Neurological deficit in injuries of the thoracic and lumbar spine. A consecutive series of 70 patients

Spinal canal invasion as a predictor of neurological deficit in traumatic vertebral burst fractures

Background:

This study correlated the extent of spinal canal compression from retropulsed traumatic burst cervical, thoracic, and lumbar spine fractures with the severity of neurological dysfunction.

Methods:

One hundred and sixty-nine patients with cervical, thoracic, or lumbar sub-axial traumatic burst fractures were seen in an emergency department from 2019 to 2021; 79.3% were men, averaging 37 years of age. The lumbar spine was most frequently involved (42%), followed by the thoracic (36.1%) and cervical (21.9%) levels. The extent of spinal canal compression was quantitated utilizing Hashimoto’s method, and correlated with patients’ extent of neurological injury based on their American Spinal Injury Association scores.

Results:

There was a positive correlation between the extent of cervical and thoracic spinal cord compression due to retro pulsed burst fragments and the severity of the patients’ neurological deficits, but this was not true for the lumbar spine.

Conclusion:

The extent of spinal cord compression from retropulsed cervical and thoracic traumatic burst fractures was readily correlated with the severity of patients’ neurological dysfunction. However, there was no such correlation between the extent of cauda equina compression from retropulsed lumbar burst fractures and the severity of their cauda equina syndromes.

FAIM Is Regulated by MiR-206, MiR-1-3p and MiR-133b

Apoptosis plays an important role during development, control of tissue homeostasis and in pathological contexts. Apoptosis is executed mainly through the intrinsic pathway or the death receptor pathway, i.e., extrinsic pathway. These processes are tightly controlled by positive and negative regulators that dictate pro- or anti-apoptotic death receptor signaling. One of these regulators is the Fas Apoptotic Inhibitory Molecule (FAIM). This death receptor antagonist has two main isoforms, FAIM-S (short) which is the ubiquitously expressed, and a longer isoform, FAIM-L (long), which is mainly expressed in the nervous system. Despite its role as a death receptor antagonist, FAIM also participates in cell death-independent processes such as nerve growth factor-induced neuritogenesis or synaptic transmission. Moreover, FAIM isoforms have been implicated in blocking the formation of protein aggregates under stress conditions or de-regulated in certain pathologies such as Alzheimer’s and Parkinson’s diseases. Despite the role of FAIM in physiological and pathological processes, little is known about the molecular mechanisms involved in the regulation of its expression. Here, we seek to investigate the post-transcriptional regulation of FAIM isoforms by microRNAs (miRNAs). We found that miR-206, miR-1-3p, and miR-133b are direct regulators of FAIM expression. These findings provide new insights into the regulation of FAIM and may provide new opportunities for therapeutic intervention in diseases in which the expression of FAIM is altered.

[The coexistence of spinal canal stenosis in fragility fractures of the spine]

BACKGROUND

In trauma care of fragility fractures of the spine, degenerative stenosis is often seen as an accompanying pathology. This may lead to a possible compression of neurogenic structures. The stenosis of the spinal canal can manifest itself with clinically significant complaints before the fracture occurs. This coexistence may have an impact on the injury itself or may provoke a complicated treatment of the fracture.

AIM

The aim of this work is to differentiate these pathophysiologies and their merger in terms of clinical diagnostics and treatment options.

DIFFERENTIAL DIAGNOSIS

The differential diagnosis is difficult and is often inadequately appreciated in everyday clinical life. The etiology and pathophysiology of both entities show, in several aspects, a congruence that enables joint treatment. If the indication is set for the decompression of a stenosing fracture, a pre-existing relevant stenosis can be addressed in the same session. Conversely, significant degenerative stenosis accompanying a fracture may lead to the indication of decompression.

Neurological recovery following traumatic spinal cord injury: a systematic review and meta-analysis

OBJECTIVE

Predicting neurological recovery following traumatic spinal cord injury (TSCI) is a complex task considering the heterogeneous nature of injury and the inconsistency of individual studies. This study aims to summarize the current evidence on neurological recovery following TSCI by use of a meta-analytical approach, and to identify injury, treatment, and study variables with prognostic significance.

