Lumbar Spine Fractures Research Articles

Predictive factors for postoperative deformity in thoracolumbar burst fractures: a statistical approach.

To assess, using statistical analysis, if and to what extent the final outcome of surgical treatment for burst fractures depends on operation type, fracture level and initial deformity severity. A database of 287 patients with single-vertebral-level thoracic and lumbar spine fractures analysed using simple and multiple linear regression analyses models. The dependent variable was last follow-up (LFU) kyphotic angle and the predictor variables were operation type [anterior approach (AA), posterior short-segment fixation (PSSF) and posterior monosegmental fixation (PMF)], fracture level (T11-L1, L2-L3 and L4-L5) and preoperative kyphotic angle. The models were applied on either the whole sample or on the operation type subgroups. In simple linear regression analysis models, fracture level accounted for 32% and 18% of the variation in LFU kyphotic angle in the AA and PMF subgroups, respectively. In the multiple linear regression models for the same subgroups, up to 40% of the variation in LFU kyphotic angle was accounted for by fracture level. Surgical treatment, as predictor variable, indicated that patients treated by PSSF developed a post-surgical kyphotic angle 8.51° more severe than those treated by AA. However, the model accounted for only 2% of the variation in LFU kyphotic angle. Simple linear regressions performed on each subgroup with preoperative kyphotic angle as the independent variable revealed that the variable accounted for 15% (PSSF subgroup), 17% (AA subgroup) and 34% (PMF subgroup) of the variation in LFU kyphotic angle. All valid regression models displayed modest explanatory power, suggesting that factors other than those taken into consideration are involved.

Incidence, impact, and risk factors of adverse events in thoracic and lumbar spine fractures: an ambispective cohort analysis of 390 patients

Background contextAdverse events (AEs) in thoracic and lumbar spine fractures are common, but little is known about the type of AEs that are specific to this population. Furthermore, very little is known about the incidence and clinical impact of these AEs on patients in the presence of traumatic spinal cord injury and whether they are treated operatively or nonoperatively. PurposeThe purpose of this study was to determine primarily the incidence of AEs in patients with thoracic or lumbar spine fractures treated both operatively and nonoperatively and their impact on length of stay (LOS) and secondarily the difference in the incidence of AEs in both neurologically intact and compromised patients. Study design/settingThis is an ambispective cohort study at a quaternary referral center. Patient samplePatients admitted at our institution with thoracic or lumbar fractures from January 2009 to December 2013 were identified. Patients with full Spine Adverse Events Severity System (SAVES) data were included. Outcome measuresNumber and type of AEs collected from SAVES were assessed. Impact of AE on acute LOS was also determined. MethodsData on intraoperative, preoperative, and postoperative AEs were prospectively collected using the SAVES data collection. Logistic regression was used to model the likelihood of experiencing at least one AE based on the patient characteristics. The impact of the total number of AEs experienced by a patient and that of each of the most common AEs on LOS was determined using Poisson regression. ResultsThree hundred and ninety patients were included in the final analysis. Two hundred and seventy-six patients (70.8%) were treated operatively. One hundred and forty patients (36%) experienced neurologic deficit as a result of their initial injury. Adverse events occurred 56% of the time in the operatively treated patients and only 13% of the time in the nonoperative group. The presence of neurologic deficit increased the risk of AEs especially in high thoracic (T1–T6) trauma increasing the odds of having an AE by 12.1 (p<.0001). The most common AEs were urinary tract infections (19.7%), neuropathic pain (12.3%), pneumonias (11.8%), delirium (10.5%), and ileus (6.2%). Length of hospital stay increased significantly with pneumonia (p<.0001) and delirium (p=.0001). ConclusionsThe presence of neurologic injury and the need for operative fixation of thoracic or lumbar injuries lead to a greater risk of AEs. Only pneumonia and delirium consistently increase LOS.

