胸腰椎爆裂骨折的治疗和展望

胸腰椎爆裂骨折占胸腰椎骨折的50%以上,其经常导致神经损伤和脊柱后凸畸形,对于每一种类型的骨折其治疗方法各不相同,目前应用于临床的方法有保守疗法、前路手术、后路手术、前后路联合手术及微创手术,然而最佳的治疗方法仍然是不明确的,没有一种精确的分型来指导爆裂骨折的治疗及手术方式的选择。文章综述了胸腰椎爆裂骨折的治疗进展。有研究表明无神经损伤的稳定型爆裂骨折保守治疗和手术治疗并无明显差别。伴有神经损伤的不稳定型爆裂骨折早期手术减压和稳定是应当考虑的,有研究表明对于短节段固定联合各种不同方式的椎体成形术重建前柱可以明显减少内固定失败及远期脊柱后凸畸形的发生率而受到广大脊柱外科医生的推崇。按照生物力学原理及考虑到患者固定节段后相邻节段退变的发生,非融合技术已逐渐应用于临床,其远期疗效尚需进一步研究证实。     

Acute thoracolumbar burst fractures in the absence of neurologic deficit. A comparison between operative and nonoperative treatment

The treatment of thoracolumbar burst fractures in the absence of neurologic deficit remains controversial. The present study is a retrospective analysis of 52 of these acute burst fractures among 104 cases of thoracolumbar burst fractures treated either operatively or nonoperatively. Results are expressed in terms of neurologic function, pain, work status, and complications. All patients who had surgical treatment and no unrelated disability returned to full-time work. Twenty-five percent of the patients treated nonoperatively were unable to return to work full time. Of the patients in the nonoperative group, 17% developed neurologic problems. Prophylactic stabilization and fusion of acute burst fractures without neurologic deficit have significant advantages over conservative management.     

Lateral corpectomy and reconstruction for thoracolumbar burst fractures with neurological injury

Spine injuries have substantial impact on quality of life, especially when neurologic injury is present, with significant associated healthcare costs. Most spine injuries occur within the thoracolumbar spine, with burst fractures representing a notable proportion. Unstable burst fractures with neurologic deficits come with difficult evaluation and management decisions. Treatment of these injuries has substantially evolved over the last 2 decades. Options for operative management include anterior, posterior, and combined anterior-posterior approaches. Posterior approaches allow for stabilization of fractures, but come with challenges of performing an adequate decompression in the setting of neurologic deficit. Anterior approaches allow for direct decompression, but traditional approaches have noteworthy complications. Growth of minimally invasive spine surgery has helped to mitigate some risks associated with traditional open approaches. Minimally invasive anterior decompression with percutaneous posterior stabilization represents a reasonable management option in unstable thoracolumbar burst fractures with neurologic deficit.     

后路短节段椎弓根内固定治疗无神经损伤胸腰段爆裂骨折

目的　探讨后路短节段椎弓根内固定、经椎弓根椎体内植骨对无神经损伤胸腰段爆裂骨折的治疗效果。方法　对 2 2例无神经损伤的胸腰段爆裂骨折 ,采用短节段椎弓根内固定器复位固定、经椎弓根椎体内植骨 ,术前、后摄X线片、CT扫描。结果　术后伤椎高度明显恢复 ,后凸显著矫正 (P <0 0 5 ) ;术后 1年 ,后凸矫正度数大量丢失 (P <0 0 5 )。结论　后路短节段椎弓根内固定是治疗无神经损伤胸腰段爆裂骨折的一种理想方法 ,经椎弓根椎体内植骨不能阻止后凸矫正度数的丢失。     

Neurologic recovery from thoracolumbar burst fractures: is it predicted by the amount of initial canal encroachment and kyphotic deformity?

