Anterior-Only Stabilization of Three-Column Thoracolumbar Injuries

Is open anterior advantageous to posterior decompression and reconstruction in fresh A3 to C3/AO type thoracolumbar junction fractures? A systematic review

INTRODUCTION

Surgical outcomes of open anterior and open posterior approaches, for thoracolumbar A3 to C3/AO type fractures, are compared.

METHODS

A PubMed search was conducted from 1990 to 2024 related to anterior, posterior, and combined approaches. Inclusion criteria: Fresh traumatic T10 to L2 fractures, age ≥13 years, ≥10 cases, minimum follow-up 6 months. Exclusion criteria: Cadaveric studies, pathological fractures, reviews, thoracoscopy-assisted, mini-open lateral (MOLA) and minimal invasive anterior or posterior approaches. Coleman Methodology Scores (CMS) (modified for spinal trauma) indicated potential selection bias in the selected studies. PRISMA guidelines were adapted.

RESULTS

Nineteen studies with 847 participants were selected. The average CMS quality score was fair. The anterior approach, although it better decompresses the compromised spinal canal, it is also associated with increased surgical complications compared to the posterior approach. The neurological outcome, the loss of correction and the reoperation rate, were similar to both approaches. This systematic review favors posterior approach.

CONCLUSIONS

The anterior approach is demanding and is associated with a higher rate of surgical complications compared to the posterior approach. The limitations of the selected studies included inconsistence in the: 1) approaches selection, 2) classifications of the fracture types and the neurological status and 3) variety of instrumentations used.

PROSPERO ID

CRD42023484222.

Operative results of AO A3 and A4 traumatic injuries in the thoracic and lumbar spine. A multicenter surveillance study of 4230 patients from the German Spine Registry (DWG-Register)

BACKGROUND

The diagnosis, classification and treatment of thoracolumbar burst fractures, continue to be controversial. Surgery is generally the preferred treatment for unstable fractures while stable fractures are managed conservatively. This study aims to describe surgical procedures, outcomes, complications, demography, clinical features and differences between A3 and A4 fractures (AO classification) of the thoracolumbar region. A subgroup of patients <91 years with osteoporotic fractures is included and analyzed.

METHODS

Analysis of data from the DWG-Register German spine registry on operative treatment for thoracolumbar AO A3 and A4 fractures out of 170 departments from January 2017 to May 2021. The evaluated variables included age, gender, surgical approach (posterior, anterior combined), and re-operation.

RESULTS

In total, 4230 AO A3 and A4 thoracolumbar fractures were identified in the registry; 2898 A3 (group 1) and 1332 A4 (group 2). The preoperative ASIA-impairment scale score in group 1 was significantly different compared with group 2 (P=0.02). Surgical procedures such as decompression/stabilization with rod-screw system cemented/non-cemented, as well as an anterior approach, were statistically significant between the groups. Odds ratio was calculated for variables that could be influenced for the type of fracture (A3 or A4): decompression 4.89, OR time >2 hours 48.22, osteoporosis 6.46 and posterior access 9.85.

CONCLUSIONS

This study provides multicenter results from a huge number of surgically treated AO A3 and A4 fractures. Anterior approaches are more often used in A4 type fractures, probably because of its inherent instability related to burst fractures, surprisingly, not associated with the occurrence of added perioperative complications. Nevertheless, A3 type fractures are presented with worse ASIA Impairment-Scale at admission, in comparison with A4 type fractures of the thoracolumbar region.

Long- versus short-segment fixation with an index vertebral screw for management of thoracolumbar fractures

The choice of the best stabilization technique for thoracolumbar fractures remains controversial. While LSF includes too many motion segments, SSF is associated with a high rate of fixation failure and subsequent loss of kyphotic correction. Our objective is to compare the surgical, clinical, and radiological outcomes of thoracolumbar spine fixation using long-segment fixation (LSF) versus short-segment fixation (SSF) with a screw in the fractured vertebra. We retrospectively evaluated 63 patients with single- level thoracolumbar fracture types A and B treated during the period between 2010 and 2017 in our institution. Group A (30 patients) was treated by SSF with an intermediate screw in the fractured vertebra, while group B (33 patients) was treated by LSF. Both groups were compared in terms of surgical, clinical, and radiological outcomes. The mean operative blood loss was significantly lower in group A than in group B (451.3 ± 79.9 and 690 ± 92.1 ml, respectively). The mean operative time in Group A was significantly shorter than in group B (58.4 ± 14.8 and 81.5 ± 12.3 minutes, respectively). Both groups achieved a similar Visual Analogue Scale (VAS) for pain and Oswestry Disability Index (ODI) score. No significant difference was found as regards the kyphotic angle correction and the correction loss at final follow-up. In conclusion, SSF with a screw in the fractured vertebra achieved comparable functional and radiological outcomes to LSS with less blood loss and operative time.

Surgical treatment was desirable to improve neuromuscular function in patients with sustained 3 years fracture-dislocation of lower cervical spine: A case report

To investigate the changes in neuromuscular function of anterior approach combined with subtotal vertebral body resection and titanium mesh cage (TMC) internal fixation for the old fracture-dislocated lower cervical spine. A 56-year-old female was admitted to the hospital with neck pain and numbness of the left upper extremity for 3 years due to a fall injury from a height, which worsened for 20 days. Although 3 years had passed, the patient still had significant left limb numbness and decreased muscle strength. Eventually, the patient was diagnosed with the old fracture-dislocation type injury of C6 and C7. C6 was II-degree anterior dislocation and the bilateral joint process was locked, C7 was burst fracture, and C5 was spinal cord segment injury. Then, the operation of the anterior approach combined with subtotal vertebral body resection and TMC internal fixation was performed under general anesthesia. Postoperative symptoms were significantly improved. And during five-year of follow-up, no adverse reactions and complications were reported. Although cervical fracture and dislocation combined with cervical spinal cord injury had persisted for many years, surgical treatment was necessary. The anterior approach combined with subtotal vertebral body resection and TMC internal fixation was desirable to improve neuromuscular function for the old fracture-dislocation of the lower cervical spine, which has some guiding effects on the clinical treatment.

Single-Stage Posterior Vertebral Column Resection With Circumferential Reconstruction for Thoracic/Thoracolumbar Burst Fractures With or Without Neurological Deficit: Clinical Neurological and Radiological Outcomes

STUDY DESIGN

Retrospective study.

OBJECTIVE

The aim of this study is to evaluate the clinical, neurological, and radiological outcomes of posterior vertebral column resection (PVCR) technique for treatment of thoracic and thoracolumbar burst fractures.

METHODS

Fifty-one patients (18 male, 33 female) with thoracic/thoracolumbar burst fractures who had been treated with PVCR technique were retrospectively reviewed. Preoperative and most recent radiographs were evaluated and local kyphosis angle (LKA), sagittal and coronal spinal parameters were measured. Neurological and functional results were assessed by the American Spinal Injury Association (ASIA) Impairment Scale, visual analogue scale score, Oswestry Disability Index, and Short Form 36 version 2.

RESULTS

The mean age was 49 years (range 22-83 years). The mean follow-up period was 69 months (range 28-216 months). Fractures were thoracic in 16 and thoracolumbar in 35 of the patients. AO spine thoracolumbar injury morphological types were as follows: 1 type A3, 15 type A4, 4 type B1, 23 type B2, 8 type C injuries. PVCR was performed in a single level in 48 of the patients and in 2 levels in 3 patients. The mean operative time was 434 minutes (range 270-530 minutes) and mean intraoperative blood loss was 520 mL (range 360-1100 mL). The mean LKA improved from 34.7° to 4.9° (85.9%). For 27 patients, the initial neurological deficit (ASIA A in 8, ASIA B in 3, ASIA C in 5, and ASIA D in 11) improved at least 1 ASIA grade (1-3 grades) in 22 patients (81.5%). Solid fusion, assessed with computed tomography at the final follow-up, was achieved in all patients.

CONCLUSION

Single-stage PVCR provides complete spinal canal decompression, ideal kyphosis correction with gradual lengthening of anterior column together with sequential posterior column compression. Anterior column support, avoidance of the morbidity of anterior approach and improvement of neurological deficit are the other advantages of the single stage PVCR technique in patients with thoracic/thoracolumbar burst fractures.

