Combined posterior-anterior stabilisation of thoracolumbar injuries utilising a vertebral body replacing implant

Return to sports/activity level after 360° thoracolumbar fusion after burst fractures in young patients

Introduction

Traumatic thoracolumbar burst fractures are the most common spinal injuries and the proper treatment is controversial. In central Europe in particular, these fractures are often treated with minimally invasive anterior-posterior reduction and fusion, whereas a conservative approach is preferred in the USA. Independent of the treatment strategy, no data exists regarding the outcome related to return to activity level/sport.

Research question

The aim of this study was to evaluate the return to sports and activity levels after 360° fusion in patients with thoracolumbar burst fractures without neurological deficits.

Methods

Between January 2013 and December 2022, 46 patients aged 18 to 40 years underwent partial or complete vertebral body replacement in the thoracolumbar region due to traumatic burst fractures without neurologic deficit as an isolated injury. Patients were contacted retrospectively by phone calls to assess their activities using a modified version of the Tegner activity scale at different time points: Before trauma, 3, 6, and 12 months post-surgery.

Results

After applying exclusion criteria, data collection was complete for 28 patients. The median modified Tegner activity scale was 5.4 before sustaining the fracture, declined to 2.9 at three months post-trauma, improved to 4.2 at six months, and reached 5.0 at 12 months. The majority (83%) of patients achieved their pre-accident activity level within 12 months. No significant differences were observed between patients with partial or complete corpectomy.

Conclusion

This is the first study assessing return to sports/physical activity based on the modified Tegner scale in young patients undergoing 360° fusion for spinal burst fractures. The majority of patients (83%) return to the pre-injury activity level within 12 months after surgery.

Treating traumatic thoracolumbar spine fractures using minimally invasive percutaneous stabilization plus balloon kyphoplasty: a 102-patient series

BACKGROUND

There is no consensus on the treatment for spinal injuries resulting in thoracolumbar fractures without neurological impairment. Many trauma centers are opting for open surgery rather than a neurointerventional approach combining posterior percutaneous short fixation (PPSF) plus balloon kyphoplasty (BK).

OBJECTIVE

To assess the safety and efficacy of PPSF+BK and to estimate the expected improvement by clarifying the factors that influence improvement.

METHODS

We retrospectively reviewed patients who underwent PPSF+BK for the treatment of single traumatic thoracolumbar fractures from 2007 to 2019. Kyphosis, loss of vertebral body height (VBH), clinical and functional outcomes including visual analog scale and Oswestry disability index were assessed. We examined the overall effects in all patients by constructing a linear statistical model, and then examined whether efficacy was dependent on the characteristics of the patients or the fractures.

RESULTS

A total of 102 patients were included. No patient experienced neurological worsening or wound infections. The average rates of change were 74.4% (95% CI 72.6% to 76.1%) for kyphosis and 85.5% (95% CI 84.4% to 86.6%) for VBH (both p<0.0001). The kyphosis treatment was more effective on Magerl A3 and B2 fractures than on those classified as A2.3, as well as for fractures with slight posterior wall protrusion on the spinal canal. A higher postoperative visual analog scale score was predictive of poorer outcome at 1 year.

CONCLUSIONS

This is the largest series reported to date and confirms and validates this surgical treatment. All patients exhibited improved kyphosis and restoration of VBH. We advise opting for this technique rather than open surgery.

In vitro comparison of personalized 3D printed versus standard expandable titanium vertebral body replacement implants in the mid-thoracic spine using entire rib cage specimens

BACKGROUND

Expandable titanium implants have proven their suitability as vertebral body replacement device in several clinical and biomechanical studies. Potential stabilizing features of personalized 3D printed titanium devices, however, have never been explored. This in vitro study aimed to prove their equivalence regarding primary stability and three-dimensional motion behavior in the mid-thoracic spine including the entire rib cage.

METHODS

Six fresh frozen human thoracic spine specimens with intact rib cages were loaded with pure moments of 5 Nm while performing optical motion tracking of all vertebrae. Following testing in intact condition (1), the specimens were tested after inserting personalized 3D printed titanium vertebral body replacement implants (2) and the two standard expandable titanium implants Obelisc™ (3) and Synex™ (4), each at T6 level combined with posterior pedicle screw-rod fixation from T4 to T8.

FINDINGS

No significant differences (P < .05) in primary and secondary T1-T12 ranges of motion were found between the three implant types. Compared to the intact condition, slight decreases of the range of motion were found, which were significant for Synex™ in primary flexion/extension (-17%), specifically at T3-T4 level (-46%), primary lateral bending (-18%), and secondary lateral bending during primary axial rotation (-53%). Range of motion solely increased at T8-T9 level, while being significant only for Obelisc™ (+35%).

