Decision-making in burst fractures of the thoracolumbar and lumbar spine

The most common site of injury to the spine is the thoracolumbar junction which is the mechanical transition junction between the rigid thoracic and the more flexible lumbar spine. The lumbar spine is another site which is more prone to injury. Absence of stabilizing articulations with the ribs, lordotic posture and more sagitally oriented facet joints are the most obvious explanations. Burst fractures of the spine account for 14% of all spinal injuries. Though common, thoracolumbar and lumbar burst fractures present a number of important treatment challenges. There has been substantial controversy related to the indications for nonoperative or operative management of these fractures. Disagreement also exists regarding the choice of the surgical approach. A large number of thoracolumbar and lumbar fractures can be treated conservatively while some fractures require surgery. Selecting an appropriate surgical option requires an in-depth understanding of the different methods of decompression, stabilization and/or fusion. Anterior surgery has the advantage of the greatest degree of canal decompression and offers the benefit of limiting the number of motion segments fused. These advantages come at the added cost of increased time for the surgery and the related morbidity of the surgical approach. Posterior surgery enjoys the advantage of being more familiar to the operating surgeons and can be an effective approach. However, the limitations of this approach include inadequate decompression, recurrence of the deformity and implant failure. Though many of the principles are the same, the treatment of low lumbar burst fractures requires some additional consideration due to the difficulty of approaching this region anteriorly. Avoiding complications of these surgeries are another important aspect and can be achieved by following an algorithmic approach to patient assessment, proper radiological examination and precision in decision-making regarding management. A detailed understanding of the mechanism of injury and their unique biomechanical propensities following various forms of treatment can help the spinal surgeon manage such patients effectively and prevent devastating complications.     

Spinal canal remodelling after stabilization of thoracolumbar burst fractures

Summary Spinal canal areas were measured prospectively in 22 consecutive burst fractures of the thoracolumbar junction, preoperatively, within 1 week postoperatively and 1 year after operation. Preoperative canal encroachment averaged 38% (range 10%–70%) of the estimated original area. The 11 patients with neurological impairment had a significantly more severe initial canal encroachment (mean 48%) than those who were neurologically intact (mean 33%). Postoperatively, canal encroachment had decreased to a mean of 18% (range 0%–62%). Within 12 to 15 months postoperatively, canal encroachment was further reduced by resorption of bone fragments to a mean of 2%. The largest observed remaining encroachment was 29%. The amount of bone resorption correlated significantly with the persistent postoperative encroachment. A critical appraisal of the methods used to assess the pre-fracture canal area revealed that reconstructing the vertebral foramen of the fractured vertebra on CT scans substantially overrated the original area as compared with averaging the canal area of the two adjacent vertebrae.     

The effect of postoperative immobilization on short-segment fixation without bone grafting for unstable fractures of thoracolumbar spine

Background:

Controversy regarding the fixation level for the management of unstable thoracolumbar spine fractures exists. Often poor results are reported with short-segment fixation. The present study is undertaken to compare the effect of fixation level and variable duration of postoperative immobilization on the outcome of unstable thoracolumbar burst fractures treated by posterior stabilization without bone grafting.

Patients and Methods:

A randomized, prospective, and consecutive series was conducted at a tertiary level medical center. Thirty-six neurologically intact (Frankel type E) thoracolumbar burst fracture patients admitted at our institute between February 2003 and December 2005 were randomly divided into three groups. Group I (n = 15) and II (n = 11) patients were treated by short-segment fixation, while Group III (n = 10) patients were treated by long-segment fixation. In Group I ambulation was delayed to 10th-14th postoperative day, while group II and III patients were mobilized on third postoperative day. Anterior body height loss (ABHL) percentage and increase in kyphosis as measured by Cobb''s angle were calculated preoperatively, postoperatively, and at follow-up. Denis Pain Scale and Work Scales were obtained during follow-up.