Surgical Techniques for Thoracolumbar Spine Fractures: WFNS Spine Committee Recommendations

To formulate the specific guidelines for the recommendation of thoracolumbar fracture regarding surgical techniques and nonfusion surgery. WFNS (World Federation of Neurosurgical Societies) Spine Committee organized 2 consensus meeting. For nonfusion surgery and thoracolumbar fracture, a systematic literature search in PubMed and Google Scholar database was done from 2010 to 2020. The search was further refined by excluding the articles which were duplicate, not in English or were based on animal or cadaveric subjects. After thorough shortlisting, only 50 articles were selected for full review in this consensus meeting. To generate a consensus, the levels of agreement or disagreement on each item were voted independently in a blind fashion through a Likert-type scale from 1 to 5. The consensus was achieved when the sum for disagreement or agreement was ≥ 66%. Each consensus point was clearly defined with evidence strength, recommendation grade, and consensus level provided. A magnitude of prospective papers were analyzed to formulate consensus on various surgical techniques that can be employed to address different types of thoracolumbar fractures. Surgical treatment of thoracolumbar fractures can be a better option over the nonoperative approach, especially for those who cannot tolerate months in an orthosis or cast, such as those with multiple extremity injuries, skin lesions, obesity, and so forth. It generally allows early mobilization, less hospital stay, reduced pulmonary complications, and better correction of sagittal balance. Current available literature fails to demonstrate any statistically significant benefit of fusion surgery over nonfusion in thoracolumbar fractures.

A Rare Case of Contiguous Three-level Lumbar Burst Fractures-treated with Combined Posterior Stabilization and Anterior Fusion

Introduction:

Burst fractures occur frequently in high energy trauma and are commonly associated with falls from height and road traffic accidents. While multiple burst fractures are not uncommon in thoracic spine, three or more contiguous level burst fractures are a relative rarity especially, in lumbar spine. The treatment of multilevel burst fractures must be individualized, and each fracture should be treated according to its inherent stability. To the best of our knowledge, this is the only case of such injury reported in English literature.

Case Report:

A 17-year-old girl who sustained contiguous three-level lumbar burst fractures with neurological compromise following alleged history of fall from height. Radiographs/computed tomography scan revealed burst fractures of L2, L3, and L4 vertebrae with retropulsion of bony fragments at all the levels. Patient underwent minimally invasive posterior stabilization and anterior Hemi-corpectomy of L2, L4, and fusion. The patient recovered completely from neurological deficits by the end of 6 months.

Conclusion:

Multiple contiguous burst fractures in the lumbar spine are a rare entity. To the best of our knowledge, this is the only case of such injury reported in English literature. The treatment requires a thorough assessment of the fracture pattern and often requires a combination of surgical approaches. Each fracture merits treatment based on individual characteristics of fracture patterns and the amount of canal compromise at each level.

Percutaneous pedicle screw fixation combined with selective transforaminal endoscopic decompression for the treatment of thoracolumbar burst fracture

Background

The objective of this study was to evaluate the feasibility, safety, efficacy, and indications of percutaneous pedicle screw fixation (PPSF) combined with selective transforaminal endoscopic decompression (TED) in the treatment of thoracolumbar burst fracture (TBLF).

Methods

From August 2015 to October 2018, a total of 41 patients with single-segment TLBF (28 men and 13 women) were enrolled in this study. X-ray and computed tomography were obtained before surgery, 1 week after surgery, and 1 year after surgery to evaluate spinal recovery. In addition, we used the visual analog scale (VAS), the Oswestry Disability Index (ODI), the Japanese Orthopedic Association score (JOA), and the Frankel classification of neurological deficits to evaluate the effectiveness of the treatments.

Results

The average follow-up time was 22.02 ± 8.28 months. The postoperative Cobb angle, vertebral body compression ratio, vertebral wedge angle, mid-sagittal canal diameter compression ratio, and Frankel grade were significantly improved. There were also significant improvements in the VAS (7.61 ± 1.41 vs. 1.17 ± 0.80, P < 0.001), ODI (89.82 ± 7.44 vs. 15.71 ± 13.50, P < 0.001), and JOA (6.90 ± 2.91 vs. 24.90 ± 3.03, P < 0.001).

Conclusions

Our results showed that PPSF combined with selective TED in the treatment of TLBF had excellent efficacy, high safety, less secondary injury than other treatments, and a wide range of indications and that it could accurately distinguish patients who did not need spinal canal decompression after posterior fixation. PPSF combined with selective TED is therefore a good choice for the treatment of TLBF.

CORRELATION BETWEEN THE SCHANZ SCREW INSERTION ANGLE AND THE LOSS OF KYPHOSIS CORRECTION IN THORACOLUMBAR FRACTURES

ABSTRACT Objective To compare the Schanz screw insertion angle and the loss of the regional kyphosis correction in thoracolumbar burst fractures following posterior short instrumentation surgery. Methods Patients with a thoracolumbar burst fracture between levels T11-L2 were divided into two groups (parallel and divergent) according to the angle formed between the Schanz screw and the vertebral plateau. Regional kyphosis was evaluated in preoperative, immediate postoperative and last follow-up radiographs. Results Of the 58 patients evaluated, 31 had a parallel assembly and 27 had a divergent assembly. When we analyzed the angle of kyphosis, no statistical difference was observed between the pre- and postoperative radiographs. However, a statistical difference in the last follow-up radiographs and in the final loss of the kyphosis correction was confirmed. Conclusion The insertion of Schanz screws with a divergent assembly presents better radiographic results with less loss of kyphosis correction angle when compared with the parallel assembly technique. Level of Evidence III; Retrospective cohort study.

Effect of the short-segment internal fixation with intermediate inclined-angle polyaxial screw at the fractured vertebra on the treatment of Denis type B thoracolumbar fracture

BACKGROUND

Short-segment internal fixation with intermediate straight-forward monoaxial screws (SSIF-SFM) and long-segment internal fixation (LSIF) are the two major surgical options for thoracolumbar (TL) fracture. However, SSIF-SFM might not provide adequate support to the spine, and LSIF is unnecessarily extensive. SSIF with intermediate inclined-angle polyxial screw (SSIF-IAP) might offer an alternative solution for the treatment of TL fracture.

METHODS

A retrospective study was conducted. Sixty-nine patients (47 males and 22 females; average 34.5 years) with Denis type B TL fracture who met the criteria for inclusion were enrolled. Sagittal Cobb's angle (SCA), anterior vertebral body height (AVBH), vertebral body index (VBI), and spinal canal encroachment (SCE) were measured and assessed. Visual analogue scale (VAS) and Oswestry disability index (ODI) were also evaluated.

RESULTS

The average values of incision length, blood loss, duration of operation, and hospital stay in the SSIF-IAP group and SSIF-SFM group were significantly decreased compared with those in the LSIF group. The AVBH and VBI in the SSIF-IAP group and LSIF group were significantly improved than those in the SSIF-SFM group at 6-month and the latest follow-ups (P < 0.05). The correction losses of AVBH and VBI (calculated by the reduction of AVBH and VBI) in the SSIF-IAP group and LSIF group were also significantly decreased compared with those in the SSIF-SFM group at 6-month and the latest follow-ups (P < 0.05). There was no significant difference of SCE among the three groups postoperatively. The VAS and ODI in the SSIF-IAP group and SSIF-SFM group were significantly decreased compared with those in the LSIF group at 6-month and the latest follow-ups (P < 0.05).

CONCLUSION

Both SSIF-IAP and LSIF can improve the biomechanical stability as compared with SSIF-SFM. Moreover, SSIF-IAP was less extensive compared to LSIF. SSIF-IAP was an effective and reliable operative technique for patients with Denis type B TL fracture.

Percutaneous pedicle screw fixation combined with transforaminal endoscopic spinal canal decompression for the treatment of thoracolumbar burst fracture with severe neurologic deficit: A case report

RATIONALE

The most common fractures of the spine are associated with the thoracolumbar junction (T10-L2). And burst fractures make up 15% of all traumatic thoracolumbar fractures, which are often accompanied by neurological deficits and require open surgeries. Common surgeries include either anterior, posterior or a combination of these approaches. Here, we report the first attempt to treat thoracolumbar burst fracture (TLBF) with severe neurologic deficits by percutaneous pedicle screw fixation (PPSF) and transforaminal endoscopic spinal canal decompression (TESCD).

PATIENT CONCERNS

A 46-year-old Chinese woman suffered from severe lower back pain with grade 0 muscle strength of lower limbs, without any sensory function below the injury level, with an inability to urinate or defecate after a motor vehicle accident. Imaging studies confirmed that she had Magerl type A 3.2 L1 burst fracture.

DIAGNOSES

Burst fracture at L1.

INTERVENTIONS

The patient underwent PPSF at the level of T12 to L2, but her neurological function did not fully recover after the operation. One week after the injury, we performed TESCD on her.

OUTCOMES

There was an immediate improvement in her neurological function in just 1 day after 2-stage operation. During the 6-month follow-up period, her neurological functions gradually recovered, and she was able to defecate and urinate. At the last follow-up visit, her spinal cord function was assessed to be at Frankel grade D.

LESSONS

PPSF plus TESCD can achieve complete spinal cord decompression, promote neurological recovery, and is therefore an effective method for the treating lumbar burst fractures with severe neurologic deficits.

