New trends in surgical stabilization of thoraco-lumbar spinal fractures with emphasis for sublaminar wiring

Hybrid Stabilization of Thoracic Spine Fractures with Sublaminar Bands and Transpedicular Screws: Description of a Surgical Alternative and Review of the Literature

Stabilization of unstable thoracic fractures with transpedicular screws is widely accepted. However, placement of transpedicular screws can cause complications, particularly in the thoracic spine with physiologically small pedicles. Hybrid stabilization, a combination of sublaminar bands and pedicle screws, might reduce the rate of misplaced screws and can be helpful in special anatomic circumstances, such as preexisting scoliosis and osteoporosis. We report about two patients suffering from unstable thoracic fractures, of T5 in one case and T3, T4, and T5 in the other case, with preexisting scoliosis and extremely small pedicles. Additionally, one patient had osteoporosis. Patients received hybrid stabilization with pedicle screws adjacent to the fractured vertebral bodies and sublaminar bands at the level above and below the pedicle screws. No complications occurred. Follow-up was 12 months with clinically uneventful postoperative courses. No signs of implant failure or loss of reduction could be detected. In patients with very small thoracic pedicles, scoliosis, and/or osteoporosis, hybrid stabilization with sublaminar bands and pedicle screws can be a viable alternative to long pedicle screw constructs.

Pedicle screw fixation in spinal disorders: a European view

Continuing controversy over the use of pedicular fixation in the United States is promoted by the lack of governmental approval for the marketing of these devices due to safety and efficacy concerns. These implants have meanwhile become an invaluable part of spinal instrumentation in Europe. With regard to the North American view, there is a lack of comprehensive reviews that consider the historical evolution of pedicle screw systems, the rationales for their application, and the clinical outcome from a European perspective. This literature review suggests that pedicular fixation is a relatively safe procedure and is not associated with a significantly higher complication risk than non-pedicular instrumentation. Pedicle screw fixation provides short, rigid segmental stabilization that allows preservation of motion segments and stabilization of the spine in the absence of intact posterior elements, which is not possible with non-pedicular instrumentation. Fusion rates and clinical outcome in the treatment of thoracolumbar fractures appear to be superior to that achieved using other forms of treatment. For the correction of spinal deformity (i.e., scoliosis, kyphosis, spondylolisthesis, tumor), pedicular fixation provides the theoretical benefit of rigid segmental fixation and of facilitated deformity correction by a posterior approach, but the clinical relevance so far remains unknown. In low-back pain disorders, a literature analysis of 5,600 cases of lumbar fusion with different techniques reveals a trend that pedicle screw fixation enhances the fusion rate but not clinical outcome. The most striking finding in the literature is the large range in the radiological and clinical results. For every single fusion technique poor and excellent results have been described. This review argues that European spine surgeons should begin to back up the evident benefits of pedicle screw systems for specific spinal disorders by controlled prospective clinical trials. This may prevent forthcoming medical licensing authorities from restricting the use of pedicle screw devices and dictating the practice of spinal surgery in Europe in the near future.

Spinal canal restoration by posterior distraction or anterior decompression in thoracolumbar spinal fractures and its influence on neurological outcome

Thirty consecutive patients who had suffered unstable fractures and dislocations of the thoracolumbar spine mostly associated with neurologic impairment and bony encroachment on the spinal canal were treated either with Harrington distraction rods combined with sublaminar wires or with the Zielke-VDS device. These patients were subsequently assessed for neurologic outcome, spinal canal clearance, sagittal and coronal spinal deformity correction preoperatively and postoperatively with a minimum follow-up of 26 months. In the follow-up evaluation, the patients who underwent surgery with Harrington rods showed an overall improvement of their neurologic function of 90.9%, whereas all patients who underwent the Zielke operation improved. Preoperatively, positive correlations were found between the level of injury and Frankel grades; the cord lesion tended to demonstrate more severe neurologic deficit when compared with cauda equina ones (P < 0.001). Furthermore, dislocation accompanying the injury resulted in a more severe neurological deficit (P < 0.05). Harrington rods and Zielke device offer sufficient initial correction of the frontal spinal deformity but did not significantly either restore or maintain sagittal plane alignment. The Harrington series showed an overall improvement of the segmental kyphosis of 26% (NS), with a subsequent loss of correction of 7.38% (NS) on the follow-up observation. The Zielke device produced an immediate, much better correction of the segmental posttraumatic kyphosis of 45% (NS), but a loss of correction of 22.9% (NS) was measured in the follow-up evaluation. Correction of the anterior and posterior vertebral height was shown to be better for the Zielke patient group.(ABSTRACT TRUNCATED AT 250 WORDS)

Use of long rods and a short arthrodesis for burst fractures of the thoracolumbar spine. A long-term follow-up study

Thirteen patients who had a burst fracture of the thoracolumbar spine (the twelfth thoracic to the fifth lumbar vertebra) were managed with the use of long rods and a short arthrodesis (the so-called rod-long, fuse-short technique). The patients were followed for an average of seventy-four months (range, thirty-four to 118 months). Six months after the operation, the rods were removed and the fusion mass was explored. At that time, twelve patients had a solid fusion at all levels of the arthrodesis. Of the eighty-eight facet joints that had been spanned by the rods but had not been included in the arthrodesis, two had nevertheless progressed to fusion, as determined radiographically. Physiological motion was present in forty-three of the forty-four segments for which a fusion had not been intended. Before the operation, the average anterior height of the fractured vertebrae was 61 per cent of the estimated height before the injury; this improved after the operation to an average of 83 per cent (median, 87 per cent) of the height before the injury. At the latest follow-up examination, the anterior height was an average of 78 per cent of the estimated height before the injury (median, 82 per cent; range, 51 to 93 per cent), a slight decrease compared with the value immediately after the operation. Kyphosis of the injured segment before the operation, measured for twelve of the thirteen patients, averaged 15 degrees (median, 12 degrees; range, 0 to 33 degrees); as a result of the operation, this improved an average of 15 degrees, to 0 degrees of kyphosis.(ABSTRACT TRUNCATED AT 250 WORDS)