Acute Thoracolumbar Burst Fractures Research Articles

Hybrid kyphoplasty with short-versus intermediate- and long-segment pedicle screw fixations for the management of thoracolumbar burst fractures

BackgroundThis study aimed to determine if the hybrid short-segment (HSS) technique is a good alternative to the intermediate-segment (IS) and long-segment (LS) techniques in pedicle screw fixations for acute thoracolumbar burst fractures (TLBFs).MethodsIn this retrospective evaluation, we examined 43 patients who underwent surgical treatments, including one- or two-level suprajacent (U) and infrajacent (L) pedicle screw fixations, for acute single-level TLBFs with neurological deficits between the T11 and L2 levels from July 2013 to December 2019. Among these patients, 15 individuals underwent HSS (U1L1), 12 received IS (U2L1), and 16 underwent LS (U2L2) fixations. Supplemental kyphoplasty of the fractured vertebral bodies was performed exclusively in the HSS group. Our analysis focused on assessing blood loss and surgical duration. Additionally, we compared postoperative thoracolumbar kyphotic degeneration using the data on Cobb angles on lateral radiographic images acquired at three time points (preoperatively, postoperative day 1, and follow-up). The end of follow-up was defined as the most recent postoperative radiographic image or implant complication occurrence.ResultsBlood loss and surgical duration were significantly lower in the HSS group than in the IS and LS groups. Additionally, the HSS group exhibited the lowest implant complication rate (2/15, 13.33%), followed by the LS (6/16, 37.5%) and IS (8/12, 66.7%) group. Implant complications occurred at a mean follow-up of 7.5 (range: 6–9), 9 (range: 5–23), and 7 (range: 1–21) months in the HSS, IS, and LS groups. Among these implant complications, revision surgeries were performed in two patients in the HSS group, two in the IS group, and one in the LS group. One patient treated by HSS with balloon kyphoplasty underwent reoperation because of symptomatic cement leakage.ConclusionsThe HSS technique reduced intraoperative blood loss, surgical duration, and postoperative implant complications, indicating it is a good alternative to the IS and LS techniques for treating acute single-level TLBFs. This technique facilitates immediate kyphosis correction and successful maintenance of the corrected alignment within 1 year. Supplemental kyphoplasty with SpineJack® devices and high-viscosity bone cements for anterior reconstruction can potentially decrease the risk of cement leakage and related issues.

Can Vertical Laminar Fracture Further Discriminate Fracture Severity Between Thoracolumbar AO Type A3 and A4 Fractures?

To determine whether vertical laminar fracture (VLF) can distinguish between AO type A3 and A4 fractures. In a retrospective review of 111 consecutive acute thoracolumbar burst fractures, 5 reviewers independently analyzed computed tomography scans to classify fractures into A3 or A4 and to identify VLF. The following computed tomography parameters were measured: spinal canal stenosis >50%, anterior vertebral height ratio <50%, load sharing score >6, and local kyphosis >20°. We calculated the diagnostic performance of VLF in detecting A4 fracture. We compared the proportion of fractures with positive bony parameters, neurological deficit, dural tears, and surgical treatment between A3, A4 with VLF, and A4 without VLF. VLF was present in 62/75 (83%) A4 fractures and 2/36 (5.5%) A3 fractures (P < 0.0001). VLF yielded a high specificity of 94% (95% confidence interval 81%-99%) and moderately high sensitivity of 83% (95% CI 72%-91%) in detecting A4 fractures. A significantly higher proportion of A4 fractures with VLF had neurological deficit (24% vs. 0, P= 0.05), spinal canal stenosis >50% (25% vs. 0, P= 0.04), and anterior vertebral height ratio <50% (24% vs. 0, P=0.05) than A4 fractures with no VLF. Interrater and intrarater κ values for VLF and AO standard criterion were excellent (>0.85). We found VLF to be highly specific, sensitive, and reliable in detecting A4 fractures. A higher proportion of A4 fractures with VLF had radiographic parameters and neurological deficit than A4 fractures with no VLF. VLF could be used as a severity modifier to further discriminate A3 and A4 fractures regarding severity and potentially guide treatment decision making.

