The analysis of functional and radiographic outcomes of conservative treatment in patients with low lumbar burst fractures

Successful Management by Posterior Approach Only of a Highly Comminuted L4 Fracture with 8 years of Follow-up: A Case Report

CASE

A 28-year old male patient was involved in a RTA and sustained a highly comminuted L4 burst fracture with more than 90% canal compromise.Considering the complete loss of power in the respective myotomes but the preservation of sacral sparing there were controversially different surgical options. We successfully performed a posterior only surgical procedure, which applied a modified transpedicle access technique to decompress the spinal canal and to restore the anterior column, achieving full neurological recovery at the final follow-up.

CONCLUSION

A well-planned and executed posterior surgery alone can achieve excellent clinical and radiological result in the treatment of severely comminuted lumbar fractures.

Burst fractures of the fifth lumbar vertebra: Case series and systematic review

BACKGROUND

Burst fractures of the fifth lumbar vertebra (L5) are rare injuries and typically occur because of high-energy axial compressive load. Their unique anatomy and biomechanical characteristics distinguish them from other lumbar spine injuries. To the best of our knowledge, the treatment strategies for L5 burst fractures have not been thoroughly described. The aims of this case series and systematic review were to highlight the treatment strategies and outcomes of the L5 burst fractures.

METHODS

We performed a retrospective case series of 8 patients treated for burst L5 fractures in our institution between 2005 and 2020. Additionally, a systematic review via PubMed and Cochrane Library databases according to PRISMA guidelines was performed to review L5 burst fractures treatment strategies. Only Articles in English with full text available were included. The references of the selected studies were checked to find all possible related articles. Treatment strategies were conservative, posterior segmental instrumentation and fixation (PSIF), PSIF with anterior corpectomy (AC), and PSIF with posterior corpectomy (PC). Outcomes measures included neurological status, radiological regional alignment, and complications.

RESULTS

A total of 1449 publications were found, and 29 articles were finally selected for analysis. Of those, 15 were retrospective case reports, and 14 were retrospective case series. One hundred and sixty-nine patients were found in the review. The author's eight cases were added to the found in the literature for a methodological quality assessment. There were 52 (29%) patients managed non-operative, and 125 (71%) underwent surgery. One-hundred-two patients were neurologically intact, of whom 46 were managed non-operative. Canal compromise in intact patients ranged between 20 and 90%. Posterior segmental fixation and instrumentation with decompression was the preferred surgical strategy in patients with neurological deficits. Patients with combined anterior column restoration and anterior approach showed vertebral height and lordosis restoration. A 79% of the operative treated group reported neurological improvement. Patients with pre-operative neurological deficit managed non-operative reported the highest rate of complications (33.3%).

CONCLUSION

In the setting of L5 burst fractures, neurological injuries have a promising prognosis after surgery and are not correlated with the degree of canal stenosis. The compromise of the L5 vertebra affects the sagittal balance and its restoration can be achieved with an anterior corpectomy. Nonoperative management can be considered in cases of reasonable alignment, and no neurologic deficit.

[Treatment of trauma-related vertebral body fractures of the thoracic and lumbar spine with orthotic devices : A review]

BACKGROUND

Trauma-related fractures of the thoracic and lumbar spine occur after exposure to high kinetic energy. To assign patients to the correct kind of treatment the AO spine classification is used.

OBJECTIVE

The aim was to describe the role of orthotic devices in the treatment of thoracic and lumbar fractures in the nondegenerative spine.

MATERIAL AND METHODS

A review of the literature was carried out according to the PRISMA protocol (Preferred Reporting Items for Systematic reviews and Meta-Analyses) in PubMed, ScienceDirect, Cochrane and Google.Scholar. A total of 118 potentially important publications were found and 16 studies with a prospective study design could be included in this analysis. RoB 2 (Cochrane Risk of Bias tool in the second Version) in the case of randomized studies and the ROBINS‑I (Risk Of Bias In Nonrandomised Studies of Interventions) for nonrandomized studies were used to assess publication quality. The level of evidence was determined according to AHCPR (Agency for Health Care Policy and Research).

RESULTS

In the case of fractures (AO types A0-A3) without degenerative changes in the bone structure of the thoracic and lumbar spine without indications for operative procedure, conservative treatment with analgesia, physiotherapy and early mobilization is recommended and orthotic treatment is not superior. Surgical treatment, even in cases where conservative treatment was possible, led to improved functionality and pain sensation faster but there were no differences in the long-term results. Assessing the neurological functional deficit, the functional success of the treatment and the kyphosis angle were measured in different ways, reducing the extent of comparability. Although mainly a level of evidence Ib-IIa could be assigned, nearly all included studies had a high risk of bias.

CONCLUSION

In individual cases treatment with an orthotic device could be a helpful add-on in conservative treatment of fractures in the thoracic and lumbar spine. A treatment with orthotic devices alone cannot be recommended in these cases.

