Outcomes of Thoracolumbar Fracture-Dislocation Managed by Short-Segment and Long-Segment Posterior Fixation: A Single-Center Retrospective Study

[Effectiveness of injured vertebra fixation with inclined-long pedicle screws combined with interbody fusion for thoracolumbar fracture dislocation with disc injury]

Objective

To investigate the effectiveness of injured vertebra fixation with inclined-long pedicle screws combined with interbody fusion for thoracolumbar fracture dislocation with disc injury.

Methods

Between January 2017 and June 2022, 28 patients with thoracolumbar fracture dislocation with disc injury were underwent posterior depression, the injured vertebra fixation with inclined-long pedicle screws, and interbody fusion. There were 22 males and 6 females, with a mean age of 41.4 years (range, 22-58 years). The causes of injury included falling from height in 18 cases, traffic accident in 5 cases, and bruise in 5 cases. Fracture segment included 1 case of T 11, 7 cases of T 12, 9 cases of L 1, and 11 cases of L 2. According to the American Spinal Injury Association (ASIA) scale, the spinal injuries were graded as grade A in 4 cases, grade B in 2 cases, grade C in 11 cases, and grade D in 11 cases. Preoperative spinal canal encroachment ratio was 17.7%-75.3% (mean, 44.0%); the thoracolumbar injury classification and severity score (TLICS) ranged from 9 to 10 (mean, 9.9). Seventeen patients were associated with other injuries. The time from injury to operation ranged from 1 to 4 days (mean, 2.3 days). The perioperative indicators (operation time, intraoperative blood loss, and the occurrence of complications), clinical evaluation indicators [visual analogue scale (VAS) score and Oswestry Disability Index (ODI)], radiologic evaluation indicators [anterior vertebral height ratio (AVHR), kyphosis Cobb angle (KCA), intervertebral space height (ISH), vertebral wedge angle (VWA), displacement angle (DA), and percent fracture dislocation displacement (PFDD)], neurological function, and interbody fusion were recorded.

Results

The operation time was 110-159 minutes (mean, 130.2 minutes). The intraoperative blood loss was 200-510 mL (mean, 354.3 mL). All incisions healed by first intention, and no surgical complications such as wound infection or hematoma occurred. All patients were followed up 12-15 months (mean, 12.7 months). The chest and lumbar pain significantly relieved, VAS scores and ODI after operation were significantly lower than those before operation, and further decreased with the extension of postoperative time, with significant differences ( P<0.05). At last follow-up, the ASIA classification of neurological function of the patients was grade A in 3 cases, grade B in 1 case, grade C in 1 case, grade D in 10 cases, and grade E in 13 cases, which was significantly different from preoperative one ( Z=-4.772, P<0.001). Imaging review showed that AVHR, KCA, ISH, VWA, DA, and PFDD significantly improved at 1 week, 3 months and last follow-up ( P<0.05). There was no significant difference between different time points after operation ( P>0.05). At last follow-up, according to the modified Brantigan score, all patients achieved good intervertebral bone fusion, including 22 complete fusion and 6 good intervertebral fusion with a few clear lines. No complications such as internal fixation failure or kyphosis occurred during follow-up.

Conclusion

The injured vertebra fixation with inclined-long pedicle screws combined with interbody fusion is an effective treatment for thoracolumbar fracture dislocation with disc injury, which can correct the fracture dislocation, release the nerve compression, restore the injured vertebral height, and reconstruct spinal stabilization.

Should the level of the posterior instrumentation combined with the intermediate screw be a short segment or a long segment in thoracolumbar fractures with fusion to the fractured segment?

PURPOSE

It was aimed to compare the results of long segment posterior instrumentation with intermediate pedicular screw + fusion at the level of the fractured segment including one vertebra above and one below the fractured vertebra (LSPI) and short segment posterior instrumentation with intermediate pedicular screw + fusion at the level of the fractured segment including one vertebra above and one below the fractured vertebra (SSPI) in the surgical treatment of thoracolumbar vertebral fractures.

