The operative stabilization and grafting of thoracic and lumbar spinal fractures

In this paper several concepts of surgical treatment of thoracic and lumbar fractures are reviewed. Most classifications of these fractures are primarily radiologic, but pathomechanical aspects are very important as these guide the insight into and the rationale of the different modes of treatment. The segment of movement can be considered biomechanically as a three-dimensional system, built up from two rings, linked together at five functional points of support. Our principal mode of surgical therapy after closed reduction by halo-femoral traction is anterolateral decompression, stabilization and grafting to induce fusion. In suitable cases, a dorsal or posterolateral approach and instrumentation can be combined with ventral methods. By using the primary anterolateral approach, one can reduce malalignment at the site where it is needed. Decompression can be carried out where it is truly necessary. One can give support within the segment of movement at the logical place from a biomechanical point of view: the weight bearing part, i.e., the anterior ring. By excision of the injured bony and ligamentous tissue, motion in the damaged segment of movement is eliminated, the original height is restored by grafting, and at the same time the load-bearing capacity of the fractured area is repaired. By applying Zielke instrumentation one can compress the grafts in accordance with modern views on fracture treatment. This “philosophy” is illustrated with case histories and a decision making flow chart.     

Neurological recovery and its influencing factors in thoracic and lumbar spine fractures after surgical decompression and stabilization

Surgical decompression and internal fixation of the injured spine have become standard procedures in the management of thoracic and lumbar spine fractures, but their effectiveness on neurological recovery remains controversial. We report on 169 consecutive patients with thoracic and lumbar spine fractures who were treated by reduction, fusion, and internal fixation using transpedicular screw-rod systems. Open decompression was carried out in 67 (39.6%) of them, including all 42 patients (25%) who presented with initial neurological deficits. At least 8 months following surgery, 30 (71%) had neurologically improved by one to three grades on the Frankel scale. Thirteen (59%) out of 22 patients whose initial deficits had been classified as motor useless (Frankel grades A to C) could walk, at least with support. Thirteen out of 20 patients with posttraumatic deficit Frankel D (motor useful) improved to full recovery (Frankel E). In six (3.6%) patients (all from the group of the 127 patients without initial neurological deficits), permanent slight postoperative neurological impairment of one Frankel grade (E to D) was seen, among them two (1.2%) with new minor motor deficit. Neurological outcome was significantly better (p<0.01) in patients operated upon within the first 24 h after injury than in those who underwent surgery later. Severity of injury also had a negative influence (p<0.001) on neurological recovery. Analysis suggests that there may be significant neurological improvement in patients treated surgically very early.     

Near-anatomical reduction and stabilization of burst fractures of the lower thoracic or lumbar spine

Summary Thirty-one consecutive symptomatic patients with burst fractures of the lower thoracic or lumbar spine (T11-L4) were treated by early surgery in a 36-month period, with near-anatomical reduction being achieved via the postero-lateral route. Fusion and reconstruction of the vertebral body was done by using autologous or processed bovine bone. Correction of the kyphotic deformity was obtained by using distraction rods or transpedicular devices. The post-operative mean degree of kyphosis, percent vertebral height, and percent canal stenosis showed statistically significant differences, compared with the corresponding pre-operative mean values. All but one of the 25 patiens with incomplete paraplegia exhibited neurological improvement, with complete recovery occurring in 20 cases (median followup: 16 months) irrespective of the location of the lesion at the thoraco-lumbar junction (T11-L1) or the lower lumbar segment (L2-L4). Out of the 6 patients with pre-operative complete paraplegia, useful motor power returned in one case with a lesion below L1.The results confirm the suitability of the postero-lateral route and are consistent with the assumption that early near-anatomical reduction and stabilization favours maximum neurological recovery in symptomatic patients.     

Risk factors for pulmonary complication following fixation of spine fractures

Background Context

Previous studies have suggested pulmonary complications are common among patients undergoing fixation for traumatic spine fractures. This leads to prolonged hospital stay, worse functional outcomes, and increased economic burden. However, only limited prognostic information exists regarding which patients are at greatest risk for pulmonary complications.