METHODS

A literature search in MEDLINE and EMBASE was performed, and studies reporting follow-up changes in American Spinal Injury Association (ASIA) Impairment Scale (AIS) or Frankel or ASIA motor score (AMS) scales were included in the meta-analysis. The proportion of patients with at least 1 grade of AIS/Frankel improvement, and point changes in AMS were calculated using random pooled effect analysis. The potential effect of severity, level and mechanism of injury, type of treatment, time and country of study, and follow-up duration were evaluated using meta-regression analysis.

RESULTS

A total of 114 studies were included, reporting AIS/Frankel changes in 19,913 patients and AMS changes in 6920 patients. Overall, the quality of evidence was poor. The AIS/Frankel conversion rate was 19.3% (95% CI 16.2-22.6) for patients with grade A, 73.8% (95% CI 69.0-78.4) for those with grade B, 87.3% (95% CI 77.9-94.8) for those with grade C, and 46.5% (95% CI 38.2-54.9) for those with grade D. Neurological recovery was significantly different between all grades of SCI severity in the following order: C > B > D > A. Level of injury was a significant predictor of recovery; recovery rates followed this pattern: lumbar > cervical and thoracolumbar > thoracic. Thoracic SCI and penetrating SCI were significantly more likely to result in complete injury. Penetrating TSCI had a significantly lower recovery rate compared to blunt injury (OR 0.76, 95% CI 0.62-0.92; p = 0.006). Recovery rate was positively correlated with longer follow-up duration (p = 0.001). Studies with follow-up durations of approximately 6 months or less reported significantly lower recovery rates for incomplete SCI compared to studies with long-term (3-5 years) follow-ups.

CONCLUSIONS

The authors' meta-analysis provides an overall quantitative description of neurological outcomes associated with TSCI. Moreover, they demonstrated how neurological recovery after TSCI is significantly dependent on injury factors (i.e., severity, level, and mechanism of injury), but is not associated with type of treatment or country of origin. Based on these results, a minimum follow-up of 12 months is recommended for TSCI studies that include patients with neurologically incomplete injury.

Relationship Between Clinical Outcomes and Spontaneous Canal Remodeling in Thoracolumbar Burst Fracture

OBJECTIVES

To analyze the relationship between clinical factors and spontaneous canal remodeling.

METHODS

We evaluated computed tomography scans, before surgery, within a week after surgery, 6 months after surgery, and 12 months after surgery. Thirty-eight consecutive patients who underwent posterior fixation and fusion after thoracolumbar burst fractures were included in. Factors potentially affecting the postoperative degree of reduction and spontaneous spinal remodeling were defined as age, location, degree of change of anterior vertebral compression ratio, fracture type of the retropulse bone, presence of injury to the posterior longitudinal ligament, and posterolateral complex fracture. Multiple regression analyses were conducted on these factors to analyze the extent of their influence on the reduction and resorption rates.

RESULTS

The recovery rate of the anterior compression (P = 0.003) was significantly related to the reduction rate after surgery; in addition, the recovery rate of the anterior compression (P = 0.022) and the comminuted type of fracture (P = 0.019) were significantly associated with the resorption rate after surgery.

CONCLUSIONS

During posterior fixation, the degree of the reduction of the vertebral body by distraction can affect the degree of postoperative reduction and spontaneous bone remodeling. Therefore, close attention must be given to the indirect reduction technique through distraction during the operation. Because comminuted fracture fragments affect spontaneous canal remodeling, the degree of postoperative resorption can be estimated by preoperative computed tomography imaging.

Demographics of Thoracolumbar Fracture in Indian Population Presenting to a Tertiary Level Trauma Centre

Study Design

Prospective, cross-sectional, observational study.

Purpose

Spine traumata are devastating injuries, which may result in serious disabilities and dire consequences. The current study involves a detailed analysis and description of patients, who were operated at a tertiary care, urban level 1 Spine Centre in India.

Overview of Literature

Various studies in literature have discussed the epidemiology and patterns of these injuries in trauma patients. However, literature describing the demographic profile and distribution of these traumata in the Indian population is scarce.