INTERPRETATION

Personalized 3D printed vertebral body replacement implants provide a promising alternative to standard expandable devices regarding primary stability and three-dimensional motion behavior in the mid-thoracic spine due to the stabilizing effect of the rib cage.

Early versus delayed corpectomy in thoracic and lumbar spine trauma. A long-term clinical and radiological retrospective study

AND BACKGROUND DATA

Many authors have demonstrated the necessity of reconstruction of the anterior column in spinal trauma with vertebral body collapse or nonunion. There is no publication comparing the result depending on the time between trauma and anterior reconstruction of the vertebral body.

OBJECTIVE

To compare long-term clinical and radiological results between early and late anterior vertebral body reconstruction with expandable cages in patients with thoracic and lumbar spine trauma.

HYPOTHESIS

An early anterior reconstruction of thoracolumbar fractures provides better clinical and radiological outcomes than a delayed one.

MATERIALS AND METHODS

A retrospective clinical study was carried out with 44 consecutive patients with injuries of the thoracic and lumbar spine treated operatively with combined posterior stabilization and anterior reconstruction with an expandable implant for vertebral body replacement. All patients were evaluated with EOS full-spine radiograph and CT-scan. The mean follow-up was 5.1 years. Clinical result was evaluated with ODI, SF12, VAS back pain, return to work and sport. Radiological result was evaluated with regional kyphosis angle (RKA) evolution, fusion rate and sagittal alignment. In Group A, twenty-nine patients underwent an early anterior reconstruction within 3 weeks after trauma. The indication of vertebral body reconstruction was placed after post-operative CT-scan for a Mc Cormack score≥7. In Group B, fifteen patients underwent a late anterior reconstruction after diagnosis of nonunion by the combination of pain and CT-scan after 1 year.

RESULTS

Clinical scores and scales were significantly better for patients operated early in Group A. Return to work and activities were significantly more important in Group A too. The mean RKA correction with posterior reduction was 9.3°. The secondary anterior approach permit to reduce 2.9° more. At last follow-up, the loss of reduction was 4.3°. There was no significant difference between groups for those results. No difference in fusion rate was observed between groups. There was no significant difference between groups in the sagittal alignment excepted for SVA that was higher for Group B while remaining under a normal value of 50mm.

CONCLUSION

Early anterior vertebral body reconstruction for fractures gives better clinical results than delayed reconstruction for patients with diagnosis of nonunion in patients with thoracic and lumbar spine trauma. Moreover, the shorter the time from trauma to operation, the better the sagittal reduction of kyphosis. The use of expandable titanium cage is a good way to perform and maintain this reduction.

LEVEL OF EVIDENCE

IV, retrospective study.

Implants for Vertebral Body Replacement - Which Systems are Available and Have Become Established

Since the first vertebral body replacement operations over 50 years ago until now, there were developed numerous methods and implants. Vertebral body replacement after corpectomy nowadays is a standard procedure in spinal surgery. At the beginning mainly bone grafts were used. Due to continuous development, PMMA and titanium implants were developed. Nowadays various expandable and non-expandable implants are available. Numerous implants can still be justified. The question arises which methods and systems are on the market and which ones have proven themselves? This article describes and compares the advantages and disadvantages of each implant type.

Vertebral body spread in thoracolumbar burst fractures can predict posterior construct failure

BACKGROUND CONTEXT

The load sharing classification (LSC) laid foundations for a scoring system able to indicate which thoracolumbar fractures, after short-segment posterior-only fixations, would need longer instrumentations or additional anterior supports.

PURPOSE

We analyzed surgically treated thoracolumbar fractures, quantifying the vertebral body's fragment displacement with the aim of identifying a new parameter that could predict the posterior-only construct failure.

STUDY DESIGN

This is a retrospective cohort study from a single institution.

PATIENT SAMPLE

One hundred twenty-one consecutive patients were surgically treated for thoracolumbar burst fractures.

OUTCOME MEASURES

Grade of kyphosis correction (GKC) expressed radiological outcome; Oswestry Disability Index and visual analog scale were considered.

METHODS

One hundred twenty-one consecutive patients who underwent posterior fixation for unstable thoracolumbar burst fractures were retrospectively evaluated clinically and radiologically. Supplementary anterior fixations were performed in 34 cases with posterior instrumentation failure, determined on clinic-radiological evidence or symptomatic loss of kyphosis correction. Segmental kyphosis angle and GKC were calculated according to the Cobb method. The displacement of fracture fragments was obtained from the mean of the adjacent end plate areas subtracted from the area enclosed by the maximum contour of vertebral fragmentation. The "spread" was derived from the ratio between this subtraction and the mean of the adjacent end plate areas. Analysis of variance, Mann-Whitney, and receiver operating characteristic were performed for statistical analysis. The authors report no conflict of interest concerning the materials or methods used in the present study or the findings specified in this paper. No funds or grants have been received for the present study.

