'Armed kyphoplasty' with posterior stabilization avoids corpectomy in complex thoracolumbar spine fractures: a case series

BACKGROUND

Complex thoracolumbar fractures require reduction and stabilization. Posterior instrumentation alone and standard cement augmentation may represent undertreatment, while corpectomy has significant morbidity. In a series of unstable thoracolumbar fractures, we assessed the feasibility, safety, and results of 'armed kyphoplasty' (AKP) and surgical posterior stabilization (PS).

METHODS

A total of 24 consecutive patients were treated with combined AKP and PS. Minimally invasive and open surgery techniques were used for PS. AKP was performed with C-arm or biplane fluoroscopic guidance, and screws were placed under navigation or fluoroscopic guidance. A postoperative CT scan and standing plain films were obtained. Patients were followed up according to clinical standards. Kyphosis correction (measured with regional Cobb angle), pain (measured with the Numeric Rating Scale), neurological status (measured with Frankel grade) were assessed.

RESULTS

A total of 25 fractures of neoplastic (40%), traumatic (32%), and osteoporotic (28%) nature were treated. Open surgery and minimally invasive techniques were applied in 16/24 and 8/24 patients, respectively. Decompressive laminectomy was performed in 13 cases. No intraprocedural complications occurred. Two patients (8%) died due to underlying disease complications and three complications (12%) required re-intervention (one surgical site infection, one adjacent fracture, and one screw pull-out) in the first month. The mean Cobb angle was 20.14±6.19° before treatment and 11.66±5.24° after treatment (P<0.0001). No re-fractures occurred at the treated levels.

CONCLUSIONS

Combined AKP and PS is feasible and effective in the treatment of complex thoracolumbar fractures of all etiologies. AKP avoided highly invasive corpectomy. Anterior and posterior support ensured stability, preventing implant failure and re-fracture. The complication rate was low compared with more invasive traditional 360° open surgical approaches.

Aggressive vertebral hemangiomas contain no adipose tissue resulting in thoracic spine kyphosis: A case report

RATIONALE

Aggressive vertebral hemangiomas (AVHs) destroy continuous vertebral bodies and intervertebral discs and resulting in spinal kyphosis is extremely rare. The very aggressive behavior was attributable to its significant vascular component and contained no adipose tissue.

PATIENT CONCERNS

We report a case of thoracic spine kyphosis of AVHs with multiple vertebral bodies and intervertebral disc destruction in a 45-year-old woman.

DIAGNOSES

Based on the imaging studies, the patient underwent surgical removal of this lesion and spinal reconstruction. Histopathology consistent with vertebral hemangioma and contained no adipose.

INTERVENTIONS

The patient underwent surgical removal of the lesion and spinal reconstruction. After subperiosteal dissection of the paraspinal muscles and exposure of the laminae, the laminae of the T5-7 vertebrae were removed and exposing the lesion. The lesion was soft and showed cystic changes, completely curetted and autogenous bone was implanted. Vertebroplasty was performed through T3-T9 pedicles bilaterally. Pedicle screw fixation was performed for segmental fixation and fusion.

OUTCOMES

After 9 days of operation, the incision healed cleanly and free of pain. She was discharged in good general condition. The patient remained asymptomatic after follow-up 6 months of postoperative.

LESSONS

AVHs destroy multiple vertebral bodies and intervertebral discs and resulting in spinal kyphosis is extremely rare.

The efficacy of machine learning models in forecasting treatment failure in thoracolumbar burst fractures treated with short-segment posterior spinal fixation

BACKGROUND

Although short-segment posterior spinal fixation (SSPSF) has shown promising clinical outcomes in thoracolumbar burst fractures, the treatment may be prone to a relatively high failure rate. This study aimed to assess the effectiveness of machine learning models (MLMs) in predicting factors associated with treatment failure in thoracolumbar burst fractures treated with SSPSF.

METHODS

A retrospective review of 332 consecutive patients with traumatic thoracolumbar burst fractures who underwent SSPSF at our institution between May 2016 and May 2023 was conducted. Patients were categorized into two groups based on treatment outcome (failure or non-failure). Potential risk factors for treatment failure were compared between the groups. Four MLMs, including random forest (RF), logistic regression (LR), support vector machine (SVM), and k-nearest neighborhood (k-NN), were employed to predict treatment failure. Additionally, LR and RF models were used to assess factors associated with treatment failure.

RESULTS

Of the 332 included patients, 61.4% were male (n = 204), and treatment failure was observed in 44 patients (13.3%). Logistic regression analysis identified Load Sharing Classification (LSC) score, lack of index level instrumentation, and interpedicular distance (IPD) as factors associated with treatment failure (P < 0.05). All models demonstrated satisfactory performance. RF exhibited the highest accuracy in predicting treatment failure (accuracy = 0.948), followed by SVM (0.933), k-NN (0.927), and LR (0.917). Moreover, the RF model outperformed other models in terms of sensitivity and specificity (sensitivity = 0.863, specificity = 0.959). The area under the curve (AUC) for RF, LR, SVM, and k-NN was 0.911, 0.823, 0.844, and 0.877, respectively.

CONCLUSIONS

This study demonstrated the utility of machine learning models in predicting treatment failure in thoracolumbar burst fractures treated with SSPSF. The findings support the potential of MLMs to predict treatment failure in this patient population, offering valuable prognostic information for early intervention and cost savings.

Risk factors for kyphosis recurrence after implant removal in percutaneous osteosynthesis for post-traumatic thoracolumbar fracture

PURPOSE

Short-segment minimally invasive percutaneous spinal osteosynthesis has now become one of the treatments of choice to treat thoracolumbar fractures. The question of implant removal once the fracture has healed is still a matter of debate since this procedure can be associated with loss of sagittal correction. Therefore, we analyzed risk factors for kyphosis recurrence after spinal implants removal in patients treated with short-segment minimally invasive percutaneous spinal instrumentation for a thoracolumbar fracture.

METHODS

A total of 32 patients who underwent implant removal in percutaneous osteosynthesis for post-traumatic thoracolumbar fracture were enrolled in our study. Patient's medical record, operative report and imaging examinations carried out at the trauma and during the follow-up were analyzed.

RESULTS

Every patient experienced fracture union. Vertebral kyphotic angle (VKA) and Cobb angle (CA) improved significantly after stabilization surgery. VKA, CA, upper disk kyphotic angle (UDKA) and lower disk kyphotic angle (LDKA) significantly gradually decreased during follow-up. Traumatic disk injury (p: 0.001), younger age (p: 0.01), canal compromise (p: 0.04) and importance of surgical correction (p < 0.001) were significantly associated with kyphosis recurrence after implant removal. Anterior body augmentation did not affect loss of correction (CA and VKA) during the follow-up period (p: 0.57).

CONCLUSION

Despite correction of the fracture after stabilization, we observed a progressive loss of correction over time appearing even before implant removal. Particular attention should be paid to post-traumatic disk damage or canal invasion, to young patients and to surgical overcorrection of the traumatic kyphosis.

Implementation of Robotic Exoscope in Minimally Invasive Corpectomy at Thoracolumbar Junction for the Treatment of Traumatic Spinal Cord Compression

The development and diffusion of minimally invasive (MI) approaches have coincided with improvements in magnification systems. The exoscope will probably open a new era in new technologies in spinal surgery. This study reports a retrospective series of 19 thoracolumbar (T11-L2) burst fractures with anterior column failure and cord compression, treated with MI corpectomy and spinal decompression assisted by a three-dimensional high-definition exoscope (Video 1). Exclusion criteria were pathologic or osteoporotic fractures, multilevel fractures, and previous surgery at the site of the fracture. Three key indicators were recorded: surgical time, blood loss, and intraoperative complications. A questionnaire was administered to assess the users' exoscope experience with ergonomics, preparation, magnification, image definition, illumination, and user-friendliness, compared with the operative microscope. To the best of our knowledge, this is the first study reporting on exoscope-assisted MI corpectomy. This procedure permitted low blood loss and less surgical time without intraoperative complications. The exoscope offers clear advantages in terms of ergonomics, definition, and user-friendliness. Moreover, it is a suitable instrument for training and education, providing an opportunity for better interaction with other members of the surgical staff.

Concurrently Occurring Spinal Cord Cross-Section and Aortic Injury After a Chalk-Stick Fracture and Dislocation in Patient with Ankylosing Spondylitis: Clinical Image

A 74-year-old woman with ankylosing spondylitis presented with back pain and complete paraplegia after a fall. A radiologic finding of a bamboo spine, a characteristic feature of ankylosing spondylitis, was observed on computed tomography, along with a fracture-dislocation involving T10 and T11 (chalk-stick fracture) and compression of the descending thoracic aorta due to the caudal bony column. The patient underwent an open reduction and T8-L3 posterior fusion in the operating room. A complete cross-section of the spinal cord was observed during surgery. Post operation, a decrease in blood pressure led to a thoracotomy and thoracic endovascular aortic repair due to a crack in the descending aorta wall. Thoracolumbar fracture-dislocations, particularly in patients with ankylosing spondylitis, are characterized by instability and can be further complicated by concurrent vascular and spinal cord injuries. It is crucial therefore to recognize the potential for vascular and spinal cord injuries early on in such cases.

Low Hounsfield unit values on computed tomography as a potential predictor of vertebral fracture in patients with rheumatoid arthritis: The KURAMA cohort study

OBJECTIVE

Hounsfield units (HU) measured using computed tomography (CT) have gained considerable attention for the detection of osteoporosis. This study aimed to investigate whether opportunistic CT could predict vertebral fractures in patients with rheumatoid arthritis (RA).

