Endoscopic osteosynthesis after thoracic spine trauma: a report of two cases

Video-assisted treatment of thoracolumbar junction fractures using a specific distractor for reduction: prospective study of 50 cases

Posterior instrumentation allows good osteosynthesis for thoracolumbar junction fractures. However, in approximately 20% of cases, anterior bone defects may persist, leading to pseudoarthrosis and loss of reduction. Anterior approaches can circumvent this drawback, but they are considered aggressive with a high rate of complications. The advent of the endoscopic mini-invasive techniques has led to a reduction in the number of complications while maintaining the same consolidation rate. Nevertheless, poor restitution of anatomic curves is a reproach for this technique. This prospective study reports clinical and radiological result of 50 patients (19 women and 31 men) operated between April 2000 and March 2006 with a video-assisted anterior approach using an endodistractor for reduction and consequent insertion of the implant. There were A3 (n = 44), A2 (n = 2), A1 (n = 3) and C1 (n = 1) fractures (Magerl classification). The specific system for fracture reduction was used in the last 39 cases of this series. A Pyramesh cage (Medtronic, Memphis, USA) was used in 15 patients, a peek cage (Creaspine, Bordeaux, France) in 30 patients and a tricortical graft in 5 patients. Standard X-rays and CT scan were performed pre-operatively. Kyphosis, and angulations were measured pre-, per- and post-operatively. Mean immediate postoperative gain in localized kyphosis was 12.18 degrees and mean gain at last follow-up was 11.71 degrees. Mean immediate postoperative gain in RA was 13.24 degrees and remained identical at last follow-up. Five patients had a transient pulmonary atelectasia and there was one pulmonary infection. No neurological complication occurred. Fracture reduction is comparable to the best thoracotomy series while limiting approach-related complications.

Endoscopy-assisted Approaches for Anterior Column Reconstruction after Pedicle Screw Fixation of Acute Traumatic Thoracic and Lumbar Fractures

Objective:

Surgical treatment of thoracic and lumbar vertebral body fractures combines instrumentation to stabilize the fracture and an anterior reconstruction to promote fusion of the fractured spine. The aim of the present study was to show that minimally invasive thoracoscopic or endoscopy-assisted approaches to the thoracic and lumbar spine are feasible for anterior column reconstruction.

Methods:

This prospective, single-center study included 83 consecutive patients harboring 100 acute thoracic and lumbar vertebral fractures. Patients' neurological status; preoperative, postoperative, and follow-up radiographic data; and surgical data were obtained.

Results:

Fractures ranged from T5 to L5. All fractures underwent posterior pedicle screw fixation followed by a thoracoscopic or endoscopy-assisted anterior approach for anterior column reconstruction to promote fusion. Ventral graft position was correct in 45 patients and acceptable in 37 patients; one patient required a surgical repositioning. Initial correction of kyphosis was 9 degrees; during follow-up (23 ± 11 mo), the mean loss of correction was 6 degrees. In 84 minimally invasive approaches, five conversions to an open approach were necessary. Complications included one case of L1 nerve root injury, two cases of transient neurological worsening, one case of posterior wound infection, and one case of pleural empyema.

Conclusion:

The minimally invasive endoscopic approach for anterior column reconstruction is a feasible strategy in the treatment of unstable thoracic and lumbar fractures. Fracture type and the material of the anterior graft can affect long-term maintenance of correction.

Distraction injury to thoracic spine treated with thoracoscopic dual-rod fixation

BACKGROUND CONTEXT

Thoracic hyperextension fracture-dislocation is a rare pattern of traumatic spinal injury, typically associated with gross spinal instability and severe neurological deficit. These extremely unstable injuries require internal fixation despite their potentially benign clinical presentation.

PURPOSE

We present a patient with a thoracic distraction injury who remained neurologically intact.

METHODS

The patient underwent thoracoscopic reduction and anterior fixation of the thoracic spine using a paired screw-rod construct.

RESULTS

Postoperatively, the patient remained neurologically intact and had no complications related to his thoracic fixation and fusion. Follow-up radiographs showed maintenance of thoracic alignment and bony fusion.

CONCLUSIONS

The endoscopic approach to the anterior thoracic spine was an excellent treatment option for this thoracic distraction injury.

[Video-assisted mini-thoracotomy for surgical treatment of thoracolumbar junction fractures]

PURPOSE OF THE STUDY

There are several solutions for the treatment of fractures of the thoracolumbar junction (classical anterior, posterior, combined approaches). The advent of video-assisted minimally invasive techniques has helped minimize complications. The aim of this work was to analyze the clinical and radiological outcome in a prospective series of 20 patients who underwent video-assisted mini-thoracotomy for the treatment of thoracolumbar junction fractures.

MATERIAL AND METHODS

This prospective study included 20 patients, mean age 43.3 years, with at least one year follow-up. All patients presented a normal neurological examination (Frankel E). Fractures were classified Magerl A (n = 19) and B (n = 1). Corporectomy/correction (aided with an endodistractor in the last nine cases) was performed with grafting and osteosynthesis. Perioperative and postoperative complications were noted. Focal kyphosis and regional angulation were noted before and after the operation and at last follow-up using the Stagnara system.

RESULTS

The arthrodesis had fused at last follow-up in all patients. There were three cases of alelectasia which regressed in two months. Overall outcome showed satisfactory angular correction which was maintained at last follow-up. The gain in focal kyphosis was 13.71 degrees on average in the immediate postoperative period and persisted at last follow-up (13.31degrees). The gain in corrected regional angulation was 14 degrees in the immediate postoperative period and 14 degrees at last follow-up. The gain in focal kyphosis and regional angulation was two-fold greater with the endodistractor than with external maneuvers.

