Posterior Short-segment Fixation Research Articles

Stability reconstruction and related complications after total spondylectomy for thoracolumbar tumors

Objective To investigate the spinal stability reconstruction and related complications after total spondylectomy for thoracolumbar tumors. Methods From January 1997 to December 2009, 34 cases with thoracolumbar tumors treated with total spondylectomy, including 20 males and 14 females with an average age of 43 years. The tumors were located in thoracic vertebra in 27 cases and lumbar vertebra in 7, including 6 spinal metastases and 28 primary tumors. The total spondylectomy was piecemeal in 23 cases and en bloc in 11. The reconstruction methods included posterior short-segment fixation in 19 cases, multi-segmental fixation in 13, anterior intervertebral fixation in 2, titanium mesh with auto-bone graft in 20 cases, titanium mesh with bone cement in 7, bone cement filling in 2, auto-bone strut graft in 2, titanium mesh with strengthened rings in 1, artificial vertebral body replacement in 2, posterior massive bone bridging graft in 8 and bone particles graft in 26. Results The mean follow-up time was 43 months. Seven patients died, 5 suffered recurrence. Poor grafted bone fusion was found in 5 cases. The intervertebral sagittal Cobb angle of adjacent vertebra was ??after operation, 9.3?at the end of follow-up or before revision operation. The average lost angle was 14.1?for cases with multi-segmental fixation, and 21.5?with short-segment fixation. Complications included internal fixation broken (5) and loosening (2), titanium mesh subsidence (6) and displacement (3). There were 5 revision surgeries. Conclusion There are relative more complications about spinal stability reconstruction after total spondylectomy. To achieve temporary stiff fixation and long-term fusion, the posterior multi-segment fixation and massive bone bridging graft combined with the anterior artificial vertebral body replacement are effective. Key words: Spine; Neoplasms; Internal fixators; Postoperaive complications

Posterior Short-Segment Fixation and Fusion in Unstable Hangmanʼs Fractures

A retrospective study. OBJECTIVE.: To introduce the method of C2-C3 posterior short-segment fixation and fusion in unstable Hangman's fracture and to evaluate the clinical effects. Hangman's fracture can be managed by closed reduction and immobilization. However, surgery is usually preferable in highly unstable cases and in rigid arthrodesis failure. The outcome of surgical treatment for unstable Hangman's fracture has not been thoroughly investigated. Thirty-five patients with unstable Hangman's fracture were treated using C2-C3 posterior short-segment fixation and fusion. Twenty-six cases used C2-C3 short-segment pedicle screw fixation. Nine cases used both C2 pedicle screw and C3 lateral mass screw short-segment fixation and fusion. C-arm fluoroscopy was used for the whole procedure. RESULTS.: All patients were observed for an average of 44 months, ranging from 12 to 78 months. There was no screw loosening or breakage, nor was there any spinal cord or vertebral artery injury intraoperatively. A total of 140 screws were placed, with 70 screws inserted into the C2 pedicle, 52 into the C3 pedicle, and 18 into the C3 lateral mass. Computed tomography scans indicated 9 screws were placed too close to the vertebral artery canal in C2, and 12 screws were too close to the canal in the C3 pedicle, all without clinical consequences. C3 lateral mass screws were placed successfully. Neurologic status improved from C and D to E in all 8 cases. Static and dynamic films demonstrated that fusion was achieved in all cases 6 months after surgery. No graft or plate-related complications were observed in any patients during the entire follow-up period. C2-C3 posterior short-segment fixation and fusion is an effective method for the management of unstable Hangman's fracture, proving its value as a technique for achieving solid bony fusion combined with a low rate of complications.

Radiological Outcome of Short Segment Posterior Stabilisation and Fusion in Thoracolumbar Spine Acute Fracture

The optimal management of thoracolumbar spine fractures remains a matter of controversy. The current literature implies that the use of short-segment pedicle screw fixation may be inappropriate because of its high reported failure rate. The purpose of this study is to report the short-term results of thoracolumbar burst and compression fractures treated with short-segment pedicle instrumentation. From 2002 to 2007, 19 patients with thoracolumbar acute traumatic fractures were instrumented with posterior short-segment pedicle screws. The patients' case notes, operation records, preoperative and postoperative radiographs (sagittal index, anterior body compression and regional kyphosis), computed tomography scans, neurological findings (Frankel functional classification), and follow-up records up to 18 months were reviewed. A statistically significant difference was found between the patients' preoperative, postoperative and follow-up sagittal index, anterior body compression and regional kyphosis measurement. One case resulted in screw pedicle screw pullout and subsequently, kyphotic deformity. The patient underwent revision surgery to long-segment posterior instrumentation and fusion. None of the patients showed an increase in neurological deficit. In conclusion, the short-term follow-up results suggest a favourable outcome for short-segment instrumentation. Load shearing classification is essential for the selection of patient for short-segment instrumentation. However, the long-term follow-up evaluation will be needed to verify our findings.