Accuracy and complications of pedicle screw insertion for lumbar and thoracolumbar fractures

Background: The accuracy of pedicle screw placement is essential for lumbar and thoracolumbar spine fracture fixation. Purpose: The aim of the present study was to assess the accuracy of the pedicle screw placement with conventional C-arm fuoroscopy-guided in these patients. Methods: A retrospective review identified patients who underwent operative management with thoracolumbar instruments at our hospital between June 2012 and August 2013. Clinical data were acquired from medical records and final screw positions were graded based on a classification of Gertzbein and Robbins. Results: A total of 216 pedicle screws in 52 patients (34 males, mean age 32.6±5.8 years) were evaluated. They were instrumented with transpedicular posterior fixation technique within 72 hours. The follow-up time was 6.1 months (ranging from 1 to 14 months). The screws were graded A (n=43 [19.9%]), B (n=89 [41.2%]), C (n=62 [28.7%]), D (n=21 [9.7%]), and E (n=1 [0.5%]). One of the screws was revised on the second day after surgery due to screw malposition. Conclusion: Based on existing facilities, the findings showed that the pedicle instrumentation screws with transpedicular posterior fixation technique in patients with lumbar and thoracolumbar fractures can be done with acceptable complication rate. However, more advanced equipment as CT navigation (O-arm) is recommended for higher accuracy.

English

BACKGROUND AND OBJECTIVES: Spinal trauma is one of the grave injuries that cause infinite morbidity and disability resulting from high energy trauma. 30-60% of all spinal injuries are concentrated in the thoracic and lumbar spine and 15-20% is associated with neurological injury. The neurological improvement is independent of treatment modality, lately consensus evolving around the world for stabilization of spine with instrumentation allowing early mobilization, prevention and limitation of neurological injury as well as restoration of spinal stability. A number of fixation systems have been advocated. The use of pedicular screws and rod system allows adequate 3 dimensional control of each motion segment and allows rigid fixation. Acceptable results have been reported in majority of patients treated with pedicle screw and rod system with good neurological recovery. The aim of the study was to access the commonest mode, level, type of fracture, efficacy of pedicle screw and rod system and the radiological, neurological and functional out come in order to recreate a stable pain free spinal column. METHODS: This study is a prospective clinical study of unstable thoracolumbar spinal injuries by posterior instrumentation (pedicular screw and rod fixation in thoracic, lumbar, and thoracolumbar spinal fractures). In all, a total of 21 cases were evaluated and assessed during the period from 1st June 2008 to 30th September 2010. The study was conducted in the Department of Orthopaedics, Vijayanagara Institute of Medical sciences, Bellary. Patient selection was according to the inclusion and exclusion criteria and was surgically treated with pedicle screw and rod system. RESULTS: In our series there were 20(94.75%) males and 1(5.25%) female patient with an average age of 28.3 years 17(82.1%) cases due to fall from height, 4(17.9%) cases following road traffic accident.16(76.1%) cases were of AO Type A, 3 (14.2%) of AO Type B, 2(9.52%) of AO type C fractures. All patients were of ASIA grade A, B, C on admission and 9(42.8%) showed improvement to ASIA grade D, E at three months and 13(62%) showed improvement ASIA grade D, E at latest follow up. Good Functional outcome with pain relief achieved in 12(57%) of cases. Fair results in 8(38%) cases, and poor results in 1 (5%). CONCLUSION: Management of thoracic and lumbar spine fractures requires careful preoperative planning, patient selection, neurological evaluation and meticulous intraoperative care and post-operative rehabilitation for good functional outcome. Pedicle screw and rod fixation should be done as early as possible in order to facilitate neurological recovery, help in good nursing care and early mobilization of the patient and to prevent deterioration of the neurological status. Pedicle screw instrumentation provides less surgical exposure, correction of deformity and better stabilization of one motion segment above and below the fracture. The administration of pre-operative steroids have shown to have a beneficial effect on the final neurological outcome. Early surgical intervention helped in good neurological recovery.

Bending strength and stiffness of canine cadaver spines after fixation of a lumbar spinal fracture-luxation using a novel unilateral stabilization technique compared to traditional dorsal stabilization.

