Treatment Of Burst Fractures Research Articles

Short-segment transpedicular fixation combined with augmentation vertebroplasty in treatment of thoracolumbar burst fractures

Objective To evaluate the efficacy of short-segment transpedicular fixation combined with augmentation vertebroplasty in treatment of thoracolumbar burst fractures. Methods From November 2006 to September 2009, 37 patients with thoracolumbar burst fracture were admitted and received transpedicular fixation combined with calcium sulfate cement augmentation vertebroplasty, and the clinical data including fracture types, complications and following-up results were collected for analysis. The multimethod evaluation strategies involved the anterior vertebral body height, the sagittal Cobb's angle, the restoration of nervous function, internal fixation failure, visual analogue scale (VAS) and Oswestry disability index (ODI) were retrospective analyzed. Results All patients were followed up for average 19 months (range, 14-37). There were no internal fixation failure, loss of reduction, neurological complications in all the patients. In 16 patients with partial neurologic deficits, 14 initially improved at the final follow-up, with no deterioration of neurologic functions. The mean time of calcium sulfate cement obvious absorption and union was 3 months and 5 months postoperatively, respectively. The anterior vertebral body height was 55.40％before surgery and 85.46％ after surgery on average, ended up with 82.35％. The sagittai Cobb's angle was improved from 22.45° to 6.86°, ended up with 9.66° on average. The mean VAS and ODI at the final followup were respectively 1.2 and 20.4 on average. Conclusion Short-segment transpedicular fixation combined with augmentation vertebroplasty appears to be effective in achieving stable biomechanics with high security,which seems to be a feasible option in the management of thoracolumbar burst fractures. Key words: Thoracic vertebrae; Lumbar vertebrae; Fractures, bone; Fracture fixation, internal

Treatment of thoracolumbar burst fractures of Denis type B by posterior bisegmental stabilization plus monosegmental fusion

Objective To investigate the efficacy of posterior bisegmental stabilization plus monosegmental fusion in the treatment of thoracolumbar burst fractures of Denis type B.Methods From July 2009 to January 2011, 8 patients with vertebral body burst fracture of Denis type B were treated with posterior bisegmental stabilization plus monosegmental fusion.The upper interspace of the injured vertebra was fused posteriorly.They were 5 men and 3 women, aged from 20 to 68 years (average, 42 years).The neurological status was evaluated by Frank grading system.The ratio of the anterior margin height of the injured vertebral body to the normal height (RAH), the ratio of the posterior margin height of the injured vertebral body to the normal height (RPH), the Cobb angle and the volume ratio of spinal canal were compared respectively between preoperation and postoperation to evaluate the clinical efficacy.Results The 8 patients were followed up for 7 to 18 months (average, 13.I months).Fracture dislocation was completely reset.No vascular or nerve damage, or other complications, such as loosening of internal fixation, was found.All patients had neuro-functional improvement by at least one Frank grade.The postoperative RAH (0.97±0.02), RPH (0.97 + 0.03), Cobb angle ( - 0.25° + 1.82°), and the spinal canal volume ratio (93.40 ±5.30) were improved significantly compared with the preoperative data (P ＜ 0.05), but had no significant differences compared with the last follow-up data ( P ＞ 0.05) .Conclusion In treatment of thoracolumbar burst fractures of Denis B-type, posterior bisegmental stabilization plus monosegmental fusion can effectively restore the spinal curvature, decompress the spinal canal, reconstruct spinal stability, and preserve the intact disc under the injured vertebra. Key words: Intervertebral disk; Spinal fusion; Throacolumbar burst fractures

Management of thoracolumbar burst fracture through anterior approach with preserved posterior vertebral wall