Clinico-radiological profile of indirect neural decompression using cage or auto graft as interbody construct in posterior lumbar interbody fusion in spondylolisthesis: Which is better?

Study design:A prospective clinical study of posterior lumbar interbody fusion in grade I and II degenerative spondylolisthesis was conducted between Mar 2007 and Aug 2008.Purpose:The objective was to assess the clinicoradiological profile of structural v/s nonstructural graft on intervertebral disc height and its consequences on the low back pain (LBP) assessed by Visual analog score (VAS) score and oswestry disability index (ODI) . This study involved 28 patients.Inclusion criteria:Age of 30–70 years, symptomatic patient with disturbed Activities of daily living (ADL), single-level L4/L5 or L5/S1 grade I or grade II degenerative spondylolisthesis.Exclusion criteria:Patients with osteoporosis, recent spondylodiscitis, subchondral sclerosis, visual and cognitive impairment and all other types of spondylolisthesis. All the patients underwent short-segment posterior fixation using CD2 or M8 instrumentation, laminectomy discectomy, reduction and distraction of the involved vertebral space. In 53.5% (n = 15) of the patients, snugly fitted local bone chips were used while in 46.4% (n = 13) of the patients, cage was used. Among the cage group, titanium cage was used in nine (32.1%) and PEEK cages were used in four (14.2%) patients. In one patient, a unilateral PEEK cage was used. The mean follow-up period was 24 months. Among the 28 patients, 67.8% (n = 19) were females and 32.14% (n = 9) were males. 68.24% (n = 18) had L4/L5 and 35.71% (n = 10) had L5/S1 spondylolisthesis. 39.28% (n = 11) were of grade I and 60.71% (n = 17) were of grade II spondylolisthesis.Conclusions:There was a statistically significant correlation (P < 0.012 and P < 0.027) between the change in disc height achieved and the improvement in VAS score in both the graft group and the cage group. The increment in disc height and VAS score was significantly better in the cage group (2 mm ± SD vis-a-vis 7.2 [88%]) than the graft group (1.2 mm ± SD vis-a-vis 5 [62 %]).

Vertebroplasty-augmented short-segment posterior fixation of osteoporotic vertebral collapse with neurological deficit in the thoracolumbar spine: comparisons with posterior surgery without vertebroplasty and anterior surgery

The surgical approach and treatment of thoracolumbar osteoporotic vertebral collapse with neurological deficit have not been documented in detail. Anterior surgery provides good decompression and solid fusion, but the surgery-related risk is relatively higher than that associated with the posterior approach. In posterior surgery, the major problem after posterior correction and instrumentation is failure to support the anterior spinal column, leading to loss of correction of kyphosis. The aim of this study was to evaluate the efficacy of reinforcing short-segment posterior fixation with vertebroplasty and to compare the outcome with those of posterior surgery without vertebroplasty and anterior surgery, retrospectively. The authors studied 83 patients who underwent surgical treatment for a single thoracolumbar osteoporotic vertebral collapse with neurological deficit. Twenty-eight patients treated by posterior surgery combined with vertebroplasty (Group A), 25 patients treated by posterior surgery without vertebroplasty (Group B), and 30 patients treated by anterior surgery (Group C) were followed up for a mean postoperative period of 4.4 years. Neurological outcome, visual analog scale pain score, and radiographic results were compared in the 3 groups. Postoperative (4-6 weeks) and follow-up neurological outcome and visual analog scale scores were not significantly different among the 3 groups. Postoperative kyphotic angle was significantly reduced in Group B compared with Group C (p = 0.007), whereas the kyphotic angle was not significantly different among the 3 groups at follow-up. The mean ± SD loss of correction at follow-up was 4.6° ± 4.5°, 8.6° ± 6.2°, and 4.5° ± 5.9° in Groups A, B, and C, respectively. The correction loss at follow-up in Group B was significantly higher compared with Groups A and C (p = 0.0171 and p = 0.0180, respectively). The results suggest that additional reinforcement with vertebroplasty reduces the kyphotic loss and instrumentation failure, compared with patients without the reinforcement of vertebroplasty. Vertebroplasty-augmented short-segment fixation seems to offer immediate spinal stability in patients with thoracolumbar osteoporotic vertebral collapse; the effect seems equivalent to that of anterior reconstruction.