Traumatic Fractures of the Thoracic Spine

The majority of traumatic vertebral fractures occur at the thoracolumbar junction and the lumbar spine and less commonly at the mid-thoracic and upper thoracic spine. In accordance, a high number of articles are dealing with thoracolumbar fractures focusing on the thoracolumbar junction. Nonetheless, the biomechanics of the thoracic spine differ from the thoracolumbar junction and the lumbar vertebral spine. The aim of this review is to screen the literature dealing with acute traumatic thoracic vertebral fractures in patients with normal bone quality. Thereby, the diagnostic of thoracic vertebral body fractures should include a CT examination. Ideally, the CT should include the whole thoracic cage particularly in patients suffering high energy accidents or in those with clinical suspicion of concomitant thoracic injuries. Generally, concomitant thoracic injuries are frequently seen in patients with thoracic spine fractures. Particularly sternal fractures cause an increase in fracture instability. In case of doubt, long segment stabilization is recommended in patients with unstable mid- und upper thoracic fractures, particularly in those patients with a high grade of instability.

Posterior Thoracolumbar Instrumented Fusion for Burst Fractures: A Meta-analysis

STUDY DESIGN

This was a meta-analysis study.

OBJECTIVE

To compare different posterior spine fixation methods for burst fracture fixation.

SUMMARY OF BACKGROUND DATA

This study was performed to elucidate if the current body of literature supports one posterior spinal fusion fixation method for burst fracture to minimize the rate of implant failure and progression of posttraumatic kyphosis.

MATERIALS AND METHODS

An extensive electronic search was conducted using PubMed for pertinent articles. The articles were examined against the inclusion and exclusion criteria. Data pertaining to kyphosis angle, Frankel score, vertebral level, blood loss, operation time, hospital stay, postoperative bracing, instrument failure, complications, and follow-up were collected. A random effects model was chosen due to variation among the individual studies' patient populations and surgical methods.

RESULTS

A total of 23 publications were eventually deemed eligible according to the criteria and included into this study. The group with 2 levels above and 1 below with intermediate screws had the greatest maintenance of spine kyphosis and lowest implant failure at final follow-up (P<0.001). There was no difference between the periods of hospital stay (P=0.788) and blood loss (P=0.154) among different tiers.

CONCLUSIONS

A fixation method consisting of 2 levels above and 1 below with intermediate screws for the thoracolumbar burst fractures showed the highest correction of kyphosis angle both at immediate and final follow-up and also the lowest implant failure at final follow-up.

Minimal invasive nonfusion technique for the treatment of noncontiguous lumbar burst fractures in young age patient: A case report

RATIONALE

In the treatment of noncontiguous lumbar burst fractures, there still remains controversy over proper surgical procedures.

PATIENT CONCERNS

A 19-year-old female patient visited our hospital after fall down from 3 m high.

DIAGNOSES

Initial neurologic examination revealed an incomplete spinal cord injury characterized by hypoesthesia and motor grade of 2 below the L2 segment. Lumbar computed tomography and magnetic resonance imaging demonstrated L2 and L5 burst fractures severely obliterating the spinal canal.

INTERVENTIONS

She underwent emergent PSSPSF at L1-2-3 and L4-5-S1 following bilateral L1 and L4 laminotomy with reduction of bony fragments by tapping method.

OUTCOMES

She was gradually recovered and able to walk with assistance two weeks after surgery. Removal of implants was performed at 12 months after surgery. Follow-up radiography showed well-preserved segmental motion and adequate decompressed spinal canal with fused fractured bony fragment. She returned to her normal daily activities without any neurologic deficits and pain.

LESSONS

Noncontiguous burst fracture of the lumbar spine is an unusual injury. For the adequate management in patient with neurologic deficit, reduction of the fractured body and stabilization of vertebral column is necessary. It is also important to preserve the segmental motion in young age patients. From that point of view, temporary PSSPSF with spinal canal decompression is considered as minimal invasive surgery with significant low morbidity, providing stability with motion saving and good clinical outcome.

Thoracolumbar Vertebral Injuries with Neurological Deficit Treated with Posterior Decompression, Short Segment Pedicle Screw Fixation, and Interlaminar Fusion

Study Design

Prospective clinical study.

Purpose

The purpose of this study was to evaluate the effect of interlaminar fusion and short segment pedicle screw fixation on thoracolumbar vertebral injuries for preventing pain and post-traumatic kyphosis.

Overview of Literature

The treatment of thoracolumbar injuries continues to be one of the most controversial areas in spine care. The main aim of surgical treatment is to decompress the spinal cord or nerve roots, realign the spine, and correct or prevent post-traumatic kyphosis. We evaluated the outcome of interlaminar fusion along with posterior decompression and short segment pedicle screw fixation in patients with thoracolumbar fractures with neurological deficit.

Methods

Twenty-two patients with traumatic thoracolumbar vertebral injuries and neurological deficit underwent short segment pedicle screw fixation above and below the fractured vertebrae, posterior decompression, and interlaminar fusion using a bone graft.

Results

All patients were followed up for 12 months postoperatively. The average operative time and blood loss was 142 minutes and 214 mL, respectively. Of the 22 patients, 14 recovered completely. Of the nine patients with American Spinal Injury Association (ASIA) grade A disease, two improved by 1 grade, whereas one each improved by grades 2, 3, and 4, and four did not recover. Radiologically, vertebral kyphosis angle improved from 20.91 preoperatively to 15.73 postoperatively, sagittal index improved from 24.77 to 18.73, the sagittal plane kyphosis angle improved from 17.45 to 11.41, regional angle kyphosis improved from 14.73 to 10.14, the superior inferior end plate angle from 16.14 to 13.00, and mean anterior body compression improved from 36.26 to 27.64 postoperatively. No implant failed and no patient had neurological deterioration.

Conclusions

Short segment pedicle screw fixation with posterior decompression and interlaminar fusion provided considerable reduction in kyphosis, restored the vertebral height of patients with thoracolumbar vertebral injuries and neurological deficit, and prevented development of delayed kyphotic deformity.

Single-stage Transpedicular Vertebrectomy and Expandable Cage Placement for Treatment of Unstable Mid and Lower Lumbar Burst Fractures

STUDY DESIGN

Retrospective clinical and radiographic study.

OBJECTIVE

To examine the efficacy and safety of vertebrectomy and expandable cage placement by a single-stage posterior approach for unstable mid and lower lumbar burst fractures (below the L3).

SUMMARY OF BACKGROUND DATA

Patients with unstable mid and lower lumbar burst fractures require surgical treatment to relieve pain, address paralysis, and stabilize the spine to prevent further segmental deformity. However, controversy remains regarding the optimal surgical treatment.

MATERIALS AND METHODS

Eleven patients underwent single-stage posterior-only vertebral column resection and vertebral body reconstruction using an expandable cage. Neurological status was classified using the American Spinal Injury Association (ASIA) Impairment Scale, whereas functional outcome was analyzed using a visual analog scale for back pain. Segmental Cobb angles were measured above and below the fractured vertebral body preoperatively, immediate postoperatively, and at the last follow-up.

RESULTS

The preoperative neurological status was ASIA grade E in 2 patients, grade D in 5 patients, grade C in 2 patients, and grade B in 2 patients. Postoperatively, neurological stability was demonstrated in 3 patients (27%), and 8 (73%) showed improvement in the ASIA grade. The mean preoperative visual analog scale score was 8.3, which decreased to 4.5 postoperatively, and to 1.8 at the final follow-up. The mean preoperative segmental lordotic angle was 9.2 degrees, which increased to 16.9 degrees postoperatively, and decreased to 15.1 degrees at the last follow-up. The mean operating time was 208.8 minutes, and the mean blood loss was 1006.3 mL. Regarding surgical complications, 1 patient experienced a dural tear and 1 patient demonstrated cage subsidence.

CONCLUSIONS

The results of this small series suggest the feasibility, efficacy, and safety of this surgical option for unstable mid and lower lumbar burst fractures. This technique from a single posterior approach offers several advantages over traditional anterior or combined approaches using strut graft or nonexpandable implants.

Short Segment versus Long Segment Pedicle Screws Fixation in Management of Thoracolumbar Burst Fractures: Meta-Analysis

Posterior pedicle screw fixation has become a popular method for treating thoracolumbar burst fractures. However, it remains unclear whether additional fixation of more segments could improve clinical and radiological outcomes. This meta-analysis was performed to evaluate the effectiveness of fixation levels with pedicle screw fixation for thoracolumbar burst fractures. MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, Springer, and Google Scholar were searched for relevant randomized and quasirandomized controlled trials that compared the clinical and radiological efficacy of short versus long segment for thoracolumbar burst fractures managed by posterior pedicle screw fixation. Risk of bias in included studies was assessed using the Cochrane Risk of Bias tool. Based on predefined inclusion criteria, Nine eligible trials with a total of 365 patients were included in this meta-analysis. Results were expressed as risk difference for dichotomous outcomes and standard mean difference for continuous outcomes with 95% confidence interval. Baseline characteristics were similar between the short and long segment fixation groups. No significant difference was identified between the two groups regarding radiological outcome, functional outcome, neurologic improvement, and implant failure rate. The results of this meta-analysis suggested that extension of fixation was not necessary when thoracolumbar burst fracture was treated by posterior pedicle screw fixation. More randomized controlled trials with high quality are still needed in the future.

