Surgical management of posttraumatic thoracolumbar kyphosis

Predictive Value of Bolster Supine X-Ray for the Correction of Segmental Deformity After Thoracolumbar Fusion Surgery

BACKGROUND AND OBJECTIVES

Assessment of thoracolumbar spine flexibility is crucial for determining which osteotomy to perform (posterior column osteotomy or 3-column osteotomy) to restore sagittal balance. Although preoperative bolster supine X-rays have been used to evaluate spine flexibility, their correlation with postoperative spinopelvic parameters has not been reported. We aimed to evaluate the predictive value of bolster X-ray for correcting sagittal deformities after thoracolumbar fusion surgery.

METHODS

We retrospectively evaluated patients who underwent bolster supine radiography before posterior thoracolumbar fusion. Demographic data, operative records, and radiographic parameters were also recorded. The segmental Cobb angle, defined as the angle between the upper endplate of the uppermost and lower endplates of the lowest instrumented vertebrae, was compared between bolster and postoperative X-ray to evaluate the correlation between them. The predictive value of bolster X-ray for postoperative deformity correction was measured using intraclass correlation coefficients (ICC).

RESULTS

Forty-two patients were included. The preoperative segmental Cobb angle (-1.4 ± 22.4) was significantly lower than the bolster segmental Cobb angle (23.2 ± 18.7, P < .001) and postoperative segmental Cobb angle (27.9 ± 22.3, P < .001); however, no significant difference was observed between the bolster and postoperative segmental Cobb angles (P = .746). Bolster X-ray showed a very strong correlation with postoperative X-ray (r = 0.950, P < .001) for segmental Cobb angle. Bolster supine X-ray had good-to-excellent reliability for postoperative X-ray with an ICC of 0.913 (95% CI, 0.760-0.962, P < .001) for the segmental Cobb angle.

CONCLUSION

Bolster supine X-rays demonstrate good-to-excellent reliability with postoperative X-rays for segmental Cobb angles. These findings offer valuable insights into the selection of appropriate osteotomy techniques for clinical practice.

Distal junctional failure after corrective surgery without pelvic fixation for thoracolumbar junctional kyphosis due to osteoporotic vertebral fracture

BACKGROUND

Thoracolumbar junctional kyphosis (TLJK) due to osteoporotic vertebral fracture (OVF) negatively impacts patients' quality of life. The necessity of pelvic fixation in corrective surgery for TLJK due to OVF remains controversial. This study aimed to: 1) evaluate the surgical outcomes of major corrective surgery for thoracolumbar junctional kyphosis due to osteoporotic vertebral fracture, and 2) identify the risk factors for distal junctional failure to identify potential candidates for pelvic fixation.

METHODS

Patients who underwent surgical correction (fixed TLJK>40°, OVF located at T11-L2, the lowermost instrumented vertebra at or above L5) were included. Sagittal vertical axis, pelvic tilt, pelvic incidence, thoracic kyphosis, lumbar lordosis (L1-S1), local kyphosis, and lower lumbar lordosis (L4-S1) were assessed. Proximal and distal junctional kyphosis (P/DJK) and failures (P/DJF) were evaluated. Pre/postoperative spinopelvic parameters were compared between DJF and non-DJF patients.

RESULTS

Thirty-one patients (mean age: 72.3 ± 7.9 years) were included. PJK was observed in five patients (16.1%), while DJK in 11 (35.5%). Twelve cases (38.7%) were categorized as failure. Among the patients with PJK, there was only one patient (20%) categorized as PJF and required an additional surgery. Contrary, all of eleven patients with DJK were categorized as DJF, among whom six (54.5%) required additional surgery for pelvic fixation. In comparisons between DJF and non-DJF patients, there was no significant difference in pre/postoperative LK (pre/post, p = 0.725, p = 0.950). However, statistically significant differences were observed in the following preoperative alignment parameters: SVA (p = 0.014), LL (p = 0.001), LLL (p = 0.006), PT (p = 0.003), and PI-LL (p < 0.001).

CONCLUSIONS

Spinopelvic parameters, which represent the compensatory function of lumbar hyperlordosis and pelvic retroversion, have notable impacts on surgical outcomes in correction surgery for TLJK due to OVF. Surgeons should consider each patient's compensatory function when choosing a surgical approach.

Surgical management of posttraumatic thoracolumbar Kyphosis: A review

Kyphosis is a condition in which there is a curvature of the spine that causes a bowing of the back, which in turn leads to slouching posture or hunchback. There are several types of Kyphosis, including posttraumatic Kyphosis, which usually occurs in the thoracic region. There are several techniques used for the surgical management of posttraumatic thoracolumbar Kyphosis. We aimed to discuss the surgical treatment of posttraumatic thoracolumbar Kyphosis. We searched for articles included in this review through scientific websites using different keywords. The articles were chosen based on inclusion criteria. The articles included in this review were published between 2006 and 2018. The review was written under titles in the discussion part. The outcome of the surgical management of posttraumatic thoracolumbar Kyphosis depends on the accurate selection of the proper surgical approach.

The Diagnostic Process of Spinal Post-traumatic Deformity: An Expert Survey of 7 Cases, Consensus on Clinical Relevance Does Exist

STUDY DESIGN

Survey of cases.

OBJECTIVE

To evaluate the opinion of experts in the diagnostic process of clinically relevant Spinal Post-traumatic Deformity (SPTD).

SUMMARY OF BACKGROUND DATA

SPTD is a potential complication of spine trauma that can cause decreased function and quality of life impairment. The question of when SPTD becomes clinically relevant is yet to be resolved.

METHODS

The survey of 7 cases was sent to 31 experts. The case presentation was medical history, diagnostic assessment, evaluation of diagnostic assessment, diagnosis, and treatment options. Means, ranges, percentages of participants, and descriptive statistics were calculated.

RESULTS

Seventeen spinal surgeons reviewed the presented cases. The items' fracture type and complaints were rated by the participants as more important, but no agreement existed on the items of medical history. In patients with possible SPTD in the cervical spine (C) area, participants requested a conventional radiograph (CR) (76%-83%), a flexion/extension CR (61%-71%), a computed tomography (CT)-scan (76%-89%), and a magnetic resonance (MR)-scan (89%-94%). In thoracolumbar spine (ThL) cases, full spine CR (89%-100%), CT scan (72%-94%), and MR scan (65%-94%) were requested most often. There was a consensus on 5 out of 7 cases with clinically relevant SPTD (82%-100%). When consensus existed on the diagnosis of SPTD, there was a consensus on the case being compensated or decompensated and being symptomatic or asymptomatic.

CONCLUSIONS

There was strong agreement in 5 out of 7 cases on the presence of the diagnosis of clinically relevant SPTD. Among spine experts, there is a strong consensus to use CT scan and MR scan, a cervical CR for C-cases, and a full spine CR for ThL-cases. The lack of agreement on items of the medical history suggests that a Delphi study can help us reach a consensus on the essential items of clinically relevant SPTD.

LEVEL OF EVIDENCE

Level V.

Automatic detection of spinal injuries under dynamic compressive loading using high-speed cine-radiography

Every year, new cases of individuals suffering from traumatic spinal injuries are detected. Advances in numerical models have allowed for the understanding of the damage caused by trauma and its impact on the patient's life. However, the kinematics and dynamics of vertebral fracture formation from its point of origin to the speed of propulsion of the fragments remain unknown. This is mainly due to the lack of data that essentially includes high-speed videos, load and displacement measurements during experimental tests reproducing spinal traumatic loading conditions. This lack of data can be addressed by the analysis of X-Ray images of animal specimens acquired during the traumatic spinal injury formation process. Thus, the purpose of this study was to develop an approach to automatically detect and track in vitro vertebral fractures using high-speed cine-radiography imaging. Four segments of porcine thoracolumbar vertebrae were dynamically compressed using a servo-hydraulic test bench. The compression process was filmed with a custom high-speed cine-radiography device, and the imaging parameters were optimized based on the physical properties of vertebrae. This paper demonstrates the feasibility of using high-speed cine-radiography imaging in this way, combined with an image processing pipeline to allow automatic documentation of the fracture's appearance and its evolution in the vertebra over time.Clinical Relevance- The proposed method will provide helpful information for proper handling of traumatic spinal injuries.

Impacts of gait biomechanics of patients with thoracolumbar kyphosis secondary to Scheuermann's disease

Introduction: Thoracolumbar kyphosis (TLK) is a common feature in patients with spinal deformities. However, due to limited studies, the impacts of TLK on gait have not been reported. The objective of the study was to quantify and evaluate the impacts of gait biomechanics of patients with TLK secondary to Scheuermann's disease. Methods: Twenty cases of Scheuermann's disease patients with TLK and twenty cases of asymptomatic participants were recruited into this study. And the gait motion analysis was conducted. Results: The stride length was shorter in the TLK group compared to control group (1.24 ± 0.11 m vs. 1.36 ± 0.21 m, p = 0.04). Compared to control group, the stride time and step time were more prolonged in the TLK group (1.18 ± 0.11s vs. 1.11 ± 0.08 s, p = 0.03; 0.59 ± 0.06 s vs. 0.56 ± 0.04 s, p = 0.04). The gait speed of the TLK group was significantly slower than it of control group (1.05 ± 0.12 m/s vs. 1.17 ± 0.14 m/s, p = 0.01); In the sagittal plane, the range of motion (ROM) of the hip in the TLK group was significantly smaller than that of the control group (37.71 ± 4.35° vs. 40.05 ± 3.71°, p = 0.00). In the transverse plane, the adduction/abduction ROMs of the knee and ankle, as well as the internal and external rotation of the knee, were smaller in TLK group than ROMs in the control group (4.66 ± 2.21° vs. 5.61 ± 1.82°, p = 0.00; 11.48 ± 3.97° vs. 13.16 ± 5.6°, p = 0.02; 9.00 ± 5.14° vs. 12.95 ± 5.78°, p = 0.00). Discussion: The main finding of this study was that measurements of gait patterns and joint movement of the TLK group were significantly lower than those of the control group. And these impacts have the potential to exacerbate degenerative progress of joints in the lower extremities. These abnormal features of gait can also serve as a guideline for physicians to focus on TLK in these patients.

