Flexion distraction and chance injuries to the thoracolumbar spine.

Seat belt legislation has resulted in increased restraint use by passengers in automobiles in Washington State. At Harborview Medical Center in Seattle, we have observed an increased incidence of seat belt-related injuries. Twenty cases of Chance-type thoracolumbar flexion-distraction fractures were reviewed retrospectively. Thirteen patients (65%) had associated life-threatening intra-abdominal trauma. Twelve of these patients had bowel wall injury. Ninety percent of the children had combined abdominal and spinal injury. Operative treatment of the spinal injury resulted in correction of lumbar kyphosis and lower incidence of back pain than nonoperatively managed cases. We recommend careful physical and radiographic examination of all patients with significant abrasion or bruising about the pelvis or abdomen related to seat belts. Victims of automobile crashes who are treated for bowel injury require thoracolumbar radiographs. Similarly, patients with Chance-type fractures should undergo diagnostic peritoneal lavage or computerized abdominal tomography.     

Hyperextension injuries of the thoracolumbar spine

A group of 965 patients treated for thoracolumbal spine injury in the period 1998 till 2003 were analysed. 307 fractures were operated on. Out of this number, 4 fractures were type B3 according to Magerl's classification, i. e. 0.21 % of the admitted and 1.31 % of the operated patients. All 4 patients were operated by stabilization with internal fixator and posterior or combined fusion. Fractures were diagnosed in older patients, age average being 63.75 years, with the range of 57-72 years. All patients were obese, average body mass index being 32.75, with the range of 30.9 to 36.4. Fractures ensued two times in patients with heavy spondylarthrosis and spondylosis, once in ankylosing spondylitis and once in intact spine. Only one patient was injured by heavy trauma, the others sustained the injury during ordinary falls. One of the predisposing factors for occurrence of this injury is probably the increased body mass index resulting in increased moment of deceleration hyperextension force.     

Classification of injuries to the thoracolumbar spine

Significant advances have been made over the past 40 years in the understanding of the pathoanatomy, biomechanics, and neurophysiology of thoracolumbar injuries. These improvements are reflected in the sophisticated classifications currently in use. Yet, we remain in a transitional phase of our classification of these fractures. Future schemes will probably offer two precise classifications--one neurologic and one structural--for every injury.     

Incomplete burst fractures of the thoracolumbar spine: a review of literature

Purpose

The purpose of this review was to analyze the biomechanical basis of incomplete burst fractures of the thoracolumbar spine, summarize the available treatment options with evidence from the literature, and to propose a method to differentiate fracture severity.

Methods

The injury pattern, classification, and treatment strategies of incomplete burst fractures of the thoracolumbal spine have been described following a review of the literature. All level I–III studies, studies with long-term results and comparative studies were included and summarized.

Results

Details of five randomized control trials were included. Additionally, three comparative studies and two studies with long-term outcomes were detailed in this review. The fracture severity reported in the included studies varied tremendously. Most classification used did not adequately describe the complexity of fracture configuration. A wide variety of treatment strategies were outlined, ranging from non-operative therapy to aggressive surgical intervention with combined anterior-posterior approaches. Thus, the treatment of incomplete burst fractures of the thoracolumbar spine is quite diverse and remains controversial.

Conclusions

Incomplete burst fractures can differ tremendously regarding the degree of instability they confer to the thoracolumbar spine. Based on a detailed review of the literature, it is clear that good results can be obtained with both non-operative and operative strategies to treat these injuries. In the authors’ opinion, the intervertebral disc plays a key role in determining the long-term clinical and radiological outcome. Thus, an incorporation of the intervertebral disc pathology into the existing classification systems would be a valuable prognostic factor.

     

Flexion-distraction injuries of the thoracolumbar spine with complete pancreatic rupture. Description of a case

A case is reported of an unstable fracture dislocation of the thoracolumbar vertebral column combined with complete rupture of the pancreas. This combination of injuries is rarely encountered but is dangerous in severely injured patients. Rapid and decisive operative treatment of both injuries should be performed, whereby adequate treatment of the pancreatic rupture has the highest priority.     