Evaluation of Posterior Stabilization Reinforced with Intravertebral Titanium Mesh Cages in Treating Acute Thoracolumbar Burst Fractures

Background Data: Burst fractures are commonly provoked by axial compression which disrupts the anterior column. In this setting, posterior stabilization using pedicle screws alone may lead to delayed kyphosis and instrumentation failure due to inadequate support of the anterior column.Purpose: To evaluate the efficacy of pedicle screw instrumentation combined with transpedicular titanium mesh cage augmentation for treatment of burst fractures.Study Design: Prospective descriptive cohort clinical case study.Patients and Methods: Fourteen neurologically intact patients with acute incomplete thoracolumbar burst fracture (AO type A 3.1), and operated upon through period from January 2016 to June 2017 were included. Patients were treated using a three vertebrae pedicle screw fixation construct combined with bilateral transpedicular titanium mesh cage augmentation of the fracture. Patients were followed for at least one year. Data about pain (VAS), function (ODI) and vertebral body deformity (Beck index and local kyphotic angle) were recorded prospectively.Results: Patients were operated within 5 days after trauma. The mean VAS score improved after surgeryfrom 8.2±1.3 to 3.7±1.1 postoperatively and to 1.8±0.7 at final follow up (P<0.05). The mean ODI score improved from 69.4±5.2 preoperatively to 17.2±2.4 at final follow up. The mean Beck index improved from 0.63 preoperatively to 0.81 postoperatively and to 0.79 at final follow up. The mean local kyphotic angle improved from 20.4o preoperatively to 11.5o postoperatively and declined to 13.7o at final visit. No patient had neurological deterioration or hardware failure during the follow up.The mean follow up was 13.4±1.8 months.Conclusion: Posterior stabilization using pedicle screw fixation in combination with titanium mesh cage augmentation can maintain vertebral restoration, prevent hardware failure and lead to better clinical outcome. (2018ESJ162)

Is additional balloon Kyphoplasty safe and effective for acute thoracolumbar burst fracture?

BackgroundBurst fracture is a common thoracolumbar injury that is treated using posterior pedicle instrumentation and fusion combined with transpedicular intracorporeal grafting after reduction. In this study, we compared the outcome of these two techniques by using radiologic imaging and functional outcome.MethodsSixty-one patients with acute thoracolumbar burst fracture were operated with kyphoplasty (n = 31) or vertebroplasty (n = 30) and retrospectively reviewed in our institution between 2011 and 2014. All 61 patients underwent surgery within 5 days after admission to the hospital and then followed-up for 12 to 24 months after surgery.ResultsSignificant improvement was found in the anterior vertebral height (92 ± 8.9% in the kyphoplasty group, 85.6 ± 7.2% in the vertebroplasty group, p < 0.01) at 1 month post-operatively and (89 ± 7.9% in the kyphoplasty group, 78 ± 6.9% in the vertebroplasty group, p < 0.01) at the 24-month follow-up. Significant improvement was also observed in the kyphotic angle (1.2 ± 0.5° in the kyphoplasty group, 10.5 ± 1.2° in the vertebroplasty group, p < 0.01) at 1 month post-operatively and (5.4 ± 1.2° in the kyphoplasty group, 11.5 ± 8.5° in the vertebroplasty group, p < 0.01) at the 24-month follow-up. Both operations led to significant improvement of the patients’ pain and the Oswestry disability index (p < 0.01). Cement leakage was noted in 29% of patients after kyphoplasty and 77% of patients after vertebroplasty (p < 0.01). Only one implant failure (3.3%), which required further surgical intervention, was reported in the vertebroplasty group.ConclusionsReduction with additional balloon at the fractured site is better than indirect reduction only by posterior instrumentation. The better reduction of kyphotic angle and the lower cement leakage rate in the kyphoplasty group indicate that additional balloon kyphoplasty is safe and effective for acute thoracolumbar burst fracture.

Comparative Study Between Short Segment Open Versus Percutaneous Pedicle Screw Fixation with Indirect Decompression in Management of Acute Burst Fracture of Thoracolumbar and Lumbar Spine with Minimal Neurological Deficit in Adults

The objective of this prospective randomized study was to compare the immediate and long-term clinico-radiological outcome of short segment open versus percutaneous pedicle screw fixation with indirect decompression achieved via distracting the posterior pedicle screw construct in management of single level acute thoracolumbar and lumbar burst fracture (TLBF) with minimal neurological deficit in adults. All patients had burst fracture of less than 72 hours and loss of vertebral body height ≥50%, angulation ≥30⁰, kyphotic deformity ≥20⁰, canal compromise ≥40⁰, failure of at least 2 columns, with intact pedicle and minimum neurological deficit [Grades C and D; according to American Spinal Injury Association (ASIA) grading system. Fractures treated either via short segment open pedicle screw fixation with indirect decompression (OPSFD) or short segment percutaneous pedicle screw fixation with indirect decompression (PPSFD) techniques, were corrected using a titanium monoaxial pedicle screw construct. Post-operatively all patients were advice brace and subjected for regular physiotherapy and followed up to 1 years. Data regarding peri-operative events, clinico-radiological outcome, duration of hospital stay and period taken to return to work was collected and analysed. Those patients treated with PPSFD techniques demonstrated superior outcomes compared to conventional OPSFD techniques, with significantly reduced operative time and blood loss during surgery, hospital stay, better neurological outcomes and early return to work. However, there was no significant difference in view of radiological improvement between the two surgical techniques. We would recommend PPSFD techniques as the best way of treating acute single level TLBF with minimum neurological deficit in adults.