RESULTS

The spread revealed to be a helpful quantitative measurement of vertebral body fragment displacement, easily reproducible with the current computed tomography (CT) imaging technologies. There were no failures of posterior fixations with preoperative spreads <42% and losses of correction (LOC)<10°, whereas spreads >62.7% required supplementary anterior supports whenever LOC>10° were recorded. Most of the patients in a "gray zone," with spreads between 42% and 62.7%, needed additional anterior supports because of clinical-radiological evidence of impending mechanical failures, which developed independently from the GKC. Preoperative kyphosis (p<.001), load sharing score (p=.002), and spread (p<.001) significantly affected the final surgical treatment (posterior or circumferential).

CONCLUSIONS

Twenty-two years after the LSC, both improvements in spinal stabilization systems and software imaging innovations have modified surgical concepts and approach on spinal trauma care. Spread was found to be an additional tool that could help in predicting the posterior construct failure, providing an objective preoperative indicator, easily reproducible with the modern viewers for CT images.

Monosegmental anterior column reconstruction using an expandable vertebral body replacement device in combined posterior-anterior stabilization of thoracolumbar burst fractures

INTRODUCTION

In combined posterior-anterior stabilization of thoracolumbar burst fractures, the expandable vertebral body replacement device (VBRD) is typically placed bisegmentally for anterior column reconstruction (ACR). The aim of this study, however, was to assess feasibility, outcome and potential pitfalls of monosegmental ACR using a VBRD. In addition, clinical and radiological outcome of monosegmental ACR was related to that of bisegmental ACR using the same thoracoscopic technique.

METHODS

Thirty-seven consecutive neurologically intact patients with burst fractures of the thoracolumbar junction (T11-L2) treated by combined posterior-anterior stabilization were included. Monosegmental ACR was performed in 18 and bisegmental ACR in 19 patients. Fracture type and extent of vertebral body comminution were determined on preoperative CT scans. Monosegmental and bisegmental kyphosis angles were analyzed preoperatively, postoperatively and at final radiological follow-up. Clinical outcome was assessed after a minimum of 2 years (74 ± 45 months; range 24-154; follow-up rate 89.2%) using VAS Spine Score, RMDQ, ODI and WHOQOL-BREF.

RESULTS

Monosegmental ACR resulted in a mean monosegmental and bisegmental surgical correction of - 15.6 ± 7.7° and - 14.7 ± 8.1°, respectively. Postoperative monosegmental and bisegmental loss of correction averaged 2.7 ± 2.7° and 5.2 ± 3.7°, respectively. Two surgical pitfalls of monosegmental ACR were identified: VBRD positioning (1) onto the weak cancellous bone (too far cranially to the inferior endplate of the fractured vertebra) and (2) onto a significantly compromised inferior endplate with at least two (even subtle) fracture lines. Ignoring these pitfalls resulted in VBRD subsidence in five cases. When relating the clinical and radiological outcome of monosegmental ACR to that of bisegmental ACR, no significant differences were found, except for frequency of VBRD subsidence (5 vs. 0, P = 0.02) and bisegmental loss of correction (5.2 ± 3.7° vs. 2.6 ± 2.5°, P = 0.022). After exclusion of cases with VBRD subsidence, the latter did not reach significance anymore (4.9 ± 4.0° vs. 2.6 ± 2.5°, P = 0.084).

CONCLUSIONS

This study indicates that monosegmental ACR using a VBRD is feasible in thoracolumbar burst fractures if the inferior endplate is intact (incomplete burst fractures) or features only a single simple split fracture line (burst-split fractures). If the two identified pitfalls are avoided, monosegmental ACR may be a viable alternative to bisegmental ACR in selected thoracolumbar burst fractures to spare a motion segment and to reduce the distance for bony fusion.

Instrumented Circumferential Fusion in Two Stages for Instable Lumbar Fracture: Long-Term Results of a Series of 74 Patients on Sagittal Balance and Functional Outcomes

OBJECTIVE

To report the radiologic and functional results of a multicenter, prospective case series of patients with comminuted lumbar fractures treated with 2-stage circumferential arthrodesis.

METHODS

A multicenter prospective case series of 74 patients with comminuted lumbar fractures was analyzed. The strategy entailed initial posterior osteosynthesis, followed by physical replacement with an expandable titanium cage filled with autologous bone via retroperitoneal lumbotomy. The mechanism of lesion formation and epidemiologic characteristics were recorded. Clinical and quality-of-life analyses (visual analog scale [VAS], Oswesty Disability Index [ODI], Short Form 12 [SF-12]) were performed over a minimum observation period of 1 year. Radiologic parameters, including deformity measurements, were recorded at each evaluation. Fusion was analyzed by means of a 1-year monitoring scan.

