Treatment Of Thoracolumbar Burst Fractures Research Articles

Bi-Pedicle Fixation of Affected Vertebra in Thoracolumbar Burst Fracture.

Burst fractures of the spine account for 14% of all spinal injuries and more than 50% of all thoracolumbar trauma. However, there is ambiguity while choosing the right treatment plan. Short Segment Pedicle screw Fixation (SSPF) has become an increasingly popular method of treatment of thoracolumbar burst fractures, providing the advantage of incorporating fewer motion segments in the fixation. Various biomechanical studies showed that the use of pedicle screws could achieve stable construct within short-segment fixation. To evaluate the efficacy of SSPF using longest possible screws in both pedicles of fractured vertebra. A retrospective chart review of 25 single burst thoracolumbar fracture patients, operated between May 2009 to 2015 in a tertiary care trauma center, was conducted. Preoperative and post-operative plain radiographs were evaluated for kyphotic angulations using the traditional Cobb method. Anterior Vertebral Height (AVH), Posteriors Vertebral Height (PVH) were measured preoperatively and immediate postoperatively. Average percentage loss of AVH and mid-sagittal height were calculated on preoperative and postoperative X-rays on follow up. Fourteen men and 11 women with an average age of 42.92 years comprised the study population. Mean age at the time of operation was 34.5±14.2 years. Mean operation time was 168±72 (minutes). Average hospitalization time was 9±7 (days). Mean blood loss was 515±485 (ml). There were two cases of postoperative infection and implant failure each. A mean of 15.2° of kyphosis correction was attained from pre-operation to post-operation (p<0.0001). Although, there was a 15° average improvement of kyphosis post-fixation, loss of correction over time was nearly 8°, resulting in a 7° mean correction of kyphosis. A mean loss of AVH on postoperative radiograph was 6.12% and maintained 12.4% at the time of review (p<0.001). Similarly, there was 32.8% mid-sagittal height loss at time of injury, which was improved to only 12.6% as compare to initial height loss (p<0.0001). In this study, we propose SSPF using longest possible screws in both pedicle of fractured vertebra. Bi-pedicular fixation gives significant radiological corrections.

Comparison of posterior 1/3 corpectomy reconstruction versus subtotal corpectomy reconstruction for thoracolumbar burst fractures

Objective To compare posterior 1/3 corpectomy versus subtotal corpectomy in recon-struction of thoracolumbar burst fractures. Methods A prospective study was conducted in the patients who were admitted into our department for treatment of thoracolumbar burst fracture between January 2010 and December 2012. Eligible patients were randomized into an experimental group (28 cases) and a control group (34 cases). The experimental group accepted posterior 1/3 corpectomy followed by reconstruction of the in-jured vertebrae using our self-designed gate-like cage while the control group subtotal corpectomy followed by cylinder mesh cage reconstruction. Surgery time, intraoperative blood loss, neurological function improvement according to American Spinal Injury Association (ASIA) grading, visual analogue scale (VAS) score, verte-bral height, kyphosis angle and fusion time were recorded before surgery, after surgery and at the final fol-low-up in both groups. Vertebral height loss was measured to evaluate endplate subsidence at the final fol-low-up. Results All the patients were available for 24-month follow-up. All the incisions healed by one intention, and no incision infection, aggravation of neural impairment symptoms or implant breakage oc-curred. The experimental group achieved significantly less surgery time and blood loss, significantly better fusion rates at 3, 6, and 9 months after surgery, and significantly lower VAS score at the final follow-up than the control group(P 0.05), but the VAS score and vertebral height loss were significantly lower in the experimental group than in the control group(P 0.05). Conclusions Posterior 1/3 corpectomy followed by gate-like cage reconstruction is an innovative technique for thoracolumbar fractures which can promote early fusion and reduce endplate subsidence. It is as fine as traditional subtotal corpectomy plus cylinder cage reconstruction in neurological function improvement and kyphosis correction. Key words: Thoracic vertebrae; Lumber vertebrae; Fracture fixation, internal; Posterior 1/3 corpectomy and reconstruction

Comparison of short-segment pedicle fixation with versus without inclusion of the fracture level in the treatment of mild thoracolumbar burst fractures

