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Vercoulen TF, Niemeyer MJ, Peuker F, Verlaan JJ, Oner FC, Sadiqi S. Surgical treatment of traumatic fractures of the thoracic and lumbar spine: A systematic review. BRAIN & SPINE 2024; 4:102745. [PMID: 38510618 PMCID: PMC10951763 DOI: 10.1016/j.bas.2024.102745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/27/2023] [Accepted: 01/03/2024] [Indexed: 03/22/2024]
Abstract
Introduction The treatment of traumatic thoracic and lumbar spine fractures remains controversial. To date no consensus exists on the correct choice of surgical approach and technique. Research question to provide a comprehensive up-to-date overview of the available different surgical methods and their quantified outcomes. Methods PubMed and EMBASE were searched between 2001 and 2020 using the term 'spinal fractures'. Inclusion criteria were: adults, ≥10 cases, ≥12 months follow-up, thoracic or lumbar fractures, and surgery <3 weeks of trauma. Studies were categorized per surgical technique: Posterior open (PO), posterior percutaneous (PP), stand-alone vertebral body augmentation (SA), anterior scopic (AS), anterior open (AO), posterior percutaneous and anterior open (PPAO), posterior percutaneous and anterior scopic (PPAS), posterior open and anterior open (POAO) and posterior open and anterior scopic (POAS). The PO group was used as a reference group. Results After duplicate removal 6042 articles were identified. A total of 102 articles were Included, in which 137 separate surgical technique cohorts were described: PO (n = 75), PP, (n = 39), SA (n = 12), AO (n = 5), PPAO (n = 1), PPAS (n = 1), POAO (n = 2) and POAS (n = 2). Discussion and conclusion For type A3/A4 burst fractures, without severe neurological deficit, posterior percutaneous (PP) technique seems the safest and most feasible option in the past two decades. If needed, PP can be combined with anterior augmentation to prevent secondary kyphosis. Furthermore, posterior open (PO) technique is feasible in almost all types of fractures. Also, this technique can provide for an additional posterior decompression or fusion. Overall, no neurologic deterioration was reported following surgical intervention.
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Affiliation(s)
- Timon F.G. Vercoulen
- Diakonessenhuis, Department of Orthopedic Surgery, Bosboomstraat 1, 3582, KE, Utrecht, the Netherlands
- University Medical Center Utrecht, Department of Orthopedic Surgery, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands
| | - Menco J.S. Niemeyer
- University Medical Center Utrecht, Department of Orthopedic Surgery, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands
| | - Felix Peuker
- University Medical Center Utrecht, Department of Orthopedic Surgery, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands
| | - Jorrit-Jan Verlaan
- University Medical Center Utrecht, Department of Orthopedic Surgery, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands
| | - F. Cumhur Oner
- University Medical Center Utrecht, Department of Orthopedic Surgery, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands
| | - Said Sadiqi
- University Medical Center Utrecht, Department of Orthopedic Surgery, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands
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Krismann O, Rauschmann M, Sellei R, Medina-Govea F, Meyer F, Vinas-Rios JM. Operative results of AO A3 and A4 traumatic injuries in the thoracic and lumbar spine. A multicenter surveillance study of 4230 patients from the German Spine Registry (DWG-Register). J Neurosurg Sci 2023; 67:543-549. [PMID: 35301839 DOI: 10.23736/s0390-5616.21.05555-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The diagnosis, classification and treatment of thoracolumbar burst fractures, continue to be controversial. Surgery is generally the preferred treatment for unstable fractures while stable fractures are managed conservatively. This study aims to describe surgical procedures, outcomes, complications, demography, clinical features and differences between A3 and A4 fractures (AO classification) of the thoracolumbar region. A subgroup of patients <91 years with osteoporotic fractures is included and analyzed. METHODS Analysis of data from the DWG-Register German spine registry on operative treatment for thoracolumbar AO A3 and A4 fractures out of 170 departments from January 2017 to May 2021. The evaluated variables included age, gender, surgical approach (posterior, anterior combined), and re-operation. RESULTS In total, 4230 AO A3 and A4 thoracolumbar fractures were identified in the registry; 2898 A3 (group 1) and 1332 A4 (group 2). The preoperative ASIA-impairment scale score in group 1 was significantly different compared with group 2 (P=0.02). Surgical procedures such as decompression/stabilization with rod-screw system cemented/non-cemented, as well as an anterior approach, were statistically significant between the groups. Odds ratio was calculated for variables that could be influenced for the type of fracture (A3 or A4): decompression 4.89, OR time >2 hours 48.22, osteoporosis 6.46 and posterior access 9.85. CONCLUSIONS This study provides multicenter results from a huge number of surgically treated AO A3 and A4 fractures. Anterior approaches are more often used in A4 type fractures, probably because of its inherent instability related to burst fractures, surprisingly, not associated with the occurrence of added perioperative complications. Nevertheless, A3 type fractures are presented with worse ASIA Impairment-Scale at admission, in comparison with A4 type fractures of the thoracolumbar region.
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Affiliation(s)
| | | | - Richard Sellei
- Department of Traumatology, Sanaklinik, Offenbach am Main, Germany
| | - Fatima Medina-Govea
- Department of Clinical Epidemiology, Autonomous University of San Luis Potosí, San Luis Potosí, Mexico
| | - Frerk Meyer
- Department of Spinal Surgery, University Clinic for Neurosurgery, Oldenburg Evangelical Hospital, Oldenburg, Germany
| | - Juan M Vinas-Rios
- Department of Spinal Surgery, Sanaklinik, Offenbach am Main, Germany -
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Hughes H, Carthy AM, Sheridan GA, Donnell JM, Doyle F, Butler J. Thoracolumbar Burst Fractures: A Systematic Review and Meta-Analysis Comparing Posterior-Only Instrumentation Versus Combined Anterior-Posterior Instrumentation. Spine (Phila Pa 1976) 2021; 46:E840-E849. [PMID: 34228696 DOI: 10.1097/brs.0000000000003934] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Meta-analysis. OBJECTIVE To compare the clinical, functional, and radiological outcomes of posterior-only versus combined anterior-posterior instrumentation in order to determine the optimal surgical intervention for thoracolumbar burst fractures. SUMMARY OF BACKGROUND DATA Unstable thoracolumbar burst fractures warrant surgical intervention to prevent neurological deterioration and progressive kyphosis, which can lead to significant pain and functional morbidity. The available literature remains largely inconclusive in determining the optimal instrumentation strategy. METHODS Electronic searches of MEDLINE (1948-May 2020), EMBASE (1947-May 2020), The Cochrane Library (1991-May 2020), and other databases were conducted. Cochrane Collaboration guidelines were used for data extraction and quality assessment. Outcomes of interest were divided into three categories: radiological (degree of postoperative kyphosis correction; loss of kyphosis correction at final follow-up), functional (visual analogue scale [VAS] pain score; Oswestry Disability Index [ODI] score), and clinical (intraoperative blood loss; length of stay [LOS]; operative time; the number and type of postoperative complications). RESULTS Four randomized control trials (RCTs) were retrieved, including 145 randomized participants. Seventy-three patients underwent posterior-only instrumentation and 72 underwent combined instrumentation. No significant difference was found in the degree of postoperative kyphosis correction (P = 0.39), VAS (centimeters) at final follow-up (P = 0.67), ODI at final follow-up (P = 0.89) or the number of postoperative complications between the two approaches (P = 0.49). Posterior-only instrumentation was associated with lower blood loss (P < 0.001), operative time (P < 0.001), and LOS (P = 0.01). Combined instrumentation had a lower degree of kyphosis loss at final follow-up (P = 0.001). There was heterogeneity in the duration of follow-up between the included studies (mean follow-up range 24-121 months). CONCLUSION The available literature remains largely inconclusive. In order to reliably inform practice in this area, there is a need for large, high-quality, multicenter RCTs with standardized reporting of outcomes, with a particular focus on outcomes relating to patient function and severe complications causing long-term morbidity.Level of Evidence: 2.
