Laminar fractures as a severity marker in burst fractures of the thoracolumbar spine

How does vertical laminar fracture impact the decision-making in thoracolumbar fractures? A systematic scoping review and meta-analysis

OBJECTIVE

Although vertical laminar fracture (VLF) is generally considered a severity marker for thoracolumbar fractures (TLFs), its exact role in decision-making has never been established. This scoping review aims to synthesize the research on VLF's role in the decision-making of TLFs.

METHODS

A systematic review was conducted following PRISMA guidelines. We searched PubMed, Scopus, and Web of Science from inception to  June 11, 2023, for studies examining the association of VLF in thoracolumbar fractures with dural lacerations, neurological deficits, radiographic parameters, or treatment outcomes. Additionally, experimental studies that analyze the biomechanics of burst fractures with VLF were included. The studies extracted key findings, objectives, and patient population. A meta-analysis was performed for the association of VLF with dural laceration and neurological deficit, and ORs were pooled with a 95% confidence interval (CI).

RESULTS

Twenty-eight studies were included in this systematic review, encompassing 2021 patients, and twelve were included in the meta-analysis. According to the main subject of the study, the association of VLF with a dural laceration (n = 14), neurological deficit (n = 4), radiographic parameters (n = 3), thoracolumbar fracture classification (n = 2), and treatment outcome (n = 2). Seven studies with a total of 1010 patients reported a significant association between VLF and neurological deficit (OR = 7.35, 95% CI [3.97, 14.25]; P < 0.001). The pooled OR estimates for VLF predicting dural lacerations were 7.75, 95% CI [2.41, 24.87]; P < 0.001).

CONCLUSION

VLF may have several important diagnostic and therapeutic implications in managing TLFs. VLF may help to distinguish AO type A3 from A4 fractures. VLF may help to predict preoperatively the occurrence of dural laceration, thereby choosing the optimal surgical strategy. Clinical and biomechanical data suggest VLF may be a valuable modifier to guide the decision-making in burst fractures; however, more studies are needed to confirm its prognostic importance regarding treatment outcomes.

Recovery with posterior decompression and dural suturing in a patient with cauda equina syndrome caused by lamina entrapment in an unstable burst fracture: A case report

INTRODUCTION

This report investigates Cauda Equina Syndrome (CES), a critical neurological condition from lumbar and sacral nerve root compression that arises from trauma, such as unstable burst fractures leading to interlaminar entrapment. This study highlights the effective management and recovery of a young woman with CES following a traumatic fall, offering new insights into the condition's treatment and recovery process.

CASE PRESENTATION

A 24-year-old female experienced severe lower back pain, bilateral lower limb weakness, saddle anesthesia, and bladder dysfunction after a 3-m fall. The neurological assessment showed reduced sensation and motor function in the lower extremities. Diagnostic imaging revealed an unstable L2 burst fracture with cauda equina entrapment. She underwent emergency posterior decompression and dural repair, followed by a tailored rehabilitation program, which is a novel aspect of this study.

DISCUSSION

This report underscores the critical need for immediate surgical intervention in CES to avert lasting neurological damage. The case represents the significance of early decompression for improving prognosis and explores the complexities of managing CES with unstable spinal fractures and dural tears. It demonstrates the challenges in surgical intervention and postoperative rehabilitation, offering a new perspective on the integrative approach to treatment.

CONCLUSION

This case exemplifies the imperative CES management post-spinal trauma. Despite severe initial deficits, an innovative multidisciplinary approach involving surgery and early rehabilitation resulted in remarkable functional recovery. This study contributes to a new understanding of CES management in acute trauma settings and calls for further research to advance treatment protocols and enhance predictive outcomes.

The association between vertical laminar fracture and recurrent kyphosis after implant removal of Thoracolumbar burst fracture: a retrospective study

BACKGROUND

Surgeons often encounter recurrent kyphosis of Cobb angle following thoracolumbar burst fracture surgery. Some factors affecting postoperative correction loss have been studied in previous studies, but few have examined the relationship between laminar fractures and postoperative loss of correction.

