One-stage anterior debridement,bone grafting and posterior instrumentation vs. single posterior debridement,bone grafting,and instrumentation for the treatment of thoracic and lumbar spinal tuberculosis

Purpose

The aim of this study was to compare single posterior debridement, interbody fusion and instrumentation with one-stage anterior debridement, interbody fusion and posterior instrumentation for treating thoracic and lumbar spinal tuberculosis.

Method

From January 2006 to January 2010, we enrolled 115 spinal tuberculosis patients with obvious surgical indications. Overall, 55 patients had vertebral body destruction, accompanied by a flow injection abscess or a unilateral abscess volume greater than 500 ml. The patients underwent one-staged anterior debridement, bone grafting and posterior instrumentation (group A) or single posterior debridement, bone grafting and instrumentation (group B). Clinical and radiographic results for the two groups were analyzed and compared.

Results

Patients were followed 12–36 months (mean 21.3 months), Fusion occurred at 4–12 months (mean 7.8 months). There were significant differences between groups regarding the post-operative kyphosis angle, angle correction and angle correction rate, especially if pathology is present in thoracolumbar and lumbar regions. Operative complications affected five patients in group A, and one patient in group B. A unilateral psoas abscess was observed in three patients 12 months postoperatively. In one of them, interbody fusion did not occur, and there was fixation loosening and interbody absorption. All of them were cured by an anterior operation.

Conclusion

Anterior debridement and bone grafting with posterior instrumentation may not be the best choice for treating patients with spinal tuberculosis. Single posterior debridement/bone grafting/instrumentation for single-segment of thoracic or lumbar spine tuberculosis produced good clinical results, except in patients who had a psoas abscess.     

Thoracoscopic interbody fusion with percutaneous posterior stabilization for thoracic and thoracolumbar injuries

Background context

Traumatic thoracolumbar discoligamentous injuries and partial burst fractures are commonly managed through posterior-only stabilization. Many cases present later with failure of posterior implant and progressive kyphotic deformities that necessitates major surgeries. Anterior interbody fusion saves the patients unnecessary long-segment fixation and provides a stable definitive solution for the injured segment.

Purpose

The purpose of this study is to assess the clinical and radiographic outcomes of combined minimal invasive short-segment posterior percutaneous instrumentation and anterior thoracoscopic-assisted fusion in thoracolumbar partial burst fractures or discoligamentous injuries.

Study design

Prospective observational study.

Patient sample

Thirty patients with acute thoracic or thoracolumbar injuries operated upon between December 2007 and January 2009.

Outcome measures

Oswestry Disability Index (ODI), clinical and neurological examination for clinical assessment. Plain X-ray for radiological evaluation.

Methods

Preoperative evaluation included clinical and neurological examination, plain X-rays, computed tomography (CT), and magnetic resonance imaging (MRI). Posterior short-segment percutaneous stabilization plus anterior thoracoscopically assisted fusion in prone position were done. The minimum follow-up period was 2 years (range 24–48 months).

Results

The mean age was 44 years. The commonest affected segment was between T10 and L1 (22 patients, 73 %). The mean total operative time was 103 min. The mean operative blood loss was 444 ml. Interbody fusion cage was used in 28 patients while iliac graft in two cases. Fusion rate at the final follow-up was 97 % (29 patients); one patient did not show definitive fusion although he was clinically satisfied. The mean final follow-up ODI was 12 %. The mean preoperative kyphosis angle was 22° improved to 6.5° postoperatively and was 7.5° at final follow-up. There were no major intraoperative or postoperative complications.

Conclusion

Combined anterior thoracoscopic fusion and short-segment posterior percutaneous instrumentation showed good clinical and radiographic outcomes in cases of thoracolumbar injuries through limiting the instrumented levels and preventing progress of posttraumatic kyphosis.     

Thoracoscopically assisted corpectomy and percutaneous transpedicular instrumentation in management of burst thoracic and thoracolumbar fractures

Study design

This is a prospective observational study.

Purpose

The aim of this study was to determine whether the combination of thoracoscopically assisted corpectomy with posterior percutaneous transpedicular instrumentation in prone position achieves treatment goals in burst thoracic or thoracolumbar fractures and minimizes the associated morbidities.