DISCUSSION

The complication rate was very low. Corrections obtained were comparable with those reported in the literature and persisted over time.

CONCLUSION

Bearing in mind the learning curve, there are fewer complications with the video-assisted minimally invasive approach than with classical thoracotomy or anterior surgery. This is true for perioperative and early and late postoperative complications. The correction achieved is satisfactory and lasting. A specific ancillary is essential for the reduction and for fitting the anterior graft without lost of correction. This technique combines the best results achieved with thoracotomy (Onimus) with a limited rate of complications.

Video-assisted thoracoscopic surgery: the Cincinnati experience

Video-assisted thoracoscopic surgery is an alternative to open thoracotomy. We analyzed our experience during a consecutive series of 100 patients who had this procedure and who were available for study at 3-year followup. Video-assisted thoracoscopic surgery was done on patients with the following diagnoses: idiopathic scoliosis (n = 49), neuromuscular spinal deformity (n = 15), Scheuermann kyphosis (n = 15), congenital and infantile scoliosis (n = 5), neurofibromatosis (n = 5), Marfan (n = 1), postradiation scoliosis (n = 1), and repair of pseudoarthrosis (n = 1). Four patients had excision of the first rib to treat thoracic outlet syndrome. One patient had excision of an intrathoracic neurofibroma and one a benign rib tumor. One had anterior arthrodesis after fracture-dislocation of the thoracic spine and another had anterior fusion for vertebral osteomyelitis. The average operative time for the thoracoscopic anterior release with discectomy and arthrodesis was 253 minutes. The average number of discs excised was 8. Final postoperative scoliosis and kyphosis corrections were 68% and 90%, respectively. Complications related to thoracoscopy occurred in eight patients. Video-assisted thoracoscopic surgery provides a safe and effective alternative to open thoracotomy in the treatment of thoracic pediatric spinal deformities.

Early experiences with video-assisted thoracoscopic surgery: our first 70 cases

STUDY DESIGN

Prospective consecutive series.

OBJECTIVE

Analysis of the results and outcomes of patients treated with video-assisted thoracoscopic surgery for spinal pathology.

SUMMARY OF BACKGROUND DATA

Video-assisted thoracoscopic surgery is an alternative to open thoracotomy. It has been suggested that the learning curve is substantial. The authors present their early experience in treating a variety of spinal pathologies with this technique.

METHODS

Seventy cases were available at the 2-year follow-up. Video-assisted thoracoscopic surgery with the goal of anterior spinal release and fusion was carried out on patients with the following diagnoses: idiopathic scoliosis, neuromuscular spinal deformity, Scheuermann kyphosis, congenital and infantile scoliosis, neurofibromatosis, Marfan syndrome, postradiation scoliosis, and repair of pseudarthrosis. Three patients had excision of the first rib to treat thoracic outlet syndrome. Two patients had excision of intrathoracic neurofibroma and a benign rib tumor. One had anterior fusion following thoracic spine fracture-dislocation.

RESULTS

The average operative time for the thoracoscopic anterior release with discectomy and fusion procedure was 256 minutes (range 150-405 minutes). The average number of discs excised was 8 (range 4-11 discs). The average operative time per disc was 32.5 minutes (range 20-45 minutes). The average blood loss during the thoracoscopic anterior release with diskectomy and fusion was 285 mL (range 150-405 mL). Final postoperative scoliosis and kyphosis corrections were 68% (range 41-91%) and 90% (range 47-100%), respectively. Complications related to thoracoscopy occurred in 3 patients. All deformity patients had evidence of anterior fusion radiographically.

CONCLUSION

Video-assisted thoracoscopic surgery provides a safe and effective alternative to open thoracotomy in the treatment of thoracic pediatric spinal deformities. The procedure remains time consuming.

Thoracoscopic Placement of Dual-Rod Instrumentation in Thoracic Spinal Trauma

OBJECTIVE AND IMPORTANCE

Traditionally, thoracic fractures that require anterior stabilization are treated through an open thoracotomy approach. Thoracoscopic instrumentation avoids many of the complications associated with an open thoracotomy but is technically challenging. We report the first cases of dual-rod internal fixation systems placed thoracoscopically for thoracic spinal trauma.

CLINICAL PRESENTATION

Two male patients sustained midthoracic spinal trauma falling from motorcycles in separate incidents. Both injuries led to unstable spinal columns, but the patients had no neurological deficits and had minimal spinal cord compression. One patient had a complex spiral fracture from T6 to T8; the other had T7 burst and T8 compression fractures. Based on the complex morphological features of the patients' fractures, anterior internal fixation was the treatment of choice for both. The two available options for an anterior stabilization were open thoracotomy and thoracoscopic instrumentation. Because extensive decompression was unnecessary, a thoracoscopic approach was used.

INTERVENTION

A dual-rod internal fixation system (Medtronic Sofamor Danek, Inc., Memphis, TN) was placed with two screws each in the T6 and T9 vertebral bodies of each patient. Thoracoscopy was used for direct visualization of the operative site with fluoroscopic guidance for screw placement. Surgery was completed without complications, and both patients did well afterward. Upright and supine x-rays demonstrated that the constructs were stable at 10 weeks and 6 months, respectively.

CONCLUSION

Thoracoscopic instrumentation offers the advantages of a minimally invasive approach but is technically challenging. The characteristics of dual-rod fixation systems (small-profile components and step-wise insertion) provide the best biomechanical profile and facilitate thoracoscopic instrumentation.