METHODS

The clinical data of 86 patients with thoracolumbar burst fracture who met the inclusion criteria and were admitted to our Department of Spine Surgery between 2013 and 2020 was retrospectively analyzed. To examine the association between laminar fracturs and postoperative correction loss, demographic and radiographic characteristics of the two groups were analyzed.

RESULTS

The presence or absence of laminar fractures was statistically different between the two groups (P < 0.05). Binary logistic regression analysis showed that laminar fractures and preoperative Cobb were statistically significant in the two groups. There were statistically significant differences in the degree of injury of laminar fractures in the coronal plane between the two groups (P < 0.05).

CONCLUSION

This study investigated that the presence or absence of laminar fractures and preoperative Cobb contribute to loss of correction after thoracolumbar burst fracture surgery. There was a statistically significant difference between full-length and partial-length laminar fractures on the loss of postoperative correction of thoracolumbar burst fractures with laminar fractures.

THE INFLUENCE OF THE RIB CAGE ON THE SEVERITY OF THORACIC SPINE BURST FRACTURES

ABSTRACT Objective: To analyze the anatomic influence of the ribs related to the severity of thoracic spine burst fractures. Methods: A retrospective review of 28 patients with thoracic spine burst fractures hospitalized by the Spine Group of the Hospital Ortopédico de Passo Fundo between January 2002 and December 2016 was conducted. The kyphosis, vertebral collapse, and narrowing of the vertebral canal measurements were compared between patients who had fractures at the true and false rib levels (T1 to T10) and those with fractures at the floating rib levels (T11 to T12). Results: The kyphosis, vertebral collapse, and narrowing of the vertebral canal values, measured only for vertebrae pertaining to the rib cage, were low. In addition, there were no statistically significant differences between the measurements of the group of patients with fractures at the level of the true and false ribs (T1 to T10) and the group of patients whose fractures were at the level of the floating ribs (T11 and T12). Conclusion: The differences between the traumatic structural changes in the vertebrae with true and false ribs (T1 to T10) and the vertebrae with floating ribs (T11 and T12) were not significant in the present study. Level of Evidence II; Retrospective study.

Can Vertical Laminar Fracture Further Discriminate Fracture Severity Between Thoracolumbar AO Type A3 and A4 Fractures?

OBJECTIVE

To determine whether vertical laminar fracture (VLF) can distinguish between AO type A3 and A4 fractures.

METHODS

In a retrospective review of 111 consecutive acute thoracolumbar burst fractures, 5 reviewers independently analyzed computed tomography scans to classify fractures into A3 or A4 and to identify VLF. The following computed tomography parameters were measured: spinal canal stenosis >50%, anterior vertebral height ratio <50%, load sharing score >6, and local kyphosis >20°. We calculated the diagnostic performance of VLF in detecting A4 fracture. We compared the proportion of fractures with positive bony parameters, neurological deficit, dural tears, and surgical treatment between A3, A4 with VLF, and A4 without VLF.

RESULTS

VLF was present in 62/75 (83%) A4 fractures and 2/36 (5.5%) A3 fractures (P < 0.0001). VLF yielded a high specificity of 94% (95% confidence interval 81%-99%) and moderately high sensitivity of 83% (95% CI 72%-91%) in detecting A4 fractures. A significantly higher proportion of A4 fractures with VLF had neurological deficit (24% vs. 0, P = 0.05), spinal canal stenosis >50% (25% vs. 0, P = 0.04), and anterior vertebral height ratio <50% (24% vs. 0, P = 0.05) than A4 fractures with no VLF. Interrater and intrarater κ values for VLF and AO standard criterion were excellent (>0.85).

