Treatment Of Unstable Thoracolumbar Fractures Research Articles

Long-Segment Versus Short-Segment Pedicle Screw Fixation Including Fractured Vertebrae for the Management of Unstable Thoracolumbar Burst Fractures.

Background For the treatment of unstable thoracolumbar fractures, this study compared the results of short-segment fixation with fracture level inclusion (SSFIFL) with long-segment pedicle fixation (LSPF). Methodology In this prospective case series study conducted from January 2015 to January 2019, 80 patients with partial spinal cord lesions were investigated. For the comparison, two groups of 40 patients each were chosen and treated with SSFIFL and LSPF. The outcomes were measured using pre and postoperative radiological parameters and clinical parameters. The radiographic variables included the kyphotic angle with loss of correction, kyphotic deformation, and the Beck index. Mean blood loss, operative time, and cost-effectiveness were also examined for clinical indicators such as the American Spinal Injury Association Impairment Scale, Visual Analog Scale (VAS), and Oswestry Disability Index (ODI). Results There were no substantial variations between the groups regarding age or gender, trauma etiology, fracture level, or fracture pattern. Between the two categories, there appeared to be no notable change in radiological indicators such as kyphotic angle, kyphotic deformation, and Beck index at the end of follow-up (p = 0.120, 0.360, and 0.776, respectively). Both groups had similar neurological outcomes (p = 0.781). In terms of ODI and VAS, statistically, there was no discernible difference (p = 0.567 and 0.161, respectively). In this study, however, there was less surgical time, blood loss, and implant cost (p = 0.05). Conclusions When fracture level is included in a short-segment fixation, the radiological and clinical results are comparable to long-segment posterior fixation. Ultimately, this treatment has proven to be not only a motion segment-saving procedure but also cost-effective.

Analysis of a Hybrid Spine Fixation Approach for the Treatment of Unstable Thoracolumbar Fractures.

Introduction The treatment of unstable thoracolumbar burst fractures and fracture dislocations of the thoracolumbar spine remains ever evolving. Anterior or posterior approaches both have equal efficacy, but the posterior approach has been preferred in our study due to its ease of application, less extensile nature, and reduced intra-operative bleeding. Posterior approaches can employ short-segment fixation or long-segment fixation techniques. Long segment fixation may need implant removal later to increase mobility in nonfusion surgeries. The thoracolumbar segment is a transition zone where the thoracic spine is a less flexible zone, and the lumbar spine is a more flexible zone. Lumbar motion is important to preserve. Hence, we proposed to study spinal fixation two levels above and one level below the fracture for stabilization. This may provide increased stability along with preservation of the motion segment at the lumbar level. Methods We retro-prospectively reviewed the results ofunstable thoracolumbar junction fractures with incomplete or intact neurology in 34 consecutive cases operated with alternate two above and one below fixation approach between June 2018 and June 2019 at our institute. Five cases were excluded due to incomplete follow up and the remaining 29 patients were included in the study. Regular follow-up in the postoperative period at three, six, and 12 months was conducted. Data analysis was done by SPSS software version 22 (IBM Corp., Armonk, NY). Results Twenty-nine patients were included in the study out of which 16 were males and 13 were females. The average age was 36.31±1.46 years (range, 14-60 years). The average follow-up duration was 14.31 months. The average injury to surgery interval was 7.17±7.31 days (range, 1-30 days). On analysis via paired t-test, pre-operative kyphotic angle (mean=20.06±8.34º) improved to immediate post-operative (mean=8.44±5.76º, p=0.0001). The postoperative kyphotic angle at 12 months follow-up showed significant stability (Mean=14.13±5.27º, p=0.0001). A median average pre-operative neurological compromise was ASIA score C and Frankel Grade C and the median average disability was an ODI score of 61%-80%. At the end of 12 months of follow-up the median average neurological compromise improved to ASIA Score D and Frankel Grade D and the median average disability improved to an ODI score of 21%-40%. Conclusion Two levels above and one level below hybrid pedicle screw fixation with decompression for the treatment of unstable thoracolumbar fractures with partial and intact neurology was successful within the limited time frame we had for follow-up in preserving progressive post-operative kyphosis, preserving one-motion segment, improving the neurological outcome and disability of the patients without any major complications.

