The surgical treatment of thoracic and lumbar fractures by posterior approach

A review of large case series, biomechanical studies and the development of surgical approaches and various types of instrumentation have led to different orientations in the surgical treatment of vertebral fractures. The authors present their experience in 67 cases treated by posterior approach using segmental fixation for the instability of the lesion and the possible association of neurologic deficit (Magerl A in 35 cases, B in 25, C in 7; Frankel A in 21 cases, B in 15, C in 9, D in 6). At a mean follow-up of 3 years, treatment by posterior approach allowed us to suitably treat most of the vertebral fractures observed with clinically satisfactory results, but without observing a definite correlation between neurologic recovery and quality of the reduction. The overall realignment of the spine with extension synthesis and adequate geometry and the development of good bone callus allowed us to obtained a stable spine, protecting consolidation of the fractured metamere.     

Comprehensive treatment algorithm for management of thoracic and lumbar tubercular spondylodiscitis by single-stage posterior transforaminal approach

Surgery in tubercular spondylodiscitis involves radical debridement and fusion by combined anterior and posterior or all posterior approaches with a posterolateral window with its associated morbidities. This study evaluates the outcome of a comprehensive treatment algorithm for thoracic and lumbar tubercular spondylodiscitis by a single-stage posterior transforaminal approach. One hundred and twenty-six patients with tubercular spondylodiscitis between T1 and S1 who underwent posterior surgery with/without fusion by transforaminal approach with a minimum follow-up of 2 years were analyzed. Radiological outcome was assessed by documenting healing with magnetic resonance imaging/computed tomography and radiographical fusion, while clinical outcome was assessed by visual analog score (VAS) for pain and Frankel grading for neurological recovery. Of the 114 patients available for follow-up with a mean age of 53 years, complete radiological healing was observed in all patients (100%) with radiographical fusion in 97.4% and neurology recovered to Frankel E in all 37 patients with deficit. The preoperative VAS score of 9.2 improved significantly to 1.7 postoperatively, and all patients returned to their preoperative occupational activities at the final follow-up. This comprehensive treatment algorithm of single-stage posterior surgery by transforaminal approach in thoracic and lumbar tubercular spondylodiscitis provided good clinical and radiological outcomes. It aids in achieving the same surgical goals, obviating the need for extensive posterior or combined surgical approaches.     

Tumors of the thoracic and lumbar spine: surgical treatment via the anterior approach

We are reporting our experience in 23 patients with tumors of the thoracic or lumbar vertebrae treated via surgical anterior decompression and stabilization. Seventeen patients had metastatic disease and were treated with vertebral body resection followed by stabilization with anterior polymethylmethacrylate and threaded Harrington rods with sacral distraction hooks. Six patients had primary tumors and, following tumor resection and partial vertebral body resection, had autogenous bone graft struts placed anteriorly as well as posterior instrumentation. Posterior instrumentation was transpedicular one level above and below in the lumbar spine, and segmental hooks and rods three levels above and below in the thoracic spine. Nineteen patients presented with severe unremitting pain, and 16 had neurologic deficits, including 7 who were unable to ambulate. Radiation therapy was used as an additional treatment and routinely begun 2 weeks postoperatively. All patients survived the surgery, and none had neurologic deterioration immediately postoperatively. Eight patients had died at the time of review. The mean survival was 14 months and ranged from 6 to 38 months. Of the surviving patients, follow-up ranged from 24 to 40 months with an average follow-up of 30 months. Pain relief was excellent in all but two patients (93%). Motor recovery occurred to some extent in all patients, and only one remained nonambulatory. Complications were minor in three patients (13%) and major in one (4%). Tumor recurrence with neurologic deterioration occurred in two patients. We are very encouraged by these results, and we recommend that patients with tumors of the vertebral body with neurologic deficit or severe unremitting pain be studied with MRI and/or myelography and CT. The patients with gross vertebral destruction and greater than 50% collapse of the vertebral body, those in need of a tissue diagnosis, or those with major neurologic deficit can be effectively treated by anterior decompression and stabilization.     

