Thoracoscopic transdiaphragmatic approach to thoracolumbar junction fractures

Navigated retrodiaphragmatic/retroperitoneal approach for the treatment of symptomatic kyphoscoliosis: an operative video

Retropleural, retrodiaphragmatic, and retroperitoneal approaches are utilized to access difficult thoracolumbar junction (T10–L2) pathology. The authors present a 58-year-old man with chronic low-back pain who failed years of conservative therapy. Preoperative radiographs demonstrated significant levoconvex scoliosis with coronal and sagittal imbalance. He underwent a retrodiaphragmatic/retroperitoneal approach for T12–L1, L1–2, L2–3, and L3–4 interbody release and fusion in conjunction with second-stage facet osteotomies, L4–5 TLIF, and T10–iliac posterior instrumented fusion. This video focuses on the retrodiaphragmatic approach assisted by 3D navigation.

The video can be found here: https://stream.cadmore.media/r10.3171/2022.3.FOCVID2215

Transdiaphragmatic Approach as a Novel Less Invasive Retroperitoneal Approach at Thoracolumbar Junction: Comparison with Conventional Diaphragmatic Incision

Introduction

Lateral corpectomy has been considered a minimally invasive surgery, allowing a “transdiaphragmatic approach” at the thoracolumbar junction. This approach allows for a small diaphragmatic incision directly in the retroperitoneal space and the affected vertebra. However, its effectiveness in comparison to a conventional approach remains unclear. Thus, in this present study, we compared the surgical outcomes between conventional diaphragmatic detachment and the transdiaphragmatic approach in patients with vertebral fracture at the thoracolumbar junction.

Methods

In total, 31 patients with a vertebral fracture at the thoracolumbar junction (T12-L2) were included in this study: 17 underwent a conventional approach, whereas 14 underwent a transdiaphragmatic approach, with a minimum 2-year follow-up. The effectiveness of surgery was evaluated in each category of the Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ).

Results

Operative time and estimated blood loss were determined to be significantly shorter in the transdiaphragmatic than in the conventional approach. Perioperative complications were observed in the conventional approach (one atelectasis and one pleural effusion), while no complication was noted in the transdiaphragmatic approach. There were no significant differences in postoperative quality of life as assessed by JOABPEQ in terms of pain-related disorders, lumbar spine dysfunction, gait disturbance, social life dysfunction, or psychological disorders between the conventional and transdiaphragmatic approaches.

Conclusions

A “transdiaphragmatic approach” using lateral access surgery has been found to be associated with a shorter operative time and less blood loss with fewer complications than the conventional approach. Given that equivalent clinical outcomes were achieved in both conventional and transdiaphragmatic approaches, this “transdiaphragmatic approach” could be useful because of its minimal invasiveness.

Surgical anatomy of minimally invasive lateral approaches to the thoracolumbar junction

OBJECTIVE

The thoracolumbar (TL) junction spanning T11 to L2 is difficult to access because of the convergence of multiple anatomical structures and tissue planes. Earlier studies have described different approaches and anatomical structures relevant to the TL junction. This anatomical study aims to build a conceptual framework for selecting and executing a minimally invasive lateral approach to the spine for interbody fusion at any level of the TL junction with appropriate adjustments for local anatomical variations.

METHODS

The authors reviewed anatomical dissections from 9 fresh-frozen cadaveric specimens as well as clinical case examples to denote key anatomical relationships and considerations for approach selection.

RESULTS

The retroperitoneal and retropleural spaces reside within the same extracoelomic cavity and are separated from each other by the lateral attachments of the diaphragm to the rib and the L1 transverse process. If the lateral diaphragmatic attachments are dissected and the diaphragm is retracted anteriorly, the retroperitoneal and retropleural spaces will be in direct continuity, allowing full access to the TL junction. The T12-L2 disc spaces can be reached by a conventional lateral retroperitoneal exposure with the rostral displacement of the 11th and 12th ribs. With caudally displaced ribs, or to expose T12-L1 disc spaces, the diaphragm can be freed from its lateral attachments to perform a retrodiaphragmatic approach. The T11-12 disc space can be accessed purely through a retropleural approach without significant mobilization of the diaphragm.

CONCLUSIONS

The entirety of the TL junction can be accessed through a minimally invasive extracoelomic approach, with or without manipulation of the diaphragm. Approach selection is determined by the region of interest, degree of diaphragmatic mobilization required, and rib anatomy.

Minimally invasive spine surgeries for treatment of thoracolumbar fractures of spine: A systematic review

PURPOSE

Many minimally invasive surgical (MIS) techniques have been developed for instrumentation of spine. These MIS techniques restore stability, alignment while achieving return to function quite early as compared to open spine surgeries. The main aim of this review was to evaluate role, indications and complications of these MIS techniques in Thoracolumbar and Lumbar fractures.

METHODS

Pubmed search using key words such as"Percutaneous pedicle screw for Thoracolumbar fractures" and "Video Assisted Thoracoscopy, Thoracoscopic, VATS for thoracolumbar, Lumbar and Spine fractures" were used till July 2016 while doing literature search. Authors analyzed all the articles, which came after search; the articles relevant to the topic were selected and used for the study. Both prospective and retrospective case control studies and randomized control trials (RCT's) were included in this review. Case reports and reviews were excluded. Studies demonstrating use of MIS in cases other than spine trauma and studies with lack of clinical follow up were excluded from this review. Variables such as number of patients, operative time and complications were evaluated in each study.

RESULTS

After pubmed search, we found total 68 studies till July 2016 out of which eight studies were relevant for analysis of Video Assisted Thoracoscopy for thoracolumbar and lumbar fractures. Total 72 articles for Percutaneous pedicle screws in thoracolumbar and lumbar fractures were retrieved out of which percutaneous pedicle screws were analyzed in eleven studies and twelve studies involved comparison of percutaneous pedicle screws and conventional open techniques.

CONCLUSION

Role and Indications of the MIS techniques in spinal trauma are expanding quite rapidly. MIS techniques restore stability, alignment while achieving early return to function and lower infection rates as compared to open spine surgeries. In long term, they provide good kyphosis correction and stable fixation and fusion of spine. They are associated with long learning curve and technical challenges but with careful patient selection and in expert hands, MIS techniques may produce better results than open trauma spine surgeries.