Methods

Between December 2007 and December 2008, 26 patients with acute burst spinal fractures were operated upon in our hospital. Those patients underwent posterior percutaneous stabilization plus anterior thoracoscopically assisted corpectomy and fusion in prone position. Clinical and radiological outcomes of these patients were evaluated after a minimum follow-up period of 2 years. The Oswestry Disability Index (ODI) combined with clinical examination was used for clinical evaluation. Plain X-ray in two views was used for the radiological evaluation.

Results

The mean operative time was 248 min. The average blood loss was 765 ml. Ten patients had preoperative neurological deficits ranging from Frankel A to D. One patient did not show any neurological improvement at the final follow-up. The mean ODI at final follow-up was about 7. The mean preoperative kyphosis angle was 25.58°, improved to 9.2° postoperatively and to 13.8° at the final follow-up. No cases of implant failure were reported at the final follow-up.

Conclusions

Minimal invasive spinal techniques including thoracoscopic decompression and fusion and short segment posterior percutaneous instrumentation showed good clinical outcomes and can be considered as alternative to open procedures with decreased rates of morbidities in managing burst thoracic and thoracolumbar fractures.     

Dorsolateraler Zugang und interkorporelle Spondylodese bei Spondylodiszitis der Brust- und Lendenwirbelsäule (TLIF-Technik)

Surgical goal

Resolve infection and achieve primary stability of instrumentation and permanent fusion of the affected spinal segment by means of debridement of the focus of infection. Defect-filling using autologous/allograft bone or a spacer, as well as immobilization by means of dorsal instrumentation.

Indication

Acute and chronic thoracolumbar spondylodiscitis.

Contraindications

Purely epidural abscesses requiring only decompression (fenestration). Defects whose size make a ventral approach necessary.

Surgical technique

Classic dorsal approach to the thoracolumbar spine. Pedicle placed using screws depending on the size of the spinal defect for mono-, bi-, or multisegmental spinal fusion. Exposure performed at the level of the infected spinal disc or vertebral body on the more strongly affected side. Focus of infection removed. Depending on the degree of infection, defect filling is carried out using autologous bone or cancellous allograft, followed by rod assembly.

Postoperative management

Back brace-free follow-up treatment, physiotherapy and back training. Antibiotic administration until inflammation values fall within the normal range, or for at least 14 days.

Results

Successful fusion of affected segments, including resolution of infection, is reported in over 90?% of cases described in the literature. The revision rate among our mostly multimorbid patient group with an average age of 66 years was 16?%. Of 39 of the 114 (34?%) patients with preoperative neurological deficits, 26 (66?%) demonstrated postoperative regression. Nine patients (23?%) showed no improvement, whilst exacerbation of existing neurological deficits was seen in four patients (11?%). Staphylococcus was the major pathogen in 34?% of cases.     

Extreme Lateral Interbody Fusion (XLIF) in the Thoracic and Thoracolumbar Spine: Technical Report and Early Outcomes

Background

Previous studies have demonstrated the distinct advantages of thoracoscopically assisted spinal fusion compared to traditional open thoracotomy. However, these techniques are limited by a steep learning curve, prolonged operative time, and lack of three-dimensional visualization of the surgical field.

Objective

The objective of this study was to describe our initial experience with an adaptation of the extreme lateral interbody fusion (XLIF) technique allowing access to the anterior aspect of the thoracic and thoracolumbar spine with specific reference to (1) early pulmonary complications, (2) non-pulmonary complications, and (3) ability of this technique to successfully achieve spinal decompression and fusion at the operative level.

Methods

Clinical and radiographic data were reviewed for the entire perioperative period. A total of 18 patients (72% females; mean age, 56.8 years) underwent a thoracic XLIF procedure for spinal pathologies including disc herniation, fracture, tumor, pseudoarthrosis, and proximal junctional kyphosis. A total of 32 levels were treated, with the majority located at the thoracolumbar junction. Twelve of the procedures were done as part of a combined anterior/posterior surgery.

Results

The mean estimated blood loss was 577 ml and the mean length of stay was 12 days. At a mean follow-up of 14 months, all patients except for one (who died of widely metastatic disease) had achieved radiographic evidence of fusion. Two patients developed pulmonary effusions requiring medical intervention. Six patients had seven non-pulmonary complications: incidental durotomy (two), infection (one), instrumentation pullout (one), cardiac arrhythmia (two), and death from metastatic disease (one).

