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Zeng Z, Zhang D, Zeng FL, Ao J. Posterior unilateral small fenestration of lamina combined with a custom-made Y-shaped fracture reduction device for the treatment of severe thoracolumbar burst fracture: a prospective comparative study. J Orthop Surg Res 2023; 18:529. [PMID: 37491312 PMCID: PMC10369761 DOI: 10.1186/s13018-023-03971-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 07/03/2023] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND The purpose was to evaluate the clinical effect of a custom-made Y-shaped fracture fragment reduction device and to assist in posterior unilateral small fenestration of lamina to reduce the fracture fragments. METHODS In this study, 40 patients were assigned to one of two groups: the traditional reduction device group (TRG) or the Y-shaped reduction device group (YRG). All patients underwent posterior unilateral small fenestration of the lamina and direct decompression through the spinal canal. And the operation time (OT), intraoperative bleeding (IB), preoperative, postoperative, and final follow-up data on the spinal stenosis rate (SSR), Cobb angle, the anterior compression ratio of injured vertebrae (ACRIV), and ASIA neurological function grade were compared between the two groups. RESULT There were no complications, including vascular and nerve injury, serious postoperative infection, internal fixation fracture, or loosening, for any of the patients. And the average follow-up time of the two groups was 14.2 months, the average operation time of the TRG was 236.6 min, and the average intraoperative blood loss was 357.20 ml. Moreover, the average operation time of the YRG was 190.6 min, and the average intraoperative blood loss was 241.5 ml. There were significant differences between the two groups in terms of operation duration and intraoperative blood loss. The YRG's was lower than that of the TRG. Besides, there was no difference in SSR, Cobb angle, ACRIV, or neurological recovery between the two groups before or immediately after the operation or at the last follow-up. CONCLUSION The Y-shaped fracture reduction device can reduce the fracture fragments and the OT and IB stably; it also has satisfactory postoperative curative effects and clinical utility.
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Affiliation(s)
- Zheng Zeng
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Zunyi Medical University, Zunyi, 563000, Guizhou, China
| | - Dan Zhang
- Department of Nursing, Affiliated Hospital of Zunyi Medical University, Zunyi, 563000, Guizhou, China
| | - Fen-Lian Zeng
- Department of Nursing, Affiliated Hospital of Zunyi Medical University, Zunyi, 563000, Guizhou, China
| | - Jun Ao
- Department of Orthopaedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, 563000, Guizhou, China.
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Prajapati HP. Thoracolumbar Junction Fracture: Principle of Management. INDIAN JOURNAL OF NEUROTRAUMA 2020. [DOI: 10.1055/s-0040-1717211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractThe thoracolumbar junction (TLJ) is the most common site of traumatic spinal injury. Its management is a highly controversial area. There are no specific guidelines for management of these injuries. The primary goal of treatment of TLJ fractures involves protecting the spinal cord from further neural damage, obtaining the stability by reconstructing anatomical alignment of spinal column, and returning patients to workplace through early mobilization and rehabilitation. There is a great variation in evaluation of stability of these fractures, which is one of the crucial factors in deciding the treatment. Controversy also exists regarding conservative versus operative treatment, timing of intervention, anterior versus posterior approach, short versus long segment fixation, and bracing versus no bracing. This article had reviewed the conflicting results and recommendations for management of TLJ fractures of previously published reports in PubMed, PubMed Central, and Medline databases. We analyzed these related articles which addresses issues regarding evaluation of stability, indications for operative and conservative treatment, timing of surgery, surgical approach, and fusion length.
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Affiliation(s)
- Hanuman Prasad Prajapati
- Department of Neurosurgery, Uttar Pradesh University of Medical Sciences, Etawah, Uttar Pradesh, India
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Venier A, Roccatagliata L, Isalberti M, Scarone P, Kuhlen DE, Reinert M, Bonaldi G, Hirsch JA, Cianfoni A. Armed Kyphoplasty: An Indirect Central Canal Decompression Technique in Burst Fractures. AJNR Am J Neuroradiol 2019; 40:1965-1972. [PMID: 31649154 DOI: 10.3174/ajnr.a6285] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 08/28/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Burst fractures are characterized by middle column disruption and may feature posterior wall retropulsion. Indications for treatment remain controversial. Recently introduced vertebral augmentation techniques using intravertebral distraction devices, such as vertebral body stents and SpineJack, could be effective in fracture reduction and fixation and might obtain central canal clearance through ligamentotaxis. This study assesses the results of armed kyphoplasty using vertebral body stents or SpineJack in traumatic, osteoporotic, and neoplastic burst fractures with respect to vertebral body height restoration and correction of posterior wall retropulsion. MATERIALS AND METHODS This was a retrospective assessment of 53 burst fractures with posterior wall retropulsion and no neurologic deficit in 51 consecutive patients treated with armed kyphoplasty. Posterior wall retropulsion and vertebral body height were measured on pre- and postprocedural CT. Clinical and radiologic follow-up charts were reviewed. RESULTS Armed kyphoplasty was performed as a stand-alone treatment in 43 patients, combined with posterior instrumentation in 8 and laminectomy in 4. Pre-armed kyphoplasty and post-armed kyphoplasty mean posterior wall retropulsion was 5.8 and 4.5 mm, respectively (P < .001), and mean vertebral body height was 10.8 and 16.7 mm, respectively (P < .001). No significant clinical complications occurred. Clinical and radiologic follow-up (1-36 months; mean, 8 months) was available in 39 patients. Three treated levels showed a new fracture during follow-up without neurologic deterioration, and no retreatment was deemed necessary. CONCLUSIONS In the treatment of burst fractures with posterior wall retropulsion and no neurologic deficit, armed kyphoplasty yields fracture reduction, internal fixation, and indirect central canal decompression. In selected cases, it might represent a suitable minimally invasive treatment option, stand-alone or in combination with posterior stabilization.
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Affiliation(s)
- A Venier
- From the Departments of Neurosurgery (A.V., P.S., D.E.K., M.R.)
| | - L Roccatagliata
- Neuroradiology (L.R., M.I., A.C.), Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - M Isalberti
- Neuroradiology (L.R., M.I., A.C.), Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - P Scarone
- From the Departments of Neurosurgery (A.V., P.S., D.E.K., M.R.)
| | - D E Kuhlen
- From the Departments of Neurosurgery (A.V., P.S., D.E.K., M.R.)
| | - M Reinert
- From the Departments of Neurosurgery (A.V., P.S., D.E.K., M.R.)
| | - G Bonaldi
- Department of Neuroradiology (G.B.), Papa Giovanni XXIII Hospital, Bergamo, Italy
- Department of Neurosurgery (G.B.), Clinica Igea, Milan, Italy
| | - J A Hirsch
- Department of Neuroradiology (J.A.H.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - A Cianfoni
- Neuroradiology (L.R., M.I., A.C.), Neurocenter of Southern Switzerland, Lugano, Switzerland
- Department of Neuroradiology (A.C.), Inselspital, University Hospital of Bern, Bern, Switzerland
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Sellei RM, Kobbe P. [The coexistence of spinal canal stenosis in fragility fractures of the spine]. DER ORTHOPADE 2019; 48:837-843. [PMID: 31240355 DOI: 10.1007/s00132-019-03773-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND In trauma care of fragility fractures of the spine, degenerative stenosis is often seen as an accompanying pathology. This may lead to a possible compression of neurogenic structures. The stenosis of the spinal canal can manifest itself with clinically significant complaints before the fracture occurs. This coexistence may have an impact on the injury itself or may provoke a complicated treatment of the fracture. AIM The aim of this work is to differentiate these pathophysiologies and their merger in terms of clinical diagnostics and treatment options. DIFFERENTIAL DIAGNOSIS The differential diagnosis is difficult and is often inadequately appreciated in everyday clinical life. The etiology and pathophysiology of both entities show, in several aspects, a congruence that enables joint treatment. If the indication is set for the decompression of a stenosing fracture, a pre-existing relevant stenosis can be addressed in the same session. Conversely, significant degenerative stenosis accompanying a fracture may lead to the indication of decompression.
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Affiliation(s)
- Richard Martin Sellei
- Klinik für Unfallchirurgie und Orthopädische Chirurgie, Sana Klinikum Offenbach, Starkenburgring 66, 63069, Offenbach am Main, Deutschland. .,Klinik für Unfallchirurgie und Wiederherstellungschirurgie, Universitätsklinik der RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Deutschland.
| | - Philipp Kobbe
- Klinik für Unfallchirurgie und Wiederherstellungschirurgie, Universitätsklinik der RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Deutschland
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Cheng J, Song K, Liang Y, Tang X, Wu B, Zhang G, Zhao Y, Wang Z. Spontaneous Remodeling of Spinal Canal After Sagittal Translation in Pedicle Subtraction Osteotomy for Correction of Thoracolumbar Kyphosis in Ankylosing Spondylitis. World Neurosurg 2019; 128:e245-e251. [PMID: 31026652 DOI: 10.1016/j.wneu.2019.04.128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/14/2019] [Accepted: 04/15/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Sagittal translations (STs) secondary to osteotomy for the correction of ankylosing spondylitis (AS) kyphosis have drawn great attention, which is considered closely related to neurologic deficits and terrible fusion. Despite being discussed in several cases, there were no relevant reports about the transformation of ST and the spinal canal remodeling in AS patients. METHODS Retrospective analysis was conducted on 16 patients with ST for the treatment of AS kyphosis through pedicle subtraction osteotomy during January 2011 to December 2014 in our hospital. Full-length free-standing spinal radiographs were available for all patients before and after surgery and also at the final follow-up. Radiologic parameters including global kyphosis (GK), thoracolumbar kyphosis (TLK), lumbar lordosis (LL), sagittal vertical axis (SVA), and ST were measured. Rates of ST transformation after the surgery and at 1-year follow-up were compared. RESULTS The average follow-up was 22 months, ranging from 12-36 months. There was no internal fixation failure during this period. The preoperative GK was 59.9 ± 21.0°, TLK was 38.0 ± 13.0°, LL was 7.4 ± 26.5°, and SVA was 27.2 ± 8.6 mm. The postoperative GK was 15.7 ± 2.1°, TLK was 5.6 ± 2.6°, LL was -36.1 ± 2.9°, and SVA was 6.1 ± 4.3 mm. ST was 7.1 ± 2.7 mm after surgery and 1.2 ± 1.0 mm at 1-year follow-up. The difference was statistically significant (P < 0.05). The rate of ST transformation was 84.9% ± 9.7%. According to Scoliosis Research Society surveys, the preoperative and the final follow-up satisfaction score was 1.6 ± 0.3 and 4.7 ± 0.4 respectively (P < 0.05). Remodeling of the spinal canal happened to all the patients with different degrees. CONCLUSIONS All patients with ST after pedicle subtraction osteotomy for AS kyphosis occurred with spontaneous remodeling of the spinal canal at 1-year follow-up, by which ST can decrease in different degrees or even disappear, and favorable fusion can be achieved even without bone grafting into the osteotomy vertebra.
