Thoracolumbar fracture management: anterior approach

Anterior approach for a stab wound with penetrating rebar injury causing incomplete cauda equina syndrome in lumbosacral spine lesion: a case report and literature review

PURPOSE

To report a unique case of incomplete CES following a rebar penetrating injury in perineal region with retro-pulsed fragment, which was treated with anterior approach and discuss suitable surgical approach.

METHODS

Incomplete cauda equina syndrome caused by non-missile penetrating injury is extremely rare. A 26-year-old male patient presented incomplete cauda equina syndrome due to a penetrating rebar wound from his perineal region to the lumbosacral spine. Computed tomography demonstrated a bony fragment broken from S1 body compressing into the spinal canal.

RESULTS

By anterior approach, we performed partial corpectomy of L5, decompression by retrieving the bony fragment and L5-S1 interbody fusion. The patient had a significant recovery, and no clinical complication was found after over 2-year follow-up.

CONCLUSION

It is challenging to determine the optimal strategy of surgical treatment for penetrating spinal injuries with retained foreign bodies, here we suggest an anterior approach situation that has the advantage of being able to effectively perform decompression and prevent iatrogenic damages of thecal sac and nerve rootlets.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PROSPERO ID

CRD42023484222.

Percutaneous versus open posterior stabilization and decompression in AOSpine-type A3 thoracolumbar fractures with neurological deficit

BACKGROUND

This retrospective cohort study aimed to compare the clinical and radiological outcomes between two treatment strategies focusing on non-osteoporotic AOSpine-type A3 fractures of the thoracolumbar spine with neurological deficits at levels T11 to L2.

METHODS

In total, 67 patients between 18 and 60 years of age who were treated operatively with either of the two treatment strategies were included. One treatment strategy included open posterior stabilization and decompression, whereas the other was based on percutaneous posterior stabilization and decompression via a tubular retraction system. Demographic data, surgical variables, and further parameters were assessed. Patient-reported outcomes (PROs), including the Visual Analog Scale (VAS), the Oswestry Disability Index (ODI), and the American Spinal Injury Association (ASIA) impairment score, were measured to assess functional outcomes. The regional Cobb angle (CA), the anterior height ratio of the fractured vertebrae (AHRV), and the degree of canal encroachment (DCE) were assessed. The ASIA score was used to assess neurological function recovery. The follow-up period was at least 12 months.

RESULTS

Surgical time and postoperative hospital stay were significantly shorter in the minimally invasive surgery (MIS) group. Intraoperative blood loss was significantly less in the MIS group. Regarding radiological outcome, CA and AHRV at the time of follow-up did not show a significant difference. DCE at the time of follow-up was significantly improved in the MIS group. Lower VAS scores and better ODIs were observed in the MIS group at the 6-month follow-up, but similar outcomes were observed at the 12-month follow-up. The ASIA score was similar between both groups at the 12-month follow-up.

CONCLUSIONS

Both treatment strategies are safe and effective; however, MIS could provide earlier pain relief and better functional outcomes compared with OS.

Effect of angular correction during posterior instrumentation of spinal fractures on postoperative outcomes and quality of life

BACKGROUND

Posterior instrumentation using pedicle screws and rods is the most commonly used technique for the treatment of thoracolumbar fractures of the spine. The procedure aims to restore the neurologic and biomechanical functions of the spine and allows for early mobilization and rapid reintegration into society. It is unclear whether the magnitude of correction has an effect on postoperative outcomes.

OBJECTIVE

We aimed to determine whether the magnitude of sagittal angular correction during posterior instrumentation of the spine had an effect on postoperative quality of life, pain and function outcomes as measured using the EQ5D-3L and the Core Outcome Measures Index (COMI) instruments. We also aimed to quantify the correlation between EQ5D-3L and COMI scores.