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Affiliation(s)
- Hannah Hughes
- Department of Trauma and Orthopaedic Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Andrea Mc Carthy
- Department of Trauma and Orthopaedic Surgery, Cork University Hospital, Wilton, Cork, Ireland
| | - Gerard Anthony Sheridan
- Department of Trauma and Orthopaedic Surgery, Cork University Hospital, Wilton, Cork, Ireland
| | - Jake Mc Donnell
- Department of Trauma and Orthopaedic Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Frank Doyle
- Faculty of Medicine and Health Sciences, School of Postgraduate Studies, Royal College of Surgeons in Ireland, Ireland
| | - Joseph Butler
- Department of Trauma and Orthopaedic Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
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Pratheep KG, Viswanathan VK. Letter to the Editor: Does Combined Anterior-Posterior Approach Improve Outcomes Compared with Posterior-only Approach in Traumatic Thoracolumbar Burst Fractures?: A Systematic Review. Asian Spine J 2020; 14:760-761. [PMID: 33108839 PMCID: PMC7595818 DOI: 10.31616/asj.2020.0388.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 07/22/2020] [Indexed: 11/23/2022] Open
Affiliation(s)
- K Guna Pratheep
- Department of Spine Surgery, Ganga Medical Centre and Hospital Pvt. Ltd., Coimbatore, India
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5
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Tan T, Donohoe TJ, Huang MSJ, Rutges J, Marion T, Mathew J, Fitzgerald M, Tee J. Does Combined Anterior-Posterior Approach Improve Outcomes Compared with Posterioronly Approach in Traumatic Thoracolumbar Burst Fractures?: A Systematic Review. Asian Spine J 2020; 14:388-398. [PMID: 31906611 PMCID: PMC7280926 DOI: 10.31616/asj.2019.0203] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 08/08/2019] [Indexed: 01/11/2023] Open
Abstract
The aim of this systematic review was to evaluate the surgical, radiological, and functional outcomes of posterior-only versus combined anterior-posterior approaches in patients with traumatic thoracolumbar burst fractures. The ideal approach (anterior-only, posterior-only, or combined anterior-posterior) for the surgical management of thoracolumbar burst fracture remains controversial, with each approach having its advantages and disadvantages. A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed (registration no., CRD42018115120). The authors reviewed comparative studies evaluating posterior-only approach compared with combined anterior-posterior approaches with respect to clinical, surgical, radiographic, and functional outcome measures. Five retrospective cohort studies were included. Postoperative neurological deterioration was not reported in either group. Operative time, estimated blood loss, and postoperative length of stay were increased among patients in the combined anterior-posterior group in one study and equivalent between groups in another study. No significant difference was observed between the two approaches with regards to long-term postoperative Cobb angle (mean difference, -0.2; 95% confidence interval, -5.2 to 4.8; p =0.936). Moreover, no significant difference in functional patient outcomes was observed in the 36item Short-Form Health Survey, Visual Analog Scale, and return-to-work rates between the two groups. The available evidence does not indicate improved clinical, radiologic (including kyphotic deformity), and functional outcomes in the combined anterior-posterior and posterior-only approaches in the management of traumatic thoracolumbar burst fractures. Further studies are required to ascertain if a subset of patients will benefit from a combined anterior-posterior approach.
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Affiliation(s)
- Terence Tan
- National Trauma Research Institute, Melbourne, VIC, Australia.,Department of Neurosurgery, The Alfred Hospital, Melbourne, VIC, Australia
| | - Tom J Donohoe
- National Trauma Research Institute, Melbourne, VIC, Australia.,Department of Neurosurgery, St. Vincent's Hospital, Melbourne, VIC, Australia
| | - Milly Shu-Jing Huang
- National Trauma Research Institute, Melbourne, VIC, Australia.,Department of Neurosurgery, The Alfred Hospital, Melbourne, VIC, Australia
| | - Joost Rutges
- Department of Orthopaedics, Erasmus MC, Rotterdam, Netherlands
| | - Travis Marion
- Division of Orthopaedic Surgery, Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Joseph Mathew
- National Trauma Research Institute, Melbourne, VIC, Australia
| | - Mark Fitzgerald
- National Trauma Research Institute, Melbourne, VIC, Australia
| | - Jin Tee
- National Trauma Research Institute, Melbourne, VIC, Australia.,Department of Neurosurgery, The Alfred Hospital, Melbourne, VIC, Australia
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Anderson PA, Raksin PB, Arnold PM, Chi JH, Dailey AT, Dhall SS, Eichholz KM, Harrop JS, Hoh DJ, Qureshi S, Rabb CH, Kaiser MG, O'Toole JE. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients with Thoracolumbar Spine Trauma: Surgical Approaches. Neurosurgery 2019; 84:E56-E58. [PMID: 30203100 DOI: 10.1093/neuros/nyy363] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/16/2018] [Indexed: 11/13/2022] Open
Abstract
QUESTION Does the choice of surgical approach (anterior, posterior, or combined anterior-posterior) improve clinical outcomes in patients with thoracic and lumbar fractures? RECOMMENDATIONS In the surgical treatment of patients with thoracolumbar burst fractures, physicians may use an anterior, posterior, or a combined approach as the selection of approach does not appear to impact clinical or neurological outcomes. Strength of Recommendation: Grade B With regard to radiologic outcomes in the surgical treatment of patients with thoracolumbar fractures, physicians may utilize an anterior, posterior, or combined approach because there is conflicting evidence in the comparison among approaches. Strength of Recommendation: Grade Insufficient With regard to complications in the surgical treatment of patients with thoracolumbar fractures, physicians may use an anterior, posterior, or combined approach because there is conflicting evidence in the comparison among approaches. Strength of Recommendation: Grade Insufficient The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_11.
