Burst fractures of the second through fifth lumbar vertebrae. Clinical and radiographic results

Novel Nerve-Sparing In Situ Assembly of an Expandable Titanium Cage to Maximize Endplate Coverage After Posterior Corpectomy for Comminuted Lumbar Burst Fractures

BACKGROUND AND OBJECTIVES

The ability to maximize corpectomy cage endcap size and vertebral endplate coverage after corpectomy for lumbar burst fractures (L1-L5) is limited by the presence of lumbar nerve roots and the larger cross-sectional area of the lumbar endplates relative to the restrictive corridor for cage insertion. This work aims to provide details and clinical examples of a novel operative technique for 3-column reconstruction and stabilization of comminuted lumbar burst fractures.

METHODS

Through a standard posterior midline approach and following posterior instrumentation and lateral extracavitary corpectomy, an in-situ assembly of a modular corpectomy cage that respects adjacent neural structures, restores segmental alignment, and maximizes endplate coverage across a lordotic segment is completed.

RESULTS

Radiographic evidence of anatomic spinal reconstruction and stabilization with complete or near-complete endplate coverage without incurrence of new clinical deficit after this novel treatment of lumbar burst fractures.

CONCLUSION

The fixation approach described in this report may be a valuable modification to a long-standing technique used for treating comminuted lumbar burst fractures (L1-L5) from a posterior-only approach without incurring additional neurological deficits and by improving endplate and apophyseal ring coverage.

Burst fractures of the fifth lumbar vertebra: Case series and systematic review

BACKGROUND

Burst fractures of the fifth lumbar vertebra (L5) are rare injuries and typically occur because of high-energy axial compressive load. Their unique anatomy and biomechanical characteristics distinguish them from other lumbar spine injuries. To the best of our knowledge, the treatment strategies for L5 burst fractures have not been thoroughly described. The aims of this case series and systematic review were to highlight the treatment strategies and outcomes of the L5 burst fractures.

METHODS

We performed a retrospective case series of 8 patients treated for burst L5 fractures in our institution between 2005 and 2020. Additionally, a systematic review via PubMed and Cochrane Library databases according to PRISMA guidelines was performed to review L5 burst fractures treatment strategies. Only Articles in English with full text available were included. The references of the selected studies were checked to find all possible related articles. Treatment strategies were conservative, posterior segmental instrumentation and fixation (PSIF), PSIF with anterior corpectomy (AC), and PSIF with posterior corpectomy (PC). Outcomes measures included neurological status, radiological regional alignment, and complications.

RESULTS

A total of 1449 publications were found, and 29 articles were finally selected for analysis. Of those, 15 were retrospective case reports, and 14 were retrospective case series. One hundred and sixty-nine patients were found in the review. The author's eight cases were added to the found in the literature for a methodological quality assessment. There were 52 (29%) patients managed non-operative, and 125 (71%) underwent surgery. One-hundred-two patients were neurologically intact, of whom 46 were managed non-operative. Canal compromise in intact patients ranged between 20 and 90%. Posterior segmental fixation and instrumentation with decompression was the preferred surgical strategy in patients with neurological deficits. Patients with combined anterior column restoration and anterior approach showed vertebral height and lordosis restoration. A 79% of the operative treated group reported neurological improvement. Patients with pre-operative neurological deficit managed non-operative reported the highest rate of complications (33.3%).

CONCLUSION

In the setting of L5 burst fractures, neurological injuries have a promising prognosis after surgery and are not correlated with the degree of canal stenosis. The compromise of the L5 vertebra affects the sagittal balance and its restoration can be achieved with an anterior corpectomy. Nonoperative management can be considered in cases of reasonable alignment, and no neurologic deficit.

Indications for Nonsurgical Treatment of Thoracolumbar Spine Fractures: WFNS Spine Committee Recommendations

Thoracolumbar spine is the most injured spinal region in blunt trauma. Literature on the indications for nonoperative treatment of thoracolumbar fractures is conflicting. The purpose of this systematic review is to clarify the indications for nonsurgical treatment of thoracolumbar fractures. We conducted a systematic literature search between 2010 to 2020 on PubMed/MEDLINE, and Cochrane Central. Up-to-date literature on the indications for nonoperative treatment of thoracolumbar fractures was reviewed to reach an agreement in a consensus meeting of WFNS (World Federation of Neurosurgical Societies) Spine Committee. The statements were voted and reached a positive or negative consensus using the Delphi method. For all of the questions discussed, the literature search yielded 1,264 studies, from which 54 articles were selected for full-text review. Nine studies (4 trials, and 5 retrospective) evaluating 759 participants with thoracolumbar fractures who underwent nonoperative/surgery were included. Although, compression type and stable burst fractures can be managed conservatively, if there is major vertebral body damage, kyphotic angulation, neurological deficit, spinal canal compromise, surgery may be indicated. AO type B, C fractures are preferably treated surgically. Future research is necessary to tackle the relative paucity of evidence pertaining to patients with thoracolumbar fractures.

Treatment Tactics for Patients with Isolated Injuries of the Fifth Lumbar Vertebra

The major management technique for lumbar burst fractures is transpedicular fixation (TPF). However, in relation to fractures of the L₅ vertebra, this tactic often has no advantages over conservative treatment, and, therefore, it is expected to be supplemented with anterior decompression and reconstruction of the anterior column of the L₅ vertebra.

The aim of the study was to determine the most optimal treatment tactics for patients with isolated burst fractures of the fifth lumbar vertebra.

Isolated unstable burst fractures of the fifth lumbar vertebra: functional and radiological outcome after posterior stabilization with reconstruction of the anterior column: About 6 cases and literature review

INTRODUCTION

L5 burst fractures represent a small percentage of all spine fractures. Treatment strategy has not yet been standardized. Anatomical features and their biomechanical characteristics create fracture patterns which differ from those at the thoracolumbar junction. The objective of this study was to evaluate L5 burst fracture surgical treatment outcomes after posterior stabilization and reconstruction of the anterior column.

PATIENTS AND METHODS

Six patients with fifth lumbar isolated unstable burst fractures were analyzed. Medical records, radiographs, and clinical scores were obtained. The results were evaluated based on restoration of vertebral body height, spinal lordosis/kyphosis, canal compromise and sagittal alignment at several phases of treatment.

RESULTS

No patient showed neurologic deterioration, regardless of treatment. The median preoperative anterior vertebral height was 41mm and postoperative was 48mm. The median preoperative kyphotic angle as measured by Cobb angle (local and regional) was 21.5 degrees and 33 degrees which improved respectively by 7.5 and 5.5 degrees following instrumentation. The median amount of backward protrusion of bony fragment into the canal was measured at 67% preoperatively and at 35% postoperatively. There were no pseudarthrosis and anterior arthrodesis solid fusion was visible in all cases. There were a sagittal alignment restoration. At one year of follow up, fusion was obtained in all the cases, all patients had minimal to moderate disability using Oswestry Disability Index. The ability to return to work revealed a good-to-excellent long-term result.

DISCUSSION

The results of treatment of 5th lumbar unstable burst fractures with posterior stabilization and reconstruction of the anterior column show benefit on durable functional outcome, spine stabilization and radiologic parameters.

LEVEL OF EVIDENCE

IV, retrospective study.

Emergency stabilisation by single-stage posterior transpedicular approach for treatment of unstable lumbar spine fracture with neurological injury

Management of unstable thoracolumbar fractures remains controversial. Furthermore, when these are accompanied by related neurological injury, the choice of approach, decompression technique and timing of the intervention could have a neuroprotective effect. In terms of site, the lumbar spine represents only 1.2% of cases, yet fractures with severe instability and neurological injury call for attainment of the same goals, i.e., neurological stability and decompression.

