Early surgery for thoracolumbar extension-type fractures in geriatric patients with ankylosing disorders reduces patient complications and mortality

BACKGROUND CONTEXTThe management of trauma patients with ankylosing spinal disorders has become an issue of increasing interest. Geriatric patients frequently sustain unstable extension type vertebral fractures with ankylosed spines. In this population, studies have shown that early surgery for other injuries such as hip fractures may reduce patient complications and mortality. These studies have changed patient care protocols in many medical centers worldwide.PURPOSEWe aim to assess the relationship between the timing of surgery for unstable vertebral fractures in ankylosed spines in the geriatric population and patient outcomes.STUDY DESIGN/SETTINGRetrospective clinical study conducted in a tertiary hospital.PATIENT SAMPLEPatients included were those diagnosed with isolated thoracolumbar extension type fractures and a spinal ankylosing disorder over 65 years old following minor trauma and with no additional injuries or neurological deficit.OUTCOME MEASURESPrimary outcome measures included postoperative medical complications and mortality at 1 and 6 months. Secondary outcome measures included rehospitalization rates, length of stay, and surgical site infections.METHODSWe searched our department's database for all that met our inclusion criteria who underwent surgery. The difference in patient outcomes that underwent early surgery defined as less than 72 hours from diagnosis as opposed to those that underwent later surgery was assessed.RESULTSA total of 82 patients underwent surgery following a diagnosis of an extension type thoracolumbar fracture at our institution between 2015 and 2021. Of these, 50 met inclusion criteria. Nineteen patients underwent surgery less than 72 hours from diagnosis and 31 more than 72 hours from diagnosis. No difference was found in age, functional status, and Elixhauser comorbidity scores between the groups. A statistically significant difference in perioperative patient complications between the early and the late groups (p=.005) was found. Mortality at six-months was significantly different between the groups as well (p=.035). There was no statistically significant difference between the groups when comparing surgical site infections, length of hospital stay, rehospitalization within a month, and perioperative mortality.CONCLUSIONSTime to surgery affects complication rates and six-month mortality in geriatric patients with spinal ankylosing disorders presenting with an isolated unstable hyperextension type thoracolumbar fracture. Early surgery of less than 72 hours from presentation in this patient population is recommended.     

经椎弓根伤椎撬拨复位植骨治疗胸腰段脊柱骨折

目的:探讨椎弓根伤椎终板撬拨复位器、去螺纹器及椎体内植骨器在治疗胸腰椎段脊柱骨折的应用。方法:自2008年3月至2011年3月收集32例胸腰椎骨折,其中男17例,女15例;年龄25～65岁,平均39.4岁。采用自行设计的经椎弓根终板撬拨复位器、去螺纹器及椎体植骨器行椎体终板复位及椎体内植骨,短节段椎弓根内固定。全部病例要求术前、术后1周、术后1年及内固定取出后3个月行伤椎X线片及CT检查,然后测量伤椎矢状面、额状面后突角度及伤椎高度。结果:32例患者均获得随访,时间14～21个月,平均16个月。随访内容包括后突角度和椎体高度的丢失、骨折愈合情况和内固定植入情况。32例均未出现植骨操作引起的神经、血管并发症,椎体内植骨融合良好。术前、术后1周、术后1年及内固定取出后3个月的统计结果显示伤椎椎体高度保持良好,未出现复位后高度、角度丢失和后期塌陷。结论:采用经椎弓根伤椎终板撬拨复位、去螺纹器及椎体植骨器行椎体终板复位及椎体内植骨治疗胸腰椎骨折能取得满意疗效,而且创伤小,椎体内植骨可促进骨折早期愈合,恢复椎体高度,重建脊柱的稳定性,预防术后晚期椎体高度及角度的丢失,避免了前路手术。     