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Affiliation(s)
- Paul A Anderson
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, Wisconsin
| | - P B Raksin
- Division of Neurosurgery, John H. Stroger, Jr Hospital of Cook County and Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
| | - Paul M Arnold
- Department of Neurosurgery, University of Kansas School of Medicine, Kansas City, Kansas
| | - John H Chi
- Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Andrew T Dailey
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Sanjay S Dhall
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Kurt M Eichholz
- St. Louis Minimally Invasive Spine Center, St. Louis, Missouri
| | - James S Harrop
- Departments of Neurological Surgery and Orthopedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Daniel J Hoh
- Lillian S. Wells Department of Neurological Surgery, University of Florida, Gainesville, Florida
| | - Sheeraz Qureshi
- Department of Orthopaedic Surgery, Weill Cornell Medical College, New York, New York
| | - Craig H Rabb
- Department of Neurosurgery, Columbia University, New York, New York
| | - Michael G Kaiser
- Department of Neurosurgery, Columbia University, New York, New York
| | - John E O'Toole
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
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7
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Verheyden AP, Spiegl UJ, Ekkerlein H, Gercek E, Hauck S, Josten C, Kandziora F, Katscher S, Kobbe P, Knop C, Lehmann W, Meffert RH, Müller CW, Partenheimer A, Schinkel C, Schleicher P, Scholz M, Ulrich C, Hoelzl A. Treatment of Fractures of the Thoracolumbar Spine: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU). Global Spine J 2018; 8:34S-45S. [PMID: 30210959 PMCID: PMC6130107 DOI: 10.1177/2192568218771668] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
STUDY DESIGN consensus paper with systematic literature review. OBJECTIVE The aim of this study was to establish recommendations for treatment of thoracolumbar spine fractures based on systematic review of current literature and consensus of several spine surgery experts. METHODS The project was initiated in September 2008 and published in Germany in 2011. It was redone in 2017 based on systematic literature review, including new AOSpine classification. Members of the expert group were recruited from all over Germany working in hospitals of all levels of care. In total, the consensus process included 9 meetings and 20 hours of video conferences. RESULTS As regards existing studies with highest level of evidence, a clear recommendation regarding treatment (operative vs conservative) or regarding type of surgery (posterior vs anterior vs combined anterior-posterior) cannot be given. Treatment has to be indicated individually based on clinical presentation, general condition of the patient, and radiological parameters. The following specific parameters have to be regarded and are proposed as morphological modifiers in addition to AOSpine classification: sagittal and coronal alignment of spine, degree of vertebral body destruction, stenosis of spinal canal, and intervertebral disc lesion. Meanwhile, the recommendations are used as standard algorithm in many German spine clinics and trauma centers. CONCLUSION Clinical presentation and general condition of the patient are basic requirements for decision making. Additionally, treatment recommendations offer the physician a standardized, reproducible, and in Germany commonly accepted algorithm based on AOSpine classification and 4 morphological modifiers.
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Affiliation(s)
- Akhil P. Verheyden
- Clinic for Trauma, Orthopaedic and Spine Surgery, Lahr, Germany,These authors contributed equally to this article.,Akhil P. Verheyden, Clinic for Trauma, Orthopaedic and Spine Surgery, Lahr, 77933, Germany.
| | - Ulrich J. Spiegl
- Klinik für Orthopädie, Unfallchirurgie und plastische Chirurgie, Leipzig, Germany,These authors contributed equally to this article
| | | | - Erol Gercek
- Zentrum für Unfallchirurgie und Orthopädie, Koblenz, Germany
| | - Stefan Hauck
- Clinic for Trauma, Orthopaedic and Spine Surgery, Lahr, Germany
| | - Christoph Josten
- Klinik für Orthopädie, Unfallchirurgie und plastische Chirurgie, Leipzig, Germany
| | - Frank Kandziora
- Zentrum für Wirbelsäulenchirurgie und Neurotraumatologie, Frankfurt am Main, Germany
| | - Sebastian Katscher
- Leitender Arzt Orthopädie / Unfallchirurgie, Sana Klinikum Borna, Borna, Germany
| | - Philipp Kobbe
- Sektion Becken- und Wirbelsäulenchirurgie, Uniklinik RWTH Aachen, Aachen, Germany
| | - Christian Knop
- Klinik für Unfallchirurgie und Orthopädie, Klinikum Stuttgart, Katharinenhospital, Stuttgart, Germany
| | - Wolfgang Lehmann
- Department of Trauma Surgery, Orthopaedics and Plastic Surgery, University Medical Center Goettingen, Göttingen, Germany
| | - Rainer H. Meffert
- Klinik und Poliklinik für Unfall-, Hand-, Plastische- und Wiederherstellungschirurgie, Universitätsklinik Würzburg, Würzburg, Germany
| | - Christian W. Müller
- Unfallchirurgische Klinik, Medizinische Hochschule Hannover, Hannover, Germany
| | | | - Christian Schinkel
- Klinik für Unfallchirurgie, Handchirurgie und Orthopädie, Klinikum Memmingen, Memmingen, Germany
| | - Philipp Schleicher
- Zentrum für Wirbelsäulenchirurgie und Neurotraumatologie, Frankfurt am Main, Germany
| | - Matti Scholz
- Zentrum für Wirbelsäulenchirurgie und Neurotraumatologie, Frankfurt am Main, Germany
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Lindtner RA, Mueller M, Schmid R, Spicher A, Zegg M, Kammerlander C, Krappinger D. Monosegmental anterior column reconstruction using an expandable vertebral body replacement device in combined posterior-anterior stabilization of thoracolumbar burst fractures. Arch Orthop Trauma Surg 2018; 138:939-951. [PMID: 29623406 PMCID: PMC5999121 DOI: 10.1007/s00402-018-2926-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Indexed: 12/26/2022]
Abstract
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.
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Affiliation(s)
- Richard A Lindtner
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Max Mueller
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Rene Schmid
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Anna Spicher
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Michael Zegg
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Christian Kammerlander
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
- Department of General, Trauma and Reconstructive Surgery, Ludwig Maximilian University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Dietmar Krappinger
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.
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9
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Piazza M, Sinha S, Agarwal P, Mallela A, Nayak N, Schuster J, Stein S. Post-operative bracing after pedicle screw fixation for thoracolumbar burst fractures: A cost-effectiveness study. J Clin Neurosci 2017; 45:33-39. [PMID: 28800928 DOI: 10.1016/j.jocn.2017.07.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 07/21/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE While frequently prescribed to patients following fixation for spine trauma, the utility of spinal orthoses during the post-operative period is poorly described in the literature. In this study, we calculated rates of reoperation and performed a decision analysis to determine the utility of bracing following pedicle screw fixation for thoracic and lumbar burst fractures. METHODS Pubmed was searched for articles published between 2005 and 2015 for terms related to pedicle screw fixation of thoracolumbar fractures. Additionally, a database of neurosurgical patients operated on within the authors institution was also used in the analysis. Incidences of significant adverse events (wound revision for either dehiscence or infection or re-operation for non-union or instability due to hardware failure) were determined. Pooled means and variances of reported parameters were obtained using a random-effects, inverse variance meta-analytic model for observational data. Utilities for surgical outcome and complications were assigned using previously published values. RESULTS Of the 225 abstracts reviewed, 48 articles were included in the study, yielding a total of 1957 patients. After including patients from the institutional registry, together a total of 2081 patients were included in the final analysis, 1328 of whom were braced. Non-braced patients were older then braced patients, although this only approached significance (p=0.051). Braced patients had significantly lower rates of re-operation for non-union or clinically significant hardware failure (1.3% vs. 1.8%, p<0.001) although the groups had comparable rates of operative wound dehiscence and infection (p=1.000). These two approaches yielded comparable utility scores (p=0.120). Costs between braced and non-braced patients were comparable excluding the cost of the brace (p=0.256); hence, the added cost of the brace suggests that bracing post-operatively is not a cost effective measure. CONCLUSIONS Bracing following operative stabilization of thoracolumbar fracture does not significantly improve stability, nor does it increase wound complications. Moreover, our data suggests that post-operative bracing may not be a cost-effective measure.