Pyogenic spondylodiscitis of the thoracic and lumbar spine : a new classification and guide for surgical decision-making

Despite modern diagnostic imaging options pyogenic infections of the spine are often detected tardily and therefore accompanied by a high mortality rate. To ensure an efficient and adequate therapy it is necessary to identify and treat the focus of inflammation. The recommendations for the operative strategy are still a highly controversial issue. On the other hand no classification and guidelines for surgical treatment and treatment strategies of pyogenic spinal infection have yet been published. Pyogenic spinal infections are often underestimated in frequency of occurrence and severity of symptoms. From 1994 until 2008, 269?patients suffering from an infection of the thoracic and lumbar spine were treated in the Department of Orthopedic Surgery Heidelberg and 221?patients underwent surgery. Within the scope of a clinical trial clinical aspects and therapeutic consequences of patients with pyogenic spinal infections were retrospectively investigated. Based on the study data a classification of pyogenic spinal infections of the thoracic and lumbar spine and a guide for surgical decision-making was developed.     

前后路联合Ⅰ期手术治疗胸腰椎结核

目的探讨前后路联合Ⅰ期手术治疗胸腰椎结核的临床疗效。方法采用Ⅰ期后路椎弓根系统内固定同时前路病灶清除、椎体间植骨治疗胸腰椎结核患者28例。在X线片上测量术前、术后后凸角度（Cobb角）,观察植骨融合情况,应用Frankel分级评分评估神经恢复情况。结果随访12～23个月,术后12～培个月所有患者均显示骨性融合。12例有神经症状的患者,术后均有一定程度的恢复,后凸畸形未见加重,无结核复发及切口感染。结论前后路联合Ⅰ期手术治疗胸腰椎结核,可以促进植骨融合和神经功能恢复,防止后凸畸形,临床疗效满意。     

Anterior approach to the thoracic spine

An anterior approach affords the spine surgeon excellent visualization and access to the anterior thoracic spine, the vertebral bodies, intervertebral disks, spinal canal, and nerve roots. This approach is currently used in the surgical treatment of thoracic disk disease, vertebral osteomyelitis or discitis, fractures and tumors of the vertebral bodies, allowing for proper decompression of neural elements and spine stabilization. Over a 10-year period in a single institution, a total of 142 patients with a mean age of 49.6 years underwent anterior thoracic exposure of the spine. The indication for surgery was trauma fracture in 20 patients, malignancy in 35, degenerative disease in 29 and correction of scoliosis in 58. Surgical approaches were determined based on the location and length of spinal involvement, including cervico-thoracic approach (15) thoracotomic approach (85) video-assisted thoracoscopy (10) and thoracolumbar exposure (32). Mean operative time was 334 min (range from 256 to 410 min). There was no perioperative mortality. Thirty-one patients (21.8%) developed postoperative complications. The anterior approach to the thoracic spine is safe and effective and even the presence of complications can be appropriately managed. An adequate preoperative evaluation stratifying the risk and instituting measures to reduce it, accurate surgical planning and careful surgical technique are key to yielding a good outcome and to reduce the risk of complications.     

前与后路病灶清除植骨融合治疗腰椎结核的比较

[目的]通过对比前、后路手术治疗腰椎结核的治愈率、神经功能改善、畸形矫正以及腰椎平衡重建等,评价两种手术方式临床疗效及技术特点。[方法]回顾性分析2012年2月~2015年12月在本院接受手术治疗的79例腰椎结核病例,根据手术方式分为两组。前路组共36例,男13例,女23例,平均年龄33.6岁,接受前路腹膜外入路病灶清除、植骨融合内固定术治疗。后路组共43例,男21例,女22例,平均年龄36.2岁,接受后路经椎间孔、椎旁入路病灶清除、植骨融合内固定术治疗。对比两组手术时间、出血量、并发症、结核愈合、神经功能改善、局部后凸畸形矫正以及腰椎前凸重建等情况。[结果]所有病例均顺利完成手术,无严重并发症发生。两组间手术时间、出血量、并发症发生率差异无统计学意义(P0.05)。所有患者均获得至少1年以上随访,平均随访时间(24.9±11.2)个月(12~61个月),除后路组2例患者结核复发经二次手术治愈,其余患者均获得一期治愈,无内固定相关并发症发生。末次随访时两组神经功能损害患者神经功能均恢复至ASIA分级E级。前路组后凸畸形平均(24.73±10.05)°,术后下降至(3.58±6.54)°,末次随访时(6.63±7.64)°;后路组后凸畸形平均(34.38±23.46)°,术后下降至(-0.78±10.01)°,末次随访时(1.16±11.09)°。两组畸形矫正与术前相比差异均具有统计学意义(P0.05),其中后路组矫正角度更大,与前路组相比差异具有统计学意义(P0.05)。后路组有后凸畸形病例平均腰椎前凸角术后与术前相比,差异具有统计学意义(P0.05),前路组无差异(P0.05)。[结论]前、后路手术治疗腰椎结核均可获得良好的临床疗效,后路手术在矫正畸形和重建腰椎生理曲度上更具有优势。     