Short Segment vs. Long Segment Pedicle Screw Fixation for Treating Thoracolumbar Junction Burst Fractures

Long segment posterior fixation (LSPF) is commonly used for burst fracture treatment. Use of short segment posterior fixation (SSPF) has historically resulted in unacceptable rates of failure of fixation and loss of reduction. More recently, there has been renewed interest in limiting the amount of motion segments fused by adding anterior column support. One of these methods involves supplementing posterior SSPF with anterior calcium phosphate (CaP) cement through a transpedicular approach (Vertebroplasty/Kyphoplasty ™).

Inclusion of the fracture level in short segment fixation of thoracolumbar fractures

Short segment posterior fixation is the preferred method for stabilizing thoracolumbar fractures. In case of significant disruption of the anterior column, the simple short segment construct does not ensure adequate stability. In this study, we tried to evaluate the effect of inclusion of the fractured vertebra in short segment fixation of thoracolumbar fractures. In a prospective randomized study, eighty patients with thoracolumbar fractures treated just with posterior pedicular fixation were randomized into two groups receiving either the one level above and one level below excluding the fracture level (bridging group), or including the fracture level (including group). Different clinical and radiological parameters were recorded and followed. A sum of 80 patients (42 patients in group 1 and 38 patients in group 2) were enrolled in the study. The patients in both the groups showed similar clinical outcome. There was a high rate of instrumentation failure in the "bridging" group. The "bridging" group showed a mean worsening (29%) in kyphosis, whereas the "including" group improved significantly by a mean of 6%. The significant effect of the "including" technique on the reduction of kyphotic deformity was most prominent in type C fractures. In conclusion, inclusion of the fracture level into the construct offers a better kyphosis correction, in addition to fewer instrument failures, without additional complications, and with a comparable-if not better-clinical and functional outcome. We recommend insertion of screws into pedicles of the fractured thoracolumbar vertebra when considering a short segment posterior fixation, especially in Magerl type C fractures.

Selection of short- or long-segment posterior fixation for treatment of unstable thoracolumbar fractures

Objective To discuss the selection of short- or long-segment posterior fixation for treatment of unstable thoracolumbar fractures. Methods A total 134 patients with thoracolumbar fractures treated with pedicle instrument fixation from January 2005 to December 2008 were studied retrospectively. According to AO fracture classification, there were 70 patients with type A fractures, 37 with type B and 27 with type C. The patients were divided into two groups according to the number of instrumented levels; short-segment posterior fixation (SSPF) group (four screws; one vertebral body above or below the fractured vertebrae) and long-segment posterior fixation (LSPF) group (eight screws; two vertebral bodies above or below the fractured vertebrae). Clinical outcomes and radiological parameters (superior-inferior endplate angle, vertebral body angle, displacement of vertebral body) were compared according to AO fracture classification. Results All type A fractures were treated with SSPF, mean superior-inferior endplate angle changed from preoperative 21.3° to postoperative 8.5° and 11.1° at final follow up. There was no statistical difference in the correction of Cobb angle for type B fractures in SSPF group (26 patients) and LSPF group (11 patients), while the correction loss of vertebral body angle was 3. 64° in SSPF group and 1.09° in LSPF group, with statistical difference (P < 0. 05). There was no statistical difference in the correction of Cobb angle for type C fractures in SSPF group (7 patients) and in LSPF group (20 patients), but the correction loss of vertebral body angle was 3.6° in SSPF group and 0. 8° in LSPF group, with statistical difference (P < 0. 05). There was no statistical difference in vertebral displacement correction. Conclusions Most types A and Bl fractures should be treated with SSPF; most types B2, B3 and C fractures should be treated with LSPF. Key words: Spinal fractures; Thoracic vertebrae; Lumbar vertebrae; Fracture fixation, internal; Fracture classification

Three-Column Reconstruction Through Single Posterior Approach for the Treatment of Unstable Thoracolumbar Fracture

