Flexion-distraction Injuries Research Articles

Thoracolumbar Flexion-Distraction Injuries

Retrospective study, prospectively gathered databases. To assess abdominal comorbidities, missed injuries, and complications associated with thoracolumbar flexion-distraction injuries (FDI). From 1989 to 2003, 153 patients with flexion-distraction type injuries were identified. Predominant injury mechanisms consisted of motor vehicle crashes, falls, and motorcycle crashes. Spinal injuries were categorized by region, injury pattern, American Spinal Injury Association grade, and motor score. Diagnostic methods, delayed diagnoses, and complications were recorded and compared with variables of spinal injury, abdominal injury, and neurologic outcome. Treatment variables included nonoperative care, posterior surgery alone, anterior surgery alone, or combination treatment. Primary outcomes were neurologic status, unintended secondary procedures, complications, and kyphosis angle. Spinal cord injury (SCI) was found in 37 of 151 patients (25%). SCI was correlated with high-grade posterior element dissociation. Intra-abdominal injury (IAI) was found in 46 of 151 of patients (30%). There was a statistically significant correlation between presence of FDI and IAI in the lumbar (L2-L4) region. There was a 3.9% incidence of delayed diagnosis of FDI and a 0.9% incidence of delayed diagnosis of IAI. Presence of a "lapbelt-sign" had a positive predictive value of 0.69 and a negative predictive value of 0.91 for IAI. Presence of a lumbar injury due to a motor vehicle crash in the presence of a lapbelt sign was positively associated with IAI. There was no increase in complications in the subpopulation of patients with concurrent SCI and FDI. Both IAI and SCI remain commonly associated with FDI of the thoracolumbar spinal column. The presence of an abdominal wall contusion (lapbelt sign) is a strong indicator of IAI. Adherence to an established trauma algorithm can minimize the risk of delayed diagnosis. Disruption of an established work-up paradigm, however, can lead to potentially life and spinal cord threatening complications.

Pseudo-Aneurysm of a Lumbar Artery After Flexion-Distraction Injury of the Thoraco-Lumbar Spine and Surgical Realignment

A unique case of pseudo-aneurysm of a lumbar artery after injury of the thoracolumbar spine was presented. To describe the exceptional occurrence of pseudo-aneurysm of a lumbar artery after flexion-distraction fracture of thoracolumbar junction and to discuss the mechanism of formation and the therapeutic solution. Injury of a lumbar artery represents a potential cause of massive, life-threatening, retroperitoneal bleeding. It may be associated with lesions of the abdomen, lower limbs, pelvic bones, and spinal column. Fracture of a transverse process may be responsible for direct laceration of a lumbar artery, but formation of a pseudo-aneurysm is an uncommon event. The diagnosis is difficult and often delayed. The treatment of choice is endovascular embolization. In a patient who had a posttraumatic severe thoracolumbar vertebral dislocation with complete spinal cord lesion after road accident, we performed surgical reduction and stabilization via posterior approach. After 7 days, he developed a progressive anemia due to retroperitoneal hemorrhage and formation of a pseudo-aneurysm of the lumbar artery at L1 level. Endovascular embolization achieved resolution of the pseudo-aneurysm, regression of the hematoma and progressive recovery of the patient during a period of 6 months. Pseudo-aneurysm of a lumbar artery has never previously been described in association with flexion-distraction type vertebral fracture, in which the spinal column is subjected to greater, shear-type, forces. Stretching of the arterial wall due to the traumatic dislocation of the spine and subsequent surgical realignment may be considered as the mechanism of formation and rupture of the pseudo-aneurysm. Dangerous bleeding in the retroperitoneal space and in the operative field can be effectively managed by endovascular intervention.

Flexion-distraction injury of the L1 vertebra treated with short-segment posterior fixation and Optimesh

We report a patient with a flexion-distraction injury of the L1 vertebra treated with a combination of short-segment posterior fixation and Optimesh (Spineology Inc., St. Paul, MN, USA), a flexible balloon-shaped mesh that is deployed into the fractured vertebra together with allograft. The patient, a 47-year-old man, was admitted after sustaining a motor vehicle accident. Imaging studies showed an L1 compression fracture. The patient had no neurologic deficits and was treated conservatively. However, intense back pain persisted and significant kyphosis was noted when he mobilized. Review of the imaging studies strongly suggested disruption of the posterior spinal ligaments. Surgical intervention was performed to address both restoration of the posterior tension band and anterior column height simultaneously. The combined procedure consisted of short-segment posterior fixation from T12 to L2, and placement of Optimesh filled with allograft into the L1 vertebral body. The anterior column height was restored and spinal alignment was corrected by the procedure, and the patient’s back pain subsided soon after the procedure. The role of minimally invasive procedures for reconstruction of the vertebral column height, including the Optimesh system, in patients with thoracolumbar compression fracture seems promising. However, the long-term efficacy of these new techniques is unknown. It also remains to be seen how the delivery of allograft into the fractured vertebra via Optimesh affects remodeling, and whether the restored vertebral height is maintained.