Biomechanical considerations of the posterior surgical approach to the lumbar spine

Background contextThe effect of the posterior midline approach to the lumbar spine, relevance of inter- and supraspinous ligament (ISL&SSL) sparing, and potential of different wound closure techniques are largely unknown despite their common use.PurposeThe aim of this study was to quantify the effect of the posterior approach, ISL&SSL resection, and different suture techniques.Study DesignBiomechanical cadaveric study.MethodsFive fresh frozen human torsi were stabilized at the pelvis in the erect position. The torsi were passively loaded into the forward bending position and the sagittal angulation of the sacrum, L4 and T12 were measured after a level-wise posterior surgical approach from L5/S1 to T12/L1 and after a level-wise ISL&SSL dissection of the same sequence. The measurements were repeated after the surgical closure of the thoracolumbar fascia with and without suturing the fascia to the spinous processes.ResultsPassive spinal flexion was increased by 0.8±0.3° with every spinal level accessed by the posterior approach. With each additional ISL&SSL resection, a total increase of 1.6±0.4° was recorded. Suturing of the thoracolumbar fascia reduced this loss of resistance against lumbar flexion by 70%. If the ISL&SSL were resected, fascial closure reduced the lumbar flexion by 40% only. In both settings, suturing the fascia to the spinous processes did not result in a significantly different result (p=.523 and p=.730 respectively).ConclusionEach level accessed by a posterior midline approach is directly related to a loss of resistance against passive spinal flexion. Additional resection of ISL&SSL multiplies it by a factor of two.Clinical SignificanceThe surgical closure of the thoracolumbar fascia can reduce the above mentioned loss of resistance partially. Suturing the fascia to the spinal processes does not result in improved passive stability.     

前、后路手术治疗骨质疏松性胸腰椎骨折合并神经损伤的疗效比较

目的比较前、后路手术治疗骨质疏松性胸腰椎骨折合并神经损伤的临床疗效。方法回顾性分析2000年8月～2005年10月采用前路减压、椎体间融合内固定（A组，n=11）和后路短缩截骨术（B组，n=14）治疗的骨质疏松性胸腰椎骨折合并神经损伤患者的临床和影像学资料。疼痛视觉模拟评分及日本整形外科学会评分法评估临床结果，Frankel分级评价神经功能，X线片评估融合及后凸矫正，并观察手术并发症。结果所有患者得到14～48个月（平均27个月）随访，末次随访A、B两组疼痛视觉模拟评分分别由术前9．3、8．9分减少到3．2、2．5分；JOA评分及其平均恢复率两组差异无统计学意义（P〉0．05）；Frankel分级A、B组分别6例、5例由术前C级恢复到D或E级，5例、9例由D级恢复到E级，分别改善1．5、1．7级；A、B组后凸角分别由术前平均36．9°、37．3°矫正到术后9．3°、6．5°和末次随访的14．5°、11．7°，术后两组差异有统计学意义（P〈0．05）。两组均无内固定相关并发症。结论前、后路手术治疗骨质疏松性胸腰椎骨折合并神经损伤临床疗效无显著差异；对于后凸角度较大者，宜选择后路短缩截骨术。     

The posterior surgical treatment for focal kyphosis in upper-middle thoracic spine

Purpose

To analyze the clinical characteristics of focal kyphosis in upper thoracic spine, and observe the outcome of the posterior corrective surgical procedures.