Characteristics of Osteoporotic Low Lumbar Vertebral Fracture and Related Lumbosacral Sagittal Imbalance

Osteoporotic vertebral fracture (OVF) usually occurs in the thoracolumbar region and rarely affects the low lumbar region. The characteristics of osteoporotic low lumbar fracture (OLLF) have not been reported. Lumbosacral sagittal balance plays an important role in preserving the normal physiologic function of the spine. However, it is unknown how lumbosacral parameters vary in patients with OLLF. The authors retrospectively analyzed the clinical and radiologic characteristics of patients with OLLF and osteoporotic thoracolumbar vertebral fracture (OTVF) who were treated at their institution. Vertebral height, local deformity angle, and visual analog scale and Oswestry Disability Index scores were assessed preoperatively and postoperatively for both groups. The changes in lumbosacral parameters were measured for patients with OLLF. The results showed that OLLF was more likely to occur at L3 (53.66%) and that the prevalence of severe trauma (29.27%) was higher among patients with OLLF (P<.05). The most common morphologic type of the vertebrae affected by OLLF was biconcave (58.54%, P<.05). Patients who had OLLF showed an apparent increase in pelvic tilt and a decrease in local lordosis and sacral slope. Postoperatively, vertebral height, local deformity angle, and visual analog scale and Oswestry Disability Index scores were significantly improved compared with preoperative values (P<.05). Among patients with OLLF, local lordosis and sacral slope increased significantly, whereas pelvic tilt decreased significantly after percutaneous kyphoplasty. Restoration of local lordosis had a mean value of 6.29°±4.80°. These results indicate that OLLF has unique characteristics compared with OTVF and that it results in lumbosacral sagittal imbalance. Percutaneous kyphoplasty is effective and safe for the treatment of OLLF and plays an important role in postoperative improvement of sagittal imbalance. [Orthopedics. 2021;44(1):e7-e12.].

Radiological Risk Factors for Neurological Deficits After Traumatic Mid and Low Lumbar Fractures

STUDY DESIGN

Retrospective study.

OBJECTIVE

We identified radiological risk factors for neurological deficits in mid and low lumbar spinal fractures.

SUMMARY OF BACKGROUND DATA

Although numerous studies have focused on radiological risk factors for neurological deficits in spinal cord injury or thoracolumbar junction area fractures, few have examined mid and low lumbar fractures at the cauda equina level.

METHODS

We retrospectively reviewed 71 consecutive patients who suffered acute traumatic mid and low lumbar fractures (L2-L5) corresponding to the cauda equina level, as confirmed on magnetic resonance imaging. We defined a neurological deficit as present if the patient had any sensory or motor deficit in the lower extremity or autonomic system at the initial assessment. Various computed tomography parameters of canal stenosis, vertebral body compression, sagittal alignment, interpedicular distance, and presence of vertical laminar fractures were analyzed as independent risk factors to predict neurological deficits using multivariate logistic regression analyses.

RESULTS

At the initial assessment, 31 patients had neurological deficits. Fracture level, AO fracture type, canal encroachment ratio, vertebral compression ratio, interpedicular distance ratio, and presence of a vertical laminar fracture were significantly associated with the presence of neurological deficits (all P < 0.05). Multivariate logistic regression identified fracture level, canal encroachment ratio (adjusted odds ratio [aOR] 1.072, 95% confidence interval [CI] 1.018-1.129), and vertebral compression ratio (aOR 0.884, 95% CI 0.788-0.992) as independent predictors of a neurological deficit. Receiver operating characteristic curve analyses revealed that only the canal encroachment ratio had good discriminatory ability (area under the curve 0.874, 95% CI 0.791-0.957), and the optimal cutoff was 47% (canal diameter 6.6 mm) with 90.3% sensitivity and 80% specificity.

CONCLUSION

The canal encroachment ratio was most strongly associated with neurological deficits in traumatic mid and low lumbar fractures, with an optimal cutoff of 47%.

LEVEL OF EVIDENCE

4.

Posterior Vertebrectomy via the Unilateral Pedicle or Bilateral Pedicle Approach in the Treatment of Lumber Burst Fracture with Neurological Deficits: A Comparative Retrospective Cohort Study

BACKGROUND Posterior vertebrectomy with bilateral pedicle approach (BPA) is widely applied in lumber burst fracture (LBF). However, some disadvantages exist, such as a prolonged operation time, extensive soft tissue injury, and excessive blood loss. Posterior vertebrectomy with unilateral pedicle approach (UPA) is a novel technique for decompression of spinal canal. Thus, we explored the potential of UPA to achieve better outcomes than BPA. MATERIAL AND METHODS Of 47 patients who underwent posterior vertebrectomy for LBF, 23 patients were treated with UPA and 24 patients were treated with BPA. Clinical and radiographical outcomes were assessed with a follow-up of more than 24 months. Patients were evaluated before and after surgery according to the following parameter: duration of operation (DO), blood loss volume (BLV), the kyphotic angle (KA), the ratio of the height of anterior vertebral edge, the ratio of the sagittal injury, visual analog scale (VAS), Oswestry Disability Index (ODI), and Frankel scores. RESULTS The follow-up time ranged from 24 to 37 months (average 26.4 months). The UPA group had significantly decreased DO and BLV (P<0.05). The 2 cohorts showed similar performance at 6 months (P>0.05), 12 months (P>0.05), and 24 months (P>0.05) post-surgery, in terms of parameters including KA, the ratio of the vertebral anterior, the ratio of sagittal damage, Frankel scores, ODI, and VAS. CONCLUSIONS UPA and BPA had a similar clinical performance for LBF. However, the shorter DO and lower BLV achieved in the UPA cohort suggested UPA is a better alternative for LBF.