Can preoperative magnetic resonance imaging be used for sagittal kyphotic flexibility assessment in patients with kyphosis secondary to symptomatic old osteoporotic thoracolumbar fracture?

OBJECTIVE

This study aimed to investigate whether preoperative magnetic resonance imaging (MRI) can be used for sagittal kyphotic (SK) flexibility assessment in patients with kyphosis secondary to symptomatic old osteoporotic thoracolumbar fracture (so-OTLF).

METHODS

The authors evaluated the radiographic data of patients with kyphosis secondary to so-OTLF. All patients underwent posterior corrective fusion surgery in the hospital. Spinal sagittal parameters were measured on standing radiographs preoperatively. The regional kyphosis angle (RKA) was also measured on preoperative supine MRI and intraoperative prone radiographs on the surgical frame. The SK flexibility in patients with kyphosis secondary to so-OTLF was defined as the difference from the RKA measured on the standing radiographs to that measured on the intraoperative prone radiographs or preoperative supine MRI. The difference and the correlation between the SK flexibility measured by these two methods were compared and analyzed.

RESULTS

Thirty-seven patients were included. The RKA measured on standing radiographs, supine MRI, and intraoperative prone radiographs were 48.0°, 34.4°, and 32.0°, respectively. Compared with the RKA measured in standing position, the RKA measured on supine MRI decreased by 13.6° (95% confidence interval 11.4°-15.8°), whereas that measured on intraoperative prone radiographs decreased by 16.1° (95% confidence interval 13.7°-18.5°). A linear correlation existed between the SK flexibility measured on supine MRI and that measured on intraoperative prone radiographs, with a mean difference of 2.4° (R² = 0.912, p < 0.001).

CONCLUSION

The degree of regional kyphosis deformity was reduced by self-reduction of the intraoperative surgical frame. With a predictive value similar to an intraoperative prone radiograph, preoperative supine MRI can be used for SK flexibility assessment in patients with kyphosis secondary to so-OTLF. The ability to predict the intraoperative degree of regional kyphosis deformity with positioning before an operation may help with surgical planning and patient counseling regarding expectations and risks of surgery.

Biomechanical Comparison of Multilevel Lumbar Instrumented Fusions in Adult Spinal Deformity According to the Upper and Lower Fusion Levels: A Finite Element Analysis

Multilevel lumbar fusion with posterior pedicle screw fixation is a widely performed surgical procedure for the management of adult spinal deformity. However, there has not been a comprehensive biomechanical study on the different types of fusion levels in terms of stability and possible complications. We aimed to investigate the biomechanical properties of multilevel lumbar fusion according to different types of upper and lower fusion levels. Six different types of fusions were performed using three-dimensional finite element models. Type A and B referred to the group of which upper fusion level was L1 and T10, respectively. Subtype 1, 2, and 3 referred to the group of which lower fusion level was L5, S1, and ilium, respectively (A1, L1-L5; A2, L1-S1; A3, L1-ilium; B1, T10-L5; B2, T10-S1; B3, T10-ilium). Flexion, extension, axial rotation, and lateral bending moments were applied, and the risk of screw loosening and failure and adjacent segment degeneration (ASD) was analyzed. Stress at the bone-screw interface of type B3 was lowest in overall motions. The risk of screw failure showed increasing pattern as the upper and lower levels extended in all motions. Proximal range of motion (ROM) increased as the lower fusion level changed from L5 to S1 and the ilium. For axial rotation, type B3 showed higher proximal ROM (16.2°) than type A3 (11.8°). In multilevel lumbar fusion surgery for adult spinal deformity, adding iliac screws and increasing the fusion level to T10-ilium may lower the risk of screw loosening. In terms of screw failure and proximal ASD, however, T10-ilium fusion has a higher potential risk compared with other fusion types. These results will contribute for surgeons to provide adequate patient education regarding screw failure and proximal ASD, when performing multilevel lumbar fusion.

Thoracic and lumbar spine trauma classification systems fail to predict post-traumatic kyphotic deformity

Background

Post-traumatic kyphosis of the thoracic and lumbar spine can lead to pain and decreased function. MRI has been advocated to assess ligament integrity and risk of kyphosis.

Methods

All thoracic and lumbar spine MRI performed for evaluation of trauma over a 3-year period at a single institution were reviewed. Patients were included if there was an MRI showing a vertebral body fracture and follow-up radiographs. Two observers retrospectively reviewed all radiographs, CT and MRI scans, and classified injuries based on the Denis, TLICS, AO and load sharing classification systems. Change in kyphosis between injury and follow-up studies was measured. The initial radiology reports made at time of patient injury were compared to the retrospective interpretations.

Results

There were 67 separate injuries in 62 patients. Kyphosis measuring ≥ 10° developed despite an intact PLC in 6/14 nonoperative cases, and 3/7 surgically treated cases; when PLC was partially injured, it developed in 6/10 cases (8 treated nonoperatively, 2 treated operatively. Thirty injuries had complete disruption of PLC by MRI, 24 treated with fusion. Kyphosis ≥ 10° developed in 3/6 treated nonoperatively, and 8/24 treated with fusion. Development of kyphosis was independent of degree of vertebral body comminution. It developed equally in patients with Grade 2 and Grade 3 Denis injuries. It developed in patients with intact PLC when multiple vertebrae were involved and/or there was compressive injury to anterior longitudinal ligament (ALL). There was high interobserver variability in assessment of severity of ligamentous injury on MRI.

Conclusions

Classification systems of thoracic and lumbar spine injury and integrity of the PLC failed to predict the risk of development of post-traumatic kyphotic deformity.

Posterior hemivertebra resection and reconstruction for the correction of old AO type B2.3 thoracic fracture kyphosis: A case report

Background

Post-traumatic malunion is one of the main causes of kyphosis and usually has serious consequences. We report a case of kyphosis caused by an old AO type B2.3 thoracic fracture, which was corrected with posterior hemivertebra resection and reconstruction.

Case presentation

A 41-year-old male was diagnosed with kyphosis caused by an old AO type B2.3 thoracic fracture. Preoperative examination and preparation were performed. His exam images showed a comminuted fracture in the left half of the T12 vertebral body, while chance-type fractures were seen in the right half of T12 vertebral body and its accessories. During the operation, posterior hemivertebra resection and reconstruction techniques were used to remove nearly half of the left vertebral body of the affected vertebra, preserve the right vertebral body and the facet joints of the affected vertebra, correct the kyphosis, and rebuild spinal stability. The patient's low back pain was completely relieved, and his thoracic kyphosis was corrected at the seventh post-operative day. CT reconstruction of the spine showed that the residual vertebrae healed well during his nine- and 18-month follow-ups. Continuous callus formation was observed inside and outside of the titanium cage at the reconstructed site, and there was no sign of subsidence of the titanium cage. The heights between the vertebrae were restored to within normal ranges and the physiological curvature of the thoracolumbar spine was achieved. The patient recovered well.

Conclusion

This operation preserved the hemivertebral body and facet joints, and maintains intervertebral height and local stability, thus avoiding titanium cage collapse, titanium cage movement, and other complications. This surgical approach is ideal for treating complex thoracic vertebral kyphosis caused by old fractures, and is worth utilizing in the clinic.

Rate and Predictors of Failure in the Conservative Management of Stable Thoracolumbar Burst Fractures: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review.

OBJECTIVES

Management of stable traumatic thoracolumbar burst fractures in neurologically-intact patients remains controversial. Conservative management fails in a subset of patients who require subsequent surgical fixation. The aim of this review is to (1) determine the rate of conservative management failure, and (2) analyze predictive factors at admission influencing conservative management failure.

METHODS

A systematic review adhering to PRISMA guidelines was performed. Studies with data pertaining to traumatic thoracolumbar burst fractures without posterior osteoligamentous injury (e.g. AO Type A3/A4) and/or the rate and predictive factors of conservative management failure were included. Risk of bias appraisal was performed. Pooled analysis of rates of failure was performed with qualitative analysis of predictors of conservative management failure.

RESULTS

16 articles were included in this review (11 pertaining to rate of conservative management failure, 5 pertaining to predictive risk factors). Rate of failure of conservative management from a pooled analysis of 601 patients is 9.2% (95% CI: 4.5%-13.9%). Admission factors predictive of conservative management failure include age, greater initial kyphotic angle, greater initial interpedicular distance, smaller initial residual canal size, greater Load Sharing Classification (LSC) score and greater admission Visual Analog Scale (VAS) pain scores.

CONCLUSION

A proportion (9.2%) of conservatively managed, neurologically-intact thoracolumbar burst fractures fail conservative management. Among other factors, age, kyphotic angle, residual canal area and interpedicular distance should be investigated in prospective studies to identify the subset of patients prone to failure of conservative management. Surgical management should be carefully considered in patients with the above risk factors.