RESULTS

The mean patient age was 38.1 years, and median duration of follow-up was 2.1 years (interquartile range, 1.3-2.9). The distribution of fractures according to the Magerl classification scheme was as follows: A, 64.8%; B, 16.7%; C, 18.5%. At the last follow-up, fusion was considered certain in 57 cases (77%). The mean VAS score was 2.1 ± 1.3, mean ODI was 14.7 ± 8.0, mean SF-12 Physical Component Summary score was 43.2 ± 9.3, and mean SF-12 Mental Component Summary score was 50.8 ± 5.9. Correction of the regional sagittal deformity was significant during the postoperative period, with a mean increase in lordosis of 9.0° (P < 0.0001). The loss of mean correction at the last follow-up (-2.9°) was not significant.

CONCLUSIONS

Circumferential arthrodesis, including posterior osteosynthesis and physical replacement with an expandable cage and autologous graft, is applicable to the treatment of comminuted lumbar fractures. A high rate of fusion was obtained with significant and long-lasting correction of the sagittal deformity. Functional scores measured at 1 year suggest mild disability. The ODI, SF-12, and VAS scores were positively correlated with fusion at the last follow-up.

Impact of Sagittal Balance on Clinical Outcomes in Surgically Treated T12 and L1 Burst Fractures: Analysis of Long-Term Outcomes after Posterior-Only and Combined Posteroanterior Treatment

Objective. Long-term radiological and clinical outcome retrospective study of surgical treatment for T12 and L1 burst fractures in perspective of sagittal balance measures. Methods. Patients with age of 16–60 years, complete radiographs, early surgical treatment surgery, and follow-up (F/U) > 18 months were included and strict exclusion criteria applied. Regional and thoracolumbar kyphosis angles (RKA and TLA) were measured preoperatively and at final F/U, as were parameters of the spinopelvic sagittal alignment. Clinical outcomes were assessed using validated measures. Results. 36 patients with age mean age of 39 years and F/U of 69 months were included. 61% of patients were treated with bisegmental posterior instrumentation (POST-I) and 39% with combined posteroanterior instrumented fusion (PA-F). At F/U, several indicators for clinical outcomes showed a significant correlation with radiographic measures in the overall cohort with inferior clinical outcomes corresponding with increasing residual deformity and sagittal malalignment. Statistical analysis failed to reach level of significance for the differences between POST-I and PA-F group at final F/U. Only a strong trend towards better restoration of the thoracolumbar alignment was observed for the PA-F group in terms of the RKA and TLA. Conclusions. Results in a surgically treated cohort of T12 and L1 burst fracture patients indicate that superior clinical outcomes depend on restoration of sagittal alignment.

Fracture reduction by postoperative mobilisation for the treatment of hyperextension injuries of the thoracolumbar spine in patients with ankylosing spinal disorders

INTRODUCTION

The aim of this study was to evaluate results of surgical stabilisation of hyperextension injuries of the thoracolumbar spine in patients with ankylosing spinal disorders using two different treatment strategies: the conventional open rigid posterior instrumentation and percutaneous less rigid posterior instrumentation. Surgical and non-surgical complications, the postoperative radiological course, and clinical outcome at final follow-up were comparatively assessed. Moreover, we sought to discuss important biomechanical and surgical aspects specific to posterior instrumentation of the ankylosed thoracolumbar spine as well as to elaborate on the advantages and limitations of the proposed new treatment strategy involving percutaneous less rigid stabilisation and fracture reduction by postoperative mobilisation.

MATERIALS AND METHODS

Between January 2006 and June 2012, a consecutive series of 20 patients were included in the study. Posterior instrumentation was performed either using an open approach with rigid 6.0 mm bars (open rigid (OR) group) or via a percutaneous approach using softer 5.5 mm bars (percutaneous less rigid (PLR) group). Complications as well as the radiological course were retrospectively assessed, and patient outcome was evaluated at final follow-up using validated outcome scores (VAS Spine Score, ODI, RMDQ, Parker Mobility Score, Barthel Score and WHOQOL-BREF).

RESULTS

Surgical complications occurred more frequently in the OR group requiring revision surgery in two patients, while there was no revision surgery in the PLR group. The rate of postoperative complications was lower in the PLR group as well (0.7 vs. 1.3 complications per patient, respectively). Fracture reduction and restoration of pre-injury sagittal alignment by postoperative mobilisation occurred within the first 3 weeks in the PLR group, and within 6 months in the OR group. The clinical outcome at final follow-up was very good in both groups with no relevant loss in VAS Spine Score (pain and function), Parker Mobility Score (mobility), and Barthel Index (social independency) compared to pre-operative values.