Wiltse Approach Versus Conventional Transforaminal Interbody Fusion for Unstable Thoracolumbar Fracture with Intervertebral Disc Lesions.

ObjectiveTo compare the clinical results of two surgical techniques, Wiltse approach and conventional transforaminal interbody fusion, for the treatment of unstable thoracolumbar fracture associated with traumatic intervertebral disc lesion (TIDL).MethodsA total of 76 patients with unstable thoracolumbar fracture associated with TIDL treated by posterior pedicle screw fixation and transforaminal thoracolumbar interbody fusion from June 2010 and July 2016 were reviewed retrospectively. These patients including 48 male and 28 female patients were divided into Wiltse approach transforaminal thoracolumbar interbody fusion (W‐TLIF) group (n = 38) and conventional transforaminal thoracolumbar interbody fusion (C‐TLIF) group (n = 38). Patients were followed up for about 33 months. Clinical and radiological records, kyphotic angle, fractured vertebral body height, visual analogue score (VAS), Oswestry Disability Index (ODI), complications, neurological improvement and fusion rate were compared between two groups.ResultsAll patients underwent posterior surgery successfully. Blood loss, operation time and hospital stay in the W‐TLIF group was 437.84 ± 143.98 ml, 118.64 ± 20.55 min and 12.32 ± 2.87 days, respectively. While those parameters in the C‐TLIF group was 862.70 ± 300.24 ml, 141.35 ± 31.72 min and 15.51 ± 2.08 days, respectively. Average operation time and hospital stay time were significantly shorter, and blood loss was significantly less in the W‐TLIF group than in the C‐TLIF group (P < 0.05). VAS and ODI in the W‐TLIF group were significantly less than those in the C‐TLIF group at 1 week after operation and final follow‐up. The kyphotic angle and vertebral body height were improved. There was 1–2 grade improvement in patients with neurological deficit. Thirty‐three patients in the W‐TLIF group and 32 patients in the C‐TLIF group had achieved fusion during follow‐up. No internal fixation failure was observed in two groups.ConclusionsThe both techniques of W‐TLIF and C‐TLIF were feasible and effective for unstable thoracolumbar fracture with TIDL. Compare to C‐TLIF, The technique of W‐TLIF was a relatively less invasive way to decompress the neural elements and an easy method to reconstruct the anterior column using the same posterior approach.

Novel Screw Insertion Method for Anterior Surgical Treatment of Unstable Thoracolumbar Fracture: Quadrant Positioning Method.

ObjectiveTo develop a novel screw positioning method to improve the treatment of unstable thoracolumbar fractures.MethodsA total of 72 patients with unstable thoracolumbar fractures who were treated with anterior screw–rod interfixation from January 2011 to October 2015 were included in this clinical study. Those patients included 48 male and 24 female patients with an average age of 45.10 years (range, 26–63 years). Patients were randomly divided into two groups: an observation group (n = 36) and a control group (n = 36). The quadrant positioning method was used for screw insertion in the observation group during the operation, while the traditional screw positioning method was used in the control group. The quadrant positioning method targeted four quadrants, including the superior anterior (SA), superior posterior (SP), inferior anterior (IA) and inferior posterior (IP) quadrants, while for the traditional screw positioning, four screws were inserted into the vertebral bodies above and below the excision. Patients were followed up for approximately 40 months to record recovery. Clinical and radiological records, local angle and fractured vertebra body height, clinical outcomes, complications, neurological improvement, and fusion rate were recorded and compared between the two groups.ResultsThe quadrant positioning method was successfully used for anterior screw insertion. The quadrant center in the lateral view of the vertebral body was well marked, and screws were easily located on the scheduled quadrant. Blood loss (BL), hospital stay (HS), and operation time (OP) in the observation group were 749.40 ± 379.90 mL, 17.10 ± 4.10 days, and 167.40 ± 44.70 min, respectively. While those parameters in the control group were 1198.40 ± 339.27 mL, 23.22 ± 3.77 days, and 221.47 ± 32.15 min, respectively. The average operation time and hospital stay time were significantly shorter, and blood loss was significantly less in the observation group than in the control group (P < 0.05). Local angle and vertebral body height were markedly improved and 1–2 grade improvement was achieved in patients with neurological deficits in both groups. Both groups of patients achieved bony fusion during follow‐up. No incision infection or internal fixation failure was observed in the two groups, and complications including cerebrospinal fluid and chylous leakage and hemothorax were resolved.ConclusionsThe quadrant positioning method can shorten operation time, reduce blood loss, and accelerate postoperative recovery. The technique provides an effective method for screw insertion for double screw–rod instrumentation fixation in the treatment of thoracolumbar fracture via the anterior approach.