Spinal fractures in patients with ankylosing spondylitis

Thirty-one consecutive patients with ankylosing spondylitis and spinal fractures were reviewed. There were 6 women and 25 men with a mean age of 60±11 years; 19 had cervical and 12 had thoracolumbar injuries. Of the patients with cervical fracture, two had an additional cervical fracture and one had an additional thoracic fracture. Three trauma mechanisms were identified: high-energy trauma in 13 patients, low-energy trauma in 13 and insufficiency fracture in 5. One-third of the patients suffered immediate neurological impairment, a further one-third developed neurological impairment before coming for treatment and only one-third remained intact. Two patients with thoracolumbar fractures had deteriorated neurologically due to displacements during surgery at other hospitals. All patients were treated operatively except the two patients with two-level cervical fractures, who were managed in halo vests. In the cervical spine both anterior and posterior approaches were employed. In the thoracolumbar spine the majority of the patients were initially treated using a posterior approach only. Complications were common. Of the 27 patients with neurological compromise, 10 had remained unchanged; 12 had improved one Frankel grade; 4 had improved by two Frankel grades; 1 had improved by four Frankel grades. We conclude that even minor trauma can cause fracture in an ankylosed spine. A high proportion of patients with spinal fractures and ankylosing spondylitis have neurological damage. The risk of late neurological deterioration is substantial. As the condition is very rare and the treatment is demanding and associated with a very high risk of complications, the treatment of these patients should be centralised in special spinal trauma units. A combined approach that stabilises the spine from both sides is probably beneficial.     

Sagittal range of motion after a spinal fracture: does ROM correlate with functional outcome?

Literature regarding the effect of a spinal fracture and its treatment in terms of resulting spinal range of motion (ROM) is scarce. However, there is need for data regarding sagittal spinal ROM, since many patients who sustain a spinal fracture are concerned about the back mobility they will have after treatment. In addition, the relationship between ROM and impairment is not clear. The literature gives conflicting results. To study spinal ROM after a spinal fracture, we measured thoracolumbar ROM in operatively and non-operatively treated patients (n=76, average 3.7 years follow-up) as well as controls (n=41). In order to study the relation between ROM and subjective back complaints, we calculated the correlation between thoracolumbar ROM and scores derived from the VAS spine score and RMDQ. To assess impairment after a spinal fracture, we compared RMDQ and VAS scores between operatively and non-operatively treated patients and healthy controls. Operatively treated patients were found to have lower thoracolumbar ROM than controls (56.7° vs 70.0°, respectively; p<0.01). There was no difference between operatively treated and non-operatively treated patients (56.7° vs 62.7°, respectively); nor was a difference found between non-operatively treated patients and controls. Correlation between ROM and subjective impairment was very weak and only significant for ROM and RMDQ scores in the whole study group (rho= –0.25; p<0.01). Patients were more impaired than controls, there was no difference between operatively and non-operatively treated patients (VAS score 76.3 vs 72.6; RMDQ score 4.5 vs 4.4, respectively). We conclude that patients treated operatively for a thoracolumbar spinal fracture have a lower thoracolumbar ROM than controls. Spinal ROM, however, does not influence impairment. A spinal fracture results in impairment, no matter what therapy is chosen.     

Application of transforaminal lumbar interbody fusion in old thoracolumbar fracture and dislocation

Abstract

Background

The main indications for surgery for old thoracolumbar fractures are pain, progressive deformity, neurological damage, or increasing neurological deficit. These fractures have been one of the greatest therapeutic challenges in spinal surgery. Anterior, posterior, or combined anterior and posterior procedures have been successful to some extent. As far as we know, there is no report in the literature of transforaminal lumbar interbody fusion (TLIF) for old thoracolumbar fracture and dislocation.

Methods

Case report.

Results

A 26-year-old man with old fracture and dislocation of T12/L1 was treated with TLIF. At 12 months' follow-up, multi-slice computed tomography (CT) scans showed that solid fusion had been achieved between T12 and L1. Back pain had resolved completely at 2-year follow-up.

Conclusions

We performed TLIF for in a man with old fracture and dislocation of T12/L1, with good clinical outcome. TLIF might be an option in the treatment of old thoracolumbar fracture.     