METHODS

A total of 233 patients with RA who underwent chest CT were included in this study. The HU values of the anterior 1/3 of the vertebral bodies based on the sagittal plane at T11-L2 after reconstruction were measured. The incidence of vertebral fractures was investigated with respect to the HU value.

RESULTS

Vertebral fractures were identified in 32 patients during a mean follow-up period of 3.8 years. In patients who experienced vertebral fractures within 2 years of CT imaging, the HU values of the vertebral bodies (T11-L2) were lower than those in patients who did not experience fractures. Receiver operating characteristic curve analysis identified that a T11 HU value of <125 was a risk factor for vertebral fracture within 2 years. Multivariate analysis showed that a T11 HU value of <125 and the existence of prevalent vertebral fractures were significant risk factors for fracture.

CONCLUSION

HU measurements of the anterior 1/3 of the vertebral body are a potential predictor for vertebral fractures in patients with RA.

Paediatric spine injuries in the thoracic and lumbar spine-results of the German multicentre CHILDSPINE study

BACKGROUND

Paediatric thoracolumbar spine injuries are rare, and meaningful epidemiological data are lacking.

OBJECTIVES

The aim of this study was to provide epidemiological data for paediatric patients with thoracolumbar spinal trauma in Germany with a view to enhancing future decision-making in relation to the diagnostics and treatment of these patients.

MATERIALS AND METHODS

A retrospective multicentre study includes patients up to 16 years of age who were suffering from thoracolumbar spine injuries who had been treated in six German spine centres between 01/2010 and 12/2016. The clinical database was analysed for patient-specific data, trauma mechanisms, level of injury, and any accompanying injuries. Diagnostic imaging and subsequent treatment were investigated. Patients were divided into three age groups for further evaluation: age group I (0-6 years), age group II (7-9 years) and age group III (10-16 years).

RESULTS

A total of 153 children with 345 thoracolumbar spine injuries met the inclusion criteria. The mean age at the time of hospitalization due to the injury was 12.9 (± 3.1) years. Boys were likelier to be affected (1:1.3). In all age groups, falls and traffic accidents were the most common causes of thoracolumbar spine injuries. A total of 95 patients (62.1%) were treated conservatively, while 58 (37.9%) of the children underwent surgical treatment. Minimally invasive procedures were the most chosen procedures. Older children and adolescents were likelier to suffer from higher-grade injuries according to the AOSpine classification. The thoracolumbar junction (T11 to L2) was the most affected level along the thoracolumbar spine (n = 90). Neurological deficits were rarely seen in all age groups. Besides extremity injuries (n = 52, 30.2%), head injuries represented the most common accompanying injuries (n = 53, 30.8%). Regarding spinal injuries, most of the patients showed no evidence of complications during their hospital stay (96.7%).

CONCLUSIONS

The thoracolumbar junction was more frequently affected in older children and adolescents. The majority of thoracolumbar spinal column injuries were treated conservatively. Nevertheless, 37.9% of hospitalized children had to be treated surgically, and there was an acceptable complication rate for the surgeries that were performed.

Hybrid kyphoplasty with short-versus intermediate- and long-segment pedicle screw fixations for the management of thoracolumbar burst fractures

BACKGROUND

This study aimed to determine if the hybrid short-segment (HSS) technique is a good alternative to the intermediate-segment (IS) and long-segment (LS) techniques in pedicle screw fixations for acute thoracolumbar burst fractures (TLBFs).

METHODS

In this retrospective evaluation, we examined 43 patients who underwent surgical treatments, including one- or two-level suprajacent (U) and infrajacent (L) pedicle screw fixations, for acute single-level TLBFs with neurological deficits between the T11 and L2 levels from July 2013 to December 2019. Among these patients, 15 individuals underwent HSS (U1L1), 12 received IS (U2L1), and 16 underwent LS (U2L2) fixations. Supplemental kyphoplasty of the fractured vertebral bodies was performed exclusively in the HSS group. Our analysis focused on assessing blood loss and surgical duration. Additionally, we compared postoperative thoracolumbar kyphotic degeneration using the data on Cobb angles on lateral radiographic images acquired at three time points (preoperatively, postoperative day 1, and follow-up). The end of follow-up was defined as the most recent postoperative radiographic image or implant complication occurrence.

RESULTS

Blood loss and surgical duration were significantly lower in the HSS group than in the IS and LS groups. Additionally, the HSS group exhibited the lowest implant complication rate (2/15, 13.33%), followed by the LS (6/16, 37.5%) and IS (8/12, 66.7%) group. Implant complications occurred at a mean follow-up of 7.5 (range: 6-9), 9 (range: 5-23), and 7 (range: 1-21) months in the HSS, IS, and LS groups. Among these implant complications, revision surgeries were performed in two patients in the HSS group, two in the IS group, and one in the LS group. One patient treated by HSS with balloon kyphoplasty underwent reoperation because of symptomatic cement leakage.

CONCLUSIONS

The HSS technique reduced intraoperative blood loss, surgical duration, and postoperative implant complications, indicating it is a good alternative to the IS and LS techniques for treating acute single-level TLBFs. This technique facilitates immediate kyphosis correction and successful maintenance of the corrected alignment within 1 year. Supplemental kyphoplasty with SpineJack® devices and high-viscosity bone cements for anterior reconstruction can potentially decrease the risk of cement leakage and related issues.

An Integrated Voice Recognition and Natural Language Processing Platform to Automatically Extract Thoracolumbar Injury Classification Score Features From Radiology Reports

BACKGROUND

Many predictive models for estimating clinical outcomes after spine surgery have been reported in the literature. However, implementation of predictive scores in practice is limited by the time-intensive nature of manually abstracting relevant predictors. In this study, we designed natural language processing (NLP) algorithms to automate data abstraction for the thoracolumbar injury classification score (TLICS).

METHODS

We retrieved the radiology reports of all Mayo Clinic patients with an International Classification of Diseases, 9th or 10th revision, code corresponding to a fracture of the thoracolumbar spine between January 2005 and October 2020. Annotated data were used to train an N-gram NLP model using machine learning methods, including random forest, stepwise linear discriminant analysis, k-nearest neighbors, and penalized logistic regression models.

RESULTS

A total of 1085 spine radiology reports were included in our analysis. Our dataset included 483 compression, 401 burst, 103 translational/rotational, and 98 distraction fractures. A total of 103 reports had documented an injury of the posterior ligamentous complex. The overall accuracy of the random forest model for fracture morphology feature detection was 76.96% versus 65.90% in the stepwise linear discriminant analysis, 50.69% in the k-nearest neighbors, and 62.67% in the penalized logistic regression. The overall accuracy to detect posterior ligamentous complex integrity was highest in the random forest model at 83.41%. Our random forest model was implemented in the backend of a web application in which users can dictate reports and have TLICS features automatically extracted.

CONCLUSIONS

We have developed a machine learning NLP model for extracting TLICS features from radiology reports, which we deployed in a web application that can be integrated into clinical practice.

Surgeon reported treatment choices for AO type B and C thoracolumbar fractures without neurological deficits: An expert survey

INTRODUCTION

Less invasive spine surgery (LISS) has become well-established for thoracolumbar burst fractures without neurological deficits. However, notable controversy persists regarding the adequacy of LISS for more unstable AO type B and C injuries, as it does not allow for formal open fusion.

MATERIALS AND METHODS

In this cross-sectional survey experienced spine surgeons of the Dutch Spine Society were invited to participate (56 participants). They were asked to indicate the most appropriate treatment for AO type B1, B2 (L1: A1 and L1: A3), B3 and C (L1: A4) injuries at level Th12-L1. Taking into account: age, AO N0-N1, or polytrauma. Specific agreement between participants was obtained applying Variation Ratio (VR).

RESULTS

A significant level of overall agreement was observed for AO type-B1 injuries with 73.8% of participants opting for percutaneous short-segment fixation (VR 0.775). For AO type-B3 injuries, 79.4% of participants favored percutaneous long-segment fixation (VR 0.794). for AO type-B2 injuries, there was less overall agreement (VR 0.571-0.657). Nonetheless, when considering all AO type-B injuries combined, percutaneous fixation emerged as the most preferred treatment option with substantial agreement (VR 0.871-0.923). Conversely, for AO type-C injuries, there was less agreement among the participants (VI 0.411), 26.5% of them chose additional open spinal fusion.

CONCLUSION

For all AO type-B injuries there was substantial agreement to treat these fractures with percutaneous techniques. For AO type-C injuries, the survey results do not support a consensus. Nevertheless, the responses raise important questions about the necessity of spinal fusion for such injuries.

Clinical Observation of Posterior Approach for Surgical Treatment of Thoracolumbar Pseudarthrosis in Ankylosing Spinal Disorders

OBJECTIVE

The objective of this study was to evaluate the surgical effectiveness of posterior procedure with long segment stabilization for treating thoracolumbar pseudarthrosis associated with ankylosing spinal disorders (ASDs) without anterior fusion or osteotomy.

METHODS

Twelve patients with thoracolumbar pseudarthrosis in ASD were enrolled. All patients underwent posterior long-segment stabilization procedures. In some patients, the percutaneous technique or the aid of a robot or O-arm navigation was utilized for pedicle screw implantation. The clinical results were evaluated by means of the visual analog scale and Oswestry Disability Index. Radiological outcomes were evaluated for bone fusion, anterior column defect, local kyphotic correction, and position of the pedicle screws.