Combined anteroposterior fixation using a titanium cage versus solely posterior fixation for traumatic thoracolumbar fractures: A systematic review and meta-analysis

Study Design:

Systematic review with meta-analysis.

Objective:

Additional anterior stabilization might prevent posterior implant failure, but over time, the disadvantageous of bone grafts have become evident. The objective of this systematic review was to compare risks and advantages of additional anterior stabilization with a titanium cage to solely posterior fixation for traumatic thoracolumbar fractures.

Methods:

An electronic search was performed in the literature from 1980 to March 2016. Studies comparing only posterior with anteroposterior fixation by means of a titanium cage were included in this study. Data extraction and Cochrane risk of bias assessment were done by two independent authors. In addition, the PRISMA statement was followed, and the GRADE approach was used to present results.

Results:

Of the 1584 studies, two randomized controlled trials (RCTs) and one retrospective cohort study were included in the meta-analysis. The RCTs reported evidence of high quality that anteroposterior stabilization maintained better kyphosis correction than posterior stabilization alone. However, these results were neutralized in the meta-analysis by the cohort study. Implant failure was reported by one study, in the posterior group. No differences in follow-up visual analog scale scores, neurologic improvement, and complications were found. Operation time, blood loss, and hospital stay all increased in the anteroposterior group.

Conclusions:

Patients with a highly comminuted or unstable fracture could benefit from combined anteroposterior stabilization with a titanium cage, for some evidence suggests this prevents loss of correction. However, large randomized studies still lack. There is a risk of cage subsidence, and increased perioperative risks have to be considered when choosing the optimal treatment.

Video-Assisted Thoracoscopic Surgery and Minimal Access Spinal Surgery Compared in Anterior Thoracic or Thoracolumbar Junctional Spinal Reconstruction: A Case-Control Study and Review of the Literature

There are no published reports that compare the outcomes of video-assisted thoracoscopic surgery (VATS) and minimal access spinal surgery (MASS) in anterior spinal reconstruction. We conducted a retrospective case-control study in a single center and systematically reviewed the literature to compare the efficacy and safety of VATS and MASS in anterior thoracic (T) and thoracolumbar junctional (TLJ) spinal reconstruction. From 1995 to 2012, there were 111 VATS patients and 76 MASS patients treated at our hospital. VATS patients had significantly (p < 0.001) longer operating times and significantly (p < 0.022) higher thoracotomy conversion rates. We reviewed 6 VATS articles and 10 MASS articles, in which there were 625 VATS patients and 399 MASS patients. We recorded clinical complications and a thoracotomy conversion rate from our cases and the selected articles. The incidence of approach-related complications was significantly (p = 0.021) higher in VATS patients. The conversion rate was 2% in VATS patients and 0% in MASS patients (p = 0.001). In conclusion, MASS is associated with reduction in operating time, approach-related complications, and the thoracotomy conversion rate.

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.

Minimally invasive thoracoscopic approach to thoracolumbar junction fractures

AIMS

A retrospective analysis of patients with thoracolumbar junction fractures who underwent video-assisted thoracoscopic surgery via a minimally invasive approach (minithoracotomy) for reconstruction of the anterior spinal column.

METHODS

Between 2002 and 2014, a total of 176 patients were treated by this technique. The patients received either posterior stabilization and, at the second stage, the minimally invasive technique via an anterior approach, or the minimally invasive anterior procedure alone.

RESULTS

In the anterior procedure, the average operative time was 90 min. (50 to 130 min). Bony fusion without complications was achieved in all patients within a year of surgery. The loss of correction after the anterior procedure with an allograft or titanium cage was up to 2 degrees at two years follow-up.

CONCLUSION

The minimally invasive approach (minithoracotomy up to 6-7 cm) combined with thoracoscopy is an alternative to an exclusively endoscopic technique enabling us to provide safe surgical treatment of the anterior spinal column.

Minimally invasive spine surgery in the treatment of thoracolumbar and lumbar spine trauma

Thoracolumbar and lumbar trauma account for the majority of traumatic spinal injuries. The mainstay of current treatments is still nonoperative therapy with bracing. Classic treatment algorithms reserved absolute surgical intervention for spinal trauma patients with neurological compromise or instability. Relative indications included incapacitating pain and obesity/body habitus making brace therapy ineffective. In the past decade, minimally invasive surgical (MIS) techniques for spine surgery have been increasingly used for degenerative conditions. These same minimally invasive techniques have seen increased use in trauma patients. The goal of minimally invasive surgery is to decrease surgical morbidity through decreased soft-tissue dissection while providing the same structural stability afforded by classic open techniques. These minimally invasive techniques involve percutaneous posterior pedicle fixation, vertebral body augmentation, and utilization of endoscopic and thoracoscopic techniques. While MIS techniques are somewhat in their infancy, an increasing number of studies are reporting good clinical and radiographic outcomes with these MIS techniques. However, the literature is still lacking high-quality evidence comparing these newer techniques to classic open treatments. This article reviews the relevant literature regarding minimally invasive spine surgery in the treatment of thoracolumbar and lumbar trauma.

Traumatic thoracolumbar spinal injury: an algorithm for minimally invasive surgical management

Object

Minimally invasive spinal (MIS) surgery techniques have been used sporadically in thoracolumbar junction trauma cases in the past 5 years. A review of the literature on the treatment of thoracolumbar trauma treated with MIS surgery revealed no unifying algorithm to assist with treatment planning. Therefore, the authors formulated a treatment algorithm.

Methods

The authors reviewed the current literature on MIS treatment of thoracolumbar trauma. Based on the literature review, they then created an algorithm for the treatment of thoracolumbar trauma utilizing MIS techniques. This MIS trauma treatment algorithm incorporates concepts form the Thoracolumbar Injury Classification System (TLICS).

Results

The authors provide representative cases of patients with thoracolumbar trauma who underwent MIS surgery utilizing the MIS trauma treatment algorithm. The cases involve the use of mini-open lateral approaches and/or minimally invasive posterior decompression with or without fusion.