BackgroundA review of the literature showed that posterior short-segment fixation including the fractured vertebra (PSFFV) has better outcomes in the treatment of thoracolumbar burst fractures(TBFs) than patients with short-segment pedicle screw fixation(SSPF) alone. However, its efficacy in mild TBFs with load-sharing scores of 3 and 4 points has not been specifically analyzed. The aim of this study was to compare the clinical, functional and radiologic results of PSFFV with SSPF for mild TBFs and to determine whether the screws in the fractured vetebra were necessary for these patients. MethodsIn this retrospective study, sixty-nine patients with mild TBFs were divided into 2 groups according to the number of instrumented levels. Group A included 34 patients treated by SSPF (four screws:one level above and below the fracture), and Group B included 35 patients treated by PSFFV (six screws: including the fractured vertebra). Clinical and radiologic parameters were evaluated before surgery, after surgery, and at follow-up. They included clinical outcomes: visual analog scale (VAS), Oswestry Disability Index (ODI). Being a radiology-based study, the radiologic measures included vertebral wedge angle (VWA), and anterior vertebral height (AVH). ResultsA sum of 69 patients (34 patients in Group A and 35 patients in Group B) were enrolled in the study. The patients in both the groups showed similar outcomes with regards to age, gender, fracture type and site. We did not find any statistically difference between the two groups in corrected rate of VWA or AVH (P > 0.05). In terms of clinical variants such as VAS and ODI scores, there were also no significant differences. However, the SSPF had advantages over PSFFV method in operative time, blood loss, postoperative drainage and postoperative hospitalization time (P > 0.05). There were no serious complications occurring during our study, such as infection, blood vessel injury, spinal cord or nerve root injury. No patient needed revision for loss of correction or failure of instrumentation. ConclusionsSSPF alone is a safe and effective surgical method for restoration and maintenance of vertebral column stability in treating mild TBFs. It gives excellent clinical and radiological results regardless of whether the fractured vertebra is included in the fixation or not.

Minimally invasive pedicle screw fixation combined with percutaneous vertebroplasty for the treatment of thoracolumbar burst fracture

IntroductionTo evaluate the feasibility, efficacy and safety of minimally invasive pedicle screw fixation (MIPS) combined with percutaneous vertebroplasty (PVP) using calcium phosphate for the treatment of thoracolumbar burst fracture without neurologic deficits. MethodsBetween September 2011 and April 2013, a total of thirty-seven patients with a mean age of 50.73 years (range 40–63 years), who suffered from thoracic or lumbar burst fracture without neurologic deficits underwent the procedure of MIPS combined with PVP using calcium phosphate. The preoperative and postoperative pain assessment were evaluated using Visual Analogue Scale (VAS) and American Spinal Injury Association (ASIA). The Cobb angles and central and anterior columns height were measured on the lateral radiographs before surgery and immediately, 1 month, 3 months, 6 months, 1 year and 2 years after surgery. ResultsThe patients were followed up for an average of 27.54 ± 2.47 months. The mean VAS significantly decreased from 9 (range 6–10) before surgery 2 (range 1–3) immediately after surgery and 1 (range 0–2) at 2-year follow-up. The Cobb angle was 22.58 ± 1.70° before surgery and 4.11 ± 1.41° immediately after surgery and 5.06 ± 1.11° at 2-year follow-up. The central and anterior vertebral body height decreased from 44.10 ± 7.0% and 49.76 ± 6.43% before surgery to 80.09 ± 4.05% and 93.31 ± 1.87% immediately after surgery, respectively. No significant changes in vertebral body height restoration were observed during 2 years follow-up after surgery. In addition, there were no instrumentation failure and complications in all patients. ConclusionsOur study indicated that MIPS combined with PVP using calcium phosphate is a good choice for the treatment of thoracolumbar burst fracture without neurologic deficits.

