Short segment posterior fixation of unstable thoracolumbar vertebral fractures with fractured vertebra augmentation with intermediate pedicle screw - a clinicoradiological analysis

INTRODUCTION

Unstable thoracolumbar burst fractures are routinely encountered in orthopedic practice. Recently, short-segment fixation with pedicle screw augmentation of the fractured vertebra for unstable thoracolumbar burst fractures has gained popularity. Nonetheless, the maintenance of the kyphotic correction during the follow-up period remains controversial. This study aimed to examine the clinical-radiological outcomes, complications, and functional outcomes of fractured vertebrae augmentation with intermediate pedicle screws in short-segment instrumentation in acute thoracolumbar spine fractures.

METHODS

This retrospective study was conducted in the Department of Orthopedics, All India Institute of Medical Sciences, Jodhpur, using medical records from January 2021 to October 2022. Parameters such as local kyphosis correction, loss of kyphotic correction at final follow-up, anterior body height correction (%), and loss of correction (%) at final follow-up were measured as primary outcomes. Various other parameters such as operative time, blood loss, length of hospital stay, and visual analog scale were measured as secondary outcomes.

RESULTS

The mean correction obtained via surgery in the immediate postoperative period was 13.7±2.3 degrees. The mean loss of correction at the final follow-up was 4.1±2.0 degrees, and the mean final local kyphotic angle was 7.2±2.4 degrees (P<0.05). The mean correction obtained via surgery in the immediate postoperative period was 37.2%±9.0%. The mean loss of correction at the final follow-up was 10.5%±5.3%, and the mean final anterior vertebral body height maintained was 72%±11.0% (P<0.05).

CONCLUSION

Short-segment posterior fixation with pedicle screw augmentation achieves good correction of local kyphotic angle and anterior vertebral height in the immediate postoperative period, but some loss of correction at final follow-up is common. In our study, the loss of correction corresponded directly to the load-sharing score.

Posterior Decompression and Fixation for Thoracic Spine Ossification: A 10-Year Follow-Up Study

Ossification of the posterior longitudinal ligament of the thoracic spine (T-OPLL) causes symptoms including leg and back pain, and motor and sensory deficits. This study retrospectively reviewed 32 patients who initially underwent posterior decompression with instrumented fusion (PDF) for T-OPLL between 2001 and 2012, with 20 qualifying for the final analysis after applying exclusion criteria. Exclusions included unknown preoperative neurological findings, follow-up less than 10 years, or prior spinal surgeries at other levels. Outcomes were assessed using the Japanese Orthopedic Association (JOA) score, recovery rate, and kyphotic angle. The average preoperative JOA score of 3.6 improved to 7.4 at 1 year post-surgery and remained at 7.4 at 10 years, with a recovery rate of 52%. The kyphotic angle at T4-12 increased from 26 degrees preoperatively to 29 degrees postoperatively and to 37 degrees at 10 years. At the fused levels, the angle remained at 26 degrees immediately post-operation and increased to 32 degrees at 10 years. Forty percent of patients required additional surgery, primarily for conditions related to cervical OPLL, such as myelopathy, or lumbar OPLL, such as radiculopathy, or cauda equina syndrome. In conclusion, PDF effectively reduces T-OPLL symptoms over the long term, but the high rate of additional surgeries calls for careful patient follow-up.

Effect of pedicle screw placement into the fractured vertebra in management of unstable thoracolumbar and lumbar fractures

BACKGROUND

Pedicle screw insertion at the level of the fractured vertebra has been shown to improve clinical and radiological outcomes in unstable thoracolumbar and lumbar fractures, albeit this requires further evidence. The study aims to evaluate the effect of pedicle screw placement on the fractured vertebra in such cases.

METHODS

A prospective study included adult patients with thoracolumbar and lumbar fractures treated with short-segment posterior instrumentation with a pedicle screw into the fractured vertebra. Anterior vertebral body height loss, kyphotic angle and degree of spinal canal compromise were measured preoperatively and postoperatively in radiographs and CT scans. The neurological status was followed up for one year of the postoperative period.