Anterior thoracolumbar locked plate fixation for the treatment of an acute unstable burst fracture of the thoracic and lumbar spine

Background In unstable burst fractures of the thoracic and lumbar spine, short segmental posterior fixation has been associated with a high rate of hardware failure, with recurrence of deformity. Anterior surgical treatment allows direct decompression of the neural elements and reconstruction of the weight-bearing column with fusion of only two levels. Aim of the work The aim of this study was to evaluate the effectiveness of anterior-only surgery and locked plate fixation in the treatment of unstable burst fractures of the thoracic and lumbar spine. Study design Prospective study. Patients and methods We included 22 patients (13 men and nine women) with acute thoracolumbar burst fractures treated with anterior surgery, strut iliac graft, and fixation with a locked thoracolumbar plate. The mean age of the patients at the time of surgery was 33.2 years (range 19–55 years). Neurologically, five patients were Frankel B, 13 were Frankel C, and four were Frankel E. All patients had preoperative and postoperative radiographs and computed tomography scan. Results The 18 patients with neurological deficit showed at least one Frankel grade improvement on final observation, with 16 (88.9%) patients showing complete neurological recovery. Sagittal alignment was improved from a mean preoperative kyphosis of 19.9–6.7π at the final observation. Conclusion Through the anterior surgery of the spine and locked plate fixation, we can achieve good canal decompression, spinal column alignment, and short segment arthrodesis.

Can the Interpedicular Distance Reliably Assess the Severity of Thoracolumbar Burst Fractures?

Retrospective analysis of 260 patients with acute spine fractures treated at a tertiary trauma center from 1989 to 2009. To correlate the Interpedicular distance (IPD) to the percentage of narrowing of the spinal canal and to the presence of neurological deficit and laminar fracture in thoracolumbar burst fractures. Several reports use radiographic findings such as severity of vertebrae collapse, comminution of the vertebral body, and grade of localized kyphosis to determine the severity of spinal traumas and establish appropriate management. However, the importance of the IPD in burst fractures has rarely been mentioned, and no report specifically describes the correlation between an increased IPD and the severity of the lesion or a higher occurrence of lamina fractures. Plain radiographs of 260 patients with acute thoracolumbar burst fractures were studied. The percentage of widening between the pedicles of the fractured vertebra (IPD) was established by comparing this distance with that of the vertebrae immediately above and below. Data concerning neurological status, percentage of narrowing of the spinal canal, and the presence of laminar fracture were correlated to the IPD. A significant correlation between IPD and the percentage of narrowing of the spinal canal was found (r = 0.39; t = 6.78; P = 0.00). IPD was significantly increased in patients with neurological deficit (24.7% ± 12.6%) and in patients with lamina fractures (24.6% ± 16.2%). IPD measured from plain radiographs proved to be a reliable instrument to assess narrowing of the spinal canal, neurological deficits, and laminar fractures.

Treatment of Thoracolumbar Burst Fractures by Means of Anterior Fusion and Cage

Retrospective case series. To evaluate the outcome of treating acute thoracolumbar burst fractures using anterior corpectomy and reconstruction with a mesh cage and instrumentation. There is increasing interest in using an anterior mesh cage with instrumentation after corpectomy for burst fractures. However, there is only limited information on this technique in the literature. Twenty-two patients (mean age 37.6 y old) that had sustained a thoracolumbar burst fracture were included in this study. On admission, 20 patients (90.9%) had an incomplete neurological deficit. An anterior thoracolumbar approach was used to perform anterior corpectomy and reconstruction with a mesh cage and lateral fixation with screws and dual rods. We studied the operation date and delayed the blood loss, and we used the American Spinal Injury Association grade to evaluate the neurological status before surgery and in the follow-up period. Local kyphosis measured by the Cobb method was compared before and after the surgery using Wilcoxon signed-rank test/2-tailed test for analysis. Ninety percent of patients were operated within 2 days after admission and all were followed for a minimum of 25 months. The mean follow-up period was 47.4 months (range, 25 to 71 mo). Blood loss averaged 1445 mL. Of the 20 patients with incomplete neurological lesions, there were 6 (30%) patients with an improvement of at least 1 American Spinal Injury Association grade. No neurological deterioration was observed in any case. The local kyphosis measured by the Cobb method was improved from a mean of 15 degrees preoperative to a mean of 9.6 degrees in early postoperative period (P=0.002). The mean after 2 years was 11.5 degrees (P=0.011). There was no instrumentation failure. Anterior thoracolumbar decompression and fusion secured with an anterior mesh cage and instrumentation in thoracolumbar burst fractures provided excellent immediate reduction of post-traumatic local kyphosis.