After suffering high-energy trauma as a result of an accidental fall, a young male patient presenting with unstable injury of the lumbar spine and neurological impairment compatible with incomplete cauda equina syndrome was treated with emergency stabilisation and decompression through single-stage posterior transpedicular approach. At one year of the intervention, the patient is making good progress, with absence of lumbar pain, isolated deficit in left ankle dorsiflexion with no need of orthosis or cane, adequate sphincter control and return to his previous activity.

Patients who present with unstable injury of the lumbar spine and incomplete neurological involvement can benefit from emergency stabilisation and decompression treatment by posterior transpedicular approach, with improvement in neurological status and functional recovery.

Predictors of Recovery After Conservative Treatment of AO-Type A Thoracolumbar Spine Fractures Without Neurological Deficit

STUDY DESIGN

Prospective, correlational, exploratory, clinical research.

OBJECTIVE

To identify the factors determining a patient's recovery after conservative treatment of compression fractures of the thoracolumbar spine.

SUMMARY OF BACKGROUND DATA

The reported results of compression fractures are poor. These results are not influenced by the severity of compression, the fracture site, or the residual deformity. Otherwise, the factors that determine a patient's recovery are unknown.

METHODS

In 48 conservatively treated patients the preinjury versus the 12-month follow-up differences (Δ) in back pain (visual analogue scale for pain), Oswestry disability index (ODI), and the Greenough and Fraser low back outcome scale were prospectively recorded. For these differences and for time lost from work and satisfaction, multiple linear regressions with combinations of 16 factors were performed.

RESULTS

At 1 year, patients with an income-insurance were 9% (P = 0.096) more disabled than those without. They reported a 15% less favorable global outcome and 27% less participation. Smokers were 13% (P = 0.010) more disabled and 11% (P = 0.044) less satisfied. With each increase of the AO-fracture type from A1 to A3 the disability was 8% worse. Patients with pre-existent chronic low back pain (CLBP) returned two points (on a visual analogue scale [VAS] pain total of 10) more closely (P = 0.041) to their preinjury pain level than those without but were 21% (P = 0.001) less satisfied. Our model offers an explanation for more than 25% of the variability of ΔODI and of the satisfaction. For sick leave, no significant predictors were found.

CONCLUSION

Smoking and insurance status are the strongest negative predictors for recovery. LBP patients returned more closely to their preinjury back pain level, but were less satisfied. The AO fracture type had a marked influence on disability, the sagittal deformity had not. The time lost from work did not depend on patient or injury-related factors.

LEVEL OF EVIDENCE

N/A.

Behavior of Injured Lamina in Lumbar Burst Fractures during Reduction Maneuvers: A Biomechanical Study

STUDY DESIGN

An experimental biomechanical study.

PURPOSE

This study aims to investigate the behavior of a lamina injury in lumbar burst fractures during reduction maneuvers.

OVERVIEW OF LITERATURE

Lumbar burst fractures are frequently accompanied by a lamina fracture. Many researchers concluded that any reduction maneuver will close the fractured lamina edges and possibly crush the entrapped neural elements. This conclusion did not rely on solid biomechanical trials and was based primarily on clinical experience.

METHODS

Eighteen fresh-frozen lamb spines were randomly divided into three groups. Using the preinjury and the dropped-mass technique, a burst fracture model was developed. A central laminectomy of 5 mm of the L3 lumbar spine was created to mimic a complete type of lamina fracture. To measure the movement of the fractured laminar edges, two holes were drilled on both sides of the upper and lower regions of the lamina to allow for optic marker placement. A single specific spine movement was applied to each group: traction, flexion, and extension. Gap changes were measured by camera extensometers.

RESULTS

After traction, the average values of the upper and lower aspects of the lamina interval showed narrowing of 1.65±0.82 mm and 1.97±1.14 mm, respectively. No statistical significance was detected between the two aspects. The upper and lower regions of the lamina gap behaved differently during extension. At 10°, 20°, and 30°, the upper part of the lamina interval was widened by an average of 0.016±0.024, 0.29±0.32, and 1.73±1.45 mm, respectively, whereas the lower part was narrowed by an average of 0.023±0.012, 0.47±0.038, and 1.94±1.46 mm, respectively.

CONCLUSIONS

Neural element crushing may take place, particularly at the lower aspect of the fractured lamina gap during extension and throughout the whole lamina gap during traction. The lamina gap widens during flexion. Reduction maneuvers should be attempted after exploring the fractured lamina to prevent further neurological compromise.

Management of burst fractures in the thoracolumbar spine

The most common fractures in the spine take place in the thoracolumbar region. Currently there is no consensus regarding optimum treatment.

OBJECTIVE

Analyze the current medical literature available regarding treatment of compression fractures of the thoracolumbar spine.

METHODS

Research of current literature in medical databases.

RESULTS

Regarding current available literature, we found no consensus in the treatment of compression fractures in the thoracolumbar spine.

CONCLUSIONS

Burst fractures of the thoracolumbar junction is a very common condition, treatment of each patient must be individualized. Conservative treatment is recommended for stable fractures without neurological compromise and less than 35° of kyphosis.

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.

Outcomes After Operative Management of Combat-Related Low Lumbar Burst Fractures

STUDY DESIGN

Retrospective review.

OBJECTIVE

Report the 2-year operative and clinical outcomes of these service members with low lumbar fractures.

SUMMARY OF BACKGROUND DATA

The majority of spinal fractures occur at the thoracolumbar level, with fractures caudal to L2 accounting for only 1% of spine fractures. A previous report from this institution regarding combat-related spine burst fractures documented an increased incidence of low lumbar burst fractures in injured service members.

METHODS

Review of inpatient and outpatient medical records in addition to radiographs for all patients treated at our institution with combat-related burst fractures occurring at the L3-L5 levels.

RESULTS

Twenty-four patients with a mean age of 28.1± 7.2 underwent surgery for low lumbar (L3-L5) burst fractures. The mean number of thoracolumbar levels injured was 2.9 ± 1.4. Eleven patients had neurological injury, 4 of which were complete. The mean days to surgery were 16.8 ± 24.5. The mean number of levels fused was 4.3 ± 2.1, with fixation extending to the pelvis in 4 patients (17%). Fourteen (61%) patients had at least 1 postoperative complication, with 7 (30%) requiring reoperation. Five patients had a postoperative wound infection. Five patients had deep venous thromboses, 3 had pulmonary emboli. Mean clinical follow-up was 3.3± 2.2 years. At latest follow-up, all were separated from military service, 10 experienced persistent bowel/bladder dysfunction, 15 had lower extremity motor deficits, and 10 had documented persistent low back pain. Nineteen had chronic pain with 18 patients still taking pain medications and/or muscle relaxers.

CONCLUSION

Low lumbar burst fractures are a rare injury with an increased incidence in combat casualties engaged in the wars in Iraq and Afghanistan. We found a high rate of acute postoperative complications (61%), as well as a high reoperation rate (30%). At approximately 3 years of follow-up, most of these patients had persistent neurological symptoms and chronic pain.

LEVEL OF EVIDENCE

4.

The analysis of functional and radiographic outcomes of conservative treatment in patients with low lumbar burst fractures

INTRODUCTION

Burst fractures of the low lumbar spine constitute approximately one percent of all lumbar fractures. There is still no consensus on the optimal treatment of low lumbar burst factures. We aimed to evaluate the functional and radiographic outcomes of conservative treatment in patients with low lumbar burst fracture.