Indirect spinal canal decompression in adult patients with thoracolumbar burst fracture

Today pedicle screw instrumentation system and short-segment fixation have been commonly used for treatment of thoracolumbar burst fractures because pedicle screw fixation allows 3-column fixation and facilitates simultaneous application of axial compression or distraction and rotational forces. Indirect decompres-sion and direct decompression are the two ways to deal with canal compromise when pedicle screw instrumentation is used. Indirect decompression is achieved to correct the canal compromise due to ligamentotaxis and hyperex-tension. The present study reviews the current research on indirect spinal canal decompression in adult patients with thoracolumbar burst fracture. Key words: Thoracic vertebrae; Lumber vertebrae; Fractures, bone; Adult; Decompression

Treatment for thoracolumbar spinal burst fracture in youth and middle-aged adults by bone cement filling

To verify whether the procedure of posterior instrumentation and vertebroplasty for treatment of thoracolumbar burst fracture in youth and middle-aged patients is safe, practical and effective in short- and long-term. A total of 50 patients aged 30-55 years old who suffered from thoracolumbar burst fracture complicated with incomplete paralysis or without neurologic symptom received surgery by using pedicle-screw implantation, reduction and bone cement filling through the unilateral or bilateral pedicles. The bone cement injection was conducted slowly and cautiously under monitor of fluoroscopy. Spinal canal exploration or decompression was performed regularly in follow-ups by X-ray films and CT scans. Cement leakage occurred in 5 cases without relevant symptom, including 1 case with leak from anterior aspect, 2 cases from lateral aspect, and 2 cases through ruptured end-plate into disc space. No spinal canal leakage or introvascular leakage was detected. The following-up duration was 5 to 10 years. There was no vertebral body height loss and regional kyphosis. The gaps within fractured vertebral body prior to surgery were disappeared completely. There was also no cement-bone interface detected. In 15 out of 50 cases, there were newly-formed bone bridges between fractured vertebral body and upper or lower adjacent vertebral body. There was no hardware failure occurred up to final follow-up. Bone cement filling combined with posterior instrumentation through pedicle-screw technique is a safe, practical and effective method for treatment of non-osteoporotic thoracolumbar spinal burst fractures without severe neurologic injury. The gaps among fracture fragments can be filled evenly and completely. Therefore, instant and permanent spinal stability can be achieved with excellent long-term result.

Posterior Fixation with Unilateral Same Segment Pedicle Fixation and Contralateral Hook in Surgical Treatment of Thoracolumbar Burst Fractures

Background: In surgical treatment of thoracolumbar burst fractures, most authors try to lower the number of vertebrae involved during the surgery. Objectives: The aim of this study was to evaluate the outcome of a medium-segment posterior spinal fixation in these patients. Patients and Methods: We retrospectively reviewed 27 patients (18 male, 9 female) with mean age of 39.4 ± 15.0 years old in a before-and-after study. The mean follow-up period was 38.4 ± 15.6 months. We involved 2 intact above vertebrae and one intact below vertebra, inserting a pedicular screw at the fractured level and supplemented the construct with contralateral infralaminar hook. Clinical and radiologic characteristics were assessed with American spinal injury association (ASIA) scale, oswestry disability index (ODI), visual analogue scale (VAS), and plain radiography. Data analysis was carried out by SPSS version 11.5 software. Results: Mean post traumatic kyphosis was + 15.7° ± 3.3° that was changed to - 8.5° ± 4.3° and +1° ± 4.4° at immediate and last visit after surgery, respectively. Mean loss of correction (LOC) was 9.5° ± 1.9° (P < 0.001). At the most recent follow-up visit, mean ODI and VAS were 15.0 ± 14.4 and 2.4 ± 2.5, respectively and 24 cases (88.9%) declared excellent or good clinical results. At the last follow-up visit, LOC had no significant correlation neither with VAS nor ODI. Conclusions: In surgical treatment of thoracolumbar burst fractures, a medium-segment posterior spinal fixation, although cannot maintain the radiologic reduction of the fractured vertebrae efficiently, is not only associated with acceptable clinical outcome but also spare one lower intact lumbar segment and therefore recommended.

