Mid-term results of PLIF/TLIF in trauma

Is restoration of vertebral body height after vertebral body fractures and minimally-invasive dorsal stabilization with polyaxial pedicle screws just an illusion?

INTRODUCTION

Thoracolumbar spine fractures often require surgical treatment as they are associated with spinal instability. Optimal operative techniques and treatment are discussed controversially. Aim of our prospective cohort study was to investigate the sagittal alignment after reduction, the secondary loss of reduction and the subjective outcome as well as the causal correlation of these parameters after minimally invasive stabilization of thoracic and lumbar fractures with polyaxial pedicle screws.

MATERIALS AND METHODS

In a single-center study, a total of 78 patients with an average age of 61 ± 17 years who suffered a fracture of the thoracic or lumbar spine were included and subjected to a clinical and radiological follow-up examination after 8.5 ± 8 months. The kyphotic deformity was measured by determining the vertebral body angle, the mono- and bi-segmental wedge angle at three time points. The patients' subjective outcome was evaluated by the VAS spine score.

RESULTS

After surgical therapy, a significant reduction of the traumatic kyphotic deformity was shown with an improvement of all angles (vertebral body angle: 3.2° ± 4.4°, mono- and bi-segmental wedge angle: 3.1° ± 5.6°, 2.0° ± 6.3°). After follow-up, a significant loss of sagittal alignment was observed for all measured parameters with a loss of correction. However, no correlation between the loss of reduction and the subjective outcome regarding the VAS spine scale could be detected.

CONCLUSION

The minimally invasive dorsal stabilization of thoracic and lumbar spine fractures with polyaxial pedicle screws achieved a satisfactory reduction of the fracture-induced kyphotic deformity immediately postoperatively with a floss of reduction in the further course. However, maybe the main goal of this surgical procedure should be the prevention of a complete collapse of the vertebral body instead of a long-lasting restoration of anatomic sagittal alignment.

LEVEL OF EVIDENCE

II.

Expandable Cage Technology-Transforaminal, Anterior, and Lateral Lumbar Interbody Fusion

This review of the literature will focus on the indications, surgical techniques, and outcomes for expandable transforaminal lumbar interbody fusion (TLIF), anterior lumbar interbody fusion (ALIF), and lateral lumbar interbody fusion (LLIF) operations. The expandable TLIF cage has become a workhorse for common degenerative pathology, whereas expandable ALIF cages carry the promise of greater lordotic correction while evading the diseased posterior elements. Expandable LLIF cages call upon minimally invasive techniques for a retroperitoneal, transpsoas approach to the disc space, obviating the need for an access surgeon and decreasing risk of injury to the critical neurovascular structures. Nuances between expandable and static cages for all 3 TLIF, ALIF, and LLIF operations are discussed in this review.

Thoracolumbar Junction Fracture: Principle of Management

The thoracolumbar junction (TLJ) is the most common site of traumatic spinal injury. Its management is a highly controversial area. There are no specific guidelines for management of these injuries. The primary goal of treatment of TLJ fractures involves protecting the spinal cord from further neural damage, obtaining the stability by reconstructing anatomical alignment of spinal column, and returning patients to workplace through early mobilization and rehabilitation. There is a great variation in evaluation of stability of these fractures, which is one of the crucial factors in deciding the treatment. Controversy also exists regarding conservative versus operative treatment, timing of intervention, anterior versus posterior approach, short versus long segment fixation, and bracing versus no bracing. This article had reviewed the conflicting results and recommendations for management of TLJ fractures of previously published reports in PubMed, PubMed Central, and Medline databases. We analyzed these related articles which addresses issues regarding evaluation of stability, indications for operative and conservative treatment, timing of surgery, surgical approach, and fusion length.

Influence of Gender on Health-Related Quality of Life and Disability at 1 Year After Surgery for Thoracolumbar Burst Fractures

STUDY DESIGN

Case series.

OBJECTIVE

Thoracolumbar burst fractures (TLBF) are the most frequent type of spinal fractures. Approximately half of the patients are neurologically intact and their treatment is still debatable. Gender could influence outcome after surgical procedures, but this is still unclear in patients sustaining a spinal fracture. The aim of this study was to investigate how gender influences health-related quality of life (HRQOL) and disability in patients operated on for TLBF.

METHODS

We identified 44 neurologically intact patients from a consecutive series of patients treated surgically for a single-level traumatic burst fracture (AOSpine Subaxial Classification System A3) in the thoracolumbar transition area (Th12-L2). At 1 year after surgery, they were evaluated using the SF-36v2 questionnaire to assess HRQOL and Oswestry Disability Index (ODI) questionnaire to evaluate disability.