Methods

The current study was conducted as a prospective trial involving patients, who were treated at our Spine Centre in India between July 2009 to December 2012. We studied 92 patients with thoraco-lumbar spine fracture, who were operated with short or long segment posterior stabilization. Epidemiological details, pre- and post-hospitalisation care received and other injury pattern factors were studied.

Results

Fall from height (46 patients, 50%) was the most common mechanism observed in the patients. Sixty-three percent injuries belonged to AO type A fractures, while 16.2% and 19.4% of the patients had suffered from AO types B and C injuries, respectively.

Conclusions

We identified interesting epidemiological data and prevailing inadequacies in Emergency Spine care management in the study patients. These observations could facilitate implementation of the changes required to improve current standards of patient care.

Clinical results of posterior stabilization without decompression for thoracolumbar burst fractures: is decompression necessary?

The purpose of this study is to investigate the clinical outcome of posterior stabilization without decompression for thoracolumbar burst fractures. Thirty-one consecutive cases of thoracolumbar fractures involving T11-L2 stabilized by a pedicle screw system were reviewed. Neither reduction of the height of a fractured body nor any decompression procedure was added during surgery. Twenty-two patients had incomplete paraplegia; one patient had complete paraplegia. Neurological recovery and remodeling of the spinal canal were evaluated. Neurological status was evaluated at the time of injury, just before and after surgery, and at final follow-up. The degree of spinal canal compromise was assessed using axial CT scan images. The duration of follow-up averaged 39.6 months. The mean spinal canal compromise at the time of injury was 41.6%, and no significant correlation was observed between the degree of canal compromise and the severity of the neurological deficit. Within 2-3 weeks, spinal canal remodeling had started in all patients whose spinal canal compromise was more than 30%, and canal compromise had decreased significantly 3-4 weeks after injury. Seventeen of 22 patients with incomplete paraplegia had already shown partial neurological recovery even before surgery. At the final follow-up, all patients with incomplete paraplegia had improved by at least one modified Frankel grade. This study suggests that the effect of decompressing thoracolumbar fractures with neurological deficits remains unclear and questions the need to operate simply to remove retropulsed bone fragments. Posterior stabilization without decompression should constitute appropriate surgical treatment for these fractures.

Analysis of the risk factors for severity of neurologic status in 216 patients with thoracolumbar and lumbar burst fractures

STUDY DESIGN

A retrospective, consecutive case series.

OBJECTIVE

To determine the risk factors that have a significant correlation with the severity of neurologic impairment in thoracolumbar and lumbar burst fractures.

SUMMARY OF BACKGROUND DATA

The correlation between spinal canal stenosis due to bony fragments and the severity of neurologic deficits in thoracolumbar and lumbar burst fractures remains controversial. Moreover, there have so far been no reports in the literature in which the risk factors (spinal canal stenosis and the disruption of posterior ligamentous complex) causing a severe neurologic deficit were analyzed using a multiple logistic regression model.

METHODS

A review of the clinical data (neurologic impairments on admission and a finding of posterior ligamentous complex disruption at the time of operation), axial computed tomography, and plain lateral radiography of 216 patients in thoracolumbar (T11-L1) and lumbar (L2-L5) burst fractures was performed. The factors related to neurologic impairments were analyzed using a multiple logistic regression model.

RESULTS

In all cases, both the spinal canal stenosis (P < 0.01) and disruption of posterior ligamentous complex (P < 0.01) were significant risk factors. Interestingly, these two risk factors varied according to the injury levels: at thoracic level, the spinal canal stenosis (P < 0.01); at the first lumbar spine, the disruption of the posterior ligamentous complex (P < 0.01); and at the lumbar spine below L2, both of the spinal canal stenosis (P < 0.01) and the disruption of posterior ligamentous complex (P < 0.05) were significant risk factors, respectively.

CONCLUSION

In the patients with thoracolumbar and lumbar burst fractures, the significance of the two important risk factors related to clinical results, namely, the stenosis ratio of spinal canal and the disruption of posterior ligamentous complex, were found to vary depending on the level of injury.