THORACOLUMBAR BURST FRACTURES, SHORT X LONG FIXATION: A META-ANALYSIS

ABSTRACT The number of fixed segments in the surgical treatment of thoracolumbar burst fractures remains controversial. This study aims to compare the results of short and long fixation in thoracolumbar burst fractures through a meta-analysis of studies published recently. MEDLINE and Cochrane databases were used. Randomized controlled trials and non-randomized comparative studies (prospective and retrospective) were selected. Data were analyzed with the software Review Manager. There was no statistically significant difference in the Cobb angle of preoperative kyphosis. Long fixation showed lower average measurements postoperatively (MD = 1.41; CI = 0.73-2.08; p&lt;0.0001) and in the last follow-up (MD = 3.98; CI = 3.22-4.75; p&lt;0.00001). The short fixation showed the highest failure rates (RD = 4.03; CI = 1.33-12.16; p=0.01) and increased loss of height of the vertebral body (MD = 1.24; CI = 0.49-1.98; p=0.001), with shorter operative time (MD = -24.54; CI = -30.16 - -18.91; p&lt;0.00001). There was no significant difference in blood loss and clinical outcomes. The high rates of kyphosis correction loss with short fixation and the lower correction rate in the immediate postoperative period were validated. There was no significant difference in the blood loss rates because arthrodesis was performed in a short segment in the analyzed studies. The short fixation was performed in a shorter operative time, as expected. No study has shown superior clinical outcomes. The short fixation had worse rates of kyphosis correction in the immediate postoperative period, and increased loss of correction in long-term follow-up, making the long fixation an effective option in the management of this type of fracture.

Nonoperative Management in Neurologically Intact Thoracolumbar Burst Fractures: Clinical and Radiographic Outcomes.

Retrospective cohort study. The identification of factors that lead to the failure of nonoperative management in neurologically intact thoracolumbar burst fractures. The treatment of thoracolumbar burst fractures (TLBF) can be controversial, particularly in the neurologically intact. Surgery for intact burst fractures has been advocated for early mobilization and a shorter hospital stay. These goals, however, have not always been achieved, rejuvenating an interest in nonoperative treatment. Sixty-eight neurologically intact patients with burst fractures of the thoracolumbar junction (T11-L2), and a thoracolumbar injury classification and severity score (TLICS) of 2, were treated at our institution. Based on CT scans, patients were scored based on the load-sharing classification (LSC) scale. Initial treatment consisted of bracing in clamshell thoracolumbar orthosis and gradual mobilization. Owing to pain limiting mobilization, 18 patients failed nonoperative management and required instrumentation. Those who failed nonsurgical management were significantly more kyphotic (8° ± 10) and stenotic (52% ± 14%) than those successfully treated nonoperatively (3° ± 7 and 63 ± 12%, respectively). The LSC score of those undergoing surgery (6.9 ± 1.1) was also greater than those successfully treated nonoperatively (5.8 ± 1.3, P = 0.006). Length of hospitalization was longer, and hospital charges higher in those requiring surgery compared to the nonoperative group. At follow-up there was no difference between groups in the visual analog score for pain (VAS) or the Oswestry disability index. Owing to pain limiting mobilization, a quarter of neurologically intact patients with thoracolumbar burst fractures and a TLICS score of 2 failed nonsurgical management. The greater the kyphosis, stenosis, and fragmentation of the fracture, the more likely patients required surgery. In addition to the TLICS classification, other radiographic and clinical parameters should be included in selecting appropriate treatment strategy. The cost savings with nonoperative treatment of intact burst fractures, when appropriate, are significant.

Implications of spine fixation on the adjacent lumbar levels for surgical treatment of thoracolumbar burst fractures: a finite element analysis

Implications of spine fixation on the adjacent lumbar levels for surgical treatment of thoracolumbar burst fractures: a finite element analysis

Inclusion of the fracture level in short-segment fixation of unstable traumatic thoracolumbar spine fractures

Introduction The diagnosis, classifications, and treatment of injuries of the thoracolumbar spine continue to attract controversy. Objective The present study evaluated the efficacy of treatment of unstable thoracolumbar burst fractures by transpedicular screw fixation including the fractured vertebra. Patients and methods From January 2013 to March 2015, 40 patients with thoracolumbar burst fracture underwent posterior pedicle screw fixation consecutively in Al-Azhar University Hospital, Damietta. Results Forty (25 male and 15 female) patients with age ranging between 16 and 66 years (mean 41.8%) were operated upon by posterior transpedicular screw fixation. According to the American Spinal Injury Association scoring system, all patients were grade E. The mean of kyphotic deformities measured preoperatively was 18.4±5.5° and after 12 months of follow-up it was 9.0±4.1°. Conclusion By applying the transpedicular screw fixation of the unstable fractures of the thoracolumbar spine, a stable fracture fixation can be achieved; this kind of fixation prevents secondary spine deformities.

