Unstable Thoracolumbar Fractures Research Articles

Magnetic resonance tomography examination of thoracolumbar spinal fractures after fixateur interne stabilization

To analyse the possible injuries of vertebral segments, especially the disc, after unstable thoracolumbar fractures stabilised with AO internal fixator, we performed magnetic resonance imaging (MRI) of the traumatised region after implant removal. There were two aspects of disc degeneration (DD):(1) biochemical changes and (2) structural damage. MRI detects biochemical processes as one aspect of DD that is often small even in the presence of greater structural damage of the nucleus pulposus caused by fracture. None of the patients presented with structural failure of the anulus fibrosus, which is the essential structural component of the vertebral segments with regard to stability. We observed biochemical changes more often in the lower of the two fracture-adjacent discs and alterations of discal shape more often in the upper of the two, whereas loss of height concerned both discs to approximately the same degree. The supporters of upper-disc resection in thoracolumbar fractures justify their procedure among other things with the structural disc damage, such as alteration of shape and loss of height (altogether more frequent in the upper disc). Our observations that a disc with a structurally altered nucleus pulposus can be biochemically intact and can show an intact anulus fibrosus are arguments in favour of disc preservation. With regard to the upper disc, the widespread opinion that complete and regular disc damage requires a resection has to be revised. The question of whether the lower disc should be resected more often because of its greater biochemical changes cannot be answered by the present study alone. Besides the excellent static information in all anatomical structures of the vertebral column available by MRI, a repeat examination in a prone position yields dynamic information on the spinal cord in the case of suspected dorsal adhesions.

Functional outcome of thoracolumbar burst fractures managed with hyperextension casting or bracing and early mobilization.

A retrospective study to review the results of unstable thoracolumbar burst fractures managed with casting or bracing and early ambulation in neurologically healthy patients. To determine the clinical outcome of patients with unstable burst fractures of the thoracolumbar spine treated without surgery, and to identify any variables that may adversely influence the final outcome. The management of unstable fractures of the thoracolumbar spine as described by Bedbrook involves a period of recumbency for 6-8 weeks followed by gradual mobilization. Newer techniques of surgical stabilization of the fracture and decompression of the neural elements have become popular because immediate stability of the spine is created and because the need for prolonged bedrest and hospitalization is eliminated. There have been only three reports in the literature describing the nonoperative management of these fractures with early mobilization; some authors believe that this is appropriate only if the posterior column is intact. The results reported in the literature of nonoperative management of thoracolumbar burst fractures have indicated that this is an effective method of management. A retrospective review of 26 patients with unstable burst fractures in the thoracolumbar region (T11-L2) was performed; follow-up evaluation was obtained from 24 patients. Clinical follow-up examination was performed by the use of a questionnaire in which the patients were asked to rate their pain, ability to work, ability to perform in recreational activities, and their overall satisfaction with treatment. Mean follow-up time for the 24 patients was 34.3 months. Mean duration of hospitalization was 8.2 days; those patients who did not have injuries other than their spine fracture had a mean hospitalization time of 5.9 days. Kyphotic deformity could be corrected with hyperextension casting but tended to recur during the course of mobilization and healing. No correlation was found between kyphosis and clinical outcome. At final follow-up evaluation, 19 patients (79%) had little or no pain; 18 patients (75%) had returned to work; 18 (75%) stated that they had little or no restrictions in their ability to work, and 16 (67%) stated that they had little or no restrictions in their ability to participate in recreational activities. Only one patient (4%) reported being dissatisfied with the initial nonoperative treatment of his spine fracture. Ten patients were found to have evidence of spinous process widening on plain films; there was no significant difference in the clinical or radiographic outcome of these 10 patients when compared with the 14 others who did not have interspinous widening. Nonoperative management of thoracolumbar burst fractures with hyperextension casting or bracing was proven to be a safe and effective method of treatment in selected patients. Clinical results were favorable; no neurologic deterioration was observed; hospitalization times were minimized, and patient satisfaction was high. The authors do not believe that ligamentous injury of the posterior column is a contraindication to nonoperative management of thoracolumbar burst fractures.

Surgical approaches for the correction of unstable thoracolumbar burst fractures: a retrospective analysis of treatment outcomes.