Conclusions

The XLIF technique can be utilized for access to the anterior column of the thoracic and thoracolumbar spine. The advantages of this minimally invasive technique include avoidance of the need for an access surgeon and for lung deflation during surgery as well as excellent visualization of the spinal pathology.     

Combined spinal arthrodesis with instrumentation for the management of progressive thoracolumbar kyphosis in children with mucopolysaccharidosis

Purpose

To evaluate the outcome and complications of a novel technique for the treatment of progressive thoracolumbar kyphosis in children with mucopolysaccharidosis (MPS).

Methods

The medical records and spinal imaging of four consecutive paediatric patients who underwent a single stage anteroposterior spinal fusion with segmental pedicle screw instrumentation were reviewed.

Results

Patients underwent spinal deformity correction at the mean age of 3 years (2.4–3.7) with mean clinical follow-up of 3.2 years (2.1–4.5) and mean postoperative radiographic follow-up was 2.4 years (0.8–3). Preoperative kyphosis was corrected from a mean angle of 65º (63º–70º) to 6.5º (–12º–13º). Vertebral subluxation at the apex of the deformity was corrected from an average 64 % (56–83 %) to 12 % (0–24 %). Spinal cord monitoring with somatosensory evoked potentials (SSEP) was successfully obtained and stable throughout surgery. No instrumentation failure, loss of correction or junctional problems occurred at final follow-up.

Conclusions

Anterior and posterior spinal arthrodesis with segmental pedicle screw instrumentation is a safety and reliable technique for the treatment of severe thoracolumbar kyphosis in children with MPS. This technique achieves excellent correction of the deformity with adequate decompression of the spinal canal. The fusion is limited to the thoracolumbar junction and interferes minimally with the longitudinal growth of the thorax. No neurological complications or intraoperative spinal cord monitoring events occurred. No loss of correction or junctional kyphosis was observed.     

Clinical outcomes of unstable thoracolumbar junction burst fractures: combined posterior short-segment correction followed by thoracoscopic corpectomy and fusion

Background

There is significant controversy surrounding the ideal management of thoracolumbar burst fractures. While several treatment and management algorithms have been proposed, the ideal treatment strategy for these fractures remains unsettled. The authors review their experience with short-segment posterior fusion followed by anterior thoracoscopic corpectomy for the treatment of unstable thoracolumbar burst fractures.

Methods

We identified all patients treated by a single surgeon at our institution from 2002 to 2009 with short-segment posterior fusion followed by anterior thoracoscopic corpectomy for unstable thoracolumbar junction burst fractures. Demographic data, mechanism of injury, classification of fracture, Cobb angle, American Spinal Injury Association score, associated injuries, tobacco use, follow-up duration, and radiographic studies were all collected. Outcomes were assessed for fracture alignment (preoperative, postoperative, and long-term follow-up kyphosis), rate of fusion, neurological outcome, and treatment complications.

Results

Thirty-two patients with burst fracture of the thoracolumbar junction defined as T10 to L1 were included. At a mean follow-up of 20.4 months, 90 % of patients had demonstrated radiographic evidence of fusion and 91 % retained the correction of their kyphotic deformity. There were three complications in the series.

Conclusions

Short-segment posterior fusion with thoracoscopic anterior corpectomy represents an alternative to traditional open treatment of thoracolumbar burst fractures. A thoracoscopic approach allows for a short-segment posterior fusion, reducing the loss of adjacent motion segments, minimizes morbidity associated with traditional open anterior approaches, allows for anterior and posterior column stabilization, and is associated with a high rate of bony fusion.     

Posterior fixation of thoracolumbar burst fractures: Is it possible to protect one segment in the lumbar region?

Background

The treatment for thoracolumbar burst fractures is controversial. The aim of this retrospective study was to compare intermediate-segment (IS) and long-segment (LS) instrumentation in the treatment for these fractures.