METHODS

15 patients (11 males, 4 females; mean age 32±8) who had low lumbar spine burst fracture treated with a custom-moulded thoracolumbosacral orthosis (TLSO) with a thigh extension were enrolled. The mean follow-up period was 22±6 months. 14 patients were neurologically intact and one had isolated nerve root injury. There were 24% type A fractures and 76% type B fractures according to the Denis classification system. Functional outcomes were evaluated by using Oswestry Disability Index (ODI), Short-Form 36 (SF-36) and Visual Analogue Scale (VAS). Radiographic outcome was analyzed by measuring anterior vertebral height loss, kyphosis angle, amount of canal retropulsion. Functional and radiographic outcomes were reviewed initially and at 1, 3, 6, 12 months, and at the latest follow-up. Functional and radiographic improvements were analyzed statistically.

RESULTS

The mean bracing period was 11.9±1.7 weeks. The mean initial ODI, SF-36, and VAS score of the patients was 78.3±9.6, 23.7±8.9, and 8.7±0.7, respectively. The mean ODI, SF-36, and VAS score of the patients at the final follow-up was 26.4±6.5, 68.1±11.2, and 2.8±1.7, respectively. The improvement in functional outcomes was measured to be significant (p<0.05 for ODI, SF-36 and VAS). The mean initial anterior vertebral height loss, kyphosis angle, amount of canal retropulsion was found to be 27.2%±9.6%, -6.8°±3.2°, 37.4%±10.2%, respectively. The mean anterior vertebral height loss, kyphosis angle, and amount of canal retropulsion at the final follow-up was 23.1%±.6.7%, -4.2°±2.4°, 19.6%±7.7%, respectively. Among the radiographic outcomes, only the amount of canal retropulsion improved statistically (p=0.042).

CONCLUSION

Conservative treatment using a custom-moulded thoracolumbosacral orthosis with a thigh extension is a safe and effective method in patients with low lumbar spine burst fractures and can improve functional and radiographic outcomes.

The effect of laminae lesion on thoraco-lumbar fracture reduction

INTRODUCTION

The treatment of fractures involving the lumbar spine has been controversial. Laminae lesion may be complete or of the greenstick type (incomplete). Dural tears and nerve root entrapment may accompany these laminae fractures. The aim of this study is twofold, to assess the effect of different types of laminae fractures on the anteriorvertebral height restoration in upper lumbar burst fractures and to determine the incidences of the intraoperatively detected dural tear and neural entrapment in complete and incomplete laminae fractures to choose the optimal treatment.

MATERIALS AND METHODS

A retrospective review was conducted on 112 patients with 114 lumbar burst fractures treated operatively, age ranged from 17 to 55 years (mean age 32). Male to female ratio was (93%/7%), 8 females. Patients were divided into three groups, group 1 patients without lamina fracture, group 2 patients with complete type lamina fracture and group 3 patients with (percutaneous) incomplete type lamina fractures. All clinical charts and radiologic data of these groups were analyzed for their association with dural tears, neural entrapment and the impact of lamina fracture (complete and incomplete types) on the efficacy of anterior vertebral height restoration. The severity of injury was determined using the ASIA (Modified Frankel scale).

RESULTS

Out of 114 upper lumbar burst fractures, lamina fracture occurred in 34 patients (29.8%), complete lamina fracture occurred in 21 patients (61.7%), whereas incomplete lamina fracture occurred in 13 patients (38.3%). Dural tear was detected in 16 patients (47%) and was predominantly higher in complete type lamina fracture 12 patients (57%) when compared to 4 dural tears (30%) in incomplete lamina fractures. Analysis of the data revealed no significant difference in the preoperative anterior vertebral height loss and local kyphotic angle between the three groups. However the anterior vertebral height and local kyhpotic angle restoration were found to be affected by the presence of complete lamina fracture when compared to other groups with incomplete lamina fracture and without lamina fracture (P=0.001).

CONCLUSION

In upper lumbar burst fractures, complete lamina fracture is an indicator of injury severity. When detected preoperatively on CT or MRI scanning, it should be operated by open book laminectomy even if the patient is neurologically intact since it carries a high risk of neural entrapment, and its presence affects the intraoperative postural and instrumental trials for anterior vertebral height restoration.

Treatment of thoracolumbar fracture

The most common fractures of the spine are associated with the thoracolumbar junction. The goals of treatment of thoracolumbar fracture are leading to early mobilization and rehabilitation by restoring mechanical stability of fracture and inducing neurologic recovery, thereby enabling patients to return to the workplace. However, it is still debatable about the treatment methods. Neurologic injury should be identified by thorough physical examination for motor and sensory nerve system in order to determine the appropriate treatment. The mechanical stability of fracture also should be evaluated by plain radiographs and computed tomography. In some cases, magnetic resonance imaging is required to evaluate soft tissue injury involving neurologic structure or posterior ligament complex. Based on these physical examinations and imaging studies, fracture stability is evaluated and it is determined whether to use the conservative or operative treatment. The development of instruments have led to more interests on the operative treatment which saves mobile segments without fusion and on instrumentation through minimal invasive approach in recent years. It is still controversial for the use of these treatments because there have not been verified evidences yet. However, the morbidity of patients can be decreased and good clinical and radiologic outcomes can be achieved if the recent operative treatments are used carefully considering the fracture pattern and the injury severity.

Evidence-based management of traumatic thoracolumbar burst fractures: a systematic review of nonoperative management

OBJECT

The overall evidence for nonoperative management of patients with traumatic thoracolumbar burst fractures is unknown. There is no agreement on the optimal method of conservative treatment. Recent randomized controlled trials that have compared nonoperative to operative treatment of thoracolumbar burst fractures without neurological deficits yielded conflicting results. By assessing the level of evidence on conservative management through validated methodologies, clinicians can assess the availability of critically appraised literature. The purpose of this study was to examine the level of evidence for the use of conservative management in traumatic thoracolumbar burst fractures.

METHODS

A comprehensive search of the English literature over the past 20 years was conducted using PubMed (MEDLINE). The inclusion criteria consisted of burst fractures resulting from a traumatic mechanism, and fractures of the thoracic or lumbar spine. The exclusion criteria consisted of osteoporotic burst fractures, pathological burst fractures, and fractures located in the cervical spine. Of the studies meeting the inclusion/exclusion criteria, any study in which nonoperative treatment was used was included in this review.

RESULTS

One thousand ninety-eight abstracts were reviewed and 447 papers met inclusion/exclusion criteria, of which 45 were included in this review. In total, there were 2 Level-I, 7 Level-II, 9 Level-III, 25 Level-IV, and 2 Level-V studies. Of the 45 studies, 16 investigated conservative management techniques, 20 studies compared operative to nonoperative treatments, and 9 papers investigated the prognosis of conservative management.

CONCLUSIONS

There are 9 high-level studies (Levels I-II) that have investigated the conservative management of traumatic thoracolumbar burst fractures. In neurologically intact patients, there is no superior conservative management technique over another as supported by a high level of evidence. The conservative technique can be based on patient and surgeon preference, comfort, and access to resources. A high level of evidence demonstrated similar functional outcomes with conservative management when compared with open surgical operative management in patients who were neurologically intact. The presence of a neurological deficit is not an absolute contraindication for conservative treatment as supported by a high level of evidence. However, the majority of the literature excluded patients with neurological deficits. More evidence is needed to further classify the appropriate burst fractures for conservative management to decrease variables that may impact the prognosis.