Anterior Z-Plate and Titanic Mesh Fixation for Acute Burst Thoracolumbar Fracture

A retrospective study. To evaluate the clinical outcome, effectiveness, and security of the surgical management of acute thoracolumbar burst fracture with corpectomy, titanic mesh autograft, and Z-plate fixation by anterior approach. Many surgical methods were adopted to treat acute burst thoracolumbar fracture. But the optimal surgical management remains controversial. A retrospective review of a consecutive series of 48 patients with thoracolumbar burst fracture treated with anterior corpectomy, titanic mesh autograft, and Z-plate internal fixation was carried out. Preoperative clinical and radiographic data of all cases were originally collected. Surgical indications were motor neurologic deficit and thoracolumbar column instability. Twenty-two patients (45.8%) with acute thoracolumbar burst fractures presented with a neurologic deficit. The postoperative recovery of neural function, restoration of anterior cortex collapse, kyphotic angle, and spinal canal compromise were observed. The preoperative kyphotic angle was improved to a mean of 5.6°, radiographic height restored to 95.8% of the adjacent normal levels, and canal compromise was 0%. None of the patients had neurologic deterioration. Mean follow-up time was 32.4 months (range, 24-47 months). All 22 patients with neurologic deficit demonstrated at least one Frankel grade improvement on final observation, with 16 (73%) patients had accomplished complete neurologic recovery. Forty-six (96%) patients reported minimal or no pain at final follow-up observation, and 40 (83%) patients who had been working before injury returned to original work. The authors considered spinal cord decompression with anterior corpectomy and stability reconstruction with titanic mesh autograft and Z-plate fixation at same time in one incision as an effective technique for unstable thoracolumbar burst fracture with and without neurologic deficit.

Assessment of Ligamentous Injury in Patients With Thoracolumbar Burst Fractures Using MRI

No consensus has been reached on the optimal radiographic evaluation of thoracolumbar burst fractures. The role of MRI in the treatment decision is not fully documented. The objectives was to measure the agreement of MRI in detecting posterior ligamentous complex (PLC) and posterior longitudinal ligament (PLL) injury, and to determine whether the findings by MRI is correlated with the results of plain radiography and computed tomography (CT) scanning as well as neurological examination and with the treatment planning. Sixty-one patients with acute thoracolumbar burst fracture were retrospectively reviewed for the presence of supraspinous ligament (SSL), interspinous ligament (ISL) or posterior longitudinal ligament (PLL) injury. The overall interobserver agreement between the three different observers was assessed by a kappa coefficient for multiple raters. The status of ligaments was correlated with the neurological function as assessed by Frankel scale and fracture severity as defined by the Load Sharing Classification. These patients were surgically treated according to the Load Sharing Classification and followed up for at least 5 years. The kappa coefficients for ISL or SSL injury ranged 0.601 to 0.736, representing substantial to almost perfect agreement, whereas the kappa coefficients for PLL injury were 0.441 to 0.574, representing moderate agreement. No significant difference (P > 0.05) of Frankel scale or load sharing score was found between patients with and without ligamentous injuries. Satisfactory results were achieved in all patients regarding the clinical and radiological assessment. MRI is reliable for detecting the ligamentous injury, especially PLC injury in thoracolumbar burst fractures but the ligamentous injury as shown by MRI is not correlated with the neurological function or fracture severity. As MRI finding is of little value in treatment planning of thoracolumbar burst fractures, MRI examination is not necessary to be used routinely for excluding occult ligamentous injury.

Anterior-Only Stabilization Using Plating With Bone Structural Autograft Versus Titanium Mesh Cages for Two- or Three-Column Thoracolumbar Burst Fractures