Methods

Thirteen patients of focal kyphosis were treated with posterior surgical procedures in our medical center. The kyphosis apex was above T6 in all cases. The surgical procedures performed in this study included pedicle subtraction osteotomy (PSO) in six cases and vertebral column resection (VCR) in seven cases. For each case, the kyphosis angle, curvature of lower thoracic spine, lumbar lordosis angle, cervical lordosis angle, pelvic parameters, and the sagittal plane balance of the spine were compared before and after surgery. Neurological function change was assessed based on Frankel grading system and oswestry disability index (ODI).

Results

The average follow-up time of this study was 28.3 months. The average kyphosis angle was reduced from 73.5º before surgery to 32.7º immediately after surgery, and remained at 33.5º at follow-up. The average ODI improved from 22.5 before surgery to 15.5 at follow-up. The neurological function improved after surgery in eight cases. There were two cases of transient neurological deficiency in the lower extremities after VCR procedure, who eventually recovered under postoperative care. One case had recurrent kyphosis due to implant failure after VCR procedure, and recovered after the revision surgery.

Conclusions

Although high risk needs to be warned, the corrective surgery for focal kyphosis in upper thoracic spine still can achieve satisfactory results. Given the comparative surgical results yet less complications, PSO seems to be a preferable procedure over VCR for kyphosis at this region.     

前后路矫形融合术治疗胸腰段/腰段青少年特发性脊柱侧凸(PUMC Ⅰb/Ⅰc/Ⅱd1型)

目的比较前后两种入路及手术方法治疗特发性胸腰段／腰段脊柱侧凸的疗效。方法青少年特发性脊柱胸腰段／腰段侧凸（PUMC Ⅰb，Ⅰc，Ⅱd1型）患者28例，分为两组。A组16例，平均14．88岁，行前路短节段矫形融合术；B组12例，平均15．50岁，行后路、椎弓根系统矫形融合术。两组均采用第三代坚强矫形内固定器械。比较两组术前一般资料和术中情况，并通过X线参数，比较两种手术的矫形效果和躯干平衡的矫正情况。结果两组术前资料无显著差异，术后均无严重手术并发症，融合效果满意。A组手术时问、术中出血及输血量、内固定材料花费明显少于B组；A组平均融合4．25个节段，B组平均融合5．95个节段。随访时间12-47个月，A组术后冠状面矫正率是82％，随访时72％；B组术后冠状面矫正率是74％，随访时70％。矢状面矫形效果均满意，两组无显著性差异；A组术后即刻躯干偏移矫正不如B组，但随访时，两组无差异。两组在矫正顶椎旋转和顶椎偏移方面无显著差异。结论前路矫形和后路椎弓根系统矫形融合术治疗轻中度胸腰段／腰段青少年特发性脊柱侧凸，均可获得满意的矫形效果，但前路融合可缩短手术时间和减少术中出血、输血量，并能保留较多运动节段。     

胸腔镜辅助下胸椎、上腰椎前路手术的体会

目的 探讨胸腔镜技术在胸、腰椎前路手术的适应证、操作要点以及单肺或双肺通气麻醉的选择。方法 对5例结核病人行胸腔镜下结核病灶清除术，其中2例同时行自体髂骨植骨术，1例以自固化磷酸钙人工骨(CPC)植入；对3例爆裂性骨折截瘫及1例L1陈旧性爆裂骨折并马尾综合征病人进行脊髓减压、自体髂骨植骨、钢板螺丝钉内固定术。结果 全部病例都得到随访，术后切口一期愈合，X光、CT检查也都显示病灶清除彻底，脊髓减压充分，复位满意，内固定可靠，位置良好。结论 胸椎、上腰椎结核或骨折，不论是否并发脊髓、马尾神经压迫的病例，均适宜在胸腔镜辅助下进行病灶清除、脊髓减压、脊柱前路内固定术。     