CONCLUSIONS

This study indicates that the proposed treatment concept involving percutaneous less rigid posterior instrumentation and fracture reduction by postoperative mobilisation is feasible, seems to facilitate adequate reduction and restoration of pre-injury sagittal alignment, and might have the potential to reduce the rate of complications in the management of hyperextension injuries of the ankylosed thoracolumbar spine.

Analysis of the spinal nerve roots in relation to the adjacent vertebral bodies with respect to a posterolateral vertebral body replacement procedure

OBJECTIVE

This study aims to improve the understanding of the anatomic variations along the thoracic and lumbar spine encountered during an all-posterior vertebrectomy, and reconstruction procedure. This information will help improve our understanding of human spine anatomy and will allow better planning for a vertebral body replacement (VBR) through either a transpedicular or costotransversectomy approach.

SUMMARY OF BACKGROUND DATA

The major challenge to a total posterior approach vertebrectomy and VBR in the thoracolumbar spine lies in the preservation of important neural structures.

METHODS

This was a retrospective analysis. Hundred normal magnetic resonance imaging (MRI) spinal studies (T1-L5) on sagittal T2-weighted MRI images were studied to quantify: (1) mid-sagittal vertebral body (VB) dimensions (anterior, midline, and posterior VB height), (2) midline VB and associated intervertebral discs height, (3) mean distance between adjacent spinal nerve roots (DNN) and mean distance between the inferior endplate of the superior vertebrae to its respective spinal nerve root (DNE), and (4) posterior approach expansion ratio (PAER).

RESULTS

(1) The mean anterior VB height gradually increased craniocaudally from T1 to L5. The mean midline and posterior VB height showed a similar pattern up to L2. Mean posterior VB height was larger than the mean anterior VB height from T1 to L2, consistent with anterior wedging, and then measured less than the mean anterior VB height, indicating posterior wedging. (2) Midline VB and intervertebral disc height gradually increased from T1 to L4. (3) DNN and DNE were similar, whereby they gradually increased from T1 to L3. (5) Mean PAER varied between 1.69 (T12) and 2.27 (L5) depending on anatomic level.

CONCLUSIONS

The dimensions of the thoracic and lumbar vertebrae and discs vary greatly. Thus, any attempt at carrying out a VBR from a posterior approach should take into account the specifications at each spinal level.

Outcome Instruments in Spinal Trauma Surgery: A Bibliometric Analysis

Study Design Literature review. Objective To identify outcomes instruments used in spinal trauma surgery over the past decade, their frequency of use, and usage trends. Methods Five top orthopedic journals were reviewed from 2004 to 2013 for clinical studies of surgical intervention in spinal trauma that reported patient-reported outcome instruments use or neurologic function scale use. Publication year, level of evidence (LOE), and outcome instruments were collected for each article and analyzed. Results A total of 58 studies were identified. Among them, 26 named outcome instruments and 7 improvised questionnaires were utilized. The visual analog scale (VAS) for pain was used most frequently (43.1%), followed by the Short Form 36 (34.5%), Frankel grade scale (25.9%), Oswestry Disability Index (20.7%) and American Spinal Injury Association Impairment Scale (15.5%). LOE 4 was most common (37.9%), and eight LOE 1 studies were identified (10.3%). Conclusions The VAS pain scale is the most common outcome instrument used in spinal trauma. The scope of this outcome instrument is limited, and it may not be sufficient for discriminating between more and less effective treatments. A wide variety of functional measures are used, reflecting the need for a disease-specific instrument that accurately measures functional limitation in spinal trauma.

Salvage Percutaneous Vertebral Augmentation Using Polymethyl Methacrylate in Patients with Failed Interbody Fusion

BACKGROUND

Percutaneous vertebral augmentation with cement is used as a salvage procedure for failed instrumentation. Few studies have reported the use of this procedure for failed anterior lumbar fusion in elderly patients with osteoporosis and other complicated diseases who have undergone a previous major operation.

METHODS

Between January 2007 and December 2015, the clinical and radiographic results of 8 patients with osteoporosis who showed subsidence and migration of the implant after an initial operation were examined. After the development of implant failure, the patients underwent vertebral augmentation with polymethyl methacrylate.

RESULTS

Mean patient age was 73.4 years (range, 67-78 years), and mean bone mineral density was -2.96 (range, -2.1 to -3.8). The mean radiologic follow-up period between augmentation and the last follow-up examination was 16 months (range, 3-38 months). Although the subjective clinical outcome was not satisfying to the patients, no loss of correction, fractures, or screw loosening occurred during the follow-up period.