METHODS

Ninety patients with thoracolumbar vertebral (T11-L2) fractures operated between March 2015 and February 2022 were included in this retrospective study. The patients were divided into two groups as those who underwent LSPI (n, 54; age, 40.3) and those who underwent SSPI (n, 36; age, 39.7). Radiological evaluations like vertebral compression angle (VCA), vertebral corpus heights (VCH), intraoperative parameters, and complications were compared between the groups.

RESULTS

Correction in early postoperative VCA was statistically significantly better in LSPI (p = 0.003). At 1-year follow-up, postoperative VCA correction was significantly more successful in LSPI (p = 0.001). There was no difference between the two groups in terms of correction loss in VCA measured at 1-year follow-up. There was no statistically significant difference between the two groups in terms of postoperative VCH, VCH at 1-year follow-up, and correction loss in VCH.

CONCLUSION

LSPI provides better postoperative kyphosis correction of the fractured vertebra than SSPI. Regarding the segment level of posterior instrumentation, there was no difference between the two groups in terms of the loss of achieved correction of VCA, ABH, and PBH at 1-year follow-up. Operating a thoracolumbar fracture with LSPI will lengthen the operation and increase the number of intraoperative fluoroscopies compared to SSPI.

A Clinical Comparative Study on Percutaneous and Open Approaches for Screw Internal Fixation in Treating Thoracolumbar Fractures

OBJECTIVE

Conventional open internal fixation surgery for thoracolumbar fractures has many complications and long recovery time. There are few clinical studies on the minimally invasive percutaneous injured vertebrae screw internal fixation. The purpose of this paper is to evaluate the application value of minimally invasive percutaneous injured vertebrae screw internal fixation in the treatment of thoracolumbar fractures (TF).

METHODS

A total of 98 patients with TF admitted to our hospital from January 2019 to December 2021 were retrospectively enrolled. According to the surgical method, the patients were divided into the study group (n = 49, treated with minimally invasive percutaneous injured vertebrae screw internal fixation) and the control group (n = 49, treated with traditional open internal fixation surgery). The two groups were compared in the perioperative period, the degree of pain at different periods, the percentage of the height of the anterior edge of the injured vertebra, the Cobb angle of the injured vertebra body and the wedge angle of the injured vertebra body at the first week and the last follow-up, and the postoperative complications and the occurrence of the cone shell after the operation were recorded. Then, statistical analysis such as Student's t test or Chi-Square test was performed.

RESULTS

The operation time (p = 0.002), intraoperative blood loss (p < 0.001), postoperative drainage volume (p = 0.011), and length of hospital stay (p = 0.003) in the study group were significantly lower than that in the control group. The VAS in the study group (3.38 ± 1.02) was significantly lower than that in the control group (4.56 ± 1.04) on the 7th day after the operation, with a significant difference (p < 0.001). The correction values of the percentage of leading edge height (LEH), Cobb angle, wedge angle in the study group were significantly lower than that in the control group at 1 week after surgery (all ps < 0.001). The incidence of postoperative complications in the study group (one case, 2.04%) was significantly lower than that in the control group (seven cases, 14.29%) (p = 0.031). At 1 month, 6 months, 10 months, and the last follow-up, the incidence of "empty shell" on CT scan in the study group were lower than that in the control group with a significant difference (all ps < 0.05).

CONCLUSION

Applying minimally invasive percutaneous injured vertebrae screw internal fixation is more beneficial to shorten the operation time and hospital stay, with fewer postoperative complications.

Finite element analysis of the indirect reduction of posterior pedicle screw fixation for a thoracolumbar burst fracture