Modified posterior decompression for the management of thoracolumbar burst fractures with canal encroachment

STUDY DESIGN

A retrospective study.

OBJECTIVE

The purpose of this study is to explore the application of a self-designed canal decompressor in the posterior surgical treatment of thoracolumbar burst fractures with canal encroachment.

SUMMARY OF BACKGROUND DATA

Surgical treatment is often indicated in the management of thoracolumbar burst fractures accompanied with canal encroachment. Efficient canal decompression would prevent progressive neurologic deterioration and facilitate recovery. Compared with anterior surgical methods, posterior approaches offer rigid fixation without formidable surgical onslaughts. However, the reduction of retropulsed bone fragments via posterior approaches is indirect and thus often inefficient.

METHODS

In this study, we designed and applied a canal decompressor in the surgical treatment of 48 cases of thoracolumbar burst fractures using posterior approaches. Canal comprise, Cobb's angles, residual vertebral body height, neurologic outcome, and back pain were evaluated preoperatively and postoperatively. Patients were followed for 18 to 28 months (mean 22.5 + or - 3.5 mo) on an outpatient basis.

RESULTS

Operations were performed within relatively short time and without significant blood loss. Radiographs indicated that applying the canal decompressor allowed efficient reduction of canal encroachment from preoperative 53.4% + or - 16.7% to postoperative 12.8 + or - 4.2%. Cobb's angles reduced from preoperative 31.0 + or - 2.5 degree to postoperative 5.1 + or - 0.6 degree. Mean vertebral height was restored to 82.5 + or - 5.7% after operations. Follow-up evaluation within 28 months indicated that neurologic recovery presented in 77.1% of patients, with average improvement of 0.86 Frankel grades. Neurologic deterioration was not observed.

CONCLUSIONS

Applying the canal decompressor enables efficient and safe reduction of bone fragments retropulsing into the canal in posterior operations. This technique thus provides an alternative method for the management of thoracolumbar burst fractures.

Thoracolumbar burst fractures without neurological deficit: the role for conservative treatment

Burst fractures are common in the thoracolumbar junction and account for 17% of all major spinal fractures. There is a considerable controversy on the efficacy of conservative treatment and the need for surgical intervention. Need for additional stability, prevention of neurological deterioration, attainment of canal clearance, prevention of kyphosis and early relief of pain are the commonly quoted reasons for surgical intervention. However, a careful review of literature does not validate any of the above arguments. The available randomised control trials prove that the results of conservative treatment for burst fractures are equal to that of surgery and also with lesser complications. Surgery for burst fractures may, however, have definite advantages in patients with polytrauma or in the rare event of deteriorating neurology. It is also important for the treating surgeon to clearly distinguish a burst fracture from other inherently unstable injuries like fracture dislocations, chance fractures and flexion rotation injuries which require surgical stabilisation.

Factors affecting neurological deficits and intractable back pain in patients with insufficient bone union following osteoporotic vertebral fracture

The purpose of this study was to examine factors affecting the severity of neurological deficits and intractable back pain in patients with insufficient bone union following osteoporotic vertebral fracture (OVF). Reports of insufficient union following OVF have recently increased. Patients with this lesion have various degrees of neurological deficits and back pain. However, the factors contributing to the severity of these are still unknown. A total of 45 patients with insufficient union following OVF were included in this study. Insufficient union was diagnosed based on the findings of vertebral cleft on plain radiography or CT, as well as fluid collection indicating high-intensity change on T2-weighted MRI. Multivariate logistic regression analysis was performed to determine the factors contributing to the severity of neurological deficits and back pain in the patients. Age, sex, level of fracture, duration after onset of symptoms, degree of local kyphosis, degree of angular instability, ratio of occupation by bony fragments, presence or absence of protrusion of flavum, and presence or absence of ossification of the anterior longitudinal ligament (OALL) in the adjacent level were used as explanatory variables, while severity of neurological deficits and back pain were response variables. On multivariate analysis, factors significantly affecting the severity of neurological deficits were angular instability of more than 15 degrees [adjusted odds ratio (OR), 9.24 (95% confidence interval, CI 1.49-57.2); P < 0.05] and ratio of occupation by bony fragments in the spinal canal of more than 42% [adjusted OR 9.23 (95%CI 1.15-74.1); P < 0.05]. The factor significantly affecting the severity of back pain was angular instability of more than 15 degrees [adjusted OR 14.9 (95%CI 2.11-105); P < 0.01]. On the other hand, presence of OALL in the adjacent level reduced degree of back pain [adjusted OR 0.14 (95%CI 0.03-0.76); P < 0.05]. In this study, pronounced angular instability and marked posterior protrusion of bony fragments in the canal were factors affecting neurological deficits. In addition, marked angular instability was a factor affecting back pain. These findings are useful in determining treatment options for patients with insufficient union following OVF.