Short-Segment Fixation With Percutaneous Pedicle Screws in the Treatment of Unstable Thoracolumbar Vertebral Body Fractures.

Clinical care of patients with unstable thoracolumbar vertebral body fractures may be challenging, especially in the setting of polytrauma patients who require other acute intervention. Compared with the traditional open approach, percutaneous short-segment fixation constructs place less surgical burden on patients regarding operative time and blood loss. Between 2008 and 2012, 32 patients with a mean age of 49 years (range, 19-80 years) underwent percutaneous short-segment fixation at the authors' institution and had a minimum of 6 months of complete clinical and radiographic follow-up. Load-sharing classification scores were determined. Outcomes evaluated included anterior body height, posterior body height, local kyphosis, regional kyphosis, thoracolumbar junctional kyphosis, mean operative time, and total blood loss. Standard binomial and categorical comparative analyses were performed. All load-sharing classification scores were 7 or less, and 11 of the 32 patients were polytrauma patients requiring surgery. No difference was seen between preoperative and late measurements of anterior body height, posterior body height, local kyphosis, regional kyphosis, or thoracolumbar junctional kyphosis. There were no complications, revisions, or anterior corpectomies. Only 2 patients (6%) underwent elective removal of hardware at 1 year. Mean operative time was 43 minutes (range, 33-56 minutes), and mean estimated blood loss was less than 50 mL. Percutaneous short-segment fixation prevented loss of vertebral body height and progression of kyphosis in the treatment of unstable thoracolumbar fractures with load-sharing classification scores of 7 or less. This study shows that these fractures with a load-sharing classification score of 6 and 7 may be stabilized using fewer screws than traditional methods in some patients and allow polytrauma patients to undergo other acute treatment. [Orthopedics. 2018; 41(6):e802-e806.].

Arthroscopic anatomical reconstruction of anterior talofibular ligament and calcaneofibular ligament for chronic ankle instability