CONCLUSIONS

The injection of cement around the instrument might help to stabilize it by providing strength to the axis and preventing further loosening. This salvage procedure could be an alternative in the management of cases with failed interbody fusion.

Percutaneous Dorsal Instrumentation of Vertebral Burst Fractures: Value of Additional Percutaneous Intravertebral Reposition-Cadaver Study

Purpose. The treatment of vertebral burst fractures is still controversial. The aim of the study is to evaluate the purpose of additional percutaneous intravertebral reduction when combined with dorsal instrumentation. Methods. In this biomechanical cadaver study twenty-eight spine segments (T11-L3) were used (male donors, mean age 64.9 ± 6.5 years). Burst fractures of L1 were generated using a standardised protocol. After fracture all spines were allocated to four similar groups and randomised according to surgical techniques (posterior instrumentation; posterior instrumentation + intravertebral reduction device + cement augmentation; posterior instrumentation + intravertebral reduction device without cement; and intravertebral reduction device + cement augmentation). After treatment, 100000 cycles (100–600 N, 3 Hz) were applied using a servohydraulic loading frame. Results. Overall anatomical restoration was better in all groups where the intravertebral reduction device was used (p < 0.05). In particular, it was possible to restore central endplates (p > 0.05). All techniques decreased narrowing of the spinal canal. After loading, clearance could be maintained in all groups fitted with the intravertebral reduction device. Narrowing increased in the group treated with dorsal instrumentation. Conclusions. For height and anatomical restoration, the combination of an intravertebral reduction device with dorsal instrumentation showed significantly better results than sole dorsal instrumentation.

Association of clinical parameters of operatively treated thoracolumbar fractures with quality of life parameters

PURPOSE

The intention of the current work was to assess the association between clinical parameters and seven different quality of life (QoL) instruments after surgical treatment of thoracolumbar spinal fractures after an average follow-up of 4.2 years.

METHODS

The following human-related quality of life and PRO measures of 66 patients were correlated to clinical parameters such as fingertip-to-floor distance (FFD), Schober measurement, pressure and percussion pain in the lumbopelvine area (PPP), and paravertebral muscle tension: reALOS, SF-36, VAS, VAS spine score, BDI, the GBB-24, and the IES-R.

RESULTS

Overall, there was a significant association between the clinical parameters of the thoracolumbar spine such as PPP, paravertebral muscle tension, FFD and Schober's sign on one side, and the seven tested instruments on the other side.

CONCLUSIONS

PPP and FFD as well as a small Schober measurement are clinical parameters which significantly influence QoL after surgical treatment of thoracolumbar fractures.

Implications of the center of rotation concept for the reconstruction of anterior column lordosis and axial preloads in spinal deformity surgery

OBJECT

In thoracolumbar deformity surgery, anterior-only approaches are used for reconstruction of anterior column failures. It is generally advised that vertebral body replacements (VBRs) should be preloaded by compression. However, little is known regarding the impact of different techniques for generation of preloads and which surgical principle is best for restoration of lordosis. Therefore, the authors analyzed the effect of different surgical techniques to restore spinal alignment and lordosis as well as the ability to generate axial preloads on VBRs in anterior column reconstructions.

METHODS

The authors performed a laboratory study using 7 fresh-frozen specimens (from T-3 to S-1) to assess the ability for lordosis reconstruction of 5 techniques and their potential for increasing preloads on a modified distractable VBR in a 1-level thoracolumbar corpectomy. The testing protocol was as follows: 1) Radiographs of specimens were obtained. 2) A 1-level corpectomy was performed. 3) In alternating order, lordosis was applied using 1 of the 5 techniques. Then, preloads during insertion and after relaxation using the modified distractable VBR were assessed using a miniature load-cell incorporated in the modified distractable VBR. The modified distractable VBR was inserted into the corpectomy defect after lordosis was applied using 1) a lamina spreader; 2) the modified distractable VBR only; 3) the ArcoFix System (an angular stable plate system enabling in situ reduction); 4) a lordosizer (a customized instrument enabling reduction while replicating the intervertebral center of rotation [COR] according to the COR method); and 5) a lordosizer and top-loading screws ([LZ+TLS], distraction with the lordosizer applied on a 5.5-mm rod linked to 2 top-loading pedicle screws inserted laterally into the vertebra). Changes in the regional kyphosis angle were assessed radiographically using the Cobb method.

