Anterior transthoracic surgical decompression of acute spinal cord injuries

Ultrasonic osteotome versus high-speed burr in cervical anterior vertebral subtotal resection: A retrospective study of 81 cases

AIM

This study aimed to investigate the safety and effectiveness of ultrasonic osteotome in cervical anterior vertebral subtotal resection.

METHODS

Retrospective clinical data were collated for 81 patients with cervical spondylotic myelopathy who required cervical anterior vertebral subtotal resection.

RESULTS

Group A (n=40) was treated with an ultrasonic osteotome and group B (n=41) with a high-speed burr. Vertebrectomy time, intraoperative blood loss, surgical complications, Japanese Orthopedic Association (JOA) scores and JOA score improvement were compared. Group A showed significantly shorter vertebrectomy time and significantly less intraoperative blood loss (P<0.05). In group A, dysphagia occurred in one patient, and superior laryngeal nerve injury in one. Urinary tract infection occurred in one patient in group B. JOA score in both groups significantly increased 3 days after surgery (P<0.05), and at last follow-up compared with 3 days after surgery (P<0.05).

CONCLUSION

Ultrasonic osteotome was a safe and effective tool for subtotal anterior cervical vertebral resection.

Thoracic spine fractures

Thoracic spine fractures have unique characteristics, and should be managed with specific criteria that are different from those used for thoracolumbar injuries. Fracture-dislocation injuries require high-energy injury, and should always be suspected in polytrauma patients with rib cage, sternum, cardiac, or pulmonary injuries. Although treatment is individualized, multisegmental posterior fixation sometimes combined with anterior decompression, is most commonly used. The authors review the current literature on this topic, and present their opinion on the management of such injuries.

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.

Anterior decompression with single segmental spinal interbody fusion for lumbar burst fracture

STUDY DESIGN

The clinical and radiologic records for seven patients with lumbar burst fracture who underwent anterior decompression with single segmental interbody fusion were reviewed.

OBJECTIVE

To determine the clinical results obtained with this method and its influence on the intervertebral disc degeneration inferior to the fusion.

SUMMARY OF BACKGROUND DATA

Some patients with Denis' type B fracture can tolerate one-segment anterior fusion. However, there is no reliable information in the literature regarding the juxtafusional disc degeneration after one-segment fusion.

METHODS

Seven patients with type B lumbar burst fractures, including four with cleavage fracture of the lower endplate, underwent anterior single segmental fusion; three patients underwent surgery with no instrumentation, and four underwent surgery with Kaneda instrumentation. The mean follow-up period lasted 85 months. The kyphosis angle and inferior intervertebral disc height adjacent to the fusion were measured before and after surgery. Pain and working status were evaluated using the scales proposed by Denis et al.

RESULTS

Significant correction loss was obtained 1 year after surgery in the patients in whom no instrumentation was used (7.3 +/- 0.6 degrees), compared with the correction loss in patients whose surgery included the use of instrumentation (0.3 +/- 0.5 degree; P = 0.00001). No further correction losses were seen in either group at the final follow-up examination. No marked reduction in disc height was observed in any patient, including the four patients with cleavage fracture of the lower endplate. All patients returned to their previous occupation; five patients were rated as P1 (no pain) and W1 (returned to heavy labor), and two patients were rated as P2 (minimal pain) and W2 (return to heavy labor with lifting restrictions) at the final follow-up examination.

CONCLUSIONS

There was slight correction loss within 1 year when no instrumentation was used, but this deformity did not affect the clinical results. The results provided no evidence that cleavage fracture of the lower endplate accelerates degeneration of the adjacent intervertebral disc.

Selection criteria and outcome of operative approaches for thoracolumbar burst fractures with and without neurological deficit

Criteria for choosing operative techniques for the treatment of thoracolumbar burst fractures remain disputed, particularly in neurologically intact patients. A retrospective study of 25 patients with thoracolumbar burst fractures was performed to assess fracture characteristics, operative approaches, fixation, radiographic results, and neurological, functional, and pain outcomes. Anterior corpectomy, allograft strut, and plate fixation were performed in 14 patients with or without neurological deficit when vertebral compression or canal encroachment was at least 40% or kyphosis was 15 degrees or more with a stable posterior column. In nine cases, an anterior operation and a posterior segmental fixation were combined for similar deformity and three-column instability. Posterior transpedicular decompression, fixation, and fusion were used primarily for two symptomatic patients with less than 40% encroachment and at most 40% compression. Overall, 21 patients (84%) were walking and 18 (72%) were continent at follow-up evaluation (mean 16.3 months) versus eight (32%) and 11 (44%) at presentation, respectively. Preoperatively, 17 patients experienced neurological deficit; 16 improved and 12 increased one Frankel grade. No patient deteriorated. Prior employment or activity level was resumed by 19 patients (76%) and only four patients professed incapacity. Pain was eliminated after 18 procedures (72%), all anterior or combined approaches. Restoration of anatomical alignment (< 5 degrees) was achieved in 19 cases. No anterior construct failed and only one patient treated posteriorly had postoperative kyphosis progression. Operative morbidity occurred in three cases (12%). Satisfactory neurological and functional outcomes were achieved in a majority of patients with thoracolumbar burst fractures after correction of canal compromise, middle column compression, and attendant deformity. These results indicate that anterior decompression and a weight-bearing strut graft are critical to clinical success in patients with significant vertebral destruction.

