[Operative treatment of traumatic fractures of the thorax and lumbar spine. Part II: surgical treatment and radiological findings]

Thoracolumbar Fractures: Comparing the Effect of Minimally Invasive Versus Open Schanz Screw Techniques on Sagittal Alignment

STUDY DESIGN

This is a retrospective comparative cohort study.

PURPOSE

This study aims to compare the effects of minimally invasive surgery (MIS) and open surgery (OS) on global sagittal alignment (GSA) in surgically managed thoracolumbar fractures.

OVERVIEW OF LITERATURE

The optimal treatment of traumatic thoracolumbar fractures (TLF) remains controversial. Both MIS techniques with polyaxial screws and OS techniques with Schanz screws have gained widespread use. The effect of each technique on the global sagittal alignment has not been reported.

METHODS

From 2014 to 2021, 22 patients with traumatic TLF underwent open posterior stabilization using an open transpedicular Schanz screw-rod construct and were compared to 15 patients who underwent minimally invasive surgery using a polyaxial percutaneous pedicle screw-rod construct. The reported radiological parameters measured on preoperative supine CT scan and immediate postop standing X-ray and on final follow-up whole spine standing X-rays included pelvic incidence (PI), pelvic tilt (PT), lumbar lordosis (LL), preoperative segmental kyphosis (Preop-K), immediate post-operative segmental kyphosis (postop-Ki), final post-operative segmental kyphosis (postop-Kf), sagittal-vertica-axis (SVA), and spino-sacral angle (SSA).

RESULTS

The average age of the OS group was 42.5 years; 5 patients had AO type B, and 17 patients had AO type A (A3 and A4) fractures. The average follow-up was 16.8 months. The average radiological parameters were: PI = 54.9°, PI-LL = 3°, PT = 17.6°, preop-K = 16.2°, postop-Ki = 8.7°, final postop-Kf = 14.3°, SVA = 4.58 cm, and SSA = 101.8°. The average age of the MIS group was 43.4 years; 5 patients had AO type B, and 10 patients had AO type A fractures. The average follow-up was 25 months. The average radiological parameters were as follows: PI = 51°, PI-LL = 8°, PT = 18°, preop-K = 18.4°, postop-Ki = 11.6°, postop-Kf = 14.3°, SVA = 6.4 cm, SSA = 106°.

CONCLUSION

The fixation technique did not significantly affect the final correction of the local kyphosis and global spine alignment parameters.

Increased incidence of vertebral fractures in German adults from 2009 to 2019 and the analysis of secondary diagnoses, treatment, costs, and in-hospital mortality

The aim of this cross-sectional study was to present the nationwide rates of hospitalized patients with vertebral fractures over one decade and to comprehensively analyze the treatment characteristics and direct costs incurred in 2019. Therefore, the trends in the incidence rate were quantified based on annual ICD-10 diagnosis codes from all German medical facilities between 2009 and 2019, provided by the Federal Statistical Office (Destatis). The ICD-10 Codes "S12.0-2; S22.0-; S32.0-, and S32.1-2" were evaluated. The relative change from 2009 through 2019 was determined. Using data from the Institute for Hospital Remuneration Systems (InEK) for 2019 the secondary diagnoses, OPS-codes, intensive care unit (ICU) treatment, in-hospital mortality, the proportion of G-DRGs and cumulative costs were evaluated. The documented number of vertebral fractures increased by 45.6% between 2009 and 2019 to an incidence of 150.7 per 100,000 inhabitants. The lumbar spine was most commonly affected with an incidence of 70.5/100,000 inhabitants in 2019 (46.8% of all vertebral fractures). The highest increases were seen in the numbers of subaxial cervical fractures (+ 121.2%) and sacral fractures (+ 306.6%). Of all vertebral fractures in 2019, 63.7% were diagnosed in women and 69.0% in patients aged 70 years or older. Osteoporosis was documented in 17.9% of cases as a concomitant diagnosis. In 10.1% of all cases, an ICU treatment was documented. The in-hospital mortality was 2.0% in 2019. I68D was the most frequently used G-DRG code, accounting for 33.3% of cases. The total direct costs for inpatient treatment in 2019 amounted to €589,205,715. The evaluation of 955,091 vertebral fractures showed a sharp increase in the nation-wide incidence rate. The presented age and sex distribution, the comorbidity profile and the in-hospital mortality rate indicate the importance of comprehensive geriatric assessment and emphasize the need for spinal care centers to be established.

[Local spinal profile following operative treatment of thoracolumbar and lumbar fractures : Impact of reduction technique and bone quality]

Hintergrund

Ziel der Operation von Wirbelsäulenverletzungen ist eine stabile Ausheilung in physiologischer Stellung. Für offene und perkutane Operationen stehen unterschiedliche Techniken zur Verfügung.

Fragestellung

Das Ausmaß der offenen Reposition und das Retentionspotenzial der Techniken nach AOSpine (AT) und nach Kluger (KT) sollen verglichen werden. Der Einfluss von Frakturmorphologie, Alter, Geschlecht und Knochenqualität auf Reposition und Retention werden untersucht.

Material und Methoden

In dieser monozentrischen retrospektiven Kohortenstudie wurden Daten von Patienten mit traumatischen thorakolumbalen und lumbalen Frakturen untersucht, welche entweder mit AT oder KT reponiert wurden. Mittels bisegmentalen Grund-Deckplatten-Winkels (bGDW) wurde die Stellung des verletzten Wirbelsäulenabschnitts beschrieben. Normalwerte für die bGDW wurden anhand von Literaturdaten angenommen. Die Veränderung des bGDW im zeitlichen Verlauf wurde unter Einbeziehung der Knochenqualität in Hounsfield Units (HU), der Verletzungsschwere nach AOSpine und des Patientenalters und -geschlechts analysiert.

Ergebnisse

Es wurden 151 Datensätze ausgewertet. Beide Methoden reponieren vom Umfang nicht unterschiedlich (AT 10 ± 6°, KT 11 ± 8°; p = 0,786). Im Follow-up trat ein Korrekturverlust von −5 ± 4° auf. Die Technik (p = 0,998) hatte keinen Einfluss darauf. Die Frakturmorphologie zeigte einen knapp signifikanten Einfluss (p = 0,043). Niedrige HU korrelierten mit geringerem Repositionsumfang (r = 0,241, p < 0,003) und größerem Korrekturverlust (r = 0,272, p < 0,001) signifikant, aber schwach. In der Altersgruppe 50 bis 65 Jahre wiesen 21 % der Männer und 43 % der Frauen eine Knochenqualität von HU < 110 auf. Alter und HU korrelieren signifikant (r = −0,701, p < 0,001).

Diskussion

Die Techniken sind gleichwertig bezüglich der Repositions- und Retentionseigenschaften. Der hohe Anteil von Patienten mit HU < 110 in der Gruppe unter 65 Jahren bei Frauen und Männern und der Einfluss auf Reposition und Retention weisen auf die Notwendigkeit einer präoperativen Knochendichtemessung hin.

Influence of endplate size and implant positioning of vertebral body replacements on biomechanics and outcome

BACKGROUND

Spinal stabilization by an anterior vertebral body replacement is frequently used in patients suffering from destroyed vertebral bodies. The aim of this study was to analyse (i) the choice of endplate size and positioning of vertebral body replacements in daily patient care and (ii) if these factors have an influence on clinical and radiological outcomes.