A randomized, controlled follow-up study to review patients with acute thoracolumbar burst fractures treated by anterior instrumentation and reconstruction. The objective of this study was to evaluate the results of anterior instrumentation in the treatment of thoracolumbar burst fractures and to determine whether anterior-only approach would be sufficient for highly unstable burst fractures. In this prospective follow-up study, we also compared the results of anterior reconstruction with structural grafting and with titanium mesh cage in a randomized fashion. Anterior decompression and reconstruction supplemented with instrumentation is generally believed to be superior to fixation with posterior pedicle screw instrumentation for a highly unstable burst fracture, but the indications and methods for anterior approach has not been fully documented. A total of 65 patients undergoing anterior plating for a thoracolumbar burst fracture with a load-sharing score of 7 or more between 2000 and 2003 were included this study. They were randomized to receive iliac crest autograft (group A, n = 32) or titanium mesh cages (group B, n = 33). The patients were similar in the distribution of 3-column injuries (n = 8 in group A vs. n = 9 in group B). During the minimum 4-year (range, 4-7 years) follow-up period, all patients were prospectively evaluated for clinical and radiologic outcomes. The Frankel scale, the ASIA motor score, and the Short Form 36 were used for clinical evaluation, whereas the fusion status and the loss of kyphosis correction for the local kyphosis angle were examined for radiologic outcome. All patients in this study achieved solid fusion, with significant neurologic improvement and no significant correction loss as defined by loss of kyphosis correction. The clinical and radiologic results were not significantly different (P > 0.05) at all time points between the 2 groups A and B. Twenty-six of 32 patients in group A still complained of donor site pain to some degree at the final follow-up. No significant impact of 3-column injuries (P > 0.05) were identified on the results for all comparisons. Anterior-only instrumentation and reconstruction with structural autograft or titanium mesh cages is sufficient for surgical treatment of thoracolumbar burst fractures with a load-sharing score of > or = 7 and even with 3-column injuries.

Posterior instrumentation with transpedicular calcium sulphate graft for thoracolumbar burst fracture

From October 2005 to September 2006, 20 patients with an acute thoracolumbar burst fracture underwent posterior instrumentation with transpedicular intracorporeal calcium sulphate grafting. The mean age of the patients at surgery was 41.8 years; 14 were men and six were women. The mean follow-up period was 28.5 months. Pre-operative computed tomography showed that the mean canal compromise was 53.5%. The Cobb angle was improved from 21.70 to 2.40 degrees, and the final loss of correction was 4.60 degrees. The anterior body height was corrected from 50.3% to 86.6%, and the average loss of anterior body height was 7.7% at final follow-up. All six patients with partial neurological deficit initially had improvement. According to the Denis criteria, the average pain score was 1.8, and the final mean work score was 2.5. Only one case had implant failure. Analysis of the results indicated that this technique can restore and maintain sagittal alignment and anterior body height, providing satisfactory short-term clinical results.

Conservative Treatment of Thoracolumbar Burst Fractures

A retrospective study to review patients with acute thoracolumbar burst fractures who were conservatively treated. The purpose of this study was to analyze the efficacy of conservative treatment of thoracolumbar burst fractures in terms of long-term results, and to determine whether the long-term results of conservative treatment would be predicted by the Load Sharing Classification. The optimal management of thoracolumbar burst fractures remains controversial, with advocates for nonoperative or operative approaches. Different criteria for treatment options have been advocated for classifying the fractures, guiding treatment decision-making, and predicting the prognosis. A total of 127 patients with an acute thoracolumbar burst fracture (Denis type B) were treated conservatively. Their Load Sharing score ranged from 3 to 9 (average, 5.3). Twenty-two (17.3%) of these patients presented with a neurologic deficit. They were followed up for at least 3 years (range, 3-12 years; average, 7.2 years) and assessed for clinical and radiologic outcomes. The motor score of the American Spinal Injury Association, and Denis pain and work scales were used for clinical evaluation, whereas the loss of kyphosis correction (LKC) for the local kyphosis angle was examined for radiologic outcome. None of the patients had neurologic deterioration during the reduction. All 22 patients with neurologic deficit experienced improvement with average recovery rate of 93%. Significant correlation (P < 0.05) was found between the Load Sharing score on admission and the LKC for local kyphosis angle at final follow-up. Most patients reported acceptable results regarding pain (111/127, 87.4%) and work (110/127, 86.6%). A positive correlation was found between the LKC and the severity of pain (r = 0.194, P < 0.05). Seven patients (5.5%) required or had undergone late surgery for correction of loss-related back pain and/or poor functional outcome. Conservative treatment is safe and effective for selected patients with thoracolumbar burst fractures, even in some cases with neurologic deficit. The Load Sharing Classification could be used for guiding the treatment of thoracolumbar burst fractures not only in surgical approach choice but also in surgical decision-making.