Conclusions

Cases involving thoracolumbar trauma can safely be treated with MIS surgery in select cases of burst fractures. The role of percutaneous nonfusion techniques remains very limited (primarily to treat thoracolumbar trauma in patients with a propensity for autofusion [for example, those with ankylosing spondylitis]).

Management of thoracolumbar spine fractures

BACKGROUND CONTEXT

Traumatic fractures of the spine are most common at the thoracolumbar junction and can be a source of great disability.

PURPOSE

To review the most current information regarding the pathophysiology, injury pattern, treatment options, and outcomes.

STUDY DESIGN

Literature review.

METHODS

Relevant articles, textbook chapters, and abstracts covering thoracolumbar spine fractures with and without neurologic deficit from 1960 to the present were reviewed.

RESULTS

The thoracolumbar spine represents a unique system from a skeletal as well as neurological standpoint. The rigid rib-bearing thoracic spine articulates with the more mobile lumbar spine at the thoracolumbar junction (T10 - L2), the site of most fractures. A complete examination includes a careful neurologic examination of both motor and sensory systems. CT scans best describe bony detail while MRI is most efficient at describing soft tissues and neurological structures. The most recent classification system is that of the new Thoracolumbar Injury Classification and Severity Score. The different fracture types include compression fractures, burst fractures - both stable and unstable -, flexion-distraction injuries and fracture dislocations. Their treatment, both operative and non-operative depends on the degree of bony compromise, neurological involvement, and the integrity of the posterior ligamentous complex. Minimally invasive approaches to the care of thoracolumbar injuries have become more popular, thus, the evidence regarding their efficacy is presented. Finally, the treatment of osteoporotic fractures of the thoracolumbar spine is reviewed, including vertebroplasty and kyphoplasty, their risks and controversies, and senile burst fractures, as well.

CONCLUSIONS

Thoracolumbar spine fractures remain a significant source of potential morbidity. Advances in treatment have minimized the invasiveness of our surgery and in certain stable situations, eliminated it all together.

[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.

Inter- and intraobserver agreement on the Load Sharing Classification of thoracolumbar spine fractures

The Load Sharing Classification (LSC) allocates one to three points to each of three different radiological characteristics of traumatic thoracolumbar fractures: the vertebral body involved in the fracture, the displacement of the fracture parts and the kyphotic deformity. Added up, a minimal score of three and a maximal score of nine can be obtained. When the LSC score is three to six, a short segment pedicle screw fixation suffices. When the LSC score is seven to nine, a high rate of failure in patients with a short segment pedicle screw fixation exists. In these cases an anterior stabilising procedure of the spine is advised. The LSC has been examined by Dai and Jin, who claim an almost perfect inter- and intraobserver agreement, according to the Landis and Koch criteria. Dai and Jin only present results for the separate three items of the LSC and for the total LSC scores. Observer agreement for the two LSC score categories (three to six and seven to nine) have not been studied. The aim of this study is to study the inter- and intraobserver agreement of the LSC for the total score, the three separate items and also for the two LSC score categories. Three observers determine twice the LSC scores of forty traumatic thoracolumbar fractures. The average standard Cohen's kappa values for the separate LSC items range between 0.06 and 0.48. For the total LSC score the average standard Cohen's kappa and weighted kappa values are 0.22 and 0.67 respectively. For the two LSC score categories, there is unanimous agreement in 55% of the cases and a majority agreement in 40%. In the remaining 5% of the fractures there is a split decision. Standard Cohen's kappa value for the two LSC score categories is 0.53. The standard Cohen's kappa values can be rated as fair to moderate. From these data it can be concluded that the inter- and intraobserver reliability of the Load Sharing Classification of Spinal fractures can be rated as fair.

Minimally invasive thoracolumbar corpectomy and reconstruction

Minimally invasive surgical approaches have been advocated to approach ventrolateral thoracolumbar pathology. This article describes our technique for performing minimally invasive surgical thoracolumbar corpectomy and reconstruction. Twenty-five consecutive patients at a single institution were treated between 2006 and 2010 for a variety of diagnoses including tumors, infections, and trauma. Treatment variables, including operating time, estimated blood loss, number of levels treated, and complications, were collected, as were visual analog scale (VAS) scores for pain.Surgical times (mean, 188.5 minutes) and blood loss (mean, 423 mL) reflect a significant improvement over standard open corpectomy procedures. More than 60% of patients did not need blood products after the corpectomy procedure because substantial blood loss encountered during an open exposure to the spine was obviated. Similarly, operative times and anesthetic load was minimal enough for ≥80% of our patients to be extubated immediately after the corpectomy procedure. A 62% decrease in self-reported VAS scores was observed. No wound complications or radiographic evidence of implant subsidence or failure were observed at last follow-up.The advantages of the minimally invasive approach for corpectomies of the thoracolumbar spine were that an access surgeon was not needed; tissue dissection and surgical exposure were reduced, improving VAS scores postoperatively; and blood loss and operative times were minimized, preventing hemodynamic deterioration in these complex cases. Corpectomies may be performed in this fashion safely, with excellent pain relief and without many of the morbidities and difficulties associated with conventional open procedures.

Advances in the management of spinal cord and spinal column injuries

Spinal cord injury (SCI) is a significant public problem, with recent data suggesting that over 1 million people in the U.S.A. alone are affected by paralysis resulting from SCI. Recent advances in prehospital care have improved survival as well as reduced incidence and severity of SCI following spine trauma. Furthermore, increased understanding of the secondary mechanisms of injury following SCI has provided improvements in critical care and acute management in patients suffering from SCI, thus limiting morbidity following injury. In addition, improved technology and biomechanical understanding of the mechanisms of spine trauma have allowed further advances in available techniques for spinal decompression and stabilization. In this chapter we review the most recent data and salient literature regarding SCI and address current controversies, including the use of pharmacological adjuncts in the setting of acute SCI. We will also attempt to provide a reader with basic understanding of the classifications of SCI and spinal column injury. Finally, we review advances in spinal column stabilization including improvements in instrumented fusion and minimally invasive surgery.