RESULTS

The study included a total of 30 patients. Five patients (16.7%) had grade C, three patients (10%) had grade D, and 22 patients (73.3%) had grade E neurological status. The mean (SD) preoperative kyphotic angle, vertebral body height and canal compromise were 5.54 (5.35), 39.67% (8.04), and 31.59% (10.62), respectively. Postoperatively there was a significant canal decompression, with a mean postoperative spinal canal compromise of 5.53% (SD=7.70; p-value <0.001). At the end of one year of follow-up, the radiological evaluation showed a correction of the kyphotic angle to 6.62 (SD=2.57; p-value <0.001), and the mean anterior vertebral body height was 70.38% (SD=11.25; p-value <0.001). At the end of one year, there was a significant overall neurological recovery with a final neurological status of grade D in 5 (16.7%) and grade E in 25 patients (83.3%). There was no significant association between canal decompression and neurology at the end of the one-year follow-up.

CONCLUSION

Unstable thoracolumbar and lumbar fractures surgically treated with short-segment fixation with an additional intermediate screw can achieve significant restoration of vertebral body height and correction of kyphotic angle without any added complications.

The Role of Classifications and Measurements of Kyphotic Angle in the Treatment Methods of Upper and Middle Thoracic Vertebral Fractures after Trauma

BACKGROUND AND AIM

Thoracic fractures can lead to death and disability. This retrospective study aimed to evaluate cases of upper and middle thoracic vertebral fractures due to trauma that had been treated, to determine the fracture type and treatment method according to age, sex, cause of injury, neurological status, fracture level, kyphotic angles, and classification methods and to discuss the results regarding that reported in the literature.

PATIENTS AND METHODS

This study included 238 patients who were evaluated for post-traumatic upper and middle thoracic vertebral fractures between January 2012 and December 2020. We classified each patient according to the Dennis, TLICS, ATLICS, and ASIA classifications using neurological examination, radiography, computed tomography, and magnetic resonance imaging. We statistically evaluated the data obtained.

RESULTS

Fifty-five percent of total patients were male. The average age was 51.11. Traffic accidents were the most common causes of trauma, with 67.2%. T8 was most affected. The ASIA classification, the Dennis, TLICS, and ATLICS classifications showed a significant increase in the severity of neurological deficits as the fracture scores increased (p < 0.001). We observed that the increase in the preoperative kyphotic angle caused an increase in the number of deficits according to the classifications (p < 0.001).

CONCLUSION

The ATLICS classification yielded more accurate results than that of the other classifications. In addition, the kyphotic angle was evaluated for upper and middle thoracic fractures, and we concluded it is important in surgical decision making.

Non-uniform Segmental Range of Motion of the Thoracic Spine During Maximal Inspiration and Exhalation in Healthy Subjects

Background and Objective: To analyse the range of motion of the thoracic spine by radiographically measuring changes in the sagittal profile of different thoracic segments during maximal inspiration and exhalation. The starting hypothesis was that forced deep breathing requires an active, but non-uniform widening of the lordotic–kyphotic range of motion of the different thoracic segments.

Methods: Cross-sectional study. Participants were 40 healthy volunteers aged 21–60. Conventional anteroposterior and functional sagittal chest radiographs were performed during maximal inspiration and exhalation. The range of motion of each spinal thoracic functional segment, global T1–T12 motion, and the sagittal displacement of the thoracic column during breathing were measured. Considering the different type of ribs and their attachment the spine and sternum, thoracic segments were grouped in T1–T7, T7–T10, and T10–T12. The displacement of the thoracic spine with respect to the sternum and manubrium was also recorded.

Results: The mean difference from inspiration to exhalation in the T1–T12 physiologic kyphosis was 15.9° ± 4.6°, reflecting the flexibility of the thoracic spine during deep breathing (30.2%). The range of motion was wider in the caudal hemicurve than in the cranial hemicurve, indicating more flexibility of the caudal component of the thoracic kyphosis. A wide range of motion from inspiration to exhalation was found at T7–T10, responsible for 73% of T1–T12 sagittal movement. When the sample was stratified according to age ranges (20–30, 30–45, and 45–60 yr.), none of the measurements for inspiration or exhalation showed statistically significant differences.

Only changes at this level showed a positive correlation with changes in the global thoracic kyphosis (r = 0.794, p <0.001).

Conclusion: The range of motion of the thoracic spine plays a relevant role in respiration dynamics. Maximal inspiration appears to be highly dependent on the angular movements of the T7–T10 segment.

Treatment of thoracolumbar fractures by temporary posterior instrumentation with selective fusion schemes

OBJECTIVE

This retrospective study investigated the clinical and radiographic outcomes following temporary transpedicular posterior instrumentation between two cohorts of patients with thoracolumbar fractures (TLF) who underwent selective or bi-segments intervertebral articular process fusion.