RESULTS

Male patients scored higher in each item of the SF-36v2, with significant differences (P < .05) for Physical Function (PF), Bodily Pain (BP), and Social Function (SF). Male patients also had lower disability scores. Overall ODI score had a strong correlation with Physical Function, Role-Physical, Bodily Pain, Vitality, Mental Health, and overall Physical Component Summary (PCS) of the SF-36 in women, but only with Physical Function, Role-Physical, Role-Emotional, and PCS in men.

CONCLUSIONS

In this study, male patients reported better outcomes at 1 year after surgery for TLBF than women. Disability strongly correlated with the overall HRQOL, physical and mental health in women, but not in men. We found gender-related differences favoring men after surgical interventions for spinal fractures.

Does Operative or Nonoperative Treatment Achieve Better Results in A3 and A4 Spinal Fractures Without Neurological Deficit?: Systematic Literature Review With Meta-Analysis

STUDY DESIGN

Systematic literature review with meta-analysis.

OBJECTIVE

Thoracolumbar (TL) fractures can be treated conservatively or surgically. Especially, the treatment strategy for incomplete and complete TL burst fractures (A3 and A4, AOSpine classification) in neurologically intact patients remains controversial. The aim of this work was to collate the clinical evidence on the respective treatment modalities.

METHODS

Searches were performed in PubMed and the Web of Science. Clinical and radiological outcome data were collected. For studies comparing operative with nonoperative treatment, the standardized mean differences (SMD) for disability and pain were calculated and methodological quality and risk of bias were assessed.

RESULTS

From 1929 initial matches, 12 were eligible. Four of these compared surgical with conservative treatment. A comparative analysis of radiological results was not possible due to a lack of uniform reporting. Differences in clinical outcomes at follow-up were small, both between studies and between treatment groups. The SMD was 0.00 (95% CI -0.072, 0.72) for disability and -0.05 (95% CI -0.91, 0.81) for pain. Methodological quality was high in most studies and no evidence of publication bias was revealed.

CONCLUSIONS

We did not find differences in disability or pain outcomes between operative and nonoperative treatment of A3 and A4 TL fractures in neurologically intact patients. Notwithstanding, the available scores have been developed and validated for degenerative diseases; thus, their suitability in trauma may be questionable. Specific and uniform outcome parameters need to be defined and enforced for the evaluation of TL trauma.

Outcome Instruments in Spinal Trauma Surgery: A Bibliometric Analysis

Study Design Literature review. Objective To identify outcomes instruments used in spinal trauma surgery over the past decade, their frequency of use, and usage trends. Methods Five top orthopedic journals were reviewed from 2004 to 2013 for clinical studies of surgical intervention in spinal trauma that reported patient-reported outcome instruments use or neurologic function scale use. Publication year, level of evidence (LOE), and outcome instruments were collected for each article and analyzed. Results A total of 58 studies were identified. Among them, 26 named outcome instruments and 7 improvised questionnaires were utilized. The visual analog scale (VAS) for pain was used most frequently (43.1%), followed by the Short Form 36 (34.5%), Frankel grade scale (25.9%), Oswestry Disability Index (20.7%) and American Spinal Injury Association Impairment Scale (15.5%). LOE 4 was most common (37.9%), and eight LOE 1 studies were identified (10.3%). Conclusions The VAS pain scale is the most common outcome instrument used in spinal trauma. The scope of this outcome instrument is limited, and it may not be sufficient for discriminating between more and less effective treatments. A wide variety of functional measures are used, reflecting the need for a disease-specific instrument that accurately measures functional limitation in spinal trauma.

Mono segmental fixation of selected types of thoracic and lumbar fractures; a prospective study

AIM OF STUDY

A prospective study to evaluate the results of monosegmental fixation; fixation of the fractured level with the adjacent vertebra sharing the same disc, in selected types of lumbar and thoracic fractures. This technique aims at saving motion levels by fusion of the only affected motion segment without sacrificing other levels.

METHODS

Forty patients enrolled in this study between August 2011 and October 2013. The inclusion criteria were recent thoracic or lumbar vertebral fractures (less than 2 weeks). The fracture involves only one of the end plates of the vertebrae (either the superior or the inferior). The other end plate and both pedicles should be intact. The exclusion criteria were cervical fractures, fractures that include both end plates or pedicles of the vertebra, fracture dislocation, and load sharing classification score more than seven. All patients underwent monosegmental fixation with pedicle screw fixation. Eight patients were supplemented with interbody grafts. Radiological evaluation was done to assess local kyphosis angle, degree of compression of the anterior column, the degree of comminution, retropulsed fragment, neural canal compromise, integrity of the affected end plate, exclusion of pedicle fracture, and most important to assure that only one end plate is affected. All patients were assessed neurologically according to Frankel grading system. Patient were assessed by Denis pain scale and Denis work scale.