RETROSPECTIVE COMPARATIVE ANALYSIS OF SURGICAL TREATMENT OF THORACOLUMBAR BURST FRACTURE: SHORT VERSUS LONG FIXATION

ABSTRACT Objective: The objective of this study is to compare short posterior fixation to long posterior fixation in thoracolumbar burst fractures. Methods: Fifty-three patients were divided into Group I (n=24) treated with short instrumentation (one level above and one below the fracture) and into Group II (n=29) treated with long instrumentation (two or more levels above and below the fracture). The load sharing classification was used to stratify cases. The evaluation of the sagittal index was performed using the Cobb method. Results: In subgroups with load sharing classification ≤ 6, Group I had loss of correction of 4.2 degrees and a procedure failure in 14.3% of cases, Group II showed loss of correction of 5.4 degrees and failure in 21.7% of cases. In subgroups with load sharing classification ≥7, Group I had a loss of correction of 11.2 degrees and procedure failure in 70% of cases, and Group II showed a loss of correction of 9 degrees and failure of 46.7%. Group I had a tendency to worse outcomes, especially in the subgroup of patients with load sharing classification ≥7. Conclusion: Despite the tendency for poorer results in the short fixation group in the cases with load sharing ≥7, in no sample was there statistically significant difference between the groups studied.

Thoracoscopic Vertebrectomy for Thoracolumbar Junction Fractures and Tumors: Surgical Technique and Evaluation of the Learning Curve

STUDY DESIGN

Retrospective study.

OBJECTIVE

The authors evaluated the surgical technique and learning curve for video-assisted thoracoscopic surgery (VATS) for treating thoracolumbar junction burst fractures and bony tumors by examining surgical data and outcome for the first 30 VATS procedures performed by a single surgeon at a training institution.

SUMMARY OF BACKGROUND DATA

VATS is commonly used in the treatment of early-stage lung cancer. Widespread use of this technique among neurosurgeons is limited by the lack of cases and the steep learning curve.

METHODS

This study was a retrospective case series of the first 30 T12 and L1 thoracoscopic vertebrectomies from 2003 to 2008. The sample was limited to 1 surgeon and 1 region of the spine to minimize the potential variation so that a learning curve could be assessed. Surgical data and outcomes were analyzed. Estimated blood loss and operation time were analyzed using a linear generalized estimating equation model with a first-order autoregression correlation structure.

RESULTS

The average operative time for thoracoscopic corpectomy was 270±65 minutes (range, 160-416 min). Operating room time decreased significantly after the first 3 operations. The authors observed a stable linear decrease in operating time over the course of the study. The average blood loss during the thoracoscopic procedure was 433±330 mL (range, 100-1500 mL) and did not change as the series progressed. Complications and conversions to open procedures occurred in 2 patients and were evenly distributed throughout the series.

CONCLUSIONS

Thoracoscopic vertebrectomy at the thoracolumbar junction has a relatively long learning curve. In this series, operating room time improved dramatically after the first 3 cases but continued to improve subsequently. The learning curve can be accomplished without an increase in blood loss, complications, rate of conversion to open procedures, or frequency of misplaced instrumentation.

Posterior Reconstruction of Vertebral Body using Expandable Cage for L5 Burst Fracture Dislocation: Case Report

INTRODUCTION

A case of young male patients aged 25 years old presented with history of injured from falling heavy object on his back. There was burst Fracture of L5 Vertebrae with grade 3 spondylolisthesis. It was completely different from the types of L5 fracture that had been published up to now. Our patient had combination of a complete burst fracture of the fifth lumbar vertebra with dislocation and complete disruption of the posterior ligamantous and bony complex between L5 and sacrum. We would like to report this unique case of comminuted burst fracture of L5 with grade III spondylolisthesis treated with reconstruction of L5 body from transforaminol approach with the good results & significant neurological improvement till his six month follow up after the operation.

CASE REPORT

A case of young male patients aged 25 years old presented with history injured from falling heavy object on his back. The physical examination revealed contusion on his back Neurological examination confirmed complete paralysis of L5 and S1 root on both sides. Loss Bladder-bowel function, sphincter tone and peri-anal sensation. Plain radiograph of lumbar-sacral spine showed the anterior dislocation of L5-S1 spondylo-listhesis approximately 75%, with the complete comminuted burst fracture of L5 vertebra.

CONCLUSION

Anterior support and reconstruction of vertebral body is of immense importance in Lumbar burst fracture, When combined with posterior short segment fixation. This can be achieved with Usage of expandable cages when opted for posterior only approach. They obviate need of anterior approach for reconstruction of vertebral body.

Single-Stage Posterior Subtotal Corpectomy and Circumferential Reconstruction for the Treatment of Unstable Thoracolumbar Burst Fractures

Objective

To illustrate the technique of single-stage posterior subtotal corpectomy and circumferential reconstruction for the treatment of unstable thoracolumbar burst fractures and to evaluate the radiographical and clinical outcomes of patients treated using this technique.

Methods

16 consecutive patients with unstable thoracolumbar burst fractures were treated with single-stage posterior subtotal corpectomy and circumferential reconstruction. The mean patient age was 54.8 years. The mean follower up period was 25 months. Five patients suffered from T12 fractures, 10 from L1, 1 from L2. The segmental kyphosis, neurologic status, visual analogue scale for back pain was evaluated before surgery and at follow up.

Results

The segmental kyphotic angle improved from 18.5 degrees before surgery to -9.2 degrees at the last follow up. The mean correction angle was 28.9 degrees. The mean surgical time was 255 minutes, and a mean intraoperative blood loss was 1073 mL. Intraoperative complications included two dural tears, and a superficial wound infection. There were no other severe complications. The mean visual analog scale of back pain decreased from a mean value of 6.6 to 2 at the last follow up.

Conclusion

The single-stage posterior subtotal corpectomy and circumferential reconstruction achieved satisfactory kyphosis correction with direct visualization of the circumferentially decompressed spinal cord, as well as good fusion with less blood loss and complications. It is a safe and reliable surgical treatment option for unstable thoracolumbar burst fractures.

Efficacy of Titanium Mesh Cages for Anterior Column Reconstruction after Thoracolumbar Corpectomy

STUDY DESIGN

This retrospective study was conducted to determine the safety and efficacy of titanium cage reconstruction and anterior plating after thoracolumbar corpectomy.

PURPOSE

To study the clinical and radiological outcome of anterior column reconstruction after thoracolumbar corpectomy.

OVERVIEW OF LITERATURE

Anterior column reconstruction aims to optimize neural decompression with adequate stabilization.

METHODS

A series of 16 patients underwent reconstruction after thoracolumbar corpectomy to treat injury due to trauma (n=10), tuberculosis (n=3), and tumor (n=3). The average duration of follow-up was 18 months (range, 8-58 months). The degree of kyphosis, construct height, and the subsidence of the cage in relation to the vertebral endplates were measured. The approach was thoracoabdominal in 10 cases and retroperitoneal in 6 cases.

RESULTS

Four patients were neurologically intact with Frankel grade E on admission, and all remained intact postoperatively. Of the 6 patients with Frankel grade D, all fully recovered full motor and sensory functions. Of the 6 patients with Frankel grade C, three improved one grade and the other three improved two grades. The mean height of the vertebra before surgery was 41 mm and the mean construct height immediately after surgery and at follow-up was 47 mm and 44 mm, respectively. Solid fusion was observed in all patients. The sagittal alignment of the fractured segment was restored immediately after surgery as a significant decrease in the local kyphotic angle.

CONCLUSIONS

Anterior instrumentation is an effective and safe treatment for thoracolumbar instability with satisfactory clinical and radiological outcomes.

Efficacy of Pedicle Screw Fixation in Unstable Upper and Middle Thoracic Spine Fractures

BACKGROUND

Treatment of unstable upper and middle thoracic spine fractures remains controversial. There is no consensus regarding optimal treatment.

OBJECTIVES

In this study, we evaluated the efficacy of pedicular screw in the management of middle thoracic spine fractures to correct kyphosis and anterolisthesis and improve neurologic condition of patients.