Factors affecting neurological outcome in traumatic conus medullaris and cauda equina injuries

The purpose of this review was to describe the relevant factors that influence neurological outcomes in patients who sustain traumatic conus medullaris injuries (CMIs) and cauda equina injuries (CEIs). Despite the propensity for spinal trauma to affect the thoracolumbar spine, few studies have adequately characterized the outcomes of CMIs and CEIs. Typically the level of neural axis injury is inferred from the spinal level of injury or the presenting neurological picture because no study from the spinal literature has specifically evaluated the location of the conus medullaris with respect to the level of greatest canal compromise. Furthermore, the conus medullaris is known to have a small but important variable location based on the spinal level. Patients with a CMI will typically present with variable lowerextremity weakness, absent lower-limb reflexes, and saddle anesthesia. The development of a mixed upper motor neuron and lower motor neuron syndrome may occur in patients with CMIs, whereas a CEI is a pure lower motor neuron injury. Many treatment options exist and should be individualized. Posterior decompression and stabilization offers at least equivalent neurological outcomes as nonoperative or anterior approaches and has the additional benefits of surgeon familiarity, shorter hospital stays, earlier rehabilitation, and ease of nursing care. Overall, CEIs and CMIs have similar outcomes, which include ambulatory motor function and a variable persistence of bowel, bladder, and potentially sexual dysfunctions.

[Classification of thoracolumbar spine fractures based on a complete imaging investigation in 33 patients]

The thoracolumbar spine fractures constitute a wide spectrum of resultant lesions, with distinct injury mechanisms. In order to reduce the controversies concerning about the management of these fractures, a universally accepted classification is necessary. In this study we evaluated retrospectively 33 patients with thoracolumbar spine fracture, with the goal of categorize and evaluate the factors related to this pathology. A complete radiological investigation, complaining of plain radiography, computed tomography and magnetic resonance imaging, was used to classify these fractures. Fall was the more common mechanism, present in 24 cases. In 57.6% of the patients, the fractures located at thoracolumbar transition (T12-L1) and the more frequent neurological presentation was total deficit, present in 45.45%. The neurological presentation was more serious in patients with thoracic lesions regarding lumbar lesions (Fischer's test, p=0.039). A positive correlation was observed between severity of the neurological presentation and gravity of the lesion according to Magerl's classification (Pearson's method, r=0.85, p<0.001). In conclusion, thoracolumbar spine fractures are serious lesions considering the initial neurological presentation; a wide and accurate classification, as we used, is necessary to describe these injuries and may help resolve some of the controversies concerning the management of these lesions.

Correlation between neurological deficit and spinal canal compromise in 198 patients with thoracolumbar and lumbar fractures

STUDY DESIGN

Review the correlation between loss of spinal canal diameter and neurological deficits in patients with thoracolumbar and lumbar burst fractures.

OBJECTIVES

To try to establish a correlation between neurological deficits and the degree of narrowing of the spinal canal.

SUMMARY OF BACKGROUND DATA

The correlation between the degree of protrusion of the bone fragments into the spinal canal and the incidence of neurological deficits in thoracolumbar and lumbar burst fractures has not been well established, raising a lot of controversies in the literature.