Ossifying fibroma of the thoracolumbar spine: a case report and review of the literature.

A 43-year-old woman with ossifying fibroma of the thoracolumbar vertebrae was presented with a 6-month history of progressive radiculomyelopathy. The symptoms were successfully treated by laminectomy and partial resection of the lesion. This is the first reported case of ossifying fibroma involving the thoracolumbar spine. The clinical significance and management of this rare lesion are discussed with a review of the literature.     

Early surgery for thoracolumbar spine injuries decreases complications

BACKGROUND: The proper timing for surgical fracture repair is controversial. Early repair of long bone and cervical fractures reduces complications and is safe. Few studies exist to compare time to surgery with outcomes in thoracolumbar (TL) spine injuries. METHODS: Patients with TL spine injuries were identified from the trauma registry and divided into two cohorts on the basis of Injury Severity Score (ISS). Cohorts were compared for infectious, respiratory, and total complications in patients who had early (<72 hours from injury) versus late (>72 hours from injury) surgical repair. A retrospective chart review was performed on High ISS patients (> or =15) to identify differences in resuscitation needs and neurologic, respiratory, and infectious complications. RESULTS: Early surgery, Low ISS patients were younger, received fewer anterior repairs, and had shorter hospitalizations. Early patients in the High ISS cohort had significantly fewer total complications and shorter hospital and intensive care unit lengths of stay. Resuscitative requirements were similar for both surgery groups. More late surgery patients required ventilator support for noninfectious reasons. There was no difference in admission or postoperative neurologic status or the incidence of head injury. CONCLUSION: Early surgery in severely injured patients with thoracolumbar spine trauma was associated with fewer complications and shorter hospital and intensive care unit lengths of stay, required less ventilator support for noninfectious reasons, and did not increase neurologic deficits.     

Sublaminar wiring of Harrington distraction rods for unstable thoracolumbar spine fractures

Sublaminar wiring of Harrington distraction rods enhances stability and resistance to pullout and is an effective means of managing unstable thoracolumbar spine fractures. The incidence of distraction rod-related failure and the duration of postoperative immobilization are reduced. Early return to full activity and successful rehabilitation are facilitated by efficient stabilization of the spinal column.     

Anterior spine stabilization and decompression for thoracolumbar injuries

In a series of patients with thoracolumbar spine injuries, anterior spinal canal decompression resulted in better neurologic recovery than did previously reported posterior instrumentation or nonoperative treatment. The technique allows stabilization over a much shorter segment of the spine than posterior instrumentation and therefore is indicated for fractures at L2 and below and in all patients with burst fractures and neurologic compromise.     

Aortic injuries in thoracolumbar spine fracture-dislocations: report of three cases

Patients with thoracolumbar fractures and fracture-dislocations of the spine often have associated injuries. One rare and potentially life-threatening concomitant injury is aortic trauma. In cases of fracture-dislocation at the thoracolumbar junction, injuries to the thoracic aorta must be diagnosed early and treated appropriately in conjunction with posterior fixation of the unstable spine.     

Vertebral artery injuries associated with cervical spine injuries: a review of the literature