RESULTS

All patients experienced effective bone fusion at the sites of pseudarthrosis. The mean operative time was 161.7 ± 57.1 minutes, and the average amount of blood loss was 305.8 ± 293.2 mL. For 6 patients who underwent surgery with the assistance of a robot or O-arm navigation, there was no statistically significant difference observed in terms of operative time and mean blood loss compared to those who used the freehand technique (P > 0.05). The visual analog scale score, Oswestry Disability Index value, and mean local kyphotic angle showed significant improvements at the final follow-up (P < 0.05). The accuracy of pedicle screw placement was 96%.

CONCLUSIONS

Posterior surgery with long-segment fixation, without anterior fusion or osteotomy, can achieve satisfactory outcomes in ASD patients with thoracolumbar pseudarthrosis. The application of percutaneous techniques, as well as the assistance of robots or navigation technique may be a good choice for the treatment of pseudarthrosis in ASD patients.

Unilateral Pediculectomy and Reduction with Short-Segment Pedicle Screw Fixation for Thoracolumbar Burst Fracture: A Case Series

BACKGROUND

This study aimed to evaluate the efficacy of unilateral pediculectomy and reduction with short-segment pedicle screw fixation for thoracolumbar burst fracture.

METHODS

We retrospectively reviewed patients who underwent a unilateral pediculectomy and reduction with short-segment fixation and interbody fusion for thoracolumbar burst fracture. The unilateral pediculectomy created sufficient space to approach the ventral side of the spinal cord for removing bone fragments and insertion of an interbody cage to correct kyphosis. Lumbar lordosis (LL), pelvic incidence (PI) minus LL, and segmental Cobb angle were measured at 3 time points: preoperatively, postoperatively, and final follow-up. Furthermore, sagittal vertical axis (SVA) was measured to assess global sagittal balance at the final follow-up.

RESULTS

A total of 10 patients, with a mean age of 39.8 ± 21.0, underwent the surgical procedure. All patients had a thoracolumbar injury classification and severity score > 5. The mean follow-up period was 15.8 ± 13.9 months. The mean postoperative LL (46.0 ± 5.8) was significantly higher (P = 0.008) than the preoperative measurement (32.8 ± 8.2). The mean postoperative PI minus LL (2.2 ± 8.4) was not significantly lower (P = 0.051) than preoperative measurement (15.4 ± 12.6). The mean postoperative segmental Cobb angle (11.4 ± 8.4) was significantly higher (P < 0.001) than the preoperative measurement (-11.6 ± 10.9). At the final follow-up, the mean sagittal vertical axiswas 10.0 ± 28.8 mm.

CONCLUSIONS

Unilateral pediculectomy and reduction with short-segment fixation and interbody fusion served as an efficient surgical method for thoracolumbar burst fracture.

Finite element study on three osteotomy methods for treating thoracolumbar osteoporotic fracture vertebral collapse complicated with neurological dysfunction

BACKGROUND

Surgical methods for patients with osteoporotic fracture vertebral collapse complicated with neurological dysfunction are still a topic of debate. We designed an improved osteotomy for the treatment of osteoporotic compression fracture patients with neurological dysfunction. Compared with traditional osteotomy methods such as pedicle subtraction osteotomy (PSO) and bone-disc-bone osteotomy (BDBO), the osteotomy range is reduced. Therefore, we use a finite element method to analyze the biomechanical conditions of these three osteotomy methods and provide a mechanical theoretical basis for the surgical treatment of these three osteotomy methods.

METHODS

Based on the CT scan of a patient with L1 osteoporotic fracture vertebral collapse and neurological dysfunction, the finite element model was constructed by importing Mimics software, and three different osteotomy models were established. The forces and displacements of internal fixation device, T1-L5 whole segment, T10 vertebral body, and T10/11 intervertebral disc were recorded under different working conditions.

RESULTS

The displacement levels of internal fixation device, T1-L5 spine, T10 vertebral body, and T10/11 intervertebral disc in the modified osteotomy group were between BDBO group and PSO group. The stress in BDBO group was concentrated in titanium mesh and its maximum stress was much higher than that in PSO group and modified osteotomy group. The mechanical distribution of T10/11 intervertebral disc showed that the maximum stress distribution of the three osteotomy methods was similar.

CONCLUSION

The relatively simple modified osteotomy has certain advantages in stress and displacement. In contrast, the stability of BDBO group was poor, especially in the lumbar intervertebral disc and lumbar body. For this type of osteotomy patients, it is recommended to avoid postoperative flexion so as not to increase the load.

Supplementary value and diagnostic performance of computed tomography scout view in the detection of thoracolumbar spine injuries

PURPOSE

Assessing the diagnostic performance and supplementary value of whole-body computed tomography scout view (SV) images in the detection of thoracolumbar spine injuries in early resuscitation phase and identifying frequent image quality confounders.

METHODS

In this retrospective database analysis at a tertiary emergency center, three blinded senior experts independently assessed SV to detect thoracolumbar spine injuries. The findings were categorized according to the AO Spine classification system. Confounders impacting SV image quality were identified. The suspected injury level and severity, along with the confidence level, were indicated. Diagnostic performance was estimated using the caret package in R programming language.

RESULTS

We assessed images of 199 patients, encompassing 1592 vertebrae (T10-L5), and identified 56 spinal injuries (3.5%). Among the 199 cases, 39 (19.6%) exhibited at least one injury in the thoracolumbar spine, with 12 (6.0%) of them displaying multiple spinal injuries. The pooled sensitivity, specificity, and accuracy were 47%, 99%, and 97%, respectively. All experts correctly identified the most severe injury of AO type C. The most common image confounders were medical equipment (44.6%), hand position (37.6%), and bowel gas (37.5%).

CONCLUSION

SV examination holds potential as a valuable supplementary tool for thoracolumbar spinal injury detection when CT reconstructions are not yet available. Our data show high specificity and accuracy but moderate sensitivity. While not sufficient for standalone screening, reviewing SV images expedites spinal screening in mass casualty incidents. Addressing modifiable factors like medical equipment or hand positioning can enhance SV image quality and assessment.

Osteoporotic vertebral fractures localized in the lumbar area significantly impact sagittal alignment

Lumbar fractures and/or multiple fractures at the lumbar or thoracolumbar regions are risk factors for sagittal malalignment in patients older than 70 years old. Although patients with OVF show a huge capacity to compensate after the fractures, lumbar and TL lumbar fractures require closer monitoring.

PURPOSE

To assess the impact of osteoporotic vertebral fractures on the sagittal alignment of the elderly and identify risk factors for sagittal malalignment.

METHODS

We performed a retrospective study on a cohort of 249 patients older than 70 years old and diagnosed with osteoporosis who suffered chronic vertebral fractures. Demographic and radiological data were collected. Full-spine lateral X-rays were obtained to analyze the sagittal plane. Patients were classified according to the number and location of the fractures. Pearson's correlation coefficient was used to assess the relationships between the type of fractures and sagittal alignment.

RESULTS

A total of 673 chronic fractures were detected in 249 patients with a mean number of vertebral fractures per patient of 2.7 ± 1.9. Patients were divided into 9 subgroups according to the location and the number of fractures. Surprisingly, any of the aggregated parameters used to assess sagittal alignment exceeded the threshold defined for malalignment. In the second part of the analysis, 41 patients with sagittal malalignment were identified. In this subpopulation, an overrepresentation of patients with lumbar fractures (34% vs. 11%) and an under-representation of thoracic fractures (9% vs. 34%) were reported. We also observed that patients with 3 or more lumbar or thoracolumbar fractures had an increased risk of sagittal malalignment.

CONCLUSIONS

Lumbar fractures and/or multiple fractures at the lumbar or thoracolumbar regions are risk factors for sagittal malalignment in patients older than 70 years old. Although patients show a remarkable capacity to compensate, fractures at the lumbar and thoracolumbar regions need closer monitoring.

Minimally Invasive Techniques in the Surgical Management of Traumatic Pediatric Thoracolumbar Fractures

BACKGROUND

Thoracolumbar (TL) fractures are uncommon in children. While surgical treatment is recommended for unstable TL fractures, there is no consensus on appropriate surgical treatment. We present a case series of pediatric patients with traumatic TL fractures treated with minimally invasive techniques. We discuss our early experience and technical challenges with navigation and robotic-assisted fixation.

METHODS

A retrospective review of a prospectively maintained trauma database from February 2018 to February 2023 of all pediatric patients (<18 years old) undergoing percutaneous fixation for unstable TL fractures was performed. Minimally invasive techniques included fluoroscopy and/or navigation-guided or robotic-assisted surgery. Clinical course, radiographic findings, and technical challenges were reviewed.

RESULTS

A cohort of 12 patients (age range, 4-17 years) with 6 (50%) Chance fractures, 2 (16%) pars fractures, 2 (16%) pedicle fracture, 1 (8%) burst fracture, and 1 (8%) other fracture were identified. Nine patients had fractures involving the lumbar spine, and the remaining 3 had thoracic fractures. In all cases, percutaneous pedicle screws were placed above and below the fracture with the use of neuronavigation or robotic-assisted navigation (n = 2). Blood loss was <30 mL for single-level fractures and instrumented fusion. Two patients had hardware-related complications. At follow-up (mean 9.67 months after surgery), patients were doing well clinically, and most imaging showed stable alignment.