Management considerations and strategies to avoid complications associated with the thoracoscopic approach for corpectomy

The thoracoscopic approach to the anterior spine is a practical and valuable means of approaching ventral spinal lesions but demands advanced technical skills and fine hand-eye coordination that is usually acquired with experience. A mutual understanding of all the ventilatory and surgical steps allows for an organized orchestration between the anesthesiologist and surgeon, which ultimately helps minimize potential complications. Despite a concerted effort by all involved to avoid risks, thoracoscopic surgery is associated with complications for which the surgical team should be cognizant. In this paper, the authors detail the operative technique of vertebral corpectomy and interbody fusion via the thoracoscopic approach for the treatment of ventral spinal pathology involving the thoracic and lower lumbar spine, discuss complications known to occur with the thoracoscopic approach, and present means to help avoid them.

Vertebral body cage use in thoracolumbar fractures: outcomes in a prospective series of 23 cases at 2 years' follow-up

INTRODUCTION

One objective of surgery in thoracolumbar spine fracture is to restore correct and lasting spinal statics. This may involve vertebral body replacement using an anterior approach. We here report results on a prospective series of 23 trauma patients managed by vertebral body replacement using an expandable cage.

PATIENTS AND METHODS

The sex ratio was 2.28. Fifteen cases involved primary treatment of recent fracture and eight secondary surgery for non-union or malunion. In 12 cases, posterior osteosynthesis was associated. Six patients were operated on using a classical approach and 17 using a video-assisted minimally invasive approach. Pre- and perioperative data were recorded, with clinical scores (VAS and Oswestry) at 6 weeks, 3 months, 6 months, 1 year and 2 years. Radiologic follow-up assessed regional traumatic kyphosis (RTK), enabling calculation of regional traumatic angulation (RTA), with control CT to check fusion.

RESULTS

Minimum follow-up was 2 years. There were no cases of postoperative neurological deterioration. There were three major postoperative complications: one hemothorax, one adhesive bowel occlusion, and one bilateral pneumothorax at 1 month. Mean Oswestry score at 6 months was 20%, and mean VAS score at 2 years was 0.36. Postoperative RTA showed a mean 7.34° improvement. Mean RTA reduction loss was 1.95° at 3 months, subsequently unchanged. All arthrodeses showed fusion at 6 months.

CONCLUSION

Results were satisfactory with this technique, comparable to those reported in the literature. The development of minimally invasive approaches and improved instrumentation procedures optimize surgery and enhance anterior reconstruction tolerance. Lasting restoration of sagittal spinal curvature improves trauma patients' functional recovery.

[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.

Minimally invasive surgery for traumatic spinal pathologies: a mini-open, lateral approach in the thoracic and lumbar spine

STUDY DESIGN

Prospective registry.

OBJECTIVE

The objective of this study was to examine patient outcomes using a mini-open, lateral approach for the treatment of traumatic thoracic and lumbar fractures.

SUMMARY OF BACKGROUND DATA

The high-quality published studies that examine treatment methods for acute traumatic thoracic and lumbar fractures are few and a few that are present contain insufficient samples to make broad conclusions. Despite this, we know that conventional surgical techniques often include large, morbid exposures. More recent advancements in less invasive surgical techniques have greatly decreased the associated morbidities of conventional approaches, namely, thoracotomy.

METHODS

A total of 52 patients were treated at 1 of 2 institutions for traumatic thoracic or lumbar fractures with a mini-open lateral approach for corpectomy. Patients were prospectively followed for clinical outcomes, with treatment and in-hospital complications collected retrospectively.

RESULTS

The majority of patients (94.2%) presented with traumatic burst fractures with instability and neurologic deficit. Patients were treated with mini-open, lateral corpectomies from T7 to L4, the majority at T12 and L1, and were followed 2 years after surgery. Supplemental internal fixation was used in all patients: 75% anterolateral plating and 46.1% transpedicular fixation (11 [21.2%] patients with combined). Median operative time, estimated blood loss, and hospital stay were 128 minutes, 300 mL, and 4 days, respectively. Complications were observed in 13.5% of patients and no reoperations occurred. Neurologic status, assessed using American Spinal Injury Association categorization, improved significantly postoperatively, with 73% of patients either completely neurologically intact or with only slight residual deficits (American Spinal Injury Association E or D). No patient experienced neurologic deterioration. Expandable wide-footprint titanium cages were used in 34.6% of patients, which resisted radiographic subsidence seen in some patients treated with expandable cylindrical titanium cages.

CONCLUSION

The mini-open lateral approach for thoracic and lumbar corpectomy was shown to be safe and effective in this series while avoiding many of the associated morbidities of thoracotomies for anterior column reconstruction and open posterior approaches.

Blood transfusions after thoracoscopic anterior thoracolumbar vertebrectomy

PURPOSE

Anterior vertebral body reconstruction (AVBR) for trauma or tumor involves corpectomy and placement of hardware to reconstitute the anterior weight-bearing stability of the spine. We report our clinical experience with thoracoscopic techniques for AVBR.

METHODS

We retrospectively analyzed patients who underwent thoracoscopic AVBR surgery for expandable cage placement. We report pathological condition, patient age, vertebral body level, operative time, estimated blood loss (EBL), and need for blood transfusion.

RESULTS

Twenty-one expandable cages were placed thoracoscopically in 15 fractures and six tumors. In fracture cases, mean age, operative time, EBL, and transfusion rate were 36.7 years, 4.9 h, 543 mL, and 7% (1/15), respectively. In tumor cases, mean age, operative time, EBL, and transfusion rate were 61.9 years, 4.9 h, 758 mL, and 17% (1/6), respectively.

CONCLUSIONS

Thoracoscopic AVBR with expandable cages can be accomplished safely with acceptable operative times and blood loss and low transfusion rates.

Endoscopic surgery on the thoracolumbar junction of the spine

The thoracolumbar junction is the section of the truncal spine most often affected by injuries. Acute instability with structural damage to the anterior load bearing spinal column and post-traumatic deformity represent the most frequent indications for surgery. In the past few years, endoscopic techniques for these indications have partially superseded the open procedures, which are associated with high access morbidity. The particular position of this section of the spine, which lies in the border area between the thoracic and abdominal cavities, makes it necessary in most cases to partially detach the diaphragm endoscopically in order to expose the operation site, and this also provides access to the retroperitoneal section of the thoracolumbar junction. A now standardised operating technique and instruments and implants specially developed for the endoscopic procedure, from angle stable plate and screw implants to endoscopically implantable vertebral body replacements, have gradually opened up the entire spectrum of anterior spine surgery to endoscopic techniques.