A prospective study was performed. To assess a technique, three-column reconstruction through single posterior (TRSP) approach, in treatment of highly unstable thoracolumbar fracture. The goal of surgical intervention for treatment of unstable thoracolumbar fractures is to decompress the neural elements, restore vertebral body height, correct angular deformity, and stabilize the columns of the spine. Operative approaches remain disputed. Common opinions include short-segment posterior fixation, multiple-segment posterior fixation, stand-alone anterior approach fixation, and combined anterior-posterior approach. Each technique has its advantages and disadvantages. A consecutive series of 37 thoracolumbar fractures with load sharing scores > or =6 were managed with TRSP between May 2004 and September 2006. All patients were observed up for a minimum of 2 years. Demographic data, neurologic status, segmental kyphosis, segmental height, the fracture severity score, Visual Analogue Scale, and treatment-related complications were evaluated. The mean operative time was 157 minutes (range, 120-240). The mean blood loss was 1086 mL (range, 700-3100). Averagely Frankel score improved from 3.46 to 4.46; kyphotic angulation improved from 25.75 degrees before surgery to 4.49 degrees at last follow-up, and the loss of segmental height improved from a mean of 35.22% before surgery to 7.01% at the time of the last follow-up. The mean preoperative Visual Analogue Scale score was 7.92, and most patients had no complain of pain at last follow-up. No patient experienced worsening of neurologic deficits and other severe complications at last follow-up. One patient developed titanium mess cage subsidence, but revision was not necessary. The technique of TRSP approach is safe, effective, and offers some advantages over the classic posterior, anterior, combined anterior-posterior approach for some specific highly unstable thoracolumbar fractures.

Posterior short-segment pedicle screw fixation at the injured level for thoracolumbar spine fractures

Objective To discuss indications,operation method and clinical outcome of posterior short-segment pedicle fixation at the injured level for treatment of thoracolumbar spine fractures.Methods A total of 38 patients with thoracolumbar spine fractures were equally randomized to Group A(treated with classic short-segment pedicle screw fixation)and Group B(treated with short-segment pedicle screw fixation at the injured level)based on fixation methods(19 patients per group).Preoperative and postoperative JOA score,segmental lordosis(Cobb' s angle),R value(anterior fractured vertebral body height/mean normal vertebral body height×100%),VSA score and internal fixation condition were assessed and compared clinically.Results All patients were followed up for 6-37 months(mean 20.5 months),which showed no statistical difference upon Frankel scores of two operation modes,while the segmental lordosis,VAS score and R value in Group B were than those in Group A.There occurred nuts loosening in one patient and screw bending in one in Group A.There was no implant breakage,loosening or emersion in Group B.Conclusion Posterior short-segmental fixation at the injured level is an adequate and effective procedure for compression fractures and mild to moderate burst fractures of the thoracolumbar spine. Key words: Spinal fractures; Thoracic vertebrae; Lumbar vertebrae; Short-segmental fixation

Combination of the AO-Magerl and Load-Sharing Classifications for the Management of Thoracolumbar Burst Fractures

The AO-Magerl classification is widely accepted for the appropriate management of patients with thoracolumbar burst fractures; however, it fails to assess the ability of the injured spine to withstand compressive loading and cannot predict instrumentation failure after short-segment posterior fixation. The load-sharing classification depends on the degree of comminution and apposition of bony fragments.We retrospectively classified according to both classifications 100 consecutive patients with 1-level thoracolumbar burst fractures treated nonoperatively or operatively within a 7-year period. Sixty neurologically intact patients (60%) were treated nonoperatively, 15 (15%) had short posterior instrumentation, 15 (15%) had short anterior instrumentation, and 10 (10%) had combined short posterior instrumentation and anterior strut grafting. Twenty-five of the 40 (60%) surgically treated patients had neurological impairment on admission. Clinical outcome was assessed using a pain and working ability scale. Mean follow-up was 52 months (range, 24-70 months). Function was satisfactory in 55 (92%) nonoperatively treated patients and in 33 (83%) surgically treated patients. Neurological improvement by American Spinal Injury Association (ASIA) grade was observed in patients with incomplete paraplegia (70% of neurologically impaired patients) who were treated operatively.The combination of AO-Magerl and load-sharing classifications provides for accurate selection of treatment, surgical approach, and length of instrumentation, and can guide the decision for additional anterior surgery.