METHODS

We analyzed the pre- and postoperative radiographs of 52 patients who underwent percutaneous pedicle screw placement for thoracolumbar fractures, as well as their self-reported EQ5D-3L and COMI quality of life, pain and functional outcome scores. Regression models were constructed to estimate the effect that the magnitude of Cobb angle correction had on postoperative outcomes. We also estimated the correlation between EQ5D-3L and COMI scores.

RESULTS

The median EQ5D-3L TTO score was 0.9 (range, -0.1 to 1). The median COMI score was 3.1 (range, 0 to 10). There was no significant effect of the magnitude of correction on EQ5d-3L TTO scores (p= 0.3379; R= 0.36) or on COMI scores (p= 0.3379; R= 0.15). Age and bone mineral density were not found to be significant predictors of outcome (p= 0.05). There was a strong correlation between the EQ5D-3L TTO and COMI scores (r=-0.62).

CONCLUSION

The magnitude of Cobb angle correction during pedicle screw instrumentation of thoracolumbar fractures did not influence quality of life, pain or function outcomes. There was good correlation between EQ5D-3L TTO scores and COMI scores.

Percutaneous balloon kyphoplasty for the treatment of very severe osteoporotic vertebral compression fractures: a case-control study

BACKGROUND CONTEXT

Controversy exists regarding percutaneous balloon kyphoplasty (PBK) in patients with a very severe osteoporotic vertebral compression fracture (vsOVCF).

PURPOSE

The study was conducted to investigate the clinical and radiological outcomes of PBK for the treatment of vsOVCF compared with those of non-vsOVCF.

STUDY DESIGN/SETTING

This is a retrospective, case-control study.

PATIENT SAMPLE

A total of 167 consecutive patients (210 vertebral bodies) who underwent PBK for OVCF between March 2010 and January 2015 were assessed.

OUTCOME MEASURES

Visual analog scale (VAS) scores for back pain, Korean Oswestry disability index (K-ODI) scores, vertebral body height variations, and kyphotic angles were evaluated preoperatively, postoperatively, and 1 year after treatment.

MATERIALS AND METHODS

Patients in the non-vsOVCF group (anterior vertebral compression of more than two-thirds on plain radiograph) who had undergone PBK where compared with those in the non-vsOVCF group (compression between 30% and two-thirds). Clinical and radiological outcomes were compared. In addition, complications were evaluated.

RESULTS

In total, 31 patients (33 vertebrae) in the vsOVCF group and 136 patients (177 vertebrae) in the non-vsOVCF group were treated with PBK. Both groups had significant postoperative improvements in the clinical and radiological outcomes (VAS score, K-ODI score, vertebral body height variation, and kyphotic angle). There was no difference regarding the VAS score and the K-ODI score between the two groups at the final follow-up (p>.05). The cement leakage occurred frequently in the vsOVCF group (26 vertebrae, 78.8%) than in the non-vsOVCF group (92 vertebrae, 52.0%), the difference was statistically significant (p<.05). But there was no case that showed neurologic complication or pulmonary embolism caused by cement leakage. The incidence of recollapse was significantly higher in the vsOVCF group (five vertebrae, 15.2%) than in the non-vsOVCF group (seven vertebrae, 4.0%) (p<.05). The incidence of an adjacent segment fracture (vsOVCF group, 6 vertebrae, 18.2%; non-vsOVCF group, 21 vertebrae, 11.9%) was not significantly different (p=.320).

CONCLUSIONS

Percutaneous balloon kyphoplasty is a safe and effective procedure for the treatment of vsOVCF.

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.

