Management of Posttraumatic Kyphosis After Thoracolumbar Injuries

Spinal Post-traumatic Deformity: An International Expert Survey Among AO Spine Knowledge Forum Members

STUDY DESIGN

Survey among spine experts.

OBJECTIVE

To investigate the different views and opinions of clinically relevant spinal post-traumatic deformity (SPTD).

SUMMARY OF BACKGROUND DATA

There is no clear definition of clinically relevant SPTD. This leads to a wide variation in characteristics used for diagnosis and treatment indications of SPTD. To understand the current concepts of SPTD a survey was conducted among spine trauma surgeons.

METHODS

Members of the AO Spine Knowledge Forum Trauma participated in an online survey. The survey was divided in 4 domains: Demographics, criteria to define SPTD, risk factors, and management. The data were collected anonymously and analyzed using descriptive statistics, absolute, and relative frequencies. Consensus on dichotomous outcomes was set to 80% of agreement.

RESULTS

Fifteen members with extensive experience in treatment of spinal trauma participated, representing the 5 AO Spine Regions. Back pain was the only criterion for definition of SPTD with complete agreement. Consensus (≥80%) was reached for kyphotic angulation outside normative ranges and impaired function. Eighty-seven percent and 100% agreed that a full-spine conventional radiograph was necessary in diagnosing and treating SPTD, respectively. The "missed B-type injury" was rated at most important by all but 1 participant. There was no agreement on other risk factors leading to clinically relevant SPTD. Concerning the management, all participants agreed that an asymptomatic patient should not undergo surgical treatment and that neurological deficit is an absolute surgical indication. For most of the participants the preferred surgical treatment of acute injury in all spine regions but the subaxial region is posterior fixation.

CONCLUSION

Some consensus exists among leading experts in the field of spine trauma care concerning the definition, diagnosis, risk factors, and management of SPTD. This study acts as the foundation for a Delphi study among the global spine community.

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.

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.