Expectations of recovery and functional outcomes following thoracolumbar trauma: an evidence-based medicine process to determine what surgeons should be telling their patients

OBJECT

The aim of this study was to define the expected functional and health-related quality of life outcomes following common thoracolumbar injuries on the basis of consensus expert opinion and the best available literature. Patient expectations are primarily determined by the information provided by health care professionals, and these expectations have been shown to influence outcome in various medical and surgical conditions. This paper presents Part 2 of a multiphase study designed to investigate the impact of patient expectations on outcomes following spinal injury. Part 1 demonstrated substantial variability in the information surgeons are communicating to patients. Defining the expected outcomes following thoracolumbar injury would allow further analysis of this relationship and enable surgeons to more accurately and consistently inform patients.

METHODS

Expert opinion was assembled by distributing questionnaires comprising 4 cases representative of common thoracolumbar injuries to members of the Spine Trauma Study Group (STSG). The 4 cases included a thoracolumbar junction burst fracture treated nonoperatively or with posterior transpedicular instrumentation, a low lumbar (L-4) burst fracture treated nonoperatively, and a thoracolumbar junction flexion-distraction injury managed with posterior fusion. For each case, 5 questions about expected outcomes were posed. The questions related to the proportion of patients who are pain free, the proportion who have regained full range of motion, and the patients' recreational activity restrictions and personal care and social life limitations, all at 1 year following injury, as well as the timing of return to work and length of hospital stay. Responses were analyzed and combined with the results of a systematic literature review on the same injuries to define the expected outcomes.

RESULTS

The literature review identified 38 appropriate studies that met the preset inclusion criteria. Published data were available for all injuries, but not all outcomes were available for each type of injury. The survey was completed by 31 (57%) of 53 surgeons representing 24 trauma centers across North America (15), Europe (5), India (1), Mexico (1), Japan (1) and Israel (1). Consensus expert opinion supplemented the available literature and was used exclusively when published data were lacking. For example, 1 year following cast or brace treatment of a thoracolumbar burst fracture, the expected outcomes include a 40% chance of being pain free, a 70% chance of regaining pre-injury range of motion, and an expected ability to participate in high-impact exercise and contact sport with no or minimal limitation. Consensus expert opinion predicts reemployment within 4-6 months. The length of inpatient stay averages 4-5 days.

CONCLUSIONS

This synthesis of the best available literature and consensus opinion of surgeons with extensive clinical experience in spine trauma reflects the optimal methodology for determining functional prognosis after thoracolumbar trauma. By providing consistent, accurate information surgeons will help patients develop realistic expectations and potentially optimize outcomes.

A review of pediatric lumbar spine trauma

Pediatric spine fractures constitute 1%–3% of all pediatric fractures. Anywhere from 20% to 60% of these fractures occur in the thoracic or lumbar spine, with the lumbar region being more affected in older children. Younger children tend to have a higher proportion of cervical injuries. The pediatric spine differs in many ways from the adult spine, which can lead to increased ligamentous injuries without bone fractures. The authors discuss and review pediatric lumbar trauma, specifically focusing on epidemiology, radiographic findings, types and mechanisms of lumbar spine injury, treatment, and outcomes.

Operative and nonoperative adverse events in the management of traumatic fractures of the thoracolumbar spine: a systematic review

Object

Thoracolumbar spine injuries are commonly encountered in patients with trauma, accounting for almost 90% of all spinal fractures. Thoracolumbar burst fractures comprise a high percentage of these traumatic fractures (45%), and approximately half of the patients with this injury pattern are neurologically intact. However, a debate over complication rates associated with operative versus nonoperative management of various thoracolumbar fracture morphologies is ongoing, particularly concerning those patients presenting without a neurological deficit.

Methods

A MEDLINE search for pertinent literature published between 1966 and December 2013 was conducted by 2 authors (G.G. and R.D.), who used 2 broad search terms to maximize the initial pool of manuscripts for screening. These terms were “operative lumbar spine adverse events” and “nonoperative lumbar spine adverse events.”

Results

In an advanced MEDLINE search of the term “operative lumbar spine adverse events” on January 8, 2014, 1459 results were obtained. In a search of “nonoperative lumbar spine adverse events,” 150 results were obtained. After a review of all abstracts for relevance to traumatic thoracolumbar spinal injuries, 62 abstracts were reviewed for the “operative” group and 21 abstracts were reviewed for the “nonoperative” group. A total of 14 manuscripts that met inclusion criteria for the operative group and 5 manuscripts that met criteria for the nonoperative group were included.

There were a total of 919 and 436 patients in the operative and nonoperative treatment groups, respectively. There were no statistically significant differences between the groups with respect to age, sex, and length of stay. The mean ages were 43.17 years in the operative and 34.68 years in the nonoperative groups. The majority of patients in both groups were Frankel Grade E (342 and 319 in operative and nonoperative groups, respectively). Among the studies that reported the data, the mean length of stay was 14 days in the operative group and 20.75 in the nonoperative group.

The incidence of all complications in the operative and nonoperative groups was 300 (32.6%) and 21 (4.8%), respectively (p = 0.1065). There was no significant difference between the 2 groups with respect to the incidence of pulmonary, thromboembolic, cardiac, and gastrointestinal complications. However, the incidence of infections (pneumonia, urinary tract infection, wound infection, and sepsis) was significantly higher in the operative group (p = 0.000875). The incidence of instrumentation failure and need for revision surgery was 4.35% (40 of 919), a significant morbidity, and an event unique to the operative category (p = 0.00396).

Conclusions

Due to the limited number of high-quality studies, conclusions related to complication rates of operative and nonoperative management of thoracolumbar traumatic injuries cannot be definitively made. Further prospective, randomized studies of operative versus nonoperative management of thoracolumbar and lumbar spine trauma, with standardized definitions of complications and matched patient cohorts, will aid in properly defining the risk-benefit ratio of surgery for thoracolumbar spine fractures.

Low lumbar burst fractures: a unique fracture mechanism sustained in our current overseas conflicts

BACKGROUND CONTEXT

The most common location for burst fractures occurs at the thoracolumbar junction, where the stiff thoracic spine meets the more flexible lumbar spine. With our current military conflicts in Iraq and Afghanistan, we have seen a disproportionate number of low lumbar burst fractures.

PURPOSE

To report our institutional experience in the management of low lumbar burst fractures.

STUDY DESIGN

Retrospective review.

METHODS

We performed a retrospective review of medical records and radiographs for all patients treated at our institution with combat-related injuries and thoracolumbar fractures. We included all patients who had sustained a burst fracture from T12 to L5 and had at least 1-year clinical follow-up.

RESULTS

Thirty-two patients sustained burst fractures. Nineteen patients (59.4%) had low lumbar (L3-L5) burst fractures, and 12 patients (37.5%) had thoracolumbar junction (T12-L2) burst fractures as their primary injury. Additionally, seven patients sustained less severe burst fractures at an additional level. One patient sustained burst fractures at both upper and lower lumbar levels. Of the low lumbar fractures, 52.6% had evidence of neurologic injury, two of which were complete. Similarly, in the upper lumbar group, 58.2% sustained a neurologic injury, two of which were complete. Twenty-two patients underwent surgical intervention, complicated by infection in 18%. At most recent follow-up, all but one patient with presenting neurologic injury had persistent deficits.