Methods

IS instrumentation was considered as pedicle fixation two levels above and one level below the fractured vertebra (infra-laminar hooks attached to lower vertebra with pedicle screws). LS instrumentation was done two levels above and two levels below the fractured vertebra. Among a total of 25 consecutive patients, Group 1 included ten patients treated by IS pedicle fixation, whereas Group 2 included fifteen patients treated by LS instrumentation.

Results

The measurements of local kyphosis (p = 0.955), sagittal index (p = 0.128), anterior vertebral height compression (p = 0.230) and canal diameter expansion (p = 0.839) demonstrated similar improvement at the final follow-up between the two groups. However, there was a significant difference (p < 0.05) between Group 1 and Group 2 regarding clinical outcome [Hannover scoring system, Oswestry disability questionnaire and the range of motion of the lumbar region compared to neutral (0°)].

Conclusions

The radiographic parameters were the same between the two groups. However, the clinical parameters demonstrated that IS instrumentation is a more effective management of thoracolumbar burst fractures.     

Single-stage posterior vertebral column resection and internal fixation for old fracture–dislocations of thoracolumbar spine: a case series and systematic review

Purpose

To evaluate the efficacy of single-stage posterior vertebral column resection for old thoracolumbar fracture–dislocations with spinal cord injury.

Methods

From January 2007 to June 2013, twelve male patients (average age, 32.6 years; range 19–57 years) with old fracture–dislocations of the thoracolumbar spine and spinal cord injury underwent single-stage posterior vertebral column resection and internal fixation. All patients were assessed for relief of the pain and restoration of neurologic function. Postoperative Cobb angle was measured and bone graft fusion was evaluated by X-ray. A systematic review of 25 studies evaluating surgical management of thoracolumbar fractures with spinal cord injuries was also performed.

Results

From our case series, six of the nine patients with Frankel grade A had significant improvement in urination and defecation after surgery. The three patients with Frankel grades B and C had progression of 1–2 grades after surgery. Bony fusion was achieved and local back pain was relieved in all patients after surgery. From our systematic review of 25 studies, the majority of patients had improved back pain, the postoperative kyphotic angle was significantly reduced compared with pre-operative kyphotic angle.

Conclusion

Single-stage posterior vertebral column resection and internal fixation for old thoracolumbar fracture–dislocations is an ideal treatment allowing for thorough decompression, relief of pain, correction of deformities, and restoration of spinal stability.

Level of evidence

IV.

     

Posterior short-segment instrumentation and limited segmental decompression supplemented with vertebroplasty with calcium sulphate and intermediate screws for thoracolumbar burst fractures

Purpose

Thoracolumbar burst fractures treated with short-segment posterior instrumentation without anterior column support is associated with a high incidence of implant failure and correction loss. This study was designed to evaluate the clinical and radiographic results following posterior short-segment instrumentation and limited segmental decompression supplemented with vertebroplasty with calcium sulphate and intermediate screws for patients with severe thoracolumbar burst fractures.

Methods

Twenty-eight patients with thoracolumbar burst fractures of LSC point 7 or more underwent this procedure. The average follow-up was 27.5 months. Demographic data, radiographic parameters, neurologic function, clinical outcomes and treatment-related complications were prospectively evaluated.

Results

Loss of vertebral body height and segmental kyphosis was 55.3 % and 20.2° before surgery, which significantly improved to 12.2 % and 5.4° at the final follow-up, respectively. Loss of kyphosis correction was 2.2°. The preoperative canal encroachment was 49 % that significantly improved to 8.8 %. The preoperative pain and function level showed a mean VAS score of 9.2 and ODI of 89.9 % that improved to 1.4 and 12.9 % at the final follow-up, respectively. No implant failure was observed in this series, and cement leakage occurred in two cases without clinical implications.

Conclusions

Excellent reduction and maintenance of thoracolumbar burst fractures can be achieved with short-segment pedicle instrumentation supplemented with anterior column reconstruction and intermediate screws. The resultant circumferential stabilization combined with a limited segmental decompression resulted in improved neurologic function and satisfactory clinical outcomes, with a low incidence of implant failure and progressive deformity.     

Radiological study on disc degeneration of thoracolumbar burst fractures treated by percutaneous pedicle screw fixation

Objective

To examine disc degeneration at levels adjacent and next adjacent to the fractured vertebra and to analyses, if the disc degeneration is determined by the endplate fracture.