To 1) assess the bending strength and stiffness of canine cadaver spines after fixation of a lumbar spinal fracture-luxation using a novel unilateral stabilization technique with pins and polymethyl methacrylate (PMMA) and 2) compare the results to a reference standard dorsal pin and PMMA technique. A randomized non-inferiority trial. Cadaveric lumbar spines (L1-L6) from 20 Greyhounds. Specimens were paired to match bodyweight and vertebral size. A standardized fracture/luxation was performed between L3 and L4. One spine within each pair was randomly assigned the unilateral fixation technique and the other received the reference standard dorsal fixation technique. Four-point bending of each specimen in flexion was performed by applying load to pins placed transversely into vertebrae L1, L2, L5, and L6. During testing, angular bending strength and stiffness were measured as a function of flexion angle. Margins for non-inferiority were defined a priori. Strength and stiffness of the specimens for each technique were compared statistically. Lower limits of 95% confidence intervals were above the defined margins for non-inferiority. Thus, based on these margins, for strength and stiffness, unilateral fixation was not inferior to dorsal fixation. This novel unilateral approach to lumbar spinal fixation yielded comparable strength and stiffness when tested for bending in flexion to that of reference standard dorsal approach. This approach is therefore a suitable alternative to the dorsal approach in appropriate lumbar spinal fracture configurations.

Réduction et fixation percutanée par voie postérieure des fractures thoracolombaires de type « burst » (éclatement)

BackgroundTreatment of A3 thoracolumbar and lumbar spinal fractures nowadays remains a controversial issue. Percutaneous techniques are becoming very popular in the last few years to reduce the approach-related morbidity associated with conventional techniques. HypothesisPurpose of the study was to analyze the clinical and radiological outcome of patients who underwent percutaneous posterior fixation without fusion for the treatment of thoracolumbar and lumbar A3 fractures. Materials and methodsSixty-three patients, having sustained a single-level thoracolumbar fracture, underwent short segment percutaneous instrumentation and were retrospectively analyzed way. Sagittal Index (SI) was calculated in all patients. Clinical and functional outcome were evaluated by Visual Analog Scale (VAS), Oswestry Disability Index (ODI) and Short Form General Health Status (SF-36). ResultsAverage operative blood loss was 82mL (50–320). Mean pre-operative SI in the thoraco-lumbar segment was 13.3° decreased to 5.8° in the immediate post-operative with a mean deformity correction of 7.5. Mean pre-operative SI in the lumbar segment was 16.5° decreased to 11.3° in the immediate post-operative with a mean deformity correction of 5.2. Not statistically significant correction loss was registered at 1year minimum follow-up. Constant clinical conditions improvement in the examined patients was observed. ConclusionPercutaneous pedicle screw fixation for A3 thoracolumbar and lumbar spinal fractures is a reliable and safe procedure. Level of evidenceLevel IV. Retrospective study.

Examination of life-threatening injuries in 431 pediatric facial fractures at a level 1 trauma center.

Pediatric facial fractures represent a challenge in management due to the unique nature of the growing facial skeleton. Oftentimes, more conservative measures are favored to avoid rigid internal fixation and disruption of blood supply to the bone and soft tissues. In addition, the great force required to fracture bones of the facial skeleton often produces concomitant injuries that present a management priority. The purpose of this study was to examine a level 1 trauma center's experience with pediatric facial trauma resulting in fractures of the underlying skeleton with regards to epidemiology and concomitant injuries. A retrospective review of all facial fractures at a level 1 trauma center in an urban environment was performed for the years 2000 to 2012. Patients aged 18 years or younger were included. Patient demographics were collected, as well as location of fractures, concomitant injuries, and surgical management strategies. A significance value of 5% was used. During this period, there were 3147 facial fractures treated at our institution, 353 of which were pediatric patients. Upon further review, 68 patients were excluded because of insufficient data for analysis, leaving 285 patients for review. The mean age of patients was 14.2 years with a male predominance (77.9%). The mechanism of injury was assault in 108 (37.9%), motor vehicle accident in 68 (23.9%), pedestrian struck in 41 (14.4%), fall in 26 (9.1%), sporting accident in 20 (7.0%), and gunshot injury in 16 (5.6%). The mean Glasgow Coma Scale (GCS) on arrival to the emergency department was 13.7. The most common fractures were those of the mandible (29.0%), orbit (26.5%), nasal bone (14.4%), zygoma (7.7%), and frontal bone/frontal sinus (7.5%). Intracranial hemorrhage was present in 70 patients (24.6%). A skull fracture was present in 50 patients (17.5%). A long bone fracture was present in 36 patients (12.6%). A pelvic or thoracic fracture was present in 30 patients (10.5%). A cervical spine fracture was present in 10 patients (3.5%), and a lumbar spine fracture was present in 11 patients (3.9%). Fractures of the zygoma, orbit, nasal bone, and frontal sinus/bone were significantly associated with intracranial hemorrhage (P < 0.05). Fractures of the zygoma and orbit were significantly associated with cervical spine injury (P < 0.05). The mean GCS for patients with and without intracranial hemorrhages was 11.0 and 14.6, respectively (P < 0.05). The mean GCS for patients with and without cervical spine fractures was 11.2 and 13.8, respectively (P < 0.05). Pediatric facial fractures in our center are often caused by interpersonal violence and are frequently accompanied by other more life-threatening injuries. The distribution of fractures parallels previous literature. Midface fractures and a depressed GCS showed a strong correlation with intracranial hemorrhage and cervical spine fracture. A misdiagnosed cervical spine injury or intracranial hemorrhage has disastrous consequences. On the basis of this study, it is the authors' recommendation that any patient sustaining a midface fracture with an abnormal GCS be evaluated for the aforementioned diagnoses.