Balloon vertebroplasty reinforced by injectable calcium sulfate cement versus posterolateral fusion for treatment of thoracolumbar burst fractures

Objective To compare the clinical curative effects of balloon vertebroplasty reinforced by injectable calcium sulfate cement (CSC) and posterolateral fusion after short-segment pedicle screw fixation through the fractured vertebra in treatment of thoracolumbar burst fractures. Methods From June 2011 to December 2013, 44 patients with single thoracolumbar burst fracture were admitted by our department. They were 30 men and 14 women, from 20 to 60 years of age (average, 42.5 years). Of them, 22 were treated by short-segment pedicle screw fixation through the fractured vertebra followed by transpedicular balloon reduction of the endplate and CSC injection (PKP group), the others underwent posterolateral fusion in addition to short-segment pedicle screw fixation through the fractured vertebra (fusion group) . The 2 groups were compared at preoperation, one week postoperation and the last follow-up in terms of visual analogue scale (VAS), Oswestry disability index (ODI), anterior height ratio of the injured vertebra, middle height ratio of the injured vertebra, the vertebral wedge angle and the sagittal cobb angle. Results The patients were followed up for an average of 24 months (range, from 18 to 46 months) . All the measure indexes at one week postoperation and the last follow-up were significantly improved than those at preoperation in all the patients (P 0.05). There was no significant between-group difference in the VAS score or ODI at either one week postoperation or the last follow-up (P > 0.05). At one week postoperation, the middle height ratio of the injured vertebra and the vertebral wedge angle in the PKP group were significantly better than in the fusion group ( P < 0.05). At the last follow-up, the PKP group showed a significantly less loss than the fusion group regarding the corrections of anterior height ratio of the injured vertebra, middle height ratio of the injured vertebra, the vertebral wedge angle and the sagittal cobb angle (P < 0.05). Conclusions In treatment of thoracolumbar burst fractures, compared with posterolateral fusion, balloon vertebroplasty reinforced by injectable CSC can better restore the shape of injured vertebral body and stability of the anterior and middle columns in the early period, and can also reduce losses of corrections. Key words: Spinal fractures; Fracture fixation, internal; Calcium sulfate; Cement

Posterior pedicle screw fixation followed by anterior decompression and fusion for the treatment of thoracolumbar burst fractures

Objective To investigate the clinical effect of posterior pedicle screw fixation combined with anterior decompression and fusion for the treatment of thoracolumbar burst fractures. Methods The clinical data of 53 patients underwent posterior pedicle screw fixation and anterior decompression and fusion were retrospectively analyzed.The vertebral height, Cobb angle, vertebral tube volume, the Frankel gradient and Fugl-Meyer score were recorded and compared before and after treatment. Results 49 patients were followed up.At the last time of follow-up, the vertebral height, Cobb angle, vertebral tube volume all significantly improved (t=24.047, P<0.001; t=21.815, P<0.001; t=31.699, P<0.001). The Frankel gradient before treatment was: A 6 cases, B 18 cases, C 15 cases, D 10 cases, E 4 cases.After treatment, it came to 3 cases, 8 cases, 11 cases, 17 cases, 10 cases, respectively.There was significant difference before and after treatment (Z=2.997, P=0.003). There was significant difference in Fugl-Meyer score before and after treatment[(74.65±8.42)points, (90.26±9.17)points, respectively, P<0.001]. Conclusion There is excellent effect on posterior pedicle screw fixation followed by anterior decompression and fusion for the treatment of thoracolumbar burst fractures.It is good for the recovery of motion and spinal function. Key words: Spinal fractures; Fracture fixation; Decompression, surgery

Curative effect of surgical treatment on thoracolumbar burst fracture complicated with incomplete spinal cord injury