Anterior versus combined anterior and posterior fixation/fusion in the treatment of distraction-flexion injury in the lower cervical spine

This study compared the results of combined anterior and posterior fixation/fusion with those of anterior fixation/fusion alone through a retrospective review of 50 patients with a distraction flexion injury of the cervical spine. Group A ( n = 28) had unilateral facet joint subluxation or dislocation (Allen stage I or II) and anterior fixation/fusion alone. Group B ( n = 10) had bilateral dislocation (Allen stage III) and anterior fixation/fusion alone. Group C ( n = 5) had unilateral subluxation or dislocation and combined anterior and posterior fixation/fusion. Group D ( n = 7) had bilateral dislocation or total dislocation (Allen stage III or IV) and combined anterior and posterior fixation/fusion. The following parameters were analyzed: the change in the vertebral height and Cobb’s angle, neurologic recovery, fusion time, fusion rate, surgery time, and the rate of complications. The mean fusion time was 3.75 ± 2.10, 6.00 ± 2.82, 3.60 ± 1.34, and 3.85 ± 2.26 months in groups A, B, C, and D, respectively. Group B had a significantly longer mean fusion time than groups A and D (Mann-Whitney U-test, P = 0,012, P = 0.014). There was a significant difference in the operation time between groups A and B and groups C and D. There were no significant differences in the changes in vertebral height and Cobb’s angle, fusion rate, and neurologic recovery. The complications encountered were three cases of distal screw loosening in group A ( n = 2) and B ( n = 1), and three cases of delayed union in group A ( n = 2) and B ( n = 1). There were no complications in groups C and D. In those with a bilateral dislocation, the fusion time was increased when only anterior fixation/fusion had been performed but the clinical results, such as neurologic recovery and complications, were similar in the four groups. Overall, anterior fixation/fusion alone in a bilateral dislocation is recommended as an alternative method.

Successful Nonoperative Treatment of a Three-Column Thoracic Fracture in a Patient With Ankylosing Spondylitis

A case report. To report the successful nonoperative management of a patient with progressive ankylosing spondylitis who sustained a three-column flexion-distraction injury of the upper thoracic spine with an intact sternal-rib complex, thereby emphasizing the existence and clinical relevance of the fourth-column concept in such patients. Three-column injuries of the cervical and lumbar spine are typically unstable and require surgical stabilization. Patients with ankylosing spondylitis are at an increase risk to sustain three-column injuries of the spine due to their progressive inflammatory disease, a state that renders the spine brittle and alters its biomechanical function. A fourth-column model of the thoracic spine has been proposed and incorporates the sternal-rib complex; however, such a model has rarely been addressed in the literature and its role regarding three-column upper thoracic spine injury with an intact sternal-rib complex in patients with ankylosing spondylitis is unknown. METHODS.: A 68-year-old white man with ankylosing spondylitis and Pickwickian body habitus sustained a three-column flexion-distraction injury at T5 following a ground-level fall. The patient complained of midthoracic back pain; however, he was neurologically intact and ambulated without aids. Because of the patient's numerous active medical issues that substantially increased his perioperative risks combined with symptomatic improvement of his pain, the patient refused surgical stabilization. In addition, because of the patient's body habitus and pulmonary issues, external brace immobilization was not tolerated. At 17 months of follow-up, the patient remained neurologically intact, ambulated well, his midthoracic back pain had subsided, and no progressive kyphosis was noted. This case confirms the existence and clinical relevance of the fourth column of the thoracic spine and its role in providing added spinal stability in the patient with ankylosing spondylitis. As such, it is still possible to achieve a favorable clinical outcome in a select subpopulation of patients with ankylosing spondylitis that sustain three-column flexion-distraction injuries who are neurologically intact and are not candidates for surgical stabilization.