RESULTS

The bone mineral density of specimens was 0.72 ± 22.6 g/cm(2). The maximum regional kyphosis angle reconstructed among the 5 techniques averaged 9.7°-16.1°, and maximum axial preloads averaged 123.7-179.7 N. Concerning correction, in decreasing order the LZ+TLS, lordosizer, and ArcoFix System outperformed the lamina spreader and modified distractable VBR. The order of median values for insertion peak load, from highest to lowest, were lordosizer, LZ+TLS, and ArcoFix, which outperformed the lamina spreader and modified distractable VBR. In decreasing order, the axial preload was highest with the lordosizer and LZ+TLS, which both outperformed the lamina spreader and the modified distractable VBR. The technique enabling the greatest lordosis achieved the highest preloads. With the ArcoFix System and LZ+TLS, compression loads could be applied and were 247.8 and 190.6 N, respectively, which is significantly higher than the insertion peak load and axial preload (p < 0.05).

CONCLUSIONS

Including the ability for replication of the COR in instruments designed for anterior column reconstructions, the ability for lordosis restoration of the anterior column and axial preloads can increase, which in turn might foster fusion.

Combined posteroanterior fusion versus transforaminal lumbar interbody fusion (TLIF) in thoracolumbar burst fractures

BACKGROUND

The optimal treatment strategy for burst fractures of the thoracolumbar junction is discussed controversially in the literature. Whilst 360° fusion has shown to result in better radiological outcome, recent studies have failed to show its superiority concerning clinical outcome. The morbidity associated with the additional anterior approach may account for these findings. The aim of this prospective observational study was therefore to compare two different techniques for 360° fusion in thoracolumbar burst fractures using either thoracoscopy or a transforaminal approach (transforaminal lumbar interbody fusion (TLIF)) to support the anterior column.

METHODS

Posterior reduction and short-segmental fixation using angular stable pedicle screw systems were performed in all patients as a first step. Monocortical strut grafts were used for the anterior support in the TLIF group, whilst tricortical grafts or titanium vertebral body replacing implants of adjustable height were used in the combined posteroanterior group. At final follow-up, the radiological outcome was assessed by performing X-rays in a standing position. The clinical outcome was measured using five validated outcome scores. The morbidity associated with the approaches and the donor site was assessed as well.

RESULTS

There were 21 patients in the TLIF group and 14 patients in the posteroanterior group included. The postoperative loss of correction was higher in the TLIF group (4.9°±8.3° versus 3.4°±6.4°, p>0.05). There were no significant differences regarding the outcome scores between the two groups. There were no differences in terms of return to employment, leisure activities and back function either. More patients suffered from donor-site morbidity in the TLIF group, whilst the morbidity associated with the surgical approach was higher in the posteroanterior group.

CONCLUSION

The smaller donor-site morbidity in the posteroanterior group is counterbalanced by an additional morbidity associated with the anterior approach resulting in similar clinical outcome. Mastering both techniques will allow the spine surgeon to be more flexible in specific situations, for example, in patients with neurological deficits or severe concomitant thoracic trauma.

Percutaneous internal fixation combined with kyphoplasty for neurologically intact thoracolumbar fractures: a prospective cohort study of 24 patients with one year of follow-up

INTRODUCTION AND HYPOTHESIS

Neurologically intact lumbar and thoracolumbar fractures are frequent but their treatment is not codified. The purpose of this study was to evaluate the effectiveness of minimally invasive treatment of such fractures by percutaneous fixation associated with balloon kyphoplasty.

PATIENTS AND METHODS

Between November 2008 and July 2010, 24 patients were treated. There were 12 men and 12 women, with a mean age of 53 years (range 20-88 years). Fractures were classified as one Magerl lesion type A1, one type A2, 19 A3 (five A31, 10 A32, four A33), and three type B2. The treatment was kyphoplasty of the fractured vertebra followed by percutaneous fixation of the vertebra above and below the fracture. Patient follow-up included an analysis of pain using the visual analogic score, the Oswestry score, and functional X-ray and CT analysis.

RESULTS

Surgery lasted a mean 99 minutes. At the last follow-up, the mean pain was scored at 0.9 and the Oswestry score was 13.2. Reduction of vertebral kyphosis was 8.6° and reduction of the corrected regional angle was 7.1°. The gain in vertebral height was 17%. All pedicle screws were positioned correctly and no neurological, septic, or thromboembolic complications were observed.

DISCUSSION AND CONCLUSION

Percutaneous osteosynthesis combined with balloon kyphoplasty is a valuable surgical technique in the treatment of thoracolumbar and lumbar fractures with no neurologic deficit. The clinical results are good and the technique allows the patient to return home earlier without having to wear a corset. The X-ray result scores are very encouraging, with corrections similar to conventional surgery in terms of vertebral height and kyphosis. This technique can be an alternative to conventional open surgery.

LEVEL OF EVIDENCE

IV: Prospective observational study.