The authors retrospectively studied 49 nonparaplegic patients who sustained acute unstable thoracolumbar burst fractures. All patients underwent surgical treatment and were followed for an average of 27 months. All but one patient achieved solid radiographic fusion. Three treatment groups were studied: the first group of 16 patients underwent anterior decompression and fusion with instrumentation; the second group of 27 patients underwent posterior decompression and fusion; and the third group of six patients had combined anterior-posterior surgery. Prior to surgical intervention, these groups were compared and found to be similar in age, gender, level of injury, percentage of canal compromise, neurological function, and kyphosis. Patients treated with posterior surgery had a statistically significant diminution in operative time and blood loss and number of units transfused. There were no significant intergroup differences when considering postoperative kyphotic correction, neurological function, pain assessment, or the ability to return to work. Posterior surgery was found to be as effective as anterior or anterior-posterior surgery when treating unstable thoracolumbar burst fractures. Posterior surgery, however, takes the least time, causes the least blood loss, and is the least expensive of the three procedures.

Long-term follow-up results of thoracolumbar fractures after posterior instrumentation.

This retrospective study examined the hospital records of 60 patients with thoracolumbar fractures treated with posterior fusion and spinal instrumentation. The mean follow-up period was 66 months. The goal of this study was to evaluate and analyze the long-term outcome and socioeconomic conditions of patients who had sustained a thoracolumbar fracture. In four patients, additional spinal injuries were detected. Three of the patients evaluated with magnetic resonance imaging showed cord contusion and edema. In six patients, ruptured disc fragments were detected by preoperative magnetic resonance imaging or during surgery. Long-term follow-up results in 60 patients with unstable thoracolumbar fractures treated with posterior fusion and spinal instrumentation were analyzed. Neurologic outcomes and independence in function and daily living activities were reviewed. Age, sex, mechanism of injury, associated injuries to the spinal cord, and associated injuries to the spinal cord and other systems were analyzed. Fractures were classified according to the system of Ferguson and Allen. The patients with incomplete spinal cord injury showed significant functional improvement. During the follow-up period, 28 patients showed neurologic improvement. Postoperative complications occurred in 11 patients. Five patients required late rod removal because of rod dislocation. Regardless of neurologic recovery, most patients reported some disability, usually caused by pain. Inability to return to alternative jobs resulted from insufficient educational background rather than neurologic dysfunction. Advanced academic achievement was the single most important predictive factor of ability to return to work.

胸腰椎骨折に対するＰｅｄｉｃｕｌａｒ ｓｃｒｅｗ ｓｙｓｔｅｍの使用経験

Sixteen cases of unstable thoracolumbar spinal fractures were treated early using short fixation with a pedicular screw system. During an average of two years follow-up neurological improvement was shown in II cases, according to Frankel's grading. Dislocation was repositioned well, and remained stable, but the kyphotic angle was reduced on average by 7.8° at follow-up. Three major causes for the loss of the kyphotic angle include breakage or bending of the screw, vertebral settling, and rod-screw loosening. Some authors suggest that pain is caused by the loss of the kyphotic angle. Fortunately, no postoperative severe pain or neurological damage occurred in any of our sases. Other techniques should be added to the short fixation and pedicular screw system, to retain the kyphotic angle.

Cotrel-Dubousset Instrumentation and Thoracolumbar Spine Trauma

A series of 55 patients treated with posterior Cotrel-Dubousset instrumentation and osteosynthesis for unstable thoracolumbar spine fractures were reviewed. Follow-up averaged 48.3 months. The fractures were all unstable, with 27 classified as fracture-dislocations (FD) and 28 classified as flexion compression injuries or unstable burst fractures (FC/B). The study population was composed of 29 men and 26 women with an average age of 31 (range 20-45) years. Mechanisms of injuries included 35 motor vehicle accidents, 19 falls, and one blunt trauma. No case worsened as a result of surgery, and 31% of the cases improved an average of 0.5 Frankel grade (range 0-2). Sixty percent of patients were braced with a custom molded thoracolumbosacral orthosis (TLSO) fitted after surgical stabilization. Minor complications occurred in 45% of the cases (urinary tract infection most common). There was a singular deep wound infection and another iliac crest donor site infection. There were no instrument failures or pseudarthroses. Radiographic analysis showed the following improvements in fracture angle, vertebral body compression, and fracture displacement. The pattern of radiographic improvement in the FD and FC/B subgroups showed significant improvement in each parameter when comparing preoperative to immediate postoperative values. Of importance, the radiographic findings comparing 1 month to the final follow-up showed little to no deterioration. Cotrel-Dubousset instrumentation proved to be a highly effective device for immediate restabilization of unstable thoracolumbar injuries.

Neurological outcome after surgery for thoracolumbar fractures. A retrospective study of 93 consecutive cases, treated with dorsal instrumentation.

