Surgical treatment of fractures of the thoracic and lumbar spine via the transpedicular route

Management of Unstable Thoraco-Lumbar Fractures with Pedicular Screw Instrumentation: A Series of 30 cases

INTRODUCTION

Trauma to spine is one of the grave injuries. They cause infinite morbidity and disability to the patient. Lately consensus is evolving across the world for stabilization of unstable spines with fusion and instrumentation even though most authors agree that neurological recovery is independent of treatment modality. Objectives of this study are to evaluate effectiveness of spinal stabilization with pedicular instrumentation in the management of thoraco-lumbar fractures to restore structural stability, early ambulation and improving neurological status of the patient Material and Methods: During the period from October 2009 to September 2010, 33 cases of thoraco-lumbar spine fractures were treated operatively with posterior decompression and pedicular screw instrumentation. Of these, 3 cases were lost to follow up. Hence the results of 30 cases were evaluated. All patients were treated by posterior decompression and pedicular screw instrumentation. Neurological and radiological parameters were assessed during serial follow-ups.

OBSERVATION AND RESULTS

The mean duration of follow-up was 11 months. Of the 30 patients 24 showed neurological improvement by at least 1 grade and average grade of improvement was 1.5 grades. Mean pre-operative sagittal angle (SA) was 19.9 degrees and sagittal index (SI) was 0.54. Mean post-operative SA was 9.3 degrees and SI was 0.72. Mean SA and SI during the final follow-up were 10.9 degrees and 0.69 respectively.

DISCUSSION AND CONCLUSION

Neurological recovery and maintenance of radiological correction in our study were comparable to other studies. The results in our short series of 30 cases have been encouraging. But there is need for more cases and longer follow-ups to come to categorical conclusion.

Thoracolumbar fracture dislocations treated by posterior reduction, interbody fusion and segmental instrumentation

BACKGROUND

Literature describing the application of modern segmental instrumentation to thoracic and lumbar fracture dislocation injuries is limited and the ideal surgical strategy for this severe trauma remains controversial. The purpose of this article was to investigate the feasibility and efficacy of single-stage posterior reduction with segmental instrumentation and interbody fusion to treat this type of injury.

MATERIALS AND METHODS

A retrospective review of 30 patients who had sustained fracture dislocation of the spine and underwent single stage posterior surgery between January 2007 and December 2011 was performed. All the patients underwent single stage posterior pedicle screw fixation, decompression and interbody fusion. Demographic data, medical records and radiographic images were reviewed thoroughly.

RESULTS

Ten females and 20 males with a mean age of 39.5 years were included in this study. Based on the AO classification, 13 cases were Type B1, 4 cases were B2, 4 were C1, 6 were C2 and 3 cases were C3. The average time of the surgical procedure was 220 min and the average blood loss was 550 mL. All of the patients were followed up for at least 2 years, with an average of 38 months. The mean preoperative kyphosis was 14.4° and reduced to -1.1° postoperatively. At the final followup, the mean kyphosis was 0.2°. The loss of correction was small (1.3°) with no significant difference compared to postoperative kyphotic angle (P = 0.069). Twenty seven patients (90%) achieved definitive bone fusion on X-ray or computed tomography imaging within 1 year followup. The other three patients were suspected possible pseudarthrosis. They remained asymptomatic without hardware failure or local pain at the last followup.

CONCLUSION

Single stage posterior reduction using segmental pedicle screw instrumentation, combined with decompression and interbody fusion for the treatment of thoracic or lumbar fracture-dislocations is a safe, less traumatic and reliable technique. This procedure can achieve effective reduction, sagittal angle correction and solid fusion.

Minimally invasive transpedicular vertebrectomy for metastatic disease to the thoracic spine

STUDY DESIGN AND OBJECTIVE

We present a series of 8 patients with thoracic metastatic disease causing acute neurologic decline. We present minimally invasive posterolateral vertebrectomy and decompression as an effective approach in patients with significant comorbidities and as palliative care.

BACKGROUND

Metastatic disease to the spine is common and frequently occurs in the thoracic vertebrae. Posterior laminectomy alone has generally been found to be ineffective in the management of spinal metastatic disease with neurologic compromise as most compression occurs ventrally. Patients with significant comorbidities are often unable to tolerate extensive surgery involving a thoracotomy. Limited life expectancy and quality of life issues also often argue against extensive surgery.

METHODS

Eight patients (mean age 74 y) with thoracic metastatic disease and acute neurologic compromise underwent a minimally invasive posterolateral vertebrectomy and partial tumor resection. Patients were considered unsuitable for an open anterior approach owing to age, comorbidities, and limited life expectancies. In the operating room, patients were positioned prone. A paramedian incision measuring 3 cm allowed the introduction of sequential dilators and the placement of a 22-mm diameter tubular retractor. Dorsal decompression was accomplished and partial vertebrectomy was performed for ventral decompression. Radiation was used postoperatively in all patients.

RESULTS

There were no complications due to the procedure. Improvement of at least 1 grade on the Nurick scale was noted in 5 of 8 (62.5%) patients. Two patients were able to ambulate independently immediately after surgery despite having significant paraparesis preoperatively. Pain improved in 5 of 8 (62.5%) patients postoperatively according to the numerical pain score. Average inpatient length of stay was 4 days after the procedure. Mean blood loss was 227 mL and mean length of the procedure was 2.2 hours.

CONCLUSIONS

Minimally invasive transpedicular vertebrectomy is an effective palliative treatment option for thoracic metastatic disease in patients not eligible for more extensive anterior transthoracic surgery and stabilization.

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

STUDY DESIGN

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

OBJECTIVES

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

SUMMARY OF BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSIONS

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