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Affiliation(s)
- Junyao Cheng
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), Beijing, PR China
| | - Kai Song
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), Beijing, PR China
| | - Yan Liang
- Department of Spinal Surgery, Chinese Peking University People's Hospital, Beijing, PR China
| | - Xiangyu Tang
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), Beijing, PR China
| | - Bing Wu
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), Beijing, PR China
| | - Guoying Zhang
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), Beijing, PR China
| | - Yongfei Zhao
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), Beijing, PR China
| | - Zheng Wang
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), Beijing, PR China.
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6
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Hoh DJ, Qureshi S, Anderson PA, Arnold PM, John HC, Dailey AT, Dhall SS, Eichholz KM, Harrop JS, Rabb CH, Raksin PB, Kaiser MG, O'Toole JE. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients With Thoracolumbar Spine Trauma: Nonoperative Care. Neurosurgery 2019; 84:E46-E49. [PMID: 30203096 DOI: 10.1093/neuros/nyy369] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/12/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Thoracic and lumbar burst fractures in neurologically intact patients are considered to be inherently stable, and responsive to nonsurgical management. There is a lack of consensus regarding the optimal conservative treatment modality. The question remains whether external bracing is necessary vs mobilization without a brace after these injuries. OBJECTIVE To determine if the use of external bracing improves outcomes compared to no brace for neurologically intact patients with thoracic or lumbar burst fractures. METHODS A systematic review of the literature was performed using the National Library of Medicine PubMed database and the Cochrane Library for studies relevant to thoracolumbar trauma. Clinical studies specifically comparing external bracing to no brace for neurologically intact patients with thoracic or lumbar burst fractures were selected for review. RESULTS Three studies out of 1137 met inclusion criteria for review. One randomized controlled trial (level I) and an additional randomized controlled pilot study (level II) provided evidence that both external bracing and no brace equally improve pain and disability in neurologically intact patients with burst fractures. There was no difference in final clinical and radiographic outcomes between patients treated with an external brace vs no brace. One additional level IV retrospective study demonstrated equivalent clinical outcomes for external bracing vs no brace. CONCLUSION This evidence-based guideline provides a grade B recommendation that management either with or without an external brace is an option given equivalent improvement in outcomes for neurologically intact patients with thoracic and lumbar burst fractures. The decision to use an external brace is at the discretion of the treating physician, as bracing is not associated with increased adverse events compared to no brace. QUESTION Does the use of external bracing improve outcomes in the nonoperative treatment of neurologically intact patients with thoracic and lumbar burst fractures? RECOMMENDATION The decision to use an external brace is at the discretion of the treating physician, as the nonoperative management of neurologically intact patients with thoracic and lumbar burst fractures either with or without an external brace produces equivalent improvement in outcomes. Bracing is not associated with increased adverse events compared to not bracing. Strength of Recommendation: Grade B The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_8.
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Affiliation(s)
- Daniel J Hoh
- Lillian S. Wells Department of Neurological Surgery, University of Florida, Gainesville, Florida
| | - Sheeraz Qureshi
- Department of Orthopaedic Surgery, Weill Cornell Medical College, New York, New York
| | - Paul A Anderson
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, Wisconsin
| | - Paul M Arnold
- Department of Neurosurgery, University of Kansas School of Medicine, Kansas City, Kansas
| | - H Chi John
- Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Andrew T Dailey
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Sanjay S Dhall
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Kurt M Eichholz
- St. Louis Minimally Invasive Spine Center, St. Louis, Missouri
| | - James S Harrop
- Departments of Neurological Surgery and Orthopedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Craig H Rabb
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - P B Raksin
- Division of Neurosurgery, John H. Stroger, Jr Hospital of Cook County and Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
| | - Michael G Kaiser
- Department of Neurosurgery, Columbia University, New York, New York
| | - John E O'Toole
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
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7
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Park SH, Kim SD, Moon BJ, Lee SS, Lee JK. Short segment percutaneous pedicle screw fixation after direct spinal canal decompression in thoracolumbar burst fractures: An alternative option. J Clin Neurosci 2018; 53:48-54. [DOI: 10.1016/j.jocn.2018.04.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/09/2018] [Indexed: 11/30/2022]
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8
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Richardson B, Paulzak A, Rusyniak WG, Martino A. Anterior Lumbar Corpectomy with Expandable Titanium Cage Reconstruction: A Case Series of 42 Patients. World Neurosurg 2017; 108:317-324. [PMID: 28887282 DOI: 10.1016/j.wneu.2017.08.179] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 08/26/2017] [Accepted: 08/28/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Burst fractures involve the anterior and middle columns with an intact posterior column. Deforming forces are magnified at areas of transition, making the thoracolumbar junction highly susceptible to injury. METHODS This is a retrospective review of 42 consecutive patients who underwent single-level anterior lumbar corpectomy using an obelisc expandable titanium cage and lateral fixation for traumatic lumbar burst fractures. RESULTS Myelopathy and sensory dysfunction were the most frequent neurologic deficits initially, occurring in 16 (38%) and 15 (36%) patients, respectively, which both decreased to 5 (13%). At follow-up, 26 patients (68%) were able to ambulate independently. No patient had significant cage displacement or needed cage replacement. Subsidence was minimal in 32 of 39 patients (82%). There were no hardware infections or surgical site infections. Options for stabilization include posterior instrumentation and fusion, anterior corpectomy with interbody fusion, and combination procedures. We believe anterior stabilization is superior because the aim is structural restoration of anterior and middle columns. The aim of posterior fixation is to replace the posterior tension band, which is not affected. There are 3 major surgical components to consider. First is anterior versus posterior decompression of the spinal canal. Second is the choice of autograft or titanium graft. Third is whether to stabilize posteriorly or anterolateral. CONCLUSIONS Anterior corpectomy with an expandable titanium cage and lateral rod fixation is safe and effective with minimal complications. It is a viable alternative to posterior decompression and instrumentation.
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Affiliation(s)
- Bradford Richardson
- Department of Neurological Surgery, University of South Alabama, Mobile, Alabama, USA.
| | - Audrey Paulzak
- Department of Neurosurgery, University of Rochester, Rochester, New York, USA
| | - Walter G Rusyniak
- Department of Neurological Surgery, University of South Alabama, Mobile, Alabama, USA
| | - Anthony Martino
- Department of Neurological Surgery, University of South Alabama, Mobile, Alabama, USA
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9
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Wu H, Zhao DX, Jiang R, Zhou XY. Surgical treatment of Denis type B thoracolumbar burst fracture with neurological deficiency by paraspinal approach. ACTA ACUST UNITED AC 2016; 49:e5599. [PMID: 27828664 PMCID: PMC5112540 DOI: 10.1590/1414-431x20165599] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 08/23/2016] [Indexed: 12/02/2022]
Abstract
We aimed to describe the surgical technique and clinical outcomes of
paraspinal-approach reduction and fixation (PARF) in a group of patients with Denis
type B thoracolumbar burst fracture (TLBF) with neurological deficiencies. A total of
62 patients with Denis B TLBF with neurological deficiencies were included in this
study between January 2009 and December 2011. Clinical evaluations including the
Frankel scale, pain visual analog scale (VAS) and radiological assessment (CT scans
for fragment reduction and X-ray for the Cobb angle, adjacent superior and inferior
intervertebral disc height, and vertebral canal diameter) were performed
preoperatively and at 3 days, 6 months, and 1 and 2 years postoperatively. All
patients underwent successful PARF, and were followed-up for at least 2 years.
Average surgical time, blood loss and incision length were recorded. The sagittal
vertebral canal diameter was significantly enlarged. The canal stenosis index was
also improved. Kyphosis was corrected and remained at 8.6±1.4o (P>0.05)
1 year postoperatively. Adjacent disc heights remained constant. Average Frankel
grades were significantly improved at the end of follow-up. All 62 patients were
neurologically assessed. Pain scores decreased at 6 months postoperatively, compared
to before surgery (P<0.05). PARF provided excellent reduction for traumatic
segmental kyphosis, and resulted in significant spinal canal clearance, which
restored and maintained the vertebral body height of patients with Denis B TLBF with
neurological deficits.
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Affiliation(s)
- H Wu
- China-Japan Union Hospital, Department of Orthopedics, Jilin University, Changchun, China
| | - D-X Zhao
- China-Japan Union Hospital, Department of Orthopedics, Jilin University, Changchun, China
| | - R Jiang
- China-Japan Union Hospital, Department of Orthopedics, Jilin University, Changchun, China
| | - X-Y Zhou
- China-Japan Union Hospital, Department of Operating Room, Jilin University, Changchun, China
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Kocis J, Kelbl M, Wendsche P, Vesely R. Minimally invasive thoracoscopic approach to thoracolumbar junction fractures. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2016; 160:566-570. [PMID: 27725783 DOI: 10.5507/bp.2016.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 09/15/2016] [Indexed: 11/23/2022] Open
Abstract
AIMS A retrospective analysis of patients with thoracolumbar junction fractures who underwent video-assisted thoracoscopic surgery via a minimally invasive approach (minithoracotomy) for reconstruction of the anterior spinal column. METHODS Between 2002 and 2014, a total of 176 patients were treated by this technique. The patients received either posterior stabilization and, at the second stage, the minimally invasive technique via an anterior approach, or the minimally invasive anterior procedure alone. RESULTS In the anterior procedure, the average operative time was 90 min. (50 to 130 min). Bony fusion without complications was achieved in all patients within a year of surgery. The loss of correction after the anterior procedure with an allograft or titanium cage was up to 2 degrees at two years follow-up. CONCLUSION The minimally invasive approach (minithoracotomy up to 6-7 cm) combined with thoracoscopy is an alternative to an exclusively endoscopic technique enabling us to provide safe surgical treatment of the anterior spinal column.
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Affiliation(s)
- Jan Kocis
- Department of Traumatology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Martin Kelbl
- Department of Traumatology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Peter Wendsche
- Department of Traumatology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Radek Vesely
- Department of Traumatology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
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11
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Curfs I, Grimm B, van der Linde M, Willems P, van Hemert W. Radiological Prediction of Posttraumatic Kyphosis After Thoracolumbar Fracture. Open Orthop J 2016; 10:135-42. [PMID: 27347242 PMCID: PMC4897332 DOI: 10.2174/1874325001610010135] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 12/23/2015] [Accepted: 12/30/2015] [Indexed: 12/05/2022] Open
Abstract
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.