Biomechanical Evaluation of Short-Segment Posterior Instrumentation With and Without Crosslinks in a Human Cadaveric Unstable Thoracolumbar Burst Fracture Model

This study evaluates the biomechanical characteristics of spinal instrumentation constructs in a human unstable thoracolumbar burst fracture model simulated by corpectomy. To compare the biomechanical characteristics of short-segment posterior instrumentation, with and without crosslinks, in a human unstable burst fracture model simulated by corpectomy. Unstable thoracolumbar burst fractures are serious injuries, and their management remains controversial. Some authors advocate the use of short-segment posterior instrumentation for certain burst fractures. Whether crosslinks contribute additional stability has not been determined. Six fresh frozen human spines (T10-L2) were potted to isolate the T11-L1 segments, and biomechanically tested in axial rotation, lateral bending, flexion, and extension. A custom spine testing system was used that allows motion with 6 degrees of freedom. After testing was completed on intact specimens, a corpectomy was performed at T12 to simulate an unstable burst fracture with loss of anterior and middle column support. Short-segment transpedicular instrumentation was then performed from T11 to L1. Each specimen was retested with 1, 2, or no crosslinks. Construct stiffness and motion data were analyzed with each intact specimen serving as its own internal control. Torsional stiffness in axial rotation was significantly increased (P < 0.05) in short-segment fixation constructs with 1 and 2 crosslinks, but none was restored to the preinjury baseline level. Significant reductions in standardized motion were also achieved with 1 and 2 crosslinks compared to no crosslinks (P < 0.05), but they remained greater than baseline. Crosslinks significantly increased stiffness and decreased motion in lateral bending, beyond the baseline level (P < 0.05). In flexion, all constructs had significantly decreased stiffness and increased motion compared to the intact specimen (P < 0.05), with crosslinks providing no additional benefit. Conversely, none of the constructs demonstrated a significant change in extension compared to baseline (P > 0.05). When attempting to load the constructs to failure, screw pullout was seen in all specimens. Crosslinks, when added to short-segment posterior fixation, improve stiffness and decrease motion in axial rotation, but do not restore baseline stability in this corpectomy model. Short-segment posterior fixation is also inadequate in restoring stability in flexion with injuries of this severity. Short-segment posterior instrumentation alone can achieve baseline stability in lateral bending, and crosslinks provide even greater stiffness.

Severe thoracolumbar osteoporotic burst fractures: Treatment combining open kyphoplasty and short-segment fixation

The majority of osteoporotic, spinal cord compressive, vertebral fractures occurs at the thoracolumbar junction level. When responsible for neurological impairment, these rare lesions require a decompression procedure. We present the results of a new option to treat these lesions: an open balloon kyphoplasty associated with a short-segment posterior internal fixation. Twelve patients, aged a mean 72.3 years, were included in this prospective series; all of them presented osteoporotic burst fractures located between T11 and L2 associated with neurological impairment. The surgical procedure first consisted of a laminectomy, for decompression, followed by an open balloon kyphoplasty. A short-segment posterior internal fixation was subsequently put into place when the local kyphosis was considered severe. A CAT scan study evaluated local vertebral body's height restoration using two pre- and postoperative radiological indices. All of the patients in the series were followed up for a mean 14 months. Local kyphosis improved a mean 10.8 (p<0.001). Vertebral body height was also substantially restored, with a mean gain of 26% according to the anterior height/adjacent height ratio and 28% according to the Beck Index (p<0.001). Two cases of cement leakage were recorded, with no adverse clinical side effect. Complete neurological recovery was observed in 10 patients; two retained a minimal neurological deficit but kept a walking capacity. The results presented in this study confirm the data reported in the literature in terms of local kyphosis correction and vertebral body height restoration. The combination of this technique with laminectomy plus osteosynthesis allowed us to effectively treat burst fractures of the thoracolumbar junction and led to stable results 1 year after surgery. This can be advantageous in a population often carrying multiple co-morbidities. With a single operation, we can achieve neurological decompression and spinal column stability in a minimally invasive way; this avoids more substantial surgery in these fragile patients. Level IV. Therapeutic prospective study.