BACKGROUND: The association between neurologic recovery and initial compromise of spinal canal and sagittal alignment has been rarely documented. This study was performed to better understand whether the degree of neurologic recovery from thoracolumbar burst fractures is affected and predicted by initial compromise of spinal canal and sagittal alignment. METHODS: Eighty-seven patients who underwent conservative or surgical treatment for thoracolumbar burst fractures between 1993 and 2001 were prospectively followed up for 3 to 10 years (average, 5.5 years). They were assessed for neurologic deficit and improvement as defined by the scoring system of ASIA, the stenotic ratio of spinal canal and kyphosis angle. RESULTS: The ASIA score in 52 patients with neurologic deficit averaged 34.0 (range, 0-50) on admission and 46.1 (range, 27-50) at final follow-up. All these patients except 2 with neurologic deficit experienced improvement with an average recovery rate of 72.7% (range, 0%-100%). No statistically significant difference (P > .05) in the stenotic ratio of spinal canal or kyphotic deformity was demonstrated among the patients with no neurologic deficit, with incomplete lesions, and with complete lesions. The stenotic ratio of spinal canal or kyphosis angle was not significantly correlated with initial and final ASIA score and recovery rate (P > .05). CONCLUSIONS: The neurologic recovery from thoracolumbar burst fractures is not predicted by the amount of initial canal encroachment and kyphotic deformity. When deciding on the treatment for patients with thoracolumbar burst fractures, both neurologic function and spinal stability should be taken into account.     

Our experience in 33 cases of thoracolumbar fracture treated by transpedicle instrument

Unstable thoracolumbar fracture (vertebromedullary traumatic lesion) is often the cause of poor sequelae, in lumbar pain caused by changes in the physiological sagittal profile, and sequelae of a neurologic nature. Thus, the concept of instability is further defined. The authors presents 33 cases of burst type thoracolumbar fractures treated by transpedicle instrumentation using the following systems: Malaga vertebral fixator 1,2 (MVF), Omega 21. Follow-up was obtained after rom 1 to 9 years. Results were: clinical-radiographic criteria (1. fusion, 2. deformity, 3. pain, 4. neurologic function). There was remodeling of the spinal cord canal in cases operated on. The authors conclude that a correct evaluation of instability of burst fractures and the consequent treatment of choice (transpedicle fixation) allows for a high favorable index of the functional capacity in these patients.     

The management of burst fractures of the thoracic and lumbar spine. Experience in 53 patients

The optimal treatment of "burst" fractures is one of the more controversial topics in spinal reconstructive surgery. While it is generally considered a stable fracture, recent trends toward operative treatment of burst injuries have raised questions regarding the necessity of stabilization and decompression. A retrospective review was conducted of all patients who presented at the University of Minnesota Hospitals from 1970 to 1980 with closed thoracolumbar spinal fractures. In 354 of 399 patients, records and roentgenograms were adequate for review. Using strict x-ray criteria for classification, 59 patients were found to have burst fractures. One-year follow-up was available on 53 patients. There were 10 thoracic and 43 lumbar fractures. Thirty-one patients had associated injuries. Eleven patients had other spinal fractures. Thirty-eight patients demonstrated neurologic deficits. Twenty-two patients were initially treated nonoperatively, and 31 had early surgery. Operations included laminectomy, posterolateral decompression, posterior spinal fusion usually with Harrington rod instrumentation, and anterior spinal fusion. At follow-up, which averaged more than 3 years, neurologic improvement was found in 68% of the surgical patients who had presented initially with a neurologic deficit. Six patients treated nonoperatively later required surgery. Back pain was more common in the surgical group, disability less common. Radiographic follow-up revealed little increase in deformity in either group. The findings in this study suggest that nonsurgical treatment of patients with burst fractures and normal neurologic function is not likely to result in neurologic deterioration or progressive deformity, but in those with neural deficits, significant neurologic improvement is unlikely, and neurologic deterioration may occur.(ABSTRACT TRUNCATED AT 250 WORDS)     

Anterior spine stabilization and decompression for thoracolumbar injuries

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

Conservative management of burst fractures of the fifth lumbar vertebra

Isolated fractures of the lumbar fifth vertebrae (L5) are very rare, and there is little information in the literature regarding comparisons between conservative management and surgical treatment of this entity. This retrospective analysis reports on five cases of isolated burst fractures of the fifth lumbar vertebra without neurologic deficit. All cases were managed nonoperatively with a short period of bed rest followed by protected mobilization. The current study reveals that conservative management is appropriate in the cases of burst fractures of the fifth lumbar vertebra with minimal canal compromise, with little deformity, and without neurologic damage.     