Posterior percutaneous reduction and fixation of thoraco-lumbar burst fractures

BackgroundTreatment of A3 thoraco-lumbar and lumbar spinal fractures nowadays remains a controversial issue. Percutaneous techniques are becoming very popular in the last few years to reduce the approach-related morbidity associated with conventional techniques. HypothesisPurpose of the study was to analyze the clinical and radiological outcome of patients who underwent percutaneous posterior fixation without fusion for the treatment of thoraco-lumbar and lumbar A3 fractures. Materials and methodsSixty-three patients, having sustained a single-level thoraco-lumbar fracture, underwent short segment percutaneous instrumentation and were retrospectively analyzed. sagittal index (SI) was calculated in all patients. Clinical and functional outcome were evaluated by Visual Analog Scale (VAS), Oswestry Disability Index (ODI) and Short Form General Health Status (SF-36). ResultsAverage operative blood loss was 82mL (50–320). Mean pre-operative SI in the thoraco-lumbar segment was 13.3° decreased to 5.8° in the immediate postoperative with a mean deformity correction of 7.5. Mean pre-operative SI in the lumbar segment was 16.5° decreased to 11.3° in the immediate postoperative with a mean deformity correction of 5.2. Not statistically significant correction loss was registered at 1-year minimum follow-up. Constant clinical conditions improvement in the examined patients was observed. ConclusionPercutaneous pedicle screw fixation for A3 thoraco-lumbar and lumbar spinal fractures is a reliable and safe procedure. Level of evidenceLevel IV. Retrospective study.

Early percutaneous fixation of spinal thoracolumbar fractures in polytrauma patients

IntroductionCare of polytrauma patients is complex and requires that a particular treatment sequence be followed during what is typically a short period of time. Early, temporary stabilization of injuries (damage control orthopedics [DCO]) is a validated strategy for the care of polytrauma patients. Application of this concept to spinal fractures has also led to good outcomes for patients. The recent development of percutaneous thoracolumbar fixation could improve the initial care of these vulnerable patients even more. The purpose of this study was to evaluate preliminary results in a series of polytrauma patients presenting with thoracolumbar fractures without neurological deficits who were treated according to DCO principles using early percutaneous fixation. Materials and methodsAll severe polytrauma patients admitted with a thoracic and/or lumbar spine fracture without neurological deficit were included in this prospective study. The care was standardized according to the degree of urgency of the initial injuries, with percutaneous spinal fixation being performed as early as feasible. The outcomes were evaluated using clinical parameters (duration of stay in intensive care unit, surgical data, blood loss) and radiographic parameters measured during a systematic postoperative CT scan (traumatic deformity, placement of pedicle screws, fusion rate). If needed, an anterior intervertebral graft was performed during a secondary procedure. ResultsIn all, 10 patients (average age of 40years) were included, corresponding to 18 vertebral fractures. During the initial assessment, at least one peripheral bone fracture was found in 90% of cases and at least one organ was injured in all patients (thoracic in 80% of cases, cerebral in 50%, facial area in 40% and abdominal-pelvis in 30%). The average time elapsed between admission and spine surgery was 4days (80% of cases before day 7). There were no cases of deep infection in any of the patients. An additional anterior procedure was needed in three patients within 1month of the initial surgery. DiscussionThe strategy for treating thoracolumbar fractures in polytrauma patients is still not widely accepted. The presence of associated lesions could make it difficult to perform conventional spine surgery early on. Development of percutaneous techniques that reduce perioperative morbidity seems to be an alternative approach well-suited to DCO, as long as there are no neurological deficits. However, a secondary evaluation of the anterior spine is essential to determining if an anterior graft remains needed. Level of evidenceLevel IV.