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Affiliation(s)
- Inez Curfs
- Department of Orthopaedic Surgery and Traumatology, Atrium Medical Centre, Heerlen, The Netherlands
| | - Bernd Grimm
- AHORSE Research Institute, Atrium Medical Center, Heerlen, The Netherlands
| | - Matthijs van der Linde
- Department of Orthopaedic Surgery and Traumatology, Atrium Medical Centre, Heerlen, The Netherlands
| | - Paul Willems
- Department of Orthopaedic Surgery, MUMC, Maastricht, The Netherlands
| | - Wouter van Hemert
- Department of Orthopaedic Surgery and Traumatology, Atrium Medical Centre, Heerlen, The Netherlands
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12
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Tisot RA, Vieira JSL, Tisot OF, Santos RTD, Badotti AA, Berardi A, Collares DDS. THORACOLUMBAR BURST FRACTURE: STRUCTURAL CHANGES AND CLINICAL OUTCOME OF TREATMENT. COLUNA/COLUMNA 2016. [DOI: 10.1590/s1808-185120161501150411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT Objective: To evaluate the correlation between structural changes in burst fractures of thoracic and lumbar spine with clinical outcome of the treatment. Methods: A retrospective study in 25 patients with fractures of thoracic and lumbar spine burst fractures without neurological deficit. Eleven patients underwent conservative treatment and for the remaining the treatment was surgical. All patients were followed up for at least 24 months. The cases were evaluated by a protocol that included: posttraumatic measurement of kyphosis, vertebral body collapse and narrowing of the spinal canal, the visual analog scale of pain, and the quality of life questionnaire SF-36 at the follow-up. For statistical analysis, the significance level was 5% and the software SPSS 18.0 was used. Results: No statistically significant difference was observed when comparing the clinical outcomes of one treatment over another. Similarly, there was no statistically significant correlation between kyphosis and post-traumatic narrowing of the spinal canal with clinical worsening in the follow-up, regardless of the treatment used. We found a positive correlation (p<0.05) between initial collapse and SF-36 domains in both groups (operated and non-operated). Conclusion: There was no significant superiority of one treatment over the other, and no correlation was found between kyphosis and spinal canal narrowing in burst fractures of the thoracic and lumbar spine without neurological deficit. However, there was correlation between initial collapse and clinical outcome in some domains of the SF-36 questionnaire.
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13
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Moon YJ, Lee KB. Relationship Between Clinical Outcomes and Spontaneous Canal Remodeling in Thoracolumbar Burst Fracture. World Neurosurg 2016; 89:58-64. [PMID: 26872515 DOI: 10.1016/j.wneu.2016.02.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 02/02/2016] [Accepted: 02/02/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To analyze the relationship between clinical factors and spontaneous canal remodeling. METHODS We evaluated computed tomography scans, before surgery, within a week after surgery, 6 months after surgery, and 12 months after surgery. Thirty-eight consecutive patients who underwent posterior fixation and fusion after thoracolumbar burst fractures were included in. Factors potentially affecting the postoperative degree of reduction and spontaneous spinal remodeling were defined as age, location, degree of change of anterior vertebral compression ratio, fracture type of the retropulse bone, presence of injury to the posterior longitudinal ligament, and posterolateral complex fracture. Multiple regression analyses were conducted on these factors to analyze the extent of their influence on the reduction and resorption rates. RESULTS The recovery rate of the anterior compression (P = 0.003) was significantly related to the reduction rate after surgery; in addition, the recovery rate of the anterior compression (P = 0.022) and the comminuted type of fracture (P = 0.019) were significantly associated with the resorption rate after surgery. CONCLUSIONS During posterior fixation, the degree of the reduction of the vertebral body by distraction can affect the degree of postoperative reduction and spontaneous bone remodeling. Therefore, close attention must be given to the indirect reduction technique through distraction during the operation. Because comminuted fracture fragments affect spontaneous canal remodeling, the degree of postoperative resorption can be estimated by preoperative computed tomography imaging.
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Affiliation(s)
- Young Jae Moon
- Department of Orthopedic Surgery, Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital Chonbuk National University Medical School, Jeonju, Korea
| | - Kwang-Bok Lee
- Department of Orthopedic Surgery, Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital Chonbuk National University Medical School, Jeonju, Korea.
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Bakhsheshian J, Dahdaleh NS, Fakurnejad S, Scheer JK, Smith ZA. Evidence-based management of traumatic thoracolumbar burst fractures: a systematic review of nonoperative management. Neurosurg Focus 2015; 37:E1. [PMID: 24981897 DOI: 10.3171/2014.4.focus14159] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The overall evidence for nonoperative management of patients with traumatic thoracolumbar burst fractures is unknown. There is no agreement on the optimal method of conservative treatment. Recent randomized controlled trials that have compared nonoperative to operative treatment of thoracolumbar burst fractures without neurological deficits yielded conflicting results. By assessing the level of evidence on conservative management through validated methodologies, clinicians can assess the availability of critically appraised literature. The purpose of this study was to examine the level of evidence for the use of conservative management in traumatic thoracolumbar burst fractures. METHODS A comprehensive search of the English literature over the past 20 years was conducted using PubMed (MEDLINE). The inclusion criteria consisted of burst fractures resulting from a traumatic mechanism, and fractures of the thoracic or lumbar spine. The exclusion criteria consisted of osteoporotic burst fractures, pathological burst fractures, and fractures located in the cervical spine. Of the studies meeting the inclusion/exclusion criteria, any study in which nonoperative treatment was used was included in this review. RESULTS One thousand ninety-eight abstracts were reviewed and 447 papers met inclusion/exclusion criteria, of which 45 were included in this review. In total, there were 2 Level-I, 7 Level-II, 9 Level-III, 25 Level-IV, and 2 Level-V studies. Of the 45 studies, 16 investigated conservative management techniques, 20 studies compared operative to nonoperative treatments, and 9 papers investigated the prognosis of conservative management. CONCLUSIONS There are 9 high-level studies (Levels I-II) that have investigated the conservative management of traumatic thoracolumbar burst fractures. In neurologically intact patients, there is no superior conservative management technique over another as supported by a high level of evidence. The conservative technique can be based on patient and surgeon preference, comfort, and access to resources. A high level of evidence demonstrated similar functional outcomes with conservative management when compared with open surgical operative management in patients who were neurologically intact. The presence of a neurological deficit is not an absolute contraindication for conservative treatment as supported by a high level of evidence. However, the majority of the literature excluded patients with neurological deficits. More evidence is needed to further classify the appropriate burst fractures for conservative management to decrease variables that may impact the prognosis.
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Affiliation(s)
- Joshua Bakhsheshian
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
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Gan M, Zou J, Zhu X, Wang G, Yang H. Balloon kyphoplasty for osteoporotic spinal fractures with middle column compromise. Injury 2014; 45:1539-44. [PMID: 25022230 DOI: 10.1016/j.injury.2014.06.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Revised: 04/13/2014] [Accepted: 06/18/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND Balloon kyphoplasty (BKP) is an effective method for osteoporotic vertebral compression fractures. However osteoporotic spinal fractures with middle column compromise are mentioned as a relative contraindication to BKP. Thus we investigated the safety and efficacy of BKP in the treatment of osteoporotic spinal fractures with middle column compromise but without neurological deficit. METHODS In this retrospective study, 45 patients who suffered osteoporotic fractures with middle column compromise but without neurological deficits were treated by BKP from May 2007 to December 2010. The final follow-ups were finished during the time of July 2011-September 2011. The mean follow-up period was 20.2 months. The height of the compromised vertebral body, the kyphotic angle and spinal canal compromise were measured before surgery, one day after surgery, and at the final follow-up. A visual analogue scale (VAS) and the Oswestry disability index (ODI) were chosen to evaluate pain and functional activity. RESULTS The mean VAS and ODI scores improved significantly from pre- to post-operation (p<0.05), and this improvement was sustained at the final follow-up. The mean anterior vertebral body height ratio improved from 57.6%± 11.8% preoperatively to 86.2%± 12.2% postoperatively (p<0.05), so did the mean middle vertebral body height ratio. The kyphotic angle improved from 16.3° ± 3.7° preoperatively to 9.3° ± 2.6° postoperatively (p<0.05). At final follow-up, BKP stabilised vertebral height and prevented further kyphotic deformity. While there were no differences in spinal canal compromise between pre-operation and one day after surgery (p>0.05), there was a significant difference from the measurement at the final follow-up (p<0.05). CONCLUSION BKP is a safe and effective method for osteoporotic spinal fractures with middle column compromise but without neurological deficit. Spontaneous remodelling of the spinal canal also occurs after BKP.
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Affiliation(s)
- Minfeng Gan
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, China
| | - Jun Zou
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, China
| | - Xuesong Zhu
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, China
| | - Genlin Wang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, China
| | - Huilin Yang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, China.
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Demineralization after balloon kyphoplasty with calcium phosphate cement: a histological evaluation in ten patients. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 23:1361-8. [PMID: 24566944 DOI: 10.1007/s00586-014-3239-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 02/05/2014] [Accepted: 02/06/2014] [Indexed: 01/21/2023]
Abstract
PURPOSE Balloon kyphoplasty (BKP) with calcium phosphate cement (CPC) is increasingly being used for spinal surgery in younger patients. In routinely performed follow-up CT scans we observed considerable areas of demineralization in CPC processed vertebrae in several patients. To rule out infections or inflammations histological examinations were planned for these patients. METHODS Ten patients (23-54 years; six men) with significant demineralization areas in CT scans after CPC balloon kyphoplasty were selected. Punch biopsies from these areas were taken in local anesthesia using a biopsy needle. One half of the specimen was decalcified and embedded in paraffin, and sections were examined histologically using hematoxylin and eosin, Van Gieson, and trichrome staining. The second half of the specimen was cast directly in methyl methacrylate and sections were examined by Paragon and von Kossa/Safranin staining. Stained slides were viewed under light microscopy. RESULTS Bone-punch specimens were taken at 17.5 months (mean) after BKP with CPC. In most cases, the cement was well surrounded by newly formed lamellar bone with very tight connections between the cement and new bone. Unmineralized areas were observed sporadically at the cement surface and adjacent to the implant. There were no pronounced signs of inflammation or osteolysis of adjacent bone. No complications were observed during or following patients' biopsy procedures. CONCLUSIONS CPC demonstrated good biocompatibility and osseointegration in clinical use, with no evidence of inflammation or osteonecrosis. Demineralized areas in CT scans could be a result of remodeling of the cancellous bone in vertebral bodies.