The economic implications of operative vs. non-operative management of thoracolumbar burst fractures: A systematic review

Thoracolumbar burst fractures are a common injury that accounts for nearly one-sixth of all thoracolumbar injuries. Management options for thoracolumbar burst fractures consist of operative or non-operative approaches, both of which have been demonstrated to be successful. However, the economic implications of different management options are poorly characterized. This article is a systematic review of the existing literature and outlines the current knowledge on comparative cost-effectiveness of operative vs. non-operative management of thoracolumbar burst fractures. Out of 259 identified articles, 32 underwent full text review and only 5 addressed economic issues that allowed for a comparison of the cost-effectiveness of operative vs. non-operative approaches. The findings suggest that there is a limited understanding of the cost-effectiveness of either approach and, in particular, a lack of American studies into this issue. Guidance is needed for decision making in regards to the most cost-effective management of thoracolumbar burst fractures. We suggest that a randomized prospective cost-effectiveness trial of thoracolumbar burst fractures treated operatively or non-operatively would be valuable in guiding efficient management of these injuries.     

Does neurological recovery in thoracolumbar and lumbar burst fractures depend on the extent of canal compromise?

STUDY DESIGN: Prospective study. OBJECTIVES: Forty-five consecutive cases of thoracolumbar and lumbar burst fractures treated non-operatively were analyzed to correlate the extent of canal compromise at the time of injury with (i) the initial neurologic deficit and (ii) with the extent of neurological recovery at 1 year. The effect of spinal canal remodeling on neurological recovery was also analyzed. SETTING: University teaching hospital in south India. METHODS: The degree of spinal canal compromise and canal remodeling were assessed from computed tomography scans. The neurologic status was assessed by Frankel's grading. RESULTS: The mean canal compromise in patients with neurologic deficit was 46.2% while in patients with no neurological deficit it was 36.3%. The mean spinal canal compromise in patients with neurological recovery was 46.1% and 48.4% in those with no recovery. The amount of canal remodeling in patients who recovered was 51.7% and 46.1% in the patients who did not recover. None of these differences was statistically significant. CONCLUSION: This study shows that there is no correlation between the neurologic deficit and subsequent recovery with the extent of spinal canal compromise in thoracolumbar burst fractures.     

Management of thoracolumbar spine trauma: An overview

Thoracolumbar spine fractures are common injuries that can result in significant disability, deformity and neurological deficit. Controversies exist regarding the appropriate radiological investigations, the indications for surgical management and the timing, approach and type of surgery. This review provides an overview of the epidemiology, biomechanical principles, radiological and clinical evaluation, classification and management principles. Literature review of all relevant articles published in PubMed covering thoracolumbar spine fractures with or without neurologic deficit was performed. The search terms used were thoracolumbar, thoracic, lumbar, fracture, trauma and management. All relevant articles and abstracts covering thoracolumbar spine fractures with and without neurologic deficit were reviewed. Biomechanically the thoracolumbar spine is predisposed to a higher incidence of spinal injuries. Computed tomography provides adequate bony detail for assessing spinal stability while magnetic resonance imaging shows injuries to soft tissues (posterior ligamentous complex [PLC]) and neurological structures. Different classification systems exist and the most recent is the AO spine knowledge forum classification of thoracolumbar trauma. Treatment includes both nonoperative and operative methods and selected based on the degree of bony injury, neurological involvement, presence of associated injuries and the integrity of the PLC. Significant advances in imaging have helped in the better understanding of thoracolumbar fractures, including information on canal morphology and injury to soft tissue structures. The ideal classification that is simple, comprehensive and guides management is still elusive. Involvement of three columns, progressive neurological deficit, significant kyphosis and canal compromise with neurological deficit are accepted indications for surgical stabilization through anterior, posterior or combined approaches.     