Attempted Suicide of an Adolescent with Autism Spectrum Disorder

Although the suicide risk of autism spectrum disorder (ASD) has been suggested to be higher than previously recognized, there are few case reports focusing on the process for preventing suicide reattempts. We reported that a 17-year-old male who had attempted suicide by jumping was admitted to our emergency department and hospitalized for lumbar spine fracture. In addition to the diagnosis of adjustment disorder, he was diagnosed as ASD according to his life history. This article presents the characteristics of the suicidal behaviors and the process for preventing a suicide reattempt associated with an adolescent with ASD who attempted suicide.

The Use of Computed Tomography Attenuation to Evaluate Osteoporosis Following Acute Fractures of the Thoracic and Lumbar Vertebra

Relatively few patients have dual-energy x-ray absorptiometry to quantify the magnitude of bone loss as they age. Recent work correlates mean computed tomography (CT) attenuation in the level I (L1) vertebra with bone mineral density (BMD), making it possible to objectively evaluate the magnitude of bone loss in osteoporosis by this method. The aims of this study were to evaluate the utility of using CT scans in patients with acute thoracic and lumbar spine fractures to diagnose osteoporosis and using CT attenuation to evaluate the association between age and BMD. We performed a retrospective study of patients with acute fractures of the thoracic or lumbar spine who had also undergone an abdominal (or L1) CT scan and compared mean CT attenuation in L1 against threshold values. We also compared differences in CT attenuation between younger (<65 years) and older (≥65 years) and older patients. A total of 124 patients were evaluated (74 thoracic and 50 lumbar fractures). Overall, there was a strong correlation between age and bone density as measured by CT attenuation (r = -.76). Among those with thoracic fractures (<65 years), mean CT attenuation was 196.51 HU. Forty-one patients were ≥65 years and had mean CT attenuation of 105.90 HU (P < .001). In patients with lumbar fractures, 27 patients were <65 years and had a mean CT attenuation of 192.26 HU and 23 patients were ≥65 years and had mean CT attenuation of 114.31 HU (P < .001). At the threshold of 110 HU, set for specificity, the magnitude of difference between the age-stratified cohorts was greater in the thoracic spine (P < .0001 vs P = .003). Using opportunistic CT, we demonstrate the relative frequency of osteoporosis in patients with acute fractures of the thoracic and lumbar spine and confirm that the association increases with age. The CT attenuation may provide a cheap and convenient method to help confirm a clinical diagnosis of osteoporosis in patients with fractures.

Results of fusion and instrumentation of thoracic and lumbar vertebral fractures in children: a prospective ten-year study

Researches on the results of surgical treatment of thoracolumbar spine fractures are infrequent. The aim of this study was to determine midterm outcomes of surgical treatment of these fractures in a prospective survey. A case series study on pediatric patients with the diagnosis of thoracic and/or lumbar vertebral fractures was conducted over a ten-year period. Surgically treated patients were evaluated in the follow-up period, based on back pain, independent function, neurological status, and radiographic indices. There were 102 pediatric individuals, 61 boys and 41 girls, aged 3-17 years (mean 12 years of age) with thoracic and/or lumbar spinal fractures. Motor vehicle accident was the most common mechanism of injury (45.0 %). L1 was the most frequent level of fractured vertebra (24.4 %), and pelvic fracture was the most common associated orthopedic injury (21.5 %). Totally, 20 patients underwent surgery, but only fifteen (14 boys and one girl) participated in follow-up (mean 49 months; range 12-81 months). Posterior spinal fusion and instrumentation was accomplished in 12 cases. Three patients were operated by anterior approach and fusion followed by posterior fusion and instrumentation because of delay in diagnosis. There were no major perioperative complications. Two cauda equina syndromes and two incomplete spinal cord injuries improved back to normal. Five cases (33.3 %) reported occasional back pain, and all patients were functionally independent. Radiographic indices improved significantly. Spinal fusion and instrumentation in pediatric patients with unstable thoracolumbar vertebral fractures with or without spinal cord injuries have favorable radiographic and functional outcomes.