Objective To evaluate the clinical result and feasibility of anterior approach with posterior vertebral wall preserved in the treatment of thoracolumbar burst fracture with or without paraplegia. Methods From 2005 to 2010, 68 patients with thoracolumbar burst fracture were treated by corpectomy, strut graft and instrumentation with preserved posterior vertebral wall. There were 49 males and 19 females at average age of 39.8 years (16-62 years). Kyphotic Cobb' s angle and spinal stenotic rate was measured preoperatively and postoperatively. The neurological status was evaluated with Frankel impairment scale. Results All patients were successfully managed with this technique, with no neurological deteriorations, cerebrospinal fluid leakage or incision infections except for the pneumothorax in three patients who were then cured through expectant treatment. Screw distraction was performed for restoration of the disc height and kyphosis in 68 patients. After the fractured fragment became loose and was removed, the dura matter was exposed in 19 patients including the eerebrospinal fluid leakage in three patients. Retrograde lumbar myelography was applied in eight patients, of whom there found the blocked spinal canal in three patients and excision of the posterior vertebral wall was performed. Lack of vertebral distraction was found in two patients and extraction of the reversed bone fracture behind the posterior longitudinal ligament was performed in one. The preservation rate of the posterior vertebral wall was 95% (65/68). Fifty-two patients were followed up for mean 2.2 years (from 3 months to 4.5 years) ,which showed no lower back kyphosis. There showed 1-3 Frankel grades of improvement in spinal cord function except for five patients at Frankel grade A. The Cobb angle was average 18.2° in 68 patients preoperatively and was corrected to 9.7°in 52 patients at last follow-up. CT scan showed that the stenotic rate was 42% preoperatively and 9% at final follow up in 68 patients,with no breakage of the screw and plate. Conclusion In the management of thoracolumbar burst fractures,anterior approach is helpful for preservation of the posterior vertebral wall. Key words: Thoracic vertebrae; Lumbar vertebrae; Spinal fractures; Anterior approach

Posterior single segment anterolateral decompression and anterior column reconstruction for type Denis B thoracolumbar burst fractures

Objective To investigate the feasibility and clinical effect of the posterior single segment anterolateral decompression and anterior column reconstruction in the treatment of thoracolumbar burst fractures. Methods A retrospective study was done on 21 patients with type Denis B thorocalumbar burst fractures who were treated by posterior approach minimal incision pedicle SCreW fixation,single segment anterolateral decompression and titanium mesh and bone graft from August 2007 to August 2009.There were 15 males and six males at mean age of 35.6 years(range,23-50 years).The involved segments included T12 in six patients,L1 in 11,L2 in three,and L3 in one.The preoperative spinal canal enemachment rate was 62.5%and the anterior-middle vertebral compression of all patients was less than 50%.CT scanning showed normal vertebral body and inferior endplate structure.The fracture reduction,graft fusion,neurological function recovery,correction loss,lumbar activities and adjacent lumbar disc degeneration were observed through preoperative,immediate postoperative and final follow up X-ray,CT and neurological examinations. Results The operation duration was 1.5-3.2 hours(average 2.1hours),with the bleeding of 350-1 000 ml(average 580 ml).All the patients were followed up for 4-26months(average 10.3 months),which showed that the vertebral fusion time was 4-6 months,with no loss of the vertebral height,implant breakage,loosening or extrusion.The nerve function was improved for 1-2 grades. Conclusions With correct selection of the indications,the posterior single segment anterolateral decompression and anterior column reconstruction is a reliable fixation,for it takes advantages of simple operation,minor trauma,less fusion segments and fast recovery. Key words: Spinal fractures; Thoracic vertebrae; Lumbar vertebrae; Reconstruction

The preliminary clinical outcomes of porous nano-hydroxyapatite polyamide 66 cage in the treatment of thracolumbar burst fracture.

Objective To evaluate the early clinical outcomes of porous nano-hydroxyapatite polyamide 66 cage in the treatment of thoracolumbar burst fracture. Methods From Jan 2008 to Sep 2008, 54 patients with thoracolumbar burst fracture were treated by anterior thoracolumbar body resection com-bined with nano-hydroxyapatite polyamide 66 cage fusion. All patients were evaluated preoperatively, post-operatively and 3, 6, 12 months postoperatively. The neurological function were measured by Frankel grade. All of the patients underwent X ray and three-dimensional CT scan. The Cobb angle were used to measured the kyphosis of the fusion segments. The intervertebral fusion were graded by criterion described by Branti-gan. Results The mean follow-up period was 9.4 month. No patients had deteriorated neurologically and all improved at least one neurologic grade, except 2 patients with Franke rank A and 8 patients with Franke rank D. The mean preoperative kyphosis has improved from 14.4°to 3.7° immediately after surgery and 3.9° at the final follow-up. The mean preoperative distance between adjacent vertebral bodies was (96.9±17.2)mm preoperatively, (109.5±17.1) mm immediately after surgery and (108.6±16.9) mm at the final follow-up. No cage displacement, internal fixation breakage or neurologie impairment were found. At the final follow-up, 19 patients had achieved grade E fusion, 10 achieved grade D, and 25 achieved grade C. Conclusion The present study demonstrates Anterior decompression combined with porous nano-hydroxyapatite polyamide 66 cage fusion was a effective method to treat thoracolumbar burst fracture. The kyphosis the intervertebral dis-tahoe was corrected effectively with a low rate of instrumentation failure and loss of correction and interver-tebral distance. Key words: Thoracic vertebrae; Lumbar vertebrae; Spinal fractures; Spinal fusion; Nanostructures