CONCLUSIONS

Our early experience shows that short segment instrumentation through a minimally invasive approach is a safe and effective surgical option for young pediatric patients with good clinical outcomes and favorable radiographic postoperative finding.

Thoracic spinous process nonunion as an unusual cause of back pain: a case report and review of the literature

BACKGROUND

Purely isolated spinous processes fractures are rare and are usually treated conservatively, although a few authors have reported cases of nonunion that ultimately required surgical resection.

CASE PRESENTATION

We present a case of an isolated T6 spinous process pseudoarthrosis that was treated by surgical resection of the tip of the spinous process. A 34-year-old Caucasian male patient was complaining of mid-thoracic back pain without neurologic impairment more than 2 years after an isolated spinous process fracture. Magnetic Resonance Imaging (MRI) and Single Photon Emission Computed Tomography (SPECT) revealed a nonunion. We performed a resection without further complication.

CONCLUSION

Although spinous process nonunions may in some cases be well tolerated, surgical resection appears to be a reliable option in case of persistent symptoms. This illustrated case shows the description of an isolated thoracic spinous process nonunion and its surgical treatment.

The choice of classification to determine the optimal tactics for treatment of the thoracolumbar junction traumatic injuries

OBJECTIVE

Aim: To evaluate the influence of the degree of detail of the nature of the pathomorphological changes in the osteoligamentous structures on the tactics of treating the patients with the traumatic damage to the thoracolumbar junction.

PATIENTS AND METHODS

Materials and Methods: A retrospective analysis of the treatment tactics was carried out in 96 patients with a traumatic injury of the thoracolumbar junction, both those who underwent a surgical treatment and those who underwent a conservative therapy. The lesions were classified using F. Magerl and AOSpine classifications; the neurological status was assessed according to the ASIA scale, the nature of the damage was specified using the McCormack criteria. The statistical data processing was performed using the Random Forest machine learning algorithm.

RESULTS

Results: The nature of the injury makes it possible to unambiguously determine the optimal method of therapy when using the F. Magerl classification with a probability of 58.33%, while in relation to the AOSpine classification this figure is 55.21%. When building the models that include the nature of the damage, the level of the neurological disorders and the McCormack criteria, it was found that the use of the F. Magerl classification demonstrates an error in unambiguously determining the most effective treatment method at the level of 26.04%, while the use of AOSpine this figure was 21.88%.

CONCLUSION

Conclusions: The application of the AOSpine classification is more promising for the development of a multifactorial algorithm for the treatment of the traumatic injuries of the thoracolumbar junction.

The effect of the size of pedicle screw on the long-term radiological and clinical results of short-segment posterior instrumentation in the management of thoracolumbar vertebral fractures

OBJECTIVE

It was aimed at evaluating the effect of the size of the pedicle screw placed on the fractured vertebra on the long-term radiological and clinical results of short-segment posterior instrumentation applied in the surgical treatment of thoracolumbar vertebral fractures.

METHODS

This retrospective study included 36 patients who underwent short-segment posterior instrumentation surgery for a single-level thoracolumbar (T11-L2) fracture between January 2015 and March 2021. The patients included in the study were divided into 2 groups according to the size of the pedicle screw placed in the fractured vertebra (group A: intermediate screw 4.5 mm, ≤35 mm+less than 50% of the vertebral corpus length, m/f: 13/4, n: 17, age: 36.5; group B: intermediate screw 5.5 mm, ≥40 mm+more than 70% of the vertebral corpus length, m/f: 11/8, n: 19, age: 42.6). All patients were periodically evaluated clinically and radiologically. Vertebral compression angle (VCA), anterior and posterior vertebral body height (ABH-PBH), intraoperative parameters (instrumentation time and intraoperative fluoroscopy number), and complications were compared between the 2 groups.

RESULTS

Both groups were comparable with respect to age, sex, level of injury, AO classification, mechanism of injury, and American Spinal Cord Injury Association impairment scale. Restoration of VCA and vertebral corpus heights was achieved sufficiently in both groups after operation (P < .0001). There was no significant difference between the 2 groups in terms of early postoperative VCA, VCA measured at final follow-up, or loss of correction in VCA. At the last follow-up, PBH was statistically significantly better preserved in group B (P=.0424). There was no difference between the 2 groups in terms of operation time and the number of intraoperative fluoroscopies. Implant failure was observed in 1 patient in group A.

CONCLUSION

This study has revealed that using a long, thick pedicle screw placed in the fractured vertebra can better preserve the PBH at the final follow-up. No correlation was found between the size of the intermediate screw and the preservation of the correction in the postoperative vertebral heights and VCA during the follow-up.

LEVEL OF EVIDENCE

Level III, Therapeutic Study.

Treatment of Thoracic Tuberculosis Through Posterior Costal Transverse Joint Window: A Clinical Study

BACKGROUND

The surgical treatment of thoracic spinal tuberculosis has garnered enormous interest from researchers toward the development of posterior surgical techniques that have contributed to greater use of the 1-stage posterior approach. This study aims to demonstrate the initial clinical experience of a modified total posterior approach, in which the 1-stage posterior approach preserves the posterior spinal column structure by combining with the endoprosthetic implant fusion for thoracic spinal tuberculosis.

METHODS

In this clinical study, we intended to report the initial idea of a modified total posterior approach. In detail, a 1-stage posterior approach was applied to preserve the posterior spinal column structure that could be applied to clinical practice.

RESULTS

The employed practical procedure presented a reduced duration of surgical intervention and intraoperative trauma. Nevertheless, further studies with large samples and multiple centers are required to explore the idea comprehensively.

CONCLUSIONS

This approach offered some advantages in terms of intraoperative exposure, blood loss volume, and length of surgery. Further, multicenter studies with large samples are needed to understand the precise effects and implications of the approach.

Is restoration of vertebral body height after vertebral body fractures and minimally-invasive dorsal stabilization with polyaxial pedicle screws just an illusion?

INTRODUCTION

Thoracolumbar spine fractures often require surgical treatment as they are associated with spinal instability. Optimal operative techniques and treatment are discussed controversially. Aim of our prospective cohort study was to investigate the sagittal alignment after reduction, the secondary loss of reduction and the subjective outcome as well as the causal correlation of these parameters after minimally invasive stabilization of thoracic and lumbar fractures with polyaxial pedicle screws.

MATERIALS AND METHODS

In a single-center study, a total of 78 patients with an average age of 61 ± 17 years who suffered a fracture of the thoracic or lumbar spine were included and subjected to a clinical and radiological follow-up examination after 8.5 ± 8 months. The kyphotic deformity was measured by determining the vertebral body angle, the mono- and bi-segmental wedge angle at three time points. The patients' subjective outcome was evaluated by the VAS spine score.

RESULTS

After surgical therapy, a significant reduction of the traumatic kyphotic deformity was shown with an improvement of all angles (vertebral body angle: 3.2° ± 4.4°, mono- and bi-segmental wedge angle: 3.1° ± 5.6°, 2.0° ± 6.3°). After follow-up, a significant loss of sagittal alignment was observed for all measured parameters with a loss of correction. However, no correlation between the loss of reduction and the subjective outcome regarding the VAS spine scale could be detected.

CONCLUSION

The minimally invasive dorsal stabilization of thoracic and lumbar spine fractures with polyaxial pedicle screws achieved a satisfactory reduction of the fracture-induced kyphotic deformity immediately postoperatively with a floss of reduction in the further course. However, maybe the main goal of this surgical procedure should be the prevention of a complete collapse of the vertebral body instead of a long-lasting restoration of anatomic sagittal alignment.

LEVEL OF EVIDENCE

II.

Case series: O-arm navigation assisted by the Wiltse approach improves the accuracy of pedicle screw placement in ankylosing spondylitis combined with thoracolumbar fractures

Here we assessed the accuracy of O-arm navigation assisted by Wiltse approach to improve based pedicle screw insertion in ankylosing spondylitis combined with thoracolumbar fractures. We then compared it with the freehand pedicle screw insertion technique. The study sample included 32 patients with ankylosing spondylitis combined with thoracolumbar fractures. Pedicle screw reduction and internal fixation was performed under an O-arm navigation system assisted by a Wiltse approach-combined osteotomy ("navigation group," n = 17) and posterior pedicle screw reduction and internal fixation was performed using freehand technique combined osteotomy ("freehand group," n = 15). We then compared the operation time and bleeding volume between the 2 groups. The visual analog scale (VAS) and Oswestry disability index (ODI) were then used to evaluate the clinical efficacy and the kyphosis Cobb angle was used to evaluate the radiological efficacy before operation, 3 days after operation and after the last follow-up. All complications were noted when detected. Finally, classification of screw positions as proposed by Neo et al was used to evaluate the relationship of the position between the screw, the bone cortex, and the incidence of screw penetration. All patients were followed up for 18 to 36 months (i.e., 24.2 ± 3.5 months). The operation time and intraoperative bleeding volume of the navigation group were significantly shorter (lower) than those of the freehand group (P < .05). In addition, Both groups showed significantly decreased VAS, ODI, and Cobb angle 3 days after the operation and at the last follow-up when compared to values recorded pre-operation. However, we found no significant difference in VAS, ODI, and Cobb angle between the 2 groups (P > .05). We identified no complications (e.g., infection, VTE/PE, or nerve injury). Moreover, the pedicle screw placement position of the navigation group was better than that of the freehand group (P < .05), and the screw cortical penetration rate was lower than the freehand group (P < .05). During the process of posterior pedicle screw placement, O-arm navigation assisted by the Wiltse approach can significantly reduce operation time, minimize the amount of bleeding volume, and enhance the accuracy of pedicle screw implantation.