[Spinal column injuries in sport: treatment strategies and clinical results]

BACKGROUND

The management of patients with sport-related injuries of the spine is a challenging issue with regard to the ability to resume former sport activities. The current study analyses the rate of resumption of sports participation after conservative and operative treatment.

METHODS

In a 2-year period, 96 patients with sport-related injuries of the thoracic and lumbar spine were included in this prospective study. Conservative (19%) or operative treatment (81%) was performed depending on the extent, severity and instability of the trauma. The reduction, the loss of reduction over time and the VAS and Odom scores were assessed. A questionnaire was included to estimate the rate of resumption of sports participation.

RESULTS

Of the patients 91% resumed sports participation and 9% had to abandon all sport activities mostly due to neurological deficits. Minor loss of correction was found in patients with 360 degrees short segment fusions and major loss was found after conservative treatment.

CONCLUSION

The current management of injuries of the spine effectuates a high rate of resumption of sports activity following conservative or operative treatment.

Endoscopy-assisted Approaches for Anterior Column Reconstruction after Pedicle Screw Fixation of Acute Traumatic Thoracic and Lumbar Fractures

Objective:

Surgical treatment of thoracic and lumbar vertebral body fractures combines instrumentation to stabilize the fracture and an anterior reconstruction to promote fusion of the fractured spine. The aim of the present study was to show that minimally invasive thoracoscopic or endoscopy-assisted approaches to the thoracic and lumbar spine are feasible for anterior column reconstruction.

Methods:

This prospective, single-center study included 83 consecutive patients harboring 100 acute thoracic and lumbar vertebral fractures. Patients' neurological status; preoperative, postoperative, and follow-up radiographic data; and surgical data were obtained.

Results:

Fractures ranged from T5 to L5. All fractures underwent posterior pedicle screw fixation followed by a thoracoscopic or endoscopy-assisted anterior approach for anterior column reconstruction to promote fusion. Ventral graft position was correct in 45 patients and acceptable in 37 patients; one patient required a surgical repositioning. Initial correction of kyphosis was 9 degrees; during follow-up (23 ± 11 mo), the mean loss of correction was 6 degrees. In 84 minimally invasive approaches, five conversions to an open approach were necessary. Complications included one case of L1 nerve root injury, two cases of transient neurological worsening, one case of posterior wound infection, and one case of pleural empyema.

Conclusion:

The minimally invasive endoscopic approach for anterior column reconstruction is a feasible strategy in the treatment of unstable thoracic and lumbar fractures. Fracture type and the material of the anterior graft can affect long-term maintenance of correction.

Mini-open anterior approach for corpectomy in the thoracolumbar spine

BACKGROUND

Traditional open anterior approaches to the TL spine were reported with a significant morbidity from a large wound field; therefore, "minimally invasive" thoracoscopic and laparoscopic anterior approaches have been recently introduced. However, these endoscopic techniques require a long and steep learning curve, require expensive disposable endoscopy material, and may be little suited for complication management. Alternatively, "mini-open" anterior approaches with table-mounted retractor systems have also been recently introduced.

METHODS

Thirty-seven patients underwent a single-level thoracic or lumbar corpectomy and cage reconstruction for an unstable traumatic burst fracture or vertebral body tumor. A transthoracic (n = 6), transthoracic transdiaphragmatic (n = 23), or retroperitoneal (n = 8) mini-open approach was conducted with the SynFrame (Stratec Medical, Oberdorf, Switzerland) table-mounted retractor. Prior posterior pedicle screw fixation was performed in 35 of 37 patients.

RESULTS

The mean surgical duration of the anterior approach was 181 minutes, and the average blood loss was 632 mL. There was no neurological worsening. On a VAS from 0 to 10, the mean local pain from the anterior approach was 1.7 at 6 months postoperatively, 1.4 at 12 months, and 1.0 at 24 months. Construct stability was found in all patients at 6 months after surgery. Six transient complications occurred.

CONCLUSIONS

The mini-open anterior approach for corpectomy in the TL spine is safe, reliable, and economical. The table-mounted SynFrame retractor provides a stable operating field through which a familiar direct 3-dimensional view of the anterior TL spine is obtained with limited approach morbidity. This technique is an excellent alternative to thoracoscopic or laparoscopic procedures, avoiding the steep learning curve, technical difficulties, and equipment costs of endoscopic procedures.

Strategies for prevention and operative treatment of aortic lesions related to spinal interventions

STUDY DESIGN

A retrospective analysis of a case series was performed.

OBJECTIVE

To give recommendations for the prevention and operative treatment of thoracic and thoracoabdominal aortic lesions in association with spinal interventions.

SUMMARY OF BACKGROUND DATA

Aortic lesions after spinal interventions for traumatic vertebral fractures, segmental spondylodiscitis, or vertebral metastasis are fortunately rare, but associated with a high perioperative mortality rate and absolute numbers are unknown. Therefore, preventive strategies to avoid perioperative major vessel injuries and recommendations for the operative treatment of aortic lesions related to spinal surgery are required.

METHODS

The clinical course of 10 patients with an acute aortic hemorrhage or an increased intraoperative risk for aortic injuries in association with primary or secondary spinal interventions is reported. All patients were evaluated before surgery by orthopedic trauma surgeons, vascular surgeons, and diagnostic radiologists.

RESULTS

Five patients had preventive vascular interventions to avoid major aortic injuries during spinal reinterventions, and 5 patients were treated as an emergency for acute intraoperative hemorrhage related to spinal interventions. The operative treatment was performed by direct aortic sutures (n = 3), segmental alloplastic reconstructions (n = 2), or endovascular stent graft implantations (n = 3). Prophylactic banding of the thoracic aorta during thoracotomy or a femoral access for possible aortic balloon blockade was performed in patients with an estimated lower risk for an aortic laceration caused by malpositioned pedicle screws. No perioperative mortality was observed in patients treated by this interdisciplinary concept, but 1 patient treated under emergency condition for spondylodiscitis with an initially unrecognized aortic lesion died.