Application of posterior short-segment fixation combined with intermediate screws in fresh thoracolumbar compressed fracture: short-term outcomes in 27 cases

To observe the short-term outcomes of the application of posterior short-segment fixation combined with intermediate screws in fresh thoracolumbar fracture. Posterior short-segment fixation combined with intermediate screws was used in 27 patients suffering from fresh thoracolumbar fracture, 19 males and 8 females, aged 45 (22-71). X-ray photography was conducted before and after operation. The height of fractured vertebra was 57.6%+/-16.5% of the normal value before operation, and was restored to 93.8%+/-11.9% after operation; the segmental kyphosis angle on the sagittal plane was 20.8+/-9.4 degrees before operation, and decreased to 5.9+/-7.4 degrees after operation (both P<0.001). Using pedicle screws on the fractured vertebra via posterior approach conditionally helps reduce the fractured vertebra and correct the kyphosis, and enhance the stiffness of the internal fixation system as well.

Balloon Kyphoplasty Combined With Posterior Instrumentation for the Treatment of Burst Fractures of the Spine-1-Year Results

Clinical and radiologic follow-up of patients with osteoporosis with painful, traumatic A3-type vertebral compression fractures in the thoracic and lumbar spine. Prospective study over the period of 1 year. Level I Trauma Center. Twenty-five patients with osteoporosis (14 women and 11 men) and painful, traumatic A3-type fractures were treated with Balloon Kyphoplasty in combination with a short-segment posterior fixation (using the Universal Spine System). Twenty-one patients returned for their 1-year follow-up visit. X-rays were taken preoperatively, postoperatively, and at 3, 6, and 12 months' follow-up to evaluate vertebral height and local Cobb angle. Pain was measured using the self-reporting Visual Analogue pain Scale (VAS). Disability was measured using the Oswestry Disability questionnaire (ODI). The mean pain score (VAS) improved significantly from pretreatment to posttreatment from 7.8 +/- 2.2 (5.6-10) to 4.9 +/- 2.1 (2.8-8.0) (P < 0.001). It improved further to 2.9 +/- 1.4 (2.1-4.3) at 3 months and increased slightly after 1 year (3.8 +/- 1.9) (1.9-4.7). Limitation of daily activities (ODI) improved significantly from 88% (78-100) to 35% (15-48) at 3 months (P < 0.05). Improvement was maintained at 1 year at 36.5% (10-42). At 1-year follow-up, maintenance of the height restoration and kyphotic deformity correction was found. Balloon Kyphoplasty in combination with short-segment posterior instrumentation in traumatic A3 vertebral fractures led to a significant reduction in pain and disability. The combination of both surgical techniques was able to restore and maintain vertebral body height and correction of angular deformity. This technique might offer important safety advantages over an invasive anterior-posterior approach.

Clinico- Radiological profile of indirect neural decompression Using cage or auto graft as interbody construct in PLIF in spondylolisthesis, which is better?

Study design A prospective clinical study of PLIF in grade I and II degenerative spondylolisthesis was conducted between Mar 2007Aug2008.The objective was to assess the clinicoradiological profile of structural v/s non-structural graft on intervertebral disc height and its consequences on the LBP assessed by VAS score and ODI. This study involved (n=28) patients. We included Age of 30-70 years,symptomatic patient with disturbed ADL,single level L4/L5 or L5/S1 Grade I or grade II degenerative spondylolisthesis. We excluded. Patients with osteoporosis, recent spondylodiscitis, subchondral sclerosis, visual and cognitive impairment, and all other types of spondylolisthesisAll the patients underwent short segment posterior fixation using CD2 or M8 instrumentation , laminectomy discectomy ,reduction and distraction of the involved vertebral space .In 53.5% (n=15) patients snugly fitted local bone chips were used while in 46..4%(n=13) patients Cage was used .Among Cage group, titanium cage was used in 9[32.1%] and PEEK cages in 4[14.2%] patient. In one patient unilateral PEEK cage was used. The mean follow-up period was 24 months..Among (n=28) patients,67.8%(n=19) were females and 32.14%(n=9) were males.68.24%(n=18) were having L4/L5 and 35.71%(n=10) L5/S1 spondylolisthesis.39.28%(n=11) were of grade I and 60.71%(n=17) were of grade II spondylolisthesis. Conclusion There was a statistically significant correlation (p<.012 and p<.027) between the change in disc height we achieved and the improvement in VAS score in both graft group and cage group. The increment in disc height and VAS score were significantly better in Cage group(2mm+S.D visa-viz 7.2(88%) ) than the graft group(1.2mm+S.D visa-viz 5(62%)