STUDY DESIGN: Literature review. OBJECTIVE: To determine the incidence of vertebral artery injuries (VAIs) in association with cervical spine trauma and investigate the optimum diagnostic and treatment protocols. SUMMARY OF BACKGROUND DATA: VAIs may result from cervical spine trauma and have the potential to cause cerebral, brainstem, and even spinal cord ischemia. Screening and treatment for traumatic VAI are very controversial, with conflicting recommendations within the trauma and spine literature. METHODS: A literature review was performed to identify publications pertaining to VAIs associated with cervical spine trauma. These publications were evaluated to determine the incidence, radiographic evaluation, and treatment options of VAIs. RESULTS: Approximately 0.5% of all trauma patients will have a VAI, and 70% of all traumatic VAIs will have an associated cervical spine fracture. Cervical spine translation injuries and transverse foramen fractures are most commonly cited as having a significant association with VAIs. The incidence of neurologic deficits secondary to VAI ranges from 0% to 24% in published series that incorporate a screening protocol for asymptomatic patients. Catheter angiography has been the gold standard for the diagnosis of VAIs; however, new 16-slice computed tomography angiography seems to have sensitivity and specificity close to that of catheter angiography. Treatment options include observation, antiplatelet agents, anticoagulation, and endovascular treatments. Although some authors have advocated antithrombotic therapy for most asymptomatic VAIs, there is a lack of class I evidence to support any strong guidelines for treatment. CONCLUSIONS: VAIs can occur in association with cervical spine trauma and have the potential for neurological ischemic events. Screening for and treatment of asymptomatic VAIs may be considered, but it is unclear based on the current literature whether these strategies improve outcomes.     

Recommendations for the treatment of thoracolumbar and lumbar spine injuries

This paper gives recommendations for treatment of thoracolumbar and lumbar spine injuries. The recommendations are based on the experience of the involved spine surgeons, who are part of a study group of the ??Deutsche Gesellschaft für Unfallchirurgie?? and a review of the current literature. Basics of diagnostic, conservative, and operative therapy are demonstrated. Fractures are evaluated by using morphologic criteria like destruction of the vertebral body, fragment dislocation, narrowing of the spinal canal, and deviation from the individual physiologic profile. Deviations from the individual sagittal profile are described by using the monosegmental or bisegmental end plate angle. The recommendations are developed for acute traumatic fractures in patients without severe osteoporotic disease.     

Surgical decision making for unstable thoracolumbar spine injuries: results of a consensus panel review by the Spine Trauma Study Group

OBJECTIVES: The optimal surgical approach and treatment of unstable thoracolumbar spine injuries are poorly defined owing to a lack of widely accepted level I clinical literature. This lack of evidence-based standards has led to varied practice patterns based on individual surgeon preferences. The purpose of this study was to survey the leaders in the field of spine trauma to define the major characteristics of thoracolumbar injuries that influence their surgical decision making. In the absence of good scientific data, expert consensus opinions may provide surgeons with a practical framework to guide therapy and to conduct future research. METHODS: A panel of 22 leading spinal surgeons from 20 level I trauma centers in seven countries met to discuss the indications for surgical approach selection in unstable thoracolumbar injuries. Injuries were presented to the surgeons in a case scenario survey format. Preferred surgical approaches to the clinical scenarios were tabulated and comments weighed. RESULTS: All members of the panel agreed that three independent characteristics of thoracolumbar injuries carry primary importance in surgical decision making: the injury morphology, the neurologic status of the patient, and the integrity of the posterior ligaments. Six clinical scenarios based on the neurologic status of the patient (intact, incomplete, or complete) and on the status of the posterior ligamentous complex (intact or disrupted) were created, and consensus treatment approaches were described. Additional circumstances capable of altering the treatments were acknowledged. CONCLUSIONS: Decision making for the surgical treatment of thoracolumbar injuries is largely dependent on three patient characteristics: injury morphology, neurologic status, and posterior ligament integrity. A logical and practical decision-making process based on these characteristics may guide treatment even for the most complicated fracture patterns.     

Comparison between square-ended distraction rods and standard round-ended distraction rods in the treatment of thoracolumbar spinal injuries. A statistical analysis

This is a retrospective clinical and roentgenographic study of two different types of instrumentation used in the treatment of thoracic and lumbar spinal fractures. Dual square-ended distraction rods contoured into lordosis produced improved results when compared with round-ended distraction rods in terms of both the degree of reduction obtained on the operating table and preventing recollapse of the fracture in the ensuing month. The importance of restoring lordosis was more apparent in the thoracolumbar junction and lumbar spine than in the thoracic region.     