Direct Reduction of Thoracolumbar Burst Fractures by Means of Balloon Kyphoplasty With Calcium Phosphate and Stabilization With Pedicle-Screw Instrumentation and Fusion

Prospective consecutive series. To evaluate the outcomes of the treatment of acute thoracolumbar burst fractures by transpedicular balloon kyphoplasty with calcium phosphate cement and posterior instrumented fusion. In the surgical treatment of thoracolumbar fractures, the major problem after posterior correction and transpedicular instrumentation is failure to support the anterior spinal column, leading to the loss of correction and instrumentation failure. Twenty-three consecutive patients with an average age of 48 years, who sustained thoracolumbar A3-type burst fracture with or without neurologic deficit were included in this prospective study. Twenty-one of 23 patients had single fractures and 2 had each one additional A1 compression contiguous fracture. On admission 5 (26%) of 23 patients had neurologic lesion (5 incomplete, 1 complete). Bilateral transpedicular balloon kyphoplasty was performed with quick hardening calcium phosphate cement to reduce segmental kyphosis and restore vertebral body height and supplementary pedicle-screw instrumentation [long including 4 vertebrae for T9-L1 fractures and short (3 vertebrae) for L2-L4 fractures]. Gardner kyphosis angle, anterior and posterior vertebral body height ratio, and spinal canal encroachment were calculated before to after surgery. All 23 patients were operated within 2 days after admission and were followed for at least 24 months after index surgery. Operating time and blood loss averaged 70 minutes and 250 cc, respectively. The 5 patients with incomplete neurologic lesions improved by at least 1 American Spine Injury Association grade, whereas no neurologic deterioration was observed in any case. Overall sagittal alignment was improved from an average preoperative 16 degrees to 1 degrees kyphosis at final follow-up observation. The anterior vertebral body height ratio improved from 0.6 before surgery to 0.9 (P < 0.001) after surgery, whereas posterior vertebral body height was improved from 0.95 to 1 (P < 0.01). Spinal canal encroachment was reduced from an average 32% before surgery to 20% after surgery. No differences in preoperative values and postoperative changes in radiographic parameters between short and long group were shown. Cement leakage was observed in 4 cases: 3 anterior to vertebral body and 1 into the disc without sequela. In the last computed tomography evaluation, there was shown a continuity between calcium phosphate and cancellous vertebral body bone. Posterolateral radiological fusion was achieved within 6 to 8 months after index operation. There was no instrumentation failure or measurable loss of sagittal curve and vertebral height correction in any group of patients. Balloon kyphoplasty with calcium phosphate cement secured with posterior long and short fixation in the thoracolumbar and lumbar spine, respectively, provided excellent immediate reduction of post-traumatic segmental kyphosis and significant spinal canal clearance and restored vertebral body height in the fracture level in an equal amount both in the short and the long instrumentation.

The Surgical Management of Unstable Thoracolumbar Burst Fractures with Anterolateral and Posterior Approach: Comparison of Clinical and Radiological Outcome

Objective: The authors evaluate the clinical and radiographic outcome of the management of acute thoracolumbar burst fractures by anterolateral or posterior approach. Methods: Thirty four (34) consecutive patients with a single-level traumatic unstable burst fracture at the thoracolumbar junction were surgically treated between Jan. 2004 and Dec. 2006. Twenty one patients were operated on by anterolateral approach, strut graft and fixation with a Kaneda plate. Thirteen patients were treated with posterior approach and transpedicular screw fixation. Clinical and radiographic evaluation was performed on all 34 patients before and after surgery. Results: There were 34 thoracolumbar burst fractures in 27 male and 7 female patients. Fifty-nine percent (20 of 34) of patients presented with a neurologic deficit. The mean follow-up duration was 18.5 months (range 7-44 months). Preoperative canal encroachment in the anterolateral and posterior groups measured 49.3±7.6%, 27.3±9% respectively (p=0.001). Preoperative angular deformity in the anterolateral and posterior groups measured 19.4±8.4° and 12.9±4.5° respectively. At discharge, angular deformity had been corrected to 10.5± 7.3° and 7.6±4.9° in both groups, respectively. Preoperative Frankel grade grade in the anterolateral and posterior groups was 3.9±1.2, 3.9±1.5 respectively (p=0.9). Postoperatively, it had been improved to 4.4±1.1, 4.2±1.4 in both groups, respectively. Conclusion: Compared with posterior approaches, the anterolateral approach can reduce fusion segment, well maintained the kyphosis correction and decompress the spinal canal completely. The selection of treatment should be based on clinical and radiological finding including neurological deficit. (J Kor Neurotraumatol Soc 2008;4:37-42)

Transpedicular hydroxyapatite grafting with indirect reduction for thoracolumbar burst fractures with neurological deficit: A prospective study.