[Effectiveness of one-stage posterior eggshell osteotomy and long-segment pedicle screw fixation for ankylosing spondylitis kyphosis combined with acute thoracolumbar vertebral fracture]

Objective

To explore the safety and effectiveness of one-stage posterior eggshell osteotomy and long-segment pedicle screw fixation in the treatment of ankylosing spondylitis kyphosis combined with acute thoracolumbar vertebral fracture.

Methods

A clinical data of 20 patients with ankylosing spondylitis kyphosis combined with acute thoracolumbar spine fracture, who were treated with one-stage posterior eggshell osteotomy and long-segment pedicle screw fixation between April 2016 and January 2022, was retrospectively analyzed. Among them, 16 cases were male and 4 cases were female; their ages ranged from 32 to 68 years, with an average of 45.9 years. The causes of injury included 10 cases of sprain, 8 cases of fall, and 2 cases of falling from height. The time from injury to operation ranged from 1 to 12 days, with an average of 7.1 days. The injured segment was T 11 in 2 cases, T 12 in 2 cases, L 1 in 6 cases, and L 2 in 10 cases. X-ray film and CT showed that the patients had characteristic imaging manifestations of ankylosing spondylitis, and the fracture lines were involved in the anterior, middle, and posterior columns and accompanied by different degrees of kyphosis and vertebral compression; and MRI showed that 12 patients had different degrees of nerve injuries. The operation time, intraoperative bleeding, intra- and post-operative complications were recorded. The visual analogue scale (VAS) score and Oswestry disability index (ODI) were used to evaluate the low back pain and quality of life, and the American spinal cord injury association (ASIA) classification was used to evaluate the neurological function. X-ray films were taken, and local Cobb angle (LCA) and sagittal vertical axis (SVA) were measured to evaluate the correction of the kyphosis.

Results

All operations were successfully completed and the operation time ranged from 127 to 254 minutes (mean, 176.3 minutes). The amount of intraoperative bleeding ranged from 400 to 950 mL (mean, 722.5 mL). One case of dural sac tear occurred during operation, and no cerebrospinal fluid leakage occurred after repair, and the rest of the patients did not suffer from neurological and vascular injuries, cerebrospinal fluid leakage, and other related complications during operation. All incisions healed by first intention without infection or fat liquefaction. All patients were followed up 8-16 months (mean, 12.5 months). The VAS score, ODI, LCA, and SVA at 3 days after operation and last follow-up significantly improved when compared with those before operation ( P<0.05), and the difference between 3 days after operation and last follow-up was not significant ( P>0.05). The ASIA grading of neurological function at last follow-up also significantly improved when compared with that before operation ( P<0.05), including 17 cases of grade E and 3 cases of grade D. At last follow-up, all bone grafts achieved bone fusion, and no complications such as loosening, breaking of internal fixation, and pseudoarthrosis occurred.

Conclusion

One-stage posterior eggshell osteotomy and long-segment pedicle screw fixation is an effective surgical procedure for ankylosing spondylitis kyphosis combined with acute thoracolumbar vertebral fracture. It can significantly relieve patients' clinical symptoms and to some extent, alleviate the local kyphotic deformity.

Biomechanical Comparison of Different Treatment Strategies for Thoracolumbar Burst Fracture: A Finite Element Study

OBJECTIVE

The aim of this study was to compare the biomechanical performance of 6 pedicle screw internal fixation strategies for the treatment of burst fractures of the thoracolumbar spine using finite element (FE) analysis.

METHODS

A finite element model of the T11-L3 thoracolumbar segment was established to simulate L1 vertebral burst fractures, and 6 models were conducted under multidirectional loading conditions: P2-D2, P1-D1, P2-D1,P1-D, P1-BF-D1, and P1-UF-D1. The range of motion (ROM) in the T12-L2 region and the von Mises stresses of pedicle screws and rods under the 6 internal fixation models were mainly analyzed.

RESULTS

The maximum ROM and von Mises stress were obtained under flexion motion in all models. The P1-BF-D1 model had the least ROM and screw stress. However, when the injured vertebra was not nailed bilaterally, the P1-UF-D1 model had the smallest ROM; the maximum von Mises stress on the screw and rod was remarkably higher than that recorded in the other models. Moreover, the P2-D1 model had a ROM similar to that of the P1-D2 model, but with lower screw stress. The 2 models outperformed the P1-D1 model in all 6 conditions. The P2-D2 model had a similar ROM with the P2-D1 model; nevertheless, the maximum von Mises stress was not substantially reduced.

CONCLUSIONS

The P1-BF-D1 model exhibited better stability and less von Mises stress on the pedicle screws and rods, thereby reducing the risk of screw loosening and fracture. The P2-D1 internal fixation approach is recommended when the fractured vertebrae are not nailed bilaterally.

Minimally Invasive Surgery for Traumatic Thoracolumbar Fractures: A Cross-Sectional Study of Spine Surgeons

OBJECTIVE

To describe the perceived feasibility of minimally invasive surgical treatment of thoracolumbar fractures among spine surgeons in Latin American centers.

METHODS

This is a cross-sectional study on minimally invasive surgical treatment for unstable thoracolumbar fractures. We conducted an online survey of spine surgeons working in Latin American centers, administered between December 16, 2022 and January 15, 2023. A nonprobabilistic sample was selected (snowball sampling). A questionnaire was sent by email and other messaging applications.

RESULTS

Data were extracted from 134 surgeons. The majority of the respondents were from Brazil (n = 30, 22.4%), Mexico (n = 24, 17.9%), Argentina (n = 22, 16.4%), and Chile (n = 15, 11.2%). Their mean age was 46.53 years (standard deviation, 9.7; range 31-67) and almost all were males (n = 128, 95.5%). Most respondents were orthopedists (n = 85, 63.4%) or neurosurgeons (n = 49, 36.9%). Most of the respondents (n = 110, 82.1%) reported at least some difficulty using minimally invasive techniques for thoracolumbar fractures. It should be noted that there were significant regional differences between the surgeons' responses (P = 0.017). Chilean surgeons reported better results than others.

CONCLUSION

Spinal surgeons from Latin American centers have identified challenges and obstacles to performing minimally invasive surgery for thoracolumbar trauma. The survey found that a majority of respondents experienced some level of difficulty, with regional variations. The most frequently reported difficulties were the high cost of the procedure, patient insurance restrictions, and long insurance approval times.

Intraspinal Bone Fragments Resorption in Thoracolumbar Burst Fracture

This case report describes a man in his 30s transported to a surgical ward with a 7-hour history of unintentional fall from over 20 m.

Thoracolumbar fractures after the 2023 Türkiye earthquake and controversial mechanism of occurrence

BACKGROUND

Earthquakes are devastating events that may severely injure the human body. The spine is one of the important parts of the human body that may be affected by earthquake trauma. The aim of this study is to focus on thoracolumbar fractures secondary to the 2023 Turkey Earthquake.

METHODS

The data of 15 patients who were affected by the earthquake, rescued from the rubble, and subsequently treated for spinal fractures in our department were reviewed retrospectively. The clinical, radiological, and surgical features of the patients were recorded, and the outcomes were investigated.

RESULTS

Among the 15 patients, 12 were female, and 3 were male. Their ages ranged from 22 to 79 years. The average duration of being trapped under debris was 4.7 hours. According to the Frankel classification, 12 patients (80%) were categorized as Frankel E, 2 patients (13.3%) as Frankel A, and 1 patient (6.6%) as Frankel C. Of these patients, 6 underwent surgical treatment, while a total of 9 patients received conservative treatment. Multiple vertebral fractures were identified in 4 patients. While 3 patients with multiple fractures were treated conservatively, 1 patient underwent surgery due to an L1 fracture. All surgeries consisted of spinal canal de-compression and spinal instrumentation. Among patients without thoracolumbar junction fractures, 1 had a T8 fracture, 1 had an L4 fracture, and 1 had a sacral fracture along with an accompanying lumbar plexus injury.

CONCLUSION

Thoracolumbar fractures are frequently observed after earthquakes. However, the exact mechanism of these fractures is not well known. Surgical management should be reserved for patients with progressive neurological deficits, while conservative treatment is the option for stable fractures.

[Analysis of the clinical effect of percutaneous pedicle screw fixation combined with transpedicular bone grafting in the treatment of thoracolumbar fracture]

OBJECTIVE

To investigate the clinical efficacy of percutaneous screw fixation combined with minimally invasive transpedicular bone grafting and non-bone grafting in the treatment of thoracolumbar fractures.

METHODS

From Janury 2021 to June 2022, 40 patients with thoracolumbar fracture were divided into the experimental group and the control group. There were 26 patients in the experimental group, including 21 males and 5 females with an aberage age of (47.3±12.3) years old, who underwent percutaneous pedicle screw fixation combined with transpedicular autogenous bone grafting. In the control group, 14 patients received percutaneous pedicle screw fixation only. including 7 makes and 7 females with an average age of (50.2±11.2) years old. The operative time, intraoperative blood loss, anterior height ratio of injured vertebrae, Cobb angle, visual analogue score (VAS), MacNab scores, loosening or broken of the implants. were compared and analyzed.