强直性脊柱炎脊柱骨折的治疗

目的 了解强且性脊柱炎(AS)脊柱骨折治疗的特点及注意事项。方法对19例AS脊柱骨折病例进行回顾性分析硬随访,19例中颈椎骨折11例,9例发生在C5-7间;胸腰椎骨折8例,7例为应力骨折,均发生存T10-L2间。二柱骨折16例。9例并发脊髓损伤,其中8例为颈椎骨折。所有19例患者均接受了手术治疗。颈椎骨折或脱位采用了4种手术方式,其中9例做了前路间盘切除或椎体次全切除、椎间值骨加钢板内固定术。胸腰椎骨折也做了4种术式,其中5例的术式为后路长节段固定加前、后联合融合,结果术岳18例患者获得了平均46．4个月的随访。并发脊髓损伤的9例患者,术后8例的神经功能有恢复。18例患者的骨折部位均已骨性愈合一术中并发脊髓损伤2例,因脑血管意外死亡1例,并发肺炎2例。结论 AS脊柱骨折好发于下颈椎及胸腰段,大多为三柱骨折,颈椎骨折并发脊髓损伤的发生率较高。胸腰椎多为应力骨折一手术治疗可使大多数患者的骨折愈合良好,神经功能有不同程度的恢复。对颈椎骨折患者,可采用前路椎体问植骨、钢板内固定的术式;而对于胸腰椎骨折,主张后路长节段固定,前、后联合植骨融合,术中及术后均可能出现并发症,应注意预防或避免。     

胸腰椎严重骨折的分型与诊治

目的探讨胸、腰椎严重骨折的表述、分类、诊断与手术治疗原则。方法分析本组收治的51例多节段脊椎骨折和脊椎骨折脱位患者,将其归属于严重的脊柱骨折范畴。并对所有病例进行了分类,给出了详细的诊断描述,对于不同类型的患者采取不同的手术策略。结果26例平均随访38个月,Frankel分级改善1级者13例,2级者8例,3级者4例,无改善者l例,未发现有迟发型神经功能障碍者。结论对于胸、腰椎严重骨折我们首先应明确其分型。对于不同的骨折类型结合其术前评估制定不同的手术策略,将对脊柱稳定性及脊髓损伤的恢复起重要作用。     

多节段脊柱骨折的治疗

目的探讨多节段脊柱骨折的损伤机制，伤情特点及诊治方法。方法对于1998年10月至2003年12月期间脊柱多阶段骨折进行回顾性分析。52例多节段骨折，相邻型33例（63．5％），非相邻型19例（36．5％），其中胸腰段损伤30例（57．5％），50例（96％）伴有神经损伤，脊髓功能按Frankel分级，A级11例，B级17例，C级15例。D级7例。E级2例，平均年龄38岁，延迟诊断19例。损伤原因以高处坠落（55．8％），交通事故（25％）为主。保守治疗28例，手术治疗24例，除7例行胸椎单纯减压以外，颈椎、胸腰段、胸椎均行切开减压并不同内固定器械固定。计有Orion1例。TSRH1例，Dick4例，SF2例，RF3例，AF2例，CD4例。固定椎体跨2节到4节不等。结果经过平均16．5个月随访。52例多节段骨折均获骨性愈合，脊髓功能改善1级者21例，改善2级者11例，无改善者20例。其中FrankelA级11例，仅有2例有改善。结论多发性脊柱骨折发生率较低，易漏诊。伤情重，合并伤多，多伴有脊髓损伤，以青壮年男性多发。高空坠落，交通事故是常见原因。损伤的康复取决于脊髓受伤程度，手术积极干预，对患者康复有帮助。     

胸腰椎爆裂性骨折手术治疗的研究进展

【摘要】胸腰椎爆裂性骨折占脊柱骨折的一半以上。由于涉及到脊柱稳定性和神经功能损害,外科处理的复杂性往往建立在个性化、甚至经验方面的的考虑,因此,胸腰椎爆裂性骨折的最好治疗方法备受争议,结点是手术治疗和保守治疗的选择,尤其是神经功能尚好的骨折。目前,开放手术一直是外科治疗的主要方式,既通过不同入路途径进行椎管减压、骨折复位及固定,达到椎体的融合和促进神经功能恢复目的。微创治疗胸腰椎爆裂性骨折并不很多,目前尚缺乏高证据水平,但随着微创技术和新型固定材料的进步,微创条件下治疗胸腰椎骨折不断增多,如采用腔镜下前外侧入路或经皮入路的固定术式。     