Minimal Invasive Circumferential Management of Thoracolumbar Spine Fractures

Introduction. While thoracolumbar fractures are common lesions, no strong consensus is available at the moment. Objectives. The aim of this study was to evaluate the results of a minimal invasive strategy using percutaneous instrumentation and anterior approach in the management of thoracolumbar unstable fractures. Methods. 39 patients were included in this retrospective study. Radiologic evaluation was based on vertebral and regional kyphosis, vertebral body height restoration, and fusion rate. Clinical evaluation was based on Visual Analogic Score (VAS). All evaluations were done preoperatively and at 1-year follow-up. Results. Both vertebral and regional kyphoses were significantly improved on postoperative evaluation (13° and 7° versus −1° and −9°  P < 0.05, resp.) as well as vertebral body height (0.92 versus 1.16, P < 0.05). At 1-year follow-up, mean loss of correction was 1°. A solid fusion was visible in all the cases, and mean VAS was significantly reduced form 8/10 preoperatively to 1/10 at the last follow-up. Conclusion. Management of thoracolumbar fractures using percutaneous osteosynthesis and minimal invasive anterior approach (telescopic vertebral body prosthesis) is a valuable strategy. Results of this strategy offer satisfactory and stable results in time.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Management of fracture and lateral dislocation of the thoracic spine without any neurological deficits: three case reports and review of the literature

BACKGROUND

Fracture and dislocation of the thoracic spine without neurological deficits are rare. Most of these cases are managed by non-operative methods or a posterior approach surgery.

AIM

To report three cases of fracture and lateral dislocation of the thoracic spine without neurological deficits and review the literature on the management strategy.

METHODS

Three patients who suffered thoracic spinal fracture and lateral dislocation without spinal cord injury underwent anterior decompression, reduction and internal fixation. The case series describe their management, surgical intervention and their follow-up.

RESULTS

Reduction was satisfactory, none of the patients had any postoperative neurological deficits. Fusion was successful, and vertebral column alignment was maintained at the last follow-up.

CONCLUSION

An anterior approach facilitated adequate decompression, reduction and stabilization through instrumentation in this series of injury without neurological deficits.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Whole-body computerized tomography and concomitant spine and head injuries: a study of 355 cases

The authors present a prospective study on the coexistence of spinal injury (SI) and severe traumatic brain injury (TBI) in patients who were involved in traffic accidents and arrived at the Emergency Department of Hospital das Clinicas of the University of Sao Paulo between September 1, 2003 and December 31, 2009. A whole-body computed tomography was the diagnostic method employed in all cases. Both lesions were observed simultaneously in 69 cases (19.4%), predominantly in males (57 individuals, 82.6%). Cranial injuries included epidural hematoma, acute subdural hematoma, brain contusion, ventricular hemorrhage and traumatic subarachnoid hemorrhage. The transverse processes were the most fragile portion of the vertebrae and were more susceptible to fractures. The seventh cervical vertebra was the most commonly affected segment, with 24 cases (34.78%). The distribution of fractures was similar among the other cervical vertebrae, the first four thoracic vertebrae and the lumbar spine. Neurological deficit secondary to SI was detected in eight individuals (11.59%) and two individuals (2.89%) died. Traumatic subarachnoid hemorrhage was the most common intracranial finding (82.6%). Spinal surgery was necessary in 24 patients (34.78%) and brain surgery in 18 (26%). Four patients (5.79%) underwent cranial and spinal surgeries. The authors conclude that it is necessary a judicious assessment of the entire spine of individuals who presented in coma after suffering a brain injury associated to multisystemic trauma and whole-body CT scan may play a major role in this scenario.

Posterior transpedicular decompression for thoracolumbar burst fractures

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Anterior, thoracoscopic-assisted reduction and stabilization of a thoracic burst fracture (T8) in a pregnant woman

