Novel reduction technique for thoracolumbar fracture-dislocations

[Clinical study of Wiltse approach with fulcrum reduction technique in the treatment of AO-A type thoracolumbar fractures]

OBJECTIVE

To investigate the effectiveness of Wiltse approach with fulcrum reduction technique and pedicle internal fixation in the treatment of AO-A type thoracolumbar fractures.

METHODS

The clinical data of 16 patients with AO-A type thoracolumbar fractures treated with Wiltse approach with fulcrum reduction technique and pedicle internal fixation between September 2013 and January 2019 were retrospectively analyzed. There were 9 males and 7 females, the age ranged from 38 to 60 years, with an average age of 50.7 years. Causes of injury included 9 cases of falling from height, 3 cases of traffic accidents, 3 cases of falling, and 1 case crushed by heavy objects. Fractured segment involved T ₁₁ in 2 cases, T ₁₂ in 5 cases, L ₁ in 7 cases, and L ₂ in 2 cases. There were 6 cases of type A1, 3 cases of type A2, 5 cases of type A3, and 2 cases of type A4 according to AO fracture classification. The operation time, intraoperative blood loss, and removal time of internal fixator were recorded. Before operation, immediately after operation, before and after removal of internal fixator, the local kyphotic angle (LKA), anterior vertebral height (AVH), and posterior vertebral height (PVH) of fractured vertebral body were measured; visual analogue scale (VAS) score of back pain were evaluated before operation, at 3 days after operation, before and after removal of internal fixator.

RESULTS

The operation time of the patients was 50-95 minutes, with an average of 70.7 minutes; the intraoperative blood loss was 50-230 mL, with an average of 132.9 mL; the internal fixator was removed after 18-30 months, with an average of 23.6 months. All patients were followed up 20-32 months, with an average of 25.6 months. No incision infection, hematoma, and other surgery-related complications, and internal fixator rupture residual complications occurred. All 16 patients achieved satisfactory reduction results. Immediate postoperative LKA, AVH, and PVH were significantly improved when compared with preoperative ones ( P<0.05). There was a certain degree of reduction loss before internal fixator removal, and the difference in LKA was significant ( P<0.05), but the difference in AVH and PVH were not significant ( P>0.05). There was a certain degree of reduction loss after internal fixator removal, but only the difference in AVH was significant ( P<0.05), and there was no significant difference in LKA and PVH ( P>0.05). The VAS score of the back pain significantly improved at 3 days after operation and before internal fixator removal when compared with preoperative score ( P<0.05). The pain after internal fixator removal was significantly worse than that before internal fixator removal ( P<0.05).

CONCLUSION

The Wiltse approach with fulcrum reduction technique and pedicle internal fixation in the treatment of AO-A thoracolumbar fractures has a short operation time, less intraoperative blood loss, and the posterior soft tissue and other structures are well protected during the operation. It can provide satisfactory clinical reduction results.

A Anchoring Technique Using Long Bent Rods for Open Reduction of Thoracolumbar Dislocation

OBJECTIVE

The purpose of this study was to evaluate the effectiveness of a novel surgical open reduction method for thoracolumbar dislocation.

MATERIALS AND METHODS

This study included a total of 15 patients of thoracolumbar dislocation. All patients underwent posterior thoracolumbar open reduction and fixation using this technique. Preoperative x-ray, computed tomography (CT), and magnetic resonance imaging were used to evaluate the dislocation. The American Spinal Injury Association grade of spinal cord injury before and afer the operation were record. All patients were followed up for 2 years, and x-ray, CT were used to observe postoperative reduction and fusion.

RESULTS

Postoperative x-ray and CT images of all patients indicated good recovery of the spinal sequence, and no neurological deterioration or surgically related complications occurred. All patients were followed up for 2 years, no patients were lost to follow-up. During the follow-up period, x-ray and CT images showed no complications related to internal fixation such as fracture and loosening of screws and rods were found.

CONCLUSION

A anchoring technique using long bent rods is a safe, simple, accurate, and easy to replicate and implement method, which can be applied in the surgical treatment for thoracolumbar dislocation.

Traumatic dorsal spondyloptosis of upper thoracic spine: case report and novel open reduction technique

Traumatic thoracic spondyloptosis represents a rare but potentially catastrophic spinal injury pattern. We present a unique case of a 37-year-old male who suffered a high-thoracic retroloptosis with resultant complete spinal cord injury following a motor vehicle accident. We describe a novel and effective method of open reduction utilising horizontally oriented temporary rods facilitating controlled, sequential sagittal distraction and unlocking, reversal of anteroposterior shear and restoration of alignment. Using our technique, successful reduction and realignment was achieved.