Bony Flexion-Distraction Injury of the Lower Lumbar Spine Treated With Instrumentation Without Fusion and Early Implant Removal: A Method of Treatment to Preserve Lumbar Motion

Most single level bony flexion-distraction injuries can be treated in a brace. Internal fixation is required, however, when a patient fails brace treatment. Instrumentation is routinely left in place for a year or more and in an unfused spine can lead to early degenerative changes of the facets and disks. Implant removal once healing has occurred can preserve motion segments in the lumbar spine and offer an advantage in a young patient over instrumentation and fusion. A case report is presented of a 17-year-old female treated successfully with internal fixation without fusion of a bony flexion-distraction injury of the lower lumbar spine with early implant removal and 2-year follow-up.

Treatment of Distractive Flexion Injury in Lower Cervical Spine using Anterior Cervical Fusion

Study Design: A retrospective study. Objectives: To evaluate the availability of anterior cervical plating in the treatment of distractive flexion injury of the lower cervical spine and the relationship between the neurologic findings, types of dislocation, and disc herniation. Summary of Literature Review: Anterior stabilization of unstable cervical spine injuries is increasing. However, the stability of anterior stabilization only is controversial for the treatment of bilateral dislocation of the cervical spine. Material and Methods: We retrospectively analyzed 32 patients treated with anterior decompression, auto-iliac bone graft, and anterior cervical plating, who suffered from distractive flexion injury in the lower cervical spine from Feb. 1999 to Feb. 2006. Unilateral dislocation occurred in 21 cases, bilateral dislocation in 11 cases, with evaluation of disc status at the injured level conducted after closed reduction by MRI. We statistically analyzed changes in vertebral body height, disc angle, fusion rate, neurologic recovery, and complications. Results: All cases were fused by 12.3±2.7 weeks after operation, and the loss of anterior and posterior vertebral body height were statistically significant (p=0.00, 0.00), changes in the disc angle were not (p=0.53). Herniation of the disc was more frequent in unilateral dislocation (p=0.02). Clinically 21 (65%) patients had neurologic deficits, but nerve root injuries recovered in all cases, with the original average ASIA motor score of 55.2 improving to 68.3 at last follow up. Conclusions: Anterior decompression, bone grafting, and metallic osteosynthesis were effective treatment modalities for distractive-flexion injuries of the lower cervical spine, causing slight vertebral body height decreases but no loss of reduction or neurologic compromise.

The Radiographic Failure of Single Segment Posterior Cervical Instrumentation in Traumatic Cervical Flexion Distraction Injuries

Background/Objectives: Unilateral and bilateral cervical facet subluxations, dislocations, and/or fractures may be managed with anterior, posterior, or combined surgical approaches. The primary objective of this study was to identify radiographic features that predispose to poor radiographic outcomes (kyphosis) when these injuries are treated with single segment posterior cervical instrumentation and fusion. Method: A retrospective radiographic review was performed on 65 patients whose unilateral or bilateral facet subluxation/dislocations or fracture dislocation was managed with single segment posterior cervical instrumentation and fusion. The pre- and postoperative plain radiographs, CT, and MRI were assessed to identify the fracture type, degree of kyphosis, translation, and radiographic failure. Results: 2 patients (3.5%) demonstrated gross radiographic failure of the posterior instrumentation. Both had bilateral facet subluxation without fracture and ultimately required anterior revision. Kyphosis at...

Chance-Type Fractures of the Thoracolumbar Spine: Imaging Analysis in 53 Patients

Chance-type fractures are subtle unstable injuries that are often associated with intraabdominal injuries. CT-based observations made during routine interpretations revealed involvement of a burst component to this fracture pattern and a clue on the transaxial images to its presence. The purpose of this review was to determine how often these features occurred in a retrospective study of a large sample because these findings influence diagnosis and management. A retrospective review of all patients identified from the University of Maryland Shock Trauma Center trauma registry and IDXRad system diagnosed with flexion-distraction injuries of the thoracolumbar spine over an 8-year period was performed. Three trauma radiologists assessed the admission spinal radiographs, CT studies with multiplanar images, and available MRI examinations. Imaging findings were confirmed by consensus. Abdominopelvic CT studies and surgical reports were reviewed for evidence and type of intraabdominal injury. A literature review of previous similar series was performed. Fifty-three patients were identified for inclusion in the study. Associated intraabdominal injury occurred in 40% and most commonly involved the bowel and mesentery. A close examination of the fracture patterns on CT revealed that a burst-type fracture with posterior cortex buckling or retropulsion was a common finding (48%). Also, serial transaxial CT images often (76%) showed a gradual loss of definition of the pedicles that we refer to as the "dissolving pedicle" sign. The study showed that the horizontally oriented fracture planes through the posterior elements can often be recognized radiographically, but these fractures can be very subtle. Intraabdominal injuries occurred in 40% of flexion-distraction thoracolumbar fractures in our study cohort, which is slightly lower than previously reported. About half of the patients with this injury displayed a burst-type component that could have a significant influence on surgical management. The dissolving pedicle sign can assist in recognition of this often subtle injury on transaxial CT.