Severe burst fractures of lumbar vertebrae treated via combined anterior and posterior approaches

Objective To evaluate the efficacy of combined anterior and posterior approaches used for the treatment of severe burst fractures of lumbar vertebrae. Methods A retrospective review was conducted for the 34 patients with severe burst fracture of lumbar vertebrae who had been surgically managed from February 2000 to December 2006. They were 31 males and 3 females, with ages ranging from 23 to 48 years old (average, 35.4 years old) . L1 was involved in 10 cases, L2 in 14, L3 in 6, and L4 in 4 ones.According to AO classification, all patients were of A3 type. All patients underwent posterior reduction and transpodicle screw internal fixation combined with anterior decompression and bone graft. One-stage surgery was performed for 19 cases, and two-stage surgery for 15 cases. Neurological status and radiographs at pre-operative, postoperative and follow-up periods were reviewed. Results All the operations were successful without any neurological deterioration. The follow-up time for the 34 cases ranged from 11 to 84 months (mean, 42.5 months) . The spinal canal was enlarged, and the lumbar spine recovered to its normal curve.No evident correction loss was observed. All the patients obtained bony fusion. No hardware failure was found.The 4 patients with complete paralysis obtained no improvement in neural function, the other 30 patients with incomplete paralysis obtained improvement in Frankel Grades. Conclusion The combined anterior and posterior approaches may be an effective surgical treatment for severe burst fractures of lumbar vertebras,provided that the operative indications are strictly observed. Key words: Lumbar vertebra; Burst fractures; Internal fixation, internal

Fixation of the fractured vertebra and its adjacent upper and lower vertebrae with pedicle-screws for treatment of burst fractures of single thoracolumbur vertebra

对于胸腰椎单椎体爆裂性骨折常规行短节段椎弓根螺钉内固定技术,即伤椎的上位正常椎体和下位正常椎体各使用2枚椎弓根螺钉(3椎体4枚螺钉)固定进行纵向撑开,达到复位,术中易出现复位高度不够,术后恢复过程中出现内固定失败,复位高度丢失.

Biomechanic research on short-segment posterior pedicle screw fixation

Objective To compare the stability effect of the fixation segment using the new test system based robotics to simulate the complex human movement at natural state about the three-level fixa-tion by using four, five or six pedicle screws in treatment of thoracolumbar burst fractures. Methods Six human cadaveric spines were dissected from T_(11)-L_3. The inferior half part of L_1 vertebral bodies and L_1-L_2 dises were resected to mimie an unstable L_1 burst fracture with loss of anterior column support. Specimens were tested in accordance with the following order:intact, 4,5 and 6 pedicle screws fixation at the three-level fixation. The range of motion (ROM) of the fixation segment (T_(11)-L_3) was measured with the six-freedom degree robotics system controlled by mixed force and displacement during flexion, exten-sion, lateral bending and axial torsion, when the stiffness was calculated. One-way statistieal analysis was used for analyzing the collected data. Results With increased number of screws, the ROM of the fixa-tion segment (T_(11)-L_3) was gradually decreased and the stiffness gradually increased. The ROM under ax-ial rotation of six and five screws group became smaller than four screws group (P 0.05). There were no significant differences in ROM and stiffness under six different loading directions between six screws group and five screws group (P > 0.05). No statistical difference was observed for three fixation modes in aspects of ROMs and stiffness under flexion-extension or lateral ben-ding (P > 0.05). Conclusions Three-level fixation of burst fractures with five or six screws offers im-proved biomechanical stability compared with traditional four screws fixation. But the difference is insig-nificant between six and five screws fixations. Key words: Spinal fractures; Biomechanies; Internal fixators; Robotics

Effects of general spinal system on the treatment of thoracolumbar vertebrac burst fracture in 48 cases