Thoracolumbar fracture dislocation (AO type C injury): A systematic review of surgical reduction techniques

Spinal injuries constitute about 3% of all injury cases and most of these injuries affect the thoracolumbar region, but thoracolumbar fracture-dislocations are much rarer. Dislocations (AO Type C injuries) of the thoracic and lumbar vertebrae, with or without associated fractures, happen due to very high energy trauma involving simultaneous, multidirectional, distractive and compressive forces across various spinal elements, which results in translational and rotational instability of the spinal column. Various reduction maneuvers have been described for thoracolumbar fracture-dislocations in the literature aiming to provide standardization in surgery for this situation. The aim of this review article is to systematically review the literature till date and describe various reduction maneuvers which help to achieve adequate sagittal and coronal balance as well as vertebral alignment with minimal soft tissue trauma. We searched the PubMed, the Cochrane Library (the most recent issue), Scopus, Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, Web of Science, International Clinical Trials Registry Platform (WHO), ClinicalTrials.gov and Google Scholar databases, besides other sources and general internet search. The strategy used in the search was briefly(''thoracolumbar'' OR ''dorsolumbar'') AND "dislocation" in PubMed. Similar searches were made in the other databases.Reference lists of the relevant papers were also examined and any further relevant studies, which were also included in the review. The initial search revealed 332 papers in Pubmed, out of which 302 were human studies. A similar search on Scopus revealed 528 documents and on WoS revealed 289 papers. Searching the Cochrane library revealed 9 trials, which were already revealed in Pubmed search results. All the references were imported into Endnote and we had 632 references after excluding duplicates and 126 papers were left in endnote after manual title screening and duplicate removal. Finally, 70 relevant papers were selected for consideration based on inclusion criteria, after excluding unrelated papers manually. We have summarised the published literature on the surgical management of thoraco-lumbar fracture dislocations and described the reduction maneuvers used in detail.

Clinical case-series report of traumatic cauda equina herniation: A pathological phenomena occurring with thoracolumbar and lumbar burst fractures

RATIONALE

Burst fractures in thoracolumbar and lumbar spine typically occur from severe trauma, which may result in cauda equina herniation (CEH). In this study, we attempted to document the incidence and evaluate the sequelae of CEH that were found during decompression and fusion surgery for patients with burst fractures.

PATIENT CONCERNS

A total of 416 patients were enrolled in this study.

DIAGNOSES

The patients had been operated on through an anterior or posterior approach for treatments of thoracolumbar and lumbar burst fractures at our department between June 1, 2008 and June 1, 2011.

INTERVENTIONS

A retrospective analysis of hospital records and a review on radiographs were performed. Data regarding demographics, injury mechanism, radiographs, surgical procedures, outcomes and follow-ups were collected and analyzed.

OUTCOMES

The CEH was observed in 49 patients (12%), including 40 males and 9 females with a mean age of 33.7 years old. The posterior approach group included 301 patients (215 males and 86 females), with 13% incident rate for CEH (40/301). The anterior approach group included 115 patients (80 males and 35 females), with 8% incident rate for CEH (9/115). Forty-four patients (90%) with CEH had neurological deficits; while other 5 patients (10%) were neurologically intact but entrapments of a significant proportion of their cauda equina rootlets in the dorsal lamina fracture were observed during operations. Both vertebrae burst fracture and lamina fracture were observed in 95% patients with posterior CEH (38 out of 40).

LESSONS

Traumatic CEH were found in 12% of the patients with thoracolumbar and lumbar burst fractures that were treated by surgery. Patients with a lumbar burst fracture showing neurological deficits in combination with a laminar fracture have an increased risk of traumatic CEH.

A Case Report on Extruded Disc Acting as Buttonhole reventing Reduction in Traumatic Fracture and Lateral Dislocation of L1-l2 Vertebrae

INTRODUCTION

There is a scanty literature support describing the incidence, mechanism of lateral dislocations of thoracolumbar spine and its management describing the reduction techniques. Hereby we present an interesting case of extruded disc acting as buttonhole preventing the reduction of lateral dislocation of L1-L2 vertebrae and this would be the first of its variety to be described ever in literature.