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Affiliation(s)
- Matthew Piazza
- Hospital of the University of Pennsylvania, Department of Neurosurgery, 3400 Spruce Street, 3 Silverstein Pavilion, Philadelphia, PA 19104, United States.
| | - Saurabh Sinha
- Hospital of the University of Pennsylvania, Department of Neurosurgery, 3400 Spruce Street, 3 Silverstein Pavilion, Philadelphia, PA 19104, United States
| | - Prateek Agarwal
- Hospital of the University of Pennsylvania, Department of Neurosurgery, 3400 Spruce Street, 3 Silverstein Pavilion, Philadelphia, PA 19104, United States
| | - Arka Mallela
- Hospital of the University of Pennsylvania, Department of Neurosurgery, 3400 Spruce Street, 3 Silverstein Pavilion, Philadelphia, PA 19104, United States
| | - Nikhil Nayak
- Hospital of the University of Pennsylvania, Department of Neurosurgery, 3400 Spruce Street, 3 Silverstein Pavilion, Philadelphia, PA 19104, United States
| | - James Schuster
- Hospital of the University of Pennsylvania, Department of Neurosurgery, 3400 Spruce Street, 3 Silverstein Pavilion, Philadelphia, PA 19104, United States
| | - Sherman Stein
- Hospital of the University of Pennsylvania, Department of Neurosurgery, 3400 Spruce Street, 3 Silverstein Pavilion, Philadelphia, PA 19104, United States
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10
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Minimally Invasive Posterior Decompression Combined With Percutaneous Pedicle Screw Fixation for the Treatment of Thoracolumbar Fractures With Neurological Deficits: A Prospective Randomized Study Versus Traditional Open Posterior Surgery. Spine (Phila Pa 1976) 2016; 41 Suppl 19:B23-B29. [PMID: 27656782 DOI: 10.1097/brs.0000000000001814] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective randomized cohort study. OBJECTIVE To compare the surgical results of minimally invasive posterior decompression combined with percutaneous pedicle screws fixation (minimally invasive surgery [MIS]) and posterior open surgery (OS) for the treatment of thoracolumbar fracture with neurological deficits. SUMMARY OF BACKGROUND DATA Thoracolumbar fracture with neurological deficits usually undergoes surgical intervention. OS can achieve satisfied results, but the main disadvantage is approach-related complications. No study, however, focused on the treatment of this disease by MIS through posterior approach. METHODS Sixty consecutive cases of thoracolumbar fractures with neurological deficits were randomized into MIS group and OS group. Incision length, blood loss, postoperative drainage volume, hospitalization days, blood transfusion rate, analgesic use rate, and x-ray exposure time were used to evaluate the perioperative information and Visual Analog Scale (VAS), Japanese Orthopedics Association (JOA) score, and American Spinal Injury Association grade for patients' symptom. For radiological assessment, sagittal Cobb angle, percentage of vertebral height, and vertebral wedging angle were measured. RESULTS Fifty-nine of sixty patients were followed-up for at least 12 months. MIS group was superior in perioperative information (P < 0.05), except in the operative time (P = 0.165) and x-ray time (P = 0.000). The operative time seemed longer in MIS group, but no significant difference was found. The x-ray time was significantly higher in MIS group. The mean Visual Analog Scale and Japanese Orthopedics Association scores of the final follow-up in MIS group were better than that in OS group (P < 0.05). Patients in both group achieved a similar neurological recovery according to American Spinal Injury Association grade (P = 0.760). A broken screw was found in one patient in MIS group and a broken rod in one patient in OS group. CONCLUSION MIS group has achieved the similar effect of OS group and it can minimize the approach-related complication. It also faced with some shortages, such as larger radiation dose and longer learning curve. LEVEL OF EVIDENCE 2.
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Skoch J, Zoccali C, Zaninovich O, Martirosyan N, Walter CM, Maykowski P, Baaj AA. Bracing After Surgical Stabilization of Thoracolumbar Fractures: A Systematic Review of Evidence, Indications, and Practices. World Neurosurg 2016; 93:221-8. [DOI: 10.1016/j.wneu.2016.05.067] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 05/21/2016] [Accepted: 05/23/2016] [Indexed: 10/21/2022]
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Sadiqi S, Lehr AM, Post MW, Jacobs WCH, Aarabi B, Chapman JR, Dunn RN, Dvorak MF, Fehlings MG, Rajasekaran S, Vialle LR, Vaccaro AR, Oner FC. The selection of core International Classification of Functioning, Disability, and Health (ICF) categories for patient-reported outcome measurement in spine trauma patients-results of an international consensus process. Spine J 2016; 16:962-70. [PMID: 27058286 DOI: 10.1016/j.spinee.2016.03.050] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 03/09/2016] [Accepted: 03/31/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT There is no outcome instrument specifically designed and validated for spine trauma patients without complete paralysis, which makes it difficult to compare outcomes of different treatments of the spinal column injury within and between studies. PURPOSE The paper aimed to report on the evidence-based consensus process that resulted in the selection of core International Classification of Functioning, Disability, and Health (ICF) categories, as well as the response scale for use in a universal patient-reported outcome measure for patients with traumatic spinal column injury. STUDY DESIGN/SETTING The study used a formal decision-making and consensus process. PATIENT SAMPLE The sample includes patients with a primary diagnosis of traumatic spinal column injury, excluding completely paralyzed and polytrauma patients. OUTCOME MEASURES The wide array of function and health status of patients with traumatic spinal column injury was explored through the identification of all potentially meaningful ICF categories. METHODS A formal decision-making and consensus process integrated evidence from four preparatory studies. Three studies aimed to identify relevant ICF categories from three different perspectives. The research perspective was covered by a systematic literature review identifying outcome measures focusing on the functioning and health of spine trauma patients. The expert perspective was explored through an international web-based survey among spine surgeons from the five AOSpine International world regions. The patient perspective was investigated in an international empirical study. A fourth study investigated various response scales for their potential use in the future universal outcome instrument. This work was supported by AOSpine. AOSpine is a clinical division of the AO Foundation, an independent medically guided non-profit organization. The AOSpine Knowledge Forums are pathology-focused working groups acting on behalf of AOSpine in their domain of scientific expertise. RESULTS Combining the results of the preparatory studies, the list of ICF categories presented at the consensus conference included 159 different ICF categories. Based on voting and discussion, 11 experts from 6 countries selected a total of 25 ICF categories as core categories for patient-reported outcome measurement in adult traumatic spinal column injury patients (9 body functions, 14 activities and participation, and 2 environmental factors). The experts also agreed to use the Numeric Rating Scale 0-100 as response scale in the future universal outcome instrument. CONCLUSIONS A formal consensus process integrating evidence and expert opinion led to a set of 25 core ICF categories for patient-reported outcome measurement in adult traumatic spinal column injury patients, as well as the response scale for use in the future universal disease-specific outcome instrument. The adopted core ICF categories could also serve as a benchmark for assessing the content validity of existing and future outcome instruments used in this specific patient population.