Surgical reconstruction and fusion form the treatment of choice for unstable thoracolumbar fractures. It remains difficult, however, to prove that surgical treatment provides an increased potential for neurological recovery. Also, the role of a decompressive laminectomy is still unclear. To address these issues, 93 consecutive cases of thoracolumbar fractures treated with dorsal instrumentation were reviewed. The neurological status at the time of admission and at a mean of 26 months postinjury was graded according to a modified Frankel scale. By using preoperative radiographs and computed tomography scans, we differentiated between fracture-dislocation lesions, dislocation lesions, flexion-distraction lesions, complete and incomplete burst fractures. Spinal stenosis was classified from grade 0 (no stenosis) to grade 3 (> 66% stenosis). All thoracolumbar fractures were treated with posterior instrumentation, using Dick's fixateur interne and Steffee's VSP plates and screws. During this procedure, laminectomy was performed in 33 patients (35%). In 17 cases (52% of the laminectomies), a surgically treatable lesion (dural tear, trapped nerve root, etc.) was found, especially in patients with a combination of a neurological deficit and a dislocation lesion, a fracture-dislocation lesion or a complete burst fracture with spinal stenosis grade 2 or 3. The neurological and functional outcome was excellent: none of the patients deteriorated, 68% made a complete neurological recovery, and 61% regained their previous level of activity.

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.

Residual Intersegmental Spinal Mobility Following Limited Pedicle Fixation of Thoracolumbar Spine Fractures With the Fixateur Interne

The Fixateur Interne has been proposed for limited pedicle fixation of thoracolumbar spine fractures with the assumption that motion in the nontraumatized spinal segments could be maintained. To date, no data exist that both localize and quantitate spinal mobility about the fractured vertebra. Voluntary maximum lateral flexion and extension radiographs were obtained on patients with unstable thoracolumbar spine fractures at a minimum of 2 years after Fixateur Interne instrumentation (implant was removed after 1 year). Residual intersegmental motion was measured at levels adjacent to both the vertebra fracture and the fixation. Fifty-nine patients were reviewed, and the posterior vertebral body angle demonstrated a mean total sagittal motion of 2.98 degrees. Cephalad and caudal to the fractured vertebra, a mean of 1.34 degrees and 3.08 degrees, respectively, of residual motion was noted; cephalad and caudal to the previously instrumented segment a mean of 3.22 degrees and 6.88 degrees, respectively, was measured. The authors conclude that residual mobility is most evident at the caudal end of the instrumented segment, removed from the fractured vertebra. The level with end plate disruption becomes essentially ankylosed, with or without a fusion.

Residual Intersegmental Spinal Mobility Following Limited Pedicle Fixation of Thoracolumbar Spine Fractures With the Fixateur Interne

The Fixateur interne has been proposed for limited pedicle fixation of thoracolumbar spine fractures with the assumption that motion in the nontraumatized spinal segments could be maintained. To date, no data exist that both localize and quantitate spinal mobility about the fractured vertebra. Voluntary maximum lateral flexion and extension radiographs were obtained on patients with unstable thoracolumbar spine fractures at a minimum of 2 years after Fixateur Interne instrumentation (implant was removed after 1 year). Residual intersegmental motion was measured at levels adjacent to both the vertebra fracture and the fixation. Fifty-nine patients were reviewed, and the posterior vertebral body angle demonstrated a mean total sagittal motion of 2.98°. Cephalad and caudal to the fractured vertebra, a mean of 1.34° and 3.08°, respectively, of residual motion was noted; cephalad and caudal to the previously instrumented segment a mean of 3.22° and 6.88°, respectively, was measured. The authors conclude that residual mobility is most evident at the caudal end of the instrumented segment, removed from the fractured vertebra. The level with end plate disruption becomes essentially ankylosed, with or without a fusion.

Unstable Thoracolumbar and Lumbar Burst Fractures Treated with the AO Fixateur Interne