Objective To compare the clinical efficacy of anteroposterior approach (APA) versus anterior approach (AA) for decompression, fusion and fixation for single-level unstable thoracolumbar vertebrae fractures concomitant with incomplete neurologic symptoms and injury to posterior ligament complex (PLC). Methods From February 2006 to June 2012, 55 patients were treated for single-level unstable thoracolumbar vertebrae fractures.Of them, 27 were treated by only anterior decompression and lateral screw-rod instrumentation and 28 by anterior decompression and fusion combined with open posterior pedicle fixation of one to two segments above and below the fracture position. The 2 groups were compared at post-operative 3 and 12 months in terms of visual analogue scale (VAS), overall score of short-form health survey (SF-36), Japanese Orthopaedics Association (JOA) score of lower back, Oswestry disability index (ODI), loss ratio of anterior margin of vertebral height, endplate angle of kyphotic deformity of superior-inferior adjacent vertebrae, wedge angle of fractured vertebra via radiographic measurement and canal compromise rate. The neurologic functional recovery was analyzed using the American Spine Injury Association (ASIA) evaluation system at postoperative 12 months. Results There were no significant differences in operative time, amount of blood loss or postoperative drainage between the 2 groups (P>0.05). At postoperative 3 months, the VAS and JOA scores in the APA group were significantly better than those in the AA group (P 0.05). All the comparative indexes were significantly improved than the preoperative values in all the patients in the 2 groups at both 3 and 12 months (P<0.05). Conclusions Compared with the merely anterior approach, the combined antero-posterior approach may have advantages of better immediate and persistent reduction, steadily rebuilding fractured alignment, continuously maintaining injured biomechanical stability, and obviously improving neurological function.As the antero-posterior approach allows for combination of posterior auxiliary reduction and fixation with anterior definitive support and decompression, it may lead to a safe and effective treatment of unstable single-level thoracolumbar fracture concomitant with incomplete neurologic and PLC impairments. Key words: Thoracic vertebrae; Lumbar vertebrae; Fracture, bone; Fracture fixation, internal; Surgical approach

Restoration of Anterior Vertebral Height by Short-Segment Pedicle Screw Fixation with Screwing of Fractured Vertebra for the Treatment of Unstable Thoracolumbar Fractures.

The treatment of unstable thoracolumbar fractures remains controversial. Long-segment pedicle screw constructs may be stiffer and impart greater forces on adjacent segments compared with short-segment constructs. Short-segment pedicle screw fixation alone may be associated with instrumentation failure. Reinforcement fractured vertebra by the placement of an additional 2 screws at fracture level may be useful in thoracolumbar fractures for restoration of anterior vertebral height. We retrospectively analyzed 35 patients (21 males, 14 females) with unstable thoracolumbar fractures. The patients were divided into 2 groups. In group I, patients were operated with posterior approach via the use of pedicle screws fixed long (2 levels above and 1 or 2 levels below of the fractured vertebra). In group II patients, short-segment stabilization with additional screwing at fracture level was made. Immediate postoperative radiologic evaluations were done by measuring the correction and maintenance of kyphotic angle at the fracture level, Cobb angle, and height of fractured vertebra. Average local kyphosis angle, anterior kyphotic angle at the fracture level, and Cobb angle were not statistically significantly different in the postoperative period (P > 0.05); however, postoperative anterior height of fractured vertebra was statistically significantly different between the 2 groups (P < 0.05). We compared a standard long-segment construct with a short-segment construct using instrumentation of the fractured segment. Short-segment pedicle screw fixation with screwing of fractured vertebra in unstable thoracolumbar fracture levels is an effective method to restoring anterior vertebral height for the treatment of unstable thoracolumbar fractures. It also provides anterior column support.

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.

Functional and radiological outcome of using long segment posterior pedicle screw constructs in unstable thoraco-lumbar fractures

Background: The treatment of unstable thoracolumbar fracture remains controversial. Various options exist, but which approach to be used and the number of levels to be instrumented still remains a matter of debate. In this study we assess the outcome of these fractures with long segment posterior pedicle constructs alone. Methods: Study comprising of 18 patients with unstable thoraco-lumbar fractures, was conducted with inclusion criteria a)age 18- 50 yrs, b)injury – surgery duration <3 weeks and exclusion criteria a)open fractures, b)pathological fractures, c)fractures dislocations, and d) pregnant and lactating females. All patients underwent posterior decompression and stabilization with long segment posterior instrumentation using 8 pedicle screws (2 above and 2 below). The average follow-up was 18.5 months. The outcomes were analysed in terms of functional quality of life measured by ODI (Oswestry Disability Index), kyphotic angle, anterior vertebral height, duration of surgery and blood loss. Results: Mean age of patients was 32.8 yrs with majority being males (14/18) and L1 was most common vertebra involved (10/18). Mean duration of surgery was 160 minutes (range 130–195) and average blood loss was 447 ml (range 290-550). Mean preoperative ODI score was 91.88% which improved to 14.42% at final follow up. Mean kyphotic angle improved from 20.22° preoperatively to 2° in immediate post operative period and was 6.1° at final follow up. The mean pre-operative anterior vertebral height was 53.21% which improved to 90.18% after surgery and was 82.08% at final follow-up. Conclusion: The authors recommend long segment posterior pedicle instrumentation alone for unstable thoraco-lumbar fractures as it has advantage of achieving better correction with maintenance of correction and decreased failure rates as compared to short segment posterior instrumentation and substantially less morbidity and complications as compared to anterior approach or combined anterior and posterior approach.