Summary of background data

Thoracolumbar burst fracture is one of the most common spinal injuries. The diagnostic (clinical and imaging) approach and treatment of a fractured vertebra is well established; however, some controversy remains. The associated disc degeneration is less well known after 9–12 months of the short segment pedicle screw fixations. There is a major controversy whether spinal trauma with vertebral endplate fractures can result in posttraumatic disc degeneration. No study to date, however, has assessed disc degeneration of the AO type A3 thoracolumbar fractures without neurologic deficits after pedicle screw fixations.

Methods

Twenty-six patients with single-level AO type A3 thoracolumbar fractures and no neurological deficit were treated by using postural reduction and short segment percutaneous pedicle screw fixation. No laminectomy and fusion were performed. Implants were removed 9–12 months after the first operation. The thoracolumbar magnetic resonance imaging (MRI) was used to assess disc degeneration at levels adjacent and next adjacent to the fractured vertebra before the first operation and after the second operation in a retrospective study.

Results

After the instrumentation removal, new disc degeneration was usually found at level adjacent to the cranial endplate of fractured vertebra by MRI examination in 24 patients. The average Pfirrmann grade of degenerative discs adjacent to the cranial fractured endplates deteriorated from 2.1 pre-operatively to 3.4 after the second operation. No change of disc degeneration was seen at the caudal disc space adjacent to the fractured vertebra and the levels next adjacent to the fractured vertebra. The discs next adjacent to the fractured vertebra were showed to be relatively normal without changes of degeneration during the study period.

Conclusions

Disc degeneration usually occurs at level adjacent to the fractured endplate of thoracolumbar burst fractures. Endplate fracture is strongly associated with disc degeneration. No correlation between fixation level and disc degeneration is seen in this study.     

Thoracolumbar spinal tuberculosis with psoas abscesses treated by one-stage posterior transforaminal lumbar debridement, interbody fusion, posterior instrumentation, and postural drainage

Purpose

Retrospective analysis of the clinical efficacy and feasibility of patients with thoracolumbar spinal tuberculosis with psoas abscesses treated by one-stage posterior transforaminal lumbar debridement, interbody fusion, posterior instrumentation, and postural drainage.

Method

A total of 18 patients with thoracolumbar tuberculosis (TB), between February 2007 and February 2011, underwent one-stage posterior transforaminal lumbar debridement, interbody fusion, posterior instrumentation, and postural drainage. And the clinical efficacy was evaluated based on surgery duration time, the blood loss, the postural drainage of time, neurological status that was recorded by American Spinal Injury Association (ASIA) Impairment Scale, the fate of bone graft fusion, kyphosis angle, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP), which were collected at certain time.

Results

The average follow-up period was 34 months (range 18–48 months). 18 patients suffered from seriously neurological deficits pre-operatively, of which 16 patients returned to normal at final follow-up. The surgery duration time was 197 ± 37.9 min, and the blood loss was 815 ± 348.5 ml. The postural drainage of time was 7.2 ± 2.7 days. The psoas abscesses disappeared in all cases, within the time range of 6–9 months (mean 7.4 ± 1.2 months). All patients of the grafted bones were thoroughly fused, with a fusion time ranging from 4 to 12 months (mean 7.8 months). Kyphosis angle was 44.32 ± 7.26° on average pre-operative and returned to 11.72 ± 2.85° at 6 weeks after operation; kyphosis angle was 13.10 ± 2.39° at final follow-up. The values of ESR and CRP were significant declined at 6 weeks post-operative, and returned to normal levels at final follow-up.

Conclusion

With standardized anti-TB chemotherapy, thoracolumbar spinal tuberculosis with psoas abscesses could be effectively treated by one-stage posterior transforaminal lumbar debridement, interbody fusion, posterior instrumentation, and postural drainage.     

Dose response and structural injury in the disability of spinal injury

Introduction

In traumatic injury there is a clear relationship between the dose of energy involved, structural tissue damage and resultant disability after recovery. This relationship is often absent in cases of non-specific chronic low back pain that is perceived by patients as attributed to a workplace injury. There are many studies assessing risk factors for non-specific low back pain. However, studies addressing causality of back pain are deficient.