Objective To investigate the timing and methods in surgical treatment of thoracolumbar burst fracture complicated with incomplete spinal cord injury. Methods A retrospective analysis was conducted on 52 patients who had surgical treatment for thoracolumbar burst fracture complicated with incomplete spinal cord injury from February 2011 to March 2014. The patients comprised 45 males and 7 females, at mean 41.8 years of age (range, 19-67 years). Multiple trauma was noted in 29 patients. Mean injury severity score (ISS) was 23 points (range, 16-50 points). There were altogether 61 fractured segments including 2 T11, 10 T12, 29 L1 and 20 L2. Ten patients suffered from bi-segmental lesions and 2 tri-segmental lesions. American Spinal Injury Association (ASIA) scale was B in 16 patients, C in 15 and D in 21. Two patients underwent anterior spinal decompression and fusion, and the remaining patients were treated by posterior reduction, decompression, interbody fusion and pedicle screw fixation. ASIA scale, sense or motion score, spinal stenosis and Cobb angle were recorded and their correlation with different operation time was evaluated. Results All patients were followed up for 13-50 months[(32.8±10.4) months]. ASIA scale (3 grade B, 14 grade C, 16 grade D and 19 grade E) and sense or motion score presented some improvements after operation, with the results much better in patients operated within 1-3 d after injury than those operated 4-7 d and 9-22 d after injury (P<0.05 or 0.01). Operation within 4-7 d postinjury exhibited no apparent improvements in spinal stenosis and Cobb angle, but the result was still better than that when operation was done 9-22 days postinjury (P<0.05). Conclusions Thoracolumbar burst fracture complicated with incomplete spinal cord injury should adopt active operation treatment within 3 days postinjury as soon as possible. The time of decompression and deformity correction should not be over 1 week postinjury. Early operation of posterior spinal decompression and fusion appears to have good effects. Key words: Spinal fractures; Thoracic vertebra; Lumbar vertebra; Spinal cord injuries; Decompression

Comparison of three different surgical approaches for treatment of thoracolumbar burst fracture

ObjectiveThe main treatment method used for thoracolumbar fractures is open reduction and internal fixation. Commonly there are three surgical approaches: anterior posterior and paraspinal. We attempt to compare the three approaches based on our clinical data analysis MethodsA group of 94 patients with Denis type A or B thoracolumbar burst fracture between March 2008 and September 2010 were recruited in this study. These patients were treated by anterior-, posterior- or paraspinal-approach reduction with or without decompression. The fracture was fixed with titanium mesh and Z-plate via anterior approach (24 patients), screw and rod system via posterior approach (38 patients) or paraspinal approach (32 patients). Clinical evaluations included operation duration, blood loss, incision length, preoperative and postoperative Oswestry disability index (ODI). ResultsThe average operation duration (94.1min±13.7min), blood loss (86.7ml±20.0ml), length of incision (9.3mm± 0.7mm) and postoperative ODI (6±0.5) were significantly lower (P<0.05) in paraspinal approach group than in traditional posterior approach group (operation duration 94.1min±13.7min, blood loss 143.3ml±28.3ml, length of incision 15.4cm±2.1cm and ODI 12±0.7) and anterior approach group (operation duration 176.3min±20.7min, blood loss 255.1ml±38.4ml, length of incision 18.6cm±2.4cm and ODI 13±2.4). There was not statistical difference in terms of Cobb angle on radiographs among the three approaches. ConclusionThe anterior approach surgery is convenient for resection of the vertebrae and reconstruction of vertebral height, but it is more complicated and traumatic. Hence it is mostly used for severe Denis type B fracture. The posterior approach is commonly applied to most thoracolumbar fractures and has fewer complications compared with the anterior approach, but it has some shortcomings as well. The paraspinal approach has great advantages compared with the other two approaches. It is in accordance with the concept of minimally invasive surgery and can replace most posterior approach operations.

Is there a regional difference in morphology interpretation of A3 and A4 fractures among different cultures?