“Short Segment pedicle screw fixation for the treatment of unstable thoracolumbar fracture”- a study of 50 cases.

Introduction: Short segment pedicle screw fixation is a popular procedure for treating unstable thoracolumbar burst fracture. But due to lack of adequate neurological improvement, progressive kyphosis and hardware failure- the efficacy of different methods remain debatable.&#x0D; Method : 50 patients with isolated thoracolumbar burst fractures were treated by short segment pedicle screw fixation and transforaminal thoracolumbar inter body fusion (TLIF) between January 2010 to December 2013. All patients were followed up for a minimum 2 years. Demographic data, Neurological improvement (Frankel) grade and Hardware failure related complication were evaluated.&#x0D; Results: All patients recovered with solid bony fusion by inter vertebral bone graft and pedicle screw without complications like misplacement of screw, nerve or vessel lesion or hardware failure. The post-operative radiographic demonstration reveals- good fracture reduction and it was well maintained until the bone graft fusion. Neurological recovery of the one to three Frankel grade was seen in 42 patients with partial neurological deficit. Among the 30 patients 3 grade improvements was seen in 4 patients, 2 grade of improvement was observed in 20 patients and 1 grade of improvement was found in 18 patients. 3 patients with Franke-D on admission showed no improvement. 5 patients with no paraplegia/hemiplegia on admission remained neurological intact.&#x0D; Conclusion: Posterior short segment pedicle fixation in conjunction with TLIF seems to be a feasible option in the management of selected thoracolumbar burst fracture with good neurological improvement.&#x0D; Bangladesh Journal of Neuroscience 2015; Vol. 31 (1): 30-33

Treatment of unstable thoracolumbar fractures through short segment pedicle screw fixation techniques using pedicle fixation at the level of the fracture: a finite element analysis.

ObjectiveTo compare the von Mises stresses of the internal fixation devices among different short segment pedicle screw fixation techniques to treat thoracic 12 vertebral fractures, especially the mono-segment pedicle screw fixation and intermediate unilateral pedicle screw fixation techniques.MethodsFinite element methods were utilised to investigate the biomechanical comparison of the four posterior short segment pedicle screw fixation techniques (S4+2: traditional short-segment 4 pedicle screw fixation [SPSF]; M4+2: mono-segment pedicle screw fixation; I6+2: intermediate bilateral pedicle screw fixation; and I5+2: intermediate unilateral pedicle screw fixation).ResultsThe range of motion (ROM) in flexion, axial rotation, and lateral bending was the smallest in the I6+2 fixation model, followed by the I5+2 and S4+2 fixation models, but lateral bending was the largest in the M4+2 fixation model. The maximal stress of the upper pedicle screw is larger than the lower pedicle screw in S4+2 and M4+2. The largest maximal von Mises stress was observed in the upper pedicle screw in the S4+2 and M4+2 fixation models and in the lower pedicle screw in the I6+2 and I5+2 fixation models. The values of the largest maximal von Mises stress of the pedicle screws and rods during all states of motion were 263.1 MPa and 304.5 MPa in the S4+2 fixation model, 291.6 MPa and 340.5 MPa in the M4+2 fixation model, 182.9 MPa and 263.2 MPa in the I6+2 fixation model, and 269.3 MPa and 383.7 MPa in the I5+2 fixation model, respectively. Comparing the stress between different spinal loadings, the maximal von Mises stress of the implants were observed in flexion in all implanted models.ConclusionAdditional bilateral pedicle screws at the level of the fracture to SPSF may result in a stiffer construct and less von Mises stress for pedicle screws and rods. The largest maximal von Mises stress of the pedicle screws during all states of motion were observed in the mono-segment pedicle screw fixation technique.