Purpose

To establish whether there exists a causal relationship between structural injury, low back pain and spinal disability.

Methods

Retrospective analysis of prospectively gathered validated spinal outcome measures [Oswestry disability index (ODI), low back outcome score (LBO), modified somatic perception (MSP), modified Zung depression index (MZD)] between patients with healed high energy thoracolumbar spinal fractures and patients with self-perceived work-related low back pain. Causality was established according to two of Bradford Hill’s criteria of medical causality, temporal and dose–response relationships.

Results

Twenty-three patients with spinal fractures (group 1) of average age 44 years were compared to 19 patients with self-reported back pain in the workplace pursuing claims for compensation (group 2) of average age 48 years. Both groups were comparable in terms of age and sex. The average ODI in group 1 was 28 % (SD 19) compared to 42 % (SD 19) in group 2 (P < 0.05). Similarly, LBOS was 39.7 versus 24.3 (P < 0.05), MSP 4.3 versus 9.3 (P < 0.05) and MZD 20.2 versus 34.8 (P < 0.05) in groups 1 and 2, respectively.

Conclusion

Despite high-energy trauma and significant structural damage to the spine, patients with the high energy injuries had better spinal outcome scores in all measures. There is no ‘dose–response’ relationship between structural injury, low back pain and spinal disability. This is the reverse of what would be anticipated if structural injury was the cause of disability in workplace reported onset of low back pain.     

Percutaneous pedicle screw fixation plus kyphoplasty for thoracolumbar fractures A2, A3 and B2

Design

Retrospective cohort.

Purpose

The aim of this study is to evaluate the effectiveness of percutaneous short fixation (PSFx) plus kyphoplasty (BP) for thoracolumbar fractures.

Methods

Thirty-six consecutive selected patients, aged 59 ± 17 years, with fresh single thoracolumbar A₂, A₃, and B₂ AO-type fracture, received PSFx plus BP. The primary outcomes pain, and vertebral body deformity; and the secondary outcomes screw malposition, facet violation, PMMA leakage, adjacent segment degeneration (ASD) and loss of correction were evaluated. The f/up was 31 ± 7 months.

Results

Pain and kyphosis decreased and vertebral body heights increased significantly postoperation. PMMA leakage occurred in five cases; 6 (4 %) screws were grades III malpositioned in relation to pedicle; facet violation occurred in 8 (5.5 %) facets; loss of kyphosis correction was 3.68°; ASD occurred in two cases; interfacet fusion in ten (28 %) patients; Three patients were reoperated for different reasons.

Conclusions

PSFx plus BP for thoracolumbar fractures reduces significantly spinal deformity and pain with few complications.

     

MRI fluid sign is reliable in correlation with osteonecrosis after vertebral fractures: a histopathologic study

Introduction

Magnetic resonance images (MRI) fluid sign and intravertebral vacuum phenomenon of the plain radiograph are considered as the characteristic radiological findings for vertebral osteonecrosis after spinal fractures. We aim to study the association between the radiological and histopathologic findings of vertebral osteonecrosis through the use of an open retrieval of specimens.

Materials and methods

Twenty consecutive patients (54–84 years, mean 73 years) of unstable vertebral compression fractures treated with anterior corpectomy and fusion were included. All the images and pathologies were correlated, especially the histopathologic changes to the fluid sign and vacuum phenomenon.

Results

MRI fluid signs and the histopathologic findings of vertebral osteonecrosis were significantly correlated and both were noted in the first 5 months after injury. The power of the fluid sign in diagnosing vertebral osteonecrosis was better than that of the intravertebral vacuum phenomenon (diagnostic odds ratio 65 vs. 2, sensitivity 86 vs. 50 %, specificity 100 vs. 67 %).

Conclusion

MRI fluid sign is more predictable to diagnose vertebral osteonecrosis in operative case, especially within the initial 5 months after injury.     

Outcomes of posterior facet versus pedicle screw fixation of circumferential fusion: a cohort study

Purpose

To compare single-level circumferential spinal fusion using pedicle (n = 27) versus low-profile minimally invasive facet screw (n = 35) posterior instrumentation.