Kyphosis After Thoracolumbar Spine Fractures: WFNS Spine Committee Recommendations

Thoracolumbar fractures change the biomechanics of the spine. Load distribution causes kyphosis by the time. Treatment of posttraumatic kyphosis is still controversial. We reviewed the literature between 2010 and 2020 using a search with keywords “thoracolumbar fracture and kyphosis.” We removed osteoporotic fractures, ankylosing spondylitis fractures, non-English language papers, case reports, and low-quality case series. Up-to-date information on posttraumatic kyphosis management was reviewed to reach an agreement in a consensus meeting of the World Federation of Neurosurgical Societies (WFNS) Spine Committee. The first meeting was conducted in Peshawar in December 2019 with WFNS Spine Committee members’ presence and participation. The second meeting was a virtual meeting via the internet on June 12, 2020. We utilized the Delphi method to administer the questionnaire to preserve a high degree of validity. We summarized 42 papers on posttraumatic kyphosis. Surgical treatment of thoracolumbar kyphosis due to unstable burst fractures can be done via a posterior only approach. Less blood loss and reduced surgery time are the main advantages of posterior surgery. Kyphosis angle for surgical decision and fusion levels are controversial. However, global sagittal balance should be taken into consideration for the segment that has to be included. Adding an intermediate screw at the fractured level strengthens the construct.

Clinical Efficacy and Safety of Controlled Distraction- Compression Technique Using Expandable Titanium Cage in Correction of Posttraumatic Kyphosis

Objective

To investigate the clinical efficacy and safety of the controlled distraction-compression technique using an expandable titanium cage (ETC) in posttraumatic kyphosis (PTK).

Methods

We retrospectively studied and collected data on 20 patients with PTK. From January 2014 to December 2017, the controlled distraction-compression technique using ETC was consecutively performed in 20 patients with PTK of the thoracolumbar zone (range, 36–82 years). Among them, nine were males and 11 were females and the mean age was 61.5 years. The patients were followed regularly at 1, 3, 6, and 12 months, and the last follow-up was more than 2 years after surgery.

Results

The mean follow-up period was 27.3±7.3 months (range, 14–48). The average operation time was 286.8±33.1 minutes (range, 225–365). The preoperative regional kyphotic angle (RKA) ranged from 35.6° to 70.6° with an average of 47.5°±8.1°. The immediate postoperative mean RKA was 5.9°±3.8° (86.2% correction rate, p=0.000), and at the last follow-up more than 2 years later, the mean RKA was 9.2°±4.9° (80.2% correction rate, p=0.000). The preoperative mean thoracolumbar kyphosis was 49.1°±9.2° and was corrected to an average of 8.8°±5.3° immediately after surgery (p=0.000). At the last follow-up, a correction of 11.9°±6.3° was obtained (p=0.000). The preoperative mean back visual analog scale (VAS) score was 7.9±0.8 and at the last follow-up, the VAS score was improved to a mean of 2.3±1.0 with a 70.9% correction rate (p=0.000). The preoperative mean Oswestry disability index (ODI) score was 32.3±6.9 (64.6%) and the last follow-up ODI score was improved to a mean of 6.85±2.9 (3.7%) with a 78.8% correction rate (p=0.000). The overall complication was 15%, with two of distal junctional fractures and one of proximal junctional kyphosis and screw loosening. However, there were no complications directly related to the operation.

Conclusion

Posterior vertebral column resection through the controlled distraction-compression technique using ETC showed safe and good results in terms of complications, and clinical and radiologic outcomes in PTK. However, to further evaluate the efficacy of this surgical procedure, more patients need long-term follow-up and there is a need to apply it to other diseases.

The Current Status of Spinal Posttraumatic Deformity: A Systematic Review

STUDY DESIGN

Systematic Review.

OBJECTIVE

To systematically analyze the definitions and descriptions in literature of "Spinal Posttraumatic Deformity" (SPTD) in order to support the development of a uniform and comprehensive definition of clinically relevant SPTD.

METHODS

A literature search in 11 international databases was performed using "deformity" AND "posttraumatic" and its synonyms. When an original definition or a description of SPTD (Patient factors, Radiological outcomes, Patient Reported Outcome Measurements and Surgical indication) was present the article was included. The retrieved articles were assessed for methodological quality and the presented data was extracted.

RESULTS

46 articles met the inclusion criteria. "Symptomatic SPTD" was mentioned multiple times as an entity, however any description of "symptomatic SPTD" was not found. Pain was mentioned as a key factor in SPTD. Other patient related parameters were (progression of) neurological deficit, bone quality, age, comorbidities and functional disability. Various ways were used to determine the amount of deformity on radiographs. The amount of deformity ranged from not deviant for normal to >30°. Sagittal balance and spinopelvic parameters such as the Pelvic Incidence, Pelvic Tilt and Sacral Slope were taken into account and were used as surgical indicators and preoperative planning. The Visual Analog Scale for pain and the Oswestry Disability Index were used mostly to evaluate surgical intervention.

CONCLUSION

A clear-cut definition or consensus is not available in the literature about clinically relevant SPTD. Our research acts as the basis for international efforts for the development of a definition of SPTD.

[Surgical treatment of delayed spinal cord injury caused by atypical compression of old thoracolumbar fractures]

OBJECTIVE

To explore the clinical characteristics and surgical treatment strategies of delayed spinal cord injury (SCI) caused by atypical compression of old thoracolumbar fracture.

METHODS

Between January 2011 and June 2018, 32 patients with delayed SCI caused by atypical compression of old thoracolumbar fracture who met the inclusion criteria were admitted and divided into group A (20 cases, underwent anterior subtotal vertebral body resection+titanium mesh reconstruction+screw rod internal fixation) and group B (12 cases, underwent posterior 270° ring decompression of vertebral canal+titanium mesh reconstruction+screw rod internal fixation) according to the different operation approaches. There was no significant difference between the two groups in age, gender, cause of injury, fracture segment, disease duration, preoperative American Spinal Injury Association (ASIA) classification, and preoperative back pain visual analogue scale (VAS) score, lumbar Japanese Orthopaedic Association (JOA) score, kyphosis angle, and vertebral canal occupational ratio ( P>0.05). The incision length, operation time, intraoperative blood loss, complications, and bone fusion time of reconstructed vertebrae were recorded and compared between the two groups; the kyphosis angle, back pain VAS score, and lumbar JOA score were used to evaluate the effectiveness.

RESULTS

Except that the incision length in group A was significantly shorter than that in group B ( t=-4.865, P=0.000), there was no significant difference in intraoperative blood loss and operation time between the two groups ( P>0.05). There was no deaths or postoperative paraplegia cases in the two groups, and no deep infection or skin infection occurred. There was 1 case of cerebrospinal fluid leakage, 1 case of inferior vena cava injury, and 1 case of chyle leakage in group A. No serious complications occurred in group B. There was no significant difference in the incidence of complications between the two groups ( P=0.274). All 32 patients were followed up 12-61 months, with an average of 20.8 months. The follow-up time for groups A and B were (19.35±5.30) months and (23.25±12.20) months respectively, and the difference was not significant ( t=-1.255, P=0.219). The reconstructed vertebrae in all cases obtained bony fusion postoperatively. The fusion time of groups A and B were (8.85±2.27) months and (8.50±2.50) months respectively, and the difference was not significant ( t=0.406, P=0.688). The kyphosis angle, back pain VAS score, and lumbar JOA score of the two groups at each time point after operation and last follow-up were significantly improved when compared with preoperatively ( P<0.05); the lumbar JOA score was further improved with time postoperatively ( P<0.05), while the kyphosis angle and the VAS score of back pain remained similarly ( P>0.05). Comparison of kyphosis angle, back pain VAS score, and lumbar JOA score between the two groups at various time points postoperatively showed no significant difference ( P>0.05). At last follow-up, the JOA score improvement rate in groups A and B were 83.87%±0.20% and 84.50%±0.14%, respectively, and the difference was not significant ( t=-0.109, P=0.914); the surgical treatment effects of the two groups were judged to be significant.

CONCLUSION

In the later stage of treatment of old thoracolumbar fractures, even mild kyphosis and spinal canal occupying may induce delayed SCI. Surgical correction and decompression can significantly promote the recovery of damaged spinal cord function. Compared with anterior approach surgery, posterior approach surgery has the advantages of less trauma, convenient operation, and fewer complications, so it can be preferred.

A Progressive Paraplegic Patient with Thalassemia Because of Extramedullary Hematopoiesis and Vertebral Fracture: A Case Report

CASE

We present a case of progressive paraplegia because of extramedullary hematopoiesis and pathological vertebral fracture in thalassemia patient. The various surgical techniques including larger pedicle screws, bicortical fixation, and convergent direction to improve pullout strength had been used secondary to osteoporotic bone and kyphotic deformity.

CONCLUSION

Prompt diagnosis and awareness of the compromised bone quality of the thalassemic patient is essential to guide the proper management and produce the desire outcomes.

Preoperative and Postoperative Sagittal Alignment and Compensatory Mechanisms in Patients With Posttraumatic Thoracolumbar Deformities Who Undergo Corrective Surgeries

BACKGROUND

Secondary posttraumatic spinal kyphosis is a fixed deformity that has an asymptomatic presentation in most patients, but in some, persistent pain and disability can develop refractory to conservative treatment, which may result in the need for corrective surgery. Our aim was to analyze the modification of sagittal alignment and the variation in compensation mechanisms of spinal-pelvic segments before and after surgical correction in a group of patients with symptomatic posttraumatic kyphosis.

METHODS

A retrospective cohort study of 16 consecutive patients from the beginning of 2007 until the beginning of 2017 who underwent surgery due to thoracolumbar sagittal deformities was performed. Regional kyphosis (RK), thoracic kyphosis (TK), lumbar lordosis (LL), lower lumbar lordosis (LLL), lumbar lordosis under the deformity (LLUD), pelvic incidence (PI), pelvic tilt (PT), sagittal vertical axis (SVA), and PI-LL were measured in preoperative and postoperative lateral full spine x rays. Statistical analysis was performed with the nonparametric Wilcoxon test to compare preoperative and postoperative radiologic variables.