Objectives To observe the effects of posterior GSS instrument intend fixiation on the treatment of thoracolumbar vertebrae burst fracture.Methods Forty-eight cases with thoracolumbar vertebrae burst fracture were surgically treated with posterior decompression,autograft bone fusion and GSS imemal fixation.Results After operation,X-ray films and CT scan demon-strated that the height of corpus vertebrae,the area of spinal cannal and sagittal plane were all restored to normal.The patients were followed up for 8 to 25 months.No pedicle screw cracking occurred.According to Frankel's grading,nerve functions,32 cases improved from Grade Ⅰ to Grade Ⅲ after operation.Conclusions GSS has the advantages of easy manipulation,good reduction,high fusion rate and reliable internal fixation in thoracolumbar vertebrae fracture and is one of the best devices for the treatment of thoracolumbar vertebrae fracture. Key words: Spinal Fractures; Internal fixators; Fracture fixation internal

Treatment of thoracolumbar burst fractures with posterior pedicle fixation and interbody bone grafting

Objective To investigate the curative effects of posterior pedicle screw fixation plus interspinal bone grafting in treatment of thoracolumbar burst fractures. Methods The study involved 62 patients with thoracolumbar burst fractures treated with posterior podicle screw instrumentation plus interspinal bone grafting. The Cobb angle, the ratio of anterior body height to the normal height and spinal canal blockage before and after surgery were compared for observation on postoperative fracture healing as well as internal fixation failure or reduction loss during follow-up. Results The oporative decompression and reduction exerted significantly positive effect on the Cobb angle, the ratio of anterior bedy height to the normal height and spinal canal blockage. The follow-up showed no significant correction loss or fixation failure. Conclusions Posterior pedicle screw plus interspinal bone grafting is an ideal method for treatment of thoracolumbar burst fractures, for it can prevent failure, reduction loss and kyphotic deformity. Key words: Spinal fractures; Thoracic vertebrae; Lumbar vertebrae; Posterior pedicle fixation

Treatment of thoracolumbar burst fractures with transpedicular fixation through the pedicle of fractured vertebra: a prospective randomized trial

Objective To compare the therapeutic results of transpedicular fixation through the pedicle of fractured vertebra and of the traditional transpedicular fixation for treatment of thoracolumbar burst fractures. Methods Between May 2004 and June 2007,48 consecutive patients seeking medical treat-ment for one level thoracolumbar burst fracture in our department were included in this study. Their average age was 40. 1 yeas old. They were randomly and evenly assigned into an experimental group of transpedicular fixation through the pediele of fractured vertebra and a control group of traditional transpedicular fixation. All patients underwent X-ray and spiral CT scan preoperatively and postoperatively. The Cobb's angle,anterior vertebral body compression percentage (AVCP),sagittal canal diameter (SCD) and vertebral body translation percentage (VBTP) were recorded for all patients. Their fusion results and neurological functions were ob-served. Results All patients were followed up for 10.6 months averagely. The shape of injured ver-tebrae was maintained and fusion of the grafted bone was observed in all patients. All parameters were improved after operation. Follow-ups revealed that the mean Cobb's angle and AVCP in the experimental group were 6.99°±6.81°and 18.60%±9.96% respectively,significantly lower than those in the con-trol group (P 0.05) . No com-plications were observed in either group. The preoperative incomplete neurological injuries obtained postop-erative improvement of one or two grades. Conclusion Transpedicular fixation through the pedicle of fractured vertebra is a better treatment for thoracolumbar vertebral fractures than the traditional transpedicular fixation,because its safer fixation and better stability help restore the shape of injured vertebra and reduce the Cobb's angle. Key words: Thoracic vertebrae; Lumbar vertebrae; Fractures; Fracture fixation,internal; Fractured vertebra

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.

Effects of short-segment posterior pedicle fixations on adjacent intervertebral discs: a robotic-based biomechanical research