METHOD

Patients' outcomes were analysed three years after vertebral body replacement implantation using the visual analogue scale spine score. Safe zones on the vertebral body endplates were defined. Overall endplate coverage and implant subsidence were evaluated by CT and X-ray. Compression tests were performed on 22 lumbar vertebral bodies to analyse endplates sizes' influence on subsidence.

FINDING

Mean coverage of the vertebral body's superior and inferior endplates by the vertebral body replacement was 27.8% and 30.8%, respectively. Mean overlap of the safe zone by the implant was 49.8% and 40.6%. Mean subsidence was 1.1 ± 1.2 mm, but it did not have any effect on the outcome. In the compression tests, no significant difference (p = 0.468) was found between the two endplate sizes.

INTERPRETATION

Coverage of vertebral body endplates and positioning of implants in the safe zone did not entirely comply with the given recommendations. The amount of endplate coverage had no influence on subsidence or long-term outcomes in daily patient care. On the other hand, correct positioning of the implant may influence its subsidence.

[Minimally invasive posterior and anterior stabilization of the thoracolumbar spine after traumatic injuries]

Injuries of the thoracolumbar junction are the most common fractures of the spine due to their anatomical position and load. Common classification systems differentiate between stable and unstable injuries and thus also between operative and conservative therapy. The majority of injuries can be treated conservatively; however, unstable injuries require surgical treatment for a variety of reasons. In the grey area between stable and unstable injuries, a clinical decision based on clinical experience is necessary in order to select the best treatment. A wide variety of parameters must be included and a change in strategy from conservative to operative may also be necessary. Posterior instrumentation is the most common procedure; purely anterior stabilization is rarely used. The length of the instrumentation/spondylodesis depends on bone quality, age of the patient, and fracture. The decision as to whether anterior operative treatment should be performed depends on fracture morphology, success of reduction, and the resulting stability. The open surgical procedure is increasingly being replaced by minimally invasive procedures in posterior and anterior techniques but can be an advantage in complex injuries (B and C injuries according to AO). Hybrid procedures are also possible. This also applies to the treatment of osteoporotic fractures, since a clear assignment between traumatic and osteoporotic cause is not always easy and possible. This article describes the principles, the possible indications, and limitations of minimally invasive posterior and anterior stabilization.

Possible advantages of early stabilization of spinal fractures in multiply injured patients with leading thoracic trauma - analysis based on the TraumaRegister DGU®

Background

Major trauma often comprises fractures of the thoracolumbar spine and these are often accompanied by relevant thoracic trauma. Major complications can be ascribed to substantial simultaneous trauma to the chest and concomitant immobilization due to spinal instability, pain or neurological dysfunction, impairing the respiratory system individually and together. Thus, we proposed that an early stabilization of thoracolumbar spine fractures will result in significant benefits regarding respiratory organ function, multiple organ failure and length of ICU / hospital stay.

Methods

Patients documented in the TraumaRegister DGU®, aged ≥16 years, ISS ≥ 16, AIS_Thorax ≥ 3 with a concomitant thoracic and / or lumbar spine injury severity (AIS_Spine) ≥ 3 were analyzed. Penetrating injuries and severe injuries to head, abdomen or extremities (AIS ≥ 3) led to patient exclusion. Groups with fractures of the lumbar (LS) or thoracic spine (TS) were formed according to the severity of spinal trauma (AIS_spine): AIS_LS = 3, AIS_LS = 4–5, AIS_TS = 3 and AIS_TS = 4–5, respectively.

Results

1740 patients remained for analysis, with 1338 (76.9%) undergoing spinal surgery within their hospital stay. 976 (72.9%) had spine surgery within the first 72 h, 362 (27.1%) later on. Patients with injuries to the thoracic spine (AIS_TS = 3) or lumbar spine (AIS_LS = 3) significantly benefit from early surgical intervention concerning ventilation time (AIS_LS = 3 only), ARDS, multiple organ failure, sepsis rate (AIS_TS = 3 only), length of stay in the intensive care unit and length of hospital stay. In multiple injured patients with at least severe thoracic spine trauma (AIS_TS ≥ 4) early surgery showed a significantly shorter ventilation time, decreased sepsis rate as well as shorter time spend in the ICU and in hospital.

Conclusions

Multiply injured patients with at least serious thoracic trauma (AIS_Thorax ≥ 3) and accompanying spine trauma can significantly benefit from early spine stabilization within the first 72 h after hospital admission. Based on the presented data, primary spine surgery within 72 h for fracture stabilization in multiply injured patients with leading thoracic trauma, especially in patients suffering from fractures of the thoracic spine, seems to be beneficial.

Percutaneous versus open posterior stabilization in AOSpine type A3 thoracolumbar fractures

Background

The purpose of this retrospective cohort study was to compare treatment strategies of two level-one trauma centers regarding clinical and radiological outcomes focusing on non-osteoporotic AOSpine type A3 fractures of the thoracolumbar spine at levels T11 to L2.

Methods

Eighty-seven patients between 18 and 65 years of age that were treated operatively in either of two trauma centers were included. One treatment strategy includes open posterior stabilization whereas the other uses percutaneous posterior stabilization. Both included additional anterior fusion if necessary. Demographic data, McCormack classification, duration of surgery, hospital stay and further parameters were assessed. Owestry Disability Index (ODI), Visual Analog Scale (VAS) and SF-36 were measured for functional outcome. Bisegmental kyphosis angle, reduction loss and sagittal alignment parameters were assessed for radiological outcome. Follow up was at least 24 months.

Results

There was no significant difference regarding our primary functional outcome parameter (ODI) between both groups. Regarding radiological outcome kyphosis angle at time of follow up did not show a significant difference. Reduction loss at time of follow up was moderate in both groups with a significantly lower rate in the percutaneously stabilized group. Surgery time was significantly shorter for posterior stabilization and anterior fusion in the percutaneous group. Time of hospital stay was equal for posterior stabilization but shorter for anterior fusion in the open stabilized group.

Conclusion

Both treatment strategies are safe and effective showing only minor loss of reduction. Clinical relevant differences in functional and radiographic outcome between the two surgical groups could not be demonstrated.

Trial registration

It was conducted according to ICMJE guidelines and has been retrospectively registered with the German Clinical Trials Registry (identification number: DRKS00015693, 07.11.2018).

Radiological and Clinical Outcomes of Balloon Kyphoplasty versus Radiofrequency Kyphoplasty in the Treatment of Vertebral Compression Fractures

STUDY DESIGN

Retrospective cohort analysis.

PURPOSE

Comparison of balloon kyphoplasty (BKP) and radiofrequency kyphoplasty (RFK) with respect to height restoration of the fractured vertebral bodies and the pain relief experienced after the surgical procedure.

OVERVIEW OF LITERATURE

BKP and RFK both offer safe, time-saving, and potent treatment options for vertebral compression fractures, but neither of these methods demonstrated any key advantage over the other yet.

METHODS

We performed a retrospective analysis of a cohort of 156 patients (mean age, 73±11 years) with 252 fractured vertebral bodies treated with kyphoplasty. Pain intensity was measured using a Visual Analogue Scale. Preoperative and postoperative computed tomography images were analyzed and gauged using modified bisegmental Cobb angle, vertebral angle, as well as anterior (Ha), middle (Hm), and posterior (Hp) vertebral body heights.