经椎旁肌间隙入路在胸腰椎骨折治疗中的应用

 目的 探讨经椎旁肌间隙入路治疗胸腰椎骨折的手术方法及其与传统手术方法的比较。方法 2006年 10月至 2008年 10月, 52例无神经损伤表现的胸腰椎骨折患者被纳入研究。±据 Denis骨折分型, 压缩型骨折 17例, 爆裂型骨折 35例, 其中男 37例, 女 15例;年龄 18耀59岁, 平均 46.5岁。 T4骨折 1例, T7骨折 2例, T8骨折 1例, T10骨折 3例, T11骨折 5例, T12骨折 14例, L1骨折 16例, L2骨折 9例, L3骨折 1例。影像学检查示: 椎管内占位约1/3, 突入椎管骨块均匀完整, 无碎裂及翻转。患者±次纳入研究, 分为两组, 其中 20例患者采用传统后正中入路, 其他 32例患者采用经椎旁肌间隙入路, 均行后路椎弓根螺钉固定。结果两组患者在性别、年龄、损伤节段、受伤至手术时间及随访时间方面比较, 差异均无统计学意义。经肌间隙入路较传统后正中入路在手术时间、术中出血量、引流放置时间、术后引流量、术后下地时间, 疼痛视觉模拟评分及 Oswestry功能障碍指数等方面具有显著优势, 两组间比较各项指标差异均有统计学意义。至 2009年 10月, 所有患者均获得随访, 平均时间 21.5个月(12耀36个月), 所有患者伤椎椎体高度均无丢失, 内固定无松动、断裂。结论与传统手术方法相比, 经椎旁肌间隙入路治疗胸腰椎骨折可完整保留脊柱后方复合体结构, 具有创伤小、出血少和恢复快等优点, 是一种安全实用的手术方法, 疗效满意。     

胸腰椎肿瘤全脊椎切除手术入路的选择与评价

目的 :探讨胸腰椎肿瘤全脊椎切除手术的入路选择,初步评价不同手术入路的临床意义。方法 :2001年10月~2013年12月共收治74例胸腰椎肿瘤患者,男31例,女43例;年龄11~69岁,平均40.2岁。分别采用单纯后正中入路、后路联合前路或后路联合侧前方入路手术完成肿瘤的全脊椎切除。分析脊柱肿瘤WBB分期及肿瘤所在部位、是否首次手术与手术入路选择的关系。结果:选择后正中入路手术者25例,肿瘤位于B~D、3~9区15例,其中单节段12例,两节段3例;B~D、1~12区4例,其中单节段3例,两节段1例;肿瘤软组织肿块较小、位于A~D/E、3~9区4例,其中单节段3例,两节段1例;A~D/E、1~12区单节段2例。整块切除24例,大块经瘤切除1例。上胸椎2例,胸椎及胸腰段21例,中下腰椎2例。后路联合前方入路手术者30例,肿瘤侵袭A~D/E、累及1~12区20例,单节段11例,两节段及以上9例,其中复发肿瘤12例;累及3~9区8例,单节段5例、两节段及以上3例,其中上胸椎5例(复发肿瘤2例);累及B~D、3~9区的L4和L5肿瘤各1例。整块切除8例,大块经瘤切除22例。上胸椎7例,下腰椎(L4-L5)5例,胸椎或胸腰段18例。后路联合侧前方入路19例,肿瘤累及A~D/E、1~12区10例,单节段肿瘤9例,2节段1例;累及A~D/E、3~9区的单节段初次手术的胸腰段肿瘤5例,软组织肿块位于脊椎的侧方;累及B~D、1~12区的中下腰椎单节段肿瘤2例,胸腰段肿瘤2例。整块切除3例,大块经瘤切除16例。胸椎及胸腰段10例,中下腰椎9例。结论:胸、腰椎肿瘤全脊椎切除手术入路应根据肿瘤侵袭范围及所在脊椎部位进行选择。局限在脊椎骨内或椎旁肿块较小的单及两节段肿瘤选择单纯后正中入路;肿瘤突破脊椎致前方有较大肿块、复发肿瘤及侵袭椎旁的上胸椎肿瘤多选择联合前方入路;软组织侵袭位于脊椎侧方的肿瘤多选择后路联合侧前方入路。     

Anterior versus posterior surgical treatment of unstable thoracolumbar burst fracture

Objective  

This retrospective study compares clinical outcomes of anterior versus posterior surgery for treatment of unstable thoracolumbar fracture.     