Background:The major problem after posterior correction and instrumentation in the treatment of thoracolumbar burst fractures is failure to support the anterior spinal column leading to loss of correction of kyphosis and hardware breakage. We conducted a prospective consecutive series to evaluate the outcome of the management of acute thoracolumbar burst fractures by transpedicular hydroxyapatite (HA) grafting following indirect reduction and pedicle screw fixation.Materials and Methods:Eighteen consecutive patients who had thoracolumbar burst fractures and associated incomplete neurological deficit were operatively treated within four days of admission. Following indirect reduction and pedicle screw fixation, transpedicular intracorporeal HA grafting to the fractured vertebrae was performed. Mean operative time was 125 min and mean blood loss was 150 ml. Their implants were removed within one year and were prospectively followed for at least two years.Results:The neurological function of all 18 patients improved by at least one ASIA grade, with nine (50%) patients demonstrating complete neurological recovery. Sagittal alignment was improved from a mean preoperative kyphosis of 17°to −2°(lordosis) by operation, but was found to have slightly deteriorated to 1° at final followup observation. The CT images demonstrated a mean spinal canal narrowing preoperatively, immediate postoperative and at final followup of 60%, 22% and 11%, respectively. There were no instances of hardware failure. No patient reported severe pain or needed daily dosages of analgesics at the final followup. The two-year postoperative MRI demonstrated an increase of one grade in disc degeneration (n = 17) at the disc above and in 11 patients below the fractured vertebra. At the final followup, flexion-extension radiographs revealed that a median range of motion was 4, 6 and 34 degrees at the cranial segment of the fractured vertebra, caudal segment and L1-S1, respectively. Bone formation by osteoconduction in HA granules was unclear, but final radiographs showed healed fractures.Conclusions:Posterior indirect reduction, transpedicular HA grafting and pedicle screw fixation could prevent the development of kyphosis and should lead to reliable neurological improvement in patients with incomplete neurological deficit. This technique does not require fusion to a segment, thereby preserves thoracolumbar motion.

Treatment of acute thoracolumbar burst fractures with kyphoplasty and short pedicle screw fixation: Transpedicular intracorporeal grafting with calcium phosphate: A prospective study

Background:In the surgical treatment of thoracolumbar fractures, the major problem after posterior correction and transpedicular instrumentation is failure to support the anterior spinal column, leading to loss of correction and instrumentation failure with associated complaints. We conducted this prospective study to evaluate the outcome of the treatment of acute thoracolumbar burst fractures by transpedicular balloon kyphoplasty, grafting with calcium phosphate cement and short pedicle screw fixation plus fusion.Materials and Methods:Twenty-three consecutive patients of thoracolumbar (T9 to L4) burst fracture with or without neurologic deficit with an average age of 43 years, were included in this prospective study. Twenty-one from the 23 patients had single burst fracture while the remaining two patients had a burst fracture and additionally an adjacent A1-type fracture. On admission six (26%) out of 23 patients had neurological deficit (five incomplete, one complete). Bilateral transpedicular balloon kyphoplasty with liquid calcium phosphate to reduce segmental kyphosis and restore vertebral body height and short (three vertebrae) pedicle screw instrumentation with posterolateral fusion was performed. Gardner kyphosis angle, anterior and posterior vertebral body height ratio and spinal canal encroachment were calculated pre- to postoperatively.Results:All 23 patients were operated within two days after admission and were followed for at least 12 months after index surgery. Operating time and blood loss averaged 45 min and 60 cc respectively. The five patients with incomplete neurological lesions improved by at least one ASIA grade, while no neurological deterioration was observed in any case. The VAS and SF-36 (Role physical and Bodily pain domains) were significantly improved postoperatively. Overall sagittal alignment was improved from an average preoperative 16° to one degree kyphosis at final followup observation. The anterior vertebral body height ratio improved from 0.6 preoperatively to 0.9 (P<0.001) postoperatively, while posterior vertebral body height improved from 0.95 to 1 (P<0.01). Spinal canal encroachment was reduced from an average 32% preoperatively to 20% postoperatively. Cement leakage was observed in four cases (three anterior to vertebral body and one into the disc without sequalae). In the last CT evaluation, there was a continuity between calcium phosphate and cancellous vertebral body bone. Posterolateral radiological fusion was achieved within six months after index operation. There was no instrumentation failure or measurable loss of sagittal curve and vertebral height correction in any group of patients.Conclusions:Balloon kyphoplasty with calcium phosphate cement secured with posterior short fixation in the thoracolumbar spine provided excellent immediate reduction of posttraumatic segmental kyphosis and significant spinal canal clearance and restored vertebral body height in the fracture level.