RESULTS

There was no significant difference in operation time, intraoperative blood loss, VAS and anterior height ratio of injured vertebrae between the two groups. Compared with the preoperative results, VAS and anterior height ratio of injured vertebrae were improved statistically(P<0.05). For Cobb angle of injured vertebra, there was no significant difference between the two groups before surgery (P=0.766). While at 1 week, 3 months and 12 months after surgery, there were statistically differences between the two groups (P values were 0.042, 0.007 and 0.039, respectively). The Cobb angle of injured vertebrae one year after operation was statistically decreased in both groups compared with that before surgery (P<0.001). One year after surgery, the excellent and good rate of Macnab scores was 96.15% in the experimental group and 92.86% in the control group, and there was no statistical differences between the two groups (P=0.648). There was one patient in the control group suffering superficial wound infection on the third day, which was cured by dressing change and anti-infection treatment. There were no postoperative screw loosening and broken in both groups.

CONCLUSION

The two surgical methods have the advantages of less trauma, less pain and quicker recovery, which can restore the height of the injured vertebra, reconstruct the spinal sequence and reduce the fracture of the vertebral body. Transpedicular autogenous bone grafting can increase the stability of the fractured vertebra and maintain the height of the vertebra better after surgery, thus reducing the possibility of complications such as kyphosis, screw loosening and broken.

[Effectiveness of sagittal top compression reduction technique in treatment of thoracolumbar vertebral fractures]

Objective

To investigate the effectiveness of sagittal top compression reduction technique in the treatment of thoracolumbar vertebral fractures.

Methods

A retrospective analysis was conducted on the clinical data of 59 patients with thoracolumbar vertebral fractures who met the selection criteria and were admitted between November 2018 and January 2022. Among them, 34 patients were treated with sagittal top compression reduction technique (top pressure group), and 25 patients were treated with traditional reduction technique (traditional group). There was no significant difference in baseline data between the two groups ( P>0.05), including gender, age, fracture segment, cause of injury, AO classification of thoracolumbar vertebral fractures, thoracolumbar injury classification and severity (TLICS) score, American Spinal Injury Association (ASIA) grading, surgical approach, preoperative vertebral body index, height ratio of the anterior margin of injured vertebra, injured vertebra angle, segmental kyphosis angle, visual analogue scale (VAS) score, and Oswestry disability index (ODI). The operation time, intraoperative blood loss, and incidence of complications between the two groups were recorded and compared. After operation, VAS score and ODI were used to evaluate effectiveness, and X-ray and CT examinations were performed to measure imaging indicators such as vertebral body index, height ratio of the anterior margin of injured vertebra, injured vertebra angle, and segmental kyphosis angle.

Results

There was no significant difference in operation time and intraoperative blood loss between the two groups ( P>0.05). No complication such as dural sac, nerve root, or vascular injury was found during operation, and all incisions healed by first intention. Patients in both groups were followed up 6-48 months, with an average of 20.6 months. No loosening, breakage, or failure of internal fixation occurred during follow-up. The imaging indicators, VAS score, and ODI of the two groups significantly improved at 1 week and last follow-up when compared to preoperative ones ( P<0.05). At last follow-up, the VAS score and ODI further significantly improved when compared to 1 week after operation ( P<0.05). At 1 week after operation and last follow-up, the vertebral body index, segmental kyphosis angle, injured vertebra angle, and ODI in the top pressure group were significantly better than those in the traditional group ( P<0.05). There was no significant difference in VAS score and height ratio of the anterior margin of injured vertebra between the two groups at 1 week after operation ( P>0.05), but the two indicators in the top pressure group were significantly better than those in the traditional group at last follow-up ( P<0.05).

Conclusion

The treatment of thoracolumbar vertebral fractures with sagittal top compression reduction technique can significantly improve the quality of vertebral reduction, and is superior to traditional reduction techniques in relieving pain and improving spinal function.

Cervical, thoracolumbar, and sacral spine trauma classifications: past, present, and future

OBJECTIVE

Traumatic spine injuries are a relatively common occurrence and are associated with functional impairment, loss of neurologic function, and spinal deformity. A number of spinal trauma classification systems have been developed with varying degrees of acceptance. This review provides a chronological overview of spinal trauma classification systems, with special consideration towards the benefits and pitfalls related to each. Cervical, thoracolumbar, and sacral trauma classification systems are discussed.

METHODS

A review of the literature was performed. Published articles that reported on bony spinal trauma classification systems were examined. No year exemptions were identified. The reference lists of all selected articles were screened for additional studies. Article inclusion and exclusion criteria were defined a priori.

RESULTS

A total of 20 classification systems were identified from years 1938-2017. Of these 20 classification systems, 6 were cervical, 11 were thoracolumbar and 3 were sacral. The modernization of bony spinal trauma classification has been characterized by the development of weighted scales that include injury morphology, integrity of associated ligamentous structures and neurologic status.

CONCLUSION

For widespread acceptance and adoption in the clinical setting, future spinal trauma scoring classification will need to remain simple, highly reproducible, and impart information with regard to clinical decision-making and prognosis that may be effectively communicated across each medical specialty involved in the care of these patients.

Delayed presentation of manubriosternal dislocation after thoracolumbar spondylodesis in a polytrauma patient - a case report

BACKGROUND

Manubriosternal dislocations are a rare entity and frequently associated with thoracic spine fractures and, in minority of cases, with cervical or thoracolumbar fractures.

METHODS

Our case represents a 38-year-old male who fell from a height resulting in multiple fractures, amongst others of the first lumbar vertebra. At primary survey and computed tomography scan no manubriosternal injury was apparent. After posterior stabilization of the thoracolumbar vertebrae a manubriosternal dislocation was identified and stabilized using plate-and-screw fixation.

RESULTS

Clinical findings of a manubriosternal dislocation are not always obvious, allowing them to be missed at initial assessment.

CONCLUSIONS

Manubriosternal dislocations can be missed at the initial investigation, even on cross-sectional imaging, and only become visible after spine stabilization because of the tight relationship between sternum and vertebrae in the thoracic cage. There is no unanimity in literature for surgical treatment of manubriosternal dislocations, although plate fixation is generally considered a safe and effective treatment option.

Subacute ascending myelopathy in adolescent athlete after spinal cord injury: a case report on dynamic complication of spine trauma

BACKGROUND

Subacute post-traumatic ascending myelopathy (SPAM) is a rare complication after spinal cord injury (SCI). SPAM onsets within few days or weeks after initial SCI. Here, we present an adolescent male athlete who developed SPAM after SCI and brief review of literature. Previous reports almost all were about adult patients. Here, we present second adolescent case in the literature.

CASE DESCRIPTION

A 15 years old adolescent athlete presented to A&E with a T10-T11 fracture dislocation of the spine and a SCI. He underwent T9-L1 posterior instrumentation and decompression. On the 11th post injury, he complained numbness of the T4 dermatome and by the 14th day, he had become tetraplegia with paralysis of the arms and required ventilation. MRI revealed C3-T10 cord changes on T2 weighed images. He received high dose methylprednisolone for 3 weeks. At one-year follow up he had fully recovered arm motor power and improved light touch and pin prick sensation.

CONCLUSIONS

SPAM may occur in adolescents with a good prognosis. Our case is well example against for proposal of arterial hypothesis.

A Clinical Comparative Study on Percutaneous and Open Approaches for Screw Internal Fixation in Treating Thoracolumbar Fractures

OBJECTIVE

Conventional open internal fixation surgery for thoracolumbar fractures has many complications and long recovery time. There are few clinical studies on the minimally invasive percutaneous injured vertebrae screw internal fixation. The purpose of this paper is to evaluate the application value of minimally invasive percutaneous injured vertebrae screw internal fixation in the treatment of thoracolumbar fractures (TF).

METHODS

A total of 98 patients with TF admitted to our hospital from January 2019 to December 2021 were retrospectively enrolled. According to the surgical method, the patients were divided into the study group (n = 49, treated with minimally invasive percutaneous injured vertebrae screw internal fixation) and the control group (n = 49, treated with traditional open internal fixation surgery). The two groups were compared in the perioperative period, the degree of pain at different periods, the percentage of the height of the anterior edge of the injured vertebra, the Cobb angle of the injured vertebra body and the wedge angle of the injured vertebra body at the first week and the last follow-up, and the postoperative complications and the occurrence of the cone shell after the operation were recorded. Then, statistical analysis such as Student's t test or Chi-Square test was performed.

RESULTS

The operation time (p = 0.002), intraoperative blood loss (p < 0.001), postoperative drainage volume (p = 0.011), and length of hospital stay (p = 0.003) in the study group were significantly lower than that in the control group. The VAS in the study group (3.38 ± 1.02) was significantly lower than that in the control group (4.56 ± 1.04) on the 7th day after the operation, with a significant difference (p < 0.001). The correction values of the percentage of leading edge height (LEH), Cobb angle, wedge angle in the study group were significantly lower than that in the control group at 1 week after surgery (all ps < 0.001). The incidence of postoperative complications in the study group (one case, 2.04%) was significantly lower than that in the control group (seven cases, 14.29%) (p = 0.031). At 1 month, 6 months, 10 months, and the last follow-up, the incidence of "empty shell" on CT scan in the study group were lower than that in the control group with a significant difference (all ps < 0.05).

CONCLUSION

Applying minimally invasive percutaneous injured vertebrae screw internal fixation is more beneficial to shorten the operation time and hospital stay, with fewer postoperative complications.

Analysis of Influencing Factors of Vertebral Height Loss After Pedicle Screw Fixation of Thoracolumbar Fracture

STUDY DESIGN

Retrospective case-control study.