Twenty-five consecutive patients with unstable thoracolumbar and lumbar burst fractures were surgically treated with the AO Fixateur Interne (Synthes USA, 1690 Russell Rd., Paoli, PA). Indications for surgery included a progressive neurologic deficit, spinal canal compromise greater than 50%, vertebral body collapse greater than 50%, or sagittal angulation greater than 20 degrees. Twenty males and five females ranging in age from 16 to 60 years (average 31) were treated surgically and prospectively followed. Twenty-one fractures occurred at the thoracolumbar junction (T10-L2) and 4 in the lumbar spine (L3-5). Twenty-four patients were followed for a minimum of 12 months, ranging from 12 to 38 months (average 22); one patient was lost to follow-up after 1 month postoperatively. Preoperatively, 12 patients had partial neurologic deficits; postoperatively, 11 improved at least 1 Frankel grade. Preoperatively, the 12 patients with partial neurologic deficits averaged 45 points (range 24-49) on the lower extremity motor index scale. After surgery, these patients improved an average of five points (range 1-23) on the motor index scale. Both patients with complete spinal cord injuries remained unchanged neurologically postoperatively; no patients deteriorated neurologically after surgery. The average preoperative sagittal kyphosis at the fracture site was +16 degrees (range +10 degrees to +31 degrees); the immediate postoperative sagittal angular correction averaged -4 degrees (lordosis) and ranged from +12 degrees (kyphosis) to -26 degrees (lordosis). At last follow-up, the sagittal angular correction remained unchanged in three patients and decreased in 21 patients to an average of +5 degrees (range +37 degrees to -14 degrees).(ABSTRACT TRUNCATED AT 250 WORDS)

Unstable thoracolumbar and lumbar burst fractures treated with the AO fixateur interne.

Twenty-five consecutive patients with unstable thoracolumbar and lumbar burst fractures were surgically treated with the AO Fixateur Interne (Synthes USA, 1690 Russell Rd., Paoli, PA). Indications for surgery included a progressive neurologic deficit, spinal canal compromise greater than 50%, vertebral body collapse greater than 50%, or sagittal angulation greater than 20 degrees. Twenty males and five females ranging in age from 16 to 60 years (average 31) were treated surgically and prospectively followed. Twenty-one fractures occurred at the thoracolumbar junction (T10-L2) and 4 in the lumbar spine (L3-5). Twenty-four patients were followed for a minimum of 12 months, ranging from 12 to 38 months (average 22); one patient was lost to follow-up after 1 month postoperatively. Preoperatively, 12 patients had partial neurologic deficits; postoperatively, 11 improved at least 1 Frankel grade. Preoperatively, the 12 patients with partial neurologic deficits averaged 45 points (range 24-49) on the lower extremity motor index scale. After surgery, these patients improved an average of five points (range 1-23) on the motor index scale. Both patients with complete spinal cord injuries remained unchanged neurologically postoperatively; no patients deteriorated neurologically after surgery. The average preoperative sagittal kyphosis at the fracture site was +16 degrees (range +10 degrees to +31 degrees); the immediate postoperative sagittal angular correction averaged -4 degrees (lordosis) and ranged from +12 degrees (kyphosis) to -26 degrees (lordosis). At last follow-up, the sagittal angular correction remained unchanged in three patients and decreased in 21 patients to an average of +5 degrees (range +37 degrees to -14 degrees).(ABSTRACT TRUNCATED AT 250 WORDS)

Operative treatment of unstable thoracolumbar fractures by the posterior approach with the use of Williams plates or Harrington rods

Two similar groups of patients with unstable fractures and fracture dislocations of the thoracic or lumbar spine have been treated with the posterior application of Williams plates or Harrington distraction rods over a period of 10 years. The instrumentation was routinely removed from 13 to 19 months after insertion. The initial preoperative kyphotic angle was corrected by a mean of 4.5 and 6.9 degrees respectively. However, follow up after a minimum of four years has shown a loss of correction by a mean of 14.4 and 12.7 degrees to an angle of 21.9 degrees even in the Harrington rod cases. These results do not show the ability to maintain correction of deformity by either method with a dorsal approach. Reduction and stabilization of fractures of the spine should be directed to the anterior part of the vertebrae to overcome late deformity of the spine.

A reduction-fixation system for unstable thoracolumbar burst fractures.

Thirty-three patients with unstable burst fractures of the lower thoracic and lumbar spine were treated with a reduction-fixation system. The new system is used both as a reduction and a fixation device for disorders of the lower thoracic and lumbar spine. In treatment of spinal fractures, it provides symmetric lordotic distraction to obtain the best possible reduction of intracanal fragments, and rigidly stabilizes the fractured vertebra while involving the minimum number of segments. All patients had a minimum follow-up of 24 months. Most patients in this series had a near-anatomic reduction of all three columns in the involved segment. The "indirect" neurologic decompression was successful in cases treated early after injury. The fixation was rigid enough to allow early mobilization and rehabilitation in a light orthosis within 1 week after surgery, and there was minimal loss of reduction during the follow-up period. The complications were minor. The reduction-fixation system achieved the surgical goals of posterior instrumentation for treatment of unstable thoracolumbar burst fractures.

Pedicle screw instrumentation for thoracolumbar burst fractures and fracture-dislocations.