OBJECT The aim of this study was to determine if the ability of a surgeon to correctly classify A3 (burst fractures with a single endplate involved) and A4 (burst fractures with both endplates involved) fractures is affected by either the region or the experience of the surgeon. METHODS A survey was sent to 100 AOSpine members from all 6 AO regions of the world (North America, South America, Europe, Africa, Asia, and the Middle East) who had no prior knowledge of the new AOSpine Thoracolumbar Spine Injury Classification System. Respondents were asked to classify 25 cases, including 6 thoracolumbar burst fractures (A3 or A4). This study focuses on the effect of region and experience on surgeons' ability to properly classify these 2 controversial fracture variants. RESULTS All 100 surveyed surgeons completed the survey, and no significant regional (p > 0.50) or experiential (p > 0.21) variability in the ability to correctly classify burst fractures was identified; however, surgeons from all regions and with all levels of experience were more likely to correctly classify A3 fractures than A4 fractures (p < 0.01). Further analysis demonstrated that no region predisposed surgeons to increasing their assessment of severity of burst fractures. CONCLUSIONS A3 and A4 fractures are the most difficult 2 fractures to correctly classify, but this is not affected by the region or experience of the surgeon; therefore, regional variations in the treatment of thoracolumbar burst fractures (A3 and A4) is not due to differing radiographic interpretation of the fractures.

Relationship between fracture-relevant parameters of thoracolumbar burst fractures and the reduction of intra-canal fracture fragment.

ObjectivePosterior longitudinal ligament reduction (PLLR) has been widely used for treatment of thoracolumbar burst fractures. However, there are no systemic studies assessing the influence of position parameters of intra-canal fracture fragment (IFF) itself on outcome of reduction. The aim of this study was to analyze the relationship between position parameters of IFF and the reduction efficacy of PLLR.MethodsSixty-two patients (average age, 36.9 years) with single thoracolumbar burst fractures and intact posterior longitudinal ligaments were recruited. Patients were divided into reduced and unreduced groups based on IFF reduction situations by PLLR. Preoperative and intraoperative computed tomography (CT) were used to evaluate reduction and location parameters of IFF, such as position, width, height, inversion, and horizontal angle, ratio of width of IFF to the transverse diameter of vertebral canal (R1), and ratio of height of IFF to height of injured vertebrae (R2) before and after PLLR.ResultsThere were significant differences in width (P < 0.001), height (P = 0.0141; R1, P < 0.001), and R2 (P = 0.0045) between the two groups. When width of IFF was more than 75 % of transverse diameter of vertebral canal and height of IFF was more than 47 % of height of injured vertebrae, the IFF could not be reduced by PLLR.ConclusionsIn patients with thoracolumbar burst fractures, IFF in apterium of the posterior longitudinal ligament cannot be reduced by PLLR. For thoracolumbar burst fractures that cover the posterior longitudinal ligament, the width and height of IFF are important parameters that influence reduction quality.

Treatment with or without an Orthosis is Equivalent for Thoracolumbar Burst Fracture without Neurologic Injury.

Bailey CS, Urquhart JC, Dvorak MF, Nadeau M, Boyd MC, Thomas KC, Kwon BK, Gurr KR, Bailey SI, Fisher CG. Orthosis Versus No Orthosis for the Treatment of Thoracolumbar Burst Fractures without Neurologic Injury: A Multicenter Prospective Randomized Equivalence Trial. Spine J. 2014 Nov 1;14(11):2557-64. ### Question: In patients with a burst fracture of the thoracolumbar spine, is treatment with a thoracolumbosacral orthosis (TLSO) equivalent to treatment without a TLSO? ### Design: Randomized (allocation concealed), blinded (outcome assessors), controlled trial with 24 months of follow-up. ### Setting: 3 Canadian tertiary spine centers. ### Patients: 96 neurologically intact patients who were 16 to 60 years of age (mean age, 40 years; 70% men) and had sustained, within the past 3 days, an isolated AO-A3 burst fracture between T10 and L3 with a kyphotic deformity of <35°. Exclusion criteria included the inability to wear a brace, mobilization with or without a brace before recruitment, pathologic or open fracture, drug or alcohol dependence, and previous injury or surgery to the thoracolumbar region. Data were available for 92 patients (96%) for measurement of the primary outcome at 3 months; the rate of follow-up was 71% at 24 months. ### Intervention: Patients were allocated to treatment with (n = 47) or without (n = 49) a …

Risk Factors for the Failure of Spinal Burst Fractures Treated Conservatively According to the Thoracolumbar Injury Classification and Severity Score (TLICS): A Retrospective Cohort Trial.