Application of transforaminal lumbar interbody fusion in old thoracolumbar fracture and dislocation

Background

The main indications for surgery for old thoracolumbar fractures are pain, progressive deformity, neurological damage, or increasing neurological deficit. These fractures have been one of the greatest therapeutic challenges in spinal surgery. Anterior, posterior, or combined anterior and posterior procedures have been successful to some extent. As far as we know, there is no report in the literature of transforaminal lumbar interbody fusion (TLIF) for old thoracolumbar fracture and dislocation.

Methods

Case report.

Results

A 26-year-old man with old fracture and dislocation of T12/L1 was treated with TLIF. At 12 months'' follow-up, multi-slice computed tomography (CT) scans showed that solid fusion had been achieved between T12 and L1. Back pain had resolved completely at 2-year follow-up.

Conclusions

We performed TLIF for in a man with old fracture and dislocation of T12/L1, with good clinical outcome. TLIF might be an option in the treatment of old thoracolumbar fracture.     

胸腰椎后路内固定翻修术的原因及对策

目的:分析胸腰椎骨折后路内固定术后翻修术的常见原因,寻求减少内固定失败和内固定翻修的有效措施。方法:对因胸腰椎骨折后路内固定术后需要进行翻修术的35例患者的内固定材料、翻修原因等进行回顾性分析。结果:本组病例随访3~46个月,平均18.5个月。按照VAS、ODI评分对患者主观感觉进行疗效判定,优10例,良17例,可8例。结论:严格掌握内固定的适应证、术中操作规范,是减少翻修的有效途径,翻修手术只要处理得当,仍可获得较好的疗效。     

NS10ANTERIOR APPROACHES FOR THORACOLUMBAR FRACTURES

The anterior approach for surgery in thoracolumbar injuries allows decompression of anterior neural compression, reconstruction of the anterior and middle columns of the thoracolumbar spine, and osteototomy through the vertebral body if there is a need for late correction of deformity. In acute injuries the burst fracture with neurological injury is the ideal indication for anterior surgery and reconstruction. Because of the neural anatomy in the spinal canal at the throracolumbar junction, the injury can involve cord, conus, nerve root and peripheral nerve in either a pure or mixed lesion, with variable prognosis for recovery. The decompression optimises neurological recovery on the basis of animal models and clinical series of late decompression cases. In the last few years there has been a dramatic increase in the reconstruction options that have improved post surgical spinal stability and reduced morbidity from major bone grafting techniques. Anterior vertebral plates, dual rod and screw systems, titanium mesh cages, and now expanding cages facilitate reconstruction and improve stability, however this procedure remains technically demanding with significant morbidity for the patient.     

Value of multidetector spiral CT in diagnosis of acute thoracolumbar spinal fracture and fracture-dislocation

Objective: To investigate the diagnostic value of multidetector spiral CT (MSCT) in acute thoracolumbar spinal fracture and fracture-dislocation. Methods: CT imaging files of 152 consecutive traumatic patients with thoracolumbar fractures were retrospectively reviewed. MSCT scannings were performed with a collimation of 3-5 mm and a pitch of 5.5. The postprocessing included sagittal and coronal multiplannar reconstruction, and 3-D reconstruction. Results: There were 88 cases of compression fracture, 54 cases of burst fracture and 10 cases of fracture-dislocation. Transverse images of MSCT could visualize all fractures directly and determine whether spinal canal was intact. Postprocessing image was helpful in depicting the displacement of fragment and orientation of dislocation. Conclusions. MSCT plays an important role in diagnosis and management of acute thoracolumhar spinal fracture and fracture-dislocation.     