METHODS

Manual measurements of axial-computed tomography scan films using a millimetric ruler were made from the spinal canal of 198 patients admitted to the hospital with thoracolumbar and lumbar burst fractures, from 1989 to 2000.

RESULTS

The probability of neurological deficit in a patient with 25, 50, and 75% narrowing of the thoracolumbar spinal canal was found to be 12, 41, and 78%, and in the lumbar spinal canal it was 8, 30, and 68%, respectively.

CONCLUSIONS

The narrowing of the spinal canal proved to be a predictive factor in establishing early neurological deficits in thoracolumbar and lumbar burst fractures, showing a positive correlation between narrowing of the spinal canal and the severity of the incomplete neurological deficit by the Frankel classification. Patients with complete spinal cord injuries (Frankel A) did not show this correlation.

Neurological recovery and its influencing factors in thoracic and lumbar spine fractures after surgical decompression and stabilization

Surgical decompression and internal fixation of the injured spine have become standard procedures in the management of thoracic and lumbar spine fractures, but their effectiveness on neurological recovery remains controversial. We report on 169 consecutive patients with thoracic and lumbar spine fractures who were treated by reduction, fusion, and internal fixation using transpedicular screw-rod systems. Open decompression was carried out in 67 (39.6%) of them, including all 42 patients (25%) who presented with initial neurological deficits. At least 8 months following surgery, 30 (71%) had neurologically improved by one to three grades on the Frankel scale. Thirteen (59%) out of 22 patients whose initial deficits had been classified as "motor useless" (Frankel grades A to C) could walk, at least with support. Thirteen out of 20 patients with posttraumatic deficit Frankel D ("motor useful") improved to full recovery (Frankel E). In six (3.6%) patients (all from the group of the 127 patients without initial neurological deficits), permanent slight postoperative neurological impairment of one Frankel grade (E to D) was seen, among them two (1.2%) with new minor motor deficit. Neurological outcome was significantly better (p<0.01) in patients operated upon within the first 24 h after injury than in those who underwent surgery later. Severity of injury also had a negative influence (p<0.001) on neurological recovery. Analysis suggests that there may be significant neurological improvement in patients treated surgically very early.

The significance of thoracolumbar spinal canal size in spinal cord injury patients

STUDY DESIGN

A prospective, consecutive case series.

OBJECTIVES

To determine the relation between spinal canal dimensions and Injury Severity Score and their association with neurologic sequelae after thoracolumbar junction burst fracture.

SUMMARY OF BACKGROUND DATA

There is a relation in the cervical spine between spinal canal dimension and its association with neurologic sequelae after trauma. A similar relation at the thoracolumbar junction has not been conclusively established.

METHODS

Forty-three patients with thoracolumbar junction burst fractures (T12-L2),13 with and 30 without neurologic deficit, were included. Computed tomographic scans were used to measure the sagittal and transverse diameters and the surface area of the spinal canal at the level of injury, as well as one level above and one level below the fracture level. Injury severity score was calculated for both groups. Statistical analysis comparing those with a neurologic deficit to those without was performed by Student's t test.

RESULTS

The ratio of sagittal-to-transverse diameter at the level of injury was significantly smaller in patients with a neurologic deficit than in those without a neurologic deficit (P < 0.05). The mean transverse diameter at the level of injury was significantly larger in patients with neurologic deficit than in the neurologically intact patients (P < 0.05). The surface area of the canal at the level below the injury was significantly larger in the patients with a neurologic deficit than in those without a deficit (P < 0.05). Patients with a neurologic deficit had a statistically higher Injury Severity Score when admitted than those without a neurologic deficit (P < 0.0001), although the difference became insignificant after the neurologic component of the scoring system was eliminated.

CONCLUSION

There are no anatomic factors at the thoracolumbar junction that predispose to neurologic injury after burst fracture. The shape of the canal after injury, however, as determined by the sagittal-to-transverse diameter ratio, was predictive of neurologic deficit.