Injuries of the spine in pregnant women are rare. Unstable fractures, incomplete neurological deficits and failed conservative treatment are indications for operative stabilization. So far, only posterior stabilization techniques performed during pregnancy have been published in case reports. This Grand Round case presentation describes a 24-year-old woman in the 19th week of gestation who was involved in a motorcycle accident as a pillion rider. Radiological examination revealed a complete burst fracture (type AO A3.3) of T8 with a slight, yet clinical unapparent narrowing of the spinal canal and a stable T5 fracture (type AO A1.2). Despite analgesia with morphine, conservative treatment failed and it was not possible to mobilize the patient. Hence, an anterior thoracoscopic-assisted reduction and stabilization in left lateral position with single lung ventilation was performed as the therapy of choice. Intraoperatively, the body of T8 was removed and plate was used to stabilize and reduce the fracture. Finally, a tricortical iliac bone graft was implanted into the bony defect. Intraoperative fluoroscopy was merely used to verify the positioning of the implants. Postoperative examination of the foetus revealed normal findings. The patient was discharged with paracetamol as residual pain medication. The degree of kyphosis of the T8 fracture was successfully reduced from 20° to 13° (segmental standard value 12°). Further clinical and radiological course of the patient was uneventful. If suitable implants are available and good bone structure exists, solely anterior thoracoscopic-assisted reduction and stabilization of an unstable thoracic burst fracture can be performed safely. In the present case, it was possible to avoid intraoperative prone positioning of the pregnant patient as well as reaching a minimum of radiation exposure.

Video-assisted treatment of thoracolumbar junction fractures using a specific distractor for reduction: prospective study of 50 cases

Posterior instrumentation allows good osteosynthesis for thoracolumbar junction fractures. However, in approximately 20% of cases, anterior bone defects may persist, leading to pseudoarthrosis and loss of reduction. Anterior approaches can circumvent this drawback, but they are considered aggressive with a high rate of complications. The advent of the endoscopic mini-invasive techniques has led to a reduction in the number of complications while maintaining the same consolidation rate. Nevertheless, poor restitution of anatomic curves is a reproach for this technique. This prospective study reports clinical and radiological result of 50 patients (19 women and 31 men) operated between April 2000 and March 2006 with a video-assisted anterior approach using an endodistractor for reduction and consequent insertion of the implant. There were A3 (n = 44), A2 (n = 2), A1 (n = 3) and C1 (n = 1) fractures (Magerl classification). The specific system for fracture reduction was used in the last 39 cases of this series. A Pyramesh cage (Medtronic, Memphis, USA) was used in 15 patients, a peek cage (Creaspine, Bordeaux, France) in 30 patients and a tricortical graft in 5 patients. Standard X-rays and CT scan were performed pre-operatively. Kyphosis, and angulations were measured pre-, per- and post-operatively. Mean immediate postoperative gain in localized kyphosis was 12.18 degrees and mean gain at last follow-up was 11.71 degrees. Mean immediate postoperative gain in RA was 13.24 degrees and remained identical at last follow-up. Five patients had a transient pulmonary atelectasia and there was one pulmonary infection. No neurological complication occurred. Fracture reduction is comparable to the best thoracotomy series while limiting approach-related complications.

Reverse and pseudoreverse cortical sign in thoracolumbar burst fracture: radiologic description and distinction--a propos of three cases

In thoracolumbar burst fracture the "reverse cortical sign" is a known entity that corresponds to a fragment of the posterior wall that has been flipped 180 degrees with the cancellous surface of the fragment facing posteriorly in the canal and the cortical surface (posterior wall) facing anteriorly. The identification of such reverse cortical fragment is crucial as ligamentotaxis is classically contraindicated as the posterior longitudinal ligament is ruptured. Recognition of such a flipped cortical fragment has relied so far on the axial CT. The advent of CT scans with sagittal reconstruction has allowed us to better describe such entities that have received little attention in the literature. The goal of this report was therefore to describe the appearance of the reverse cortical sign and its likes as they can appear on axial CT scans, sagittal reconstructions and MRI. During 1-year practice at our institution we had to treat three patients with thoracolumbar burst fracture associated with what looked like a reverse cortical sign on the axial CT scans. Further analysis of the sagittal reconstruction CT could differentiate the true reverse cortical sign from a new entity that we coined "the pseudoreverse cortical sign" as observed in two out of the three cases. In the pseudo reverse cortical sign what appears to be a flipped piece of posterior vertebral body is actually part of the superior or inferior endplate that is depressed into the comminuted vertebral body. In such cases the posterior longitudinal ligament appears to be in continuity and therefore such fracture can theoretically be treated with posterior ligamentotaxis as evidenced in one of our case. Careful analysis of the CT scan and specifically the sagittal reconstruction and MRI can differentiate two separate entities that may correspond to a different severity injury.