新型脊柱固定器械的研制与临床应用

自１９８９年以来，临床应用一种新型脊柱固定器械，共６８例，其中５２例为胸腰椎骨折，１６例为椎体滑脱。经临床观察和随访，治疗效果满意。这种新型固定器械，既可行胸腰椎骨折的固定，也可行椎体滑脱的复位。根据临床需要，该器械可行压缩、撑开、成角和中立位固定。作者强调，脊柱损伤只要有手术指征，手术时机甚为重要，应早期或立即手术，有利于脊柱骨折和椎管前方骨块的复位，早期也有利于神经功能的恢复。     

多节段非相邻型胸腰椎骨折的手术治疗及分型

目的：探讨多节段非相邻型胸腰椎骨折的手术治疗方式和分型。方法：2005年12月至2008年12月共治疗24例多节段非相邻型胸腰椎骨折患者,其中男16例,女8例;年龄18～63岁,平均36岁。根据ASIA脊髓神经功能损伤分级：A级1例,B级2例,C级2例,D级8例,E级11例。按改进的MNSF分类方法将骨折分为：A型15例,B型9例。骨折范围T6～L4,共累及48个椎体。按ASIA分级评分及影像学资料进行回顾性分析。结果：24例患者均接受手术治疗,无漏诊或延迟诊断。患者术后均获随访,随访时间3～36个月,平均18.3个月。骨折全部获得骨性愈合,骨折椎体高度无明显丢失,无钉棒弯曲、松动或断裂。术前13例脊髓神经损伤患者,术后除1例A级和1例B级无恢复外,其余11例均有1级以上脊髓神经功能恢复,共计A级1例,B级1例,C级1例,D级2例,E级19例。结论：对传统分类方法进行改进以便指导临床治疗,多节段非相邻型胸腰椎骨折的治疗方式应该根据神经损伤情况、骨折稳定性及骨折类型决定。     

Thoracolumbar fractures in patients with multiple injuries: diagnosis and treatment-a review of 147 cases

BACKGROUND: The initial evaluation and treatment of patients with multiple injuries are challenging. However, little is known about thoracolumbar fractures in patients with multiple injuries. We aimed to determine the incidence of missed injuries of the thoracolumbar spine in patients with multiple injuries, to examine the reasons for the delay in diagnosis, and to study the selection of treatment options in the management and timing of surgical intervention. METHODS: One hundred forty-seven consecutive patients with acute thoracolumbar fractures and multiple trauma at the authors' hospital between 1988 and 1997 were retrospectively reviewed. The incidence of missed injuries of the thoracolumbar spine and the reasons for the delay in diagnosis were determined. All these patients were observed for a minimum of 3 years after surgery, except four who died during their hospital stay. RESULTS: Delayed diagnosis of thoracolumbar fractures was made in 28 patients (19%). There was an increased incidence of pulmonary complications (p < 0.01) and increased length of hospital stay (p < 0.05) in patients treated nonoperatively compared with patients treated operatively. Although no significant differences in the recovery rate of neurologic function (p > 0.05) were noted between the groups, the surgical patients had highly significantly less pain compared with the nonoperative patients (p < 0.01). The relationship between the timing of thoracolumbar surgery and complications failed to show statistical significance (p > 0.05). Neither the severity of injury nor the timing of surgery had any significant effect on the recovery rate (p > 0.05). CONCLUSION: Patients with blunt trauma caused by high-energy impact injuries are much more likely to have thoracolumbar fractures even if injuries elsewhere have been noted. Further radiographic studies of the thoracolumbar spine should be performed if there is any question related to a thorough and systematic examination. Choice of treatment options of thoracolumbar fractures in patients with multiple injuries is not different from that in patients with no associated injuries to other systems. Appropriate timing of thoracolumbar fracture fixation in patients with multiple injuries should not be dependent on a rigid protocol.     