RESULTS

The mean postoperative pain relief was 5.1±1.8, which was maintained over the entire follow-up period. There were no significant differences in the pain relief between BKP and RFK. Postoperative changes in the vertebral angle (-1.3°±3.3°, p <0.001) and Ha, Hm, and Hp vertebral body heights (Ha, 1.5±2.9 mm; Hm, 2.1±2.9 mm; Hp, 0.9±2.1 mm; p <0.001) were significant. However, the initial height restoration could not be maintained by the 6-week and 1-year follow-up. Neither BKP nor RFK could achieve a clinically relevant advantage over each other. There was no correlation between pain relief and height restoration after kyphoplasty.

CONCLUSIONS

Both BKP and RFK had comparable beneficial clinical and radiological effects in the treatment of vertebral compression fractures. However, neither the actual extent of height restoration nor its loss seems to affect the marked pain relief.

[Frequency and age distribution of combined sternovertebral injuries : Analysis of routine data from German hospitals 2005-2012]

BACKGROUND

Combinations of sternal and spinal fractures often occur due to high velocity accidents and are associated with a high incidence of concomitant injuries. The anterior thoracic wall is described as the fourth column of torso stability, which is why sternovertebral injuries (SVI) present a high risk of sagittal deformation of the trunk, in particular injuries of the thoracic spine. To date, no studies have been published on the frequency distribution of the involved vertebral bodies in large patient groups.

OBJECTIVES

This study was intended to elaborate a frequency distribution of vertebral fractures accompanying sternal fractures (SF) and examine the risk of a vertebral fracture accompanying a SF.

MATERIAL AND METHODS

A total of 48,193 cases with the main or secondary diagnosis of a SF and 897,963 cases with vertebral fractures based on routine data of German hospitals from the years 2005-2012 were evaluated. A concomitant injury to the spinal column was examined for each vertebral body and then evaluated statistically.

RESULTS AND CONCLUSIONS

Of all patients with a SF 30.96% also suffered from a vertebral fracture. Of these 3.11% were SF as the main diagnosis and 60.89% the secondary diagnosis. While vertebral fractures generally occurred most frequently in the region of the thoracolumbar transition and the second cervical vertebral body, the SVI showed a further frequency peak in the range from the lower cervical spine to the middle thoracic spine. The present study was able to show a frequency distribution of accompanying vertebral body injuries in a large and representative collective in the case of SF for the first time.

Prediction of MRI findings including disc injury and posterior ligamentous complex injury in neurologically intact thoracolumbar burst fractures by the parameters of vertebral body damage on CT scan

OBJECTIVE

To formulate radiological indexes based on CT for further MRI examination to detect posterior ligamentous complex injury (PLC) or disc injury in thoracolumbar burst fractures without neurological deficit in the emergent setting.

MATERIALS AND METHODS

Patients with a single thoracolumbar burst fracture and no neurological deficit were included into this study. Radiological indexes on CT included canal compromise (CC), anterior and posterior vertebral height ratio (PVH and AVH ratio), local kyphosis (LK) and regional kyphosis (RK). PLC and disc injury were assessed on MRI. Statistical analysis was performed to identify the predictive power for radiological indexes for any MRI findings either or both disc and PLC injury.

RESULTS

Eighty-four patients were included in this study. According to MRI, patients with no PLC and disc injury were allocated into MRI finding negative group, others were defined as positive group. There was no significant difference in AVH ratio, PVH ratio and RK between these two groups. The CC and LK were significant higher in positive group than that in negative group (p < 0.001).The areas under receiver operating characteristic curve were 0.826 and 0.893 for CC and LK respectively and without significant difference. The best thresholds for CC and LK were 0.19 (sensitivity: 69.4%; specificity: 87.5%) and 14.00° (sensitivity: 83.3%; specificity: 83.3%), respectively.

CONCLUSION

The presence of CC > 0.19 and/or LK > 14.00° on CT scan can predict MRI findings including PLC and disc injury. These thresholds may be the guideline for MRI examination in patients with neurologically intact thoracolumbar burst fracture in the emergent condition.

Radiological Results and Clinical Patient Outcome After Implantation of a Hydraulic Expandable Vertebral Body Replacement following Traumatic Vertebral Fractures in the Thoracic and Lumbar Spine: A 3-Year Follow-Up

STUDY DESIGN

A prospective monocentric study.

OBJECTIVE

The aim of the current study was the analysis of patient outcome and radiological results 3 years after implantation of a hydraulic expandable vertebral body replacement (VBR) system.

SUMMARY OF BACKGROUND DATA

Around 70% to 90% of all traumatic spinal fractures are located in the thoracic and lumbar spine. Dorso-ventral stabilization is a frequently used procedure in traumatic vertebral body fracture treatment. VBR systems can be used to bridge bony defects. In the current study, a new VBR expanded by water pressure with adjustable endplates is used.

METHODS

All patients who suffered a singular traumatic fracture to a thoracic or lumbar vertebral body (Th 5-L 5) in the period from November 2009 to December 2010 and (i) underwent dorsal instrumentation and (ii) afterwards received the implantation of a hydraulic VBR were included in this study. The clinical outcome (visual analogue scale [VAS] spine score, questionnaire) and radiological findings (sagittal angle, implant subsidence, and implant position) 3 years after implantation were analyzed.

RESULTS

The follow-up was successful for n = 47 patients (follow-up rate: 89%). Most of the patients (n = 40) were "generally/very satisfied" with their outcome. The mean rating of the VAS spine score was 65.2 ± 23.1 (range: 20.5-100.0). The analysis of the radiological data showed an average subsidence of the implants of 1.1 ± 1.2 mm (range 0.0-5.0 mm). After the initial operation, the local sagittal angle remained stable in the follow-up 3 years later both for the thoracic spine and lumbar spine. Furthermore, no change in the implant's position was observed.

CONCLUSION

The implantation of a hydraulically expandable VBR allows a permanent stable fixation after traumatic fractures of the thoracic and lumbar spine.

LEVEL OF EVIDENCE

2.

Do low profile implants provide reliable stability in fixing the sternal fractures as a "fourth vertebral column" in sternovertebral injuries?

BACKGROUND

Flexion and compression forces to the trunk can cause severe instability of the vertebral column and the anterior chest wall, mostly associated with an unstable fracture of the sternum. In combination, the worst case would be a complete disruption of the trunk. Some authors consider the sternum-rib-complex to be the fourth vertebral column. This study discusses the possibilities to treat instable trunk injuries with sternal fractures concomitant to vertebral spine fractures through anterior sternal plating employing a locked plate osteosynthesis in a low profile design instead of the use of bulky implants.

METHODS

11 Patients suffering from at least one fracture of a vertebral body in combination with an unstable sternum fracture were stabilized through a locked plate osteosynthesis in low profile design at the sternum between November 2011 and October 2014. The vertebral spine injury was stabilized as well, if necessary. Patients were followed up with a look at the consolidation of the fractures and the question if any failure of the implants occurred.

RESULTS

Anterior sternal plating was uneventful in all cases. All Sternal fractures showed sufficient consolidation. No failure of implants has been seen during follow up over two years..

CONCLUSIONS

A locked plate osteosynthesis of a sternal fracture in low profile design seem to be an appropriate option for stabilization of the sternum in combined sternovertebral injuries.