Because burst fractures often involve damage to the column and posterior structures of the spine, the fracture block may invade the spinal canal and compress the spinal cord or the cauda equina, causing corresponding neurological dysfunction. When a thoracolumbar burst fracture is accompanied by the presence of bone in the spinal canal, whether posterior surgery requires spinal canal incision decompression is still controversial. Computed tomography images of the thoracolumbar spine of a 31-year-old male with an L1 burst fracture and Mimics 10.0 were used to establish a three-dimensional fracture model for simulating the indirect reduction process. The model was imported into Ansys 10.0 (ANSYS, Inc., Canonsburg, PA), and a 1 to 10 mm displacement was loaded 10° behind the Z-axis on the upper endplate of the L1 vertebral body to simulate position reduction and open reduction. The displacement and stress changes in the intervertebral disc, fractured vertebral body and posterior longitudinal ligament were observed during reduction. Under a displacement loaded 10° behind the Z-axis, the maximum stress in the vertebral body was concentrated on the upper disc of the injured vertebrae. The maximum displacement was in the anterior edge of the vertebral body of the injured vertebrae, and the vertebral body height and the anterior lobes were essentially restored. When the displacement load was applied in the positive Z-axis direction, the maximum displacement was in the posterior longitudinal ligament behind the injured vertebrae. Under a 6 mm load, the posterior longitudinal ligament displacement was 11.3 mm. Under an 8 mm load, this displacement significantly increased to 15.0 mm, and the vertebral stress was not concentrated on the intervertebral disc. A reduction in the thoracolumbar burst fractures by positioning and distraction allowed the injured vertebrae to be restored to normal height and kyphosis. The reduction in the posterior longitudinal ligament can push the bone block in the spinal canal into the reset space and achieve a good reset.

Long- versus short-segment fixation with an index vertebral screw for management of thoracolumbar fractures

The choice of the best stabilization technique for thoracolumbar fractures remains controversial. While LSF includes too many motion segments, SSF is associated with a high rate of fixation failure and subsequent loss of kyphotic correction. Our objective is to compare the surgical, clinical, and radiological outcomes of thoracolumbar spine fixation using long-segment fixation (LSF) versus short-segment fixation (SSF) with a screw in the fractured vertebra. We retrospectively evaluated 63 patients with single- level thoracolumbar fracture types A and B treated during the period between 2010 and 2017 in our institution. Group A (30 patients) was treated by SSF with an intermediate screw in the fractured vertebra, while group B (33 patients) was treated by LSF. Both groups were compared in terms of surgical, clinical, and radiological outcomes. The mean operative blood loss was significantly lower in group A than in group B (451.3 ± 79.9 and 690 ± 92.1 ml, respectively). The mean operative time in Group A was significantly shorter than in group B (58.4 ± 14.8 and 81.5 ± 12.3 minutes, respectively). Both groups achieved a similar Visual Analogue Scale (VAS) for pain and Oswestry Disability Index (ODI) score. No significant difference was found as regards the kyphotic angle correction and the correction loss at final follow-up. In conclusion, SSF with a screw in the fractured vertebra achieved comparable functional and radiological outcomes to LSS with less blood loss and operative time.

Seat belt syndrome is caused by a different mechanism: A case report

Introduction and importance

Seat belt syndrome is associated with multiple visceral injuries and vertebral burst fractures. Small Intestinal perforations are seen in 5–15 % of blunt abdominal trauma. In our case, we will report a case that presented small intestinal perforation and thoracic vertebral fracture caused by a different mechanism.

Case presentation

Previously healthy 48-year-old male presented to the emergency department following falling from 15 feats height. He was a paraplegic with a sensory level at T12. He did not have a clinical feature of spinal shock. He was complaining of epigastric and central abdominal pain and tenderness and was diagnosed to have a proximal Jejunal perforation associated with an unstable fracture of T12 causing spinal compression. Open intestinal repair followed by a posterior spinal exploration and pedicle screw fixation done.

Clinical discussion

Violent injury due to different mechanisms can have similar injuries to Seat belt syndrome. Ultrasonography is used to detect pneumoperitoneum, but the Contrast study is the gold standard to detect visceral injuries. The surgical approach to visceral injury depends on the patient's condition. But the laparoscopic approach has a more favorable postoperative outcome than open access.

Conclusion

Intestinal perforations associated with the neurological deficit are difficult to identify in an initial clinical assessment. Thoracolumbar fractures can associate with small bowel injuries during high-velocity trauma. Early identification and repair of the intestinal injury are important to prevent devastating complications and to improve neurological recovery after spinal surgery.

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Seat belt syndrome is associated with a characteristic set of visceral injuries and spinal fractures.

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Violent injuries caused by a different mechanism can cause similar injuries to Seat belt syndrome.

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Thorough clinical examination with ultrasonography and contrast studies helps to detect visceral injuries.