METHODS

Patients with TLF who underwent the temporary posterior fixation with selective fusion (Group SF), or bi-segments fusion (Group BF) were studied. Superior intervertebral articular process and interlaminar fusion were performed in Group SF, whereas in Group BF, the patients underwent bi-segments fusion in both superior and inferior articular processes, as well as interlaminar fusion. We measured the distal and proximal intervertebral mobility, regional kyphotic angle, and vertebral height before and after surgery in both groups. Greenough Low-Back Outcome Score was used to assess the clinical outcomes.

RESULTS

Sixty-five patients with TLF from T12 to L2 fractures were enrolled in the study period: 33 patients in the Group SF and 32 patients in the Group BF. All the patients experienced fracture healing (mean follow-up time: 19.7 months). The mean postoperative functional outcomes were 65.0 ± 2.0 points for the Low-Back Outcome Score in the Group SF and 65.2 ± 1.8 for the Group BF. A progressive regional kyphotic angle was observed with time regardless of fusion but was not significantly different between the two groups. There was a statistical difference between unfused inferior proximal adjacent and inferior distal adjacent segment regardless of fracture segments.

CONCLUSIONS

The strategy of selective fusion is reported to be useful for the treatment of patients with TLF. The motion in the un-fused and adjacent segment could be better regained after instrumentation removal in the selective fusion group.

LEVEL OF EVIDENCE

Level 3.

Immediate Effects of Myofascial Release on the Thoracolumbar Fascia and Osteopathic Treatment for Acute Low Back Pain on Spine Shape Parameters: A Randomized, Placebo-Controlled Trial

BACKGROUND

Spine shape parameters, such as leg length and kyphotic or lordotic angle, are influenced by low back pain. There is also evidence that the thoracolumbar fascia plays a role in such pathologies. This study examined the immediate effects of a myofascial release (MFR) technique on the thoracolumbar fascia and of an osteopathic treatment (OMT) on postural parameters in patients with acute low back pain (aLBP).

METHODS

This study was a single-blind randomized placebo-controlled trial. Seventy-one subjects (43.8 ± 10.5 years) suffering from aLBP were randomly and blindedly assigned to three groups to be treated with MFR, OMT, or a placebo intervention. Spinal shape parameters (functional leg length discrepancy (fLLD), kyphotic angle, and lordotic angle) were measured before and after the intervention using video raster stereography.

RESULTS

Within the MFR group, fLLD reduced by 5.2 mm, p < 0.001 and kyphotic angle by 8.2 degrees, p < 0.001. Within the OMT group, fLLD reduced by 4.5 mm, p < 0.001, and kyphotic angle by 8.4°, p = 0.007.

CONCLUSION

MFR and OMT have an influence on fLLD and the kyphotic angle in aLBP patients. The interventions could have a regulating effect on the impaired neuromotor control of the lumbar muscles.

Comparison of efficacies of unipedicular kyphoplasty and bipedicular kyphoplasty for treatment of single-level osteoporotic vertebral compression fractures: A STROBE-compliant retrospective study

Kyphoplasty (KP) is an effective method for treating osteoporotic vertebral compression fractures (OVCFs). Although the bipedicular approach is considered the main treatment approach, the unipedicular approach has also been shown to be effective. This study aimed to retrospectively compare the radiological and clinical outcomes of unipedicular and bipedicular KP in the treatment of single-level OVCFs.In total, 96 patients with single-level OVCF who received KP were divided into 2 groups: the unipedicular group, in which 28 patients underwent KP via the unipedicular approach, and the bipedicular group, in which 68 patients underwent KP via the bipedicular approach. Clinical results, radiological findings, and complications were compared between the groups. The clinical results were evaluated for up to 1 year after surgery using a numerical rating scale score. The radiological findings were compared in terms of recovery of the lowest vertebral body height at the same location on radiographs taken both 1 day and 1 year after surgery. The degrees of recovery of the kyphotic angle (KA) were simultaneously compared. The surgical time, amount of cement used, and any postoperative complications were also compared.Both groups showed significant improvements in all clinical and radiological parameters until 1 year after surgery. The unipedicular group required significantly lower amounts of cement than the bipedicular group (unipedicular: 4.4 ± 0.8 mL, bipedicular: 5.6 ± 1.0 mL, P = .00), but there were no significant differences in the clinical and radiological results for up to 1 year after surgery. There were no significant differences in leakage of intradiscal cement, appearance of adjacent vertebral compression fractures within 1 year of surgery, and surgical time.Unipedicular and bipedicular KP significantly reduced the pain experienced by patients with single-level OVCF, restored vertebral height, and corrected the KA, which remained stable for at least 1 year after treatment. Unipedicular KP required lower amounts of cement than bipedicular KP and was as effective as bipedicular KP in terms of radiological and clinical outcomes. The results of this study have level three evidence and grade B recommendation.