CONCLUSION

In patients with complex spinal trauma, spondylodiscitis or difficult vertebral reinterventions, and an increased risk of major vessel injury, a preoperative interdisciplinary evaluation is recommended, even under emergency conditions. Endovascular stent graft technique is an additional option for prevention and treatment of suspected or acute aortic injuries of thoracic and infrarenal aortic lesions, whereas injuries to the visceral aortic segment still require advanced vascular reconstructions.

Clinical Analysis of Video-assisted Thoracoscopic Spinal Surgery in the Thoracic or Thoracolumbar Spinal Pathologies

OBJECTIVE

Thoracoscopic spinal surgery provides minimally invasive approaches for effective vertebral decompression and reconstruction of the thoracic and thoracolumbar spine, while surgery related morbidity can be significantly lowered. This study analyzes clinical results of thoracoscopic spinal surgery performed at our institute.

METHODS

Twenty consecutive patients underwent video-assisted thoracosopic surgery (VATS) to treat various thoracic and thoracolumbar pathologies from April 2000 to July 2006. The lesions consisted of spinal trauma (13 cases), thoracic disc herniation (4 cases), tuberculous spondylitis (1 case), post-operative thoracolumbar kyphosis (1 case) and thoracic tumor (1 case). The level of operation included upper thoracic lesions (3 cases), midthoracic lesions (6 cases) and thoracolumbar lesions (11 cases). We classified the procedure into three groups: stand-alone thoracoscopic discectomy (3 cases), thoracoscopic fusion (11 cases) and video assisted mini-thoracotomy (6 cases).

RESULTS

Analysis on the Frankel performance scale in spinal trauma patients (13 cases), showed a total of 7 patients who had neurological impairment preoperatively : Grade D (2 cases), Grade C (2 cases), Grade B (1 case), and Grade A (2 cases). Four patients were neurologically improved postoperatively, two patients were improved from C to E, one improved from grade D to E and one improved from grade B to grade D. The preoperative Cobb's and kyphotic angle were measured in spinal trauma patients and were 18.9+/-4.4 degrees and 18.8+/-4.6 degrees , respectively. Postoperatively, the angles showed statistically significant improvement, 15.1+/-3.7 degrees and 11.3+/-2.4 degrees , respectively (P<0.001).

CONCLUSION

Although VATS requires a steep learning curve, it is an effective and minimally invasive procedure which provides biomechanical stability in terms of anterior column decompression and reconstruction for anterior load bearing, and preservation of intercostal muscles and diaphragm.

Thoracoscopic Debridement and Stabilization of Pyogenic Vertebral Osteomyelitis

The role of surgical debridement and internal fixation in treatment of vertebral osteomyelitis has been evolving. The standard surgical approach to thoracolumbar vertebral osteomyelitis requiring extensive thoracotomy or retroperitoneal exposure carries significant associated morbidity and postoperative pain. Minimally invasive thoracoscopic spine surgery is designed to improve postoperative morbidity associated with the traditional open surgery. We report a case of a 70-year-old man who developed T11-T12 pyogenic vertebral osteomyelitis 3 months after undergoing posterior laminectomy and microsurgical excision of a herniated thoracic disc. The patient underwent minimally invasive thoracoscopic radical debridement and anterior spinal reconstruction and fusion. Patients with vertebral osteomyelitis may benefit from the decreased postoperative morbidity that is associated with minimally invasive thoracoscopic spinal surgery.

Video-assisted techniques in the management of thoracolumbar fractures

The thoracolumbar junction is the most common region of the spine to be affected by injuries. Acute instability with structural damage to the anterior load-bearing spinal column and posttraumatic deformity represent the most frequent indications for surgery. A standardized operating technique with instruments and implants specially developed for the endoscopic procedure, ranging from an angled, stable plate and screw implant to endoscopically implantable vertebral body replacements, have gradually opened up the entire spectrum of anterior spine surgery to endoscopic techniques at the thoracolumbar junction.

Five-year follow-up examination after purely minimally invasive posterior stabilization of thoracolumbar fractures: a comparison of minimally invasive percutaneously and conventionally open treated patients

INTRODUCTION

It is well known that during posterior stabilization of the spinal column conventionally open methods are predominantly used. However, in this study a minimally invasive method was chosen to decrease the morbidity of the operative access and to protect the paravertebral musculature, which serves as an important spine-stabilizing factor during posterior stabilization. The aims of this retrospective non-randomized case-control study were to compare the clinical and radiological results of minimally invasive on the one hand and conventionally open posterior surgery on the other with each other and to measure the loss of correction after purely posterior stabilization.

METHODS

Twenty-one consecutive non-randomized patients with thoracolumbar vertebral body fractures, which had been stabilized posteriorly without any intervertebral body fusion between 1996 and 1997, and without any neurological symptoms, were examined retrospectively more than 5 years after trauma. Eleven patients had been treated conventionally open and 10 patients minimally invasive. As methods of evaluation, the intra- and postoperative amount of blood loss, the X-ray time, the Hannover-Spine-Score, the SF-36 Health Questionnaire and radiological assessment of the bisegmental wedge and vertebral body angle were made use of.

RESULTS

The blood loss was significantly lower among those patients who had been operated in a minimally invasive way. The operating time, the time of X-ray exposure and the loss of correction were identical in both groups. The first year after implant removal, the loss of correction was the highest with 2.1 degrees for the body angle and 6.86 degrees for the bisegmental wedge angle. Neither in the Hannover-Spine-Score nor in the SF-36 Health Questionnaire did both groups show a difference. A correlation between the loss of correction and the clinical results could not be demonstrated.

CONCLUSION

The minimally invasive posterior stabilization leads to lower blood loss in comparison to the conventionally open method and can be carried out without any special effort limited to A-fractures without any neurological symptoms.

[Video-assisted thoracic surgery to treat spinal deformities: climbing the learning curve]

OBJECTIVE

The aim of this study was to analyze the impact of the learning curve on the preliminary results of video-assisted thoracic surgery for spinal deformities in a general hospital setting.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of 15 patients who underwent video-assisted thoracic surgery performed by a multidisciplinary team comprising orthopedic and thoracic surgeons. Endoscopic anterior release and fusion were followed by posterior instrumentation in a single procedure. Demographic, orthopedic, morbidity, and mortality statistics were compiled for the 15 patients and compared to results reported for similar series.