CONCLUSION

Low lumbar burst fractures are the predominant combat-related spine injury in our current military conflicts. The rigidity offered by current body armor may effectively lower the transition zone that normally occurs at the thoracolumbar junction, thereby, transferring forces into the lower lumbar spine. Increased awareness of this fracture pattern is warranted by all surgeons because of unique clinical challenges associated with its treatment. Although the incidence is increased in the military population, other surgeons may be involved with long-term care of these patients on completion of their military service.

Neurological L5 burst fracture: posterior decompression and lordotic fixation as treatment of choice

PURPOSE

We report our experience and literature review concerning surgical treatment of neurological burst fractures of the fifth lumbar vertebra.

MATERIALS AND METHODS

Nineteen patients with L5 neurological burst fractures were consecutively enrolled; 6 patients had complete motor deficits, and 12 had sphincter dysfunction. We performed 18 posterior and one combined approaches. To avoid kyphosis, posterior internal fixation was achieved by positioning patients on the operating table with hips and knees fully extended. At the latest follow-up (mean 22 months, range 10-66), neurological recovery, canal remodeling and L4-S1 angle were evaluated.

RESULTS

Vertebral body replacement was difficult, which therefore resulted in an oblique position of the cage. Vertebral bodies still remained deformed, even though fixation allowed for an acceptable profile (22°, range 20-35). We observed three cases of paralysis, five complete, and three incomplete recoveries. In the remaining eight patients, sphincter impairment was the only finding. In 15 patients, pain was absent or occasional; in four individuals, it was continuous but not invalidating. Remodeling was visible by X-ray and/or CT, without significant secondary stenosis.

CONCLUSIONS

The L5 burst fractures are rare and mostly due to axial compression. Cauda and/or nerve root injuries are absolute indications for surgery. If an anterior approach is technically difficult, laminectomy can allow for decompression, and it can be easily combined with transpedicular screw fixation. Posterior instrumented fusion, also performed with the aim to restore sagittal profile, when associated with an accurate spinal canal exploration and decompression, may be looked at as an optimal treatment for neurological L5 burst fractures.

Kyphoplasty as an alternative treatment of traumatic thoracolumbar burst fractures Magerl type A3

INTRODUCTION

Traumatic thoracolumbar spine fractures are frequently classified as burst fractures Magerl type A3. There still are many controversies regarding the treatment of this fracture. The therapeutic spectrum ranges from conservative to invasive operative methods with attendant morbidities. The minimal-invasive technique of kyphoplasty has established itself as a common treatment of osteoporotic vertebral compression fractures and is associated with a low complication rate. The aim of this study is to evaluate the functional and radiological results after kyphoplasty of traumatic thoracolumbar burst fractures.

PATIENTS AND METHODS

Patients with traumatic thoracolumbar fractures type A3.1, A3.2 and A3.3, who were treated with kyphoplasty, were included in this study. The clinical outcome was measured at follow up with a neurological assessment, the visual analogue pain scale (VAS), the Oswestry Disability Score (ODI) and the SF-36 Health Survey. The radiological measurements, performed on preoperative, postoperative and follow up radiographs, included the sagittal index, the wedge angle and the modified Cobb angle of Daniaux.

RESULTS

26 patients with 23 A3.1, one A3.2 and five A3.3 fractures were treated between 2004 and 2007, including five patients with multiple vertebral fractures. At follow up the Oswestry Disability Score (26.2%) and the SF-36 score (60.1%) assessed a moderately limitation of functional outcome and quality of life without any neurological deficits. Radiological measurements showed a postoperative height restoration and reduction of kyphosis, but at follow up a secondary loss of correction except in five cases. Six minor ventrocranial cement leakages without further clinical consequence were observed.

CONCLUSIONS

The present study showed that kyphoplasty is a safe and feasible method for the treatment of burst fractures. It allowed the correction of the kyphosis, stabilisation of the facture, pain reduction and early mobilisation.

Minimally invasive decompression with posterior column reinforcement for the treatment of symptomatic osteoporotic fracture with spinal stenosis in lumbar vertebrae

An osteoporotic fracture (OF) in the second to fifth lumbar vertebrae with spinal stenosis may be an indication for surgical treatment, but carries the risks of instability or instrumentation failure. Modified surgical procedures have been developed to manage patients with challenging OF. We retrospectively studied 12 patients (three male, nine female; mean age±standard deviation=73.5±7.2 years) who underwent minimally invasive decompression and posterior column reinforcement with polymethylmethacrylate. During a mean follow-up period of 24.8±3.1 months, pain severity and functional impairment were both significantly reduced, as measured by the visual analog scale and the Oswestry disability index. Nine patients (75%) experienced a satisfactory outcome while the other three (25%) were unchanged. Plain radiographs showed stable spinal alignment and immobilization of flexion-extension within the PMMA construct. Five complications were managed successfully, including one by revision surgery. These procedures are a feasible surgical option in the elderly population studied.

Predictable factors for dural tears in lumbar burst fractures with vertical laminar fractures

OBJECTIVE

The purpose of the present study was to determine the incidence of dural tears and predictable factors suggesting dural tears in patients who had lumbar burst fractures with vertical laminar fractures.

METHODS

A retrospective review was done on thirty-one patients who underwent operative treatment for lumbar burst fractures with vertical laminar fractures between January 2003 and December 2008. All patients were divided into two groups according to existence of dural tears, which were surgically confirmed; 21 patients with dural tears and 10 patients without dural tears. Clinical and radiographic findings were analyzed for their association with dural tears.

RESULTS

Among a total of 31 patients, dural tears were detected in 21 (67%) patients. A preoperative neurological deficits and mean separation distances of the edges in laminar fractures were found to be the reliable factors of dural tears (p=0.001 and 0.002, respectively). Decreased ratio of the central canal diameter and interpedicular distance were also the reliable factors suggesting dural tears (p=0.006 and 0.015, respectively). However, dural tears showed no significant association with age, sex, level of injury, absence of a posterior fat pad signal, the angle of retropulsed segment, or site of laminar fracture.

CONCLUSION

Our study of lumbar burst fracture combined laminar fracture revealed that dural tears should be ruled out in cases of a preoperative neurological deficits, wide separation of the laminar fracture, severe canal encroachment, and wider interpedicular distance.

Combined posterior-anterior stabilisation of thoracolumbar injuries utilising a vertebral body replacing implant

The authors report on a prospectively followed series of 35 patients with injuries of the thoracolumbar spine from T7 to L3. The radiological course after combined posterior-anterior surgery with anterior column reconstruction with a distractible vertebral body replacing implant demonstrated a stable reconstruction technique with almost no re-kyphosing. In 18/18 patients with CT follow-up intervertebral fusion was observed as bony bridging lateral to the VBR implant. The functional/clinical outcome of the patients was analysed with a set of eight validated outcome scales. After an average follow-up period of 2(1/2) years encouraging results were noticed. The neurological improvement rate (> or =1 Frankel/ASIA grade) was 8/12 patients (67%) with a complete recovery in 6 cases. 17/29 patients returned to former occupation; 20/29 patients returned to former leisure activities; 24/28 patients rated their general outcome as "unlimited and pain free" or "occasionally and/or mild complaints" with a VAS score of >80 (scale 0-100). The psychometric questionnaires revealed good results with strong correlation comparing the different scoring systems statistically: mean McGill Pain Questionnaire 12.5 (0-40); mean Oswestry Disability Index 20% (0-51). 13/29 patients scored <4 in the Roland and Morris Disability Questionnaire. The German back pain questionnaire (Funktionsfragebogen Hannover Rücken) showed a mean "functional capacity" of 75%, corresponding with moderate restriction. We concluded the presented method as highly effective to completely reduce and maintain an anatomic spinal alignment. The outcome tended to be better in comparison with non-operatively treated patients as well as with norm populations with low back pain.