RESULTS

Sixteen patients were included with a median age of 47.5 years (32-62 years), the median time elapsed from the accident until corrective surgery was 7 months (2-33 months), the median follow-up time was 16.5 months (6-80 months), and the most used corrective strategy was pedicle subtraction osteotomy (11/16 patients). Statistically and radiologically significant improvements were observed in RK (33.5° versus 12°, P < .001) and LLUD (68.5° versus 61°, P = .017), with a noticeable decrease in PI-LL (15° versus 9.5°, P = .233). There were no statistically significant results regarding TK, LL, LLL, PI, PT, or SVA.

CONCLUSIONS

Osteotomies are an effective tool to correct angular deformities at a local level after spine trauma. Posttraumatic kyphosis results in the compensation of sagittal imbalance through modification of segmental alignment of the mobile spine under the deformity.

LEVEL OF EVIDENCE

3.

CLINICAL RELEVANCE

This work shows the compensation mechanisms after post-traumatic kyphosis in patients with previously healthy spines.

The role of radiography in the study of spinal disorders

Despite the growing use of computed tomography (CT) and magnetic resonance imaging (MRI) in the study of spinal disorders, radiography still plays an important role in many conditions affecting the spine. However, the study and interpretation of spine radiograph is receiving less attention and radiologists are increasingly unfamiliar with the typical findings in normal and pathologic conditions of the spine. The aim of this article is to review the radiologic indications of radiograph in different pathologic conditions that affect the spine, including congenital, traumatic, degenerative, inflammatory, infectious and tumour disorders, as well as their main radiographic manifestations.

Secondary thoracolumbar deformity and sagittal imbalance due to osteoporosis in a young man with Cushing's disease: A case report

•

Vertebral fractures are frequent due to osteoporosis in Cushing disease.

•

Treating de primary cause of the disease reduces the risk of new fractures.

•

Surgical treatment may be needed for secondary deformity.

Introduction

To describe an unusual case of Cushing’s disease with spontaneous axial pain due to multiple consecutive vertebral fractures which led to secondary deformity that required surgical treatment.

Presentation of case

A 43-year-old man was referred to our service with back pain without previous trauma. He was diagnosed of refractory arterial hypertension and we observed centripetal obesity during exploration. With clinical findings and laboratory studies, ACTH-dependent Cushing’s syndrome due to a pituitary microadenoma was diagnosed and the patient underwent an endoscopic-assisted endonasal transsphenoidal resection. Dual energy X-ray absorptiometry (DXA) revealed spine and hip osteoporosis. Moreover, X-ray, MR and CT showed multiple vertebral osteoporotic compression fractures in thoracic and thoracolumbar area. Secondary kyphosis thoracolumbar deformity and sagittal imbalance was treated by two-level Smith-Petersen osteotomies (SPO) and instrumented posterolateral arthrodesis T10-L3 using fenestrated pedicles screws with polymethyl methacrylate (PMMA). At six years of follow-up dual energy X-ray absorptiometry (DXA) recovered normal values (T-score lumbar spine L2–L4 1.4 and T-score hip -1.9) and X-ray study showed an adequate sagittal vertebral axis.

Discussion

Osteoporosis is a common feature of CD and fractures occur in 30–50% of cases. Treating the underlying cause reduces the risk of new fractures. Medical therapy is usually enough but consecutive multiple vertebral fractures related to glucocorticoid excess may lead to secondary painful deformity.

Conclusion

Vertebral compression fractures result from secondary corticoid-induced osteoporosis in Cushing’s disease. Early detection and treatment of primary disease decreases the risk of new fractures. However, unusual secondary spinal deformity or disability may require surgery.

Multi-Level Vertebroplasty for 6 or More Painful Osteoporotic Vertebral Body Compression Fractures Performed in the Same Procedural Setting: A Safety and Efficacy Report in Cancer Patients

PURPOSE

To assess safety and efficacy of multi-level vertebroplasty, when treating 6 or more levels in the same procedural setting for the management of osteoporotic vertebral compression fractures (oVCF) in cancer patients.

MATERIALS AND METHODS

Single institution retrospective review from 2015 to 2019 of patients treated for multi-level oVCF in a single session procedural setting by vertebroplasty of 6 or more levels. Procedure outcomes collected included procedural complications, pre- and 4 week post-procedure pain score by numeric rating scale, opioid usage, and vertebral height changes.

RESULTS

In total, 197 vertebral levels were treated in 24 procedures (mean 8.2 ± 1.8 levels). Mean procedure duration was 167 + / - 41 min, and mean postoperative hospitalization duration was 2.1 + / - 1.9 days. Four grade I or II complications occurred according to CIRSE classification. Two patients had a symptomatic pulmonary cement embolism; although there was no statistical difference between pre- and postoperative mean blood saturation (95.9 + / - 1.7% and 94.8 + / - 2.0%, respectively, p = 0.066). Pain score significantly improved after treatment (6.5 ± 1.3 vs 3.2 + / - 1.4, p < 0.0001) with a mean decrease of 3.3 (51%). Post-procedure daily opioid use also significantly improved (mean 35.8 + / - 36.8 mg/24 h vs 18.5 + / - 27.8 mg/24 h, p = 0.0089), with a mean decrease of 17.3 mg/24 h (48%). Refracture was found in 2 of 105 levels treated (1.9%), and no difference was found in thoraco-lumbar height and angulation. Five patients experienced new painful fractures at a non-treated level.

CONCLUSION

Multi-level vertebroplasty for 6 or more levels is a safe and effective treatment for the management of multi-level oVCF in cancer patients.

Dynamics of spinal cord compression with different patterns of thoracolumbar burst fractures: Numerical simulations using finite element modelling

BACKGROUND

In thoracolumbar burst fractures, spinal cord primary injury involves a direct impact and energy transfer from bone fragments to the spinal cord. Unfortunately, imaging studies performed after the injury only depict the residual bone fragments position and pattern of spinal cord compression, with little insight on the dynamics involved during traumas. Knowledge of underlying mechanisms could be helpful in determining the severity of the primary injury, hence the extent of spinal cord damage and associated potential for recovery. Finite element models are often used to study dynamic processes, but have never been used specifically to simulate different severities of thoracolumbar burst fractures.

METHODS

Previously developed thoracolumbar spine and spinal cord finite element models were used and further validated, and representative vertebral fragments were modelled. A full factorial design was used to investigate the effects of comminution of the superior fragment, presence of an inferior fragment, fragments rotation and velocity, on maximum Von Mises stress and strain, maximum major strain, and pressure in the spinal cord.

FINDINGS

Fragment velocity clearly was the most influential factor. Fragments rotation and presence of an inferior fragment increased pressure, but rotation decreased both strains outputs. Although significant for both strains outputs, comminution of the superior fragment isn't estimated to influence outputs.

INTERPRETATION

This study is the first, to the authors' knowledge, to examine a detailed spinal cord model impacted in situ by fragments from burst fractures. This numeric model could be used in the future to comprehensively link traumatic events or imaging study characteristics to known spinal cord injuries severity and potential for recovery.

Thoracoscopic Correction of Post-traumatic Kyphosis with an Expandable Cage: Radiologic and Patient-Reported Outcomes

Study Design

Retrospective cohort study.

Purpose

To determine the long-term functional and radiological outcomes after thoracoscopic post-traumatic kyphosis (PTK) correction (PTKC).

Overview of Literature

PTK after insufficient treatment of unstable fractures usually presents with pain and decreased back function. The results of PTKC using a minimally invasive thoracoscopic approach with an anterior titanium cage have not previously been reported.

Methods

Data in this study were collected from all patients who underwent thoracoscopic PTKC with an expandable cage between 2007 and 2017. Kyphosis and intervertebral body height were assessed on radiographic material. Quality of life (QOL) and functional outcome scores were determined by the Euroquol 5 dimensions (EQ5D) and the Oswestry Disability Index (ODI). Additionally, satisfaction and subjective symptom improvement were determined.

Results

Fourteen patients were treated for symptomatic PTK using a combined thoracoscopic anterior and posterior approach. Nine patients received initial conservative fracture treatment and five patients underwent initial posterior fracture fixation. All patients presented with pain and without neurologic injury. The mean time between injury and PTKC was 15.4 months. Cobb angle (CA) improved with 10.6° immediately after PTKC. During the first follow-up, 4.8° kyphosis correction was lost, but CAs remained stable at longer follow-up. Bony fusion was achieved in 92% of the patients after 16 months. The majority of patients reported an improvement of symptoms 85 months after surgery, satisfaction with and willingness to undergo the procedure again. The mean EQ5D index score was 0.71 and the mean ODI score was 22.3.

Conclusions

The results of minimally invasive thoracoscopic PTKC using an expandable cage were satisfactory. The majority of the patients were satisfied after treatment and no neurological complications occurred. Functional and QOL scores were fairly good. Whereas some postoperative kyphosis correction was lost over time, bony fusion was achieved in the majority of the patients. The thoracoscopic approach minimizes surgical morbidity, does not lead to serious complications, and provides a good option for PTKC.

Preventive Vertebroplasty for Long-Term Consolidation of Vertebral Metastases

INTRODUCTION

To evaluate the long-term consolidation of vertebral metastases (VM) after preventive vertebroplasty (PV) and to report risk factors of pathological fracture despite PV.

MATERIALS AND METHODS

Files of 100 consecutives cancer patients referred for PV of VM were retrospectively analyzed. We enumerated 215 VM at the time of the PV procedure (T0): 138 VM were considered at risk of pathological fracture and had PV (treated-VM), and 77 VM were not cemented. We compared the VM characteristics using the spine instability neoplastic score (SINS) at T0 and the rate of pathologic fracture between treated-VM and untreated-VM using Kaplan-Meier method. We analyzed risk factors of pathological fracture despite PV using treated-VM characteristics and quality of cement injection criteria.