Minimally Invasive Stabilization for Thoracolumbar Fractures

Minimally invasive approaches are becoming increasingly widespread due to numerous potential advantages (smaller scars, diminished local pain, reduced blood loss, reduced postoperative wound pain, shorter hospital stays) in spinal surgery. Nowadays, minimally invasive stabilization is more frequently used to treat some thoracolumbar fractures. The aim of this study is to explore the feasibility and effect of minimally invasive stabilization for the treatment of unstable thoracolumbar fractures without neurological impairment. From October 2011 to February 2012, 20 patients with thoracolumbar fracture who were treated with minimally invasive stabilization were included in this study. Charts and operative notes were analyzed for epidemiological data, injured segments, operative time, bleeding volume, mobilization interval, complications and lengths of stay. All patients were successfully managed with minimally invasive stabilization. There were 14 males and 6 females with a mean age of 33.75 years ranging from 18 to 59 years. The L1 vertebra was the most injured vertebral level (35%), followed by T12 and L2. Mechanisms of injury included falling from a height (12 patients) and traffic accidents (8 patients). The average operative time was 72 minutes (range 60 to 122 min). The average intraoperative blood loss was 80 ml (range 50 to 270 ml). Minimally invasive instrumentation of the spine reduces intraoperative blood loss, soft tissue trauma, operative time, infection rates and hospital stay. Future developments in minimally invasive technology will lead to improved results with increased indications and applications.

Is it useful to apply transpedicular intracorporeal bone grafting to unstable thoracolumbar fractures? A systematic review

The debate over the use of intracorporeal bone graft in treating unstable thoracolumbar fractures continues. We compiled evidence for the effect of transpedicular intracorporeal bone grafting (TPG) on outcome in patients with traumatic thoracolumbar fractures. A systematic review was conducted to compare the outcomes of short segment fixation and posterolateral fusion (PLF) with or without TPG. We reviewed articles in PubMed, Ovid, and the Cochrane Database published between January 1995 and August 2011. The correction loss and hardware failure between TPG and TPG+PLF were compared. We assessed the methodological quality of the studies according to the inclusion criteria. We divided 19 papers, involving 22 series, into two groups: posterolateral fusion, and posterolateral fusion combined with intracorporeal bone graft. Meta-analysis regression revealed statistically significant differences in correction loss and hardware failure between the two groups. There were no statistically significant differences in average age, follow-up period, fracture levels, or application of orthosis rate between the two groups. PLF+TPG reduces hardware failure and correction loss compared with PLF alone. It also minimizes the likelihood of severe correction loss. For serious spinal injury cases, PLF+TPG was recommended to improve the prognosis. Further studies would be useful in determining the benefits of applying this method to the treatment of unstable thoracolumbar 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.

Two levels above and one level below pedicle screw fixation for the treatment of unstable thoracolumbar fracture with partial or intact neurology