OBJECTIVE

To explore the related factors of vertebral height loss (VHL) after pedicle screw fixation of thoracolumbar fracture and to determine the optimum prediction point.

SUMMARY OF BACKGROUND DATA

With the widespread application of thoracolumbar fracture internal fixation, VHL after the operation is increasingly presented. However, there is no unified conclusion on the specific cause of VHL and how to predict it.

METHODS

A total of 186 patients were selected and divided into the loss group (n = 72) and the not-loss group (n = 114) according to whether the fractured vertebral height was lost after the operation. The two groups were compared concerning sex, age, body mass index, osteoporosis self-assessment tool for Asians (OSTA), fracture types, number of fractured vertebrae, preoperative Cobb angle and compression degree, number of screws, and extent of vertebral restore. Univariate analysis and Multivariate logistic regression analysis were performed to identify the independent factors for the VHL with the receiver operating characteristic curve and the optimal prediction value was calculated according to area under the curve.

RESULTS

Multivariate logistic regression analysis showed that OSTA ( P < 0.05) and preoperative vertebral compression ( P < 0.05) were significantly correlated with postoperative VHL, which were independent risk factors for postoperative VHL. The OSTA of 2.32 and the preoperative vertebral compression degree of 38.5% were the best prediction points for postoperative VHL based on the Youden Index analysis.

CONCLUSIONS

The OSTA and preoperative vertebral compression were independent risk factors for VHL. The risk of postoperative VHL was significantly higher when the OSTA was ≤2.32 or the preoperative vertebral compression was ≥38.5%.

LEVEL OF EVIDENCE

Level III.

Thoraco-lumbar-sacral orthoses in older people - A narrative literature review

Fractures in the thoracolumbar region have a bimodal distribution, with an increasing number of older people presenting with acute vertebral fractures after atraumatic or low energy mechanisms of injury. In the absence of neurological compromise and significant vertebral instability, thoracolumbar fractures are often managed conservatively and bracing is widely recommended. However, in older cohorts, bracing is often ill fitting and poorly tolerated with non-compliance leading to prolonged immobilization. Systematic reviews and meta-analyses have challenged the motive of bracing, but as evidence quality is low, the role of exploratory analysis has been limited. This descriptive review summarises and examines the current evidence that underpins the use of spinal orthoses, specific to older patients, in an effort to streamline its judicious use in clinical practice and identify scope to direct further research.

Iatrogenic Abdominal Aortic Rupture During Transpedicular Bone Grafting for Thoracolumbar Burst Fractures Successfully Treated by Endovascular Stent Implantation

PURPOSE

Vascular injury resulting from transpedicular bone grafting in the treatment of thoracolumbar burst fractures has not been reported but can be lethal. The management of patients with iatrogenic aortic injury remains a difficult clinical problem. This study describes a case of iatrogenic abdominal aortic rupture at the level of L2 during transpedicular bone grafting for the first time.

CASE REPORT

A 55 year-old male patient suffered from a T12 vertebral body mild compression fracture and an L2 vertebral body burst fracture due to falling. This patient was treated with posterior open reduction and pedicle screw fixation combined with transpedicular bone grafting in the L2 vertebrae using a paravertebral approach. Unfortunately, during transpedicular bone grafting, the abdominal aorta was punctured by the tip of the graft funnel. The use of endovascular stent implantation successfully averted a clinical catastrophe. The patient had a good clinical outcome, and no complications associated with vascular trauma were apparent at a 1-year follow-up examination.

CONCLUSION

For the repair of vascular injury caused by transpedicular bone grafting, endovascular techniques can provide a safe, minimally invasive, and effective treatment option.

CLINICAL IMPACT

Surgeons should carefully evaluate the specificity of the patient's anatomical structures preoperatively and be more cautious during transpedicular bone grafting in the treatment of thoracolumbar burst fractures.

[Analysis of life quality on patients with thoracolumbar fractures]

Background

Patients with thoracolumbar fractures with TLICS 4 classification are at the limit of surgical fixation with regards to conservative treatment; however, results in our environment are not known, which is why this study has innovative characteristics.

Objective

To determine the quality of life in patients with TLICS 4 thoracolumbar fractures using traditional fixation with regards to no fixation in a third level hospital.

Material and methods

A cohort prospective study was carried out in patients with TLICS 4 classification thoracolumbar fractures using traditional fixation with regards to no fixation in beneficiaries from the Mexican Institute for Social Security. The SF-12 instrument, which assessed quality of life, was administered; age, sex, days of hospitalization, time of spinal cord injury were searched in the patients' medical history. It was used descriptive and inferential statistics using Student's t or Mann-Whitney U.

Results

20 patients participated and 9 had traditional fixation (45%). All patients had type E spinal cord injuries according to the International Standards for Neurological Classification of Spinal Cord Injury. Mean age of non-fixation was 42.2 ± 12.9 and of fixation 44.9 ± 10.2; in non-fixation 6 (67%) were male. The quality of life score was 29.1 ± 0.9 in the conservative treatment and 28.7 ± 1.3 in the surgical treatment, p < 0.462.

Conclusions

No differences in quality of life were observed in patients with TLICS 4 thoracolumbar fractures using traditional fixation with regards to no fixation.

[Analysis of life quality on patients with thoracolumbar fractures]

Background

Patients with thoracolumbar fractures with TLICS 4 classification are at the limit of surgical fixation with regards to conservative treatment; however, results in our environment are not known, which is why this study has innovative characteristics.

Objective

To determine the quality of life in patients with TLICS 4 thoracolumbar fractures using traditional fixation with regards to no fixation in a third level hospital.

Material and methods

A cohort prospective study was carried out in patients with TLICS 4 classification thoracolumbar fractures using traditional fixation with regards to no fixation in beneficiaries from the Mexican Institute for Social Security. The SF-12 instrument, which assessed quality of life, was administered; age, sex, days of hospitalization, time of spinal cord injury were searched in the patients' medical history. It was used descriptive and inferential statistics using Student's t or Mann-Whitney U.

Results

20 patients participated and 9 had traditional fixation (45%). All patients had type E spinal cord injuries according to the International Standards for Neurological Classification of Spinal Cord Injury. Mean age of non-fixation was 42.2 ± 12.9 and of fixation 44.9 ± 10.2; in non-fixation 6 (67%) were male. The quality of life score was 29.1 ± 0.9 in the conservative treatment and 28.7 ± 1.3 in the surgical treatment, p < 0.462.

Conclusions

No differences in quality of life were observed in patients with TLICS 4 thoracolumbar fractures using traditional fixation with regards to no fixation.

A Comparison of Outcomes between the Wiltse Approach with Pedicle Screw Fixation and the Percutaneous Pedicle Screw Fixation for Multi-Segmental Thoracolumbar Fractures

OBJECTIVE

Multi-segmental thoracolumbar fracture (MSF) generally refers to fractures occurring in two or more segments of the thoracolumbar spine. With the development of minimally invasive concept, there is little research on its application in the field of MSF. The purpose of this study is to compare two minimally invasive surgical techniques and determine which one is more suitable for treating patients with neurologically intact MSF.

METHODS

We retrospectively analyzed the clinical data of 49 MSF patients with intact nerves who were admitted from January 2017 to February 2019. Among them, 25 cases underwent percutaneous pedicle screw fixation (PPSF), and 24 cases underwent Wiltse approach pedicle screw fixation (WAPSF). The operation time, number of fixed segments, blood loss, length of incision, postoperative ambulation time, accuracy of pedicle screw placement, facet joint violation (FJV), number of C-arm exposures, as well as pre- and postoperative visual analogue scale (VAS), Oswestry disability index (ODI), local Cobb's angle (LCA), and percentage of anterior vertebral body height (PAVBH) were recorded for both groups. Paired sample t-test was used for intra-group comparison before and after surgery while independent sample t-test was used for inter-group comparison.

RESULTS

The differences in the number of fixed segments, intraoperative bleeding, postoperative bed time, accuracy rate of pedicle screw placement, VAS, and ODI between the two groups were not statistically significant (p > 0.05). However, the operative time and total surgical incision length were significantly shorter in the WAPSF group than in the PPSF group (p < 0.05), and the FJV was significantly higher in the PPSF group than in the WAPSF group (p < 0.05). Also, the PPSF group received more intraoperative fluoroscopy (p < 0.05). The result of LCA and PAVBH in the WAPSF group were significantly better than in the PPSF group (p < 0.05).

CONCLUSIONS

Both PPSF and WAPSF were found to be safe and effective in the treatment of MSF without neurological deficits through our study. However, considering radiation exposure, FJV, vertebral height restoration, correction of kyphosis, and learning curve, WAPSF may be a better choice for neurologically intact MSF.

Clinic choice of long or short segment pedicle screw-rod fixation in the treatment of thoracolumbar burst fracture: From scan data to numerical study

Based on computerized tomography scanning images of human lumbar vertebrae, finite element (FE) analysis is performed to predict the stress of pedicle screws, rods, and fractured vertebra as well as the displacement of fractured vertebra after internal fixation treatment of thoracolumbar burst fracture. A three-dimensional FE model of L1-L5 lumbar vertebrae with L3 burst fracture has been established and four fixation methods, namely, short segment cross- and trans-injured vertebrae, long segment cross- and trans-injured vertebrae fixations, have been adopted to perform posterior pedicle fixation. The stress distributions of the screws, rods, and fractured vertebra and the total deformation of the fractured vertebra are investigated under six different physiological motions. From the view of the stress on the screw-rod system and the deformation of the fractured vertebral body, the long segment cross-injured vertebra fixation has the best mechanical performance, followed by the long segment trans-injured vertebra fixation, and then the short segment fixation trans-injured vertebra. The short segment fixation cross-injured vertebra performs the worst. Among the six motions, the forward flexion movement has the greatest impact on the screw-rod system and the fractured vertebra. However, the rotation motion greatly affects the stress of the screw in the long segment fixation. This indicates that the longer the fixed segment is, the more susceptible it is to human rotation. Thus, for patients with severe fracture, the long segment cross-injured vertebra is preferred. On the contrary, the short segment trans-injured vertebra fixation is optimal.