[Trisegmental fusion by vertebral body replacement : Outcome following traumatic multisegmental fractures of the thoracic and lumbar spine]

BACKGROUND

Around 5% of all trauma patients suffer from spinal trauma. Spinal fractures are mainly located in the thoracic and lumbar spine. For multisegmental vertebral fractures categorized as instable, combined dorsal instrumentation and ventral stabilization is recommended. Numerous vertebral body replacement systems are available for ventral stabilization.

OBJECTIVES

The aim of the current study was to analyze radiological results following the implantation of a hydraulic expandable vertebral body replacement and the evaluation of patients' outcome three years after implantation.

MATERIALS AND METHODS

All patients who suffered traumatic multisegmental fractures of the thoracic or lumbar spine in the period from September 2009 to September 2012 were included in this study. Patients with additional injuries or abnormal sensitivity or motor function were excluded from the current study. All patients underwent dorsal percutaneous instrumentation. Afterwards, implantation of the vertebral body replacement was performed via the mini-open approach at our level I trauma center. In the computed tomography and X‑ray imaging, the sagittal kyphotic angle was measured. Furthermore, the clinical outcome (patients' satisfaction, VAS spine score) was analyzed using a questionnaire.

RESULTS

During the above mentioned period, seven patients (four female; three male) underwent dorsal instrumentation and ventral trisegmental fusion and were identified fitting the inclusion/exclusion criteria and thus could be included in the study. Most fractures were located in the thoracic-lumbar junction and were categorized A4 according to the AO Spine classification system. The analysis of the radiological data showed a pre-operative average traumatic segmental angle of 18.1 ± 14.9°, which could be decreased by reposition procedure to 6.4 ± 1.7°. The complete follow-up, including the data three years after implantation of the vertebral body implant, was available for three patients. The traumatic segmental angle remained stable in the follow-up three years later. In one case, a subsidence of the implant of 1.5 mm was observed, having no influence on the patients' satisfaction. All three patients indicated to be very satisfied with their outcome. The VAS spine score rating was in the range between 62.4 and 70.2.

CONCLUSIONS

The current study shows that in the case of multisegmental fractures complete reposition by ligamentotaxis and by the percutaneous instrumentation system is possible. In addition to the percutaneous dorsal instrumentation, the implantation of a hydraulically expandable vertebral body replacement may allow a stable fusion after complex traumatic fractures of the thoracic and lumbar spine. Patients are very satisfied with their outcome after this procedure.

The unstable thoracic cage injury: The concomitant sternal fracture indicates a severe thoracic spine fracture

INTRODUCTION

The thoracic cage is an anatomical entity composed of the upper thoracic spine, the ribs and the sternum. The aims of this study were primarily to analyse the combined injury pattern of thoracic cage injuries and secondarily to evaluate associated injuries, trauma mechanism, and clinical outcome. We hypothesized that the sternal fracture is frequently associated with an unstable fracture of the thoracic spine and that it may be an indicator for unstable thoracic cage injuries.

PATIENTS AND METHODS

Inclusion criteria for the study were (a) sternal fracture and concomitant thoracic spine fracture, (b) ISS≥16, (c) age under 50 years, (d) presence of a whole body computed-tomography performed at admission of the patient to the hospital. Inclusion criteria for the control group were as follows: (a) thoracic spine fracture without concomitant sternal fracture, (b)-(d) same as study cohort.

RESULTS

In a 10-year-period, 64 patients treated with a thoracic cage injury met inclusion criteria. 122 patients were included into the control cohort. In patients with a concomitant sternal fracture, a highly unstable fracture (AO/OTA type B or C) of the thoracic spine was detected in 62.5% and therefore, it was significantly more frequent compared to the control group (36.1%). If in patients with a thoracic cage injury sternal fracture and T1-T12 fracture were located in the same segment, a rotationally unstable type C fracture was observed more frequently. The displacement of the sternal fracture did not influence the severity of the concomitant T1-T12 fracture.

CONCLUSIONS

The concomitant sternal fracture is an indicator for an unstable burst fracture, type B or C fracture of the thoracic spine, which requires surgical stabilization. If sternal and thoracic spine fractures are located in the same segment, a highly rotationally unstable type C fracture has to be expected.

[Fractures of the thoracic and lumbar spine]

Fractures of the thoracic and lumbar spine result from high velocity trauma, assuming bone density is normal. The main location of fractures is the thoracolumbar junction. Most injuries can be treated conservatively; however, patients transferred to hospitals and spine centers represent a preselection with more severe trauma and a higher incidence of operative treatment. There is a large variety of operative techniques that can be used, which can be principally differentiated by the approach: posterior or anterior. Dorsal approaches are differentiated by the instrumentation for spondylodesis as open or percutaneous techniques. Minimally invasive options are favored more and more. For osteoporotic bone, cement augmented solutions may be used. Correct reduction of mainly kyphotic malalignment is crucial for the long-term outcome. Biomechanically stable reconstruction of the anterior spinal column is important mainly for the thoracolumbar junction.

Two-Nation Comparison of Classification and Treatment of Thoracolumbar Fractures: An Internet-Based Multicenter Study Among Spine Surgeons

STUDY DESIGN

Web-based multicenter study.

OBJECTIVE

The aim of the study was to assess and compare the management strategy for traumatic thoracolumbar fractures between German and Dutch spine surgeons.

SUMMARY OF BACKGROUND DATA

To date, there is no evidence-based treatment algorithm for thoracolumbar spine fractures, thereby an international controversy concerning optimal treatment exists.

METHODS

In this web-based multicenter study (www.spine.hostei.com), computed tomography scans of traumatic thoracolumbar fractures (T12-L2) were evaluated by German and Dutch spine surgeons. Supplementary case-specific information such as age, sex, height, weight, neurological status, and injury mechanism were provided.By using a questionnaire, fractures were classified according to the AO-Magerl Classification, followed by 6 questions concerning the treatment algorithm. Data were analyzed using SPSS (Version 21, 76, Chicago, IL). The interobserver agreement was determined by using Cohen κ. Statistical significance was defined as P < 0.05.

RESULTS

Twelve surgeons (6 per country) evaluated each 91 cases. The fractures were classified as AO Type A in 82% (898 votes), Type B in 14% (150 votes), and Type C in 4% (44 votes). No significant difference concerning the AO Classification between German and Dutch spine surgeons was found. Overall German spine surgeons had a lower threshold concerning the indication for surgical treatment (Ger 87% vs. NL 30%; P < 0.05). There was a consensus about operative stabilization of AO Type B and C injuries and injuries with neurologic deficit, whereas a discrepancy in the therapeutic algorithm for AO Type A fractures was observed. This difference was most pronounced regarding the indication for posterior (Ger 96.6%; NL 41.2%; P < 0.05) and circumferential stabilization (Ger 53.4%; NL 0%; P < 0.05) for burst fractures.

CONCLUSION

There is a consensus to stabilize AO Type B and C fractures, whereas country-specific differences in the treatment of Type A fractures, especially in case of burst fractures, occur. Prospective, controlled multicenter outcome studies may provide more evidence in optimal treatment for thoracolumbar fractures.

LEVEL OF EVIDENCE

2.

Spinal fracture reduction with a minimal-invasive transpedicular Schanz Screw system: clinical and radiological one-year follow-up

INTRODUCTION

Surgical management of thoracolumbar trauma involves correction of posttraumatic deformity and placement of transpedicular instrumentation. The aim of this prospective cohort study was to generate first results reflecting the clinical and radiological outcome of patients treated with percutaneous dorsal instrumentation for fractures of the thoracic and lumbar spine with the use of a transpedicular new Schanz Screw system (USS Fracture MIS, DePuy Synthes).