Objective To compare the effects of three-level fixations by 4, 5 and 6 pedicle screws into the adjacent upper and lower vertebrae on the strain changes at the adjacent intervertebral discs in the treatment of thoracolumbar burst fractures. Methods Six human cadaveric spines were dissected to prepare specimens of T11-L3. The inferior half of the L1 vertebral bodies and L1-L2 discs were resected tosimulate an unstable L1 burst fracture without support of anterior column. Biomechanical tests were performed in groups of intact condition and three-level fixations by 4, 5 and 6 pedicle screws. The strain changes at T11/12, L2/3 disc were measured by a robotic system of 6 degrees of freedom under loadings at flexion, extension, the left and right lateral bendings, and the left and fight axial torsions. One-way statistical analysis was used to compare the data collected. Results With the increase in number of screws, the strain at the adjacent intervertebral discs (T11/12, L2/3) was gradually increasing. The strains at T11/12 disc in fixations by 5 and 6 screws were significantly lager than in fixation by 4 screws only under axial rotation (P 0.05). The strains at L2/3 disc were not significantly different among the 3 groups under any loading (P>0.05). Conclusions In the three-level fixations by 4, 5 and 6 pedicle screws to treat thoracolumbar burst fractures, strains at the adjacent intervertebral discs may be gradually increasing with the increase in number of screws. Since the strain at the adjacent upper intervertebral disc is increased more markedly, the upper disc is more likely to degenerate than the lower disc. Key words: Thoracic vertebrae; Lumbar vertebrae; Fracture fixation, internal; Biomechanics

Treatment of thoracolumbar burst fracture with dilator-kyphoplasty combined with autologous bone graft in fractured vertebra

Objective To investigate the effect of the self-designed dilator-kyphoplasty combined with autologous bone graft in fractured vertebra for treatment of thoracolumbar burst fractures. Methods From August 2007 to March 2008, 16 patients with thoracolumbar burst fracture were treated by our self-designed dilator-kyphoplasty combined with autologous bone graft in fractured vertebra. Based on AO classification, 10 patients were of A2 and 6 of A3. According to the ASIA (American Spinal Injury Associ-ation) neurological function grading system, there were 2 cases of grade A, 2 grade B, 2 grade C, 3 grade D and 7 grade E. Results On average, the anterior height of fractured vertebrae increased from 18.3±2.5 mm before operation to (25.1±2.8) mm after operation. Their mean Cobb' s angle was restored from 36.33°±2.14°before operation to 2.77°±0.41°after operation. The average amount of bone graft was (10.53±3.62) cm3. There was no perioperative or postoperative vessel or nerve injury. A follow-up of 6 months re-vealed fine fusion of grafts and no implant rupture or loosening. For patients with incomplete neurological injuries, improvement of 1 to 2 grades was made in neurological functions. Conclusion Because the self-designed dilator-kyphoplasty may effectively restore the height of fractured vertebrae, reconstruct the sta-bility of anterior and middle columns of the fractured vertebrae and avoid the complications caused by simple pedicle screw fixation, it should be used widely in clinic for thoracolumbar burst fractures. Key words: Thoracic vertebrae; Lumbar vertebrae; Fracture; Bone transplantation; Dila-tor-kyphoplasty

Pedicle screw fixation combing with the bioactive glass posterolateral fusion in the treatment of thoracolumbar burst fractures

目的 探讨经椎弓根内固定附加生物活性玻璃行椎体后外侧融合手术治疗胸腰椎爆裂骨折的临床疗效观察.方法 38例胸腰椎爆裂骨折应用后路短节段椎弓根螺钉内固定后,用生物活性玻璃行椎体后外侧融合.结果 随访3～16月,脊柱融合效果明显,融合率高达89.5%,椎体后突畸形及高度得到明显的恢复,X线未见一例断钉,断杆,内固定松动现象,无明显脊柱后凸畸形,矫正高度再丢失现象.结论 经椎弓根内固定附加生物活性玻璃行椎体后外侧融合手术治疗胸腰椎爆裂骨折疗效显著,方法简单,值得推广。