Long Versus Short-segment Stabilization in Patients with Traumatic Thoracolumbar Fractures

BACKGROUND

Posterior stabilization surgery is considered the gold standard for restoring spine stability in patients with traumatic thoracolumbar fractures. However, whether long-segment (LS) stabilization or short-segment (SS) stabilization is an optimal approach for achieving more effective restoration of spinal stability remains unclear.

MATERIAL AND METHODS

Patients who underwent posterior stabilization surgery for traumatic thoracolumbar fractures were included in the study. Radiological parameters were measured using pre- and post-surgical thoracolumbar computed tomography (CT) scans and compared between patients who received LS and SS stabilization.

RESULTS

Ninety-eight consecutive patients (mean age 4414, 50% male) who underwent posterior stabilization surgery for traumatic thoracolumbar fractures were included. LS stabilization was performed in 52 patients, while SS stabilization was performed in 46 patients. Among spinal stability parameters measured on pre-surgical thoracolumbar CT scans, the anterior vertebral height (AVH) was significantly lower in the LS stabilization group compared to the SS stabilization group (14.44.0 mm vs. 16.44.0 mm, p=0.017), indicating a more severe compression fracture in the LS stabilization group. However, all parameters improved on post-surgical thoracolumbar CT scans, and there were no significant differences between LS stabilization and SS stabilization groups in terms of the restoration of spinal stability parameters. The type of stabilization (LS vs. SS stabilization) did not show an association with post-surgical measurements of spinal stability parameters (B=0.27, 95% CI -1.87 to 2.42, p=0.800 for superior inferior end plate angle (SIEA), B=0.20, 95% CI -1.33 to 1.74, p=0.796 for AVH, and B=0.39, 95% CI -1.72 to 2.50, p=0.714 for Cobb angle).

CONCLUSIONS

Both LS and SS stabilization approaches yield similar results in terms of restoring spine stability parameters in patients with traumatic thoracolumbar fractures. The choice of surgical approach should be individualized based on the patient's overall status and the surgeon's experience.

Unilateral biportal endoscopic technique combined with percutaneous transpedicular screw fixation for thoracolumbar burst fractures with neurological symptoms: technical note and preliminary report

BACKGROUND

Previous studies on thoracolumbar fractures with neurological symptoms have focused on how to achieve satisfactory fracture reduction, adequate nerve decompression, and stable spinal alignment. With the development of the minimally invasive spine surgery technique, achieving satisfactory treatment results and reducing iatrogenic trauma at the same time has become a new goal of spinal surgery. This research used percutaneous transpedicular screw distraction to partially reduce the fractured vertebrae, followed by completing nerve decompression and reducing residual displacement bone fragments with the assistance of the unilateral biportal endoscopic (UBE) technique to achieve full protection of bone-ligament tissue and obtain good clinical efficacy.

METHODS

Guide wires were safely inserted into the fractured vertebra and adjacent upper and lower vertebra under the surveillance of anteroposterior and lateral X-ray fluoroscopy. Transpedicular screws were implanted via guide wires on the side with mild neurological deficits or bone fragment compression (the opposite side of the endoscopic operation). A titanium rod was installed and moderately distracted to reduce the fractured vertebra. Then, under the guidance of the endoscopic view, the laminectomy and ligamentum flavum resection were completed according to the position of the protruding bone fragment into the spinal canal, and the compressed dural sac or nerve root was fully exposed and decompressed. An L-shaped replacer was used to reduce residual bone fragments. The ipsilateral transpedicular screws and rod were installed and adjusted to match the contralateral side. The drainage tube was indwelled, and the incision was closed. The preoperative and postoperative images of the patients were evaluated, and the recovery of neurological symptoms was observed.

RESULTS

Surgery was successfully completed on all six patients, and no intraoperative conversion to open surgery was performed. Postoperative images showed good reduction of the protruding bone fragment and good placement of all screws. At the last follow-up, the neurological symptoms of all patients returned to normal.

CONCLUSION

The UBE technique combined with percutaneous transpedicular screw fixation in the treatment of thoracolumbar fractures with neurological symptoms can effectively achieve the reduction of displaced bone fragments, improve damaged nerve function, stabilize spinal alignment, and protect the integrity of bone-ligament tissue.

Surgical Management Thoracolumbar Fractures in Patients with Ankylosing Spondylitis: Technical Note with Case Series

OBJECTIVE

Ankylosing spondylitis (AS) is a chronic inflammatory joint disease. Complications such as traumatic spinal fractures are mostly caused by hyperextension and are unstable. We report the cases of 5 patients with AS surgically treated for thoracolumbar fractures.

METHODS AND RESULTS

We shared our experience of posterior stabilization surgery performed for the treatment of thoracolumbar fractures after traumas such as fall-accident in patients with AS. Patients were all men, and their ages were between 52 and 77 years. The first 3 patients woke up with neurologic deficits and were managed surgically under general anesthesia. We managed the last 2 patients with unilateral short-level stabilization under local anesthesia followed by bilateral long-level stabilization under general anesthesia. No neurologic deterioration was found in the postoperative examination of these 2 patients. We assume that the reason for neurologic deterioration after general anesthesia is the relaxation of muscles. All 3 columns of the spine are affected in patients with AS and the stability is provided by the tone of the muscles around the spine.

CONCLUSIONS

To prevent postoperative neurologic complications after the surgical treatment of traumatic hyperextension thoracic and lumbar fractures in patients with AS, we recommend securing the fracture level with unilateral short-level stabilization under local anesthesia and then completing the operation with general anesthesia.

Adult Trauma Patients With Thoracolumbar Injury Classification and Severity Score of 4: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

Evaluate characteristics of patients with thoracolumbar injury classification and severity (TLICS) score of 4 (To4) severity traumatic thoracolumbar injury.

SUMMARY OF BACKGROUND DATA

The TLICS score is used to predict the need for operative versus nonoperative management in adult patients with traumatic thoracolumbar injury. Ambiguity exists in its application and score categorization.

METHODS

A systematic review of the literature was performed. The databases of MEDLINE, Embase, Web of Science, and Cochrane Review were queried. Studies included adults with traumatic thoracolumbar injury with assigned TLICS score and description of management strategy.

RESULTS

A total of 16 studies met inclusion criteria representing 1911 adult patients with traumatic thoracolumbar injury. There were 503 (26.32%) patients with To4, of which 298 (59.24%) were operative. Studies focusing on the thoracolumbar junction and AO Type A fracture morphology had To4 patient incidences of 11.15% and 52.94%, respectively. Multiple studies describe better quality of life, pain scores, and radiographic outcomes in To4 who underwent operative treatment patients.

CONCLUSION

To4 injuries are more commonly AO Type A and located in the thoracolumbar junction in adult patients with traumatic thoracolumbar injury. Despite ambiguous recommendations regarding treatment provided by TLICS, outcomes favor operative intervention in this subset of traumatic thoracolumbar injury patients.

Occupancy Rate of Pedicle Screw Below 80% is a Risk Factor for Upper Instrumented Vertebral Fracture After Adult Spinal Deformity Surgery

STUDY DESIGN

Retrospective study.

OBJECTIVE

To determine whether an occupancy rate of a pedicle screw (ORPS) <80% in an upper instrumented vertebra (UIV) is a risk factor for UIV fracture (UIVF).

SUMMARY OF BACKGROUND DATA

The ratio of the length of the pedicle screw to the anteroposterior diameter of the vertebral body at the UIV is defined as ORPS. Previous studies showed that the stress on the UIV is reduced to the greatest degree when ORPS is >80%. However, it remains unclear whether these results are clinically valid.

PATIENTS AND METHODS

A total of 297 patients who had undergone adult spinal deformity surgery were included in the study. The group with an ORPS ≥80% and <80% was defined as the H (n = 198) and L (n = 99) group, respectively. Propensity score matching and logistic regression analysis were used to evaluate the association between ORPS and the development of UIVF adjusting for confounders.

RESULTS

The mean age of both groups was 69 years. The average ORPS in the L and H groups was 70% and 85%, respectively. The incidence of UIVF was 30% in group L and 15% in group H ( P < 0.01). In addition, the 99 patients in group H were subdivided into 2 groups according to whether the screws penetrated the anterior wall of the vertebral body: 68 patients had no penetration (group U ), whereas 31 patients showed evidence of penetration (group B ). A total of 10% and 26% of the patients in the U and B groups, respectively, experienced UIVF ( P < 0.05). Logistic regression analysis indicated that ORPS <80% was significantly associated with UIVF ( P = 0.007, odds ratio: 3.9, 95% CI 1.4-10.5).

CONCLUSION

To reduce UIVF, screw length should be set with a target ORPS of 80% or higher. If the screw penetrates the anterior wall of the vertebral body, the risk of UIVF is greater.