The Treatment of Acute Thoracolumbar Burst Fractures With Transpedicular Intracorporeal Hydroxyapatite Grafting Following Indirect Reduction and Pedicle Screw Fixation: A Prospective Study

Prospective consecutive series. To evaluate the outcomes of the treatment of acute thoracolumbar burst fractures by transpedicular hydroxyapatite grafting following indirect reduction and pedicle screw fixation. In the treatment of thoracolumbar burst fractures, the major problem after posterior correction and instrumentation is failure to support the anterior spinal column, leading to the loss of correction of kyphosis and instrumentation breakage. There were 15 consecutive patients who had thoracolumbar burst fractures and associated incomplete neurologic deficit. They underwent surgery within 4 days of admission, had their implants removed within 1 year, and were prospectively followed for at least 2 years. Following indirect reduction and pedicle screw fixation, transpedicular intracorporeal hydroxyapatite grafting to the fractured vertebrae was performed. Median operating time was 130 minutes, and median blood loss was 155 g. The neurologic function of all 15 patients improved by at least 1 American Spine Injury Association grade, with 9 (60%) having complete neurologic recovery. Sagittal alignment was improved from a median preoperative kyphosis of 20 degrees to -1 degrees (lordosis) by surgery but was found to have slightly deteriorated to 1 degrees at final follow-up observation. Computerized tomography showed a median spinal canal narrowing of 64%, 22%, and 11%, respectively. There were no instances of instrumentation failure. Posterior indirect reduction, transpedicular hydroxyapatite grafting, and pedicle screw fixation could provide reliable neurologic improvement in patients with incomplete neurologic deficit, and could prevent the development of kyphosis. This technique does not require fusion to a segment, thereby preserves thoracolumbar motion.

The Management of Acute Thoracolumbar Burst Fractures with Anterior Corpectomy and Z-Plate Fixation

A retrospective review of a consecutive series of patients with acute thoracolumbar burst fractures who were surgically treated with an anterior corpectomy and fusion with anterolateral Z-plate fixation. To evaluate the clinical and radiographic success of the management of acute thoracolumbar burst fractures by corpectomy, structural grafting, and anterolateral internal fixation. Burst fractures are frequently associated with instability or neurologic deficit. Modern surgical procedures for these fractures have been performed via both anterior and posterior approaches. Anterior surgical treatment allows direct decompression of the neural elements and correction of deformity. Newer anterior instrumentation devices, combined with a structural graft, allow a stable construct that may obviate a posterior procedure. An anterior procedure generally requires fusion of only two levels compared to posterior fusion, which generally requires more. A retrospective review of a consecutive series of patients with thoracolumbar burst fractures treated with anterior surgery, strut graft, and fixation with a Z-plate was carried out. Fractures were considered acute if surgically treated within 30 days. Clinical and radiographic evaluation was performed on all 35 patients with acute thoracolumbar burst fractures. Surgical indications were incomplete neurologic deficit, segmental kyphotic deformity, or significant comminution. All patients with acute thoracolumbar burst fractures with spinal cord injury were treated with an intravenous steroid protocol and were operated on within 24 hours of admission unless medically precluded. Forty-six percent (16 of 35) of patients with acute thoracolumbar burst fractures presented with a neurologic deficit. All 16 patients with neurologic deficit demonstrated at least one Frankel grade improvement on final observation, with 11 (69%) patients demonstrating complete neurologic recovery. Thirty-three patients were treated with anterolateral instrumentation only. Twenty-nine of thirty patients demonstrated radiographic healing. Five were lost to follow-up observation. One patient required subsequent posterior fusion for increasing kyphotic deformity. There were no instances of hardware failure. Sagittal alignment was improved from a mean preoperative kyphosis of 18 degrees to 6 degrees at final follow-up observation. Anterior corpectomy, strut graft, and Z-plate fixation is an effective treatment for thoracolumbar burst fractures. It allows direct decompression of the spinal cord in the acute setting and was associated with a high rate of neurologic improvement, no instances of neurologic worsening in any case, and a low complication rate.

Acute thoracolumbar burst fractures: a new view of loading mechanisms.

An in vitro investigation of loading mechanisms in acute thoracolumbar burst fractures. To assess the validity of the authors' hypothesis that anterior shear forces transmitted by the facet joints are responsible for causing the severe canal compromise associated with acute thoracolumbar burst fractures. Thoracolumbar burst fractures created in the laboratory rarely match the severity of clinical cases. To date, no studies have examined in great detail the role of facet joint loading in the burst-fracture mechanism. An incomplete understanding of loading mechanisms may contribute to the controversies regarding management. Nine human cadaveric motion segments were instrumented with strain gages and subjected to axial compression or axial impact coupled with an extension moment. Failure loads, strain information, and radiographs were collected. Fracture patterns characteristic of acute thoracolumbar burst fractures were observed in the three specimens tested with an extension moment. In this group, high strains were also recorded at the bases of the pedicles, indicating a probable site of fracture initiation. Specimens tested in a neutral orientation experienced crush fractures without an increase in interpedicular distance. Strain patterns were more uniform in this group. The severity and clinical relevance of the injuries sustained by the specimens tested in extension suggest that facet joint loading plays a critical role in the acute thoracolumbar burst-fracture loading mechanism. Fracture patterns and strain concentrations are in agreement with clinical observations as well as past experimental studies.