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Ray WZ, Krisht KM, Dailey AT, Schmidt MH. Clinical outcomes of unstable thoracolumbar junction burst fractures: combined posterior short-segment correction followed by thoracoscopic corpectomy and fusion. Acta Neurochir (Wien) 2013; 155:1179-86. [PMID: 23677637 DOI: 10.1007/s00701-013-1737-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Accepted: 04/22/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND There is significant controversy surrounding the ideal management of thoracolumbar burst fractures. While several treatment and management algorithms have been proposed, the ideal treatment strategy for these fractures remains unsettled. The authors review their experience with short-segment posterior fusion followed by anterior thoracoscopic corpectomy for the treatment of unstable thoracolumbar burst fractures. METHODS We identified all patients treated by a single surgeon at our institution from 2002 to 2009 with short-segment posterior fusion followed by anterior thoracoscopic corpectomy for unstable thoracolumbar junction burst fractures. Demographic data, mechanism of injury, classification of fracture, Cobb angle, American Spinal Injury Association score, associated injuries, tobacco use, follow-up duration, and radiographic studies were all collected. Outcomes were assessed for fracture alignment (preoperative, postoperative, and long-term follow-up kyphosis), rate of fusion, neurological outcome, and treatment complications. RESULTS Thirty-two patients with burst fracture of the thoracolumbar junction defined as T10 to L1 were included. At a mean follow-up of 20.4 months, 90 % of patients had demonstrated radiographic evidence of fusion and 91 % retained the correction of their kyphotic deformity. There were three complications in the series. CONCLUSIONS Short-segment posterior fusion with thoracoscopic anterior corpectomy represents an alternative to traditional open treatment of thoracolumbar burst fractures. A thoracoscopic approach allows for a short-segment posterior fusion, reducing the loss of adjacent motion segments, minimizes morbidity associated with traditional open anterior approaches, allows for anterior and posterior column stabilization, and is associated with a high rate of bony fusion.
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Jung HJ, Kim SW, Ju CI, Kim SH, Kim HS. Bone cement-augmented short segment fixation with percutaneous screws for thoracolumbar burst fractures accompanied by severe osteoporosis. J Korean Neurosurg Soc 2012; 52:353-8. [PMID: 23133724 PMCID: PMC3488644 DOI: 10.3340/jkns.2012.52.4.353] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Revised: 08/28/2012] [Accepted: 10/04/2012] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The purpose of this study was to determine the efficacy of bone cement-augmented short segment fixation using percutaneous screws for thoracolumbar burst fractures in a background of severe osteoporosis. METHODS Sixteen patients with a single-level thoracolumbar burst fracture (T11-L2) accompanying severe osteoporosis treated from January 2008 to November 2009 were prospectively analyzed. Surgical procedures included postural reduction for 3 days and bone cement augmented percutaneous screw fixation at the fracture level and at adjacent levels without bone fusion. Due to the possibility of implant failure, patients underwent implant removal 12 months after screw fixation. Imaging and clinical findings, including involved vertebral levels, local kyphosis, canal encroachment, and complications were analyzed. RESULTS Prior to surgery, mean pain score (visual analogue scale) was 8.2 and this decreased to a mean of 2.2 at 12 months after screw fixation. None of the patients complained of pain worsening during the 6 months following implant removal. The percentage of canal compromise at the fractured level improved from a mean of 41.0% to 18.4% at 12 months after surgery. Mean kyphotic angle was improved significantly from 19.8° before surgery to 7.8 at 12 months after screw fixation. Canal compromise and kyphotic angle improvements were maintained at 6 months after implant removal. No significant neurological deterioration or complications occurred after screw removal in any patient. CONCLUSION Bone cement augmented short segment fixation using a percutaneous system can be an alternative to the traditional open technique for the management of selected thoracolumbar burst fractures accompanied by severe osteoporosis.
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Affiliation(s)
- Hyun Jin Jung
- Department of Neurosurgery, School of Medicine, Chosun University, Gwangju, Korea
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Lehman RA, Paik H, Eckel TT, Helgeson MD, Cooper PB, Bellabarba C. Low lumbar burst fractures: a unique fracture mechanism sustained in our current overseas conflicts. Spine J 2012; 12:784-90. [PMID: 21982760 DOI: 10.1016/j.spinee.2011.09.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2010] [Revised: 07/27/2011] [Accepted: 09/07/2011] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The most common location for burst fractures occurs at the thoracolumbar junction, where the stiff thoracic spine meets the more flexible lumbar spine. With our current military conflicts in Iraq and Afghanistan, we have seen a disproportionate number of low lumbar burst fractures. PURPOSE To report our institutional experience in the management of low lumbar burst fractures. STUDY DESIGN Retrospective review. METHODS We performed a retrospective review of medical records and radiographs for all patients treated at our institution with combat-related injuries and thoracolumbar fractures. We included all patients who had sustained a burst fracture from T12 to L5 and had at least 1-year clinical follow-up. RESULTS Thirty-two patients sustained burst fractures. Nineteen patients (59.4%) had low lumbar (L3-L5) burst fractures, and 12 patients (37.5%) had thoracolumbar junction (T12-L2) burst fractures as their primary injury. Additionally, seven patients sustained less severe burst fractures at an additional level. One patient sustained burst fractures at both upper and lower lumbar levels. Of the low lumbar fractures, 52.6% had evidence of neurologic injury, two of which were complete. Similarly, in the upper lumbar group, 58.2% sustained a neurologic injury, two of which were complete. Twenty-two patients underwent surgical intervention, complicated by infection in 18%. At most recent follow-up, all but one patient with presenting neurologic injury had persistent deficits. CONCLUSION Low lumbar burst fractures are the predominant combat-related spine injury in our current military conflicts. The rigidity offered by current body armor may effectively lower the transition zone that normally occurs at the thoracolumbar junction, thereby, transferring forces into the lower lumbar spine. Increased awareness of this fracture pattern is warranted by all surgeons because of unique clinical challenges associated with its treatment. Although the incidence is increased in the military population, other surgeons may be involved with long-term care of these patients on completion of their military service.
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Affiliation(s)
- Ronald A Lehman
- Integrated Department of Orthopaedics and Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA.
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Kim HY, Kim HS, Kim SW, Ju CI, Lee SM, Park HJ. Short Segment Screw Fixation without Fusion for Unstable Thoracolumbar and Lumbar Burst Fracture : A Prospective Study on Selective Consecutive Patients. J Korean Neurosurg Soc 2012; 51:203-7. [PMID: 22737299 PMCID: PMC3377876 DOI: 10.3340/jkns.2012.51.4.203] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Revised: 03/10/2012] [Accepted: 04/15/2012] [Indexed: 12/03/2022] Open
Abstract
Objective The purpose of this prospective study was to evaluate the efficacy and safety of screw fixation without bone fusion for unstable thoracolumbar and lumbar burst fracture. Methods Nine patients younger than 40 years underwent screw fixation without bone fusion, following postural reduction using a soft roll at the involved vertebra, in cases of burst fracture. Their motor power was intact in spite of severe canal compromise. The surgical procedure included postural reduction for 3 days and screw fixations at one level above, one level below and at the fractured level itself. The patients underwent removal of implants 12 months after the initial operation, due to possibility of implant failure. Imaging and clinical findings, including canal encroachment, vertebral height, clinical outcome, and complications were analyzed. Results Prior to surgery, the mean pain score (visual analogue scale) was 8.2, which decreased to 2.2 at 12 months after screw fixation. None of the patients complained of worsening of pain during 6 months after implant removal. All patients were graded as having excellent or good outcomes at 6 months after implant removal. The proportion of canal compromise at the fractured level improved from 55% to 35% at 12 months after surgery. The mean preoperative vertebral height loss was 45.3%, which improved to 20.6% at 6 months after implant removal. There were no neurological deficits related to neural injury. The improved vertebral height and canal compromise were maintained at 6 months after implant removal. Conclusion Short segment pedicle screw fixation, including fractured level itself, without bone fusion following postural reduction can be an effective and safe operative technique in the management of selected young patients suffering from unstable burst fracture.
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Affiliation(s)
- Hee Yul Kim
- Department of Neurosurgery, School of Medicine, Chosun University, Gwangju, Korea
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Gnanenthiran SR, Adie S, Harris IA. Nonoperative versus operative treatment for thoracolumbar burst fractures without neurologic deficit: a meta-analysis. Clin Orthop Relat Res 2012; 470:567-77. [PMID: 22057820 PMCID: PMC3254755 DOI: 10.1007/s11999-011-2157-7] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Accepted: 10/17/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Decision-making regarding nonoperative versus operative treatment of patients with thoracolumbar burst fractures in the absence of neurologic deficits is controversial. Lack of evidence-based practice may result in patients being treated inappropriately and being exposed to unnecessary adverse consequences. PURPOSE Using meta-analysis, we therefore compared pain (VAS) and function (Roland Morris Disability Questionnaire) in patients with thoracolumbar burst fractures without neurologic deficit treated nonoperatively and operatively. Secondary outcomes included return to work, radiographic progression of kyphosis, radiographic progression of spinal canal stenosis, complications, cost, and length of hospitalization. METHODS We searched MEDLINE, EMBASE(®), and the Cochrane Central Register of Controlled Trials for 'thoracic fractures', 'lumbar fractures', 'non-operative', 'operative' and 'controlled clinical trials'. We established five criteria for inclusion. Data extraction and quality assessment were in accordance with Cochrane Collaboration guidelines. The main analyses were performed on individual patient data from randomized controlled trials. Sensitivity analyses were performed on VAS pain, Roland Morris Disability Questionnaire score, kyphosis, and return to work, including data from nonrandomized controlled trials and using fixed effects meta-analysis. We identified four trials, including two randomized controlled trials consisting of 79 patients (41 with operative treatment and 38 with nonoperative treatment). The mean followups ranged from 24 to 118 months. RESULTS We found no between-group differences in baseline pain, kyphosis, and Roland Morris Disability Questionnaire scores. At last followup, there were no between-group differences in pain, Roland Morris Disability Questionnaire scores, and return to work rates. We found an improvement in kyphosis ranging from means of 12.8º to 11º in the operative group, but surgery was associated with higher complication rates and costs. CONCLUSIONS Operative management of thoracolumbar burst fractures without neurologic deficit may improve residual kyphosis, but does not appear to improve pain or function at an average of 4 years after injury and is associated with higher complication rates and costs. LEVEL OF EVIDENCE Level II, therapeutic study. See the Guidelines for Authors for a complete description of level of evidence.