METHODS

A total of 26 patients with fractures of the thoracic and lumbar spine were operatively treated with bi-segmental dorsal instrumentation between January and December 2012. Radiological data acquisition was performed pre- and postoperatively, after six weeks, three, six, and twelve months. The radiological parameter of interest was the bi-segmental kyphotic end plate angle (Cobb angle). The Chronic Disability Index (CDI), the Oswestry Disability Index (ODI), and the Spine Tango Core Outcome Measurement Index (COMI) were applied to investigate the clinical outcome.

RESULTS

The clinical follow-up was completed by 22 patients (84.6%), and the radiological follow-up by 21 (80.8%) patients. Our patient population had a mean age of 47.4 ± 4.1 years. Twelve patients received dorsal instrumentation, and 14 patients were treated with an additional ventral reconstruction. Intraoperative reduction was 11.5 ± 1.5° among all patients (p < 0.01). A considerable amount of the operative correction was lost after six weeks with a loss of reduction of 4.6 ± 1.4° (p < 0.01). At one year follow-up, the measured loss of reduction was significant in comparison to the postoperative state, 6.9 ± 1.3° among all patients, 8.7 ± 2.1° after dorsal and 4.9 ± 1.1° after dorsoventral stabilisation (all p < 0.01). Moreover, all patients had minimal to moderate disability with a CDI of 1.8 ± 0.4 (0 - 7), and an ODI of 15.6 ± 3.6 (0 - 60).

CONCLUSION

The new transpedicular Schanz screw system can deliver a correction and stabilization of thoracic and lumbar spine fractures. Patients report minimal to moderate disability as a result of their severe injury one year after trauma. We advocate the use of the transpedicular Schanz screw system to correct posttraumatic kyphotic deformity, with secondary anterior fusion in our treatment strategy of thoracolumbar incomplete burst fractures in patients without a neurologic deficit.

Comparison of therapeutic effects of anterior decompression and posterior decompression on thoracolumbar spine fracture complicated with spinal nerve injury

Objective:

To compare the clinical therapeutic effects of anterior decompression and posterior decompression on thoracolumbar spine fracture (TSF) complicated with spinal nerve injury (SNI).

Methods:

A total of 120 patients with TSF and SNI were selected and divided into a treatment group and a control group that were then treated by anterior decompression and posterior decompression respectively. The preoperative and postoperative motor scores, tactile scores, heights of injured vertebral body and Cobb’s angles, as well as surgical times and intraoperative blood losses were recorded and compared.

Results:

Before surgeries, the motor score, tactile score, height of injured vertebral body and Cobb’s angle of the treatment group were similar to those of the control group (P>0.05). After surgeries, the values of the treatment group were significantly different from those of the control group (P<0.05). The two groups also had significantly different intraoperative blood losses and surgical times (P<0.05).

Conclusion:

Compared with posterior decompression, anterior decompression improved spinal cord function better and relived spinal cord compression more effectively with a more reasonable mechanics of internal fixation. Although this protocol caused more blood loss, the overall therapeutic effects were more satisfactory.

Percutaneous dorsal instrumentation for thoracolumbar extension-distraction fractures in patients with ankylosing spinal disorders: a case series

BACKGROUND CONTEXT

Thoracolumbar extension-distraction fractures are rare injuries mainly restricted to patients suffering from ankylosing spinal disorders. The most appropriate surgical treatment of these unstable spinal injuries remains to be clarified.

PURPOSE

To report on a cohort of 10 patients treated with closed reduction and percutaneous dorsal instrumentation.

STUDY DESIGN

Case series.

PATIENT SAMPLE

Ten consecutive patients with ankylosing spinal disorders and thoracolumbar extension-distraction fractures (Type B3 according to the AOSpine Thoracolumbar Spine Injury Classification System).

OUTCOME MEASURES

Postoperative reduction, alignment, and implant position were analyzed by computed tomography. Loss of reduction was assessed on lateral radiographs by using the Cobb technique. Ambulation ability and pain were assessed at follow-up.

METHODS

Minimally invasive dorsal percutaneous instrumentation was performed in 10 consecutive patients (3 men, 7 women) with a mean age of 81.5 (range 72-90) years between May 2010 and December 2012. The mean postoperative follow-up time was 7.9 (range 4-28) months.

RESULTS

All 10 patients were treated with closed reduction and dorsal instrumentation; in no case was conversion to an open approach required. The mean operation time was 60.2 (range 32-135) minutes. None of the patients presented neurologic deficits. Cement-augmented screws were implanted in two cases. Sufficient radiographic correction was achieved in all patients; no case of loss of reduction was noted at final follow-up. In one case, complete hardware removal was performed 9 months after the index operation because of persistent back pain at the level of the implant. One patient died of postoperative inferior vena cava obstruction. At discharge, all patients were able to ambulate without the need for crutches or opioid analgesics. At final follow-up, all patients ambulated with full weight bearing; four patients reported persistent back pain.

CONCLUSIONS

In fragile patients with ankylosing spinal disorders and thoracolumbar extension-distraction fractures, closed reduction and percutaneous dorsal instrumentation provide a satisfying midterm functional outcome while minimizing perioperative risks compared with conventional dorsoventral procedures.

[Release of moveable segments after dorsal stabilization : Impact on affected discs]

BACKGROUND

Bisegmental dorsal stabilization is a common treatment option for instable compression fractures of the thoracolumbar spine; however, it remains unknown to what extent bridging compromises intervertebral discs.

OBJECTIVES

The purpose of this study was to determine the disc height and functional features in comparison to healthy intervertebral discs after removal of the dorsal fixator and particularly under consideration of the time span between dorsal stabilization and implant removal (IR).

MATERIAL AND METHODS

The IR was performed in 19 patients after an average of 13 months (range 8-24 months) after dorsal stabilization of instable vertebral compression fractures of the thoracolumbar junction and lumbar spine. An additional ventral monosegmental spondylodesis was performed in 10 patients with incomplete burst fractures. Thus, a total of 28 intervertebral discs were temporarily bridged (bridged discs), with an adjacent endplate fracture in 10 (injured discs) and no adjacent bony lesion in 18 discs (healthy discs). The intervertebral discs superior and inferior to the instrumentation were selected as controls (control discs). Standardized conventional lateral radiographs were taken prior to and after IR as well as after 6 months. Additionally, standardized lateral radiographs in flexion and extension were taken. The intervertebral disc height (disc height) was determined by two independent board approved orthopedic observers by measuring the anterior, central and dorsal intervertebral disc spaces on all lateral radiographs as well as the intervertebral disc angles (disc angle) defined by the intervertebral upper and lower endplates in the flexion and extension views. Intradisc function (disc function) was defined as the difference between the disc angle in extension and flexion. The measurements were repeated after 12 months. Univariate analysis was performed using ANOVA and significance was set at p < 0.05. Interobserver and intraobserver comparisons of the disc heights and the disc angles were determined with intraclass correlation coefficients.