Thirty-eight patients with unstable thoracolumbar and lumbar (T12-L5) spine fractures were treated with Cotrel-Dubousset pedicle screw instrumentation. They were followed for an average of 22.73 months (range 12-39). Measurements of canal compromise, wedge index, and kyphosis correction at follow-up examination were made. Thirty-three (86%) patients responded to a questionnaire concerning overall satisfaction, use of pain medication and return to work. There was an overall correction of kyphosis at follow-up of only one degree after a loss of six degrees from operative correction. There were nine cases of bent or broken screws that occurred at the thoracolumbar junction. Only one patient with instrumentation required continued pain medication and most had returned to work. Thirty-two of thirty-three patients were satisfied with the overall surgical result and twenty-eight of thirty-three patients had returned to work.

A New Instrumentation System for the Reduction and Posterior Stabilization of Unstable Thoracolumbar Fractures

A New Instrumentation System for the Reduction and Posterior Stabilization of Unstable Thoracolumbar Fractures

A new instrumentation system for the reduction and posterior stabilization of unstable thoracolumbar fractures.

An innovative instrumentation and stabilization system was used for the treatment of unstable thoracolumbar fractures. The new osteosynthesis apparatus employs pedicle screw fixation, plate application, and a mechanical device for dynamic reduction in stable posterior fixation. Sixteen patients were treated with this operative technique that included a decompressive laminectomy, an arthropedunculectomy, and the removal of vertebral canal bone fragments. In most patients, three vertebral bodies, rather than four or five, were immobilized. All patients were studied pre- and postoperatively with plain radiographs and computed tomography. Pre- and postoperative examinations demonstrated no alteration in neurological status. All patients, however, with incomplete lesions showed improvement in neurological function at a mean follow-up period of 12 months. The authors' experience suggests that the new system offers ease and versatility of application, restoration of vertebral alignment through mechanical reduction, and enhanced spinal stability. The new system, moreover, enables the reduction of lateral dislocation.

ImDroved Postoperative Course After Spinous Process Segmental Instrumentation of Thoracolumbar Fractures

This article compares the postoperative course of 40 patients who had Harrington instrumentation with 40 patients who had Harrington instrumentation and interspinous process segmental instrumentation of unstable thoracolumbar fractures and reviews the findings. The two groups of patients were otherwise homogeneous, and average operative time, total blood loss, and days to oral intake were similar for both groups of patients. On average, however, patients undergoing interspinous process segmental instrumentation were out of bed sooner (4.5 versus 7.7 days, P less than 0.0001), discharged sooner (32 versus 38 days, P less than 0.079), and brace-free earlier (2.1 versus 5.9 months, P less than 0.001) and had fewer fixation-related complications than did patients undergoing Harrington instrumentation alone. Comparison of average hospital costs documented a savings of $5,160 for the typical patient undergoing interspinous process segmental instrumentation.

Cotrel-Dubousset Instrumentation for the Treatment of Thoracolumbar Fractures

Abstract Cotrel-Dubousset instrumentation (CDI) was introduced in 1984 primarily for the treatment of scoliosis. The applications of this unique and versatile system have expanded to other diseases of the spine. Thoracolumbar fractures are a common management problem for which the device seems to be well suited. We review our results of 15 patients with unstable thoracolumbar fractures treated with CDI at an average of 24 months‘ follow-up. The results are promising and compare favorably with other forms of surgical and medical management. Postoperatively, there was a loss of 2° in the angle of deformity and 0.9 mm of vertebral body displacement. Incomplete neurological injuries improved one or more Frankel grades in 75% of our patients. There were three complications (20%). CDI offers theoretical advantages over Harrington instrumentation and conservative (nonoperative) management. The use of CDI in the treatment of unstable thoracolumbar fractures is endorsed by these results.

Cotrel-Dubousset instrumentation for the treatment of thoracolumbar fractures

Cotrel-Dubousset instrumentation (CDI) was introduced in 1984 primarily for the treatment of scoliosis. The applications of this unique and versatile system have expanded to other diseases of the spine. Thoracolumbar fractures are a common management problem for which the device seems to be well suited. We review our results of 15 patients with unstable thoracolumbar fractures treated with CDI at an average of 24 months' follow-up. The results are promising and compare favorably with other forms of surgical and medical management. Postoperatively, there was a loss of 2 degrees in the angle of deformity and 0.9 mm of vertebral body displacement. Incomplete neurological injuries improved one or more Frankel grades in 75% of our patients. There were three complications (20%). CDI offers theoretical advantages over Harrington instrumentation and conservative (nonoperative) management. The use of CDI in the treatment of unstable thoracolumbar fractures is endorsed by these results.