BackgroundThe management of thoracolumbar (TL) burst fractures is still controversial. The thoracolumbar injury classification and severity score (TLICS) algorithm is now widely used to guide clinical decision making, however, in clinical practice, we come to realize that TLICS also has its limitations for treating patients with total scores less than 4, for which conservative treatment may not be optimal in all cases.PurposeThe aim of this study is to identify several risk factors for the failure of conservative treatment of TL burst fractures according to TLICS algorithm.MethodsFrom June 2008 to December 2013, a cohort of 129 patients with T10-l2 TL burst fractures with a TLISC score ≤3 treated non-operatively were identified and included into this retrospective study. Age, sex, pain intensity, interpedicular distance (IPD), canal compromise, loss of vertebral body height and kyphotic angle (KA) were selected as potential risk factors and compared between the non-operative success group and the non-operative failure group.ResultsOne hundred and four patients successfully completed non-operative treatment, the other 25 patients were converted to surgical treatment because of persistent local back pain or progressive neurological deficits during follow-up. Our results showed that age, visual analogue scale (VAS) score and IPD, KA were significantly different between the two groups. Furthermore, regression analysis indicated that VAS score and IPD could be considered as significant predictors for the failure of conservative treatment.ConclusionThe recommendation of non-operative treatment for TLICS score ≤3 has limitations in some patients, and VAS score and IPD could be considered as risk factors for the failure of conservative treatment. Thus, conservative treatment should be decided with caution in patients with greater VAS scores or IPD. If non-operative management is decided, a close follow-up is necessary.

Application of titanium plate reconstruction in laminoplasty during the thoracolumbar burst fractures

Objective To investigate the application value of using reconstruction of the posterior wall of vertebral canal with titantium plate and bone grafting in the thoracolumbar burst fracture surgery. Methods Twenty-seven patients with thoracolumbar burst fracture with spinal cord injury were treated with posterior pedicle screw fixation+ holo-laminectomy+ titanium plate bending for reconstruction of posterior expansive laminoplasty, and the depressurized lamina process was trimmed into bone grains and were mixed with allogeneic bone for bone grafting along the titanium plate surface. The kyphotic Cobb angle, bone graft fusion, and neurological recovery were of the patients were assessed after procedure. Results The postoperative CT and MRI findings in 27 patients suggested that the vertebral canal volume recovered well, the spinal cord compression relieve was satisfactory. The neurological function of 16 patients was improved during the hospitalization. All patients were followed up after discharge. They were followed up for 12 to 30 months (mean 17.8 months). Their final neurological function was improved in 21 patients compare with before procedure (ASIA grade: type A 3 cases, type B 6 cases, type C 8 cases, and type D 10 cases), and 14 of them recovered completely, 7 recovered partially, and 6 did not have any changes (ASIA grade: type A 3 cases, type B 3 cases, type C 3 cases, type D 4 cases, and type E 14 cases). The function improvement rate of the patients was 78% (21/27) after procedure. No symptoms of delayed spinal cord compression were observed during the follow up period. The internal fixation screw rods of 9 patients were removed from 13 to 21 months after procedure because of their personal reasons, but the forming titantium plates were reserved. All patients did not have the phenomena including increased kyphosis angle, titantium plate shift, deformation, and decreased vertebral canal volume. The bone grafting fusion rate was 100%. No spine instability was observed. There was no significant differences in the lost degrees of kyphosis angle and the height change ratio of the injured vertebrae (P>0.05). Conclusions Using titanium plate for laminoplasty and bone grafting are simple, safe and reliable after surgical reduction decompression and fixation in the treatment of thoracolumbar burst fractures with spinal cord injury. It is conducive to maintaining the integrity and stability of spines. The recovery of spinal cord function is satisfactory. Key words: Titanium plate; Thoracolumbar fracture; Fracture