后路椎弓根钉治疗伴有脊髓损伤的多节段胸腰椎骨折

目的探讨后路椎弓根钉固定治疗伴有脊髓损伤的多节段胸腰椎骨折（multiple—level spinal fracture,MSF）的临床疗效。方法2005年8月至2010年2月,收治18例伴有脊髓损伤的MSF患者,男12例,女6例,年龄20～56岁,平均37岁。其中Ⅰ型（相邻型）10例,Ⅱ型（非相邻型）8例。脊髓损伤按AsIA分级,A级、B级各2例,C级5例,D级9例。18例多节段胸腰椎骨折患者经后路切开复位、椎弓根内固定、椎板减压及后外侧植骨融合治疗,所有患者均于术前、术后、内固定取出前、后拍摄脊柱正侧位x线片和CT片。结果所有病例随访14～30个月,平均随访18个月,术后无内固定物松动、断裂,无继发性脊柱后凸畸形加重,脊髓损伤均有不同程度恢复。结论后路椎弓根固定联合椎板减压能有效恢复椎体高度、重建脊柱稳定性、促进脊髓神经功能恢复,具有手术创伤小、患者术后恢复快等优点,是治疗MSF并脊髓神经损伤的理想方法之一。     

AF内固定与术中脊髓造影治疗胸腰段骨折脱位的临床意义

目的　探讨在AF内固定术中结合脊髓造影治疗胸腰段骨折脱位的临床意义。方法　 32例胸腰段骨折脱位伴不同程度神经损伤患者均行开放复位AF内固定手术治疗 ,术中暂不行椎管直接减压。AF复位内固定后 ,用Omnipaque造影剂 ,由手术切口行术中脊髓造影 ,注入造影剂前 ,回抽脑脊液 ,检查是否为血性 ,如为血性 ,不行此检查 ,造影后 ,C形臂X线机动态观察椎管通畅情况 ,了解减压复位情况 ,决定进一步治疗方案。结果　 32例患者中 ,除 2例为血性脑脊液未行此检查外 ,30例均行此检查 ,2 0例显示椎管通畅 ,骨折脱位得到解剖复位。生理曲线得到恢复 ,造影剂通畅无受压。未行椎管直接减压 ,占6 6 6 %。 6例显示椎管不畅 ,压迫来自前方。 4例行后路椎弓根侧前方减压 ,2例行骨块轻敲复位。 4例显示椎管不畅系后方压迫造成 ,行椎板减压。平均随访 36个月 ,所有病例均得到解剖复位 ,无复位丢失 ,不全瘫患者术后功能提高 1级或 1级以上者占 73 3%。结论　不是所有胸腰段骨折脱位患者都必须行切除椎管结构进行直接减压 ,复位固定本身即是椎管减压 ,术中脊髓造影简单、安全 ,直观。可术中监护复位减压情况 ,及时弥补不足 ,对进一步治疗有一定指导意义     

Thoracolumbar fractures associated with the use of personal watercraft

BACKGROUND: Personal watercraft (PWC) are in widespread and growing use. Injuries involving PWC have been reported, but to date no report has focused on spine injuries as a result of this activity. METHODS: We report a retrospective case series of spinal injuries related to the use of PWC that we term "wave-jumper's fracture." RESULTS: From 1995 to 1999, eight patients suffered spinal fracture after operating PWC. The mechanism of injury was of a "hard landing" on the seat of the PWC after becoming airborne. The average age was 36 years (range, 20-51 years). Fractures were compression or burst type injuries at the thoracolumbar transition zone (T12-L2). Only one patient suffered a transient neurologic injury. No patient required surgery. CONCLUSION: There is a mechanism of injury in PWC use where axial loading may cause thoracolumbar fracture. The public and physicians should be aware of the risks involved in the use of personal watercraft.     

通用脊柱椎弓根钉棒矫形固定系统治疗胸腰椎骨折脱位的疗效分析

目的评价通用脊柱椎弓根钉棒矫形固定系统治疗胸腰椎骨折脱位的临床效果。方法对应用通用脊柱椎弓根钉棒矫形固定系统治疗的110例胸腰椎骨折脱位的患者进行随访,平均时间为14月。结果术后X线片显示脱位椎体全部复位,随诊时的X线片显示椎弓根钉固定牢固,无松动。并发症6例,术中并发症3例,发生率为2.7%;术后并发症3例,发生率为2.7%。术后神经症状明显改善。结论通用脊柱椎弓根钉棒矫形固定技术治疗胸腰椎骨折脱位疗效确切,是一种简捷,可靠的治疗方法。