CASE REPORT

A 30 year old female was referred to our hospital on post trauma day 7 with bilateral fascet fracture and lateral dislocation of L1-L2 vertebrae and fracture humerus on right arm following a road traffic accident. She presented with clinical signs consistent of cauda equina lesion. She underwent surgical reduction and TLIF L1-L2. On one year follow-up X-Rays showed maintenance of dorsolumbar saggital alignment without collapse.

CONCLUSION

Dislocations of spine are three column injuries, are highly unstable requiring surgical stabilisation. Posterior instrumentation is the routinely followed technique to achieve reduction and for posterolateral fusion. In this case lateral dislocation was reduced only after removal of the laterally extruded disc. After complete discectomy TLIF was considered a good option for restoring disc space height and maintaining saggital balance.

The significance of removing ruptured intervertebral discs for interbody fusion in treating thoracic or lumbar type B and C spinal injuries through a one-stage posterior approach

Objectives

To identify the negative effect on treatment results of reserving damaged intervertebral discs when treating type B and type C spinal fracture-dislocations through a one-stage posterior approach.

Methods

This is a retrospective review of 53 consecutive patients who were treated in our spine surgery center from January 2005 to May 2012 due to severe thoracolumbar spinal fracture-dislocation. The patients in Group A (24 patients) underwent long-segment instrumentation laminectomy with pedicle screw-rod fixators for neural decompression. In Group B (29 patients), the patients underwent long-segment instrumentation laminectomy with pedicle screw-rod fixators for neural decompression evacuating of the ruptured disc and inserting of a bone graft into the evacuated disc space for interbody fusion. The mean time between injury and operation was 4.1 days (range 2–15 days). The clinical, radiologic and complication outcomes were analyzed retrospectively.

Results

Periodic follow-ups were carried out until an affirmative union or treatment failure took place. A progressive kyphosis angle larger than 10°, loss of disc height, pseudoarthrosis, recurrence of dislocation or subluxation, or instrument failure before fusion were considered treatment failures. Treatment failures were detected in 13 cases in Group A (failure rate was 54.2%). In Group B, there were 28 cases in which definitive bone fusion was demonstrated on CT scans, and CT scans of the other cases demonstrated undefined pseudoarthrosis without hardware failure. There were statistically significant differences between the two groups (p<0.001 chi-square test). The neurologic recoveries, assessed by the ASIA scoring system, were not satisfactory for the neural deficit patients in either group, indicating there was no significant difference with regard to neurologic recovery between the two groups (p>0.05 Fisher's exact test).

Conclusion

Intervertebral disc damage is a common characteristic in type B and C spinal fracture-dislocation injuries. The damaged intervertebral disc should be removed and substituted with a bone graft because reserving the damaged disc in situ increases the risk of treatment failure.

Thoracolumbar fracture dislocations treated by posterior reduction, interbody fusion and segmental instrumentation

BACKGROUND

Literature describing the application of modern segmental instrumentation to thoracic and lumbar fracture dislocation injuries is limited and the ideal surgical strategy for this severe trauma remains controversial. The purpose of this article was to investigate the feasibility and efficacy of single-stage posterior reduction with segmental instrumentation and interbody fusion to treat this type of injury.

MATERIALS AND METHODS

A retrospective review of 30 patients who had sustained fracture dislocation of the spine and underwent single stage posterior surgery between January 2007 and December 2011 was performed. All the patients underwent single stage posterior pedicle screw fixation, decompression and interbody fusion. Demographic data, medical records and radiographic images were reviewed thoroughly.

RESULTS

Ten females and 20 males with a mean age of 39.5 years were included in this study. Based on the AO classification, 13 cases were Type B1, 4 cases were B2, 4 were C1, 6 were C2 and 3 cases were C3. The average time of the surgical procedure was 220 min and the average blood loss was 550 mL. All of the patients were followed up for at least 2 years, with an average of 38 months. The mean preoperative kyphosis was 14.4° and reduced to -1.1° postoperatively. At the final followup, the mean kyphosis was 0.2°. The loss of correction was small (1.3°) with no significant difference compared to postoperative kyphotic angle (P = 0.069). Twenty seven patients (90%) achieved definitive bone fusion on X-ray or computed tomography imaging within 1 year followup. The other three patients were suspected possible pseudarthrosis. They remained asymptomatic without hardware failure or local pain at the last followup.

CONCLUSION

Single stage posterior reduction using segmental pedicle screw instrumentation, combined with decompression and interbody fusion for the treatment of thoracic or lumbar fracture-dislocations is a safe, less traumatic and reliable technique. This procedure can achieve effective reduction, sagittal angle correction and solid fusion.