Percutaneous balloon kyphoplasty in the treatment of vertebral compression fractures: a single-center analysis of pain and quality of life outcomes

BACKGROUND

Vertebral body compression fractures are one of the most common causes of disability and morbidity, especially among the elderly population. The present study was performed in order to evaluate the effect of percutaneous balloon kyphoplasty (BKP) on patients' pain and quality of life (QOL) in Iran.

METHODS

The study was conducted on a consecutive series of 54 patients with symptomatic vertebral compression fractures who failed conservative management between 2014 and 2017. A quasi-experimental design was employed in which the pain severity, quality of life, and kyphotic angle were measured before and 3 and 12 months after the PBK procedure. Pain and quality of life outcomes were determined using a Visual Analogue Scale (VAS) for Pain and the 12-Item Short Form Health Survey (SF-12) for QOL.

RESULTS

Excellent improvement in VAS was documented at 3 and 12 months after the BKP procedure (p = 0.001). Improvement at 3 months was maintained through the 12 months follow-up period. A statistically significant improvement in QOL was documented at 3 months after BKP that continued to improve through 12 months follow-up. The mean kyphotic angle before PBK was 19.4 ± 5.3 degrees which after 3 months improved to 12.8 ± 3.1 degrees; this reduction was significant (p < 0.001). No new fractures occurred during the follow-up period.

CONCLUSION

Balloon kyphoplasty was determined to be a safe and successful method for treating symptomatic vertebral compression fractures. It leads to significant pain relief, an improvement in self-reported QOL measures, and correction in kyphotic deformity.

Posterior paraspinal muscle versus post-middle approach for the treatment of thoracolumbar burst fractures: A randomized controlled trial

BACKGROUND

This randomized controlled trial (RCT) aimed to compare the clinical outcomes of thoracolumbar burst fractures (TLBFs) treated with open reduction and internal fixation via the posterior paraspinal muscle approach (PPMA) and the post-middle approach (PA).

METHODS

Patients with a traumatic single-level TLBFs (T10-L2), treated at our hospital between December 2009 and December 2014, were randomly allocated to Group A (PPMA) and Group B (PA). Sex, age, time from injury to surgery, the American Spinal Injury Association Impairment Scale score (ASIAIS), comorbidities, vertebral level, pre- and postoperative kyphotic angle (KA), visual analog scale (VAS) pain score, and the Oswestry Disability Index (ODI) scores were included in the analysis. Operative time, intraoperative blood loss, x-ray exposure time, postoperative drainage volume, superficial infection, and occurrence of deep infection were documented. The patients were followed up at 2 weeks; 1, 3, and 6 months; 1 and 2 years; and every 6 months thereafter. Radiological assessments were performed to assess fracture union and detect potential loosening and breakage of the pedicle screws and rods at each follow-up. Postoperative VAS and ODI scores were used to evaluate the clinical outcomes.

RESULTS

A total of 62 patients were enrolled (30 in Group A and 32 in Group B, respectively). The operative time (P < .001) and x-ray exposure time (P < .001) in Group A were significantly longer than those in Group B. However, compared to Group B, there were less intraoperative blood loss (P < .001), lower postoperative drainage volume (P < .001), lower VAS scores (2-week (P = .029), 1-month (P = .023), 3-month (P = .047), and 6-month follow-up (P = .010)), and lower ODI scores (2-week, P = .010; 1-month, P < .001; 3-month, P = .028; and 6-month follow-up, P = .033) in Group A.

CONCLUSIONS

Although PPMA required a longer operative time and x-ray exposure time, PPMA provided several advantages over PA, including less intra-operative blood loss and lower postoperative drainage volume, and greater satisfaction with postoperative pain relief and functional improvement, than PA, especially at the 6-month follow-up after surgery. Further high-quality multicenter studies are warranted to validate our findings.