RESULTS

Endoscopic surgery was indicated for 15 patients: 11 women (73.3%) and 4 men (26.7%). The median age was 15 years (interquartile range [IQR], 14-19 years). Three patients (20%) required conversion to thoracotomy. There were 2 serious (13.3%) and 3 minor complications (20%). They all resolved satisfactorily and there was no perioperative mortality. The median Cobb angle was 71 degrees (IQR, 63.75 degrees -75.25 degrees ) before surgery and 41 degrees (IQR, 30 degrees -50 degrees ) after surgery. Median duration of surgery was 360 minutes (IQR, 300-360 minutes), duration of postoperative recovery unit stay was 1.5 days (IQR, 1-2.75 days), and total hospital stay was 11.5 days (IQR, 8.25-14 days).

CONCLUSIONS

Despite the complexity of video-assisted thoracic surgical procedures, we believe they will become the standard approach to treating spinal deformities in the near future. By working together in general hospital settings, orthopedic and thoracic surgeons can help to overcome the steep yet manageable learning curve.

Endoscopic treatment of spinal trauma at the thoracolumbar junction

Attempts of treating unstable fractures of the thoracolumbar junction by posterior reduction and fixation alone often result in a significant loss of correction, especially in lesions where a severe destruction of the vertebral body and the intervertebral disc is present. The conventional open approaches like classic thoraco-phreno-lumbotomy produces additional iatrogenic trauma at the lateral chest and abdominal wall which not rarely leads to intercostal neuralgia, as well as post-thoracotomy syndromes. The endoscopic trans-diaphragmatic approach described below opens up the whole thoracolumbar junction to a minimally invasive procedure allowing one to perform all the procedures needed for a full reconstruction of the anterior column of the spine like corpectomy, decompression, vertebral body replacement and anterior plating. The key to address also the subdiaphragmal and retroperitoneal section of the thoracolumbar junction is a partial detachment of the diaphragm which runs along the attachment at the spine and the ribs. The technique was published first in 1998 and has been used now in 650 endoscopic procedures at the thoracolumbar junction out of a total of more than 1300 thoracoscopic operations of the spine in the BG Unfallklinik Murnau, Germany since 1996.

Minimally Invasive Transmuscular Pedicle Screw Fixation of the Thoracic and Lumbar Spine

OBJECTIVE:

This study assessed the feasibility and safety of percutaneous posterior pedicle screw fixation for instabilities of the thoracic and lumbar spine, using standard instruments designed for the open approach and fluoroscopy.

METHODS:

All patients who underwent percutaneous posterior pedicle screw fixation of the thoracic and lumbar spine were studied retrospectively. Charts and operative notes were analyzed for epidemiological data, underlying spinal pathological features, and indications for stabilization, stabilized segments, number of implanted pedicle screws, surgical time, and complications. Postoperative computed tomographic scans were analyzed for screw position.

RESULTS:

From May 2002 through May 2005, 115 internal fixators were implanted percutaneously in 104 patients. A total of 488 pedicle screws were implanted, stabilizing 1 to 5 spinal motion segments. Median surgical time was 93 minutes. On postoperative computed tomographic scans, 87% of screw positions were rated good, 10% were rated acceptable, and 3% were rated unacceptable. A total of 11 revisions were necessary, 9 for misplaced screws and 2 for loosening of anchor bolts. Only two of the patients experienced new clinical symptoms (i.e., radicular pain) because of screw misplacement. No patients experienced new neurological deficits or other surgery-related morbidity. @@@@CONCLUSION:@@ This study shows that percutaneous internal pedicle screw fixation using standard instruments is feasible and safe for posterior stabilization of the thoracic and lumbar spine. It is a straightforward alternative for open approaches or minimally invasive ones using navigation in conjunction with customized instruments. Accuracy of screw placement is similar to that reported for other techniques.

Endoscopic surgery on the thoracolumbar junction of the spine

The thoracolumbar junction is the section of the truncal spine most often affected by injuries. Acute instability with structural damage to the anterior load-bearing spinal column and post-traumatic deformity represents the most frequent indications for surgery. In the past few years, endoscopic techniques for these indications have partially superseded the open procedures, which are associated with high access morbidity. The particular position of this section of the spine, which lies in the transition area between the thoracic and abdominal cavities, makes it necessary in most cases to partially detach the diaphragm endoscopically in order to expose the surgical site, and this also provides access to the retroperitoneal section of the thoracolumbar junction. A now standardised operating technique, instruments and implants specially developed for the endoscopic procedure, from angle stable plate and screw implants to endoscopically implantable vertebral body replacements, have gradually opened up the entire spectrum of anterior spine surgery to endoscopic techniques.

Use of minimally invasive surgical techniques in the management of thoracolumbar trauma: current concepts

STUDY DESIGN

Literature review and expert opinion.

OBJECTIVE

To provide an overview of the current concepts of minimally invasive surgical (MIS) techniques for the management of thoracolumbar (TL) spinal trauma.

SUMMARY OF BACKGROUND DATA

Current surgical treatment of thoracolumbar trauma typically involves open placement of spinal instrumentation with fusion. Conventional open spinal exposures can be associated with significant muscle morbidity that can lead to subsequent paraspinal muscular atrophy, scarring, decreased extensor strength and endurance, as well as pain. This approach-related morbidity is the main impetus for application MIS techniques to spinal procedures including trauma.

METHODS

A review of the relevant English literature was performed.

RESULTS

The current rationale, clinical applications, outcomes, and limitation of MIS management of TL injuries are summarized.

CONCLUSION

The application of MIS techniques to spinal trauma is theoretically sound. However, the indications and technology are currently in evolution. Although very limited information is available, the results of current MIS techniques for the management of TL trauma are encouraging.