RESULTS

No significant differences were seen in disc function and disc height between the controls and the bridged discs at all times of measurement; however, injured discs showed a significantly reduced disc height and disc angle in extension compared to healthy discs (p = 0.028 and p = 0.027, respectively). Additionally, patients with IR during the first 12 months had significantly reduced disc heights compared to those patients with delayed IR within the second postoperative year (p = 0.018). Interobserver and intraobserver agreement for disc function was 0.80 (95 % confidence interval CI: 0.68-0.88) and 0.85 (95 % CI 0.76-0.90), respectively. The interobserver and intraobserver correlations for disc height were 0.85 (95 % CI: 0.76-0.90) and 0.93 (95 % CI 0.88-0.95), respectively.

CONCLUSION

Bridging of an intervertebral disc with IR within 24 months does not cause immediate loss of disc function or reduction of disc height; however, temporary bridging in combination with an adjacent endplate fracture causes significant reduction of disc height and loss of extension. Additionally, no beneficial effects could be seen by reducing the time span between stabilization and IR to below 12 months.

The influence of distraction force on the intradiscal pressure gradient in the bridged lumbar spine: a biomechanical investigation using a calf model

STUDY DESIGN

A biomechanical calf cadaver study.

OBJECTIVE

The purpose of this study was to determine the intradiscal pressure gradient of bridged healthy intervertebral segments in correlation with intraoperative distraction force.

SUMMARY OF BACKGROUND DATA

Bisegmental dorsal stabilization and anatomic reduction is a common treatment option for incomplete burst fractures of the lumbar spine. However, it remains unknown to what extent bridging and intraoperative distraction compromises an intact intervertebral disc.

METHODS

The L2-L3 intervertebral disc level was evaluated in 6 freshly frozen calf cadaver spines. Pressure measurements were obtained with the spine uninstrumented, after dorsal segmental instrumentation from L1 to L3, and after distraction with 400 N and 800 N. Pressure gradient measurements were accomplished with a balloon pressure sensor placed within the nucleus pulposus of the L2-L3 intervertebral disc. Pressure data were recorded by computer data acquisition. Flexion, extension, and lateral bending moments were applied continuously by a testing machine up to a load moment of 7.5 N·m. The pressure gradients were compared with respect to the effects of added instrumentation and distraction.

RESULTS

After segmental bridging the mean pressure gradients were significantly reduced in all movement directions (P < 0.001). However, after dorsal stabilization a continuously rising intervertebral disc pressure was recordable. In contrast, no relevant additional reduction of the intradiscal pressure gradient was detectable after applying distraction forces of 400 N or 800 N.

CONCLUSION

In a calf model, a distraction force of up to 800 N leads to no additional reduction of the pressure gradient of bridged healthy lumbar segments under flexion and extension moments.

Thoracoscopically assisted corpectomy and percutaneous transpedicular instrumentation in management of burst thoracic and thoracolumbar fractures

STUDY DESIGN

This is a prospective observational study.

PURPOSE

The aim of this study was to determine whether the combination of thoracoscopically assisted corpectomy with posterior percutaneous transpedicular instrumentation in prone position achieves treatment goals in burst thoracic or thoracolumbar fractures and minimizes the associated morbidities.

METHODS

Between December 2007 and December 2008, 26 patients with acute burst spinal fractures were operated upon in our hospital. Those patients underwent posterior percutaneous stabilization plus anterior thoracoscopically assisted corpectomy and fusion in prone position. Clinical and radiological outcomes of these patients were evaluated after a minimum follow-up period of 2 years. The Oswestry Disability Index (ODI) combined with clinical examination was used for clinical evaluation. Plain X-ray in two views was used for the radiological evaluation.

RESULTS

The mean operative time was 248 min. The average blood loss was 765 ml. Ten patients had preoperative neurological deficits ranging from Frankel A to D. One patient did not show any neurological improvement at the final follow-up. The mean ODI at final follow-up was about 7. The mean preoperative kyphosis angle was 25.58°, improved to 9.2° postoperatively and to 13.8° at the final follow-up. No cases of implant failure were reported at the final follow-up.

CONCLUSIONS

Minimal invasive spinal techniques including thoracoscopic decompression and fusion and short segment posterior percutaneous instrumentation showed good clinical outcomes and can be considered as alternative to open procedures with decreased rates of morbidities in managing burst thoracic and thoracolumbar fractures.

[Current status of thoracoscopic surgery for thoracic and lumbar spine. Part 1: general aspects and treatment of fractures]

INTRODUCTION

Thoracoscopic surgery or video-assisted thoracic surgery (VATS) of the thoracic and lumbar spine has greatly evolved since it appeared less than 20 years ago. Nowadays, it is indicated in a large number of processes and injuries. The aim of this article, in its 2 parts, is to review the current status of VATS in treatment of the thoracic and lumbar spine in its entire spectrum.

DEVELOPMENT

After reviewing the current literature, we develop each of the large groups of indications where VATS is used, one by one. This first part contains a description of general thoracoscopic surgical technique including the necessary prerequisites, transdiaphragmatic approach, techniques and instrumentation used in spine reconstruction, as well as a review of treatment and specific techniques in the management of spinal fractures.

CONCLUSIONS

Thoracoscopic surgery is in many cases an alternative to conventional open surgery. The transdiaphragmatic approach has made endoscopic treatment of many thoracolumbar junction processes possible, thus widening the spectrum of therapeutic indications. These include the treatment of fractures and deformities, as well as the reconstruction of injured spinal segments and decompression of the spinal canal in any etiological processes if the lesion placement is favourable to antero-lateral approach. Good clinical results of thoracoscopic surgery are supported by the growing experience reflected in a large number of articles. The degree of complications in thoracoscopic surgery is comparable to open surgery, with benefits in morbidity of the approach and subsequent patient recovery.

AO spine injury classification system: a revision proposal for the thoracic and lumbar spine

PURPOSE

The AO Spine Classification Group was established to propose a revised AO spine injury classification system. This paper provides details on the rationale, methodology, and results of the initial stage of the revision process for injuries of the thoracic and lumbar (TL) spine.

METHODS

In a structured, iterative process involving five experienced spine trauma surgeons from various parts of the world, consecutive cases with TL injuries were classified independently by members of the classification group, and analyzed for classification reliability using the Kappa coefficient (κ) and for accuracy using latent class analysis. The reasons for disagreements were examined systematically during review meetings. In four successive sessions, the system was revised until consensus and sufficient reproducibility were achieved.

RESULTS

The TL spine injury system is based on three main injury categories adapted from the original Magerl AO concept: A (compression), B (tension band), and C (displacement) type injuries. Type-A injuries include four subtypes (wedge-impaction/split-pincer/incomplete burst/complete burst); B-type injuries are divided between purely osseous and osseo-ligamentous disruptions; and C-type injuries are further categorized into three subtypes (hyperextension/translation/separation). There is no subgroup division. The reliability of injury types (A, B, C) was good (κ = 0.77). The surgeons' pairwise Kappa ranged from 0.69 to 0.90. Kappa coefficients κ for reliability of injury subtypes ranged from 0.26 to 0.78.

CONCLUSIONS

The proposed TL spine injury system is based on clinically relevant parameters. Final evaluation data showed reasonable reliability and accuracy. Further validation of the proposed revised AO Classification requires follow-up evaluation sessions and documentation by more surgeons from different countries and backgrounds and is subject to modification based on clinical parameters during subsequent phases.