Traumatic thoracic and lumbar spinal fractures: operative or nonoperative treatment: comparison of two treatment strategies by means of surgeon equipoise

STUDY DESIGN

A center parallel cohort study with blinded inclusion based on clinical equipoise.

OBJECTIVE

To compare outcomes of nonoperative and operative treatment strategies in terms of quality of life and neurologic and functional status.

SUMMARY OF BACKGROUND DATA

Despite a considerable body of literature, sound evidence regarding the optimal treatment for traumatic thoracic and lumbar spine fractures is lacking.

METHODS

Medical records of patients hospitalized for traumatic spinal fractures between 1991 and 2002 were identified in 2 trauma centers in the same country with established and different treatment strategies. Eligibility was retrospectively assessed for each case by a panel of orthopaedic surgeons who were representative of the 2 medical centers, and who were blinded to the treatment actually administered. Patients were included in the study when there was disagreement on the suggested treatment method. Thus, 2 comparable groups were identified undergoing nonoperative or operative treatment. Outcome assessment and comparison across groups focused on quality of life, residual pain, neurologic recovery, and employment in the middle-long-term follow-up.

RESULTS

Discordance in regards to choice of treatment was identified in 190 (95 treated nonoperative, 95 operative) of 636 potentially eligible patients. Patients were comparable regarding baseline characteristics, except for a somewhat higher proportion of males and neurologic impairment in the operative group. Seventeen percent of the nonoperative and 21% of the operative group developed complications and 3 patients displayed neurologic deterioration for which a treatment change was considered necessary. Follow-up was complete in 79%; mean follow-up time was 6.2 years with a minimum of 2 years. Pain scores, disability indexes, and general health outcome were comparable at follow-up. Compared with matched population norms, outcomes were poorer regardless of treatment method. Neurologic recovery was better in the operative group, but this difference did not reach statistical significance. Multivariate regression analyses revealed that female gender and neurologic impairment were independent predictors of poor functional outcome. Eighty-eight and 83% of the nonoperatively and operatively treated patients were employed at some point after a rehabilitation period.

CONCLUSION

Overall outcome of nonoperative and operative treatment in middle-long-term follow up is comparable, although there seems to be a difference in neurologic recovery patterns. Studies on the cost-effectiveness of treatment options and the patterns of recovery within 2 years after injury would assist in guideline development and stimulate interest for future research.

Importance of greenstick lamina fractures in low lumbar burst fractures

Lumbar burst fractures (L3-L5) represent a small percentage of all spinal fractures. The treatment of fractures involving the lumbar spine has been controversial. Lamina fractures may be complete or of the greenstick type. Dural tears and nerve root entrapment may accompany these lamina fractures. The aim of this retrospective study was to determine the incidence of dural tear in patients who had lumbar burst fractures with greenstick lamina fractures and the importance of these lamina fractures when choosing the optimum treatment. Twenty-six patients with 28 lumbar burst fractures were treated from 1995 through 2002. The average follow-up was 60 months (range 32-110 months). The male to female ratio was 21:5 and the mean age was 37 years (17-64). Dural tear was detected in seven (25%) out of 28 burst fractures. The functional outcome of the entire study group was assessed using the Smiley-Webster Scale. Good to excellent results were obtained in 24 (92%) of 26 patients. Lumbar burst fractures with greenstick lamina fractures occur mostly in the L2-L4 area. In the surgical treatment, any reduction manoeuvre will close the fracture and crush the entrapped neural elements. Therefore, it may be better to explore the greenstick lamina fracture whether there is any neural entrapment or not, before any reduction manoeuvre is attempted.

Surgical Decision Making for Unstable Thoracolumbar Spine Injuries

OBJECTIVES

The optimal surgical approach and treatment of unstable thoracolumbar spine injuries are poorly defined owing to a lack of widely accepted level I clinical literature. This lack of evidence-based standards has led to varied practice patterns based on individual surgeon preferences. The purpose of this study was to survey the leaders in the field of spine trauma to define the major characteristics of thoracolumbar injuries that influence their surgical decision making. In the absence of good scientific data, expert consensus opinions may provide surgeons with a practical framework to guide therapy and to conduct future research.

METHODS

A panel of 22 leading spinal surgeons from 20 level I trauma centers in seven countries met to discuss the indications for surgical approach selection in unstable thoracolumbar injuries. Injuries were presented to the surgeons in a case scenario survey format. Preferred surgical approaches to the clinical scenarios were tabulated and comments weighed.

RESULTS

All members of the panel agreed that three independent characteristics of thoracolumbar injuries carry primary importance in surgical decision making: the injury morphology, the neurologic status of the patient, and the integrity of the posterior ligaments. Six clinical scenarios based on the neurologic status of the patient (intact, incomplete, or complete) and on the status of the posterior ligamentous complex (intact or disrupted) were created, and consensus treatment approaches were described. Additional circumstances capable of altering the treatments were acknowledged.

CONCLUSIONS

Decision making for the surgical treatment of thoracolumbar injuries is largely dependent on three patient characteristics: injury morphology, neurologic status, and posterior ligament integrity. A logical and practical decision-making process based on these characteristics may guide treatment even for the most complicated fracture patterns.

Pediatric spine injuries

Pediatric spine injuries are rare, not only due to the plasticity of the pediatric spine, but also due to the difficulty of diagnosis and the usually severe, if not fatal, associated injuries. Mechanisms of injury, transportation, initial management, diagnostic exams, and management of such lesions are different from those of the adult, and an individualized approach to each case, looking for specific injury patterns, avoids misdiagnosis. The goal of this manuscripts is to summarize the specific spinal injury patterns of the pediatric population, as well as the present literature regarding their diagnosis and treatment.

Management of traumatic thoracolumbar fractures: a systematic review of the literature

The management of unstable traumatic thoracolumbar fractures without neurological deficits remains controversial. The objective of this study was to compare the effectiveness of operative and conservative treatment of unstable traumatic thoracolumbar fractures. PubMed was used to search for articles published from January 1992 to January 2003 using a variety of keywords. References were checked to identify additional studies. Inclusion criteria were: (1) traumatic lumbar, thoracic or thoracolumbar fractures, (2) unstable fractures without neurological deficits, (3) a comparison between operative and conservative treatment, (4) at least ten patients were included in the study. Seventeen studies were identified; four prospective and 13 retrospective studies. Sample sizes in 15 studies were relatively small (18--100 patients); two studies had larger sample sizes. Comparison among different studies was difficult due to insufficient description of interventions, different outcome measures, and different length of follow-up periods. The current literature does not provide a reliable answer to whether operative or conservative treatment is more effective for unstable traumatic thoracolumbar fractures. High quality randomised controlled trials are direly needed.

Treatment of Thoracolumbar Burst Fractures with Variable Screw Placement or Isola Instrumentation and Arthrodesis

BACKGROUND

The controversy of burst fracture surgical management is addressed in this retrospective case study and literature review.

METHODS

The series consisted of 40 consecutive patients, index included, with 41 fractures treated with stiff, limited segment transpedicular bone-anchored instrumentation and arthrodesis from 1987 through 1994.