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Affiliation(s)
- Said Sadiqi
- Department of Orthopaedics, University Medical Center Utrecht, HP G05.228, P.O. Box 85500, 3508GA Utrecht, The Netherlands.
| | - A Mechteld Lehr
- Department of Orthopaedics, University Medical Center Utrecht, HP G05.228, P.O. Box 85500, 3508GA Utrecht, The Netherlands
| | - Marcel W Post
- Rehabilitation Center "De Hoogstraat", Rembrandtkade 10, 3583TM Utrecht, The Netherlands; Department of Rehabilitation Medicine, Center for Rehabilitation, University Medical Center Groningen, Hanzeplein 1, 9713 Groningen, The Netherlands
| | - Wilco C H Jacobs
- Department of Neurosurgery, Leiden University Medical Center, Rijnsburgerweg 10, 2333 AA Leiden, The Netherlands
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland, 22 S Greene St, Suite S-12-D, Baltimore, MD, USA
| | - Jens R Chapman
- Department of Neurosurgery, Swedish Neurosciences Institute, 500 17th Ave, Seattle, WA, USA
| | - Robert N Dunn
- Division of Orthopedic Surgery, Groote Schuur Hospital, University of Cape Town, Main Road, Observatory, 7935, Cape Town, South Africa
| | - Marcel F Dvorak
- Department of Orthopaedics, University of British Columbia, 818 10th Avenue West, Vancouver, British Columbia, V5Z 1M9 Canada
| | - Michael G Fehlings
- Division of Neurosurgery, 4W449, Toronto Western Hospital, 399 Bathurst St, Toronto, M5T 2S8, Ontario, Canada
| | - S Rajasekaran
- Department of Orthopaedic and Spine Surgery, Ganga Hospital, 313 Mettupalayam Road, Coimbatore, India
| | - Luiz R Vialle
- Department of Orthopaedics, Catholic University of Parana, Brigadeiro Franco 979 80.430-210, Curitiba, Brazil
| | - Alexander R Vaccaro
- Department of Orthopaedics, Thomas Jefferson University, 925 Chestnut Street, 5th Floor, Philadelphia, PA, USA
| | - F Cumhur Oner
- Department of Orthopaedics, University Medical Center Utrecht, HP G05.228, P.O. Box 85500, 3508GA Utrecht, The Netherlands
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Kepler CK, Vaccaro AR, Schroeder GD, Koerner JD, Vialle LR, Aarabi B, Rajasekaran S, Bellabarba C, Chapman JR, Kandziora F, Schnake KJ, Dvorak MF, Reinhold M, Oner FC. The Thoracolumbar AOSpine Injury Score. Global Spine J 2016; 6:329-34. [PMID: 27190734 PMCID: PMC4868575 DOI: 10.1055/s-0035-1563610] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 07/13/2015] [Indexed: 11/10/2022] Open
Abstract
Study Design Survey of 100 worldwide spine surgeons. Objective To develop a spine injury score for the AOSpine Thoracolumbar Spine Injury Classification System. Methods Each respondent was asked to numerically grade the severity of each variable of the AOSpine Thoracolumbar Spine Injury Classification System. Using the results, as well as limited input from the AOSpine Trauma Knowledge Forum, the Thoracolumbar AOSpine Injury Score was developed. Results Beginning with 1 point for A1, groups A, B, and C were consecutively awarded an additional point (A1, 1 point; A2, 2 points; A3, 3 points); however, because of a significant increase in the severity between A3 and A4 and because the severity of A4 and B1 was similar, both A4 and B1 were awarded 5 points. An uneven stepwise increase in severity moving from N0 to N4, with a substantial increase in severity between N2 (nerve root injury with radicular symptoms) and N3 (incomplete spinal cord injury) injuries, was identified. Hence, each grade of neurologic injury was progressively given an additional point starting with 0 points for N0, and the substantial difference in severity between N2 and N3 injuries was recognized by elevating N3 to 4 points. Finally, 1 point was awarded to the M1 modifier (indeterminate posterolateral ligamentous complex injury). Conclusion The Thoracolumbar AOSpine Injury Score is an easy-to-use, data-driven metric that will allow for the development of a surgical algorithm to accompany the AOSpine Thoracolumbar Spine Injury Classification System.
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Affiliation(s)
- Christopher K. Kepler
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Alexander R. Vaccaro
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Gregory D. Schroeder
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, United States,Address for correspondence Gregory D. Schroeder, MD 925 Chestnut Street, 5th floor, Philadelphia, PA 19107United States
| | - John D. Koerner
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Luiz R. Vialle
- Department of Orthopaedic Surgery, Catholic University, Curitiba, Brazil
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | | | - Carlo Bellabarba
- Department of Orthopaedic Surgery, University of Washington, Seattle, Washington, United States
| | - Jens R. Chapman
- Department of Orthopaedic Surgery, The Swedish Neuroscience Institute, Seattle, Washington, United States
| | - Frank Kandziora
- Center for Spinal Surgery and Neurotraumatology, Berufsgenossenschaftliche Unfallklinik Frankfurt, Frankfurt/Main, Germany
| | - Klaus J. Schnake
- Center for Spinal Surgery, Schön Klinik Nürnberg Fürth, Fürth, Germany
| | - Marcel F. Dvorak
- Department of Orthopaedic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Max Reinhold
- Department of Orthopaedic Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - F. Cumhur Oner
- Department of Orthopaedic Surgery, University Medical Center, Utrecht, The Netherlands
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The Influence of Spine Surgeons' Experience on the Classification and Intraobserver Reliability of the Novel AOSpine Thoracolumbar Spine Injury Classification System-An International Study. Spine (Phila Pa 1976) 2015; 40:E1250-6. [PMID: 26165219 DOI: 10.1097/brs.0000000000001042] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN International validation study. OBJECTIVE To investigate the influence of the spine surgeons' level of experience on the intraobserver reliability of the novel AOSpine Thoracolumbar Spine Injury Classification system, and the appropriate classification according to this system. SUMMARY OF BACKGROUND DATA Wide variability has been demonstrated for intraobserver reliability of the AOSpine classification system. The spine surgeons' level of experience may play a crucial role in the appropriate classification of thoracolumbar fractures, and the degree of reproducibility of the same observer on separate occasions. However, this has not been previously investigated. METHODS After a training on the classification system, high quality CT images together with clinical data from 25 patients with thoracolumbar fractures were independently assessed by 100 spine surgeons from across the world on 2 different occasions, 1 month apart from each other. The spine surgeons were allocated to a subgroup, according to their years of experience. Intraobserver reliability was calculated for each individual surgeon and for each subgroup, using the Kappa statistics (κ). Descriptive statistics was used to describe any differences between the subgroups. Analysis of any misclassifications was performed by calculating sensitivity and specificity estimates. RESULTS Almost all surgeons demonstrated at least moderate intraobserver reliability. All surgeon subgroups demonstrated substantial reliability (κ = 0.67-0.69) for fracture subtype grading, and almost all subgroups demonstrated excellent reliability (κ = 0.79-0.83) for fracture morphology type regardless of subtype identified. In general, the fractures were most frequently misclassified by the most experienced surgeons. No major differences were observed among the subgroups when comparing the sensitivity and specificity rates. CONCLUSION This international study demonstrated that the spine surgeons' level of experience does not substantially influence the classification and intraobserver reliability of the recently described AOSpine Thoracolumbar Spine Injury Classification System. LEVEL OF EVIDENCE 4.