Transpedicle Body Augmenter: A Further Step in Treating Burst Fractures

Dear Sir, We read with interest the article “Transpedicle Body Augmenter A Further Step in Treating Burst Fractures” by Li et al. [5]. This article addressed short-segment fixation well by comparing patients treated with a transpedicle body augmenter with a control group of patients treated with short-segment posterior instrumentation. The issue of short-segment versus long-segment fixation is a matter of debate among spine surgeons. Where short-segment fixation allows preservation of more mobile segments of the spine, it compromises the strength of fixation construct [4, 6]. This led to a new dimension in management of vertebral fractures, that is, augmentation of short-segment fixation. The methods used for augmentation of short-segment fixation include kyphoplasty [1], vertebroplasty [2], transpedicle bone grafting [3] and transpedicle body augmenter [5]. Except for transpedicle bone grafting, good results have been reported for all other forms of augmentation as compared with short-segment fixation alone. Short-segment pedicle screw fixation is reportedly associated with a 20% to 50% incidence of pedicle screw failure and progressive spinal deformity. The question today is whether the various techniques used for augmentation of short-segment pedicle screw fixation have results comparable to those of long-segment pedicle screw fixation, which we believe is a gold standard [8] for posterior spine stabilization as far as sagittal index and anterior body compression are concerned. We have some concerns regarding the study by Li et al. [5]. First, the postoperative protocol is important in any kind of spinal surgery, however, the authors provide no details of the protocol in this article. As delayed ambulation after short-segment fixation is known to give good results [7], postoperative protocol with specific mention of ambulation should be provided. Moon et al. [7] reported short-segment fixation without posterolateral fusion is an effective procedure for compression and burst fractures if postoperative mobilization is delayed by 2 to 4 weeks. It would be better if the results of the transpedicle body augmenter were compared with results of long-segment fixation. Second, Li et al. report mean times of surgery as 66.1 ± 12.1 minutes and 63.4 ± 16.6 minutes for the augmenter and control groups respectively. Does this mean no additional time is required for: (1) preparation of bilateral pedicle tunnels to the fractured vertebra by an awl followed by serial custom made trials (enlargers) to prepare for TpBA passage; (2) harvesting the bone graft from the iliac crest; (3) filling the vertebral body with autologous bone graft; (4) inserting the augmenter through the pedicle; and (5) filling the pedicle tunnel space with bone graft? Third, blood losses reported for the augmenter and control groups are 216 ± 65 cc and 240 ± 87 cc, respectively, which means the blood loss was less in the group in which two additional pedicle tunnels were made and bone graft was harvested from the iliac crest. If this is correct, the authors should state the reason. Fourth, in the Materials and Methods section, Li et al. reported that flexion and extension xrays were taken after 1 year and at the final visit. The purpose of flexion-extension xrays is not mentioned in the article. Generally, flexion-extension xrays are required to judge bony union after spinal fusion is attempted. However, Li et al. compared only results of vertebral body augmentation with short-segment fixation alone. Therefore, the authors should state what additional information was acquired from the flexion-extension xrays once the anterior body height and kyphosis angle were measured on neutral thoracolumbar radiographs. Finally, Li et al. reported one failure necessitating implant removal. In this case, the patient had intraoperative pedicle rupture during augmenter insertion, which later caused root irritation and neuralgia. As per our knowledge, it is safe to violate the superior and lateral cortices of the pedicle. The authors should state whether the patient had neurologic symptoms even though the inferior and medial cortices of the pedicle were preserved or if the augmenter was implanted despite violation of the inferior or medial cortex of the pedicle.

Reply to Letter to the Editor by Pandher and Boparai (MS 08-00749)

Dear Sirs: I appreciate your interest and comments regarding the article by Li et al. [1]. I received numerous comments about this paper. I and the other authors of that article believe more discussion and critical review will aid progress. In response to your concerns, first, delaying mobilization is against our principles. Our postoperative protocol is based on mobilizing the patient as early as possible. Approximately 80% of our patients with Frankel E and D spinal injuries walked within 6 to 8 hours after surgery, and the remaining 20% after 8 to 24 hours. We encourage patients to walk as soon and as much as possible. We also believe that most burst fractures without neural deficits will not need any surgery if patients can stay in bed for 3 months to allow bone and disc healing. We believe short-segment fixation with TpBA augmentation is the gold standard for one burst fracture. We believe long-segment fixation is unnecessary for most burst fractures and we do not use it. Therefore, we would be unable to follow your suggestion to compare results of long-segment fixation with TpBA augmentation. Ideally, a single vertebral body problem should be treated over the lesion site alone; we believe fusion involving an intact vertebra is not logical and unnecessary and should be avoided if possible. I predict the trend to treat burst fractures will be long-segment fixation, then short-segment fixation with anterior support, and finally only vertebral reconstruction. With practice, blood loss and operating time can be limited. After acquiring experience with the TpBA technique, inserting one TpBA is no more than one pedicle screw. We used dynamic views to check the spine, including stability of the TpBA and status of adjacent discs or vertebrae. Finally, the failure in one of our patients occurred during the early learning curve and the pedicle cortex problem was neglected at primary surgery. At revision surgery we noted the inferior cortex of the pedicle had been violated. More than 5000 TpBA vertebroplasties have now been performed at our hospital and such problems with pedicle rupture essentially have been eliminated.

