Near-anatomical reduction and stabilization of burst fractures of the lower thoracic or lumbar spine

Timing of thoracolomber spine stabilization in trauma patients; impact on neurological outcome and clinical course. A real prospective (rct) randomized controlled study

OBJECTIVE

Optimal timing of stabilization for spinal injuries is discussed controversially. The goal of this study is to investigate the neurological recovery and its influencing factors in thoracolumbar spine fractures after surgical decompression and stabilization within 8 h of spinal cord injury versus surgery which is performed between 3 and 15 days.

METHODS

Twenty-seven patients undergoing thoracolumbar stabilization with neurological deficit for an acute thoracolumbar spinal injury at the level of Th8-L2 vertebra at Selcuk University between March 2004 and December 2006 were recorded. Patients with neurological deficit and medically stable for surgery underwent immediate stabilization within 8 h defined as group I (n = 12) and patients underwent operation in 3-15 days after thoracolumbar injury were defined as group II (n = 15). Patients were assessed for neurologic deficit and improvement as defined by the scoring system of American spinal injury association (ASIA).

RESULTS

In spite of comparable demographic data, patients in group I had a significantly shorter overall hospital and intensive care unit stay and had lesser systemic complications such as pneumonia and also exhibited better neurological improvement than group II (p < 0.05).

CONCLUSION

Early surgery may improve neurological recovery and decrease hospitalization time and also additional systemic complications in patients with thoracolumbar spinal cord injuries. Thus early stabilization of thoracolumbar spine fractures within 8 h after trauma appears to be favorable.

Anterior stabilization of three-column thoracolumbar spinal trauma

Object

The purpose of this study was to evaluate the results obtained in patients who underwent anterior stabilization for three-column thoracolumbar fractures.

Methods

The authors retrospectively reviewed available clinical and radiographic data (1997–2006) to classify three-column thoracolumbar fractures according to the Association for the Study of Internal Fixation (AO) system, neurological status, spinal canal compromise, pre- and postoperative segmental angulation, and arthrodesis rate.

The mean computed tomography–measured preoperative spinal canal compromise was 48.3% (range 8–92%), and the mean vertebral body height loss was 39.4%. The mean preoperative kyphotic deformity of 14.9° improved to 4.6° at the final follow-up examination. Although this angulation had increased a mean of 1.8° during the follow-up period, the extent of correction was still significant compared with the preoperative angulation (p < 0.01). There were no cases of vascular complication or neurological deterioration.

Conclusions

Contemporary anterior spinal reconstruction techniques can allow certain types of unstable three-column thoracolumbar fractures to be treated via an anterior approach alone. Compared with traditional posterior approaches, the anterior route spares lumbar motion segments and obviates the need for harvesting of the iliac crest.

Neurological recovery and its influencing factors in thoracic and lumbar spine fractures after surgical decompression and stabilization

Surgical decompression and internal fixation of the injured spine have become standard procedures in the management of thoracic and lumbar spine fractures, but their effectiveness on neurological recovery remains controversial. We report on 169 consecutive patients with thoracic and lumbar spine fractures who were treated by reduction, fusion, and internal fixation using transpedicular screw-rod systems. Open decompression was carried out in 67 (39.6%) of them, including all 42 patients (25%) who presented with initial neurological deficits. At least 8 months following surgery, 30 (71%) had neurologically improved by one to three grades on the Frankel scale. Thirteen (59%) out of 22 patients whose initial deficits had been classified as "motor useless" (Frankel grades A to C) could walk, at least with support. Thirteen out of 20 patients with posttraumatic deficit Frankel D ("motor useful") improved to full recovery (Frankel E). In six (3.6%) patients (all from the group of the 127 patients without initial neurological deficits), permanent slight postoperative neurological impairment of one Frankel grade (E to D) was seen, among them two (1.2%) with new minor motor deficit. Neurological outcome was significantly better (p<0.01) in patients operated upon within the first 24 h after injury than in those who underwent surgery later. Severity of injury also had a negative influence (p<0.001) on neurological recovery. Analysis suggests that there may be significant neurological improvement in patients treated surgically very early.

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

STUDY DESIGN

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

OBJECTIVES

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

SUMMARY OF BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Treatment of L5-S1 Spondyloptosis With Single-Stage Surgery Through the Posterior Approach-Case Report-

A 21-year-old male patient with L5-S1 spondyloptosis was treated by total L-5 laminectomy with foraminotomy and posterior fusion through the posterior approach. His complaints of severe low back pain and limited spine mobility were resolved. No new deficits occurred. The surgical management of spondyloptosis includes one-, two-, or three-stage operations with posterior, anterior, or combined approaches. Careful posterior decompression and posterior fusion without reduction may be adequate for the treatment of L5-S1 spondyloptosis.