Percutaneous interbody osteosynthesis in the treatment of thoracolumbar traumatic or tumoural lesions. A review of 51 cases

The authors describe a technique of percutaneous interbody osteosynthesis applicable to the dorsal and lumbar spine. 51 patients were so treated for different aetiologies: traumatic conditions (35 cases) and tumoural lesions (16 cases). The material used consisted of special instruments that are positioned in double obliquity by a percutaneous posterolateral approach. A posterior approach limited to the pathological focus was used jointly whenever a graft or a decompression was necessary (19 cases). Several types of anaesthesia were used (local, local-regional, general, neuroleptanalgesia). The patients benefited by the advantages that usually accompany percutaneous techniques. The advantages and limitations of the method are discussed.

Bilateral posterolateral approach to the thoracolumbar spine through transversoarthropediculectomy with corporectomy

Surgery of the dorsolumbar spine is currently benefiting from diverse approaches and the advent of computed tomography. This report describes a bilateral posterolateral approach with transversoarthropediculectomy and corporectomy. The advantages and disadvantages of this approach and its indications are discussed.

Posterolateral approach to tumours of the dorsolumbar spine

The authors outline the possible approaches to vertebromedullary tumours of the thoraco-lumbar spine using unilateral or bilateral transverso-arthro-pediculectomy and corporectomy. In a personal series of 20 cases. The technique and indications are described and the results.

Fractures of the thoraco-lumbar spine

A personal prospective study of 98 consecutive patients presenting with neurological impairment and fractures or dislocations between the 9th thoracic and 2nd lumbar vertebrae bodies. Fifty-three patients underwent Harrington instrumentation, and 45 patients were treated recumbently. Neurological improvement was much better following Harrington rods in the complete paraplegia group but there was no difference in neurological recovery between the two groups in those with incomplete paraplegia. Forty-two patients who had been stabilised with Harrington rods underwent post-operative myelography or tomography to assess the adequacy of spinal decompression. The best results were in patients with adequate neural canal decompression. In 21 cases decompression had not been adequate, usually due to a stereotyped pattern in which the postero-superior aspect of the fractured body remained in the neural canal. All 21 underwent anterior decompression at an average of five months post injury. All the incomplete anterior decompression at an average of five months post injury. All the incomplete paraplegics (nine patients) regained the ability to walk, three of the 12 complete paraplegics improved and regained the ability to walk with bilateral ankle-foot orthoses. Neurological improvement was dependent upon the adequacy of spinal cord decompression and not upon Harrington rods. per se. Harrington rods alone were not adequate to decompress the spinal canal in 50 per cent of cases. The best results after anterior decompression occurred where neural compression was caused by a minimally displaced wedge fracture distal to T12.

Injuries of the thoracolumbar junction. Clinical and radiological results in 149 patients

In a series of 149 fractures of the thoracolumbar junction (Th12-L1), treated at the Central Hospital of Tampere from 1968 to 1975, 101 patients were seen after an average interval of 5 years. Over half of the fractures were sustained at home or in leisure hours. Over 90% were anterior wedge fractures. One patient died in the hospital of other injuries. The injury caused peraplegia in three cases and other neurological lesions in six. The treatment was conservative except in the patients with paraplegia, who were surgically treated. The patients were mobilized after an average of 15 days. The neurological condition did not deteriorate. Noteworthy changes of the radiological findings occurred during follow-up. The clinical result was considered good in two thirds of the patients, and 91% were able to return to work. The frequency of neurological findings was significant in patients showing radiological deformities. The force responsible for the fracture correlated with the radiological findings and the occurrence of neurological lesions. Narrowing of the vertebral canal and degenerative changes observed on admission had a significant and unfavorable effect on the clinical result.

Myelography for severe thoracolumbar injuries

Myelography was carried out on 30 patients with severe thoracolumbar injuries. In ten cases the myelography gave specific information which could not have been obtained by any other method. Myelography made within 1 month of trauma gave specific information in only one of 16 cases. Late myelography, in nine of 14 cases, provided valuable specific information about the type of cord atrophy, dorsal scar formation and transsection of the cord.

Oxygen myelography for cervical spinal cord injuries

Oxygen myelographies were performed on 15 patients with cervical spinal cord injuries, in seven of whom narrowing of the spinal cord was caused by a fracture-dislocation. In eight the fracture was of bursting type, and the neurological involement in these was more severe than in the former type. The main findings in seven early myelograms were swelling of the cord (3/7) and non-visualization of the spinal canal at the injury level (6/7). The main findings in eight late myelograms were narrowing of the cord (5/8) and anterior stretching of the cord over the obstructing bony ridge.