Spontaneous remodeling of the spinal canal after conservative management of thoracolumbar burst fractures

STUDY DESIGN

Forty-two conservatively treated patients with a burst fracture of the thoracic, thoracolumbar, or lumbar spine with more than 25% stenosis of the spinal canal were reviewed more than 1 year after injury to investigate spontaneous remodeling of the spinal canal.

OBJECTIVES

To investigate the natural development of the changes in the spinal canal after thoracolumbar burst fractures.

SUMMARY OF THE BACKGROUND DATA

Surgical removal of bony fragments from the spinal canal may restore the shape of the spinal canal after burst fractures. However, it was reported that restoration of the spinal canal does not affect the extent of neurologic recovery.

METHODS

Using computerized tomography, the authors compared the least sagittal diameter of the spinal canal at the time of injury with the least sagittal diameter at the follow-up examination.

RESULTS

Remodeling and reconstitution of the spinal canal takes place within the first 12 months after injury. The mean percentage of the sagittal diameter of the spinal canal was 50% of the normal diameter (50% stenosis) at the time of the fracture and 75% of the normal diameter (25% stenosis) at the follow-up examination. The correlation was positive between the increase in the sagittal diameter of the spinal canal and the initial percentage stenosis. There was a negative correlation between the increase in the sagittal diameter of the spinal canal and age at time of injury. Remodeling of the spinal canal was not influenced by the presence of a neurologic deficit.

CONCLUSION

Conservative management of thoracolumbar burst fractures is followed by a marked degree of spontaneous redevelopment of the deformed spinal canal. Therefore, this study provides a new argument in favor of the conservative management of thoracolumbar burst fractures.

Burst fractures of the second through fifth lumbar vertebrae. Clinical and radiographic results

Fifty-five patients who had sustained a burst fracture of the lumbar spine were followed for a mean of seventy-nine months (range, twenty-four to 192 months) after the injury. Thirty patients had been managed non-operatively with a short period of bed rest followed by protected mobilization. The remaining twenty-five patients had been managed operatively: eight, with posterior arthrodesis with long-segment hook-and-rod fixation; eight, with posterior arthrodesis with short-segment transpedicular fixation; six, with posterior arthrodesis and instrumentation followed by anterior decompression and arthrodesis; and three, with anterior decompression and arthrodesis. Thirty-six patients had been neurologically intact at the time of presentation and had remained so throughout the follow-up period. No neurological deterioration or symptoms of late spinal stenosis were seen. Isolated partial single-nerve-root deficits resolved regardless of the method of treatment. Patients who had had a complete single or a multiple-nerve-root paralysis seemed to have benefited from anterior decompression. Although the anatomical results as seen on the most recent radiographs were superior for the group that had been managed operatively with long posterior fixation or anterior and posterior arthrodesis, the most recent pain scores and the functional outcomes were similar for all treatment groups. At the latest follow-up evaluation, some loss of spinal alignment was noted in the patients who had been managed with short transpedicular fixation; the alignment at the most recent follow-up examination was comparable with that in the patients who had been managed non-operatively. For the patients who had had non-operative treatment, we were unable to predict the deformity at the time of follow-up on the basis of the initial diagnostic radiographs. The clinical outcome was not related to the deformity at the latest follow-up evaluation. On the basis of the results of our study, we recommend non-operative treatment for patients who do not have neurological dysfunction or who have an isolated partial nerve-root deficit at the time of presentation. For patients who have a multiple-nerve-root paralysis, anterior decompression is indicated.

Thoracic spinal trauma and associated injuries: should early spinal decompression be considered?

The relative benefits of conservative or surgical treatment in thoracic spinal trauma are still controversial. Owing to its anatomic relations, thoracic spinal trauma is specific regarding neurologic prognosis, the high incidence of associated injuries, and surgical management. Over a 30-month period, 49 patients sustained thoracic spinal trauma with neurologic impairment. The authors review population characteristics, associated injuries, and surgical management, and underline the high incidence of associated injuries, in particular, blunt chest trauma. In their opinion, early spinal decompression has no indication in complete paraplegia. Concerning partial paraplegia, early surgery may enhance neurologic recovery. Nevertheless, they suggest three main criteria in deciding whether or not to perform surgery early: the existence of residual spinal compression, the degree of neurologic impairment, and the presence of potential hemorrhagic lesions or blunt chest trauma, especially pulmonary contusion.