Pathogenesis analysis of proximal junctional lordosis after short-level posterior pedicle screw fixation in lumbar spine

To analyze the possible reasons for proximal junctional lordosis (PJL) after short-segment posterior pedicle screw fixation in lumbar spine and discuss its proper management. From December 2001 to August 2005, 345 patients were treated by short-segment pedicle screw fixation and these patients were reviewed. Clinical outcome was evaluated according to Oswestry Disability Index (ODI). Proximal junctional lordosis was assessed evaluated on radiographs, by measuring lumbar lordosis angle, segmental angle at proximal level and lumbar-sacral angle. Risk factors of proximal junctional lordosis were analyzed. All patients were followed-up for 2 to 6 years (average 3.8 years). ODI after lumbar surgery was 9.7-46.2 ( average 19.6 +/- 10.7). PJL was noted in 78 patients (22.6%), 37 (10.7%) of whom were symptomatic and 21 (6.1%) received revision surgery. PJL was more commonly occurred in patients over 60 years old, with reduced lumbar lordosis or vertical sacrum. The number of fusion-segment was not correlated to the occurrence of PJL. Short-segment posterior pedicle screw fixation can not improve lumbar sagittal alignment. Age over of 60 years, reduced lumbar lordosis and vertical sacrum are possible risk factors of PJL sacrum.

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.

Giant cell tumor of the lumbar spine: operative management via spondylectomy and short-segment, 3-column reconstruction with pedicle recreation

Background Giant cell tumors of the lumbar spine are uncommon lesions. Aggressive management of such lesions via spondylectomy to obtain local control and prevent recurrence is often necessary. Spinal reconstruction after total spondylectomy can be challenging. Traditional reconstructions typically require multisegment fixation with an association loss of segmental motion and limited 3-column reconstruction. Methods The authors report a case of a GCT of the lumbar spine occurring in a 49-year-old woman. The authors describe the surgical management of such a lesion via a 1-stage posterior-anterior-posterior procedure that entails a lumbar spondylectomy and short-segment posterior fixation with 3-column reconstruction using a stackable carbon-fiber–reinforced cage device with direct posterior rod connection for pedicle reconstruction. Results At 33 months postoperative follow-up, neither tumor recurrence nor instrumentation-related complications were noted, bone fusion was prevalent, and sagittal alignment was well maintained. The patient reported no loss of functions, was neurologically intact, and remained active. Conclusions Aggressive operative management via spondylectomy of a lumbar GCT provides local tumor control. In select patients, spinal reconstruction after a spondylectomy via a 1-stage posterior-anterior-posterior approach to establish short-segment, 3-column reconstruction with recreation of the pedicles is a promising procedure that provides immediate spinal stabilization without evidence of early instrumentation-related complications, maintains spinal alignment, promotes a quick return to daily activities, and avoids sacrificing excessive motion segments and biomechanical function associated with more traditional procedures.

NS11 POSTERIOR APPROACHES FOR THORACO‐LUMBAR FRACTURES

The controversies remain in the management of thoraco‐lumbar fractures. These include who should receive surgical intervention, what constitutes instability of the thoraco‐lumbar spine, should an anterior or posterior approach be used to stabilise thoraco‐lumbar spine fractures, what length of instrumentation should be used and should bracing be utilised?At the present time there is a paucity of level 1 evidence to support a best practice recommendation for the management of thoraco‐lumbar spine trauma. Various classification systems have been introduced over the last 30–40 years to assist in the decision making process. These include the Holdsworth classification in 1970, the Dennis classification in 1983 and the Magerl AO classification in 1994.Very recently the thoraco‐lumbar injury classification and severity score has been introduced to try and further assist in the decision making on surgical intervention. The Burwood Spinal Injuries Service has also utilised the double ring concept of spinal instability in decision making. Various fracture patterns including burst fractures, flexion/distraction injuries and complex fracture dislocations, the indications for surgical intervention and the posterior approach to stabilising these fractures will be presented. A short segment posterior fixation with or without fusion for burst fractures and flexion/distraction injuries is recommended. Complex fracture dislocations and neurologically complete patients frequently require longer fixation with short or long fusion depending on fracture comminution and inherent stability. Recent developments with the use of image guided surgery, bone morphogenic protein and the potential for spinal cord regeneration are adding to our ability to deal surgically with thoraco‐lumbar spine trauma.