RESULTS

Despite a lower SINS value at T0 (p < 0.001), the rate of pathological fracture was significantly higher among untreated-VM compared to the treated-VM, (log-rank, p < 0.001). Major risk factors of fracture among treated-VM were: SINS value ≥ 8 (p < 0.012), mechanical pain (p = 0.001), osteolytic lesion (p = 0.033), metastatic vertebral body involvement > 50% with no collapse (p < 0.001) and unilateral posterior involvement by the vertebral metastasis (p = 0.024), Saliou score < 9 (p = 0.008), vertebral metastasis filling with cement < 50% (p = 0.007) and the absence of cement's contact with vertebral endplates (p = 0.014).

CONCLUSION

PV is long-term effective for consolidation of VM and must be discussed at the early diagnosed. Quality of cement injection matters, suggesting that techniques that improve the quantity and the quality of cement diffusion into the VM must be developed.

Modified grade 4 osteotomy for kyphosis due to old osteoporotic vertebral compression fractures: Two case reports

RATIONALE

The kyphosis caused by old osteoporotic vertebral compression fracture usually requires osteotomy to correct it. Various osteotomy techniques have been reported, but each has its own advantages and disadvantages.

PATIENT CONCERNS

We reviewed 2 cases of old osteoporotic vertebral compression fractures with kyphosis in our hospital. One patient complained of persistent low-back pain, another patient complained of low-back pain and weakness of both lower extremities.

DIAGNOSIS

Old osteoporotic vertebral compression fractures with kyphosis were diagnosed based on computer tomography and magnetic resonance imaging.

INTERVENTIONS

We performed modified grade 4 osteotomy for 2 patients.

OUTCOMES

Both patients said significant improvement in preoperative symptoms, and x-ray showed that the kyphosis was corrected. Both patients were satisfied with the treatment at the last follow-up, and the kyphosis was not aggravated.

LESSONS

Modified grade 4 osteotomy is an effective option for the treatment of old osteoporotic fracture with kyphosis. It can restore the spine sequence and achieve better clinical result.

Analysis of the Risk Factors for Unfavorable Radiologic Outcomes after Fusion Surgery in Thoracolumbar Burst Fracture : What Amount of Postoperative Thoracolumbar Kyphosis Correction is Reasonable?

Objective

The aims in the management of thoracolumbar spinal fractures are not only to restore vertebral column stability, but also to obtain acceptable alignment of the thoracolumbar junction (T-L junction) to prevent complications. However, insufficient surgical correction of the thoracolumbar spine would be likely to cause late progression of abnormal kyphosis. Therefore, we identified the surgical factors that affected unfavorable radiologic outcomes of the thoracolumbar spine after surgery.

Methods

This study was conducted in a single institution from January 2007 to December 2013. A total of 98 patients with unstable thoracolumbar spine fracture were included. In these patients, fixation was done through transpedicular screws with rods by three surgical patterns. We reviewed digital radiographs and analyzed the images preoperatively and postoperatively during follow-up visits to compare the change of the thoracolumbar Cobb angle with radiologic parameters and clinical outcomes. The unfavorable radiologic group was defined as the patients who were measured as having greater than 20 degrees of thoracolumbar Cobb angle on the last follow-up, or who underwent kyphotic progression of thoracolumbar Cobb angle greater than 10 degrees from the immediate postoperative state to final follow-up, or who had overt instrument failure with/without additional surgery. We assessed the risk factors that affected the unfavorable radiologic outcomes.

Results

We had 43 patients with unfavorable radiologic outcomes, including 35 abnormal thoracolumbar alignments and 14 instrumental failures with/without additional surgery. The multivariate logistic regression test showed that immediate postoperative T-L junction Cobb angle less than 10.5 degrees was a statistically significant risk factor, as well as the presence of osteoporosis (p=0.017 and 0.049, respectively).

Conclusion

Insufficient correction of thoracolumbar kyphosis was considered to be a major factor of an unfavorable radiological outcome. The spinal surgeon should consider that having a T-L junction Cobb angle larger than 10.5 degrees immediately after surgery could result in an unfavorable radiological outcome, which is related to a poor clinical outcome.

The Quest of Sagittal Balance Parameters and Clinical Outcome after Short Segment Spinal Fusion

Introduction:

Sagittal imbalance leads to muscular distress and results in low back pain.

Objectives:

This study scrutinize the segmental impact of short spinal fusion on spinopelvic parameters and the global patient’s clinical outcome.

Materials and Methods:

A retrospective analysis evaluated 56-patients who underwent lumbar fusion surgery at Klinikum Dortmund, from July 2013 to February 2014. The population was allocated into two groups: (1-level group), (2-levels group). EOS imaging applied for radiological evaluation and measurements of the following spinopelvic parameters: pelvic incidence (PI), sacral slope (SS), pelvic tilt (SS), lumbar lordosis (LL), and sagittal vertical axis (SVA). The radiological measurements were implemented during the preoperative, postoperative, 3 months and 1 year follow-up visits. All patients completed clinical questionnaires.

Results:

Statistically, the Pearson correlation coefficient revealed in the 1-level group that the clinical parameters correlated with the PT (R=0.40), SSA (R=-0.38) and SVA (R=-0.41) (p<0.05). While clinically, the mean preoperative VAS and mean ODI improved significantly in both groups.There was also a high correspondence between LL and SS (R=0.90); this relationship persisted at the same level even after a year. For the 2-level group, the only parameter that was interrelated with clinical parameters was the SVA (R=0.49) (p<0.05). There was also a high correlation between LL and SS (R=0.88).

Conclusion:

Scrutiny conducted showed: Patient with one level would improve clinically in terms of pain and radiculopathy, with only small alterations in spino-pelvic parameters. Meanwhile, two-level fusions have a statistically substantial clinical improvement interrelated to re-establishment of lumbar lordosis and sagittal vertical axis.

Compensatory mechanism of the spine after corrective surgery without lumbar-sacral fixation for traumatic thoracolumbar kyphotic spine deformity

BACKGROUND

It remains unclear whether long fusion including lumbar-sacral fixation is needed in corrective surgery to obtain good global sagittal balance (GSB) for the treatment of traumatic thoracolumbar kyphotic spine deformity. The purposes of this study were to evaluate compensatory mechanism of the spine after corrective surgery without lumbar-sacral fixation and to evaluate the parameters affecting the achievement of good GSB post-operatively.

METHODS

Twenty (20) subjects requiring corrective surgery (distal end of fixation was L3) were included in this study. The radiographic parameters were measured pre-operatively and at one month after surgery. Sagittal Vertical Axis (SVA), Lumber Lordosis angle altered by fracture (fLL), Thoracic Kyphosis angle altered by fracture (fTK), Pelvic Tilt (PT), Sacral Slope (SS), Pelvic Incidence (PI), Segmental Lumbar Lordosis (sLL: L3-S/L4-S), and local kyphotic angle were measured. The correlation between correction of local kyphotic angle (CLA) and the change in radiographic parameters was evaluated. Post-operatively, subjects with SVA<50 mm and PI-fLL<10°were regarded as the "good GSB group (G group). The radiographic parameters affecting the achievement of G group were statistically evaluated.

RESULTS

fLL, sLL:L3-S and sLL:L4-S were decreased indirectly because the local kyphosis was corrected directly (CLA: 26.5 ± 8.6°) (P < 0.001). CLA and the change in fLL showed significant correlation (r = 0.821), the regression equation being: Y = -0.63X+3.31 (Y: The change in fLL, X: CLA). The radiographic parameters significantly affecting the achievement of G group were: SVA, PT, PI-fLL, sLL: L3-S, and sLL: L4-S (P < 0.01).

CONCLUSION

The main compensatory mechanism was the decrease of lordosis in the lumbar spine. fLL was decreased to approximately 60% of CLA after surgery. SVA was not corrected by the compensatory mechanism.

Malunion of post-traumatic thoracolumbar fractures

Thoracolumbar malunion is the result of loss of correction, insufficient correction or even no correction (both in the frontal and sagittal planes) of a thoracolumbar fracture. The main causes are incorrect assessment of the fracture's complexity (burst fracture), its potential progression to kyphosis and associated disc or ligament damage. It can also be the result of a poorly conducted initial treatment. The types of malunion have changed over the years because of the introduction of vertebroplasty and kyphoplasty. The malunion can be well tolerated if there is only a moderate deformity. However, the functional and pain-related limitations can be severe with large deformities. Functional limitation is mainly related to sagittal imbalance, but also to sequelae associated with the injury in various ways (non-union, disc degeneration, spinal cord compression, syringomyelia, etc.). The deformity and its consequences are evaluated globally using full-body standing radiographs (EOS), CT scan and MRI. Comparison of MRI images taken in a lying position to weight bearing views or even dynamic ones is an additional means to evaluate whether the lesions are reducible. Differences in spine morphology and compensatory mechanisms to combat the sagittal imbalance induced by the deformity must also be analyzed. These provide more complete information about the consequences of the malunion and help to establish the best corrective strategy. These compensatory mechanisms consist of accentuation of lumbar lordosis along with reduction of thoracic kyphosis. As a last resort, the pelvis and femur contribute to this compensation when there is a large deformity or a stiff spine due to preexisting osteoarthritis. Treatment strategies are fairly well standardized. When the deformity is reducible, a two-stage surgery is indicated. When the deformity is not reducible, posterior transpedicular closed wedge osteotomy is the gold standard. Nevertheless, the best way to treat thoracolumbar malunion is to prevent it.