PATIENTS AND METHODS

Twenty-five patients with unstable T1-T10 fractures treated with pedicle screw fixation technique were studied. Neurologic situation, preoperative and postoperative radiographs were evaluated. Radiographic measurements included kyphotic deformity and anterolisthesis. An American Spinal Injury Association (ASIA) scale was used for neurologic classification of the patients.

RESULTS

From a total of 25 patients, 21 cases were male and 4 were female. The mean age of the patients was 35.40 ± 14.39 years. The mean degree of kyphosis improved from 27.04 ± 7.33 degrees preoperatively to 15.96 ± 5.76 degrees at final follow-up. The mean of anterolisthesis improved from 6.44 ± 4.93 mm to 0.96 ± 0.36 mm at final follow-up. Kyphosis (P = 0.0001), anterolisthesis (P = 0.0001) and neurological state (P = 0.01) improved significantly after operation. No cases of hardware failure, neurological deterioration and loss of correction were reported.

CONCLUSIONS

Application of pedicular screw in unstable upper and middle thoracic spine fractures is an effective method that can correct kyphotic deformity and anterolisthesis and improve neurologic deficit.

The Effect of Polymethyl Methacrylate Augmentation on the Primary Stability of Cannulated Bone Screws in an Anterolateral Plate in Osteoporotic Vertebrae: A Human Cadaver Study

Study Design Cohort study. Objective Expandable anterolateral plates facilitate the reduction of posttraumatic deformities of thoracolumbar spine injuries and are commonly used in cases of unstable injuries or compromised bone quality. In this in vitro study, the craniocaudal yield load of the osseous fixation of an anterior angular stable plate fixation system and the effect of polymethyl methacrylate (PMMA) screw augmentation on the primary stability of the screw-bone interface during kyphosis reduction was evaluated in 12 osteoporotic human thoracolumbar vertebrae. Methods The anterolateral stabilization device used for this study is comprised of two swiveling flanges and an expandable midsection. It facilitates the controlled reduction of kyphotic deformities in situ with a geared distractor. Single flanges were attached to 12 thoracolumbar vertebrae. Six specimens were augmented with PMMA by means of cannulated bone screws. The constructs were subjected to static, displacement-controlled craniocaudal loading to failure in a servohydraulic testing machine. Results The uncemented screws cut out at a mean 393 ± 66 N, whereas the cemented screws showed significantly higher yield load of 966 ± 166 N (p < 0.02). We detected no significant correlation between bone mineral density and yield load in this setting. Conclusion Our results indicate that PMMA augmentation is an effective method to increase two- to threefold the primary stability of the screw-bone interface of an anterolateral spine stabilization system in osteoporotic bone. We recommend it in cases of severely compromised bone quality to reduce the risk of screw loosening during initial kyphosis correction and to increase long-term construct stability.

Contribution of Round vs. Rectangular Expandable Cage Endcaps to Spinal Stability in a Cadaveric Corpectomy Model

BACKGROUND

Expandable cages are gaining popularity in anterior reconstruction of the thoracolumbar spine following corpectomy as they can provide adjustable distraction and deformity correction. Rectangular, rather than circular, endcaps provide increased resistance to subsidence by spanning the apophyseal ring; however their impact on construct stability is not known. The objective of this study was to investigate the contribution of expandable corpectomy cage endcap shape (round vs. rectangular) and fixation method (anterior plate vs. posterior pedicle screws) to the stability of an L1 sub-total corpectomy construct.

METHODS

Eight fresh-frozen cadaveric specimens (T11-L3) were subjected to multi-directional flexibility testing to 6 N·m with a custom spine simulator. Test conditions were: intact, L1 sub-total corpectomy defect, expandable cage (round endcap) alone, expandable cage (round endcap) with anterior plate, expandable cage (round endcap) with bilateral pedicle screws, expandable cage (rectangular endcap) alone, expandable cage (rectangular endcap) with anterior plate, expandable cage (rectangular endcap) with bilateral pedicle screws. Range-of-motion across T12-L2 was measured with an optoelectronic system.

RESULTS

The expandable cage alone with either endcap provided significant stability to the corpectomy defect, reducing motion to intact levels in flexion-extension with both endcap types, and in lateral bending with rectangular endcaps. Round endcaps allowed greater motion than intact in lateral bending, and axial rotation ROM was greater than intact for both endcaps. Supplemental fixation provided the most rigid constructs, although there were no significant differences between instrumentation or endcap types.

CONCLUSIONS

These results suggest anterior-only fixation may be adequate when using an expandable cage in a sub-total corpectomy application and choice of endcap type may be driven by other factors such as subsidence resistance.

Is lateral stabilization enough in thoracolumbar burst fracture reconstruction? A biomechanical investigation

BACKGROUND CONTEXT

Traditional reconstruction for burst fractures involves columnar support with posterior fixation at one or two levels cephalad/caudad; however, some surgeons choose to only stabilize the vertebral column.

PURPOSE

The aim was to distinguish biomechanical differences in stability between a burst fracture stabilized through a lateral approach using corpectomy spacers of different end plate sizes with and without integrated screws and with and without posterior fixation.

STUDY DESIGN/SETTING

This was an in vitro biomechanical study assessing thoracolumbar burst fracture stabilization.

METHODS

Six human spines (T11-L3) were tested on a six-degrees-of-freedom simulator enabling unconstrained range of motion (ROM) at ±6 N·m in flexion-extension (FE), lateral bending (LB), and axial rotation (AR) after a simulated burst fracture at L1. Expandable corpectomy spacers with/without integrated screws (Fi/F; FORTIFY Integrated/FORTIFY; Globus Medical, Inc., Audubon, PA, USA) were tested with different end plate sizes (21×23 mm, 22×40-50 mm). Posterior instrumentation (PI) via bilateral pedicle screws and rods was used one level above and one level below the burst fracture. Lateral plate (LP) fixation was tested. Devices were tested in the following order: intact; Fi21×23; Fi21×23+PI; F21×23+PI+LP; F21×23+LP; F22×40-50+LP; F22×40-50+PI+LP; Fi22×40-50+PI; Fi22×40-50.

RESULTS

In FE and AR, constructs without PI showed no significant difference (p<.05) in stability compared with intact. In LB, F22×40-50+LP showed a significant increase in stability relative to intact, but no other construct without PI reached significance. In FE and LB, circumferential constructs were significantly more stable than intact. In AR, no construct showed significant differences in motion when compared with the intact condition.

CONCLUSIONS

Constructs without posterior fixation were the least stable of all tested constructs. Circumferential fixation provided greater stability in FE and LB than lateral fixation and intact. Axial rotation showed no significant differences in any construct compared with the intact state.

Range of motion after thoracolumbar corpectomy: evaluation of analogous constructs with a novel low-profile anterior dual-rod system and a traditional dual-rod system

STUDY DESIGN

An in vitro biomechanical study.

OBJECTIVES

To compare the biomechanical stability of traditional and low-profile thorocolumbar anterior instrumentation after a corpectomy with cross-connectors. Dual-rod anterior thoracolumbar lateral plates (ATLP) have been used clinically to stabilize the thorocolumbar spine.

METHODS

The stability of a low-profile dual-rod system (LP DRS) and a traditional dual-rod system (DRS) was compared using a calf spine model. Two groups of seven specimens were tested intact and then in the following order: (1) ATLP with two cross-connectors and spacer; (2) ATLP with one cross-connector and spacer; (3) ATLP with spacer. Data were normalized to intact (100 %) and statistical analysis was used to determine between-group significances.

RESULTS

Both constructs reduced motion compared to intact in flexion-extension and lateral bending. Axial rotation motion became unstable after the corpectomy and motion was greater than intact, even with two cross-connectors with both systems. Relative to their respective intact groups, LP DRS significantly reduced motion compared to analogous DRS in flexion-extension. The addition of cross-connectors reduced motion in all loading modes.

CONCLUSIONS

The LP DRS provides 7.5 mm of reduced height with similar biomechanical performance. The reduced height may be beneficiary by reduced irritation and impingement on adjacent structures.

Anterior D-rod and titanium mesh fixation for acute mid-lumbar burst fracture with incomplete neurologic deficits: A prospective study of 56 consecutive patients

BACKGROUND

Anterior decompression and reconstruction have gained wide acceptance as viable alternatives for unstable mid-lumbar burst fracture, but there are no mid and long term prospective studies regarding clinical and radiologic results of mid-lumbar burst fractures.

MATERIALS AND METHODS

An Institutional Review Board-approved prospective study of 56 consecutive patients of mid-lumbar burst fractures with a load-sharing score of 7 or more treated with anterior plating was carried out. All patients were evaluated for radiologic and clinical outcomes. The fusion status, spinal canal compromise, segmental kyphotic angle (SKA), vertebral body height loss (VBHL), and adjacent segment degeneration was examined for radiologic outcome, whereas the American Spinal Injury Association scale, the visual analog scale (VAS), and the employment status were used for clinical evaluation.