BackgroundTreatment of unstable thoracolumbar fractures is controversial regarding short or long segment pedicle screw fixation. Although long level fixation is better, it can decrease one motion segment distally, thus increasing load to lower discs.MethodsWe retrospectively analyzed 31 unstable thoracolumbar fractures with partial or intact neurology. All patients were operated with posterior approach using pedicle screws fixed two levels above and one level below the fracture vertebra. No laminectomy, discectomy or decompression procedure was done. Posterior fusion was achieved in all. Post operative and at final follow-up radiological evaluation was done by measuring the correction and maintenance of kyphotic angle at thoracolumbar junction. Complications were also reported including implant failure.ResultsAverage follow-up was 34 months. All patients had full recovery at final follow-up. Average kyphosis was improved from 26.7° to 4.1° postoperatively and to 6.3° at final follow-up. And mean pain scale was improved from 7.5 to 3.9 postoperatively and to 1.6 at final follow-up, All patients resumed their activity within six months. Only 4 (12%) complications were noted including only one hardware failure.ConclusionTwo levels above and one level below pedicle screw fixation in unstable thoracolumbar burst fracture is useful to prevent progressive kyphosis and preserves one motion segment distally.

Operative procedures for thoraco-lumbar burst fractures coupled with neurological dysfunction

Objective To explore the indications of anterior and posterior approach operations for unstable thoraco-lumbar fractures coupled with neurologic deficits and prevention of intraoperative and postoperative complications. Methods We investigated 107 consecutive eases of thoraco-lumbar fractures coupled with spinal cord injury who had been operated on from January 2000 to December 2006.Their average age was 37.8(range.17 to 78) years old. They were 71 males and 36 females. Anterior approach was selected for 46 cases and posterior approach for 61 cases according to their McCormack grades. By the Frankle system for neurologie deficits, 7 cases were graded as A,16 as B,39 as C and 45 as D. Fracture height vecoveries before and after surgery were analyzed statistically. Kyphotic deformity was assessed on lateraJ radiographs using the Cobb method. Results The mean follow-up of 97 cases was 2.8(range,0.5 to 6) years. In both groups. All the cases gained at least 1 grade improvement except those with Frankle grade A. The mean kyphotic angles before operation, after operation and at the latest follow-up were 23.7°,10.6°and13.1°respectively, with significant differences(P＜0.01),in the anterior approach group, while 16.3°,8.4°and 11.7°respectively, with significant differences(P＜0.01),in the posterior approach group. Some complications, such as deficit of cutaneous nerve of thigh, appeared in the 2 groups. Conclusions In treatment of unstable thoraco-lumbar fractures coupled with neurologic deficits, the anterior approach may be better than the posterior approach. The posterior approach can be applied for the cases with less than 7 points in McCormack index. Correct selection of operative approach, careful operation and good rehabilitation after operation are necessary for the prevention of complications. Key words: Lumbar vertebrae; Fracture; Spinal cord injuries; Surgery

The role of imaging in the choice of correct treatment of unstable thoraco-lumbar fractures

The concept of unstable burst fracture has been discussed since over 50 years and this injury has received much attention in the literature as regards its radiological diagnosis and clinical treatment. The purpose of this article is to review the way we use imaging to diagnose the injury and to guide treatment.

Surgical Treatment of Unstable Thoracolumbar Fractures with Posterior Approach

Surgical Treatment of Unstable Thoracolumbar Fractures with Posterior Approach

Results of the AO spinal internal fixator in the surgical treatment of thoracolumbar burst fractures.

The potential for clinical instability following thoracolumbar fractures has evoked a progressive increase in interest in the surgical treatment of unstable thoracolumbar fractures. From September 1988 to October 1991, 44 thoracolumbar burst fractures were treated surgically by the AO Spinal Internal Fixator at the Orthopaedics and Traumatology Clinics of Ankara Social Security Hospital. Mean follow-up period was 28.8 (range 12-48) months. Fourteen (31.8%) of the patients were female, and 30 (68.2%) were male. Postoperatively, the mean anterior vertebral height loss and spinal canal compromise were corrected by 36.5% and 39.9%, respectively. Also, postoperatively 15.9% of improvement was obtained in the mean kyphosis angle. The mean compression angle, which was 19.5 degrees preoperatively, was corrected by 12.3 degrees and came to an average of 7.1 degrees postoperatively. In light of these data, it is suggested that the AO Spinal Internal Fixator effectively restores three-dimensional alignment of the spine and provides a rigid fixation.