Improved anchorage in osteoporotic vertebrae with new implant designs

The goal of our study was to evaluate two newly developed implant designs and their behavior in terms of subsidence in lumbar vertebral bodies under cyclic loading. The new implants were evaluated in two different configurations (two small prototypes vs. one large prototype with similar load-bearing area) in comparison to a conventional screw-based implant (MACS TL). A pool of 13 spines with a total of 65 vertebrae was used to establish five testing groups of similar bone mineral density (BMD) distribution with eight lumbar vertebrae each. In additional to BMD assessment via dual-energy X-ray absorptiometry, cancellous BMD and structural parameters were determined using a new generation in vivo 3D-pQCT. The specimens were loaded sinusoidally in force control at 1 Hz for 1000 cycles at three load levels (100, 200, and 400 N). A survival analysis using the number of cycles until failure (Cox regression with covariates) was applied to reveal differences between implant groups. All new prototype configurations except the large cylinder survived significantly longer than the control group. The number of cycles until failure was significantly correlated with the structural parameter Tb.Sp. and similarly with the cancellous BMD for three of five implants. In both large prototypes the cycle number until failure significantly correlated with the preoperative distance to the upper endplates. Although the direct relationship between bone structure or density and mechanical breakage behavior cannot be conclusively proven, all the prototypes adapted for poor bone structure performed better than the comparable conventional implant.

The learning curve associated with thoracoscopic spinal instrumentation

STUDY DESIGN

Consecutive case prospective radiographic and medical record review.

OBJECTIVE

To define the learning curve associated with thoracoscopic spinal instrumentation by evaluating operative data and early outcomes of 1 surgeon's (B.L.) cases.

SUMMARY OF BACKGROUND DATA

Thoracoscopic spinal instrumentation for the treatment of thoracic adolescent idiopathic scoliosis has emerged as an alternative to open anterior and posterior techniques. The technique is technically demanding and has been perceived as having a prohibitive learning curve.

METHODS

The operative reports, charts, and surgeon's database were used to evaluate operating time, estimated blood loss, levels fused, complication rate, blood transfusions, and curve correction, among other variables. For purposes of analysis, the entire cohort was divided into 2 groups of 28 and 29 patients, respectively, and then 4 groups of 14 patients (the last group with 15) were used for comparison.

RESULTS

The records of 57 patients were evaluated. No significant difference in estimated blood loss or number of levels fused was noted for either comparison (P = 0.46 and P = 0.66, respectively). There was no significant difference in blood transfusion requirements, with 7% in group 1 and 18% in group 2 (P = 0.35). Operating time was significantly less after 28 patients were operated on 6.2 +/- 1.3 hours versus 5.3 +/- 1.2 hours (P = 0.011). Percent curve correction was significantly better after 28 cases were performed, 54.4 +/- 17.9 in the former groups versus 65.7 +/- 10.4 in the latter half of cases (P = 0.005). Complications were evenly distributed throughout the series. No significant differences were observed between the 2 groups in terms of rate of complication (P = 0.50). No major complications, such as neurologic deficit or significant hemorrhage, were observed.

CONCLUSIONS

The learning curve associated with thoracoscopic spinal instrumentation appears to be acceptable. Significant differences were noted in operating time and percent curve correction after 28 cases. The complication rates remained stable throughout the surgeon's experience.

Thoracoscopic spine surgery for decompression and stabilization of the anterolateral thoracolumbar spine

The anterior thoracolumbar spine can be exposed via a variety of approaches. Historically, open anterolateral or pos-terolateral approaches have been used to gain access to the anterior thoracolumbar spinal column. Although the exposure is excellent, open approaches are associated with significant pain and respiratory problems, substantial blood loss, poor cosmesis, and prolonged hospitalization. With the increasing use of the endoscope in surgical procedures and recent advances in video-assisted thoracoscopic surgery, minimally invasive thoracoscopic spine surgery has been developed to decrease the morbidity associated with open thoracotomy. The purpose of this article is to illustrate the surgical technique of a minimally invasive thoracoscopic approach to the anterolateral thoracolumbar spine and to discuss its potential indications and contraindications in patients with diseases involving the anterior thoracic and lumbar regions.

[CT-based assessment score after ventral spondylodesis for thoracolumbar spine fracture]

BACKGROUND

Dorsoventral stabilization is a common procedure to treat thoracolumbar spine fractures. Especially in respect of the evaluation of alternative procedures to autogenous bone graft, a standardized evaluation score for ventral spondylodesis is necessary.

PATIENTS AND METHODS

In a group of 44 patients a follow-up CT scan was evaluated with a standardized scoring system by four different independent evaluators (a trauma surgeon, an orthopedic surgeon, and two radiologists). The score is based on the morphologic classification of the region between graft and vertebral body. It allows a classification of the spondylodesis as sufficient, partial, and not sufficient.

RESULTS

The statistical evaluation of the classification of the different evaluators shows very good interobserver agreement in monosegmental fusion and good agreement in bisegmental fusion.

CONCLUSION

The demonstrated score is easy to handle, does not need special equipment for CT scans, and shows good interobserver agreement in the classification of spinal fusion after ventral spondylodesis for thoracolumbar spine fracture.

Endoskopische Knochentransplantation an der Wirbels�ule

The application of autogenous bone grafts represents the golden standard for reconstruction of the load-bearing anterior column in the thoracolumbar spine. However, the osseous integration of the implanted grafts is demanding and delayed union or pseudarthrosis may occur. There are no standardized data available yet indicating the further course in such cases. The aim of this study was to evaluate the incorporation of endoscopically applied grafts and to develop therapeutic strategies for delayed or non-fusions. Twenty patients suffering from unstable injuries of the thoracolumbar spine were studied in a prospective clinical trial. After primary dorsal stabilization, the anterior column was thoracoscopically reconstructed with an autogenous iliac crest graft and a fixed-angle implant (MACS). The osseous integration of the bone grafts was detected by MSCT 1 year postoperatively. Complete integration of the transplanted bone grafts was observed in only 65% of the cases. In 25% partial integration was detected and in two cases a fracture of the transplanted iliac crest graft occurred. Despite the incomplete integration of the bone grafts, the further course without surgical intervention revealed no clinical or radiological evidence of a concomitant implant loosening or a relevant secondary loss of correction. Similar to the open technique, endoscopic reconstruction of the anterior column with autogenous bone grafts may lead to disadvantageous results concerning the integration and healing of the applied bone grafts. Decision making in such cases depends on the individual clinical and radiological findings (i.e., evidence of implant loosening and concomitant loss of correction).