Flexion-Distraction Injuries of the Thoracolumbar Spine: Health-Related Quality of Life and Radiographic Outcomes

Objective: The assessment of long-term radiographic, generic, and disease-specific health-related quality of life (HRQoL) outcome of patients who have sustained thoracolumbar flexion-distraction injuries. Background: Current management recommendations regarding flexion-distraction injuries of the spine often rely on small heterogeneous cohorts characterized by variability in reported outcomes and lack of longterm functional follow-up. Method: A database search identified all patients treated for thoracolumbar (T11-L2) flexion-distraction injury between 1995 and 2000 at a tertiary spine referral center. The Short Form-36 (SF-36) and NASS Lumbar Outcome instruments were administered, and radiographic assessment was performed. Results: 40 patients constituted the cohort. There were 26 males and 14 females with a mean age of 27.4 years (range, 16-48). Average follow-up was 3.3 years (range, 2.5-7), with 25 patients (64.9%) treated surgically and 15 (35.1%) treated nonsurgically. The follow-up mean SF-36 score...

Thoraco-Lumbar Flexion-Distraction Injury in a Competitive Gymnast: A Case Report

Thoraco-Lumbar Flexion-Distraction Injury in a Competitive Gymnast: A Case Report

Anterior plate fixation for cervical distractive flexion injuries: a biomechanical comparison of different types of design

目的 探讨采用前路钢板固定颈椎屈曲牵张型损伤治疗的可靠性,并比较静力化固定和动力化固定等不同设计类型钢板在恢复损伤节段稳定性方面的差异.方法采用12具小牛颈椎标本,在C4,5节段制作屈曲牵张损伤模型,切除椎间盘、植骨后随机分为3组,分别采用Orion、Codman、Window钢板、螺钉固定,测试手术固定各组在颈椎前屈、后伸、侧屈及旋转运动时的稳定性并与正常标本比较.结果颈椎屈曲损伤后,无论采用哪种钢板固定,其术后运动范围(ROM值)均比正常颈椎要大.Orion固定最接近正常标本,但在旋转运动时有明显差异.Codman固定仅在侧曲时的稳定性接近正常和Orion固定组.Window固定最弱,在各运动状态下的刚度均明显低于正常组.结论在颈椎屈曲牵张型损伤时,前路静力化固定相对稳定,动力化固定可能牺牲一定的固定强度,尤其是选择平移类设计的钢板固定更要谨慎。

Availability of Anterior Cervical Plating in Distractive Flexion Injury in Lower Cervical Spine - Radiologic Aspects -

Availability of Anterior Cervical Plating in Distractive Flexion Injury in Lower Cervical Spine - Radiologic Aspects -

Internal fixation without fusion of a flexion-distraction injury in the lower cervical spine of a three-year-old

Background Reported surgical treatment of unstable pediatric cervical spine injuries typically involves posterior fusion with internal fixation, usually with posterior wiring. Purpose To discuss management issues in the treatment of an unstable Salter-Harris type I pediatric cervical spine injury and surgical intervention without fusion. Study design A case report. Methods Summary of the management of an unstable flexion-distraction injury in a 3-year-old child is presented with literature review. Results A rare unstable flexion distraction injury of the pediatric cervical spine was successfully treated with posterior wiring without fusion. The wires underwent fatigue failure and maintenance of motion achieved without instability at 2-year follow-up. Conclusions In select physeal injuries of the pediatric cervical spine, internal fixation can provide stability while healing occurs, with avoidance of fusion and maintenance of motion.

Unusual Mechanism Of Chance Fracture In An Adult

Flexion-distraction injuries of the upper lumbar spine typically occur in case of a head-on motor vehicle collision, while wearing a lap seat belt without shoulder strap. According to Smith and Kaufer the axis of flexion is situated at the point of contact of the belt with the abdominal wall. This results in a horizontal separation of the anterior, middle and posterior columns. The lesion is called a Chance fracture when it involves primarily bone, rather than ligaments. However, a Chance fracture can happen in unbelted persons: the present case concerns a 30-year-old man who fell from a height.