CONCLUSIONS

We found VLF to be highly specific, sensitive, and reliable in detecting A4 fractures. A higher proportion of A4 fractures with VLF had radiographic parameters and neurological deficit than A4 fractures with no VLF. VLF could be used as a severity modifier to further discriminate A3 and A4 fractures regarding severity and potentially guide treatment decision making.

Association of the presence and its types of lamina fractures with posterior dural tear and neurological deficits in traumatic thoracic and lumbar burst fractures

Introduction

The appropriate and optimal treatment for thoracic and lumbar (TL) burst fractures remains a topic of debate. Characterization of vertical laminar fractures (coronal cross-sectional imaging) is presented in this study to determine the severity and treatment options in TL burst fractures.

Methods

A retrospective evaluation of 341 consecutive patients with TL burst fractures was divided into Group I (whole), Group II (partial), and Group III (intact) based on the vertical laminar fracture morphology from coronal images on computed tomography (CT) scans. The presence of preoperative neurological status was reviewed, and several radiological parameters were measured. In addition, the incidence of dural tears was calculated in patients that underwent a decompression with posterior approach.

Results

In total, 270 lumbar and 71 thoracic burst fractures were analyzed. Compared with the intact group, the two other groups had significantly shorter central canal distance, wider interpedicular distance, and smaller spinal canal area, in particular, Group III. The incidences of preoperative neurological deficits in Groups I to III were 63.0, 22.2, and 6.3%, respectively. The incidences of dural tears in Groups I to III were 25.6, 6.3, and 0%, respectively.

Conclusion

The morphology of vertical laminar fractures observed across the coronal plane was important. Patients with “whole”, “partial” and “intact” laminar fractures indicated different severity of TL burst fractures. Due to the high probability of dural tears, decompression is recommended as a primary intervention for patients with “whole” laminar fractures. However, for patients without vertical laminar fractures, minimally invasive technique might be a better choice to avoid approach-related complications.

Comparison of Wiltse's paraspinal approach and open book laminectomy for thoracolumbar burst fractures with greenstick lamina fractures: a randomized controlled trial

Background

Posterior short-segment pedicle screw fixation is used to treat thoracolumbar burst fractures. However, no randomized controlled studies have compared the efficacy of the two approaches––the Wiltse’s paraspinal approach and open book laminectomy in the treatment of thoracolumbar burst fractures with greenstick lamina fractures.

Materials and methods

Patients with burst fractures of the thoracolumbar spine without neurological deficit were randomized to receive either the Wiltse’s paraspinal approach (group A, 24 patients) or open book laminectomy (group B, 23 patients). Patients were followed postoperatively for average of 27.4 months. Clinical and radiographic data of the two approaches were collected and compared.

Results

Our results showed the anterior segmental height, kyphotic angle, visual analog scale (VAS) score, and Smiley-Webster Scale (SWS) score significantly improved postoperatively in both groups, indicating that both the Wiltse’s paraspinal approach and open book laminectomy can effectively treat thoracolumbar burst fractures with greenstick lamina fractures. The Wiltse’s paraspinal approach was found to have significantly shorter operating time, less blood loss, and shorter length of hospital stay compared to open book laminectomy. However, there were two (2/24) patients in group A that had neurological deficits postoperatively and required a second exploratory operation. Dural tears and/or cauda equina entrapment were subsequently found in four patients in group B and all two patients of neurological deficits in group A during operation. No screw loosening, plate breakage, or other internal fixation failures were found at final follow-up.

Conclusions

The results demonstrated that either of the two surgical approaches can achieve satisfactory results in treating thoracolumbar burst fractures in patients with greenstick lamina fractures. However, if there is any clinical or radiographic suspicion of a dural tear and/or cauda equina entrapment pre-operation, patients should receive an open book laminectomy to avoid a second exploratory operation. More research is still needed to optimize clinical decision-making regarding surgical approach.

Electronic supplementary material

The online version of this article (10.1186/s13018-018-0743-z) contains supplementary material, which is available to authorized users.