Complete burst fracture of the fifth lumbar vertebra treated by posterior surgery using expandable cage

STUDY DESIGN

This report characterises a 25 year old male patient with a complete burst fracture of the fifth lumbar vertebra with dislocation. He was treated by posterior surgery with transpedicular instrumentation and an expandable cage from the posterior approach.

OBJECTIVES

Burst fractures of the fifth lumbar vertebra are extremely rare. Patients with positive neurological findings should be treated by the posterior approach. This surgery consists of reduction, decompression, transpedicular stabilisation and fusion.

MATERIALS AND METHODS

The young man in our report was treated by posterior surgery only. It consisted of laminectomy, suture of the thecal sac tear, discectomies and subtotal removal of the fifth lumbar vertebra. Repositioning was carried out simultaneously with support using Synex TM Synthes USA telescopic cage and SOCON TM Aesculap Germany transpedicular fixator.

RESULTS

The patient suffered neither wound complications nor instrumentation failure. He is currently able to walk with the help of peroneal bands but without crutches.

CONCLUSIONS

Treatment of fractures of the fifth lumbar vertebra depends on fracture type and neurological findings. Conservative management of this condition is appropriate provided there is no neurological damage and canal stenosis and deformity is minimal. Surgical treatment of burst lumbar fractures with neurological deficit is strongly recommended. The optimum treatment remains debatable.

Anterior approach to thoracic and lumbar spine lesions: results in 145 consecutive cases

Object

The authors report on a series of 145 consecutive patients with different types of spine lesions surgically treated via an anterior approach (AA) at the thoracic and lumbar levels during the past 10 years. Indications, techniques, and surgical results are described.

Methods

This series included 92 patients with fractures, 30 with neoplasms, 13 with thoracic disc hernias, and 10 with spinal infections. Based on the lesion to be addressed, the AA was used for lesion excision, corpectomy, vertebral body reconstruction with cages, realignment, and/or plating or screwing. The approach was extracavitary in 55 patients and intracavitary in 90. In 126 patients (86.8%), neural decompression and spine stabilization were achieved via a stand-alone AA (SA-AA), whereas 19 patients (13.1%) were treated using a 2-stage anteroposterior approach. This circumferential approach was reserved for select cases of severe traumatic dislocation, particular types of tumors, or specific anatomical locations. The authors developed a simple neuronavigation-based method of identifying the severely injured patients who were eligible for the SA-AA by evaluating the angle of lateral dislocation.

Results

There were no deaths and no instances of major surgery-related morbidity. Minor morbidity was almost always transitory and was reported in 13 patients (8.9%). Neurological improvement was reported in 20% of injured patients with a preoperative incomplete lesion. Postoperatively, all patients were able to stand or at least sit without load pain. During the follow-up (mean ± standard deviation 3.8 ± 2.4 years), there were no cases of failure, fracture, dislocation, or bending of the anterior instrumentation, and the rate of pseudarthrosis was 0%.

Conclusion

The anterior route provides direct access to most spine diseases and allows optimal neural decompression and the possibility of adequate realignment and strong reconstruction/fixation. Stability of the vertebral column is achieved, resolution of clinical pain is rapid and almost complete, and the rate of surgical complications is very low. The authors assert that the SA-AA offers so many advantages and has such good results that the 2-stage anteroposterior approach can be reserved for a minority of select cases and that the time for using the posterior approach alone is over.