RESULTS

No major acute complications such as death, paralysis, or infection occurred. For the 30 fractures with pre- and postoperative computed tomography studies, spinal canal compromise was 61% and 32%, respectively. Neurologic function improved in 7 of 14 patients (50%) and did not worsen in any. The principal problem encountered was screw breakage, which occurred in 16 of the 41 (39%) instrumented fractures. As we have previously reported, transpedicular anterior bone graft augmentation significantly decreased variable screw placement (VSP) implant breakage. However, it did not prevent Isola implant breakage in two-motion segment constructs. Compared with VSP, Isola provided better sagittal plane realignment and constructs that have been found to be significantly stiffer. Unplanned reoperation was necessary in 9 of the 40 patients (23%). At 1- and 2-year follow-up, 95% and 79% of patients were available for study, and a satisfactory outcome was achieved in 84% and 79%, respectively. These satisfaction and reoperation rates are consistent with the literature of the time.

CONCLUSIONS

Based on these observations and the loads to which implant constructs are exposed following posterior realignment and stabilization of burst fractures, we recommend that three- or four-motion segment constructs, rather than two motion, be used. To save valuable motion segments, planned construct shortening can be used. An alternative is sequential or staged anterior corpectomy and structural grafting.

Surgical treatment of traumatic fractures of the thoracic and lumbar spine: a systematic review of the literature on techniques, complications, and outcome

STUDY DESIGN

A systematic review of the literature, pertaining surgical treatment of traumatic thoracic and lumbar spine fractures, was performed.

OBJECTIVES

To provide information on surgical techniques for traumatic spine fracture management, their respective performance and complication rates, based on previously published information.

SUMMARY OF BACKGROUND DATA

The treatment of traumatic fractures of the thoracic and lumbar spine remains controversial. There is insufficient evidence in the literature to choose between the various surgical options. In absence of conclusive studies, a systematic review can be an alternative to obtain more convincing information.

METHODS

Full-text papers from 1970 until 2001 were included if strict inclusion criteria were met. Five surgical subgroups were recognized: posterior short-segment (PS), posterior long-segment (PL), reports on both posterior short- and long-segment (PSL), anterior (A), and anterior combined with posterior (AP) techniques. Clearly defined and generally accepted parameters were scored and subsequently analyzed. The preoperative injury severity of the surgical groups was compared. The neurologic, radiologic, and functional outcome and complications of all groups were assessed.

RESULTS

A total of 132 papers, the majority being retrospective case-series, were included representing 5,748 patients. The preoperative injury severity revealed an inequality between the subgroups. Partial neurologic deficits had the potential to resolve irrespective of treatment choice. None of the five techniques used was able to maintain the corrected kyphosis angle. The functional outcome after surgery seems to be better than generally believed. Complications are relatively rare.

CONCLUSIONS

In general, surgical treatment of traumatic spine fractures is safe and effective. Surgical techniques can only be compared using randomized controlled trials.

Evaluation of the lower spine after blunt trauma using abdominal computed tomographic scanning supplemented with lateral scanograms

BACKGROUND

Patients at risk for thoracolumbar junction (TLJ) and lumbar spine (LS) injury after blunt trauma are classically evaluated using conventional radiographs. Frequently, these patients also undergo abdominal and pelvic computed tomographic (CT) scanning to exclude the presence of associated intra-abdominal injuries. Standard abdominal and pelvic CT scan usually includes an anteroposterior (AP) scout film (scanogram) obtained before the cross-sectional imaging. The objective of this study was to determine whether a lateral CT scanogram and axial CT views would provide adequate imaging to allow for evaluation of the TLJ and LS and therefore eliminate the need for conventional screening computed lumbar spine radiographs (CLSRs).

METHODS

Patients who sustained blunt injury and required both CLSRs as well as abdominal and pelvic CT scans were prospectively identified. The study protocol (CT + S) added lateral CT scanograms to all helical abdominal and pelvic CT scan studies. The AP and lateral CT scanograms were included with the axial images, and these views were reviewed together during final radiographic interpretation and diagnosis. The results of CT + S were compared with readings of the CLSRs (AP and lateral) in a blinded fashion by a trauma radiologist.

RESULTS

Lateral scanograms were generated for 71 patients. All scanograms were technically adequate, with image quality equal or superior to computed plain radiographs. Ten patients were found to have 20 fractures, 19 acute and 1 chronic. All abnormalities identified by plain radiographs were seen using CT + S (sensitivity, 100%; specificity, 100%). Eight transverse process and two spinous process fractures not seen on CLSRs were identified using CT + S.

CONCLUSION

Our CT + S protocol (axial CT images plus AP and lateral scanograms) outperformed screening CLSRs in the detection of fractures of the lower spine (TLJ + LS) after blunt trauma. In addition, scanogram imaging is less dependent on body habitus and adds no additional cost or time to abdominal and pelvic CT scanning. Further study is required to determine whether CT + S can routinely replace conventional radiographs of the lower spine after blunt trauma.

Acute thoracolumbar burst fractures: a new view of loading mechanisms

STUDY DESIGN

An in vitro investigation of loading mechanisms in acute thoracolumbar burst fractures.

OBJECTIVES

To assess the validity of the authors' hypothesis that anterior shear forces transmitted by the facet joints are responsible for causing the severe canal compromise associated with acute thoracolumbar burst fractures.

SUMMARY OF BACKGROUND DATA

Thoracolumbar burst fractures created in the laboratory rarely match the severity of clinical cases. To date, no studies have examined in great detail the role of facet joint loading in the burst-fracture mechanism. An incomplete understanding of loading mechanisms may contribute to the controversies regarding management.

METHODS

Nine human cadaveric motion segments were instrumented with strain gages and subjected to axial compression or axial impact coupled with an extension moment. Failure loads, strain information, and radiographs were collected.

RESULTS

Fracture patterns characteristic of acute thoracolumbar burst fractures were observed in the three specimens tested with an extension moment. In this group, high strains were also recorded at the bases of the pedicles, indicating a probable site of fracture initiation. Specimens tested in a neutral orientation experienced crush fractures without an increase in interpedicular distance. Strain patterns were more uniform in this group.

CONCLUSIONS

The severity and clinical relevance of the injuries sustained by the specimens tested in extension suggest that facet joint loading plays a critical role in the acute thoracolumbar burst-fracture loading mechanism. Fracture patterns and strain concentrations are in agreement with clinical observations as well as past experimental studies.

Health-related quality of life after short segment instrumentation of lumbar burst fractures

Management of lumbar burst fractures remains controversial. Surgical reduction/stabilization is becoming more popular; however, the functional impact of operative intervention is not clear. The purpose of this study was to assess health-related quality of life and functional outcome after posterior fixation of lumbar burst fractures with either posterolateral or intrabody bone grafting. Twenty-four subjects were included. Radiographs and computed tomography scans were evaluated for deformity (kyphosis, vertebral compression, lateral angulation, lateral body height, and canal compromise) postoperatively, at 1 year, and at final follow-up (mean 3.2 years). Patients completed the SF 36 Health Survey and the Oswestry Low Back Pain Disability Questionnaire at final follow-up. Significant improvement was noted in midsagittal diameter compromise, vertebral compression, and kyphosis. The difference observed between the respondents mean scores on the SF 36 was not significantly different from those presented as the U.S. national average (p = 0.053). Data from the Oswestry questionnaire indicated a similarly high level of function. Overall, we found posterior spinal instrumentation to correlate with positive functional outcome based on both general health (SF 36) and joint-specific outcome scales (Oswestry). Posterior instrumentation provides sound canal decompression, kyphotic reduction, and maintains vertebral height with minimal transgression and long-term sequelae. In cases of severe initial deformity and neurologic compromise, intrabody bone grafting is most certainly indicated; the additional support provided by a posterolateral graft may also prove beneficial as an adjunct.