Short-segment pedicle instrumentation of thoracolumbar burst fractures: does transpedicular intracorporeal grafting prevent early failure?

STUDY DESIGN: A prospective, randomized study comparing two treatment methods for thoracolumbar burst fractures: short-segment instrumentation with transpedicular grafting and the same procedure without transpedicular grafting. OBJECTIVE: To evaluate the efficacy of transpedicular grafting in preventing failure of short-segment fixation for the treatment of thoracolumbar burst fractures. SUMMARY OF BACKGROUND DATA: Short-segment pedicle instrumentation for thoracolumbar burst fractures is known to fail early because of the absence of anterior support. Additional transpedicular grafting has been offered as an alternative to prevent this failure. However, there is controversy about the results of transpedicular grafting. METHODS: Twenty patients with thoracolumbar burst fractures were included in the study. The inclusion criterion was the presence of fractures through the T11-L3 vertebrae without neurologic compromise. The patients were randomized by a simple method into two groups. Group 1 patients were treated using short-segment instrumentation with transpedicular grafting (TPG) (n = 10), and Group 2 patients were treated by short-segment fixation alone (NTPG) (n = 10). Clinical (Likert's questionnaire) and radiologic (sagittal index, percentage of anterior body height compression, and local kyphosis) outcomes were analyzed. RESULTS: The two groups were similar in age, follow-up period, and severity of the deformity and fracture. The postoperative and follow-up sagittal index, percentage of anterior body height compression, and average correction loss in local kyphosis in both groups were not significantly different. The failure rate, defined as an increase of 10 degrees or more in local kyphosis and/or screw breakage, was also not significantly different (TPG = 50%, NTPG = 40%, P = 0.99). CONCLUSIONS: Short-segment transpedicular instrumentation of thoracolumbar burst fractures is associated with a high rate of failure that cannot be decreased by additional transpedicular intracorporeal grafting.     

胸腰椎爆裂性骨折后椎管重建—兼论非手术治疗的意义

目的 证实胸腰椎爆裂性骨折后的椎管重建现象,并探讨非手术治疗的意义。方法 回顾性分析３１例胸腰椎爆裂性骨折,其中未治疗７例,非手术治疗１６例,手术治疗８例,随访时间３～７年。记录初次诊治入院时和随访时脊髓损伤程度。以及出院和随访时椎管狭窄率。结果 ３１例患者的椎管狭窄率由初次诊治出院时的１２．３％～７４．５％（平均２６．２％）降至随访时的５．４％～４６．５％（平均１９．２％）,差异具有极显著性意义     

Unstable thoracolumbar injuries.

The treatment of thoracolumbar fractures was traditionally conservative. With increasing demands for early mobilization, operative reduction and stabilization has become more popular, even in less severe injuries. The Harrington instrumentation is still useful and efficient. However, in fractures with posterior element ruptures, the internal fixator is superior in stabilizing the fracture. Early mobilization in a body cast is an equivalent treatment to surgery in less severe burst fractures if the neurology is intact. A treatment program for different fractures is presented.     

The nonoperative treatment of burst fractures of the thoracolumbar junction

Treatment of thoracolumbar spine burst fracture with a neurologically intact patient is controversial, with advocates of operative and nonoperative approaches. Of 404 patients in a prospective spinal trauma study, 21 had burst fractures, were neurologically intact, and had greater than 1-year followup. This group was analyzed to evaluate treatment with early mobilization using a thoracolumbar total contact orthosis. The average time in a brace was 6 months. Two patients had pulmonary embolus treated successfully with anticoagulants. No patient required subsequent surgery for increasing kyphosis or neurologic deficit. Change in K angle at followup was 4.6 degrees (+/- 5.7) and change in anterior vertebral height was 6.1 degrees (+/- 10). All patients had a satisfactory pain score and most individuals returned to full employment. It is concluded that it is not necessary to routinely treat patients operatively with burst fractures if they fulfill the following criteria: 1) neurologically intact; 2) kyphosis angle less than 35 degrees; 3) other injuries do not preclude the use of a total contact orthosis; and 4) the patient is capable of understanding and cooperating with the treatment regime. These criteria are irrespective of the CT findings of posterior vertebral retropulsion and spinal canal narrowing.     