Results:

Mean follow-up was 13.7 months (range 3-27 months). At the final follow-up the mean ABHL was 4.73% in group I compared with 16.2% in group II and 6.20% in group III. The mean Cobb''s angle loss was 1.8° in group I compared with 5.91° in group II and 2.3° in group III. The ABHL difference between groups I and II was significant (P = 0.0002), while between groups I and III was not significant (P = 0.49).

Conclusion:

The short-segment fixation with amenable delayed ambulation is a valid option for the management of thoracolumbar burst fractures, as radiological results are comparable to that of long-segment fixation with the advantage of preserving maximum number of motion segments.     

Short segment fixation of thoracolumbar burst fractures without fusion

There continues to be controversy surrounding the management of thoracolumbar burst fractures. Numerous methods of fixation have been described for this injury, but to our knowledge, spinal fusion has always been part of the stabilising procedure, whether this involves an anterior or a posterior approach. Apart from an earlier publication from this centre, there have been no reports on the use of internal fixation without fusion for this type of fracture. The aim of the study was to determine the outcome of patients with thoracolumbar burst fractures who were treated with short segment pedicle screw fixation without fusion. This is a retrospective review of 28 consecutive patients who had short segment pedicle screw fixation of thoracolumbar burst fractures without fusion performed between 1990 and 1993. All patients underwent a clinical and radiological assessment by an independent observer. Outcome was measured using the Low Back Outcome Score. The minimum follow-up period was 2 years (mean 3.1 years). Fifty percent of patients achieved an excellent result with the Low Back Outcome Score, while 12% were assessed as good, 20% fair and 16% obtained a poor result. The only significant factor affecting outcome was the influence of a compensation claim (P < 0.05). The implant failure rate (14% of patients) and the clinical outcome was similar to that from series where fusion had been performed in addition to pedicle screw fixation. The results of this study support the view that posterolateral bone grafting is not necessary when managing patients with thoracolumbar burst fractures by short segment pedicle screw fixation. Received: 24 February 1998 Revised: 1 March 1999 Accepted: 27 May 1999     

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     

Percutaneous vertebroplasty for the treatment of osteoporotic burst fractures

Background  Vertebroplasty is a minimally invasive surgical procedure which involves injecting polymethylmethacrylate into the compressed vertebral body. At present the indications include the treatment of osteoporotic compression fractures, vertebral myeloma, and metastases. The value of vertebroplasty in osteoporotic compression fracture has been discussed comprehensively. The surgical operation for burst fractures without neurological deficit remains controversial. Some authors have asserted that vertebroplasty is contraindicated in patients with burst fracture. However, we performed the procedure, after considering the patents general condition, to reduce surgical risks and the duration of immobilisation. The purpose of this study is to investigate clinical outcomes, kyphosis correction, wedge angle, and height restoration of thoraco-lumbar osteoporotic burst fractures treated by percutaneous vertebroplasty. Materials and methods  Twenty-five patients with osteoporotic burst fracture were treated with postural reduction followed by vertebroplasty. We measured the kyphosis, wedge angle, spinal canal compromise and the height of the fractured vertebral body initially, after postural reduction, and after vertebroplasty. Findings  The average height of the collapsed vertebral bodies was 24.8% of the original height. Average kyphosis angle was 19.4° and average wedge angle was 19.8° at first. Mean canal encroachment was initially 25.1%. Kyphosis angle, wedge angle, and anterior, middle, and posterior height improved significantly after the procedure. The mean amelioration of the spinal canal encroachment after vertebroplasty was 23.3%. The average increase in anterior vertebral body height was 7.5 mm, central was 5.8 mm, and posterior was 0.9 mm. The mean reduction in kyphosis angle was 6.8° and the mean reduction in wedge angle was 9.7°. Conclusion  Although vertebroplasty has been considered as contraindicated in thoraco-lumbar burst fractures, we successfully used the procedure as a safe treatment in patients with osteoporotic burst fracture without neurologic deficit. This method could eliminate the need for and risks of major spinal surgery. We would like to offer it as a relatively safe and effective methods of management in thoraco-lumbar burst fractures.     