Vertebral fractures in motor vehicle accidents–a medical and technical analysis of 33,015 injured front-seat occupants

Spinal injuries pose a considerable risk to life and quality of life. In spite of improvements in active and passive safety of motor vehicles, car accidents are regarded as a major cause for vertebral fractures. The purpose of this study was to evaluate the current incidence of vertebral fractures among front-seat occupants in motor vehicle accidents, and to identify specific risk factors for sustaining vertebral fractures in motor vehicle accidents. Data from an accident research unit were accessed to collect collision details, preclinical data, and clinical data. We included all data on front-seat occupants. Hospital records were retrieved, and radiological images were evaluated.We analysed 33,015 front-seat occupants involved in motor vehicle accidents over a 24-year period. We identified 126 subjects (0.38%) with cervical spine fractures, 78 (0.24%) with thoracic fractures, and 99 (0.30%) with lumbar fractures. The mean relative collision speeds were 48, 39, and 40kph in subjects with cervical, thoracic, and lumbar spine fractures, respectively, while it was 17.3kph in the whole cohort. Contrary to the overall cohort, these patients typically sustained multiple hits rather than simple front collisions. Occupants with vertebral fractures frequently showed numerous concomitant injuries; for example, additional vertebral fractures. The incidence of vertebral fractures corresponded with collision speed. Safety belts were highly effective in the prevention of vertebral fractures.Apart from high speed, complex injury mechanisms as multiple collisions or rollovers were associated with vertebral fractures. Additional preventive measures should focus on these collision mechanisms.

Functional outcome of minimally invasive posterior stabilisation in dorsal and lumbar spine fractures

Background: Minimally invasive spinal surgery will be a highlight of operative approaches in the twenty-first century and already has been popularized worldwide. This procedure will provide surgical options that address several pathological conditions in the spinal column without producing the types of morbidity commonly seen in open surgical procedures. The objective was to assess the outcomes of minimally invasive posterior stabilization of dorsal and lumbar spine fractures. Methods: This was a prospective study of twenty patients with dorsal or lumbar fractures who were admitted at Sri Ramachandra University. All patients having dorsal and lumbar spinal fractures with intact neurology were included in the study. All the patients underwent minimally invasive posterior stabilization by freehand technique. Functional outcomes were measured by VAS scale, ASIA scoring (neurology), and their ability to mobilize. Results: The average duration of surgery was 85.50 minutes. The average blood loss in our study group was 77 ml. The average operation to mobilization time was 2.2 days. The average post-operative Cobb’s angle was 0.6 degree of kyphosis. The average post-operative gain was 12 degree. Conclusion: Minimally invasive percutaneous stabilization of the spine helps to minimize approach related morbidity and secondary iatrogenic soft tissue trauma. It enables early mobilization, which contributes to improved outcome.

Seat belt syndrome, a new pattern of injury in developing countries. Case report and review of literature

Classically, seat belt syndrome appears with seat belt marks on the body, bowel perforations, and lumbar spine fractures. However the symptoms are not limited to those previously mentioned, and organ damage can vary greatly. A 34-year-old female passenger, was admitted to our hospital after a motor vehicle crash. The physical examination revealed an ecchymosis across the chest, a transverse abdominal abrasion, and fractures of the left humerus, the left femur, and the right tibia. The laparotomy revealed multiple jejunal perforations, such as a seromuscular tear of the hepatic and splenic flexure of the colon and a defect of the abdominal wall. The primary suture of jejunum, resection with end to end anastomosis of jejunum, suture of a seromuscular tear of the colon, and primary repair of the abdominal wall defect procedures were performed. On the fifth day, the patient underwent osteosynthesis. The abdominal pain in the polytraumatized patients with seat belt syndrome may be dominated by the pain caused by extra-abdominal injuries. The presence of a seat belt mark across the abdomen increases suspicion of abdominal injuries.