ADJACENT LEVEL DEGENERATION AND POST-TRAUMATIC DEFORMITY AFTER THORACOLUMBAR FRACTURES

ABSTRACT Objectives: To evaluate thoracolumbar fractures and the complications such as adjacent disc degeneration (ADD) and post-traumatic deformity. Methods: We evaluated 32 patients divided into two equal groups, 16 in the case group (removal of the synthesis material) and 16 in the control group (not submitted to removal of the synthesis material) in order to verify if there was difference between the incidence of these complications. Results: There were no statistically significant differences between the groups regarding the progression of the ADD and the post-traumatic deformity, but both progressed during the 2-year follow-up. Conclusion: It was concluded that the removal of the synthesis material was not effective in preventing these complications after surgical fractures of the thoracolumbar spine.

Comparison of the Posterior Vertebral Column Resection With the Expandable Cage Versus the Nonexpandable Cage in Thoracolumbar Angular Kyphosis

STUDY DESIGN

This was a retrospective study.

OBJECTIVE

To compare the radiographic and clinical results of anterior support with nonexpandable cage with those of expandable cage.

SUMMARY OF BACKGROUND DATA

The goals of surgical treatment in patients with thoracolumbar angular kyphosis are to improve the neurological deficit through neural decompression, to restore the normal alignment by correction of deformity, and to stabilize the spinal column by arthrodesis. Mesh cages have been traditionally used for reconstruction after corpectomy. However, expandable cages are gaining popularity due to some advantages over mesh cages, structural autograft or allograft, and poly-ether-ether-ketone/carbon fiber.

MATERIALS AND METHODS

We performed a retrospective study in a consecutive series of 42 subjects with a male-to-female ratio of 15:27, a mean age of 65.3±10.9 years, and a mean follow-up period of 36.4±7.1 months, who underwent posterior vertebral column resection at our medical institutions between 2006 and 2011. They consist of 32 patients with posttraumatic kyphosis with a mean kyphotic angle of 33.1 degrees (range, 12.2-58.1 degrees) and 10 patients with tuberculous kyphosis with a mean kyphotic angle of 53.9 degrees (range, 22.6-126.0 degrees). The mean follow-up period was 36.4 months (range, 28-54 mo). We compared the clinical outcomes between the 2 groups based on radiographic findings, neurological status, and complications. Intervertebral heights and kyphosis at the level of vertebral column resection were used to measure the radiographic outcomes. Neurological outcome was evaluated using the modified Frankel grading system.

RESULTS

Postoperatively, the mean kyphosis angle was 3.0±10.8 and 6.7±7.2 degrees (P=0.094). At a final follow-up, these values were 4.7±10.1 and 12.3±18.9 degrees in the corresponding order (P=0.099). There were 19 (80.0%) and 21 (86.4%) patients with solid arthrodesis of grade 1. On modified Frankel grading system, all the patients but one achieved improvement. But there was no significant difference in the grade between the 2 groups (P>0.05). Also in our series, there were 12 patients with cage subsidence and 6 with screw loosening.

CONCLUSIONS

Nonexpandable cage and expandable cage are viable options for anterior support; both cages allow for correction of kyphosis with good fusion rate with similar neurological outcomes. Expandable cage is effective for the anterior support of posterior vertebral column resection.

Temporary Percutaneous Instrumentation and Selective Anterior Fusion for Thoracolumbar Fractures

STUDY DESIGN

Prospective clinical trial in thoracolumbar trauma with 5-year follow-up.

OBJECTIVE

To analyze clinical and radiographic outcomes of minimal invasive surgery, and the rational of circumferential fracture treatment with regard to age, degenerative changes, bone mineral density, and global sagittal balance.

SUMMARY OF BACKGROUND DATA

Non-neurologic fractures with anterior column defect can be treated by posterior percutaneous instrumentation and selective anterior fusion. After consolidation, instrumentation can be removed at 1 year to provide mobility in non-fused segments.

METHODS

Fifty-one patients, 47 (18-75) years, were operated for A2, A3, or B-type fractures. Visual analog scale (VAS) for back pain and Oswestry Disability Index (ODI) were assessed. Radiographic measurements were: sagittal index, regional kyphosis, T4-T12 kyphosis, L1-S1 lordosis, pelvic incidence, pelvic tilt, sacral slope, and T9 tilt. Anterior fusion and facet joints were analyzed on computed tomography (CT) at 1 year.

RESULTS

The ODI was 8.8 before accident, 35.4 at 3 months, 17.8 at 2 years, 14.4 at 5 years. The VAS was 2.0 at 3 months and 1.0 at 5 years. The sagittal index was 18.0° preoperatively and 1.0° at 3 months (P < 0.0001). A loss of reduction of 1.1° occurred after implant removal (P = 0.009). Global sagittal balance remained unchanged. Ten patients with osteopenia or osteoporosis had a worse ODI: 24.7 versus 11.9 (P = 0.016), and a greater loss of correction: 4.9° versus 1.3° (P = 0.007). Cages filled with cancellous bone from the fractured vertebra fused regularly. Spontaneous facet joint fusions were observed in two patients at the fracture level in B-type injuries.

CONCLUSION

Percutaneous instrumentation and selective anterior fusion using autologous bone and mesh cages lead to high fusion rates, which provided good long-term clinical results in younger patients with thoracolumbar fractures. Sagittal alignment was maintained after instrumentation removal without damaging paravertebral muscles. Outcomes were worse in elderly patients presenting osteopenia or osteoporosis.

LEVEL OF EVIDENCE

3.

Impact of Sagittal Balance on Clinical Outcomes in Surgically Treated T12 and L1 Burst Fractures: Analysis of Long-Term Outcomes after Posterior-Only and Combined Posteroanterior Treatment

Objective. Long-term radiological and clinical outcome retrospective study of surgical treatment for T12 and L1 burst fractures in perspective of sagittal balance measures. Methods. Patients with age of 16–60 years, complete radiographs, early surgical treatment surgery, and follow-up (F/U) > 18 months were included and strict exclusion criteria applied. Regional and thoracolumbar kyphosis angles (RKA and TLA) were measured preoperatively and at final F/U, as were parameters of the spinopelvic sagittal alignment. Clinical outcomes were assessed using validated measures. Results. 36 patients with age mean age of 39 years and F/U of 69 months were included. 61% of patients were treated with bisegmental posterior instrumentation (POST-I) and 39% with combined posteroanterior instrumented fusion (PA-F). At F/U, several indicators for clinical outcomes showed a significant correlation with radiographic measures in the overall cohort with inferior clinical outcomes corresponding with increasing residual deformity and sagittal malalignment. Statistical analysis failed to reach level of significance for the differences between POST-I and PA-F group at final F/U. Only a strong trend towards better restoration of the thoracolumbar alignment was observed for the PA-F group in terms of the RKA and TLA. Conclusions. Results in a surgically treated cohort of T12 and L1 burst fracture patients indicate that superior clinical outcomes depend on restoration of sagittal alignment.

Radiological Prediction of Posttraumatic Kyphosis After Thoracolumbar Fracture

Objectives:

Classification methods that are currently being used for clinical decision making in thoracolumbar fractures, are limited by reproducibility and prognostic value. Additionally, they do not include kyphosis. As a posttraumatic kyphosis is related to persistent pain, it is of importance to determine a risk of posttraumatic kyphosis based on fracture type and patient characteristics.

Purpose:

To determine risk factors (AO classification, age, gender, localization) that may lead to progressive kyphosis after a thoracolumbar fracture.

Materials and Methods:

Retrospective radiographic analysis of a consecutive patientcohort that presented in our clinic with a traumatic fracture of the thoracolumbar spine between 2004 and 2011. Cobb angle, Gardner angle, vertebral compression angle and anterior vertebral body compression were measured on plain radiographs, direct post-trauma and at follow-up.

Results:

Age and localization are not significantly correlated, but there seems to be an increased risk of progression of kyphosis in age > 50 years and fractures localized at Th12 or L1. A3 type fractures are significantly more at risk for posttraumatic kyphosis compared to A1 and A2 type fractures. 30-50% of the A3 type fractures have an end Gardner angle and end vertebral compression angle of more than 20 degrees.

Conclusion:

AO-type A3 fractures appear to be at risk of progression of kyphosis. Localization at Th12-L1 and age above 50 years seem to be risk factors for significant posttraumatic kyphosis. These findings should be used in patient counseling and a meticulous evaluation by weekly radiographs is recommended to determine the treatment strategy of thoracolumbar fractures.

Modified closing-opening wedge osteotomy for the treatment of sagittal malalignment in thoracolumbar fractures malunion

BACKGROUND CONTEXT

Many techniques have been described for the surgical treatment of rigid posttraumatic thoracolumbar kyphosis, but none is well adapted to the modified shape of the wedged vertebra.

PURPOSE

The study aimed to describe the modified closing-opening wedge osteotomy (MCOWO), a new osteotomy technique that adapts to the triangular shape of the wedged apical vertebra of the deformity.

STUDY DESIGN

A retrospective assessment of the degree of correction before and after the MCOWO was carried out.

PATIENT SAMPLE

Ten patients presenting rigid posttraumatic thoracolumbar kyphosis were enrolled in this study.

OUTCOME MEASURES

We used preoperative and postoperative whole spine radiographs to assess the sagittal plane parameters, and computed tomography scan for measurement of the vertebral segment height at the osteotomy level, spinal cord length, aorta length, and fusion rate.

METHODS

Ten patients underwent the MCOWO at T12 or L1. The procedure involves removing the postero-superior triangular corner of the wedged vertebra and transforming it to a shape similar to a trapezoid.

RESULTS

The patients' mean age was 36.6±7.5 years, the mean time between the fracture and the surgery was 12.2±5.6 months, and the mean follow-up was 30.6±5 months. In all patients, statistically significant improvement was observed in the sagittal plane after surgery. The thoracolumbar angle improved from 52±6° preoperatively to 7.1±5.7° at the last follow-up. Mean osteotomy angle was 38.1±2.6°, mean spinal cord shortening was 1.2±0.2 cm, and mean aorta lengthening was 2.3±0.4 cm. All the patients showed complete fusion at 2 years, and none required revision surgery. Two patients presented a temporary unilateral weakness that recovered completely within 3 months after the surgery.