Thoracolumbar burst fractures with a neurological deficit treated with posterior decompression and interlaminar fusion

Introduction  

To our knowledge, thoracolumbar burst fractures with a neurological deficit treated with posterior decompression and interlaminar fusion have never been reported. Our study was to assess the outcome of posterior decompression and interlaminar fusion in treating thoracolumbar burst fractures with a neurological deficit.     

Results of the AO spinal internal fixator in the surgical treatment of thoracolumbar burst fractures

Summary The potential for clinical instability following thoracolumbar fractures has evoked a progressive increase in interest in the surgical treatment of unstable thoracolumbar fractures. From September 1988 to October 1991, 44 thoracolumbar burst fractures were treated surgically by the AO Spinal Internal Fixator at the Orthopaedics and Traumatology Clinics of Ankara Social Security Hospital. Mean follow-up period was 28.8 (range 12–48) months. Fourteen (31.8%) of the patients were female, and 30 (68.2%) were male. Postoperatively, the mean anterior vertebral height loss and spinal canal compromise were corrected by 36.5% and 39.9%, respectively. Also, postoperatively 15.9° of improvement was obtained in the mean kyphosis angle. The mean compression angle, which was 19.5° preoperatively, was corrected by 12.3° and came to an average of 7.1° posteroperatively. In light of these data, it is suggested that the AO Spinal Internal Fixator effectively restores three-dimensional alignment of the spine and provides a rigid fixation.     

Percutaneous pedicle screw fixation and kyphoplasty for management of thoracolumbar burst fractures

OBJECTIVE: To evaluate outcome and potential advantages of a percutaneous posterior approach to burst fractures of the thoraco-lumbar junction without neurological complications by means of a technique combining balloon kyphoplasty and percutaneous pedicule screw fixation. METHODS: In this preliminary study patients who suffered traumatic of the thoraco-lumbar junction presented a Magerl type A3 fracture. The mean age of the patients was 64 years (54-78 years). All had a normal neurological examination. A combined technique using balloon kyphoplasty, that allows restoration of the vertebral height and fixation by means of cement injection with percutaneous osteosynthesis was performed as a minimal invasive alternative treatment. Mean follow-up (plain radiograph and CT scan, pain assessment) was 12 months (range 5-14 months). RESULTS: All patients experienced an early pain relief, successfully mobilized on day 1 after surgery and discharged after a mean stay of 4.5 days. Immediately postoperatively the mean vertebral height restoration was 11.5% and the reduction of the kyphotic angle was 9 degrees. Those results were maintained over the complete follow-up period. Only one patient required analgesic treatment with weak opioids (step II of the WHO pain ladder) 3 months after surgery. CONCLUSIONS: The treatment of burst fractures of the thoraco-lumbar junction with no neurological complication by associating minimally invasive techniques results in good fracture reduction and stabilisation. The main advantage of this approach is to shorten the hospital stay.     

Percutaneous kyphoplasty and pedicle screw fixation for the management of thoraco-lumbar burst fractures

The study design includes prospective evaluation of percutaneous osteosynthesis associated with cement kyphoplasty on 18 patients. The objective of the study is to assess the efficacy of a percutaneous method of treating burst vertebral fractures in patients without neurological deficits. Even if burst fractures are frequent, no therapeutic agreement is available at the moment. We report in this study the results at 2 years with a percutaneous approach for the treatment of burst fractures. 18 patients were included in this study. All the patients had burst vertebral fractures classified type A3 on the Magerl scale, between levels T9 and L2. The patients’ mean age was 53 years (range 22–78 years) and the neurological examination was normal. A percutaneous approach was systematically used and a kyphoplasty was performed via the transpedicular pathway associated with percutaneous short-segment pedicle screw osteosynthesis. The patients’ follow-up included CT scan analysis, measurement of vertebral height recovery and local kyphosis, and clinical pain assessments. With this surgical approach, the mean vertebral height was improved by 25% and a mean improvement of 11.28° in the local kyphotic angle was obtained. 3 months after the operation, none of the patients were taking class II analgesics. The mean duration of their hospital stay was 4.5 days (range 3–7 days) and the mean follow-up period was 26 months (range 17–30 months). No significant changes in the results obtained were observed at the end of the follow-up period. Minimally invasive methods of treating burst vertebral fractures can be performed via the percutaneous pathway. This approach gives similar vertebral height recovery and kyphosis correction rates to those obtained with open surgery. It provides a short hospital stay, however, and might therefore constitute a useful alternative to open surgical methods.     