RESULTS

The age of the patients was of a mean of 34.5 years old. All patients were Frankle E at time of presentation and remained the same post-operative. The mean operative time from incision time to end of skin closure was 74.2 min. The mean blood loss was 230 ml. The pre-operative degree of local kyphosis; was of a mean 8.22°. This was improved to 2.25° at the immediate postoperative x-rays. At two years follow up, the loss of correction was of a mean 0.85° which was insignificant. The pre-operative percentage of height lost improved from a mean of 56.05 % to post-operative mean of 90.125 %. At the end of follow up, no pseudoarthrosis cases or metal failure were noticed.

DISCUSSION

Thoracic and lumbar fractures are common in young adults. Surgical treatment offers early rehabilitation and preserves spine alignment. Monosegmental fixation technique in selected types of dorsal and lumbar fractures offers spine stability and preserves motion segments. It fuses only one motion segment that is prone for later instability or deformity. Reconstrcution of the anterior column can be achieved through TLIF approach in combination of monosegmental fixation to achieve 360° fusion.

CONCLUSION

Monosegmental fixation is an effective technique. It can save motion segments in young patients with adequate spine stability and good functional outcomes.

The benefits of elective spinal implant removal: a retrospective study of 137 patients

PURPOSE

While spinal instrumentations are becoming more common, the advantages of elective spinal implant removal remain ambiguous. We hypothesized that elective implant removal of the posterior spine is beneficial.

METHODS

A retrospective study evaluated 137 consecutive trauma patients with elective implant removal of the posterior spine. If additional cages were present, they were not removed. Primary outcomes were the change in pre- and post-operative pain, fingertip-floor distance (FFD), and Cobb angles. Some secondary outcomes consisted of complications, work disability, and pelvic incidence (PI). Different stabilization approaches and cage sizes were compared.

RESULTS

The presence and amount of pain as well as the FFD showed significant improvement. There was no loss of reduction. Delayed wound healing was observed in 9%, but only 3% needed revision. Thoracic fascial dehiscences were seen only in patients (9%) that had stand-alone posterior surgery. Larger cages were associated with increased work disability. An increased PI was associated with less post-operative pain and decreased FFD.

CONCLUSIONS

In this study, trauma patients benefited from elective implant removal of the posterior spine due to lower presence and level of pain, improved function and low revision rates; irrespective of an initial combined or stand-alone posterior approach or varying cage sizes. However, stand-alone posterior instrumentation may be accompanied by increased rates of fascial dehiscence surgeries and larger cages may lead to increased work disability. Increased PI may be associated with less pain after spinal implant removal.

Treatment of thoracolumbar fracture

The most common fractures of the spine are associated with the thoracolumbar junction. The goals of treatment of thoracolumbar fracture are leading to early mobilization and rehabilitation by restoring mechanical stability of fracture and inducing neurologic recovery, thereby enabling patients to return to the workplace. However, it is still debatable about the treatment methods. Neurologic injury should be identified by thorough physical examination for motor and sensory nerve system in order to determine the appropriate treatment. The mechanical stability of fracture also should be evaluated by plain radiographs and computed tomography. In some cases, magnetic resonance imaging is required to evaluate soft tissue injury involving neurologic structure or posterior ligament complex. Based on these physical examinations and imaging studies, fracture stability is evaluated and it is determined whether to use the conservative or operative treatment. The development of instruments have led to more interests on the operative treatment which saves mobile segments without fusion and on instrumentation through minimal invasive approach in recent years. It is still controversial for the use of these treatments because there have not been verified evidences yet. However, the morbidity of patients can be decreased and good clinical and radiologic outcomes can be achieved if the recent operative treatments are used carefully considering the fracture pattern and the injury severity.

Clinical application of the paraspinal erector approach for spinal canal decompression in upper lumber burst fractures

Objective

Percutaneous pedicle screw fixation is commonly used for upper lumber burst fractures. The direct decompression remains challenging with this minimally invasive surgery. The objective was to evaluate a novel paraspinal erector approach for effective and direct decompression in patients with canal compromise and neurologic deficit.