Spiroid fractures of the thoracic and lumbar spine

The review of our observations of fractures of the thoracic and lumbar spine (588 files could be used from 1969 to 1989) allowed us to demonstrate fractures not included in the usual classification. In our opinion, the fracture line is spiral. The mechanism therefore includes a very likely axial rotation. The fracture line may be confined to the vertebral body (this is the type called S1) or extends to the posterior arch as well (S2 type). The fractures often cause nerve root lesions. However, no complications involving the cord were noted in our series, even in the few cases showing considerable displacement. Note the tendency to axial telescoping of the focus, which requires specific modalities of treatment.     

Burst fractures of the thoracic and lumbar spine

A burst fracture may be defined as an unstable compression fracture of the posterior wall of the vertebral body that allows fragments to be retropulsed into the spinal canal. Computerized axial tomography evaluation of these injuries often reveals posterior element fracture heretofore not stressed in the literature. In surgical treatment for these injuries four important considerations must be met; (1) the coronal and sagittal alignment of the spine; (2) patency of the neural canal; (3) the two-column concept of spinal stability; and (4) bony vertebral body reconstitution. An algorithm for treatment may be developed with the aid of these principles. Distraction and the creation of spinal lordosis are necessary for reduction.     

Risk factors for respiratory failure following femoral fractures: the role of multiple intramedullary nailing

Controversy exists on the relationship between intramedullary nailing (IMN) and the timing of fixation in the development of respiratory failure (RF) following femoral fractures. The purpose of this study is to identify risk factors for RF and evaluate the role of multiple IMN in the above setting. We prospectively observed 126 consecutive patients with femoral fractures for the development of RF. Twenty-one patients (17%) developed RF. This occurred before fracture fixation in 11 patients and after IMN in 10 patients; five after multiple IMN and five after a single IMN procedure. Patients who underwent multiple IMN demonstrated a significant increase of RF after fracture fixation (5/8,) compared to patients with one IMN procedure (5/114, 4.4%, p<0.001). Stepwise regression analysis identified two independent RF risk factors: thoracic injury and multiple IMN (odds ratios: 40.6 and 25.6, respectively). Thoracic injury and multiple IMN procedures are independent risk factors for RF in patients with femoral fractures, and the combination of the above conditions is highly predictive of the development of RF.     

Early rod-sleeve stabilization of the injured thoracic and lumbar spine

The rod-sleeve method provides adjustable corrective forces in all directions so as to accomplish anatomic alignment and three-dimensional rigid fixation for acute spinal injuries. The authors studied a prospective series of 135 consecutive cases treated with this new technique. Results showed improved indirect canal decompression and neurologic recovery, few complications, and greater maintenance of correction than previously reported.     

Surgical stabilization of thoracic and lumbar spine fractures: a retrospective study in a military population

Twenty-two patients underwent surgical stabilization of thoracic and lumbar spine fractures. Twenty patients were operated on within 4 weeks of the injury and two patients more than 1 year following injury. Harrington rods were used in 21 and Dwyer instrumentation in one. The presenting neurological deficits were: four complete, five incomplete, and 13 intact. Clinical failure was noted in four patients, two of whom underwent posterior instrumentation more than 1 year following the initial injury. The most important contributing factor to failure was use of instrumentation in deviation from standard practice. The aim of operative treatment to maintain fracture reduction, decompress neural elements, promote fracture healing, and shorten hospitalization was achieved.     

Functional recovery after decompressive operation for thoracic and lumbar spine fractures