[Reconstruction after spinal fractures in the thoracolumbar region]

The morbidity of anterior approaches has significantly influenced the development of therapeutic concepts for the treatment of thoracolumbar spine fractures. Minimally-invasive techniques such as mini-open and endoscopic have enlarged the numbers of anterior reconstruction after spinal fractures in the thoracolumbar region. These minimally-invasive approaches have been facilitated by the development of special implants adapted to the new technique and to the local anatomical requirements.Two multi center studies in Germany (MCSI and II) showed the trend towards minimal invasive procedures and anterior approaches in the German speaking spine centers. Since the first report on thoracoscopic anterior procedures in Germany in 1997 a growing number of spine centers established this method. There is still no evidence based high level literature to substantiate a significant benefit for the patients by anatomical reduction and reconstruction of the anterior spinal column. However, there are some reports on better short outcomes in radiological parameters as well as better clinical results in 5 to 8 year follow-ups.The minimal invasive anterior approach seems to be advantageous for the patients by reducing significantly additive operation morbidity. It has become more important over the last two decades for anterior reconstruction after trauma and posttraumatic malalignment of the thoracolumbar spine.

Anterior vertebroplasty of adjacent levels after vertebral body replacement

The aim of this study was to evaluate the feasibility of a new method, which should help to avoid cage subsidence after vertebrectomy in short fusions. After implantation of an extendable vertebral body replacement (VBR) the two adjacent endplates to the fractured or destroyed vertebra were augmented with bone cement using the anterior approach in 20 patients with short circumferential fusion. All patients were followed up for 2 years clinically and radiographically. X-rays were reviewed for kyphosis, cage subsidence, presence of a solid fusion mass and instrumentation failure. Changes in every day activities (Oswestry Disability Index-ODI) and visual analogue scale (VAS), pain score, as well as technique-related complications were examined. The mean amount of kyphosis correction was 12.8° (±6.4°) and changed by only 0.3° (±0.4°) until last follow-up. Pain (VAS) and ODI scores were significantly improved and did not change until last follow-up. In all but two cases, the authors observed solid union with incorporation of the cage. No surgery-related complications were recorded. In one case revision was advised because of non-union due to septic loosening. The augmentation of the adjacent vertebras after anterior VBR provides an enhancement of the interface between cage and vertebra in cases with poor bone quality and in revision surgery. The technique is simple and safe, as the needles can be placed under visual control. Cement augmentation of the endplates may reduce interbody device subsidence.

Mid-term results of PLIF/TLIF in trauma

Treatment of thoracolumbar fractures is still controversial. Several treatment options are reported to yield satisfactory results. There is no evidence indicating superiority of any treatment option. We have already presented radiological results of the use of PLIF/TLIF in trauma, which showed satisfactory results concerning intervertebral fusion and acceptable loss of correction. We examined 50 patients regarding loss of correction after implant removal and clinical outcome using a validated visual analogue score. The average time of follow-up (FU) was 35 months. We observed a total loss of correction of 4°. The pre-injury mean VAS score was 92. At FU, there was an average reduction of 17.2 points. Owing to the presented results, we suggest this method as an alternative to combined procedures.

PLIF in thoracolumbar trauma: technique and radiological results

Patients with fractures from the 11th thoracic to the 5th lumbar vertebra had a reconstruction of the anterior column with monocortical iliac crest autograft by using a single dorsal approach. The loss of correction was observed using X-rays pre- and post-operatively, at 3 months and after implant removal (IR). Successful fusion was assessed using computed tomography after the implant removal. To assess the loss of correction and intervertebral fusion rate of this technique. There are still controversial discussions about the treatment modalities of spine lesions, especially in cases of burst fractures. Dorsal, combined and ventral procedures are reported with different assets and drawbacks. We want to present a method to restore the weight-bearing capability of the anterior column using a single dorsal approach. From 2001 to 2005, a total of 100 patients was treated with this technique at our department. Follow-up examination was possible in 82 patients. The X-rays and CT scans were proofed for loss of correction and fusion rate. The anterior column has been restored using a monocortical strut graft via a partial resection of the lamina and the apophyseal joint on one side to access the disc space. The dorsal reduction has been achieved using an angular stable pedicle screw system. The mean follow-up time was 15 months (range 8-39); 67 patients had a CT scan at follow-up and 83% showed a 360 degrees fusion. The average post-operative loss of correction was 3.3 degrees (range 0-21). The average duration of operation was 192 min (range 120-360) and the mean blood loss was 790 ml (range 300-3,400 ml). Regarding the complications we did not have any deep wound infections. We had two epidural haematomas postoperatively with a neurological deterioration that had to be revised. We were able to decompress the neurological structures and restore the weight-bearing capability of the anterior column in a one-stage procedure. So we think that this technique can be an alternative procedure to combined operations regarding the presented radiological results of successful fusion and loss of correction.