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Affiliation(s)
- Sonali R. Gnanenthiran
- South West Sydney Clinical School, University of New South Wales, Sydney, NSW Australia
- Whitlam Orthopaedic Research Centre, Liverpool Hospital, Liverpool, NSW Australia
| | - Sam Adie
- South West Sydney Clinical School, University of New South Wales, Sydney, NSW Australia
- Whitlam Orthopaedic Research Centre, Liverpool Hospital, Liverpool, NSW Australia
| | - Ian A. Harris
- South West Sydney Clinical School, University of New South Wales, Sydney, NSW Australia
- Whitlam Orthopaedic Research Centre, Liverpool Hospital, Liverpool, NSW Australia
- PO Box 906, Caringbah, NSW 2229 Australia
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Clinical results of posterior stabilization without decompression for thoracolumbar burst fractures: is decompression necessary? Neurosurg Rev 2011; 35:447-54; discussion 454-5. [PMID: 22076677 DOI: 10.1007/s10143-011-0363-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Revised: 05/19/2011] [Accepted: 08/20/2011] [Indexed: 10/15/2022]
Abstract
The purpose of this study is to investigate the clinical outcome of posterior stabilization without decompression for thoracolumbar burst fractures. Thirty-one consecutive cases of thoracolumbar fractures involving T11-L2 stabilized by a pedicle screw system were reviewed. Neither reduction of the height of a fractured body nor any decompression procedure was added during surgery. Twenty-two patients had incomplete paraplegia; one patient had complete paraplegia. Neurological recovery and remodeling of the spinal canal were evaluated. Neurological status was evaluated at the time of injury, just before and after surgery, and at final follow-up. The degree of spinal canal compromise was assessed using axial CT scan images. The duration of follow-up averaged 39.6 months. The mean spinal canal compromise at the time of injury was 41.6%, and no significant correlation was observed between the degree of canal compromise and the severity of the neurological deficit. Within 2-3 weeks, spinal canal remodeling had started in all patients whose spinal canal compromise was more than 30%, and canal compromise had decreased significantly 3-4 weeks after injury. Seventeen of 22 patients with incomplete paraplegia had already shown partial neurological recovery even before surgery. At the final follow-up, all patients with incomplete paraplegia had improved by at least one modified Frankel grade. This study suggests that the effect of decompressing thoracolumbar fractures with neurological deficits remains unclear and questions the need to operate simply to remove retropulsed bone fragments. Posterior stabilization without decompression should constitute appropriate surgical treatment for these fractures.
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Mohanty SP, Bhat SN, Ishwara-Keerthi C. The effect of posterior instrumentation of the spine on canal dimensions and neurological recovery in thoracolumbar and lumbar burst fractures. Musculoskelet Surg 2011; 95:101-106. [PMID: 21547491 DOI: 10.1007/s12306-011-0111-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2009] [Accepted: 02/22/2011] [Indexed: 05/30/2023]
Abstract
A prospective study was designed to determine whether posterior instrumentation of the spine in thoracolumbar and lumbar burst fractures produces indirect decompression of the spinal canal leading to better remodeling and neurological recovery. The study was conducted in Kasturba Medical College Manipal, India. Sixty-eight consecutive cases of thoracolumbar and lumbar burst fractures were treated by posterior instrumentation, and approval from the hospital ethical committee was obtained. The degree of initial spinal canal compromise, indirect decompression, and remodeling were assessed from the computed tomography scans. The neurological status at the time of presentation and at final follow-up was assessed by the American Spinal Injury Association's modified Frankel's grading. The median canal compromise in patients with and without neurological deficit was 47.32 and 39.33%, respectively. The overall mean canal compromise at the time of admission, post-operative, and final follow-up were 47.37, 26.58 and 14.85%, respectively (P = <0.001). The median canal compromise in patients who recovered was 44.5% and in those with no neurological recovery was 55.85%. The median percentage of canal decompression achieved in patients who recovered was 22.15%, whereas it was 22% in those who did not recover. The median remodeling in recovered and non-recovered groups was 64.50 and 80%, respectively. None of these differences was statistically significant. This study shows that posterior instrumentation of the spine produces significant indirect decompression of the spinal canal and better remodeling. However, these factors may not improve the neurological recovery.
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Affiliation(s)
- S P Mohanty
- Department of Orthopaedics, Division of Spine Surgery, Kasturba Medical College, Manipal 576104, Karnataka, India
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Thoracolumbar burst fractures with a neurological deficit treated with posterior decompression and interlaminar fusion. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2011; 20:2195-201. [PMID: 21688000 DOI: 10.1007/s00586-011-1875-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2010] [Revised: 03/07/2011] [Accepted: 06/04/2011] [Indexed: 10/18/2022]
Abstract
INTRODUCTION To our knowledge, thoracolumbar burst fractures with a neurological deficit treated with posterior decompression and interlaminar fusion have never been reported. Our study was to assess the outcome of posterior decompression and interlaminar fusion in treating thoracolumbar burst fractures with a neurological deficit. MATERIALS AND METHODS Forty-one patients suffering from thoracolumbar burst fractures with a neurological deficit were included this study. All patients were treated with posterior decompression, interlaminar fusion and short-segment fixation of the vertebrae above and below the fracture level and the fractured vertebrae. RESULTS All patients were followed up for at least 24 months after surgery. Operative time and blood loss averaged 72 min and 325 ml, respectively. Thirty-eight patients with incomplete neurological lesions improved, by at least one American Spine Injury Association grade, whereas no neurological deterioration was observed in any case. Overall sagittal alignment improved from an average preoperative 22.4°-4.6° kyphosis at the final follow-up observation. The anterior vertebral body height ratio improved from 0.61 before surgery to 0.90 after surgery, whereas posterior vertebral body height ratio improved from 0.90 to 0.95. Spinal canal encroachment was reduced from an average 61.5% before surgery to 8.7% after surgery. Interlaminar radiological fusion was achieved within 6-8 months after surgery. No instrumentation failure was found in any patients. CONCLUSION Posterior decompression, interlaminar fusion with posterior short-segment fixation provided excellent immediate reduction for traumatic segmental kyphosis and significant spinal canal clearance, and restored vertebral body height in the fracture level in patients with a thoracolumbar burst fracture and associated neurological deficit.
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Jang KS, Ju CI, Kim SW, Lee SM. Screw Fixation without Fusion for Low Lumbar Burst Fracture : A Severe Canal Compromise But Neurologically Intact Case. J Korean Neurosurg Soc 2011; 49:128-30. [PMID: 21519504 DOI: 10.3340/jkns.2011.49.2.128] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2010] [Revised: 02/09/2010] [Accepted: 01/13/2011] [Indexed: 11/27/2022] Open
Abstract
The low lumbar spine is deeply located in flexible segments, and has a physiologic lordosis. Therefore, burst fractures of the low lumbar spine are uncommon injuries. The treatment for such injuries may either be conservative or surgical management according to canal compromise and the neurological status. However, there are no general guidelines or consensus for the treatment of low lumbar burst fractures especially in neurologically intact cases with severe canal compromise. We report a patient with a burst fracture of the fourth lumbar vertebra, who was treated surgically but without fusion because of the neurologically intact status in spite of severe canal compromise of more than 85%. It was possible to preserve motion segments by removal of screws at one year later. We also discuss why bone fusion was not necessary with review of the relevant literature.
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Affiliation(s)
- Kun Soo Jang
- Department of Neurosurgery, College of Medicine, Chosun University, Gwangju, Korea
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Malik S, Mitra A, Bashir K, Mahapatra A. Lumbar spine burst fracture as a result of hypoglycaemia induced seizure. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.injury.2010.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Zhao X, Fang XQ, Zhao FD, Fan SW. Traumatic canal stenosis should not be an indication for surgical decompression in thoracolumbar burst fracture. Med Hypotheses 2010; 75:550-2. [PMID: 20708338 DOI: 10.1016/j.mehy.2010.07.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2010] [Revised: 07/15/2010] [Accepted: 07/15/2010] [Indexed: 11/27/2022]
Abstract
Thoracolumbar burst fracture (TLBF) is a common type of spinal injuries and frequently causes spinal cord injury. The frequency of neurological deficits in all TLBF can reach up to 50-60%. The typical TLBF images seen on axial computerized tomography are the bone fragment projected into the spinal canal, which always persuade surgeons that the narrowed canal must compress the neural content and therefore is responsible for neurological deficits, with the corollary that surgical decompression of spinal canal is an essential therapeutic strategy for functional recovery. We hypothesize that in TLBF, traumatic canal stenosis is a predictive factor for neurological dysfunction and the surgical decompression is vital to the recovery of neurological function. After a review of the available evidences, we conclude that spinal canal stenosis is poorly correlated with neurological dysfunction in TLBF, and surgical decompression is not vital to the neurological recovery. Therefore, traumatic canal stenosis should not be an isolated indication for surgical decompression in TLBF.
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Affiliation(s)
- Xing Zhao
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, Medical College of Zhejiang University, 3 East Qingchun Road, Hangzhou 310016, China
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Alpantaki K, Bano A, Pasku D, Mavrogenis AF, Papagelopoulos PJ, Sapkas GS, Korres DS, Katonis P. Thoracolumbar burst fractures: a systematic review of management. Orthopedics 2010; 33:422-9. [PMID: 20806752 DOI: 10.3928/01477447-20100429-24] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The management of thoracolumbar burst fractures remains challenging. Ideally, it should effectively correct the deformity, induce neurological recovery, allow early mobilization and return to work, and be associated with minimal risk of complication. This article reviews the related studies reporting their clinical data for the management of thoracolumbar burst fractures, discusses the most suitable approach in cases such as these, highlights specific treatment recommendations, and proposes a treatment algorithm. Using PubMed and Scopus databases to search the term thoracolumbar burst fractures, abstracts and original articles in English investigating the treatment of thoracolumbar burst fractures were searched and analyzed.
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Affiliation(s)
- Kalliopi Alpantaki
- Department of Orthopedics, University Hospital of Heraklion, Crete, Greece
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29
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Abstract
BACKGROUND Burst fractures are rare in the pediatric population. There is limited information available on the best treatment for these injuries. The aims of our study were to evaluate the risk of spinal cord injury (SCI) and the potential for neurologic recovery associated with pediatric burst fractures; to compare sagittal alignment between nonoperative and operative treatment; and to determine whether functional outcomes are improved after surgery. METHODS All pediatric patients who sustained thoracic or lumbar burst fractures at 2 institutions between 1991 and 2005 were identified. The medical records were reviewed for patient demographics, injury, treatment, and outcomes. Health Survey data were collected from a subset of patients in both the operative and nonoperative groups. RESULTS Thirty-seven patients met the inclusion criteria. There were 17 male patients and 20 female patients, with an average age of 14.6 years (range, 6 to 18 y). Nine patients were treated nonoperatively and 28 patients were treated operatively. The nonoperative group was treated with hyperextension casting or bracing and showed progression of kyphotic deformity from 16.1 degrees at injury to 23.1 degrees at final follow-up. In patients treated operatively, the kyphotic deformity improved from 17.1 degrees at presentation to 7.2 degrees at final follow-up. Twenty-four patients were neurologically intact at presentation, whereas 13 presented with neurologic deficit. Six of 13 patients with SCI had some improvement. The risk of SCI was highest in patients with thoracic-level fractures. The risk of SCI did not correlate with canal compromise. There were no significant differences in functional outcome between the 2 groups. CONCLUSIONS The risk of neurologic injury in pediatric burst fractures of the spine may be more closely related to the level of injury (thoracic) than the degree of spinal canal compromise. Prognosis for recovery of neurologic injury is related to the severity of the initial neurologic injury. LEVEL OF EVIDENCE Prognostic level 2.