A series of 105 operative cases of thoracic and lumbar spine trauma is presented. All patients underwent an anterior decompression and fusion via the lateral extracavity approach with or without an accompanying posterior internal stabilization procedure (modified Weiss springs or Harrington distraction rods). All patients were allowed to plateau neurologically before reconstructive spine surgery was performed. The patient's neurological grade at the time of surgery and after recovery was assessed according to a seven-grade scale presented herein. None of the 34 patients with a motor and sensory complete myelopathy recovered any function below the level in injury. Of the 10 motor-complete patients with some sensory perception, 4 improved neurologically; however, only 1 of these improved to a state of limited ambulation. The rest remained nonambulatory. Of the 33 patients with significantly disabling incomplete motor and sensory myelopathies, 17 improved to a level of minimal neurological deficit; only 3 patients were left nonambulatory. Of the 21 patients whose physical finding demonstrated a minimal neurological deficit preoperatively, 17 recovered to a normal neurological state. Seven patients were neurologically normal preoperatively and were unchanged postoperatively. Reconstruction of the spine with an anterior decompression and an accompanying stabilization procedure, when appropriate, leads to a better neurological outcome than that expected with either a conservative, nonoperative approach or an operative posterior stabilization approach.     

Conservative treatment of fractures of the thoracic and lumbar spine

Patients with burst fractures of the thoracic and lumbar spines must receive individualized case analysis before a course of therapy can be decided. A consideration of fracture stability, degree of canal compromise, and patient evaluation becomes significant in determining operative or nonoperative treatment. In neurologically intact patients with selected fractures, nonoperative treatment can be successful in the functional rehabilitation of the patient.     

Classification of thoracic and lumbar spine fractures: problems of reproducibility

Reproducibility of fracture classification systems in general has been a matter of controversy. The reproducibility of spinal fracture classifications has not been sufficiently studied. We studied the inter-observer and intra-observer reproducibility of the Magerl (AO) classification using radiograms, CTs and MRIs of 53 patients. We compared this classification with the older and simpler Denis classification. Five observers classified the fractures, first using the radiograms and CTs and, 6 weeks later, with radiograms and MRIs. Three of the observers repeated the readings after 3 months. Three observers also classified the fractures according to Denis. Agreement was measured using Cohen's kappa test. The type (A, B, C) classification of the AO system was fairly reproducible with CTs. With MRI this was only moderate. Group subclassification of the types yielded higher kappa values, corresponding to substantial agreement. The agreement was, in general, better with the Denis classification, but the variance was higher due to the difficulty of finding proper categories for some injury patterns. Although the AO classification allows proper registration of all kinds of injury, the reproducibility, especially at the type level, is problematic. Use of MRI and better definition of the distinctive properties of the three different types may enhance the reproducibility of the scheme.     

Compression fractures of the thoracic and lumbar spine from compensable injuries

Compression fractures of the thoracic and lumbar spine have a worse prognosis than is commonly realized. A study of 142 patients with this type of injury reveals several important features which affect the long term prognosis in these injuries. Severe compression, comminution, disc space narrowing adjacent to the fracture site, a low anatomical level of the fracture site, a low anatomical level of the fracture, and body cast immobilization in those with mild or moderate type fractures, are some of the factors associated with persistent long term back problems.     

Standard operative technic in fresh fractures of the thoracic and lumbar vertebrae

Undesirable sequelae of spinal column injuries are chronic instabilities and decompensated axis shifts. If a poor functional result can be expected after the initiation of conservative treatment, indication for surgery should be considered as early as possible. The authors describe a surgical technique which can be employed both in emergencies and electively on account of its standardization; it consists of dorsal repositioning manoeuvres that result in short-distance fusioning of the spinal column to achieve stable functioning. However, repositioning via the dorsal approach can be effected with maximum success only if it is done within the first 10 to 14 days.     

Results of a locking-hook spinal rod for fractures of the thoracic and lumbar spine

The results of a consecutive series of 110 patients treated with the locking-hook spinal rod are presented. A prospective protocol was completed in 95 patients. Pain was absent or mild in 93%. In those patients with a partial neurologic deficit, there was recovery of at least one Frankel grade in 84%. The overall kyphotic deformity was reduced from 21 to 17 degrees. In those patients in whom no anterior surgery was performed, the deformity improved from 21 to 13 degrees. No rod fractures occurred, and the overall instrument complication rate was 13.7%, of which one was due to infection and four secondary to uncrimped nuts, for a true complication rate of 8.4%. The locking-hook spinal rod has proven to be a satisfactory internal fixation device in the treatment of unstable thoracolumbar fractures.