Burst fracture of the thoracolumbar spine: correlation between kyphosis and clinical result of the treatment

<sec><title>OBJECTIVE:</title><p> To evaluate the correlation between kyphosis due to burst fractures of thoracic and lumbar spine and clinical outcome in patients undergoing conservative or surgical treatment.</p></sec><sec><title>METHODS:</title><p> A retrospective, cross-sectional study was conducted with 29 patients with thoracolumbar burst fractures treated by the Spine Group in a trauma reference hospital between the years 2002 and 2011. Patients were followed-up as outpatients for a minimum of 24 months. All cases were clinically evaluated by Oswestry and SF-36 quality of life questionnaires and the visual analogue scale (VAS) of pain. They were also evaluated by X-ray examinations and CT scans of the lumbosacral spine at the time of hospitalization and subsequently as outpatients by Cobb method for measuring the degree of kyphosis.</p></sec><sec><title>RESULTS:</title><p> There was no statistically significant correlation between the degree of initial kyphosis and clinical outcome measured by VAS and by most of the SF-36 domains in both patients treated conservatively and the surgically treated. The Oswestry questionnaire showed benefits for patients who received conservative treatment (p=0.047) compared to those surgically treated (p=0.335). The analysis of difference between initial and final kyphosis and final kyphosis alone in relation to clinical outcome showed no statistical correlation in any of the scores used.</p></sec><sec><title>CONCLUSION:</title><p> The clinical outcome of treatment of the thoracic and lumbar burst fractures was not influenced by a greater or lesser degree of initial or residual kyphosis, regardless of the type of treatment.</p></sec>

Dynamics of interpedicular widening in spinal burst fractures: an in vitro investigation

BACKGROUND CONTEXT

Spinal burst fractures are a significant cause of spinal instability and neurologic impairment. Although evidence suggests that the neurologic trauma arises during the dynamic phase of fracture, the biomechanics underpinning the phenomenon has yet to be fully explained. Interpedicular widening (IPW) is a distinctive feature of the fracture but, despite the association with the occurrence of neurologic deficit, little is known about its biomechanics.

PURPOSE

To provide a comprehensive in vitro study on spinal burst fracture, with special attention on the dynamics of IPW.

STUDY DESIGN

Experimental measurements in combination with computed tomography scanning were used to quantitatively investigate the biomechanics of burst fracture in a cadaveric model.

METHODS

Twelve human three-adjacent-vertebra segments were tested to induce burst fracture. Impact was delivered through a drop-weight tower, whereas IPW was continuously recorded by two displacement transducers. Computed tomography scanning aided quantifying canal occlusion (CO) and evaluating sample anatomy and fracture appearance. Two levels of energy were delivered to two groups: high energy (HE) and low energy (LE).

RESULTS

No difference was found between HE and LE in terms of the residual IPW (ie, post-fracture), maximum IPW, or CO (median 20.2%). Whereas IPW was not found to be correlated with CO, a moderate correlation was found between the maximum and the residual IPW. At the fracture onset, IPW reached a maximum median value of 15.8% in approximately 20 to 25 milliseconds. After the transient phase, the pedicles were recoiled to a median residual IPW of 4.9%.

CONCLUSIONS

Our study provides for the first time insight on how IPW actually evolves during the fracture onset. In addition, our results may help shedding more light on the mechanical initiation of the fracture.

Hybrid cadaveric/surrogate model of thoracolumbar spine injury due to simulated fall from height