Fluoroscopically-guided indirect posterior reduction and fixation of thoracolumbar burst fractures without fusion

This article presents an evaluation of fluoroscopy for indirect, posterior reduction and fixation of thoracolumbar burst fractures. A prospective study of 25 patients with thoracolumbar burst fractures who underwent C-arm machine-guided posterior indirect reduction and short segment fixation without fusion is described. No laminotomies were performed. All patients had a mean follow-up of 30.4 months. At postoperative review, the average anterior and posterior vertebral heights were corrected from 57.9% to 99.0% and 89.0% to 99.5%, respectively. The Cobb angle was corrected from 18.4 degrees to 0.17 degrees . The canal compromise ratio was improved from 35.2% to 8.6%. In all 25 cases, neurological status was intact at last follow-up. Fluoroscopy guidance is an effective method to accomplish indirect reduction and fixation. Reduction was confirmed on lateral fluoroscopic views by looking for a "one-line sign," which is the reconstitution of the posterior border of the vertebral body.

[Video-assisted mini-thoracotomy for surgical treatment of thoracolumbar junction fractures]

PURPOSE OF THE STUDY

There are several solutions for the treatment of fractures of the thoracolumbar junction (classical anterior, posterior, combined approaches). The advent of video-assisted minimally invasive techniques has helped minimize complications. The aim of this work was to analyze the clinical and radiological outcome in a prospective series of 20 patients who underwent video-assisted mini-thoracotomy for the treatment of thoracolumbar junction fractures.

MATERIAL AND METHODS

This prospective study included 20 patients, mean age 43.3 years, with at least one year follow-up. All patients presented a normal neurological examination (Frankel E). Fractures were classified Magerl A (n = 19) and B (n = 1). Corporectomy/correction (aided with an endodistractor in the last nine cases) was performed with grafting and osteosynthesis. Perioperative and postoperative complications were noted. Focal kyphosis and regional angulation were noted before and after the operation and at last follow-up using the Stagnara system.

RESULTS

The arthrodesis had fused at last follow-up in all patients. There were three cases of alelectasia which regressed in two months. Overall outcome showed satisfactory angular correction which was maintained at last follow-up. The gain in focal kyphosis was 13.71 degrees on average in the immediate postoperative period and persisted at last follow-up (13.31degrees). The gain in corrected regional angulation was 14 degrees in the immediate postoperative period and 14 degrees at last follow-up. The gain in focal kyphosis and regional angulation was two-fold greater with the endodistractor than with external maneuvers.

DISCUSSION

The complication rate was very low. Corrections obtained were comparable with those reported in the literature and persisted over time.

CONCLUSION

Bearing in mind the learning curve, there are fewer complications with the video-assisted minimally invasive approach than with classical thoracotomy or anterior surgery. This is true for perioperative and early and late postoperative complications. The correction achieved is satisfactory and lasting. A specific ancillary is essential for the reduction and for fitting the anterior graft without lost of correction. This technique combines the best results achieved with thoracotomy (Onimus) with a limited rate of complications.

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.

Posterior instrumentation for thoracolumbar fractures

Thoracolumbar fractures are relatively common injuries. Numerous classification systems have been developed to characterize these fractures and their prognostic and therapeutic implications. Recent emphasis on short, rigid fixation has influenced surgical management. Most compression and stable burst fractures should be treated nonsurgically. Neurologically intact patients with unstable burst fractures that have >25 degrees of kyphosis, >50% loss of vertebral height, or >40% canal compromise often can be treated with short, rigid posterior fusions. Patients with unstable burst fractures and neurologic deficits require direct or indirect decompression. Posterior stabilization can be effective with Chance fractures and flexion-distraction injuries that have marked kyphosis, and in translational or shear injuries. Advances in understanding both biomechanics and types of fixation have influenced the development of reliable systems that can effectively stabilize these fractures and permit early mobilization.