Acute thoracolumbar burst fractures: a new view of loading mechanisms

STUDY DESIGN

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

OBJECTIVES

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

SUMMARY OF BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Adjacent fracture-dislocations of the lumbosacral spine: case report

OBJECTIVE AND IMPORTANCE

Traumatic fracture-dislocations of the lumbosacral junction are rare, with all previously reported cases involving fracture-dislocations at a single level. No cases of multiple fracture-dislocations of contiguous spinal segments in the lumbosacral spine have been reported. A case of traumatic adjacent fracture-dislocations of the fifth lumbar segment is presented.

CLINICAL PRESENTATION

An 18-year-old male patient sustained open lumbar spinal trauma after a motor vehicle accident. A neurological examination revealed an L4 level. Radiographic evaluation of the spine revealed a three-column injury at L5 with spondyloptosis of the L5 vertebral body. Aorto-ilio-femoral angiography revealed no evidence of vascular injury.

INTERVENTION

The patient was treated with a combined anterior and posterior approach in a two-stage operation. Six months postoperatively, he was neurologically unchanged; however, he was able to walk with the aid of a cane. Plain films revealed normal alignment of the lumbosacral spine.

CONCLUSION

The management of traumatic lumbosacral fracture-dislocations requires careful consideration of retroperitoneal structures and possible exploration of the iliac vessels in addition to spinal reconstruction.

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

STUDY DESIGN

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

OBJECTIVES

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

SUMMARY OF BACKGROUND DATA

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

METHOD

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

RESULTS

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

CONCLUSION

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

Posterior approach with Louis plates for fractures of the thoracolumbar and lumbar spine with and without neurologic deficits

STUDY DESIGN

This is a retrospective revue of the long-term outcome of posterior Louis plate fixation for the treatment of irreducible or ligamentously unstable fractures of the thoracolumbar and lumbar spine with or without neurologic deficit.

OBJECTIVES

To determine the clinical, radiologic, and functional status of patients who underwent posterior fracture fixation with Louis plates and to evaluate the effect of instrumentation length on the construct's ability to maintain reduction of the fracture.

SUMMARY OF BACKGROUND DATA

Since the development of pedicle screw fixation described by Roy-Camille, there has been a rapid evolution in the number and complexity of systems available for posterior spinal stabilization. Along with this escalation in implant and instrument sophistication, there has been a corresponding increase in implant cost. To date, no series has been reported of the clinical, radiologic, and functional results of posterior instrumentation with semirigid Louis plates for spinal fractures.

METHODS

A retrospective review of spinal fractures from T11 to L5 treated since 1985 by posterior plate fixation showed that 56 patients (37 men and 19 women) with an average age of 34 years and a minimum follow-up of 2 years (average, 41 months) were available for review. There were 36 burst fractures, 4 Chance fractures and 16 fracture-dislocations treated. Forty-three patients had neurologic injury.

RESULTS

Before surgery, vertebral kyphosis averaged 15 degrees, improved to 5 degrees with reduction, and reached a steady 10 degrees at final follow-up. Similarly, corrected kyphosis initially averaged 12 degrees but improved to 0.5 degree with reduction, and was 10 degrees at final follow-up. Vertebral canal compromise initially averaged 50% but was reduced to 13% with surgery and 6% at 1 year. There was no significant difference between the ability of short and long constructs to maintain reduction. Eighty-eight percent of patients with neurologic injury improved at least one Frankel grade with treatment. Functional and pain evaluation by the Denis scale showed 25 patients rated P1, 25 rated P2, and 6 rated P3. Twenty-eight were rated W1, 16 were W3, and 12 were W5 at last follow-up.

CONCLUSIONS

Fractures of the thoracolumbar spine can be treated effectively with the semirigid Louis plating system. Because of its low cost and ease of insertion, the Louis system is an excellent choice for short arthrodesis and instrumentation of these fractures. Although there is some loss of reduction when compared with more rigid systems, there is no functional compromise in these patients.