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Marco RAW, Meyer BC, Kushwaha VP. Thoracolumbar burst fractures treated with posterior decompression and pedicle screw instrumentation supplemented with balloon-assisted vertebroplasty and calcium phosphate reconstruction. Surgical technique. J Bone Joint Surg Am 2010; 92 Suppl 1 Pt 1:67-76. [PMID: 20194345 DOI: 10.2106/jbjs.i.01236] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The treatment of unstable thoracolumbar burst fractures with short-segment posterior spinal instrumentation without anterior column reconstruction is associated with a high rate of screw breakage and progressive loss of reduction. The purpose of the present study was to evaluate the functional, neurologic, and radiographic results following transpedicular, balloon-assisted fracture reduction with anterior column reconstruction with use of calcium phosphate bone cement combined with short-segment posterior instrumentation and a laminectomy. METHODS A consecutive series of thirty-eight patients with an unstable thoracolumbar burst fracture with or without neurologic deficit were managed with transpedicular, balloon-assisted fracture reduction, calcium phosphate bone cement reconstruction, and short-segment spinal instrumentation from 2002 to 2005. Twenty-eight of the thirty-eight patients were followed for a minimum of two years. Demographic data, neurologic function, segmental kyphosis, the fracture severity score, canal compromise, the Short Form-36 score, the Oswestry Disability Index score, and treatment-related complications were evaluated prospectively. RESULTS All thirteen patients with incomplete neurologic deficits had improvement by at least one Frankel grade. The mean kyphotic angulation improved from 17 degrees preoperatively to 7 degrees at the time of the latest follow-up, and the loss of vertebral body height improved from a mean of 42% preoperatively to 14% at the time of the latest follow-up. Screw breakage occurred in two patients, and pseudarthrosis occurred in one patient. CONCLUSIONS The present study demonstrates that excellent reduction of unstable thoracolumbar burst fractures with and without associated neurologic deficits can be maintained with use of short-segment instrumentation and a transpedicular balloon-assisted reduction combined with anterior column reconstruction with calcium phosphate bone cement performed through a single posterior incision. The resultant circumferential stabilization combined with a decompressive laminectomy led to maintained or improved neurologic function in all patients with neurologic deficits, with a low rate of instrumentation failure and loss of correction.
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Affiliation(s)
- Rex A W Marco
- Department of Orthopaedic Surgery, The University of Texas Health Science Center at Houston, Suite 110, Bellaire, TX 77401, USA.
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Shi J, Yang H. Comparison of radiography and computed tomography in evaluating posterior indirect reduction of spinal canal bone fragment. Orthopedics 2010; 33. [PMID: 20349868 DOI: 10.3928/01477447-20100129-14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This article describes a retrospective study of patients who underwent posterior indirect reduction procedures for thoracolumbar burst fractures. The goal of this study was to explore a simple and effective method for evaluating the reduction of spinal canal fragments during posterior indirect reduction procedures.Sixty-four burst fractures with retropulsed bone fragments encroaching the spinal canal at the thoracolumbar junction were performed. C-arm fluoroscopy was used to evaluate the spinal canal fragments' reduction. A standard lateral view of the thoracolumbar spine was set up. When a continuous and smooth posterior vertebral body line of the injured vertebrae appeared, similar to below and above the vertebrae, the spinal canal bone fragment was considered to be satisfactorily reduced. The midsagittal diameter of the injured segment was measured on preoperative and postoperative computed tomography (CT) scans. Narrowing of the midsagittal diameter of the injured segment was improved from 41.4%+/-15.9% to 13.7%+/-9.7%. The correction value was 27.6%+/-15.6%. All pre- and postoperative outcome variables had statistical significance (P<.01). Forty-two patients experienced a restored posterior vertebral body line with a continuous and smooth vertical line, indicating that the fragment reduction was satisfactory. Post-operative CT showed that the spinal canal compromise was <10% (range, 0%-9.8%; mean, 6.1%+/-2.9%).Continuous and smooth posterior vertebral body line imaging is a simple and effective method to judge the reduction of a bone fragment retropulsed into the spinal canal. It can provide evidence as to whether a laminotomy and pushing the bone fragment are necessary during posterior surgery.
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Affiliation(s)
- Jinhui Shi
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Suzhou City, China
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Gan M, Yang H, Zhou F, Zou J, Wang G, Mei X, Qian Z, Chen L. Kyphoplasty for the treatment of painful osteoporotic thoracolumbar burst fractures. Orthopedics 2010; 33:88-92. [PMID: 20192146 DOI: 10.3928/01477447-20100104-17] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This study explored the feasibility and clinical outcome of kyphoplasty for the treatment of painful osteoporotic thoracolumbar burst fractures without neurological deficit. A total of 25 consecutive patients with painful type-A3 amyelic thoracolumbar fractures without neurological deficit were treated by kyphoplasty. Pain was measured using the self-reporting visual analog pain scale (VAS) preoperatively, postoperatively, and at 6-month follow-up. Disability was measured using the Oswestry Disability Index (ODI) preoperatively, postoperatively, and at 6-month follow-up. The height of the fractured vertebral body, kyphotic angle, and spinal canal compromise were measured preoperatively, postoperatively, and at 6-month follow-up. Relief of pain was achieved 24 hours postoperatively. Mean VAS score decreased from 8.2+/-1.3 preoperatively to 2.8+/-0.8 postoperatively (P<.05), and was maintained at 2.9+/-1.1 at 6-month follow-up. The ODI score varied from 68.2%+/-6.6% preoperatively to 35.3%+/-2.8% postoperatively (P<.05). Improvement was maintained at 6-month follow-up. Postoperatively, the height of anterior vertebrae (Ha) was restored from 61.5%+/-13.9% to 85.3%+/-10.6%, the height of midline vertebrae (Hm) restored from 73.0%+/-19.3% to 83.3%+/-7.4%, the kyphotic angle from 21.7 degrees +/-7.8 degrees to 8.6 degrees +/-6.6 degrees, and the spinal canal compromise from 20.1%+/-4.1% to 17.8%+/-1.3%. At 6-month follow-up, maintenance of the height restoration and kyphotic deformity correction was found. No significant difference was noted in pre- and postoperative spinal canal compromise. Kyphoplasty is a relatively safe and effective method for the treatment of painful osteoporotic thoracolumbar burst fractures.
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Affiliation(s)
- Minfeng Gan
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Suzhou, China
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Lakshmanan P, Jones A, Mehta J, Ahuja S, Davies PR, Howes JP. Recurrence of kyphosis and its functional implications after surgical stabilization of dorsolumbar unstable burst fractures. Spine J 2009; 9:1003-9. [PMID: 19819190 DOI: 10.1016/j.spinee.2009.08.457] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2008] [Revised: 06/26/2009] [Accepted: 08/27/2009] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Treatment of unstable burst fractures in the dorsolumbar spine still remains controversial. Surgical stabilization has been aimed to prevent long-term back pain and progression of deformity. PURPOSE This study was aimed to analyze the degree of loss of correction of the angle of kyphosis with pedicle screw instrumentation in place and the components responsible for the recurrence of kyphosis after surgical stabilization of dorsolumbar A3 fractures and to assess the return of functional capacity in these patients. STUDY DESIGN Retrospective study. PATIENT SAMPLE This study involves 26 patients who had dorsolumbar unstable burst fractures (Arbeitsgemeinschaft für Osteosynthesefragen type A3). OUTCOME MEASURES Radiological assessment at injury, immediate postoperative period, and most recent follow-up along with functional assessment using short form 36 (SF-36) and return to work. METHODS All the patients had posterior pedicle screw instrumentation without fusion for unstable dorsolumbar burst compression (A3) fractures. The mean follow-up period was 25.5 months. All of them had their fractures stabilized with Universal Spinal System (Synthes, Welwyn Garden City, UK) Fracture System. Serial standing lateral radiographs were taken from the immediate postoperative period to the most recent follow-up. The angle of kyphosis; the heights of the discs above and below the fractured vertebra; and the heights of the vertebral bodies above, at, and below the fractured level were measured. The height at each level was measured in three segments (anterior, middle, and posterior). The values were normalized to avoid discrepancies while comparing radiographs. The difference in the height of each segment measured between the immediate postoperative period and the most recent follow-up was computed. RESULTS The mean angle of kyphosis was 6.3+/-8.9 in the immediate postoperative period and 15.7+/-6.7 at the most recent follow-up (p<.001). The mean patient function score from SF-36 was 52.3%, and the mean pain score was 44.9%. There was no relationship to the loss of correction angle of kyphosis to the patient function score (r=0.06, p=.76) and the pain score (r=0.11, p=.58). The correlation between the corresponding difference in the height of each segment and the degree of loss of correction of the angle of kyphosis showed positive correlation to the decrease in the anterior and middle segment heights at the fractured vertebral level. CONCLUSION There is a progressive loss of correction of the angle of kyphosis after posterior stabilization with instrumentation even without implant removal that mainly corresponds to the decrease in the anterior segment height of the fractured vertebral body.
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Hoshino M, Nakamura H, Terai H, Tsujio T, Nabeta M, Namikawa T, Matsumura A, Suzuki A, Takayama K, Takaoka K. Factors affecting neurological deficits and intractable back pain in patients with insufficient bone union following osteoporotic vertebral fracture. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2009; 18:1279-86. [PMID: 19484434 DOI: 10.1007/s00586-009-1041-6] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2008] [Revised: 03/17/2009] [Accepted: 05/12/2009] [Indexed: 10/20/2022]
Abstract
The purpose of this study was to examine factors affecting the severity of neurological deficits and intractable back pain in patients with insufficient bone union following osteoporotic vertebral fracture (OVF). Reports of insufficient union following OVF have recently increased. Patients with this lesion have various degrees of neurological deficits and back pain. However, the factors contributing to the severity of these are still unknown. A total of 45 patients with insufficient union following OVF were included in this study. Insufficient union was diagnosed based on the findings of vertebral cleft on plain radiography or CT, as well as fluid collection indicating high-intensity change on T2-weighted MRI. Multivariate logistic regression analysis was performed to determine the factors contributing to the severity of neurological deficits and back pain in the patients. Age, sex, level of fracture, duration after onset of symptoms, degree of local kyphosis, degree of angular instability, ratio of occupation by bony fragments, presence or absence of protrusion of flavum, and presence or absence of ossification of the anterior longitudinal ligament (OALL) in the adjacent level were used as explanatory variables, while severity of neurological deficits and back pain were response variables. On multivariate analysis, factors significantly affecting the severity of neurological deficits were angular instability of more than 15 degrees [adjusted odds ratio (OR), 9.24 (95% confidence interval, CI 1.49-57.2); P < 0.05] and ratio of occupation by bony fragments in the spinal canal of more than 42% [adjusted OR 9.23 (95%CI 1.15-74.1); P < 0.05]. The factor significantly affecting the severity of back pain was angular instability of more than 15 degrees [adjusted OR 14.9 (95%CI 2.11-105); P < 0.01]. On the other hand, presence of OALL in the adjacent level reduced degree of back pain [adjusted OR 0.14 (95%CI 0.03-0.76); P < 0.05]. In this study, pronounced angular instability and marked posterior protrusion of bony fragments in the canal were factors affecting neurological deficits. In addition, marked angular instability was a factor affecting back pain. These findings are useful in determining treatment options for patients with insufficient union following OVF.