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Tang HZ, Xu H, Yao XD, Lin SQ. Single-stage posterior vertebral column resection and internal fixation for old fracture-dislocations of thoracolumbar spine: a case series and systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 25:2497-513. [PMID: 25953526 DOI: 10.1007/s00586-015-3955-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 04/11/2015] [Accepted: 04/11/2015] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate the efficacy of single-stage posterior vertebral column resection for old thoracolumbar fracture-dislocations with spinal cord injury. METHODS From January 2007 to June 2013, twelve male patients (average age, 32.6 years; range 19-57 years) with old fracture-dislocations of the thoracolumbar spine and spinal cord injury underwent single-stage posterior vertebral column resection and internal fixation. All patients were assessed for relief of the pain and restoration of neurologic function. Postoperative Cobb angle was measured and bone graft fusion was evaluated by X-ray. A systematic review of 25 studies evaluating surgical management of thoracolumbar fractures with spinal cord injuries was also performed. RESULTS From our case series, six of the nine patients with Frankel grade A had significant improvement in urination and defecation after surgery. The three patients with Frankel grades B and C had progression of 1-2 grades after surgery. Bony fusion was achieved and local back pain was relieved in all patients after surgery. From our systematic review of 25 studies, the majority of patients had improved back pain, the postoperative kyphotic angle was significantly reduced compared with pre-operative kyphotic angle. CONCLUSION Single-stage posterior vertebral column resection and internal fixation for old thoracolumbar fracture-dislocations is an ideal treatment allowing for thorough decompression, relief of pain, correction of deformities, and restoration of spinal stability. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Huan-Zhang Tang
- Department of Orthopaedic Surgery, Fuzhou General Hospital of Nanjing Command PLA, No. 156, North Xi-er-huan Road, Fuzhou, 350025, China.
| | - Hao Xu
- Department of Orthopaedic Surgery, Fuzhou General Hospital of Nanjing Command PLA, No. 156, North Xi-er-huan Road, Fuzhou, 350025, China
| | - Xiao-Dong Yao
- Department of Orthopaedic Surgery, Fuzhou General Hospital of Nanjing Command PLA, No. 156, North Xi-er-huan Road, Fuzhou, 350025, China
| | - Song-Qing Lin
- Department of Orthopaedic Surgery, Fuzhou General Hospital of Nanjing Command PLA, No. 156, North Xi-er-huan Road, Fuzhou, 350025, China
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Scheer JK, Bakhsheshian J, Fakurnejad S, Oh T, Dahdaleh NS, Smith ZA. Evidence-Based Medicine of Traumatic Thoracolumbar Burst Fractures: A Systematic Review of Operative Management across 20 Years. Global Spine J 2015; 5:73-82. [PMID: 25648401 PMCID: PMC4303483 DOI: 10.1055/s-0034-1396047] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 10/12/2014] [Indexed: 11/16/2022] Open
Abstract
Study Design Systematic literature review. Objective The management of traumatic thoracolumbar burst fractures (TLBF) remains challenging, and analyzing the levels of evidence (LOEs) for treatment practices can reform the decision-making process. However, no review has yet evaluated the operative management of traumatic thoracolumbar burst fractures with particular attention placed on LOE from an established methodology. The objective of the present study was to characterize the literature evidence for TLBF, specifically for operative management. Methods A comprehensive search of the English literature over the past 20 years was conducted using PubMed (MEDLINE). The inclusion criteria consisted of (1) traumatic burst fractures (2) in the thoracic or lumbar spine. Exclusion criteria included (1) osteoporotic burst fractures, (2) pathologic burst fractures, (3) cervical fractures, (4) biomechanical studies or those involving cadavers, and (5) computer-based studies. Studies were assigned an LOE and those meeting level 1 or 2 were included. Results From 1,138 abstracts, 272 studies met the criteria. Twenty-three studies (8.5%) met level 1 (n = 4, 1.5%) or 2 (n = 19, 7.0%) criteria. All 23 studies were reported. Conclusions The literature contains a high LOE to support the operative management of traumatic thoracolumbar burst fractures. For patients who are neurologically intact, a high LOE demonstrated similar functional outcomes, lower complication rates, and less costs with conservative management when compared with surgical management. There is a high LOE for short- or long-segment pedicle instrumentation without fusion and less invasive (percutaneous and paraspinal) approaches. Furthermore, the posterior approaches are associated with lower complications as opposed to the anterior or combined approaches.
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Affiliation(s)
- Justin K. Scheer
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, United States,Address for correspondence Justin K. Scheer, BS Department of Neurological Surgery, Northwestern UniversityFeinberg School of Medicine, 676 N. St. Clair Street, Suite 2210, Chicago, IL 60611United States
| | - Joshua Bakhsheshian
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, United States
| | - Shayan Fakurnejad
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, United States
| | - Taemin Oh
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, United States
| | - Nader S. Dahdaleh
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, United States
| | - Zachary A. Smith
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, United States
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Kepler CK, Vaccaro AR, Koerner JD, Dvorak MF, Kandziora F, Rajasekaran S, Aarabi B, Vialle LR, Fehlings MG, Schroeder GD, Reinhold M, Schnake KJ, Bellabarba C, Cumhur Öner F. Reliability analysis of the AOSpine thoracolumbar spine injury classification system by a worldwide group of naïve spinal surgeons. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 25:1082-6. [PMID: 25599849 DOI: 10.1007/s00586-015-3765-9] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 01/08/2015] [Accepted: 01/09/2015] [Indexed: 11/29/2022]
Abstract
PURPOSE The aims of this study were (1) to demonstrate the AOSpine thoracolumbar spine injury classification system can be reliably applied by an international group of surgeons and (2) to delineate those injury types which are difficult for spine surgeons to classify reliably. METHODS A previously described classification system of thoracolumbar injuries which consists of a morphologic classification of the fracture, a grading system for the neurologic status and relevant patient-specific modifiers was applied to 25 cases by 100 spinal surgeons from across the world twice independently, in grading sessions 1 month apart. The results were analyzed for classification reliability using the Kappa coefficient (κ). RESULTS The overall Kappa coefficient for all cases was 0.56, which represents moderate reliability. Kappa values describing interobserver agreement were 0.80 for type A injuries, 0.68 for type B injuries and 0.72 for type C injuries, all representing substantial reliability. The lowest level of agreement for specific subtypes was for fracture subtype A4 (Kappa = 0.19). Intraobserver analysis demonstrated overall average Kappa statistic for subtype grading of 0.68 also representing substantial reproducibility. CONCLUSION In a worldwide sample of spinal surgeons without previous exposure to the recently described AOSpine Thoracolumbar Spine Injury Classification System, we demonstrated moderate interobserver and substantial intraobserver reliability. These results suggest that most spine surgeons can reliably apply this system to spine trauma patients as or more reliably than previously described systems.