CONCLUSIONS

The MCOWO is an interesting procedure for patients with posttraumatic thoracolumbar kyphosis. The modified osteotomy is adapted to the modified shape of the compressed vertebra. Spinal cord shortening and aorta lengthening were well tolerated in all patients.

Clinical and radiological outcomes of modified posterior closing wedge osteotomy for the treatment of posttraumatic thoracolumbar kyphosis

OBJECT

Most thoracolumbar fractures have a good healing outcome with adequate treatment. However, posttraumatic thoracolumbar kyphosis can occur in a proportion of thoracolumbar fractures after inappropriate treatment, osteoporosis, or osteonecrosis of the vertebral body. There are several surgical options to correct posttraumatic thoracolumbar kyphosis, including anterior, posterior, and combined approaches, which are associated with varying degrees of success. The aim of this study was to assess the use of a modified closing wedge osteotomy for the treatment of posttraumatic thoracolumbar kyphosis and to evaluate the radiographic findings and clinical outcomes of patients treated using this technique.

METHODS

Thirteen consecutive patients with symptomatic posttraumatic thoracolumbar kyphosis were treated using a modified closing wedge osteotomy. The mean patient age was 62 years. The kyphosis apex ranged from T-10 to L-2. The sagittal alignment, kyphotic angle, neurological function, visual analog scale for back pain, and Oswestry Disability Index were evaluated before surgery and at follow-up.

RESULTS

The mean preoperative regional angle was 27. 4°, and the mean correction angle was 29. 6°. Sagittal alignment improved with a mean correction rate of 58. 3%. The mean surgical time was 275 minutes, and the mean intraoperative blood loss was 1585 ml. The intraoperative complications included 2 dural tears, 1 nerve root injury, and 1 superficial wound infection. The mean visual analog scale score for back pain improved from 6. 6 to 2, and the Oswestry Disability Index score decreased from 55. 4 to 22. 6 at the last follow-up. All patients achieved bony anterior fusion based on the presence of trabecular bone bridging at the osteotomy site.

CONCLUTIONS

The modified posterior closing wedge osteotomy technique achieves satisfactory kyphosis correction with direct visualization of the circumferentially decompressed spinal cord, as well as good fusion with less blood loss and fewer complications. It is an alternative method for treating patients with posttraumatic thoracolumbar kyphosis.

Percutaneous vertebral augmentation with polyethylene mesh and allograft bone for traumatic thoracolumbar fractures

Purpose. In cases of traumatic thoracolumbar fractures, percutaneous vertebral augmentation can be used in addition to posterior stabilisation. The use of an augmentation technique with a bone-filled polyethylene mesh as a stand-alone treatment for traumatic vertebral fractures has not yet been investigated. Methods. In this retrospective study, 17 patients with acute type A3.1 fractures of the thoracic or lumbar spine underwent stand-alone augmentation with mesh and allograft bone and were followed up for one year using pain scales and sagittal endplate angles. Results. From before surgery to 12 months after surgery, pain and physical function improved significantly, as indicated by an improvement in the median VAS score and in the median pain and work scale scores. From before to immediately after surgery, all patients showed a significant improvement in mean mono- and bisegmental kyphoses. During the one-year period, there was a significant loss of correction. Conclusions. Based on this data a stand-alone approach with vertebral augmentation with polyethylene mesh and allograft bone is not a suitable therapy option for incomplete burst fractures for a young patient collective.

Closing-opening wedge osteotomy for thoracolumbar traumatic kyphosis

Background

Surgical treatment modalities for post-traumatic kyphosis (PTK) remain controversial. Like vertebral column resection, closing-opening wedge osteotomy (COWO) can achieve satisfactory results for kyphosis with multiple etiologies. However, few studies have assessed this procedure for PTK. Our purpose was to evaluate the radiographic and clinical outcomes of COWO in a selected series of patients with PTK via a single posterior approach.

Methods

In this retrospective case series, seven patients with symptomatic PTK in the thoracolumbar spine were reviewed. Five patients underwent surgery at the time of initial injury, and the other two initially underwent conservative treatment. All seven patients underwent COWO procedures through a single posterior approach. The Cobb angle was assessed preoperatively, postoperatively, and at the final follow-up. A visual analog scale (VAS) and the American Spinal Injury Association scale were used to evaluate back pain and neurological function preoperatively and at final follow-up, respectively. Operation-associated complications were also recorded.

Results

The mean follow-up period was 34.3 months (range, 24 to 43 months). The mean kyphotic angle was significantly (P <0.05) reduced from 57.7° (range, 36° to 100°) preoperatively to 8° postoperatively (range, −12° to 50°). The mean VAS improved from 5.9 to 2.1 (P <0.05). Three patients exhibited improved neurological function. Bony fusion was achieved in all patients. No significant correction loss or permanent complication was noted.

Conclusions

Though technically demanding, COWO via a single posterior approach can provide satisfactory outcomes for selected patients with PTK. Additional studies are required to improve patient selection and outcomes for this condition.

TheT1 pelvic angle, a novel radiographic measure of global sagittal deformity, accounts for both spinal inclination and pelvic tilt and correlates with health-related quality of life

BACKGROUND

Adult spinal deformity is a prevalent cause of pain and disability. Established measures of sagittal spinopelvic alignment such as sagittal vertical axis and pelvic tilt can be modified by postural compensation, including pelvic retroversion, knee flexion, and the use of assistive devices for standing. We introduce the T1 pelvic angle, a novel measure of sagittal alignment that simultaneously accounts for both spinal inclination and pelvic retroversion. The purpose of this study was to investigate the relationship of the T1 pelvic angle and other established sagittal alignment measures and to correlate these parameters with health-related quality-of-life measures.

METHODS

This is a multicenter, prospective, cross-sectional analysis of consecutive patients with adult spinal deformity. Inclusion criteria were adult spinal deformity, an age of greater than eighteen years, and any of the following: scoliosis, a Cobb angle of ≥ 20°, sagittal vertical axis of ≥ 5 cm, thoracic kyphosis of ≥ 60°, and pelvic tilt of ≥ 25°. Clinical measures of disability included the Oswestry Disability Index (ODI), Scoliosis Research Society (SRS)-22, and Short Form-36 (SF-36) questionnaires.

RESULTS

Five hundred and fifty-nine consecutive patients with adult spinal deformity (mean age, 52.5 years) were enrolled. The T1 pelvic angle correlated with the sagittal vertical axis (r = 0.837), pelvic incidence minus lumbar lordosis (r = 0.889), and pelvic tilt (0.933). Categorizing the patients by increasing T1 pelvic angle (<10°, 10° to 20°, 21° to 30°, and > 30°) revealed a significant and progressive worsening in health-related quality of life (p < 0.001 for all). The T1 pelvic angle and sagittal vertical axis correlated with the ODI (0.435 and 0.455), SF-36 Physical Component Summary (-0.445 and -0.458), and SRS (-0.358 and -0.383) (p < 0.001 for all). Utilizing a linear regression analysis, a T1 pelvic angle of 20° corresponded to a severe disability (an ODI of >40), and the meaningful change in T1 pelvic angle corresponding to one minimal clinically important difference was 4.1° on the ODI.

CONCLUSIONS

The T1 pelvic angle correlates with health-related quality of life in patients with adult spinal deformity. The T1 pelvic angle is related to both pelvic tilt and sagittal vertical axis; however, unlike sagittal vertical axis, it does not vary on the basis of the extent of pelvic retroversion or patient support in standing. Since the T1 pelvic angle is an angular and not a linear measure, it does not require calibration of the radiograph. Thus, the T1 pelvic angle measures sagittal deformity independent of many postural compensatory mechanisms, and it can be useful as a preoperative planning tool, with a target T1 pelvic angle of < 14°.

LEVEL OF EVIDENCE

Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Floating spine after pedicle subtraction osteotomy for post-traumatic kyphosis

PURPOSE

Pedicle subtraction osteotomy (PSO) was developed to achieve significant correction of a deformity. It was initially used to correct sagittal plane deformities associated with ankylosing spondylitis, but recently it has also been performed in patients with post-traumatic kyphosis. Our aim was to report a case of a floating spine after PSO for post-traumatic kyphosis.

METHODS

A 50-year-old man was injured after a fall. He had a compression fracture at T12 and an open fracture of the right lower limb. Although he presented with focal back pain, his open fracture was treated first by surgical intervention. The T12 compression fracture was treated conservatively. One year later, he had lower limb numbness and muscle weakness. His imaging demonstrated focal kyphosis on T12 and spinal cord compression. The diagnosis was post-traumatic kyphosis, which was treated with PSO. We performed osteotomy at T12, discectomy and bone graft at T11-T12, and posterior fusion from T10 to L2.

RESULTS

One year after PSO, we removed the instruments because he complained of pain around them and found complete bony union between T11 and T12. He immediately experienced worse pain and could not walk or stand for more than 10 min. Imaging showed a floating spine between T12 and L1. He underwent anterior fusion at T12-L1, after which his severe back pain disappeared.

CONCLUSIONS

This case points out a pitfall of PSO. Although it is a powerful tool for correcting an imbalanced spine, we should recognize its pitfalls and try to avoid them.

