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

[Winter sports injuries of the thoracic and lumbar spine : Etiology, classification and stage-specific therapy]

BACKGROUND

Overall, spinal injuries in winter sports are extremely rare. The incidence is given as approximately 0.01/1000 ski days. While falls and collisions at high speed are the main concerns for skiers, spinal injuries for snowboarders occur primarily on landing after a jump. The age of a typical spinally injured skier is 40, which is older than that of the average snowboarder at 23.

CLASSIFICATION

Primarily, the thoracolumbar junction is injured and hereby mainly anterior compression fractures (type A1) and burst fractures (types A3 and A4) occur. Injuries caused by flexion or distraction mechanisms (Type B) or rotation injuries (Type C) are less common. Injuries to the cervical spine are rare overall, but they are also represented in the very few cases with neurological deficits.

THERAPY

With appropriate X‑ray diagnostics, including CT and, if necessary, MRI, the appropriate therapy can be initiated so that a return to sport is possible in most cases. Furthermore, there is ongoing scientific discussion as to when conservative therapy is superior and when surgery is superior.

Long-term results after thoracoscopic anterior spondylodesis with or without posterior stabilization of unstable incomplete burst fractures of the thoracolumbar junction: a prospective cohort study

Background

Minimally invasive, thoracoscopic anterior spondylodesis (MIAS) is an established treatment for burst fractures of the thoracolumbar spine. Good restoration of the local sagittal alignment and good functional results have been reported. The aim of this study was to evaluate long-term results of MIAS in patients with incomplete burst fractures and to analyze the influence on global sagittal alignment, clinical outcomes, and adjacent segment degeneration.

Methods

From 2002 to 2003, 18 patients were treated with MIAS for incomplete thoracolumbar burst fractures. Mono-segmental spondylodesis was performed with an iliac crest bone graft and bisegmental spondylodesis with a titanium cage. In this single-center prospective cohort study, 15 patients were available for follow-up (FU) after an average of 12.9 years (12.1–14.4). Seven patients were treated with a combined anterior and posterior instrumentation and eight patients with anterior spondylodesis only. The primary clinical outcome parameter was the Oswestry Disability Index (ODI); secondary parameters were the Short Form 36 (SF36) and the visual analog scale (VAS spine). Full spine radiographs were assessed for bisegmental Cobb angle, alignment parameters, and signs of adjacent segment degeneration (ASD).

Results

ODI evaluation showed a mean impairment of 11.7% with minimal limitations in 13 patients. Neither a significant deterioration over time nor significant differences between both therapy strategies were found in the clinical scores at the latest follow-up. The mean bisegmental increase of regional malalignment of reduction was 8.8° (± 7.3°) with no significant correlation to any clinical outcome scores. The majority of patients had no signs of adjacent segment degeneration. Two patients showed minor radiologic changes. All patients had a balanced sagittal spine profile.

Conclusions

In conclusion, MIAS leads to good clinical results with—in majority—minimal spine-related impairment at the latest follow-up. No significant deterioration at 12-year FU was detectable compared to the 6-year results for the SF36 and VAS spine scores. There was no association between sagittal alignment, clinical outcome scores, and ASD.

Trial registration

The study was retrospectively registered in the German Clinical Trials Register (Nr.00015656).

Which anatomic structures are responsible for the reduction loss after hybrid stabilization of osteoporotic fractures of the thoracolumbar spine?

Introduction

Hybrid stabilization is an accepted therapy strategy for unstable osteoporotic thoracolumbar fractures. However, a moderate reduction loss has been reported and it remains unclear which anatomic structure is responsible for the reduction loss.

Methods

This retrospective study was performed at a level I trauma center. Patients aged 61 and older were stabilized using hybrid stabilization after suffering acute and unstable osteoporotic vertebral body fractures at the thoracolumbar spine. Posterior stabilization was done short-segmental and minimal invasive with cement-augmentation of all pedicle screws. The minimum follow-up has been 2 years. The outcome parameters were the reduction loss and the relative loss of height of both intervertebral discs adjacent to the fractured vertebral body, the fractured vertebral body and a reference disc (intervertebral disc superior of the stabilization) between the postoperative and latest lateral radiographs. Additionally, implant positioning and loosening was analyzed.

Results

29 mainly female (72%) patients (73.3 ± 6.0 years) were included. Fractures consisted of 26 incomplete burst fractures and 3 complete burst fractures of the thoracolumbar junction (Th11 – L2: 86%) and the midlumbar spine. The mean follow-up time was 36 months (range: 24–58 months). The mean reduction loss was 7.7° (range: 1–25). The relative loss of heights of both intervertebral discs adjacent to the fractured vertebral body, the reference disc, and the central vertebral body were significant. Thereby, the relative loss of the superior disc height was significant higher compared to the reference disc. Additionally, only the relative loss of central vertebral body height and reduction loss correlated significantly. There were no signs of implant loosening in any patient.

Conclusions

The mean reduction loss was moderate 3 years after hybrid stabilization of unstable osteoporotic vertebral fractures of the thoracolumbar spine. A significant loss of both adjacent disc heights and the central vertebral body was seen, with the highest loss in the superior adjacent disc significantly outranging the reference disc. The superior adjacent intervertebral disc and the central part of the fractured vertebral body seem to be responsible for the majority of reduction loss.

Treatment of Fractures of the Thoracolumbar Spine: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU)

STUDY DESIGN

consensus paper with systematic literature review.

OBJECTIVE

The aim of this study was to establish recommendations for treatment of thoracolumbar spine fractures based on systematic review of current literature and consensus of several spine surgery experts.

METHODS

The project was initiated in September 2008 and published in Germany in 2011. It was redone in 2017 based on systematic literature review, including new AOSpine classification. Members of the expert group were recruited from all over Germany working in hospitals of all levels of care. In total, the consensus process included 9 meetings and 20 hours of video conferences.

RESULTS

As regards existing studies with highest level of evidence, a clear recommendation regarding treatment (operative vs conservative) or regarding type of surgery (posterior vs anterior vs combined anterior-posterior) cannot be given. Treatment has to be indicated individually based on clinical presentation, general condition of the patient, and radiological parameters. The following specific parameters have to be regarded and are proposed as morphological modifiers in addition to AOSpine classification: sagittal and coronal alignment of spine, degree of vertebral body destruction, stenosis of spinal canal, and intervertebral disc lesion. Meanwhile, the recommendations are used as standard algorithm in many German spine clinics and trauma centers.

CONCLUSION

Clinical presentation and general condition of the patient are basic requirements for decision making. Additionally, treatment recommendations offer the physician a standardized, reproducible, and in Germany commonly accepted algorithm based on AOSpine classification and 4 morphological modifiers.

Temporary stabilization of unstable spine fractures

PURPOSE OF REVIEW

We will review the recent literature concerning the necessity of supplemental fusion to spinal instrumentation and discuss if temporal spinal fixation is a viable option for the treatment of unstable spine fractures. Advancements in minimally invasive techniques offer an alternative approach to traditional open stabilization for unstable spine fractures. The use of minimally invasive surgery offers many advantages concerning operative morbidly; fusion is not utilized and instrumentation can be removed in a delayed fashion.

RECENT FINDINGS

There are limited differences in amount of correction loss over time, and multiple studies report equivocal to superior results in patient's functional outcomes when comparing temporary internal stabilization to long segment instrumentation with fusion. Removal of implants can restore segmental motion. Review of the literature demonstrates that temporary internal stabilization for unstable fractures is a viable option. Close clinical and radiographic follow-up is recommended to avoid delayed spinal deformity.