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Affiliation(s)
- Masatoshi Hoshino
- Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
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Avanzi O, Landin E, Meves R, Caffaro MFS, Bortoli JD. Fratura toracolombar explosão: correlação entre o comprometimento do canal vertebral e os resultados do tratamento conservador. COLUNA/COLUMNA 2009. [DOI: 10.1590/s1808-18512009000100010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUÇÃO: o tratamento das fraturas explosão toracolombares sem comprometimento neurológico é controverso. A porcentagem de estreitamento do canal vertebral tem sido utilizada como parâmetro de indicação cirúrgica, mas a sua significância em pacientes sem comprometimento neurológico permanece incerta. OBJETIVO: avaliar pacientes com fratura toracolombar explosão, correlacionando o estreitamento inicial do canal vertebral e os resultados clínicos do tratamento conservador. MÉTODOS: foram avaliados de forma retrospectiva os prontuários, radiografias e filmes de tomografia computadorizada (TC) de pacientes adultos, portadores de fratura toracolombar explosão, incluindo os níveis de T11 a L2, do tipo A3 da classificação de Magerl, com menos de 10 dias de evolução, tratados conservadoramente com o uso de órtese tipo TLSO (Jewett) ou gesso em hiperextensão. Foi ainda aplicado um questionário que incluía as escalas visual-analógico de dor ou EVA, escala de Dor e Trabalho de Denis, índice de Oswestry e questionário de qualidade de vida SF-36. RESULTADOS: não houve correlação entre o estreitamento canal vertebral e a EVA ou a Escala de Dor de Denis. Houve correlação negativa entre a porcentagem de estenose do canal vertebral e a Escala de Trabalho de Denis. Também houve correlação negativa entre o índice de Oswestry e a porcentagem de estenose do canal vertebral, indicando que os pacientes com maiores escores de incapacidade apresentaram menor porcentage de estenose. Na análise de correlação entre os índices obtidos nos domínios do SF-36 e a porcentagem de estenose do canal vertebral, houve correlação significativa apenas no domínio capacidade funcional, indicando que os pacientes com melhor capacidade funcional ou escores mais próximos a 100%, também apresentavam maior porcentagem de estenose. CONCLUSÃO: os resultados obtidos confirmam a inexistência de correlação entre maior estreitamento do canal vertebral e piores resultados clínicos, conforme descrito na literatura.
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Marco RAW, Kushwaha VP. Thoracolumbar burst fractures treated with posterior decompression and pedicle screw instrumentation supplemented with balloon-assisted vertebroplasty and calcium phosphate reconstruction. J Bone Joint Surg Am 2009; 91:20-8. [PMID: 19122075 DOI: 10.2106/jbjs.g.01668] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The treatment of unstable thoracolumbar burst fractures with short-segment posterior spinal instrumentation without anterior column reconstruction is associated with a high rate of screw breakage and progressive loss of reduction. The purpose of the present study was to evaluate the functional, neurologic, and radiographic results following transpedicular, balloon-assisted fracture reduction with anterior column reconstruction with use of calcium phosphate bone cement combined with short-segment posterior instrumentation and a laminectomy. METHODS A consecutive series of thirty-eight patients with an unstable thoracolumbar burst fracture with or without neurologic deficit were managed with transpedicular, balloon-assisted fracture reduction, calcium phosphate bone cement reconstruction, and short-segment spinal instrumentation from 2002 to 2005. Twenty-eight of the thirty-eight patients were followed for a minimum of two years. Demographic data, neurologic function, segmental kyphosis, the fracture severity score, canal compromise, the Short Form-36 score, the Oswestry Disability Index score, and treatment-related complications were evaluated prospectively. RESULTS All thirteen patients with incomplete neurologic deficits had improvement by at least one Frankel grade. The mean kyphotic angulation improved from 17 degrees preoperatively to 7 degrees at the time of the latest follow-up, and the loss of vertebral body height improved from a mean of 42% preoperatively to 14% at the time of the latest follow-up. Screw breakage occurred in two patients, and pseudarthrosis occurred in one patient. CONCLUSIONS The present study demonstrates that excellent reduction of unstable thoracolumbar burst fractures with and without associated neurologic deficits can be maintained with use of short-segment instrumentation and a transpedicular balloon-assisted reduction combined with anterior column reconstruction with calcium phosphate bone cement performed through a single posterior incision. The resultant circumferential stabilization combined with a decompressive laminectomy led to maintained or improved neurologic function in all patients with neurologic deficits, with a low rate of instrumentation failure and loss of correction.
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Affiliation(s)
- Rex A W Marco
- Department of Orthopaedic Surgery, The University of Texas Health Science Center at Houston, 6700 West Loop South, Suite 110, Bellaire, TX 77401, USA.
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Traumatic thoracic and lumbar spinal fractures: operative or nonoperative treatment: comparison of two treatment strategies by means of surgeon equipoise. Spine (Phila Pa 1976) 2008; 33:1006-17. [PMID: 18427323 DOI: 10.1097/brs.0b013e31816c8b32] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A center parallel cohort study with blinded inclusion based on clinical equipoise. OBJECTIVE To compare outcomes of nonoperative and operative treatment strategies in terms of quality of life and neurologic and functional status. SUMMARY OF BACKGROUND DATA Despite a considerable body of literature, sound evidence regarding the optimal treatment for traumatic thoracic and lumbar spine fractures is lacking. METHODS Medical records of patients hospitalized for traumatic spinal fractures between 1991 and 2002 were identified in 2 trauma centers in the same country with established and different treatment strategies. Eligibility was retrospectively assessed for each case by a panel of orthopaedic surgeons who were representative of the 2 medical centers, and who were blinded to the treatment actually administered. Patients were included in the study when there was disagreement on the suggested treatment method. Thus, 2 comparable groups were identified undergoing nonoperative or operative treatment. Outcome assessment and comparison across groups focused on quality of life, residual pain, neurologic recovery, and employment in the middle-long-term follow-up. RESULTS Discordance in regards to choice of treatment was identified in 190 (95 treated nonoperative, 95 operative) of 636 potentially eligible patients. Patients were comparable regarding baseline characteristics, except for a somewhat higher proportion of males and neurologic impairment in the operative group. Seventeen percent of the nonoperative and 21% of the operative group developed complications and 3 patients displayed neurologic deterioration for which a treatment change was considered necessary. Follow-up was complete in 79%; mean follow-up time was 6.2 years with a minimum of 2 years. Pain scores, disability indexes, and general health outcome were comparable at follow-up. Compared with matched population norms, outcomes were poorer regardless of treatment method. Neurologic recovery was better in the operative group, but this difference did not reach statistical significance. Multivariate regression analyses revealed that female gender and neurologic impairment were independent predictors of poor functional outcome. Eighty-eight and 83% of the nonoperatively and operatively treated patients were employed at some point after a rehabilitation period. CONCLUSION Overall outcome of nonoperative and operative treatment in middle-long-term follow up is comparable, although there seems to be a difference in neurologic recovery patterns. Studies on the cost-effectiveness of treatment options and the patterns of recovery within 2 years after injury would assist in guideline development and stimulate interest for future research.
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Dai LY, Jiang SD, Wang XY, Jiang LS. A review of the management of thoracolumbar burst fractures. ACTA ACUST UNITED AC 2007; 67:221-31; discussion 231. [PMID: 17320622 DOI: 10.1016/j.surneu.2006.08.081] [Citation(s) in RCA: 112] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2006] [Accepted: 08/22/2006] [Indexed: 11/25/2022]
Abstract
BACKGROUND Burst fractures account for more than half of all thoracolumbar fractures, which often cause a neurologic deficit and present a significant economic burden to the family and society. Accepted methods of treatment of thoracolumbar burst fractures include conservative therapy, posterior reduction and instrumentation, and anterior decompression and instrumentation. However, the management of thoracolumbar burst fractures has been the subject of much controversy. METHODS Publications reporting clinical data relating to the thoracolumbar burst fractures were reviewed. These articles were determined via review of the results of PubMed searches and articles gathered through compilation of references from those articles. RESULTS There exist different criteria for the choice of the management based on the severity of kyphotic deformity, canal compromise, vertebral height loss, and neurologic status. To our knowledge, none of the existing criteria for the treatment of thoracolumbar burst fractures are generally accepted. CONCLUSIONS In thoracolumbar burst fractures without a neurologic deficit, there is no superiority of conservative therapy over operative therapy. When the neurologic involvement is significant, the choice of operative management is advised. Also, there is no obvious superiority of one approach over the other.
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Affiliation(s)
- Li-Yang Dai
- Department of Orthopedic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China.
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Mueller LA, Degreif J, Schmidt R, Pfander D, Forst R, Rommens PM, Mueller LP, Rudig L. Ultrasound-guided spinal fracture repositioning, ligamentotaxis, and remodeling after thoracolumbar burst fractures. Spine (Phila Pa 1976) 2006; 31:E739-46; discussion E747. [PMID: 16985441 DOI: 10.1097/01.brs.0000237012.83128.80] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Computed tomography aided evaluation of spinal decompression by ultrasound-guided spinal fracture repositioning, ligamentotaxis, and remodeling after thoracolumbar burst fractures. OBJECTIVES To determine the necessity of spinal canal widening by ultrasound-guided fracture repositioning for fractures with and without neurologic deficit. SUMMARY OF BACKGROUND DATA Ultrasound-guided spinal fracture repositioning is an alternative new approach. Reports have varied concerning ligamentotaxis and remodeling. METHODS Computed tomography aided planimetry of the spinal canal (64 consecutive burst fractures) and neurologic evaluation by Frankel grades. RESULTS Ultrasound-guided spinal fracture repositioning (n = 37) reduced the stenosis of the spinal canal area from 45% before surgery to 20% after surgery of the estimated original area. Fifteen patients had a primary neurologic deficit, which improved markedly in 11 cases after treatment. Patients with neurologic symptoms had a greater preoperative spinal stenosis than those without. No correlation was seen between the degree of pretreatment spinal stenosis, fracture type, and severity of the neurologic deficit. Ligamentotaxis (n = 27) reduced the stenosis from 30% before surgery to 18% after surgery and remodeling (n = 11) from 25% after surgery to 13% after metal removal. CONCLUSION Ultrasound-guided fracture repositioning is an efficient method for spinal canal decompression of burst fractures with neurologic symptoms. The marked degree of widening of the spinal canal due to the effects of ligamentotaxis and remodeling may render the reposition of retropulsed fragments unnecessary in cases of fractures without a neurologic deficit.
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Affiliation(s)
- Lutz Arne Mueller
- Department of Orthopaedic Surgery, University of Erlangen, Erlangen, Germany.