Treatment of thoracolumbar burst fractures without neurologic deficit by indirect reduction and posterior instrumentation: bisegmental stabilization with monosegmental fusion

This study retrospectively reviews 20 sequential patients with thoracolumbar burst fractures without neurologic deficit. All patients were treated by indirect reduction, bisegmental posterior transpedicular instrumentation and monosegmental fusion. Clinical and radiological outcome was analyzed after an average follow-up of 6.4 years. Re-kyphosis of the entire segment including the cephaled disc was significant with loss of the entire postoperative correction over time. This did not influence the generally benign clinical outcome. Compared to its normal height the fused cephalad disc was reduced by 70% and the temporarily spanned caudal disc by 40%. Motion at the temporarily spanned segment could be detected in 11 patients at follow-up, with no relation to the clinical result. Posterior instrumentation of thoracolumbar burst fractures can initially reduce the segmental kyphosis completely. The loss of correction within the fractured vertebral body is small. However, disc space collapse leads to eventual complete loss of segmental reduction. Therefore, posterolateral fusion alone does not prevent disc space collapse. Nevertheless, clinical long-term results are favorable. However, if disc space collapse has to prevented, an interbody disc clearance and fusion is recommended. Received: 21 October 1998 Revised: 26 March 1999 Accepted: 12 April 1999     

Remodeling of the spinal canal after thoracolumbar burst fractures

Thirty-one patients with thoracolumbar burst fractures, seven untreated, 16 treated nonoperatively, and eight treated operatively, were analyzed retrospectively and followed up for 3 to 7 years. The initial and final degrees of neurologic deficit and the stenotic ratio of the spinal canal were recorded. Stenotic ratio significantly decreased from the first examination (range, 12.3%-74.5%; average, 26.2%) to the final followup (range, 5.4%-46.5%; average, 19.2%), but there were no differences of the percentage of remodeling between patients who were untreated and those treated nonoperatively and operatively. The recovery rate was highly significantly related to the stenotic ratio at first examination. Nonoperative management may be considered for treatment of patients who are neurologically intact or only slightly impaired with thoracolumbar burst fractures.     

Management of thoracolumbar spine fractures

Background contextTraumatic fractures of the spine are most common at the thoracolumbar junction and can be a source of great disability.PurposeTo review the most current information regarding the pathophysiology, injury pattern, treatment options, and outcomes.Study designLiterature review.MethodsRelevant articles, textbook chapters, and abstracts covering thoracolumbar spine fractures with and without neurologic deficit from 1960 to the present were reviewed.ResultsThe thoracolumbar spine represents a unique system from a skeletal as well as neurological standpoint. The rigid rib-bearing thoracic spine articulates with the more mobile lumbar spine at the thoracolumbar junction (T10 - L2), the site of most fractures. A complete examination includes a careful neurologic examination of both motor and sensory systems. CT scans best describe bony detail while MRI is most efficient at describing soft tissues and neurological structures. The most recent classification system is that of the new Thoracolumbar Injury Classification and Severity Score. The different fracture types include compression fractures, burst fractures - both stable and unstable -, flexion-distraction injuries and fracture dislocations. Their treatment, both operative and non-operative depends on the degree of bony compromise, neurological involvement, and the integrity of the posterior ligamentous complex. Minimally invasive approaches to the care of thoracolumbar injuries have become more popular, thus, the evidence regarding their efficacy is presented. Finally, the treatment of osteoporotic fractures of the thoracolumbar spine is reviewed, including vertebroplasty and kyphoplasty, their risks and controversies, and senile burst fractures, as well.ConclusionsThoracolumbar spine fractures remain a significant source of potential morbidity. Advances in treatment have minimized the invasiveness of our surgery and in certain stable situations, eliminated it all together.