RESULTS

The patients underwent clinical and radiologic followup for at least 5 years after the surgery. At the last followup, there was no case of internal fixation failure, adjacent segment degeneration, and other complications. Interbody fusion was achieved in all cases. The average fusion time was 4.5 months. No patient suffered neurological deterioration and the average neurologic recovery was 1.3 grades on final observation. Based on VAS pain scores, canal compromise, percentage of VBHL and SKA, the difference was statistically significant between the preoperative period and postoperative or final followup (P < 0.05). Results at postoperative and final followup were better than the preoperative period. However, the difference was not significant between postoperative and final followup (P > 0.05). Thirty-four patients who were employed before the injury returned to work after the operation, 15 had changed to less strenuous work.

CONCLUSION

Good mid term clinicoradiological results of anterior decompression with D-rod and titanium mesh fixation for suitable patients with mid-lumbar burst fractures with incomplete neurologic deficits can be achieved. The incident rate of complications was low. D-rod is a reliable implant and has some potential advantages in L4 vertebral fractures.

Predictive factors for a kyphosis recurrence following short-segment pedicle screw fixation including fractured vertebral body in unstable thoracolumbar burst fractures

Objective

The technique of short segment pedicle screw fixation (SSPSF) has been widely used for stabilization in thoracolumbar burst fractures (TLBFs), but some studies reported high rate of kyphosis recurrence or hardware failure. This study was to evaluate the results of SSPSF including fractured level and to find the risk factors concerned with the kyphosis recurrence in TLBFs.

Methods

This study included 42 patients, including 25 males and 17 females, who underwent SSPSF for stabilization of TLBFs between January 2003 and December 2010. For radiologic assessments, Cobb angle (CA), vertebral wedge angle (VWA), vertebral body compression ratio (VBCR), and difference between VWA and Cobb angle (DbVC) were measured. The relationships between kyphosis recurrence and radiologic parameters or demographic features were investigated. Frankel classification and low back outcome score (LBOS) were used for assessment of clinical outcomes.

Results

The mean follow-up period was 38.6 months. CA, VWA, and VBCR were improved after SSPSF, and these parameters were well maintained at the final follow-up with minimal degree of correction loss. Kyphosis recurrence showed a significant increase in patients with Denis burst type A, load-sharing classification (LSC) score >6 or DbVC >6 (p<0.05). There were no patients who worsened to clinical outcome, and there was no significant correlation between kyphosis recurrence and clinical outcome in this series.

Conclusion

SSPSF including the fractured vertebra is an effective surgical method for restoration and maintenance of vertebral column stability in TLBFs. However, kyphosis recurrence was significantly associated with Denis burst type A fracture, LSC score >6, or DbVC >6.

Biomechanical analysis of four- versus six-screw constructs for short-segment pedicle screw and rod instrumentation of unstable thoracolumbar fractures

BACKGROUND CONTEXT

Conventionally, short-segment fusion involves instrumentation of one healthy vertebra above and below the injured vertebra, skipping the injured level. This short-segment construct places less surgical burden on the patient compared with long-segment constructs, but is less stable biomechanically, and thus has resulted in clinical failures. The addition of two screws placed in the fractured vertebral body represents an attempt to improve the construct stiffness without sacrificing the benefits of short-segment fusion.

PURPOSE

To determine the biomechanical differences between four- and six-screw short-segment constructs for the operative management of an unstable L1 fracture.

STUDY DESIGN

Biomechanical study of instrumentation in vertebral body cadaveric models simulating an L1 axial load injury pattern.

METHODS

Thirteen intact spinal segments from T12 to L2 were prepared from fresh-frozen cadaver spines. An axial load fracture of at least 50% vertebral body height was produced at L1 and then instrumented with pedicle screws. Specimens were evaluated in terms of construct stiffness, motion, and rod strain. Two conditions were tested: a four-screw construct with no screws at the L1 fractured body (4S) and a six-screw construct with screws at all levels (6S). The two groups were compared statistically by paired Student t test.

RESULTS

The mean stiffness in flexion-extension was increased 31% (p<.03) with the addition of the two pedicle screws in L1. Relative motion in terms of vertical and axial rotations was not significantly different between the two groups. The L1-L2 rod strain was significantly increased in the six-screw construct compared with the four-screw construct (p<.001).

CONCLUSIONS

In a cadaveric L1 axial load fracture model, a six-screw construct with screws in the fractured level is more rigid than a four-screw construct that skips the injured vertebral body.

Posterior short segment pedicle screw fixation and TLIF for the treatment of unstable thoracolumbar/lumbar fracture

Background

Currently, Posterior Short Segment Pedicle Screw Fixation is a popular procedure for treating unstable thoracolumbar/lumbar burst fracture. But progressive kyphosis and a high rate of hardware failure because of lack of the anterior column support remains a concern. The efficacy of different methods remains debatable and each technique has its advantages and disadvantages.

Methods

A consecutive series of 20 patients with isolated thoracolumbar/lumbar burst fractures were treated by posterior short segment pedicle screw fixation and transforaminal thoracolumbar/lumbar interbody fusion (TLIF) between January 2005 and December 2007. All patients were followed up for a minimum of 2 years. Demographic data, neurologic status, anterior vertebral body heights, segmental Cobb angle and treatment-related complications were evaluated.

Results

The mean operative time was 167 minutes (range, 150–220). Blood loss was 450 ~ 1200 ml, an average of 820 ml. All patients recovered with solid fusion of the intervertebral bone graft, without main complications like misplacement of the pedicle screw, nerve or vessel lesion or hard ware failure. The post-operative radiographs demonstrated a good fracture reduction and it was well maintained until the bone graft fusion. Neurological recovery of one to three Frankel grade was seen in 14 patients with partial neurological deficit, three grades of improvement was seen in one patient, two grades of improvement was observed in 6 patients and one grade of improvement was found in 6 patients. All the 6 patients with no paraplegia on admission remained neurological intact, and in one patient with Frankel D on admission no improvement was observed.

Conclusion

Posterior short-segment pedicle fixation in conjunction with TLIF seems to be a feasible option in the management of selected thoracolumbar/lumbar burst fractures, thereby addressing all the three columns through a single approach with less trauma and good results.

Kyphosis in fractures: evaluation of digital measuring

Objective: This study evaluates the manual and digital reliability and reproducibility of five methods of measuring deformity (kyphosis) in thoracolumbar burst fractures. Method: Ninety (90) tomographic images were evaluated and, in each case, kyphotic deformity was measured, both manually and digitally, through the five most relevant methods described in the literature. For the assessment of intraobserver error, 20 cases were measured again. Results: The results show that all five methods are highly reliable and digitally reproducible, with estimated error near or lower than that indicated in the intraobserver error analysis. Cobb's method had the highest concordance (96%) while the sagittal index had the lowest concordance (75%). It is also suggested that digital assessment is more reliable then the manual method. Conclusion: All tested methods are highly reliable and digitally reproducible.

Long-term functional results after short-segment pedicle fixation of thoracolumbar fractures

PURPOSE

A retrospective study to assess the health-related quality of life in patients undergoing posterior fixation of thoracolumbar fractures, and to compare the outcome with norm scores and HRQL in patients undergoing surgical treatment for degenerative conditions of the spine.

METHODS

The study population consisted of 93 consecutive patients surgically treated for a thoracolumbar fracture from 2005 to 2009. All patients underwent posterior pedicle screw fixation and fusion. 83 patients were available for follow-up. Three questionnaires reflecting health-related quality of life (HRQL) were mailed to the patients: SF-36, ODI, and EQ-5D.

RESULTS

52 men and 31 women were operated with an average age at the time of surgery of 46 years. All fractures were AO-type A3.1 and A3.2 with L1 being the primary fracture level. All patients were neurologically intact; Frankel E. The overall response rate on the questionnaires was 75% with no significant differences between responders and non-responder on basic demographic characteristics. The median follow up period was 3.8 years (range 2-6 years). The scores on all three questionnaires were significantly reduced compared to the national norm scores (p<0.05).

CONCLUSION

Health-related quality of life is affected several years after short segment posterior instrumentation of thoracolumbar fractures without neurological deficit.

Clinical outcomes of unstable thoracolumbar junction burst fractures: combined posterior short-segment correction followed by thoracoscopic corpectomy and fusion

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.

Six-year outcome of thoracoscopic ventral spondylodesis after unstable incomplete cranial burst fractures of the thoracolumbar junction: ventral versus dorso-ventral strategy

PURPOSE

The purpose of this study is to determine the long term-results after thoracoscopic spondylodesis particularly with respect to a ventral versus dorso-ventral treatment strategy.