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Payer M. Unstable burst fractures of the thoraco-lumbar junction: treatment by posterior bisegmental correction/fixation and staged anterior corpectomy and titanium cage implantation. Acta Neurochir (Wien) 2006; 148:299-306; discussion 306. [PMID: 16311837 DOI: 10.1007/s00701-005-0681-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2005] [Accepted: 10/06/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Controversy exists about the best treatment of unstable thoraco-lumbar (TL) burst fractures. Kyphosis correction and canal decompression in case of a neurological deficit are recognized treatment objectives, and various conservative and surgical strategies have been proposed. This prospective observational study evaluates the benefits and risks of a posterior bisegmental transpedicular correction/fixation and staged anterior corpectomy and titanium cage implantation in unstable TL junction burst fractures. METHOD 20 consecutive patients with a single-level traumatic unstable burst fracture at the TL junction were operated on by a bisegmental posterior correction/fixation, followed by anterior corpectomy and titanium cage implantation 7-10 days later. The radiological and clinical course is documented over a period of 24 months. FINDINGS The mean posttraumatic loss of anterior vertebral body height was 58% (45-70%). The posttraumatic mean regional kyphosis was 16 degrees and could be corrected by the posterior approach to a mean lordosis of 2 degrees. Mean secondary loss of the kyphosis correction was 3 degrees over 24 months. No hardware failure occurred, and construct stability was observed in all 20 patients. One surgical complication occurred during the posterior approach, and three transient surgical complications by the anterior approach. 12 of the 14 patients with an initial neurological deficit recovered an average of 1.5 grades on the ASIA scale. At 24 months postoperatively, the mean regional TL back pain on a VAS (0-10) was 1.6, and the mean pain at the anterior approach site was 1.2. CONCLUSION Posterior bisegmental transpedicular correction/fixation and staged anterior corpectomy and titanium cage implantation is a safe and reliable surgical treatment option in unstable TL junction burst fractures. The advantages of this technique are a complete kyphosis correction, immediate stability, maintenance of kyphosis correction, and complete spinal canal decompression in case of a neurological deficit. However, these advantages have to be carefully weighed against the double approach morbidity.
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Affiliation(s)
- M Payer
- Department of Neurosurgery, University Hospital of Geneva, Genève, Switzerland.
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Verlaan JJ, Oner FC, Dhert WJA. Anterior spinal column augmentation with injectable bone cements. Biomaterials 2006; 27:290-301. [PMID: 16102818 DOI: 10.1016/j.biomaterials.2005.07.028] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2005] [Accepted: 07/13/2005] [Indexed: 11/24/2022]
Abstract
A vertebral fracture, whether originating from osteoporosis or trauma, can be the cause of pain, disability, deformation and neurological deficit. The treatment of vertebral compression fractures has, for many years until the advent of vertebroplasty, consisted of bedrest and analgesics. Vertebroplasty is a percutaneous technique during which bone cement is injected in a vertebral body to provide immediate pain relief by stabilization. Inflatable bone tamps can, prior to the injection of cement, be used to create a void in the vertebral body, in which case the technique is known as balloon vertebroplasty (or kyphoplasty). The chance of extracorporal cement leakage is smaller for balloon vertebroplasty than for vertebroplasty. Some authors also claim to have gained some correction in vertebral body height or angulation. Both interventions can be used for several indications, including osteoporotic compression fractures and osteolytic lesions of the vertebral body such as myeloma, hemangioma or metastasis, and also for traumatic burst fractures in combination with pedicle screw instrumentation. Polymethyl methacrylate cement is the bone void filler that is used most frequently, although the application of calcium phosphate cements has been studied widely in vitro, in vivo and also in small-scale clinical series. The clinical results of (balloon-) vertebroplasty are favorable with 85-95% of all patients experiencing immediate and long-lasting relief of pain. Serious complications are relatively rare but include neurological deficit and pulmonary embolism. In this paper, both vertebroplasty and balloon vertebroplasty and their respective indications, techniques and results are described in relation with the application and limitations of permanent and resorbable injectable bone cements.
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Affiliation(s)
- Jorrit-Jan Verlaan
- Department of Orthopaedics, University Medical Center Utrecht, Heidelberglaan 100, 3584CX Utrecht, The Netherlands.
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Ağuş H, Kayali C, Arslantaş M. Nonoperative treatment of burst-type thoracolumbar vertebra fractures: clinical and radiological results of 29 patients. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2005; 14:536-40. [PMID: 15168239 PMCID: PMC3489243 DOI: 10.1007/s00586-004-0740-2] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2003] [Revised: 11/24/2003] [Accepted: 04/23/2004] [Indexed: 11/30/2022]
Abstract
The treatment of neurologically intact patients with thoracolumbar burst fractures is still controversial. This study was designed to evaluate the role of nonoperative treatment for 29 neurologically intact patients with two- or three-column-injured thoracolumbar burst fractures. Neurologically intact patients with types A, B and C burst fractures were treated conservatively and divided into groups GI and GII, according to their column involvement, with two and three injured columns, respectively. Local kyphosis angle (LKA), anterior and posterior vertebral heights (AVH and PVH) and canal encroachment (CE) were examined for radiological parameters, while Denis' s work and pain criteria were used for clinical assessment. Remodeling determining factors of canal encroachment and the correlation between radiology and functionality were analyzed. The vertebral column deformity that occurred after the injury was stable in GI, while it was progressive for GII patients. There was significant remodeling of CE, proportional to the amount of initial CE but not related to age and radiological parameters. No correlation was found between radiological and functional parameters. None of the patients had neurological deterioration. Most of the functional results were satisfactory. As a result, it was concluded that nonoperative treatment could be an alternative method for neurologically intact two- and three-column-injured Denis-types A, B and C thoracolumbar burst fractures.
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Affiliation(s)
- Haluk Ağuş
- 2nd Clinic of Orthopaedics and Traumatology, S.S.K Tepecik Hospital, Izmir, Turkey.
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46
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Abstract
Posterior short-segment pedicle screw constructs are commonly used for reduction and fixation of traumatic thoracolumbar spine fractures. Although this technique is usually simple and effective, complications such as loss of fixation or recurrence of deformity are common because of the insufficiency of the damaged anterior column. Anterior approaches to address this deficiency are associated with high morbidity and complications. We have developed a technique to reduce and support the fractured anterior column through a transpedicular approach. Balloon-assisted-endplate-reduction (BAER) followed by vertebroplasty (VTP) with calcium phosphate cement in combination with short segment pedicle screw construct seem to be a safe and effective technique to reconstruct the anterior column in a less invasive manner. In this article, the rationale behind this technique, experimental studies, and the first clinical results are discussed.
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Affiliation(s)
- F Cumhur Oner
- Department of Orthopedics, University Medical Center Utrecht, The Netherlands.
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47
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Abstract
The management of thoracic and lumbar spine fractures is a controversial topic. This article seeks to examine the anatomy, mechanism of injury, classification, initial assessment and treatment and the definitive management, both conserva tive and operative of these injuries, and to try and explain the pros and cons of each.
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48
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Abstract
Thoracolumbar fractures are relatively common injuries. Numerous classification systems have been developed to characterize these fractures and their prognostic and therapeutic implications. Recent emphasis on short, rigid fixation has influenced surgical management. Most compression and stable burst fractures should be treated nonsurgically. Neurologically intact patients with unstable burst fractures that have >25 degrees of kyphosis, >50% loss of vertebral height, or >40% canal compromise often can be treated with short, rigid posterior fusions. Patients with unstable burst fractures and neurologic deficits require direct or indirect decompression. Posterior stabilization can be effective with Chance fractures and flexion-distraction injuries that have marked kyphosis, and in translational or shear injuries. Advances in understanding both biomechanics and types of fixation have influenced the development of reliable systems that can effectively stabilize these fractures and permit early mobilization.
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Affiliation(s)
- Mark R Mikles
- Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, MI 48109-0328, USA
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Alvine GF, Swain JM, Asher MA, Burton DC. Treatment of Thoracolumbar Burst Fractures with Variable Screw Placement or Isola Instrumentation and Arthrodesis. ACTA ACUST UNITED AC 2004; 17:251-64. [PMID: 15280752 DOI: 10.1097/01.bsd.0000095827.98982.88] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The controversy of burst fracture surgical management is addressed in this retrospective case study and literature review. METHODS The series consisted of 40 consecutive patients, index included, with 41 fractures treated with stiff, limited segment transpedicular bone-anchored instrumentation and arthrodesis from 1987 through 1994. RESULTS No major acute complications such as death, paralysis, or infection occurred. For the 30 fractures with pre- and postoperative computed tomography studies, spinal canal compromise was 61% and 32%, respectively. Neurologic function improved in 7 of 14 patients (50%) and did not worsen in any. The principal problem encountered was screw breakage, which occurred in 16 of the 41 (39%) instrumented fractures. As we have previously reported, transpedicular anterior bone graft augmentation significantly decreased variable screw placement (VSP) implant breakage. However, it did not prevent Isola implant breakage in two-motion segment constructs. Compared with VSP, Isola provided better sagittal plane realignment and constructs that have been found to be significantly stiffer. Unplanned reoperation was necessary in 9 of the 40 patients (23%). At 1- and 2-year follow-up, 95% and 79% of patients were available for study, and a satisfactory outcome was achieved in 84% and 79%, respectively. These satisfaction and reoperation rates are consistent with the literature of the time. CONCLUSIONS Based on these observations and the loads to which implant constructs are exposed following posterior realignment and stabilization of burst fractures, we recommend that three- or four-motion segment constructs, rather than two motion, be used. To save valuable motion segments, planned construct shortening can be used. An alternative is sequential or staged anterior corpectomy and structural grafting.
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Affiliation(s)
- Gregory F Alvine
- University of Kansas Medical Center, Kansas City, KS 66160-7387, USA
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Harrop JS, Hunt GE, Vaccaro AR. Conus medullaris and cauda equina syndrome as a result of traumatic injuries: management principles. Neurosurg Focus 2004; 16:e4. [PMID: 15202874 DOI: 10.3171/foc.2004.16.6.4] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Conus medullaris syndrome (CMS) and cauda equina syndrome (CES) are complex neurological disorders that can be manifested through a variety of symptoms. Patients may present with back pain, unilateral or bilateral leg pain, paresthesias and weakness, perineum or saddle anesthesia, and rectal and/or urinary incontinence or dysfunction. Although patients typically present with acute disc herniations, traumatic injuries at the thoracolumbar junction at the terminal portion of the spinal cord and cauda equina are also common. Unfortunately, a precise understanding of the pathophysiology and optimal treatments, including the best timing of surgery, has yet to be elucidated for either traumatic CES or CMS. In this paper the authors review the current literature on traumatic conus medullaris and cauda equina injuries and available treatment options.
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Affiliation(s)
- James S Harrop
- Department of Neurosurgery, Jefferson Medical College, Rothman Institute, Philadelphia, Pennsylvania, USA.
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