Surgery for kyphosis

Kyphosis is a difficult topic of spinal surgery, and its management contains many controversies. Surgical management needs consideration of different aspects of the kyphotic deformity such as neurological status, the presence of spinal cord compression, angle of the kyphosis, the quality of bone, and accompanying diseases. In case of significant cord compression and neurological compromise, anterior surgery should have the priority. However, in smooth-angled kyphosis and ankylosing spondylitis patients, deformity can easily be reduced by a posterior-only approach. Since they have no neurological deficits, and large spinal canals, most suitable patients for pedicle subtraction osteotomy are the patients with ankylosing spondylitis.In lumbar kyphosis one-level pedicle subtraction osteotomy (especially at L2 or L3 levels), in thoracic kyphosis multilevel osteotomies, and in cervicothoracic kyphosis an osteotomy at C7-T1 level should be preferred.Pedicle subtraction osteotomy is a technically demanding procedure that requires surgeons to perform meticulous technique and consider biomechanical issues to achieve satisfactory results and avoid complications. An attempt to correct the rigid fixed spinal deformity is a difficult task and requires the capability of a highly experienced spine surgeon. Although the physical outcome and patient satisfaction of surgical treatment is quite good, risks and complications should always be considered by both the physician and patient.

Posterior Surgery Alone in the Treatment of Post-traumatic Kyphosis by Posterior Column Osteotomy, Spondylodesis, Instrumentation, and Vertebroplasty

Study Design

Retrospective study.

Purpose

To determine if posterior surgery alone can satisfactorily treat post-traumatic kyphosis (PTK).

Overview of Literature

One of the worst complications of vertebral fractures is PTK. The type of surgery and approach to treat a symptomatic and refractory PTK is a challenging issue in spinal surgery, and yet, there is no specific treatment algorithm.

Methods

From August 2003 to September 2010, we collected 26 cases (male to female ratio, 2.25; mean age, 31.9±9.7 years and follow-up period of 42.4±8.1 months) with PTK treated by posterior column osteotomy, spondylodesis, instrumentation and cement vertebroplasty in one stage posterior surgery. PTK angle, Oswestry Disability Index (ODI), visual analogue scale (VAS), and subjective satisfaction from surgery were used to determine the results. We used a student t test for analyzing the data before and after surgery.

Results

In our patients, T11 and L1 had the highest incidence of vertebral fractures. The results indicated that in PTK, ODI, and VAS were significantly improved this surgery. Solid fusion occurred in 96.2% of patients with 3.2°±2.1° loss of correction. A total of 84.6% of patients have satisfaction level of excellent and good.

Conclusions

Posterior surgery alone with posterior column osteotomy, vertebroplasty, posterior spinal fusion and instrumentation can effectively treat symptomatic PTK.

Relationships between the Arbeitsgemeinschaft für Osteosynthesefragen Spine System and the Thoracolumbar Injury Classification System: an analysis of the literature

CONTEXT

The Thoracolumbar Injury Classification System (TLICS) has been recently described to help surgeons in the decision-making process of thoracolumbar spinal trauma.

OBJECTIVE

To analyze the potential relationships between the TLICS scores with the Arbeitsgemeinschaft für Osteosynthesefragen (AO) Spine System and patient's neurological status.

METHODS

Literature analysis of the potential scored injuries in the TLICS system, based on its individual scores, its total score, and its suggested proposed treatment, correlating these with the AO system and neurological status.

RESULTS

Findings are presented according to the TLICS score. Patients with a TLICS 1-3 points, receiving conservative treatment, are AO type A injuries, generally neurologically intact. TLICS 4 group also included AO type A fractures, neurologically ranging from intact to complete spinal cord injury. TLICS 5-10 points includes AO type B and C injuries, regarding their neurological status, and burst fractures (AO type A) with concomitant neurological injury and most of the patients with incomplete deficits and cauda equina syndrome.

CONCLUSIONS

As a general overview, according to the TLICS, patients without neurological deficit and with AO type A injuries are conservatively treated. AO type B and C injuries are managed surgically, with regard to neurological status. Patients with cauda equina or incomplete injuries also received a higher severity score. Controversies still exist regarding the management of unstable burst fractures without neurological status. The role of the posterior ligamentous complex status and the magnetic resonance imaging in the decision-making process require more clinical evidence.

Kümmell's disease, an uncommon and complicated spinal disorder: a review

Kümmell's disease is an uncommon and complicated spinal condition first described in 1891. Patients develop a kyphosis in the lower thoracolumbar spinal region months to years after sustaining an otherwise asymptomatic minor spinal trauma. The patho physiology, clinical presentation, imaging and treatment options of this disease remain controversial. The most widely accepted hypothetical patho physiology is avascular osteonecrosis. The intravertebral vacuum cleft phenomenon is considered a radiographic sign of avascular osteonecrosis of the vertebral body and is highly suggestive of Kümmell's disease. Treatment options include nonsurgical and surgical treatment, and percutaneous vertebral augmentation. The primary aims of surgical treatment of Kümmell's disease are neural decompression and stabilization of the spinal column. Surgery can involve an anterior, posterior, or combined anterior and posterior approach. Surgery and percutaneous vertebral augmentation provide significant symptomatic relief, functional improvement and deformity correction. Treatment of this disease must be individualized according to the stage of disease and the experience and preference of the surgeon.

Post-traumatic deformity: prevention and management

Traumatic spinal column injuries (SCI) can result in devastating deformities that often have long-term impact on the patient's quality of life. These deformities result in pain and occasionally neurological deficits. The deformities affecting adults often differ slightly from those in the pediatric population. In adults, injuries to the spinal column frequently result in a sagittal plane deformity, such as kyphosis or lordosis. However, in children, spinal cord injuries often cause coronal deformities, such as scoliosis. Patients with post-traumatic spinal column deformities may present acutely immediately after the injury, many years after the inciting event, or at any time in-between. Patients with post-traumatic spinal deformity initially complain of pain at the site of the deformity, but with time may complain of pain above or below the deformity as a result of degenerative changes. Any change or worsening of neurological status is a worrisome complaint, and often these patients require surgical intervention. Procedures such as fusions and spinal column osteotomies have shown promising results in treating patients with post-traumatic spinal deformities and have been shown to improve their quality of life.

Implications of the center of rotation concept for the reconstruction of anterior column lordosis and axial preloads in spinal deformity surgery

OBJECT

In thoracolumbar deformity surgery, anterior-only approaches are used for reconstruction of anterior column failures. It is generally advised that vertebral body replacements (VBRs) should be preloaded by compression. However, little is known regarding the impact of different techniques for generation of preloads and which surgical principle is best for restoration of lordosis. Therefore, the authors analyzed the effect of different surgical techniques to restore spinal alignment and lordosis as well as the ability to generate axial preloads on VBRs in anterior column reconstructions.

METHODS

The authors performed a laboratory study using 7 fresh-frozen specimens (from T-3 to S-1) to assess the ability for lordosis reconstruction of 5 techniques and their potential for increasing preloads on a modified distractable VBR in a 1-level thoracolumbar corpectomy. The testing protocol was as follows: 1) Radiographs of specimens were obtained. 2) A 1-level corpectomy was performed. 3) In alternating order, lordosis was applied using 1 of the 5 techniques. Then, preloads during insertion and after relaxation using the modified distractable VBR were assessed using a miniature load-cell incorporated in the modified distractable VBR. The modified distractable VBR was inserted into the corpectomy defect after lordosis was applied using 1) a lamina spreader; 2) the modified distractable VBR only; 3) the ArcoFix System (an angular stable plate system enabling in situ reduction); 4) a lordosizer (a customized instrument enabling reduction while replicating the intervertebral center of rotation [COR] according to the COR method); and 5) a lordosizer and top-loading screws ([LZ+TLS], distraction with the lordosizer applied on a 5.5-mm rod linked to 2 top-loading pedicle screws inserted laterally into the vertebra). Changes in the regional kyphosis angle were assessed radiographically using the Cobb method.

RESULTS

The bone mineral density of specimens was 0.72 ± 22.6 g/cm(2). The maximum regional kyphosis angle reconstructed among the 5 techniques averaged 9.7°-16.1°, and maximum axial preloads averaged 123.7-179.7 N. Concerning correction, in decreasing order the LZ+TLS, lordosizer, and ArcoFix System outperformed the lamina spreader and modified distractable VBR. The order of median values for insertion peak load, from highest to lowest, were lordosizer, LZ+TLS, and ArcoFix, which outperformed the lamina spreader and modified distractable VBR. In decreasing order, the axial preload was highest with the lordosizer and LZ+TLS, which both outperformed the lamina spreader and the modified distractable VBR. The technique enabling the greatest lordosis achieved the highest preloads. With the ArcoFix System and LZ+TLS, compression loads could be applied and were 247.8 and 190.6 N, respectively, which is significantly higher than the insertion peak load and axial preload (p < 0.05).

CONCLUSIONS

Including the ability for replication of the COR in instruments designed for anterior column reconstructions, the ability for lordosis restoration of the anterior column and axial preloads can increase, which in turn might foster fusion.

Application of transforaminal lumbar interbody fusion in old thoracolumbar fracture and dislocation

BACKGROUND

The main indications for surgery for old thoracolumbar fractures are pain, progressive deformity, neurological damage, or increasing neurological deficit. These fractures have been one of the greatest therapeutic challenges in spinal surgery. Anterior, posterior, or combined anterior and posterior procedures have been successful to some extent. As far as we know, there is no report in the literature of transforaminal lumbar interbody fusion (TLIF) for old thoracolumbar fracture and dislocation.

METHODS

Case report.

RESULTS

A 26-year-old man with old fracture and dislocation of T12/L1 was treated with TLIF. At 12 months' follow-up, multi-slice computed tomography (CT) scans showed that solid fusion had been achieved between T12 and L1. Back pain had resolved completely at 2-year follow-up.

CONCLUSIONS

We performed TLIF for in a man with old fracture and dislocation of T12/L1, with good clinical outcome. TLIF might be an option in the treatment of old thoracolumbar fracture.