METHODS

In this prospective cohort study, a follow-up examination was performed in 19 patients (seven men, 12 women, average age: 37.7 years, follow-up rate: 79 %), six years after ventral thoracoscopic spondylodesis of unstable, incomplete burst fractures. Nine patients received a ventral monosegmental spondylodesis with iliac crest bone graft. The other ten cases were treated dorso-ventrally, five undergoing a ventral monosegmental treatment with iliac crest bone graft; the other five a ventral bisegmental treatment with expandable titanium cage.

RESULTS

The complication rate was 15.7 %, the rate of revision of 10.5 %. No complication was related to the ventral thoracoscopic approach, whereas all of them were related to the iliac crest bone graft. The operative bisegmental kyphotic reduction was higher in the dorso-ventrally treated group. Afterwards, the loss of reduction was similar in both study groups. The mean VAS spine score summed up to more than 80 in both groups. The mean PCS scores were comparable to a normal healthy collective of the same age.

CONCLUSIONS

The ventral thoracoscopic approach to the spine seems to be a safe therapeutic strategy. A dorso-ventral treatment concept goes along with a higher operative reduction potential.

Single screw-rod anterior instrumentation for thoracolumbar burst fractures with incomplete neurological deficit

PURPOSE

To evaluate the outcome of single screwrod anterior instrumentation for thoracolumbar burst fractures with incomplete neurological deficit.

METHODS

16 men and 5 women aged 22 to 55 (mean, 34) years underwent single screw-rod anterior instrumentation for thoracolumbar burst fractures with incomplete neurological deficit. The vertebrae involved were T10 (n=2), T11 (n=2), T12 (n=7), L1 (n=8), and L2 (n=2). No patient had disruption of the posterior ligament complex. Postoperatively, a thoracolumbar sacral orthosis was used until solid fusion. Outcome measures included neurological recovery, degree of kyphosis, complications, and pain and functional status of the patients.

RESULTS

The mean follow-up duration was 36 (range, 13-50) months. All patients recovered neurologically by at least one grade. Of the 21 patients, 6 improved from grade B to grade C (n=4) or grade D (n=2), 13 from grade C to grade D, and 2 from grade D to grade E. The mean degree of kyphosis improved from 23º ± 5º to 7º ± 3º. Seven patients had complications including ipsilateral basal atelectasis (n=3), urinary tract infection (n=1), haematuria (n=1), postoperative ileus (n=1), and superficial wound infection (n=1). None had iatrogenic visceral or vascular injury, pseudoarthrosis or hardware-related complications. Only one patient had severe back pain persistently.

CONCLUSION

Single screw-rod anterior instrumentation supplemented with an orthosis can be an alternative for double screw-rod anterior instrumentation for thoracolumbar burst fractures in patients with smaller vertebral bodies.

Outcome after thoracoscopic ventral stabilisation of thoracic and lumbar spine fractures

BACKGROUND AND PURPOSE

Thoracoscopic-assisted ventral stabilisation for thoracolumbar fractures has been shown to be associated with decreased recovery time and less morbidity when compared with open procedures. However, there are a limited number of studies evaluating late clinical and radiological results after thoracoscopic spinal surgery.

METHODS

We performed an analysis of the late outcomes of thoracolumbar fractures after minimally invasive thoracoscopic ventral instrumentation. Between August 2003 and December 2008, 70 patients with thoracolumbar fractures (T5-L2) underwent ventral thoracoscopic stabilisation. Tricortical bone grafts, anterior plating systems (MACS-System), and cage implants were used for stabilisation. Outcomes measured include radiologic images (superior inferior endplate angle), Visual Analogue Scale (VAS), VAS Spine Score, quality of life scores SF-36 and Oswestry Disability Index (ODI).

RESULTS

Forty seven patients (67%, 47 out of 70) were recruited for the follow up evaluation (2.2 ± 1.5 years). Lower VAS Spine scores were calculated in patients with intra- or postoperative complications (44.7 (± 16.7) vs. 65.8 (± 24.5), p=0.0447). There was no difference in outcome between patients treated with bone graft vs. cage implants. Loss of correction was observed in both bone graft and titanium cage groups.

INTERPRETATION

The present study demonstrates diminished long-term quality of life in patients treated with thoracoscopic ventral spine when compared with the outcome of german reference population. In contrast to the other patients, those patients without intra-operative or post-operative complications were associated with improved outcome. The stabilisation method (bone graft versus spinal cage) did not affect the long-term clinical or radiographic results in this series.

Simultaneous posterior and anterior approaches with posterior vertebral wall preserved for rigid post-traumatic kyphosis in thoracolumbar spine

STUDY DESIGN

A retrospective study.

OBJECTIVE

To evaluate the radiological and clinical results of simultaneous surgery with preservation of the posterior vertebral wall for rigid post-traumatic kyphosis in the thoracolumbar spine.

SUMMARY OF BACKGROUND DATA

Management of rigid post-traumatic kyphosis has been a challenge for surgeons. Current widely used posterior osteotomy procedures have the disadvantages of significant invasiveness, spinal column shortening, and instrumentation-related complications.

METHODS

From 2004 to 2009, 21 patients with rigid post-traumatic kyphosis in the thoracolumbar spine (T11-L2) were managed in our hospital. Average kyphotic angle was 45.2° ± 11.2° (range, 31°-67°). The surgical technique used was posterior and anterior circumferential release and anterior corpectomy with posterior vertebral wall preservation and short segmental instrumentation. Preoperative and postoperative kyphotic angle was measured to assess the degree of kyphosis correction and maintenance. Changes in low back pain were assessed by Japanese Orthopaedic Association scores.

RESULTS

All patients were successfully managed with this procedure without major complications. Most patients (19 of 21) were instrumented with anterior-only fixation, while posterior interspinal wire was added in 2 patients with osteoporosis. The mean blood loss was 470 mL (range, 300-700 mL). Patients were followed for an average of 32 months (range, 6-70 mo) postoperatively. Back pain was relieved to some degree in all patients and the improvement in Japanese Orthopaedic Association scores was 76.9% ± 7.9. Average kyphotic angle was 6.0° ± 5.7° (range, -2 to 17) immediately after surgery and 7.2° ± 5.8° (range, -3 to 17) at final follow-up. Average of 1° of correction loss was documented and all patients obtained solid fusion uneventfully.

CONCLUSION

This technique is indicated for most patients with rigid post-traumatic kyphosis in the thoracolumbar spine and can yield satisfactory clinical results not only in terms of pain relief, kyphosis correction, vertebral height restoration, and spinal canal integrity preservation, but also in reducing the risk of excessive bleeding and spinal cord injury.

Minimally invasive thoracic corpectomy: surgical strategies for malignancy, trauma, and complex spinal pathologies

The rapid expansion of minimally invasive techniques for corpectomy in the thoracic spine provides promise to redefine treatment options in this region. Techniques have evolved permitting anterior, lateral, posterolateral, and midline posterior corpectomy in a minimally invasive fashion. We review the numerous techniques that have been described, including thoracoscopy, tubular retraction, and various instrumentation techniques. Minimally invasive techniques are compared to their open predecessors from a technical and complication standpoint. Advantages and disadvantages of different approaches are also considered, with an emphasis on surgical strategies and nuance.

Anterior Decompression and Shortening Reconstruction with a Titanium Mesh Cage through a Posterior Approach Alone for the Treatment of Lumbar Burst Fractures

STUDY DESIGN

A retrospective study.

PURPOSE

To examine the efficacy and safety for a posterior-approach circumferential decompression and shortening reconstruction with a titanium mesh cage for lumbar burst fractures.

OVERVIEW OF LITERATURE

Surgical decompression and reconstruction for severely unstable lumbar burst fractures requires an anterior or combined anteroposterior approach. Furthermore, anterior instrumentation for the lower lumbar is restricted through the presence of major vessels.

METHODS

Three patients with an L1 burst fracture, one with an L3 and three with an L4 (5 men, 2 women; mean age, 65.0 years) who underwent circumferential decompression and shortening reconstruction with a titanium mesh cage through a posterior approach alone and a 4-year follow-up were evaluated regarding the clinical and radiological course.

RESULTS

Mean operative time was 277 minutes. Mean blood loss was 471 ml. In 6 patients, the Frankel score improved more than one grade after surgery, and the remaining patient was at Frankel E both before and after surgery. Mean preoperative visual analogue scale was 7.0, improving to 0.7 postoperatively. Local kyphosis improved from 15.7° before surgery to -11.0° after surgery. In 3 cases regarding the mid to lower lumbar patients, local kyphosis increased more than 10° by 3 months following surgery, due to subsidence of the cages. One patient developed severe tilting and subsidence of the cage, requiring additional surgery.

CONCLUSIONS

The results concerning this small series suggest the feasibility, efficacy, and safety of this treatment for unstable lumbar burst fractures. This technique from a posterior approach alone offers several advantages over traditional anterior or combined anteroposterior approaches.