A unique two-level noncontiguous ligamentous flexion—distraction injury in the thoracolumbar spine

The authors report the case of a patient who sustained traumatic two-level noncontiguous ligamentous flexion-distraction injuries in the thoracolumbar spine. To the best of their knowledge, this is the first reported case of this combined injury pattern.

Surgical outcome of thoracolumbar burst fractures with flexion–distraction injury of the posterior elements

Between 1991 and 2002 we treated 48 patients surgically for thoracolumbar burst fractures associated with flexion-distraction injury of the posterior elements. The degree of kyphotic deformity and the degree of vertebral wedging deformity were measured on plain lateral radiographs. The spinal canal compromise was measured on computer tomography. The mean postoperative follow-up was 70 (24-108) months. The preoperative kyphosis averaged 25.7 degrees and the mean sagittal index was 28.8 degrees . The mean wedging deformity of the fractured vertebral body was 46% (24-66%). The mean preoperative spinal canal compromise secondary to retropulsed bony fragments was 64%. Immediately after surgery, the correction of kyphosis averaged 98%. There was no loss of correction at the final follow-up. A satisfactory reduction and good stabilisation with solid fusion were achieved in all cases.

5:12 163. The radiographic failure of single segment posterior cervical instrumentation in traumatic cervical flexion distraction injuries

BACKGROUND CONTEXT: Cervical distractive flexion injuries may be treated with anterior, posterior, or a combined approach; the literature provides little to guide the surgeon in the choice between specific approaches for a specific injury pattern.

Chance-Type Flexion-Distraction Injuries in the Thoracolumbar Spine: MR Imaging Characteristics

To evaluate retrospectively the magnetic resonance (MR) imaging features of Chance-type flexion-distraction injuries. The authors' institutional review board does not require its approval or patient informed consent for retrospective studies. Imaging data were reviewed retrospectively for 24 patients (15 male, nine female; mean age, 28 years; range, 9-71 years) who had sustained radiographically typical Chance-type flexion-distraction injuries. The posterior vertebral body height remained unchanged or was increased in these patients. Two radiologists recorded a variety of bone and soft-tissue abnormalities seen with MR imaging. Based on consensus, the documented findings were sequentially analyzed to determine their frequencies. Combined bone and soft-tissue injuries occurred in 23 (96%) of 24 patients, were more common than soft-tissue damage alone (one [4%] of 24 patients), and occurred primarily at the thoracolumbar junction. Contiguous vertebral injury was seen in 20 (83%) of 24 patients, usually in the form of anterosuperior vertebral endplate edema, while noncontiguous injury occurred in eight (33%) of 24 patients. Extensive subcutaneous and paraspinal muscle edema was seen in all patients and extended over several segments. Posterior osteoligamentous complex disruption also occurred in all patients. Horizontally oriented fractures of the posterior neural arches produced an MR imaging pattern that the authors call the sandwich sign, which consists of linear hemorrhage framed by marrow edema. This sign was seen in 12 (50%) of 24 patients. In seven (29%) of 24 patients, a fracture line extending from a damaged pedicle was seen to exit through the contralateral posterosuperior aspect of the vertebral body, with extension of the fracture fragments into the spinal canal. A spectrum of features is discernible with MR imaging in Chance-type injuries.

Traumatic scoliosis

On December 24th, 2003, a healthy 7-year-old boy was involved in a motor-vehicle collision. He was a restrained passenger wearing a lap seatbelt (a belt without shoulder restraint). On arrival at hospital he was tachycardic and tachypnoeic, but vital signs were stable. Examination showed an abrasion across the abdomen secondary to the seat belt (“positive seatbelt sign”).He was tender to palpation over the lumbar spine posteriorly. Neurologically he was awake, alert, appropriate, had full movement of his limbs, with intact motor and sensory function. Rectal examination was normal. Initial radiographs showed no fractures nor dislocations. Magnetic resonance imaging of the lumbar spine showed no bony injury, but oedema within the ligaments suggestive of a posterior ligamentous disruption. The diagnosis of a single-level ligamentous flexion-distraction injury was made. Spine precautions (bedrest and logroll for transfers) and bracing was instituted until medical stabilisation and evaluation of associated injuries were completed.