Method

Patients (n = 21) with neurological deficiency and Denis B type upper lumbar burst fracture were enrolled in the study, including 14 cases in the L1 and 7 cases in the L2. The patients underwent removal of bone fragments from the spinal canal through intervertebral foramen followed by short-segment fixation. Evaluations included surgery-related, such as duration of surgery and blood loss, and 12-month follow-up, such as the kyphotic angle, the height ratio of the anterior edge of the vertebra, the ratio of sagittal canal compromise, visual analog scale (VAS), Oswestry Disability Index (ODI), and Frankel scores.

Results

All patients achieved direct spinal canal decompression using the paraspinal erector approach followed by percutaneous pedicle screw fixation. The mean operation time (SD) was 173 (23) min, and the mean (SD) blood loss was 301 (104) ml. Significant improvement was noted in the kyphotic angle, 26.2 ± 8.7 prior to operation versus 9.1 ± 4.7 at 12 months after operation (p <0.05); the height ratio of the anterior edge of the injured vertebra, 60 ± 16% versus 84 ± 9% (p <0.05); and the ratio of sagittal canal compromise, 46.5 ± 11.4% versus 4.3 ± 3.6% (p <0.05). Significant improvements in VAS (7.3 ± 1.2 vs. 1.9 ± 0.7, p <0.05), ODI (86.7 ± 5.8 vs. 16.7 ± 5.1, p <0.05), and Frankel scores were also noted.

Conclusions

The paraspinal erector approach was effective for direct spinal canal decompression with minimal injury in the paraspinal muscles or spine. Significant improvements in spinal function and prognostics were achieved after the percutaneous pedicle screw fixation.

Morphological similarities after compression trauma of bovine and human intervertebral discs: Do disc cells have a chance of surviving?

To study the behavior of bovine disc cells and changes in disc matrix following in vitro compression tests; to compare the findings to investigations on human intervertebral discs (IVD) after burst fracture of the cervical spine. Healthy IVDs (n = 21) from three bovine tails were studied at 6 and 12 h post-mortem, with 16 IVDs subjected to impact loading and five as unloaded controls. IVDs (n = 8) from patients with burst fractures were compared to the bovine compression group. Specimens were studied macroscopically, histologically, and ultrastructurally for healthy cells, balloon cells, and disc cell death (DCD). Annulus ruptures were seen in both post-trauma groups, with radial ruptures being present histologically in all loaded bovine discs. Balloon cells were found in some human IVDs and were induced in vitro in bovine loaded discs within a distinct range of absorbed energy. There was a positive correlation between DCD and absorbed energy in all compartments of bovine discs. Both species showed similar patterns of DCD in the different compartments. This study was able to show similarities between both species in cell morphologies and matrix damage. The survival of the disc after substantial compression trauma thus seems to remain highly questionable.

Short-segment posterior instrumentation combined with anterior spondylodesis using an autologous rib graft in thoracolumbar burst fractures

BACKGROUND AND PURPOSE

There are very few data concerning the outcome after short-segment posterior stabilization and anterior spondylodesis with rib grafts in patients suffering from unstable thoracolumbar burst fractures. We have therefore investigated the clinical and radiographic outcome after posterior bisegmental instrumentation and monosegmental anterior spondylodesis using an autologous rib graft for unstable thoracolumbar burst fractures.

PATIENTS AND METHODS

This was a retrospective analysis of 32 consecutive patients at a single center. The monosegmental Cobb angle was measured preoperatively, postoperatively, then 6 and 12 months postoperatively, and also after implant removal. Anterior vertebral fusion was graded on conventional radiographs according to the criteria proposed by Molinari.

RESULTS

Segmental kyphosis at the fracture site was corrected from a median of -20° (95% CI: -21.2 to -18.8) to -1.0° (95% CI: -2.7 to 0.7) postoperatively. 1 year after surgery, the segmental angle had decreased by a median of 2.0° (95% CI: 0.2 to 2.8). The spondylodesis fused in all patients, which was evident from incorporation and remodeling of the rib grafts. The median correction loss after implant removal was 0.0° (95% CI: -0.5 to 0.5). 26 of the 32 patients reported having no back complaints at the last follow-up (2 years postoperatively). 1 patient suffered from intercostal neuralgia, and 5 patients reported mild to moderate back pain.

INTERPRETATION

Short-segment posterior instrumentation and anterior spondylodesis using an autologous rib graft resulted in sufficient correction of posttraumatic segmental kyphosis. There was no clinically relevant correction loss, and the majority of patients had no back complaints at the 2-year follow-up.

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.