Anterior spine surgery in recent thoracolumbar fractures: An update

Surgical treatment of thoracolumbar spine fractures aims to achieve bony union and restore spinal anatomy. It may associate, as needed, decompression, reduction, graft and/or internal fixation, using a posterior, anterior or combined approach. Indications for an anterior approach weigh the pros and cons as well as the type of osteo-ligamentous lesion, degree of instability and patient's neurological status. The main interest of an anterior approach is to enable medullary decompression by corporectomy while allowing reconstruction of the anterior spine. The technique was less frequently used mainly due to its associated morbidity risk; but the development of videoscopy tools now allows less invasive surgery, compared to conventional thoracophrenolombotomy. Given also the mechanical drawbacks of posterior assembly in certain types of fracture, a video-assisted anterior approach is becoming more common. A conjunction of a staged anterior followed by a posterior approach has progressively developed, to address the needs of spinal trauma: this encompasses posterior surgical reduction-internal fixation, sometimes performed in emergency, with or without laminectomy followed by corporectomy, then anterior spinal reconstruction by graft with or without osteosynthesis to improve medullary decompression and avoid secondary correction loss and non-union. Adapting vertebroplasty techniques to spinal traumatology should gradually limit indications for an anterior approach for purely mechanical purposes; this later will, however, logically remain indicated when anterior spinal cord compression is present with associated neurological deficit, whether or not persisting after posterior reduction-osteosynthesis.

Thoracolumbar burst fractures with a neurological deficit treated with posterior decompression and interlaminar fusion

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.

Posterior transpedicular decompression for thoracolumbar burst fractures

OBJECTIVES

To demonstrate the feasibility of spinal canal decompression through the posterior transpedicular approach in patients with thoracolumbar burst fractures.

METHODS

We present 25 consecutive patients (19 men and 6 women; mean age 36 years; age range, 24-48 years) with incomplete neurological deficits (ASIA B and C) resulting from thoracolumbar burst fractures treated by posterior transpedicular spinal canal decompression and posterior segmental instrumented fusion. Canal compromise at presentation was 51.7 +/- 11.2%.

RESULTS

The mean surgical time was 122 minutes (range, 108-122 minutes), and the mean blood loss was 528 +/- 123 ml. Canal compromise improved to 15.3 +/- 7.8%. At a mean followup of 14 months (range, 6-18 months), fourteen patients improved to ASIA D and were able to walk with an orthosis; seven improved to ASIA C, and four had no improvement (ASIA B). Seven ASIA B and all ASIA C patients had immediate postoperative neurological improvement to ASIA C and ASIA D; two ASIA B patients improved to ASIA C within six weeks after the operation. Anterior decompression was necessary in two (8%) ASIA B patients who did not improve after the initial operation; these patients, subsequently improved to ASIA C. There were no intraoperative complications. Superficial wound infections occurred in two patients and were treated with wound care and antibiotics; deep infection occurred in one patient and was treated with debridement and antibiotics.

CONCLUSION

Posterior transpedicular spinal canal decompression and instrumentation is a reasonable alternative technique to anterior decompression procedures and circumferential fusion, providing for satisfactory canal decompression and neurological improvement.

Anterior Z-plate and titanic mesh fixation for acute burst thoracolumbar fracture

STUDY DESIGN

A retrospective study.

OBJECTIVE

To evaluate the clinical outcome, effectiveness, and security of the surgical management of acute thoracolumbar burst fracture with corpectomy, titanic mesh autograft, and Z-plate fixation by anterior approach.

SUMMARY OF BACKGROUND DATA

Many surgical methods were adopted to treat acute burst thoracolumbar fracture. But the optimal surgical management remains controversial.

METHODS

A retrospective review of a consecutive series of 48 patients with thoracolumbar burst fracture treated with anterior corpectomy, titanic mesh autograft, and Z-plate internal fixation was carried out. Preoperative clinical and radiographic data of all cases were originally collected. Surgical indications were motor neurologic deficit and thoracolumbar column instability. Twenty-two patients (45.8%) with acute thoracolumbar burst fractures presented with a neurologic deficit. The postoperative recovery of neural function, restoration of anterior cortex collapse, kyphotic angle, and spinal canal compromise were observed.

RESULTS

The preoperative kyphotic angle was improved to a mean of 5.6°, radiographic height restored to 95.8% of the adjacent normal levels, and canal compromise was 0%. None of the patients had neurologic deterioration. Mean follow-up time was 32.4 months (range, 24-47 months). All 22 patients with neurologic deficit demonstrated at least one Frankel grade improvement on final observation, with 16 (73%) patients had accomplished complete neurologic recovery. Forty-six (96%) patients reported minimal or no pain at final follow-up observation, and 40 (83%) patients who had been working before injury returned to original work.

CONCLUSION

The authors considered spinal cord decompression with anterior corpectomy and stability reconstruction with titanic mesh autograft and Z-plate fixation at same time in one incision as an effective technique for unstable thoracolumbar burst fracture with and without neurologic deficit.

Biomechanical advantage of the index-level pedicle screw in unstable thoracolumbar junction fractures

OBJECT

Unstable fractures at the thoracolumbar junction often require extended, posterior, segmental pedicular fixation. Some surgeons have reported good clinical outcomes with short-segment constructs if additional pedicle screws are inserted at the fractured level. The goal of this study was to quantify the biomechanical advantage of the index-level screw in a fracture model.

METHODS

Six human cadaveric T10-L4 specimens were tested. A 3-column injury at L-1 was simulated, and 4 posterior constructs were tested as follows: one-above-one-below (short construct) with/without index-level screws, and two-above-two-below (long construct) with/without index-level screws. Pure moments were applied quasistatically while 3D motion was measured optoelectronically. The range of motion (ROM) and lax zone across T12-L2 were measured during flexion, extension, left and right lateral bending, and left and right axial rotation.

RESULTS

All constructs significantly reduced the ROM and lax zone in the fractured specimens. With or without index-level screws, the long-segment constructs provided better immobilization than the short-segment constructs during all loading modes. Adding an index-level screw to the short-segment construct significantly improved stability during flexion and lateral bending; there was no significant improvement in stability when an index-level screw was added to the long-segment construct. Overall, bilateral index-level screws decreased the ROM of the 1-level construct by 25% but decreased the ROM of the 2-level construct by only 3%.

CONCLUSIONS

In a fracture model, adding index-level pedicle screws to short-segment constructs improves stability, although stability remains less than that provided by long-segment constructs with or without index-level pedicle screws. Therefore, highly unstable fractures likely require extended, long-segment constructs for optimum stability.

In vitro biomechanics of an expandable vertebral body replacement with self-adjusting end plates

BACKGROUND CONTEXT

Unstable burst fractures of the thoracolumbar spine may be treated surgically. Vertebral body replacements (VBRs) give anterior column support and, when used with supplemental fixation, impart rigidity to the injured segments. Although some VBRs are expandable, device congruity to the vertebral end plates is imprecise and may lead to stress risers and device subsidence.

PURPOSE

The objective of this study was to compare the rigidity of a VBR that self-adjusts to the adjacent vertebral end plates versus structural bone allograft and with an unsupported anterior column in a traumatic burst fracture reconstruction model.

STUDY DESIGN

Biomechanical flexibility testing with rod strain measurement.

PATIENT SAMPLE

Twelve T11-L3 human spine segments.

OUTCOME MEASURES

Range of motion, neutral zone, and posterior fixation rod stress (moments).

METHODS

Flexibility testing was performed to ± 6 Nm in flexion-extension, lateral bending, and axial rotation on 12 intact human T11-L3 specimens. Burst fractures were created in L1, and flexibility testing was repeated in three additional states: subtotal corpectomy with posterior instrumentation (PI) only from T12 to L2, reconstruction with a femoral strut allograft and PI, and reconstruction with a VBR (with self-adjusting end plates) and PI. The PI consisted of pedicle screws and strain gage instrumented rods that were calibrated to measure rod stress via flexion-extension bending moments.

RESULTS

There was no statistical difference in range of motion or neutral zone between the strut graft and VBR constructs, which both had less motion than the PI-only construct in flexion/extension and torsion and were both less than the intact values in flexion/extension and lateral bending (p < .05). Posterior rod moments were significantly greater for the PI-only construct in flexion/extension relative to the strut graft and VBR states (p = .03).

CONCLUSIONS

This study, which simulated the immediate postoperative state, suggests that a VBR with self-adjusting end plate components has rigidity similar to the standard strut graft when combined with PI. Posterior rod stress was not significantly increased with this type of VBR compared with the strut graft reconstruction. The benefits of burst fracture stabilization using a self-adjusting VBR ultimately will not be known until long-term clinical studies are performed.