Evaluation of the short-term outcome of anterior approach surgery of the dorsal and lumbar spine

ObjectiveThe aim of this study is to evaluate the short-term outcome of anterior decompression and fusion surgery of the dorsal and lumbar spine, in cases of traumatic and pathologic vertebral fractures, in terms of stability and function.BackgroundSurgical treatment of dorsal and lumbar spine fractures aims to achieve bony union and restore spinal anatomy. An anterior approach is recommended for repair of anterior bone loss and to release medullary compression.Materials and methodsSelection criteria included traumatic and pathologic lesions causing vertebral body comminution, kyphotic angulation, or intractable pain. Exclusion criteria included patients with complete cord injury, osteoporosis, or less than 3 months life expectancy. Seven patients (group A) underwent the solo anterior approach surgery, whereas the other seven patients (group B) underwent initial posterior decompression and instrumented fusion, followed by anterior surgery. Operative and postoperative events were noted. Patients were followed up clinically and radiologically for 6 months.ResultsSeven patients showed improved ASIA grade postoperatively. The mean improvement in the ASIA grade was 0.6 in group A and 1.0 in group B. Seven patients regained bladder control, whereas two remained catheter dependent (one from each group). The pain visual analog scale range was 3-9 preoperatively and 0-5 postoperatively. The mean postoperative improvement in segmental kyphosis was 2.42° in group A and 1.85° in group B. After 6 months, 28.57% of patients in group A had grade-5 bone fusion, 42.86% had grade-4 fusion, 7.14% had grade-3, and 7.14% had grade-2 fusion, whereas 42.86% of patients in group B had grade-5 bone fusion and 57.14% had grade-4 fusion. No instability was detected in the dynamic radiographic films of all patients. Only one case had metallic device malposition because of trauma. Postoperative complications included chest infection (four cases), wound infection (two cases), urinary tract infection (one case), retroperitoneal hematoma (one case), and sympathetic dysfunction (one case).ConclusionThe anterior approach for dorsal and lumbar fractures enables direct, under-vision satisfactory decompression of the neural tissue, facilitating improvement in the neurological functions of the patients. It also helps to correct the instability of the fractured vertebral column by both internal metallic fixation for temporary stability and bone grafting with a high percentage of bony fusion to achieve permanent stability.

Percutaneous Pedicle Screw and Rod Insertion for the Treatment of Thoracic and Lumbar Spine Fracture

Introduction: Standard techniques for lumbar pedicle screw and rod fixation involve open exposure and extensive muscle dissection. Percutaneous pedicle screw system minimises the morbidity associated with traditional open approaches without compromising the quality of spinal fixation. A preliminary experience with this device has been encouraging. The purpose of this study was to demonstrate operative techniques and experiences with percutaneous lumbar pedicle screw and rod insertion for internal fixation of the lumbar spine without use of Zig. Methods: It was hospital based retrospective interventional study done at the department of Orthopaedics, B.P. Koirala Institute of Health Sciences, Dharan, Nepal over a period of 2 and half years. The study enrolled 30 patients aged 18-55 years who had presented with traumatic fracture of thoracic and lumbar spine. All thirty patients underwent percutaneous pedicle screw and rod fixation and successful percutaneous single/two level fusions. The follow up period ranged from 6 to 24 months. Results: The study comprised of 25 males and 5 females. Average patient’s age was 36.5 years (range 18-55 years). The common mode of injury was fall from height, road traffic accident, physical assault followed by sports related injury. All patients were having unstable spine fracture without neurological deficit. Operation time, loss of blood, post operative pain was less in percutaneous method. Post operative rehabilitation was easier. Spinal fusion was achieved in all patients in 6 months to 1 year time. There was no post-operative neurological deficit, infection, implant failure. Conclusion: Our early experience suggests that Minimally invasive approaches for performing lumbar fusion, is able to achieve the same clinical results as conventional open procedures. DOI: http://dx.doi.org/10.3126/noaj.v3i1.9322 Nepal Orthopedic Association Journal 2013 Vol.3(1): 23-27

Surgical outcome of posterior short segment trans-pedicle screw fixation for thoracolumbar fractures