Early surgery for thoracolumbar spinal cord injury: initial experience from a developing spinal cord injury centre in India

The spinal cord injury centre of Nizam's Institute of Medical Sciences, Andhra Pradesh, India has been functioning now for 8 months and offers its services to the population of 80 million in the state. To date, 92 patients with a spinal cord injury have been treated; 51 had a thoracolumbar spinal injury. This report presents the results of the management of these 51 patients. Preoperatively both CT and MRI were performed and the radiological findings were correlated with outcome. Twenty five had a thoracic and 26 a lumber location. Twenty nine patients underwent surgical treatment (15 thoracic and 14 lumbar) and the others were treated conservatively (10 thoracic and 12 lumbar). All these operations were carried out within 2 weeks following trauma, and methylprednisolone therapy was instituted in those who reached the hospital early. Contraindications for surgery included a delay in admission of more than 3 weeks following trauma, a focus of sepsis, bedsores, a generalised bone disorder such as osteopenia, and medical illnesses. Transpedicular screw-plate fixation was performed in 27 patients, and two patients underwent decompressive laminectomy and interlaminar bone and wire fixation. Delayed spinal decompression was offered to one patient to relieve radiculopathy. Fracture-dislocation spinal injury and those with transection of the spinal cord had the worst outcome, whilst patients with a wedge compression fracture and cord oedema fared better. Operated cases had a shorter hospital stay, and complications of immobilisation were limited. Positive psychological influence of mobilisation and early acclimatisation to the altered style of living with their disability were the most significant outcomes following surgery.

Reduced transverse spinal area secondary to burst fractures: is there a relationship to neurologic injury?

A retrospective case-control study was undertaken to determine the best technique to measure neural canal encroachment at each lumbar level following burst fracture and its relationship to the presence of neurologic deficit. Only patients with postinjury CT scans demonstrating a disrupted posterior body with a retropulsed bone fragment were included. Patients were divided into groups based on the level of bony injury (T12-L5) and neurologic status. Neurologic injury was classified as follows: normal (N), root (R), or cauda equina/conus/paraplegic/paraparetic (C/P). The mean transverse spinal area (TSA, cm2), spinal canal percentage patency (PP), and midsagittal diameter (MSD) were determined for each neurologic group and lumbar level. A "calculated" TSA, based on midsagittal and anterior-posterior diameters, was also derived for each patient. The data were compared level by level and correlated with the patient's neurologic status. At L1, the critical TSA was 1.0 cm2. All patients with TSAs less than this were paraplegic. At both T12 and L1, TSAs in the range of 1.0-1.25 cm2 were observed in both normal and neurologically impaired patients. A critically significant TSA was not established for levels T12, L2, L3, L4, or L5; however, the data indicated that a smaller TSA can be tolerated at successively caudal levels without neurologic deficit. No meaningful correlation between root injury and TSA was observed. The data also indicated that measurement of TSA is a more accurate method for evaluating neural canal encroachment than PP or MSD. The "calculated" TSA is a simple, objective method for obtaining this information without the aid of a computer. This study suggests that absolute TSA should be utilized in future studies evaluating decompressive treatment of thoracolumbar pathology.

Transpedicular decompression and stabilization of burst fractures of the lumbar spine

Twenty-seven consecutive patients with neurological impairment due to burst fractures of the lumbar spine were operated upon, via the postero-lateral route, over a 38-month-period. Transpedicular fixation devices [posterior segmental fixator (PSF) or variable screw placement system (VSP)] were applied in all cases, in order to achieve short-segment fusion of the fractured spinal segment. Return to useful motor power or neurological normality (median follow-up: 18.7 months) occurred in 22 cases (81% of the whole series), with this outcome resulting in all but one of the cases with preoperative incomplete neurological deficit. Postoperative encroachment of the spinal canal, degree of kyphotic deformity, and reduction of the vertebral height showed statistically significant differences compared with the corresponding preoperative values.