Outcome after thoracoscopic ventral stabilisation of thoracic and lumbar spine fractures

BACKGROUND AND PURPOSE

Thoracoscopic-assisted ventral stabilisation for thoracolumbar fractures has been shown to be associated with decreased recovery time and less morbidity when compared with open procedures. However, there are a limited number of studies evaluating late clinical and radiological results after thoracoscopic spinal surgery.

METHODS

We performed an analysis of the late outcomes of thoracolumbar fractures after minimally invasive thoracoscopic ventral instrumentation. Between August 2003 and December 2008, 70 patients with thoracolumbar fractures (T5-L2) underwent ventral thoracoscopic stabilisation. Tricortical bone grafts, anterior plating systems (MACS-System), and cage implants were used for stabilisation. Outcomes measured include radiologic images (superior inferior endplate angle), Visual Analogue Scale (VAS), VAS Spine Score, quality of life scores SF-36 and Oswestry Disability Index (ODI).

RESULTS

Forty seven patients (67%, 47 out of 70) were recruited for the follow up evaluation (2.2 ± 1.5 years). Lower VAS Spine scores were calculated in patients with intra- or postoperative complications (44.7 (± 16.7) vs. 65.8 (± 24.5), p=0.0447). There was no difference in outcome between patients treated with bone graft vs. cage implants. Loss of correction was observed in both bone graft and titanium cage groups.

INTERPRETATION

The present study demonstrates diminished long-term quality of life in patients treated with thoracoscopic ventral spine when compared with the outcome of german reference population. In contrast to the other patients, those patients without intra-operative or post-operative complications were associated with improved outcome. The stabilisation method (bone graft versus spinal cage) did not affect the long-term clinical or radiographic results in this series.

[Spine fractures in patients with ankylosing spondylitis: an analysis of 129 fractures after surgical treatment]

INTRODUCTION

The ankylosing spondylitis (AS) is a systemic rheumatic disease, which affects the skeleton, joints and internal organs. Attributed to the augmented rigidity of the spine and the concomitant impairment of compensatory mechanism minor force might cause spine fractures. Multilevel stabilization and dorsoventral instrumentation is a well - established procedure. This study was to evaluate the surgical outcome of 119 patients with AS associated spine fractures.

METHODS

From 07/96 to 01/10, 119 patients with 129 spine fractures due to AS were treated in our department. Data were collected retrospectively. In all patients the operative treatment of the fracture was either performed by ventral and/or dorsal spondylodesis.

RESULTS

The median age was 67 years (37-95). There were 51 cervical, 55 thoracic and 23 lumbar spine fractures. On initial presentation no fractures in 18 patients (15%) and stable fractures in 15 patients (13%) were detected, which further secondarily dislocated. Thus, in 28% of the patients the injury was assessed falsely. 47% of the fractures were preceded by a trivial trauma in domestic surrounding. 61 patients (51%) developed either an incomplete or a complete paraplegia. In 32 patients ventral instrumentation, in 82 patients dorsal and in 15 patients dorsoventral instrumentation were performed. 14% developed postoperative wound infection an in 15% revision surgery due to implant loosening or insufficient stabilization was required.

CONCLUSION

Early diagnostic of AS associated spine fractures using conventional radiographs and computed tomography scans is important for the detection and adequate treatment. A great amount of spine fractures are obviously either under diagnosed or underestimated, initially. A secondary dislocation of the fracture might result in severe neurological complications up to paraplegia.

Kyphoplasty as an alternative treatment of traumatic thoracolumbar burst fractures Magerl type A3

INTRODUCTION

Traumatic thoracolumbar spine fractures are frequently classified as burst fractures Magerl type A3. There still are many controversies regarding the treatment of this fracture. The therapeutic spectrum ranges from conservative to invasive operative methods with attendant morbidities. The minimal-invasive technique of kyphoplasty has established itself as a common treatment of osteoporotic vertebral compression fractures and is associated with a low complication rate. The aim of this study is to evaluate the functional and radiological results after kyphoplasty of traumatic thoracolumbar burst fractures.

PATIENTS AND METHODS

Patients with traumatic thoracolumbar fractures type A3.1, A3.2 and A3.3, who were treated with kyphoplasty, were included in this study. The clinical outcome was measured at follow up with a neurological assessment, the visual analogue pain scale (VAS), the Oswestry Disability Score (ODI) and the SF-36 Health Survey. The radiological measurements, performed on preoperative, postoperative and follow up radiographs, included the sagittal index, the wedge angle and the modified Cobb angle of Daniaux.

RESULTS

26 patients with 23 A3.1, one A3.2 and five A3.3 fractures were treated between 2004 and 2007, including five patients with multiple vertebral fractures. At follow up the Oswestry Disability Score (26.2%) and the SF-36 score (60.1%) assessed a moderately limitation of functional outcome and quality of life without any neurological deficits. Radiological measurements showed a postoperative height restoration and reduction of kyphosis, but at follow up a secondary loss of correction except in five cases. Six minor ventrocranial cement leakages without further clinical consequence were observed.

CONCLUSIONS

The present study showed that kyphoplasty is a safe and feasible method for the treatment of burst fractures. It allowed the correction of the kyphosis, stabilisation of the facture, pain reduction and early mobilisation.

Combined posteroanterior fusion versus transforaminal lumbar interbody fusion (TLIF) in thoracolumbar burst fractures

BACKGROUND

The optimal treatment strategy for burst fractures of the thoracolumbar junction is discussed controversially in the literature. Whilst 360° fusion has shown to result in better radiological outcome, recent studies have failed to show its superiority concerning clinical outcome. The morbidity associated with the additional anterior approach may account for these findings. The aim of this prospective observational study was therefore to compare two different techniques for 360° fusion in thoracolumbar burst fractures using either thoracoscopy or a transforaminal approach (transforaminal lumbar interbody fusion (TLIF)) to support the anterior column.

METHODS

Posterior reduction and short-segmental fixation using angular stable pedicle screw systems were performed in all patients as a first step. Monocortical strut grafts were used for the anterior support in the TLIF group, whilst tricortical grafts or titanium vertebral body replacing implants of adjustable height were used in the combined posteroanterior group. At final follow-up, the radiological outcome was assessed by performing X-rays in a standing position. The clinical outcome was measured using five validated outcome scores. The morbidity associated with the approaches and the donor site was assessed as well.

RESULTS

There were 21 patients in the TLIF group and 14 patients in the posteroanterior group included. The postoperative loss of correction was higher in the TLIF group (4.9°±8.3° versus 3.4°±6.4°, p>0.05). There were no significant differences regarding the outcome scores between the two groups. There were no differences in terms of return to employment, leisure activities and back function either. More patients suffered from donor-site morbidity in the TLIF group, whilst the morbidity associated with the surgical approach was higher in the posteroanterior group.

CONCLUSION

The smaller donor-site morbidity in the posteroanterior group is counterbalanced by an additional morbidity associated with the anterior approach resulting in similar clinical outcome. Mastering both techniques will allow the spine surgeon to be more flexible in specific situations, for example, in patients with neurological deficits or severe concomitant thoracic trauma.

[Recommendations for the treatment of thoracolumbar and lumbar spine injuries]

This paper gives recommendations for treatment of thoracolumbar and lumbar spine injuries. The recommendations are based on the experience of the involved spine surgeons, who are part of a study group of the "Deutsche Gesellschaft für Unfallchirurgie" and a review of the current literature. Basics of diagnostic, conservative, and operative therapy are demonstrated. Fractures are evaluated by using morphologic criteria like destruction of the vertebral body, fragment dislocation, narrowing of the spinal canal, and deviation from the individual physiologic profile. Deviations from the individual sagittal profile are described by using the monosegmental or bisegmental end plate angle. The recommendations are developed for acute traumatic fractures in patients without severe osteoporotic disease.