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Affiliation(s)
- Christopher K Kepler
- Thomas Jefferson University and Rothman Institute, 925 Chesnut Street, 5th Floor, Philadelphia, PA, 19107, USA
| | - Alexander R Vaccaro
- Thomas Jefferson University and Rothman Institute, 925 Chesnut Street, 5th Floor, Philadelphia, PA, 19107, USA
| | - John D Koerner
- Thomas Jefferson University and Rothman Institute, 925 Chesnut Street, 5th Floor, Philadelphia, PA, 19107, USA
| | | | - Frank Kandziora
- Berufsgenossenschaftliche Unfallklinik Frankfurt, Center for Spinal Surgery and Neurotraumatology, Friedberger Landstrasse 430, 60389, Frankfurt, Germany
| | | | - Bizhan Aarabi
- University of Maryland Medical Center, College Park, MD, USA
| | | | - Michael G Fehlings
- University of Toronto Spine Program and Toronto Western Hospital, Toronto, ON, Canada
| | - Gregory D Schroeder
- Thomas Jefferson University and Rothman Institute, 925 Chesnut Street, 5th Floor, Philadelphia, PA, 19107, USA.
| | - Maximilian Reinhold
- Klinikum Suedstadt Rostock, Department of Orthopaedic and Trauma Surgery, Suedring 81, 18059, Rostock, Germany
| | - Klaus John Schnake
- Center for Spinal Surgery and Neurotraumatology, Berufsgenossenschaftliche Unfallklinik Frankfurt, Friedberger Landstrasse 430, 60389, Frankfurt/Main, Germany
| | - Carlo Bellabarba
- Harborview Medical Center, University of Washington School of Medicine, 325 9th Avenue, Box 359798, Seattle, WA, 98104, USA
| | - F Cumhur Öner
- School of Medicine, University of Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, Netherlands
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Wood KB, Buttermann GR, Phukan R, Harrod CC, Mehbod A, Shannon B, Bono CM, Harris MB. Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit: a prospective randomized study with follow-up at sixteen to twenty-two years. J Bone Joint Surg Am 2015; 97:3-9. [PMID: 25568388 DOI: 10.2106/jbjs.n.00226] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Studies comparing operative with nonoperative treatment of a stable burst fracture of the thoracolumbar junction in neurologically intact patients have not shown a meaningful difference at early follow-up. To our knowledge, longer-term outcome data have not before been presented. METHODS From 1992 to 1998, forty-seven consecutive patients with a stable thoracolumbar burst fracture and no neurological deficit were evaluated and randomized to one of two treatment groups: operative treatment (posterior or anterior arthrodesis) or nonoperative treatment (a body cast or orthosis). We previously reported the results of follow-up at an average of forty-four months. The current study presents the results of long-term follow-up, at an average of eighteen years (range, sixteen to twenty-two years). As in the earlier study, patients at long-term follow-up indicated the degree of pain on a visual analog scale and completed the Roland and Morris disability questionnaire, the Oswestry Disability Index (ODI) questionnaire, and the Short Form-36 (SF-36) health survey. Work and health status were obtained, and patients were evaluated radiographically. RESULTS Of the original operatively treated group of twenty-four patients, follow-up data were obtained for nineteen; one patient had died, and four could not be located. Of the original nonoperatively treated group of twenty-three patients, data were obtained for eighteen; two patients had died, and three could not be located. The average kyphosis was not significantly different between the two groups (13° for those who received operative treatment compared with 19° for those treated nonoperatively). Median scores for pain (4 cm for the operative group and 1.5 cm for the nonoperative group; p = 0.003), ODI scores (20 for the operative group and 2 for the nonoperative group; p <0.001) and Roland and Morris scores (7 for the operative group and 1 for the nonoperative group; p = 0.001) were all significantly better in the group treated nonoperatively. Seven of eight SF-36 scores also favored nonoperative treatment. CONCLUSIONS While early analysis (four years) revealed few significant differences between the two groups, at long-term follow-up (sixteen to twenty-two years), those with a stable burst fracture who were treated nonoperatively reported less pain and better function compared with those who were treated surgically.
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Affiliation(s)
- Kirkham B Wood
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Yawkey OCC #3800 Boston, MA 02114. E-mail address for K.B. Wood:
| | - Glenn R Buttermann
- Midwest Spine Institute, 1950 Curve Crest Boulevard West, Suite 100, Stillwater, MN 55082
| | - Rishabh Phukan
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Yawkey OCC #3800 Boston, MA 02114. E-mail address for K.B. Wood:
| | - Christopher C Harrod
- Bone and Joint Clinic of Baton Rouge, 7301 Hennessy Boulevard, Suite 300, Baton Rouge, LA 70808
| | - Amir Mehbod
- Twin Cities Spine Center, Piper Building, 913 East 26th Street, Suite 600, Minneapolis, MN 55404
| | - Brian Shannon
- Sharon Regional Hospital, 740 East State Street, Sharon, PA 16146
| | - Christopher M Bono
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, Boston, MA 02115
| | - Mitchel B Harris
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, Boston, MA 02115
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Minimally invasive spinal surgery for the treatment of traumatic thoracolumbar burst fractures. J Clin Neurosci 2015; 22:42-7. [DOI: 10.1016/j.jocn.2014.05.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 04/21/2014] [Accepted: 05/04/2014] [Indexed: 11/22/2022]
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Clinical application of the paraspinal erector approach for spinal canal decompression in upper lumber burst fractures. J Orthop Surg Res 2014; 9:105. [PMID: 25387608 PMCID: PMC4240844 DOI: 10.1186/s13018-014-0105-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 10/21/2014] [Indexed: 11/10/2022] Open
Abstract
Objective Percutaneous pedicle screw fixation is commonly used for upper lumber burst fractures. The direct decompression remains challenging with this minimally invasive surgery. The objective was to evaluate a novel paraspinal erector approach for effective and direct decompression in patients with canal compromise and neurologic deficit. Method Patients (n = 21) with neurological deficiency and Denis B type upper lumbar burst fracture were enrolled in the study, including 14 cases in the L1 and 7 cases in the L2. The patients underwent removal of bone fragments from the spinal canal through intervertebral foramen followed by short-segment fixation. Evaluations included surgery-related, such as duration of surgery and blood loss, and 12-month follow-up, such as the kyphotic angle, the height ratio of the anterior edge of the vertebra, the ratio of sagittal canal compromise, visual analog scale (VAS), Oswestry Disability Index (ODI), and Frankel scores. Results All patients achieved direct spinal canal decompression using the paraspinal erector approach followed by percutaneous pedicle screw fixation. The mean operation time (SD) was 173 (23) min, and the mean (SD) blood loss was 301 (104) ml. Significant improvement was noted in the kyphotic angle, 26.2 ± 8.7 prior to operation versus 9.1 ± 4.7 at 12 months after operation (p <0.05); the height ratio of the anterior edge of the injured vertebra, 60 ± 16% versus 84 ± 9% (p <0.05); and the ratio of sagittal canal compromise, 46.5 ± 11.4% versus 4.3 ± 3.6% (p <0.05). Significant improvements in VAS (7.3 ± 1.2 vs. 1.9 ± 0.7, p <0.05), ODI (86.7 ± 5.8 vs. 16.7 ± 5.1, p <0.05), and Frankel scores were also noted. Conclusions The paraspinal erector approach was effective for direct spinal canal decompression with minimal injury in the paraspinal muscles or spine. Significant improvements in spinal function and prognostics were achieved after the percutaneous pedicle screw fixation.