Dural tears in lumbar burst fractures with greenstick lamina fractures

STUDY DESIGN

This study investigated the incidence, predictions, and treatment principles of greenstick lamina fractures in lumbar burst fractures.

OBJECTIVE

To determine the incidence of dural tears in lumbar burst fracture with greenstick lamina fracture and to find out if any specific clinical and radiographic factors or intraoperative pathologic findings are predictive of dural tears and nerve root entrapment.

SUMMARY OF BACKGROUND DATA

A retrospective review was conducted on 45 patients with 47 lumbar burst fractures treated operatively. Ages ranged from 15 to 70 years (average, 33 years). The duration of follow-up ranged from 32 months to 8 years (average, 52 months).

METHODS

All clinical charts and radiologic data of these patients were reviewed. Age, sex, etiology, and all the radiologic parameters were analyzed for their association with greenstick lamina fracture and dural tear. Student's t test and multiple logistic regression analysis were used for statistical analysis.

RESULTS

Greenstick lamina fracture occurred in 20 (42.5%) of 47 burst fractures. Dural tear was detected in 9 (19%) of 47 burst fractures and was predominantly higher in L3 (6 of 9 burst fractures). According to multiple logistic regression analysis of the data, a 20% increase in the interpedicular distance gives a 79% probability of greenstick lamina fracture. The distance between the edges of greenstick lamina fractures was obviously higher in fractures with dural tear. Neurologic status was completely normal before surgery in three of the patients with dural tear and nerve root entrapment.

CONCLUSIONS

It is not possible to detect dural tear and nerve root entrapment in greenstick lamina fracture before surgery. Therefore, if there is any suspicion of such an occurrence, it should be the rule to begin with posterior approach and use the open book technique to expose the dura safely before any reduction maneuver.

Sexual dysfunction in men with paraparesis in lumbar burst fractures

STUDY DESIGN

A retrospective follow-up study.

OBJECTIVES

To review and analyze the sexual function of patients who have sustained lumbar fractures with incomplete paraparesis.

SUMMARY OF BACKGROUND DATA

As a result of advances in surgical techniques, most patients with lumbar fractures have significant recovery of neurologic status. Because motor functions are important to patients, most of the studies have concentrated their analyses on motor recovery. Many patients who have almost completely recovered motor function, however, may have sexual dysfunction, especially men.

METHODS

Forty-three patients with lumbar fractures that resulted in incomplete paraparesis were analyzed. American Spinal Injury Association motor index points were determined for each patient before and after surgery and used for comparison between American Spinal Injury Association motor index and international index of erectile function score. Eleven male patients who reported sexual dysfunction were evaluated by using Rigiscan.

RESULTS

During the follow-up period, 42 patients showed neurologic recovery. Average improvement of American Spinal Injury Association motor score was 13. 1 and average international index of erectile function score was 45. Average improvement of American Spinal Injury Association motor score for patients who had not reported sexual dysfunction was 12.5, and average international index of erectile function score was 52. For 11 patients in the sexual dysfunction group, preoperative motor score was 28.0, and average improvement of score was 14.9. Nocturnal penile tumescence monitoring results were abnormal in four cases. Averaged international index of erectile function score was 15. There was a statistically significant difference between the sexually healthy and dysfunctional groups in international index of erectile function score (P < 0.05), whereas no difference was noted in American Spinal Injury Association motor score.

CONCLUSIONS

Neurologic recovery after lumbar fractures was improved. Regardless of neurologic recovery, most patients reported some disability, usually caused by pain and occasionally sexual dysfunction. Impairment of sexual function was present in four patients (9.3%). Although these patients may preserve psychiatric erection potential, they usually experienced sexual problems.

Functional outcome of low lumbar burst fractures. A multicenter review of operative and nonoperative treatment of L3-L5

STUDY DESIGN

A retrospective review of 42 patients treated at three major medical centers for burst fractures of L3, L4, and L5. This is the largest low lumbar (L3-L5) burst fracture study in the literature to date. The study was designed to assess both radiographic and clinical outcomes in a cohort of patients treated during a 16-year period.

OBJECTIVES

The objective of this study was to determine whether conservatively treated patients with low lumbar burst fractures had satisfactory outcomes compared with those in a surgically treated cohort of patients. The study included patients with and without neurologic deficits.

SUMMARY OF BACKGROUND DATA

Burst fractures of the low lumbar spine (L3-L5) represent a small percentage of all spine fractures. The iliolumbar ligaments and location below the pelvic brim are two stabilizing factors that are unique to these fractures when compared with burst fractures at the thoracolumbar junction.

METHODS

Forty-two (n = 42) patients with low lumbar burst fractures were identified from 1980 through 1996. Medical records, radiographs, and follow-up Dallas Pain Questionnaires were obtained. Loss of anterior vertebral height, kyphotic angulation, and amount of retropulsion were recorded at several phases of treatment. Mean follow-up time was 45.2 months (range, 5-132 months). Twenty patients were treated without surgery (18 were neurologically intact, and 2 had isolated nerve root injury), and 22 underwent surgery (14 had neurologic injury, 8 were intact).

RESULTS

No patient showed neurologic deterioration, regardless of treatment. Fracture of the third lumbar segment showed the greatest tendency toward kyphotic collapse and loss of height in the nonoperative group, although this was not reflected in the final functional outcome of both groups. The ability to return to work and achieve a good-to-excellent long-term result was not significantly different among fracture levels or between surgical and nonsurgical treatments.

CONCLUSIONS

The results of nonoperative treatment of low lumbar burst fractures were comparable with those of operative treatment. The rate of repeat surgery (41%) and absence of a clearly definable long-term functional or radiographic benefit in patients without neurologic compromise may make surgery less appealing.

Complete rotational burst fracture of the third lumbar vertebra managed by posterior surgery. A case report

STUDY DESIGN

Case report of a young man with rotational burst fracture of the third lumbar vertebra, treated by posterior surgery.

OBJECTIVES

To describe the management of a rotational burst fracture of the third lumbar vertebra by posterior surgery consisting of reduction, decompression, fusion, and transpedicular instrumentation.

SUMMARY OF BACKGROUND DATA

Surgery is the generally recommended means of managing lumbar burst fractures with neurologic deficit. Some surgeons recommend anterior decompression, fusion, and instrumentation. Posterior surgery with decompression through laminectomy, spongioplasty of the vertebral body, interbody fusion of damaged discs, posterolateral fusion, and transpedicular fixation is also a safe and successful management technique. The combined approach consists of posterior decompression, fusion, transpedicular fixation, and anterior fusion using pelvic autografts. The optimum method of management remains in question.

METHOD

An 18-year-old man with complete rotational burst fracture of the third lumbar vertebra was treated by posterior surgery. This surgery consisted of reduction, laminectomy, decompression, structure of dural sac tears, spongioplasty of the vertebral body, interbody fusion of both damaged discs, and the implantation of a transpedicular Socon fixator (Aesculap, Tuttlingen, Germany), including a transverse connector. The case was documented by radiographs and computed tomography scans before surgery and after fixator removal 19 months after surgery.

RESULTS

The patient healed solidly with no instrumentation failure. The neurologic deficit Frankel Grade B improved to Frankel Grade D.

CONCLUSION

Surgery to manage lumbar burst fracture must include reduction, decompression, restoration and fusion of anterior and posterior elements by using autologous pelvic spongious autografts, and anterior or posterior instrumentation. Posterior surgery including suturing of dural sac tears, fusion of damaged structures, and transpedicular fixation is successful in young patients and patients with good bone quality.