Anterior instrumentation for the treatment of pyogenic vertebral osteomyelitis of thoracic and lumbar spine

Anterior radical debridement and bone grafting is popular in the treatment of pyogenic infection of the spine, but there remains great concern of placing instrumentation in the presence of infection because of the potentiality of infection recurrence after surgery. The objective of this study was to prospectively evaluate the efficacy and safety of anterior instrumentation in patients who underwent simultaneous anterior debridement and autogenous bone grafting for the treatment of pyogenic vertebral osteomyelitis. The series consisted of 22 consecutive patients who were treated with anterior debridement, interbody fusion with autogenous bone grafting and anterior instrumentation for pyogenic vertebral osteomyelitis of thoracic and lumbar spine. The patients were prospectively followed up for a minimum of 3 years (average 46.1 months; range 36–74 months). Data were obtained for assessing clinically the neurological function and pain and radiologically the spinal alignment and fusion progress as well as recurrence of the infection. All the patients experienced complete or significant relief of back pain with rapid improvement of neurological function. Kyphosis was improved with an average correction rate of 93.1% (range 84–100%). Solid fusion and healing of the infection was achieved in all the patients without any evidence of recurrent or residual infection. The study shows that combined with perioperative antibiotic regimen, anterior instrumentation is effective and safe in the treatment of pyogenic vertebral osteomyelitis of thoracic and lumbar spine directly following radical debridement and autogenous bone grafting.     

借助胸腔镜技术的胸段、上腰段脊柱前路手术

目的探讨胸腔镜辅助胸椎、上腰椎前路手术的适应证 ,单肺或双肺通气的选择以及术中注意事项。方法　应用胸腔镜、骨科常规手术器械或自制的骨科器械 ,在胸腔镜辅助下行病灶清除、脊髓减压、植骨、钢板螺丝钉内固定术。结果　全部病例手术都顺利完成 ,切口均一期愈合 ,随访 3～ 10个月 ,影像学检查显示病灶清除彻底 ,脊髓减压充分 ,除 1例骨折复位、固定后仍有轻度侧方成角畸形外 ,其他病例复位满意、内固定可靠 ,位置良好。结论胸椎、上腰椎疾患 ,不论是否并发脊髓、马尾神经压迫 ,都能在胸腔镜辅助下完成病灶清除术 ,必要时还可进行脊髓减压、脊柱前路植骨、内固定手术。原则上可选择常规气管插管、双肺通气下完成手术。     

Anterior versus posterior approach in the treatment of chronic thoracolumbar fractures

The purpose of this study was to compare the results of anterior approach vs posterior approach in the treatment of chronic thoracolumbar fractures. A total of 36 patients with chronic thoracolumbar fractures were divided into 2 groups. Group A was treated by an anterior approach and group B was treated by a posterior approach. During the minimum 24-month follow-up period (range, 24-62 months), all patients were prospectively evaluated for clinical and radiologic outcomes. Intraoperative blood loss, operative time, operative complications, pulmonary function, Frankel scale, and American Spinal Injury Association (ASIA) motor score were used for clinical evaluation, and Cobb angle was examined for radiologic outcome. All patients in this study achieved solid fusion, with significant neurologic improvement. Operative time, perioperative blood loss, ASIA score on admission and at final follow-up, and complications of respiratory tract infection and intercostal nerve pain were not significantly different between the 2 groups (P>.05), but complications of hemopneumothorax, abdominal distension, and constipation were fewer in group B (P<.05). Postoperative pulmonary function (P<.05) and correction of posttraumatic kyphosis were better in group B (P<.05).     

A posterior versus anterior surgical approach in combination with debridement,interbody autografting and instrumentation for thoracic and lumbar tuberculosis

Purpose  

The purpose of this study was to compare posterior and anterior surgical approach in combination with debridement, interbody autografting and instrumentation for thoracic and lumbar tuberculosis. These approaches were compared in terms of the operation duration, intraoperative blood loss, bony fusion, intraoperative and postoperative complications, neurological status and the angle of kyphosis.