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Abstract
STUDY DESIGN A randomized, controlled clinical trial. OBJECTIVE This randomized controlled clinical trial was aimed at comparing the clinical outcomes of combined posteroanterior (P-A) fusion and transforaminal thoracic interbody fusion (TTIF) in cases of thoracolumbar fracture-dislocation. SUMMARY OF BACKGROUND DATA The optimal treatment strategy for thoracolumbar fracture-dislocation remains controversial. METHODS Sixty-one patients presenting with acute fracture-dislocation of the thoracolumbar joint between March 2010 and December 2011 were enrolled and randomly assigned to the P-A or TTIF group. The radiological outcome was assessed by acquiring radiographs in the standing position and computed tomographic scans. The clinical outcome was measured in terms of the American Spinal Injury Association score, visual analogue scale score, and Oswestry Disability Index. Moreover, we assessed the severity of overall morbidity and morbidity at the donor site in the 2 patient groups. The Student t and χ tests were used for the analysis of independent variables and categorical data, respectively. RESULTS Only 57 of the enrolled patients were available for the required 24-month follow-up period, 27 underwent TTIF and 30 underwent P-A fusion. Both treatments were similar with respect to the fusion rate, extent of decompression, loss of correction, rate of instrumentation failure, American Spinal Injury Association score, visual analogue scale score, and Oswestry Disability Index (P > 0.05). However, the blood loss, operating time, and rate of perioperative complications were greater in the P-A group than in the TTIF group (P < 0.05). CONCLUSION The clinical and radiological outcomes were similar for both the treatment procedures. However, our findings suggest that TTIF allows for safe interbody fusion and circumferential decompression, requires only a posterior approach, and is associated with a lower incidence of surgery-related complications. LEVEL OF EVIDENCE 2.
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A Pilot Evaluation of the Role of Bracing in Stable Thoracolumbar Burst Fractures Without Neurological Deficit. ACTA ACUST UNITED AC 2014; 27:370-5. [DOI: 10.1097/bsd.0b013e31826eacae] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Deng Z, Zou H, Cai L, Ping A, Wang Y, Ai Q. The retrospective analysis of posterior short-segment pedicle instrumentation without fusion for thoracolumbar burst fracture with neurological deficit. ScientificWorldJournal 2014; 2014:457634. [PMID: 24723809 PMCID: PMC3958728 DOI: 10.1155/2014/457634] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2013] [Accepted: 12/19/2013] [Indexed: 11/25/2022] Open
Abstract
This study aims to investigate the efficacy of posterior short-segment pedicle instrumentation without fusion in curing thoracolumbar burst fracture. All of the 53 patients were treated with short-segment pedicle instrumentation and laminectomy without fusion, and the restoration of retropulsed bone fragments was conducted by a novel custom-designed repositor (RRBF). The mean operation time and blood loss during surgery were analyzed; the radiological index and neurological status were compared before and after the operation. The mean operation time was 93 min (range: 62-110 min) and the mean intraoperative blood loss was 452 mL in all cases. The average canal encroachment was 50.04% and 10.92% prior to the surgery and at last followup, respectively (P < 0.01). The preoperative kyphotic angle was 17.2 degree (± 6.87 degrees), whereas it decreased to 8.42 degree (± 4.99 degrees) at last followup (P < 0.01). Besides, the mean vertebral body height increased from 40.15% (± 9.40%) before surgery to 72.34% (± 12.32%) at last followup (P < 0.01). 45 patients showed 1-2 grades improvement in Frankel's scale at last followup. This technique allows for satisfactory canal clearance and restoration of vertebral body height and kyphotic angle, and it may promote the recovery of neurological function. However, further research is still necessary to confirm the efficacy of this treatment.
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Affiliation(s)
- Zhouming Deng
- Department of Orthopaedic, Zhongnan Hospital of Wuhan University, No. 169 Donghu Road, Wuhan, Hubei Province 430071, China
| | - Hui Zou
- Department of Orthopaedic, Central Hospital of Huanggang City, Huanggang, China
| | - Lin Cai
- Department of Orthopaedic, Zhongnan Hospital of Wuhan University, No. 169 Donghu Road, Wuhan, Hubei Province 430071, China
| | - Ansong Ping
- Department of Orthopaedic, Zhongnan Hospital of Wuhan University, No. 169 Donghu Road, Wuhan, Hubei Province 430071, China
| | - Yongzhi Wang
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Qiyong Ai
- Department of Orthopaedic, Zhongnan Hospital of Wuhan University, No. 169 Donghu Road, Wuhan, Hubei Province 430071, China
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Amoretti N, Huwart L. Combination of percutaneous osteosynthesis and vertebroplasty of thoracolumbar split fractures under CT and fluoroscopy guidance: a new technique. Cardiovasc Intervent Radiol 2014; 37:1363-8. [PMID: 24482031 DOI: 10.1007/s00270-014-0849-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 12/23/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The purpose of our study was to evaluate the technical feasibility of the combination involving percutaneous screw fixation and vertebroplasty in split fractures of thoracolumbar spine. METHODS Institutional review board approval and informed consent were obtained. Ten consecutive adult patients who had posttraumatic vertebral split fractures (Magerl A2) were prospectively treated by an interventional radiologist under computed tomography and fluoroscopy guidance. Using a bilateral route under local anesthesia, one 4.0-mm cannulated screw was placed on one side to fix the fracture, and on the other side, vertebroplasty was performed. Follow-up ranging from 12 to 24 months was assessed using visual analog scale (VAS) and Oswestry disability index (ODI) RESULTS: Combined procedures were performed on thoracic and lumbar vertebrae, creating both osteosynthesis and cement bridge between the displaced fragment and the rest of the vertebral body. Mean VAS measurements ± standard deviation (SD) decreased from 7.5 ± 1.5 preoperatively to 3.2 ± 1.9 at 1 day, 2.1 ± 1.2 at 1 month, and 1.9 ± 1.4 at the last examination (P < 0.001). Mean ODI scores ± SD decreased from 65.3 ± 16.2, preoperatively, to 16.1 ± 5.0 at the final examination (P < 0.001). CONCLUSIONS This study suggests that type A2 vertebral fractures could be successfully stabilized by the combination of percutaneous osteosynthesis and vertebroplasty.
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Affiliation(s)
- Nicolas Amoretti
- Department of Radiology, Centre Hospitalo-Universitaire de Nice, Hôpital Archet 2, 151, route Saint-Antoine de Ginestière, 06200, Nice, France
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