lumbar fractures. Our study also demonstrates higher rates of radiological collapse in the OS cohort.

Operative treatment as a part of the comprehensive care for patients with injuries of the thoracolumbar spine. A review

In a total appraisal, the advantages and drawbacks of operative decompression and stabilisation of the injured thoracolumbar spine should be evaluated in the treatment of a paraplegic patient and of a patient without neural damage. Operative treatment may be advantageous independent of its effect on the neural damage. Only a few studies allow direct comparison between operative and conservative treatment. Some studies are only of historical value. Today, a general operative policy is to use Harrington rods in the thoracic spine. For injuries caudal to the 9th thoracic vertebra and for those with injuries in the lumbar spine, internal fixators with transpedicular screws are used. Anterior decompression and stabilisation are also warranted in some cases. New implants are continuously being developed, e.g. implants which combine the advantages of hooks and pedicular screws. No study shows conclusively that operative treatment improves the neurological status compared with conservative care. Conservative and operative treatment may both have particular complications. It appears that neurological deterioration is more likely to occur after conservative treatment, while complications related to wound healing and from the implants burden the operative alternative. Mobilisation is quicker and easier after operative treatment, improving psychological and social rehabilitation. Also, these patients experience less in the way of chronic back pain. A high level of expertise is required for operative treatment and this illustrates the general need for the centralisation of the treatment of these relatively rare and severe injuries.