Graded surgery for old thoracolumbar osteoporotic fractures

Abstract

Objective To investigate the effect of graded surgical treatment according to injury classification on old thoracolumbar vertebral compression fractures (OVCFs). Methods A retrospective case series study was conducted to analyze the clinical data of 238 patients with old thoracolumbar OVCFs admitted to the Honghui Hospital affiliated to the College of Medicine, Xi'an Jiaotong University from February 2013 to November 2016. There were 49 males and 189 females, aged 63-78 years, with an average age of 66.8 years. The bone density T value was (-3.8±0.3)SD. The injured segments were located at T7-T9 in 35 patients, T10-L2 in 171, and L3-L4 in 32. A total of 16 patients had neurological injury, including 14 with grade C and two with grade D according to the American Spinal Injury Association (ASIA) neurological function classification. According to the patient's clinical manifestations and imaging complexity, the patients were assigned with I to V grades for individualized surgical treatment. Among them, 86 patients with grade I were treated with vertebral augmentation; 60 patients with grade II received posterior reduction and internal fixation combined with vertebral augmentation when necessary; 44 patients with grade III were treated with posterior decompression and reduction and internal fixation; 30 patients with grade IV received posterior osteotomy and orthopedic fusion; 18 patients with grade V were treated based on the major symptoms. The visual analogue score (VAS), Oswestry dysfunction index (ODI), vertebral sagittal index, and the American Spinal Injury Association (ASIA) grading before operation and at the last follow-up as well as the postoperative complications were recorded. Results All patients were followed up for 12-38 months with an average of 18.5 months. The VAS of patients with grade I to V improved from preoperative (8.0±0.7)points, (8.1±0.7)points, (8.3±0.89)points, (8.1±0.7)points, (8.2±0.2)points to (2.1±0.8)points, (2.0±0.8)points, (2.2±0.8)points, (2.3±0.8)points, (2.2±0.8)points at the last follow-up (P<0.05); ODI was improved from preoperative 69.5±3.0, 70.1±2.0, 70.3±2.1, 69.9±1.9, 70.0±2.2 to 39.8±2.2, 39.1±2.4, 40.1±2.1, 39.0±2.3, 39.5±2.3 at the last follow-up (P<0.05); the vertebral sagittal index improved from (89.7±2.1)%, (74.4±8.3)%, (75.0±6.7)%, (72.3±5.2)%, (71.1±2.1)% to (85.2±7.4)%, (84.2±5.5)%, (85.1±4.4)%, (86.2±3.5)%, (83.4±1.7)% (P<0.05). For 16 patients with nerve injury, the ASIA grading was improved from preoperative grade C in 14 patients and grade D in two patients to grade D in four patients and grade E in 12 patients at the last follow-up. A total of 11 patients (seven patients with grade I, one with grade II, two with grade IV, and one patient with grade V) had vertebral height loss in the later stage, but only two patients underwent secondary surgery for severe low back pain. Conclusions For obsolete thoracolumbar OVCFs, the concept of graded surgery can effectively guide the treatment strategies of these patients. Different surgical schemes for patients with different conditions can effectively alleviate the pain, restore spinal stability, correct kyphosis deformity, relieve nerve compression and promote functional recovery. Key words: Osteoporotic fractures; Spinal fractures; Thoracic vertebrae; Lumbar vertebrae