Treatment of serious lumbar burst fractures with fixation by vertebral pedicle system combined with minimally-invasive injectable bone graft

Objective To discuss the clinical effects of fixation by vertebral pedicle system combined with minimally-invasive injectable bone graft in the treatment of serious lumbar burst fractures.Methods Thirty-eight patients with serious lumbar burst fractures were treated by vertebral pedicle system combined with minimally-invasive injectable graft.According to the Denis classification,the fractures were diagnosed as type A in 5 cases,type B in 16,type C in 8,type D in 3,and type E in 6.Their preoperative and postoperative plain X-ray films were evaluated.Analysis involved kyphotic angulation,anterior vertebral body height,neural function and back pain.The results were statistically analyzed,with a P value less than 0.05 indicating significant difference. Results All the patients were followed up from 18 months to 36 months(26 months on average).The vertebral heights were regained very well.There were significant differences in Cobb'S angle,anterior vertebral body height and back pain between preoperatively and postoperatively.No patients complained of neurological complications or leakage of the MIIG from the spinal channel.There were no such complications as plate-screw loosening or breaking,or segmental instability.All patients recovered,without notable correction loss or implant failure during the follow-up.Only 2 patients suffered from back pain. Conclusions Treatment of serious lumbar burst fractures with fixation by vertebral pedicle system combined with minimally invasive injectable graft can reduce loss of the vertebral height,correct kyphosis abnormality and relieve back pain.Besides positive curative effects,it is also safe and easy. Key words: Lumbar vertebrae; Fracture; Fracture fixation,intemal; Bone graft

Long-term results of transpedicle body augmenter in treating burst fractures

Long-term results of transpedicle body augmenter in treating burst fractures

Nonoperatively treated burst fractures of the thoracic and lumbar spine in adults: a 23- to 41-year follow-up

Background context Several studies report a favorable short-term outcome after nonoperatively treated two-column thoracic or lumbar burst fractures in patients without neurological deficits. Few reports have described the long-term clinical and radiological outcome after these fractures, and none have, to our knowledge, specifically evaluated the long-term outcome of the discs adjacent to the fractured vertebra, often damaged at injury and possibly at an increased risk of height reduction and degeneration with subsequent chronic back pain. Purpose To evaluate the long-term clinical and radiological outcome after nonoperatively treated thoracic or lumbar burst fractures in adults, with special attention to posttraumatic radiological disc height reduction. Study design Case series. Patient sample Sixteen men with a mean age of 31 years (range, 19–44) and 11 women with a mean age of 40 years (range, 23–61) had sustained a thoracic or lumbar burst fracture during the years 1965 to 1973. Four had sustained a burst fracture Denis type A, 18 a Denis type B, 1 a Denis type C, and 4 a Denis type E. Seven of these patients had neurological deficits at injury, all retrospectively classified as Frankel D. Outcome measures The clinical outcome was evaluated subjectively with Oswestry score and questions regarding work capacity and objectively with the Frankel scale. The radiological outcome was evaluated with measurements of local kyphosis over the fractured segment, ratios of anterior and posterior vertebral body heights, adjacent disc heights, pedicle widths, sagittal width of the spinal canal, and lateral and anteroposterior displacement. Methods From the radiographical archives of an emergency hospital, all patients with a nonoperatively treated thoracic or lumbar burst fracture during the years 1965 to 1973 were registered. The fracture type, localization, primary treatment, and outcome were evaluated from the old radiographs, referrals, and reports. Twenty-seven individuals were clinically and radiologically evaluated a mean of 27 years (range, 23–41) after the injury. Results At follow-up, 21 former patients reported no or minimal back pain or disability (Oswestry Score mean 4; range, 0–16), whereas 6 former patients (of whom 3 were classified as Frankel D at baseline) reported moderate or severe disability (Oswestry Score mean 39; range, 26–54). Six former patients were classified as Frankel D, and the rest as Frankel E. Local kyphosis had increased by a mean of 3° (p<.05), whereas the discs adjacent to the fractured vertebrae remained unchanged in height during the follow-up. Conclusions Nonoperatively treated burst fractures of the thoracic or lumbar spine in adults with or without minor neurological deficits have a predominantly favorable long-term outcome, and there seems to be no increased risk for subsequent disc height reduction in the adjacent discs.