Method

A prospective two-arm cohort study with 5-year outcomes as follow-up was conducted. Assessment included back and leg pain, pain drawing, Oswestry disability index (ODI), pain medication usage, self-assessment of procedure success, and >1-year postoperative lumbar magnetic resonance imaging.

Results

Significantly less operative time, estimated blood loss and costs were incurred for the facet group. Clinical improvement was significant for both groups (p < 0.01 for all outcomes scales). Outcomes were significantly better for back pain and ODI for the facet relative to the pedicle group at follow-up periods >1 year (p < 0.05). Postoperative magnetic resonance imaging found that 20 % had progressive adjacent disc degeneration, and posterior muscle changes tended to be greater for the pedicle screw group.

Conclusion

One-level circumferential spinal fusion using facet screws proved superior to pedicle screw instrumentation.     

Rod fracture after long construct fusion for spinal deformity: clinical and radiographic risk factors

Background

No reports have been published on detailed risk factors for rod fracture after spinal deformity correction and fusion. The purpose of this study was to analyze clinical and radiographic risk factors of rod fracture after long construct fusion for spinal deformity.

Methods

The survey subjects were 155 cases who were diagnosed with spinal deformity and underwent correction and fusion surgery with long construct instrumentation (>3 levels, average 10.3 levels) between July 2004 and June 2010. The subjects comprised 32 males and 123 females with a mean age of 19.0 (range 8–78) years. The mean Cobb angle was 61.0 ± 16.1° preoperatively and 25.7 ± 16.9° postoperatively. Univariate analysis and logistic regression analysis were performed.

Results

Rod fracture occurred in 8 of 155 cases (5.2 %). The mean period from surgery to rod fracture was 18.1 months (range 2–37). The level of fracture ranged from the thoracolumbar junction to the lumbosacral vertebrae. Six patients had fracture near the fused lower end and two patients had fracture at the thoracolumbar junction. Univariate analysis revealed that non-ambulatory status, preoperative kyphosis, small-diameter rods, multiple surgery, and use of iliac screws were significant risk factors for rod fracture. Sex, obesity, severity of preoperative scoliosis, and rod material were not significant risk factors. Logistic regression analysis revealed that use of iliac screws (odds ratio: 81.9, 95 % confidence interval: 7.2–935.0, p < 0.001) and small-diameter (<6 mm) rods (odds ratio: 16.3, 95 % confidence interval: 1.7–152.6, p = 0.015) were risk factors for rod fracture.

Conclusions

The incidence of rod fracture after long construct fusion for spinal deformity was 5.2 %. Iliac screw fixation and small-diameter rods were risk factors for rod fracture.     

X-Ray assessment of the effect of pedicle screw on vertebra and spinal canal growth in children before the age of 7 years

Purpose

To determine the reliability of pedicle screws placed in children younger than 7 years of age, and to evaluate the effect of pedicle screw insertion on further growth of the vertebra and spinal canal.

Methods

A retrospective study of 35 consecutive patients through Jan 2003–Dec 2010 for congenital scoliosis in <7 years children was performed at one spine center. Patients undergoing pedicle screw instrumentation of at least two levels, which had been followed-up for at least 24 months were included. Measurements were performed in instrumented and adjacent non-instrumented levels. The effect of pedicle screw insertion on further growth was evaluated.

Results

The average age at surgery was 4.4 year (53 months, range, 23–84 months). 190 segments in 35 patients met the inclusion criteria. 77 segments had no screws and 113 had at least one screw. There was a significant difference between the pre-operative and final follow-up values of the measurement of spinal canal and vertebral body parameters (P < 0.001). No significant difference existed between growth rates of vertebral bodies and the sagittal diameters of spinal canal with or without screws. The growth rates of vertebral bodies in lumbar spine were higher than in thoracic spine in both instrumented and adjacent groups.

Conclusion

Pedicle screw instrumentation does not cause a retardation effect on the development of vertebral bodies and the spinal canal in children at an early age. It is a safe and reliable procedure to achieve a stable fixation.     

When and how to operate on thoracic and lumbar spine fractures?

Purpose

To discuss when and how to operate on thoracic and lumbar spine fractures.