BackgroundVast majority of spine fractures in thoracolumbar region are unstable and often associated with neurological deficit. With the advancement of technology, these fractures are now more often managed operatively. The present study aimed at evaluating the role of open reduction & internal fixation using pedicle screws and short segment fixation in patients with Thoracic and Lumbar spine fractures. DesignIn this prospective study, 25 patients in age group of 15–65 years (mean age 28.25 years) with thoracolumbar fractures with associated neurological deficit or compression fractures with loss of more than 50% vertebral height or angulations more than 20° with or without neurological deficit were included. The results were evaluated based on restoration and maintenance of vertebral body height, spinal lordosis/kyphosis and evaluation of the neurological recovery which was done at regular intervals using Frankel's grading. ResultsThe mean follow-up period was 20.3 months. The average preoperative kyphotic angle as measured by Cobbs method was 20° which improved to 7.8° following instrumentation. The average preoperative vertebral height was 58.65% which improved to 78.55% postoperatively. Preoperatively, only 20% of patients had useful paraplegia (Frankel grade D and E) while 80% had useless paraplegia (Frankel's grade C and below). Following surgery, 60% patients had useful paraplegia while 40% had useless paraplegia. ConclusionShort segment trans-pedicle posterior fixation is helpful for not only stabilization of the fractures and restoration of anatomy, but also maintaining the same over a period with good functional outcome.

When and how to operate on thoracic and lumbar spine fractures?

To discuss when and how to operate on thoracic and lumbar spine fractures. We retrospectively studied 77 consecutive patients with thoracic and lumbar spine fractures treated from 2000 to 2011; 28 patients experienced high-energy spinal trauma and 49 low-energy spinal trauma. Mean follow-up was 5 years (1-11 years). Surgical treatment was done in 15 patients with neurological deficits, and in 16 neurologically intact patients with fractures-dislocations, burst fractures and fractures with marked deformity. Non-surgical treatment was done in 46 neurologically intact patients with simple fracture configurations. Clinical and imaging examination and the Oswestry Disability Index (O.D.I.) questionnaire were obtained. All patients treated surgically maintained spinal alignment; patients with long fusion maintained the best alignment; however, they experienced back stiffness and moderate low back pain. Patients with combined posterior fusion and kyphoplasty experienced earlier recovery and improved sagittal correction. Mean O.D.I. was 22.4 and 14.2% at 3 and 12 months postoperatively. Thirty six (78%) patients treated non-surgically were asymptomatic, 22 (48%) experienced mild residual kyphosis, 10 (22 %) developed marked deformity during their follow-up and were finally operated; mean O.D.I. was 28.6 and 12.1% at 3 and 12 months. No difference in O.D.I. was observed between patients who had surgical and non-surgical treatment. Progressive neurological deficits and/or mechanical instability of the spine are absolute indications for early surgical treatment. Younger patients with high-energy spinal trauma, unstable fractures and neurological deficits should be treated surgically in order to provide optimum conditions for neurologic recovery, early mobilization and possibly ambulation. Most cases can be adequately operated through a posterior only surgical approach; an anterior or combined approach is usually indicated for burst and thoracic spine fractures. Postoperative complications, more common infection and neurological deterioration may occur. Elderly, neurologically intact patients with low-energy, stable spinal fractures without marked spinal deformity may be successfully treated conservatively. Most of these patients will do well; however, follow-up for progressive posttraumatic deformity is required.

Complications in minimally invasive percutaneous fixation of thoracic and lumbar spine fractures and tumors

We propose to evaluate the complication rate in minimally invasive stabilization (MIS) for spine fractures and tumors, as a common alternative to open fusion and conservative treatment. From 2000 to 2010, 187 patients were treated by minimally invasive percutaneous fixation in 133 traumatic fractures and 54 primitive and/or secondary spine tumors. Complications were classified, according to the period of onset as intraoperative and postoperative, and according to the severity, as major and minor. A total of 15 complications (8 %) were recorded: 5 intraoperative (3 %), 6 early postoperative (3 %) and 4 late postoperative (2 %); 6 were minor complications (3 %) and 9 were major complications (5 %). Minimally invasive stabilization of selected spine pathologies appears to be a safe technique with low complication rate and high patient satisfaction. MIS reduces hospitalization and allows a fast functional recovery improving the quality of life.