A fall from high height can cause thoracolumbar spine fracture with retropulsion of endplate fragments into the canal leading to neurological deficit. Our objectives were to develop a hybrid cadaveric/surrogate model for producing thoracolumbar spine injury during simulated fall from height, evaluate the feasibility and performance of the model, and compare injuries with those observed clinically. Our model consisted of a 3-vertebra human lumbar specimen (L3-L4-L5) stabilized with muscle force replication and mounted within an impact dummy. The model was subjected to a fall from height of 2.2 m with impact velocity of 6.6 m/s. Kinetic and kinematic time-history responses were determined using spinal and pelvis load cell data and analyses of high-speed video. Injuries to the L4 vertebra were evaluated by fluoroscopy, radiography, and detailed anatomical dissection. Peak compression forces during the fall from height occurred at 7 ms and reached 44.7 kN at the ground, 9.1 kN at the pelvis, and 4.5 kN at the spine. Pelvis acceleration peaks reached 209.9 g at 8 ms for vertical and 62.8 g at 12 ms for rearward. Tensile load peaks were then observed (spine: 657.0 N at 47 ms; pelvis: 569.4 N at 61 ms). T1/pelvis peak flexion of 68.3° occurred at 38 ms as the upper torso translated forward while the pelvis translated rearward. Complete axial burst fracture of the L4 vertebra was observed including endplate comminution, retropulsion of bony fragments into the canal, loss of vertebral body height, and increased interpedicular distance due to fractures anterior to the pedicles and a vertical split fracture of the left lamina. Our dynamic injury model closely replicated the biomechanics of real-life fall from height and produced realistic, clinically relevant burst fracture of the lumbar spine. Our model may be used for further study of thoracolumbar spine injury mechanisms and injury prevention strategies.

Fratura tipo explosão da coluna torácica e lombar: correlação entre o segmento biomecânico sagital acometido e as alterações estruturais da vértebra fraturada

OBJETIVO: Analisar as fraturas tipo explosão da coluna torácica e lombar e fazer a correlação entre o segmento biomecânico sagital acometido e as alterações estruturais da vértebra fraturada. MÉTODOS: Estudo retrospectivo de 72 pacientes com fraturas tipo explosão da coluna torácica e lombar. O estreitamento do canal vertebral, o colapso vertebral e a cifose local foram avaliados em três segmentos distintos: torácico, transição toracolombar e lombar. RESULTADOS: Houve diferença estatística significativa (p < 0,05) dos valores do estreitamento do canal vertebral e cifose local nos diferentes segmentos da coluna vertebral avaliados. CONCLUSÃO: As fraturas tipo explosão da coluna torácica e lombar, embora apresentem características semelhantes, independentemente do local de ocorrência, sofrem influência direta do segmento biomecânico sagital no que diz respeito às alterações estruturais que ocorrem na vértebra fraturada.

Can the interpedicular distance reliably assess the severity of thoracolumbar burst fractures?

STUDY DESIGN

Retrospective analysis of 260 patients with acute spine fractures treated at a tertiary trauma center from 1989 to 2009.

OBJECTIVE

To correlate the Interpedicular distance (IPD) to the percentage of narrowing of the spinal canal and to the presence of neurological deficit and laminar fracture in thoracolumbar burst fractures.

SUMMARY OF BACKGROUND DATA

Several reports use radiographic findings such as severity of vertebrae collapse, comminution of the vertebral body, and grade of localized kyphosis to determine the severity of spinal traumas and establish appropriate management. However, the importance of the IPD in burst fractures has rarely been mentioned, and no report specifically describes the correlation between an increased IPD and the severity of the lesion or a higher occurrence of lamina fractures.

METHODS

Plain radiographs of 260 patients with acute thoracolumbar burst fractures were studied. The percentage of widening between the pedicles of the fractured vertebra (IPD) was established by comparing this distance with that of the vertebrae immediately above and below. Data concerning neurological status, percentage of narrowing of the spinal canal, and the presence of laminar fracture were correlated to the IPD.

RESULTS

A significant correlation between IPD and the percentage of narrowing of the spinal canal was found (r = 0.39; t = 6.78; P = 0.00). IPD was significantly increased in patients with neurological deficit (24.7% ± 12.6%) and in patients with lamina fractures (24.6% ± 16.2%).

CONCLUSION

IPD measured from plain radiographs proved to be a reliable instrument to assess narrowing of the spinal canal, neurological deficits, and laminar fractures.