[Reconstruction after spinal fractures in the thoracolumbar region]

The morbidity of anterior approaches has significantly influenced the development of therapeutic concepts for the treatment of thoracolumbar spine fractures. Minimally-invasive techniques such as mini-open and endoscopic have enlarged the numbers of anterior reconstruction after spinal fractures in the thoracolumbar region. These minimally-invasive approaches have been facilitated by the development of special implants adapted to the new technique and to the local anatomical requirements.Two multi center studies in Germany (MCSI and II) showed the trend towards minimal invasive procedures and anterior approaches in the German speaking spine centers. Since the first report on thoracoscopic anterior procedures in Germany in 1997 a growing number of spine centers established this method. There is still no evidence based high level literature to substantiate a significant benefit for the patients by anatomical reduction and reconstruction of the anterior spinal column. However, there are some reports on better short outcomes in radiological parameters as well as better clinical results in 5 to 8 year follow-ups.The minimal invasive anterior approach seems to be advantageous for the patients by reducing significantly additive operation morbidity. It has become more important over the last two decades for anterior reconstruction after trauma and posttraumatic malalignment of the thoracolumbar spine.

Palliative surgical approach to rehabilitate spinal injury patient in Indian rural setup

OBJECTIVE

To evaluate the usefulness of conventional spinal surgery as palliative procedure to rehabilitate dorsolumbar injuries in a rural setup.

MATERIALS AND METHODS

Twenty-three patients with dorsolumbar spine injury with complete paraplegia were assessed on the clinical and social rehabilitation parameters after surgical stabilization at Acharya Vinoba Bhave Rural Hospital Sawangi, Wardha, India. The study group comprised 21 male and 2 female patients. The dorsolumbar spine injury was fixed by conventional posterior instrumentation using short-segment pedicle screw system and Harrington rod system with or without fusion. Functional and neurologic outcome was recorded in the follow-up period by using Functional Independence Measure and Frankel grade, respectively. Correlation and analysis of results was established statistically.

RESULTS

Functional outcome showed statistically significant improvement. Social cognition was found intact in a significant number of patients.

CONCLUSION

This study demonstrates the usefulness of conventional instrumentation as palliative surgical approach to stabilize and rehabilitate patients from deprived sector of rural India.

Mid-term results of PLIF/TLIF in trauma

Treatment of thoracolumbar fractures is still controversial. Several treatment options are reported to yield satisfactory results. There is no evidence indicating superiority of any treatment option. We have already presented radiological results of the use of PLIF/TLIF in trauma, which showed satisfactory results concerning intervertebral fusion and acceptable loss of correction. We examined 50 patients regarding loss of correction after implant removal and clinical outcome using a validated visual analogue score. The average time of follow-up (FU) was 35 months. We observed a total loss of correction of 4°. The pre-injury mean VAS score was 92. At FU, there was an average reduction of 17.2 points. Owing to the presented results, we suggest this method as an alternative to combined procedures.

Can computer-assisted surgery reduce the effective dose for spinal fusion and sacroiliac screw insertion?

BACKGROUND

The increasing use of fluoroscopy-based surgical procedures and the associated exposure to radiation raise questions regarding potential risks for patients and operating room personnel. Computer-assisted technologies can help to reduce the emission of radiation; the effect on the patient's dose for the three-dimensional (3-D)-based technologies has not yet been evaluated.

QUESTIONS/PURPOSES

We determined the effective and organ dose in dorsal spinal fusion and percutaneous transsacral screw stabilization during conventional fluoroscopy-assisted and computer-navigated procedures.

PATIENTS AND METHODS

We recorded the dose and duration of radiation from fluoroscopy in 20 patients, with single vertebra fractures of the lumbar spine, who underwent posterior stabilization with and without the use of a navigation system and 20 patients with navigated percutaneous transsacral screw stabilization for sacroiliac joint injuries. For the conventional iliosacral joint operations, the duration of radiation was estimated retrospectively in two cases and further determined from the literature. Dose measurements were performed with a male phantom; the phantom was equipped with thermoluminescence dosimeters.

RESULTS

The effective dose in conventional spine surgery using 2-D fluoroscopy was more than 12-fold greater than in navigated operations. For the sacroiliac joint, the effective dose was nearly fivefold greater for nonnavigated operations.

CONCLUSION

Compared with conventional fluoroscopy, the patient's effective dose can be reduced by 3-D computer-assisted spinal and pelvic surgery.

LEVEL OF EVIDENCE

Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Epidemiology and Management of Injuries to the Spinal Cord and Column in Pediatric Multiple-Trauma Patients

Injuries to the spinal column and cord in children are a rare condition. Epidemiological data could help to establish an evidence-based assessment and therapy of these patients. We present a retrospective chart analysis of children with spinal injuries who were admitted to the emergency room. The patients were analyzed regarding age, mechanism, and distribution of their injuries to all spinal regions and treatment strategies. Thirty-five children met the inclusion criteria with severe spinal injuries (Abbreviated Injury Scale [AIS] for Region 6 [spine]; AIS region 6) in a period from January 2003 to December 2009. The incidence was extremely low in younger children, with increasing numbers during adolescence. Neurological deficit without fracture accounted for almost 25% of all patients. The majority of patients were treated conservatively; operative treatment was performed in 25% of patients with unstable fractures, particularly in adolescents. Treatment strategies differ according to the type and degree of injury, age, and level of spine maturation.

PLIF in thoracolumbar trauma: technique and radiological results

Patients with fractures from the 11th thoracic to the 5th lumbar vertebra had a reconstruction of the anterior column with monocortical iliac crest autograft by using a single dorsal approach. The loss of correction was observed using X-rays pre- and post-operatively, at 3 months and after implant removal (IR). Successful fusion was assessed using computed tomography after the implant removal. To assess the loss of correction and intervertebral fusion rate of this technique. There are still controversial discussions about the treatment modalities of spine lesions, especially in cases of burst fractures. Dorsal, combined and ventral procedures are reported with different assets and drawbacks. We want to present a method to restore the weight-bearing capability of the anterior column using a single dorsal approach. From 2001 to 2005, a total of 100 patients was treated with this technique at our department. Follow-up examination was possible in 82 patients. The X-rays and CT scans were proofed for loss of correction and fusion rate. The anterior column has been restored using a monocortical strut graft via a partial resection of the lamina and the apophyseal joint on one side to access the disc space. The dorsal reduction has been achieved using an angular stable pedicle screw system. The mean follow-up time was 15 months (range 8-39); 67 patients had a CT scan at follow-up and 83% showed a 360 degrees fusion. The average post-operative loss of correction was 3.3 degrees (range 0-21). The average duration of operation was 192 min (range 120-360) and the mean blood loss was 790 ml (range 300-3,400 ml). Regarding the complications we did not have any deep wound infections. We had two epidural haematomas postoperatively with a neurological deterioration that had to be revised. We were able to decompress the neurological structures and restore the weight-bearing capability of the anterior column in a one-stage procedure. So we think that this technique can be an alternative procedure to combined operations regarding the presented radiological results of successful fusion and loss of correction.