Patients and methods

We retrospectively studied 77 consecutive patients with thoracic and lumbar spine fractures treated from 2000 to 2011; 28 patients experienced high-energy spinal trauma and 49 low-energy spinal trauma. Mean follow-up was 5 years (1–11 years). Surgical treatment was done in 15 patients with neurological deficits, and in 16 neurologically intact patients with fractures–dislocations, burst fractures and fractures with marked deformity. Non-surgical treatment was done in 46 neurologically intact patients with simple fracture configurations. Clinical and imaging examination and the Oswestry Disability Index (O.D.I.) questionnaire were obtained.

Results

All patients treated surgically maintained spinal alignment; patients with long fusion maintained the best alignment; however, they experienced back stiffness and moderate low back pain. Patients with combined posterior fusion and kyphoplasty experienced earlier recovery and improved sagittal correction. Mean O.D.I. was 22.4 and 14.2 % at 3 and 12 months postoperatively. Thirty six (78 %) patients treated non-surgically were asymptomatic, 22 (48 %) experienced mild residual kyphosis, 10 (22 %) developed marked deformity during their follow-up and were finally operated; mean O.D.I. was 28.6 and 12.1 % at 3 and 12 months. No difference in O.D.I. was observed between patients who had surgical and non-surgical treatment.

Conclusions

Progressive neurological deficits and/or mechanical instability of the spine are absolute indications for early surgical treatment. Younger patients with high-energy spinal trauma, unstable fractures and neurological deficits should be treated surgically in order to provide optimum conditions for neurologic recovery, early mobilization and possibly ambulation. Most cases can be adequately operated through a posterior only surgical approach; an anterior or combined approach is usually indicated for burst and thoracic spine fractures. Postoperative complications, more common infection and neurological deterioration may occur. Elderly, neurologically intact patients with low-energy, stable spinal fractures without marked spinal deformity may be successfully treated conservatively. Most of these patients will do well; however, follow-up for progressive posttraumatic deformity is required.     

Accuracy of spinal curvature assessed by a computer-assisted device and anthropometric indicators in discriminating vertebral fractures among individuals with back pain

Summary

This study examined the accuracy of thoracic and lumbar kyphotic angles as well as anthropometric indicators for discriminating patients with vertebral fracture among Japanese women >50 years old with back pain. Along with region-specific kyphotic angles and anthropometric indicators, the combination of thoracic and lumbar kyphotic angles offered the highest accuracy.

Introduction

Vertebral fractures have been associated with thoracic kyphosis. However, reports on lumbar kyphotic changes in association with vertebral fracture are scarce. This study investigated the accuracy of thoracic kyphotic angle (TKA) and lumbar kyphotic angle (LKA) measurements as well as anthropometric indicators (wall–occiput distance (WOD) and rib–pelvis distance (RPD)) in discriminating patients with vertebral fracture.

Methods

Lateral radiographs of the spine were obtained in 70 postmenopausal Japanese women who visited an orthopedic clinic with low back pain (mean age, 76.2?±?9.0 years). Radiographic vertebral fracture was diagnosed using quantitative measurement according to Japanese criteria. Osteoarthritis (OA) was defined as Kellgren–Lawrence (KL) grade 3 or higher. TKA and LKA were measured using SpinalMouse®. WOD and RPD were also measured.

Results

At least one vertebral fracture was present in 49 subjects (70 %). Women with vertebral fractures showed significant increases in LKA, TKA?+?LKA, and WOD and decreases in RPD. Logistic regression analysis showed significant association between TKA?+?LKA and vertebral fracture independent of the presence of OA. Receiver operating characteristic analysis revealed that TKA was useful for discriminating thoracic fractures (area under the curve (AUC), 0.730) and LKA was useful for lumbar fractures (AUC, 0.691). The combination of TKA?+?LKA offered the highest accuracy for detecting thoracic, lumbar, and any vertebral fractures, with AUCs of 0.779, 0.728, and 0.783, respectively. WOD and RPD showed low-to-moderate accuracies for thoracic, lumbar, and any vertebral fractures.

Conclusions

Assessment of spinal kyphosis by SpinalMouse® as well as anthropometric indicators proved useful in discriminating subjects with vertebral fractures. These convenient and radiation-free methods could contribute to early diagnosis of vertebral fractures and subsequent appropriate treatment, thus preventing additional osteoporotic fractures.