Current status of short segment fixation in thoracolumbar spine injuries

Short segment fixation aims to restore spinal stability and alignment in thoracolumbar spine injuries while preserving spinal motion by decreasing the levels of spine involved in fixation. In its simplest form it applies to fixation one level above and one level below the fractured vertebra. It has proven effective with good clinical, functional and radiological results in well selected cases. However not insignificant rates of sagittal collapse and recurrence of kyphosis with or without clinical implications have also been reported. Most of the failures were attributed to lack of anterior column integrity and relatively inferior robustness of earlier posterior short segment constructs. With better understanding of fracture biomechanics, better implant designs and evolution of strategies to increase the biomechanical strengths of posterior constructs, the rates of kyphosis recurrence and implant failure have been significantly reduced. Although there is lack of robust evidence to guide a surgeon to the best approach for a particular fracture, adhering to basic biomechanical principals increases the efficacy and reliability of short segment fixation. This narrative review highlights the status of short segment fixation in dorsolumbar spine injuries with emphasis on patient selection and strategies to increase effectiveness and reduce failures of short segment fixation.     

胸腰椎屈曲牵张型骨折的诊断与手术治疗策略

目的探讨胸腰椎屈曲牵张型骨折的诊断和手术治疗方法。方法22例胸腰椎屈曲牵张型骨折,均为男性,年龄为21~56岁,平均34.8岁。损伤节段:T128例,L18例,L25例,L31例。神经功能Frankel A级3例,B级1例,C级2例,D级6例,E级10例。骨折按Denis分型,A型9例,B型1例,C型11例,D型1例。行短节段椎弓根螺钉复位内固定治疗,术中根据骨折情况个体化运用撑开与压缩技术。随访时间为10~47个月,平均29个月。结果1例因操作方法不当而复位不良,其余21例术后畸形矫正满意,后凸畸形完全恢复。除Frankel A级3例神经功能无明显恢复外,其余神经损伤者均获得了不同程度神经功能的改善。结论个体化灵活运用椎弓根螺钉的撑开与压缩技术治疗胸腰椎屈曲牵张型骨折,效果满意。     

Lateral distraction injuries to the thoracic and lumbar spine. A report of three cases

Three patients sustained a lateral distraction injury to the thoracic or lumbar spine. These injuries were associated with multiple fractures of the ribs and extremities as well as with thoracic and abdominal visceral injuries. No patient had an injury to the spinal cord or cauda equina. The injuries to the spine were successfully treated with open reduction of the unilateral subluxation of the facet joint and with internal fixation with Harrington instrumentation. Fusion was achieved with the spine in anatomical alignment, without any complications, in all three patients.     

Flexion myelopathy of the thoracic spine. Case report

The authors report a rare case of surgically treated symptomatic thoracic kyphosis caused by dynamic compression in an elderly man. Myelopathy due to thoracic kyphosis has been reported in patients with congenital kyphosis, Scheuermann dorsal kyphosis, and Cushing disease, but to the authors' knowledge this is the first report of dynamic kyphosis in an elderly person. This otherwise healthy 84-year-old man presented with a 2-year history of progressive difficulty in walking and bilateral leg dysesthesia. Despite several cervical and lumbar surgeries, his symptoms gradually worsened. A radiological examination revealed severe thoracic kyphosis, with a lateral Cobb angle of 59 degrees from T-2 to T-12. On a dynamic computed tomography (CT) myelogram, severe thoracic spinal cord draping and stretching on flexion was demonstrated. On extension, however, imaging studies failed to show draping or stretching. Posterior corrective fusion was performed with instrumentation from T-2 to T-9. Postoperative CT myelography demonstrated no significant spinal cord compression with restoration of the cerebrospinal fluid space anterior to the spinal cord, and the successful correction of the kyphosis to 44 degrees. The patient's neurological sequelae gradually resolved throughout 6 months of follow up.