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

Fifty-five patients who had sustained a burst fracture of the lumbar spine were followed for a mean of seventy-nine months (range, twenty-four to 192 months) after the injury. Thirty patients had been managed non-operatively with a short period of bed rest followed by protected mobilization. The remaining twenty-five patients had been managed operatively: eight, with posterior arthrodesis with long-segment hook-and-rod fixation; eight, with posterior arthrodesis with short-segment transpedicular fixation; six, with posterior arthrodesis and instrumentation followed by anterior decompression and arthrodesis; and three, with anterior decompression and arthrodesis. Thirty-six patients had been neurologically intact at the time of presentation and had remained so throughout the follow-up period. No neurological deterioration or symptoms of late spinal stenosis were seen. Isolated partial single-nerve-root deficits resolved regardless of the method of treatment. Patients who had had a complete single or a multiple-nerve-root paralysis seemed to have benefited from anterior decompression. Although the anatomical results as seen on the most recent radiographs were superior for the group that had been managed operatively with long posterior fixation or anterior and posterior arthrodesis, the most recent pain scores and the functional outcomes were similar for all treatment groups. At the latest follow-up evaluation, some loss of spinal alignment was noted in the patients who had been managed with short transpedicular fixation; the alignment at the most recent follow-up examination was comparable with that in the patients who had been managed non-operatively. For the patients who had had non-operative treatment, we were unable to predict the deformity at the time of follow-up on the basis of the initial diagnostic radiographs. The clinical outcome was not related to the deformity at the latest follow-up evaluation. On the basis of the results of our study, we recommend non-operative treatment for patients who do not have neurological dysfunction or who have an isolated partial nerve-root deficit at the time of presentation. For patients who have a multiple-nerve-root paralysis, anterior decompression is indicated.

Early surgery for thoracolumbar spinal cord injury: initial experience from a developing spinal cord injury centre in India

The spinal cord injury centre of Nizam's Institute of Medical Sciences, Andhra Pradesh, India has been functioning now for 8 months and offers its services to the population of 80 million in the state. To date, 92 patients with a spinal cord injury have been treated; 51 had a thoracolumbar spinal injury. This report presents the results of the management of these 51 patients. Preoperatively both CT and MRI were performed and the radiological findings were correlated with outcome. Twenty five had a thoracic and 26 a lumber location. Twenty nine patients underwent surgical treatment (15 thoracic and 14 lumbar) and the others were treated conservatively (10 thoracic and 12 lumbar). All these operations were carried out within 2 weeks following trauma, and methylprednisolone therapy was instituted in those who reached the hospital early. Contraindications for surgery included a delay in admission of more than 3 weeks following trauma, a focus of sepsis, bedsores, a generalised bone disorder such as osteopenia, and medical illnesses. Transpedicular screw-plate fixation was performed in 27 patients, and two patients underwent decompressive laminectomy and interlaminar bone and wire fixation. Delayed spinal decompression was offered to one patient to relieve radiculopathy. Fracture-dislocation spinal injury and those with transection of the spinal cord had the worst outcome, whilst patients with a wedge compression fracture and cord oedema fared better. Operated cases had a shorter hospital stay, and complications of immobilisation were limited. Positive psychological influence of mobilisation and early acclimatisation to the altered style of living with their disability were the most significant outcomes following surgery.

Delayed worsening of the surgical correction of angular and axial deformity consequent to burst fractures of the thoracolumbar or lumbar spine

Forty-one patients with burst fractures of the thoracolumbar junction, or the lumbar spine (T12 to L5), were followed for 6-48 months (mean follow-up = 19.9 months) after early surgery (usually within 24 hours). Preoperative, early postoperative, and late postoperative degrees of kyphosis, as well as percent reduction of the height of the vertebral body were calculated and compared. Early postoperative radiologic evaluations showed a statistically significant difference (p < 0.0001) between the mean values of both parameters calculated respectively before and after surgery. The decrease of the surgical correction, from the initial postoperative radiographs to follow-up, was statistically significant (p < 0.0001). However, the final values were better when compared with the preoperative features (p < 0.003 and p < 0.0001, respectively for degree of kyphosis and reduction in vertebral height.

Transpedicular decompression and stabilization of burst fractures of the lumbar spine

Twenty-seven consecutive patients with neurological impairment due to burst fractures of the lumbar spine were operated upon, via the postero-lateral route, over a 38-month-period. Transpedicular fixation devices [posterior segmental fixator (PSF) or variable screw placement system (VSP)] were applied in all cases, in order to achieve short-segment fusion of the fractured spinal segment. Return to useful motor power or neurological normality (median follow-up: 18.7 months) occurred in 22 cases (81% of the whole series), with this outcome resulting in all but one of the cases with preoperative incomplete neurological deficit. Postoperative encroachment of the spinal canal, degree of kyphotic deformity, and reduction of the vertebral height showed statistically significant differences compared with the corresponding preoperative values.