Kyphoplasty for the treatment of incomplete osteoporotic burst fractures

Kyphoplasty has become a standard procedure in the treatment of painful osteoporotic compression fractures. According to current guidelines, involvement of the posterior wall of the vertebral body is a relative contraindication. From February 2002 until January 2008, 97 patients with at least one AO classification A 3.1 fracture were treated by kyphoplasty. There was a structured follow-up for the medium-term evaluation of the patients’ outcome. Ninety-seven patients (68 of whom were females and 29 of whom were males) with involvement of the vertebra’s posterior margin averaging 76.1 ± 12.36 (59–98) years were treated by kyphoplasty. The fractures of 75 patients were caused by falls from little height, 5 patients had suffered traffic accidents and in the case of 17 patients, no type of trauma was remembered. According to the AO classification, there were 109 A 3.1.1 and one A3.1.3 injuries. Prior to surgery, all patients were neurologically without pathological findings. Seventy-nine fractures were accompanied by a narrowing of the spinal canal [average of 15% (10–40)]. Overall, 134 vertebras were treated by Balloon kyphoplasty (81 × 1 segment, 22 × 2 segments, 3 × 3 segments). In 47.4% of the patients, cement leakage was observed after surgery. All patients with cement extravasation, however, were clinically unremarkable. Using the visual analog scale, patients stated that prior to surgery their pain averaged 8.1, whereas after surgery it significantly decreased and averaged 1.6 (p < 0.001). In geriatric patients with osteoporotic vertebral fractures with partial inclusion of the posterior wall of the vertebral body, kyphoplasty is an effective procedure with few complications.     

Vertebroplasty increases compression of adjacent IVDs and vertebrae in osteoporotic spines

Background contextApproximately 25% of vertebroplasty patients experience subsequent fractures within 1 year of treatment, and vertebrae adjacent to the cemented level are up to three times more likely to fracture than those further away. The increased risk of adjacent fractures postaugmentation raises concerns that treatment of osteoporotic compression fractures with vertebroplasty may negatively impact spine biomechanics.PurposeTo quantify the biomechanical effects of vertebroplasty on adjacent intervertebral discs (IVDs) and vertebral bodies (VBs).Study designA biomechanics study was conducted using cadaveric thoracolumbar spinal columns from elderly women (age range, 51–98 years).MethodsFive level motion segments (T11–L3) were assigned to a vertebroplasty treated or untreated control group (n=10/group) such that bone mineral density (BMD), trabecular architecture, and age were similar between groups. Compression fractures were created in the L1 vertebra of all specimens, and polymethylmethacrylate bone cement was injected into the fractured vertebra of vertebroplasty specimens. All spine segments underwent cyclic axial compression for 115,000 cycles. Microcomputed tomography imaging was performed before and after cyclic loading to quantify compression in adjacent VBs and IVDs.ResultsCyclic loading increased strains 3% on average in the vertebroplasty group when compared with controls after 115,000 cycles. This global strain manifested locally as approximately fourfold more compression in the superior VB (T12) and two- to fourfold higher axial and circumferential deformations in the superior IVD (T12–L1) of vertebroplasty-treated specimens when compared with untreated controls. Low BMD and high cement fill were significant factors that explained the increased strain in the vertebroplasty-treated group.ConclusionsThese data indicate that vertebroplasty alters spine biomechanics resulting in increased compression of adjacent VB and IVD in severely osteoporotic women and may be the basis for clinical reports of adjacent fractures after vertebroplasty.     

椎体成形术治疗胸腰椎内固定术后置钉椎压缩性骨折疗效观察

目的 探讨椎体成形术在治疗胸腰椎内固定术后置钉椎压缩性骨折的临床疗效。方法 2016 年 6月至2019年6月期间,共有12例胸腰椎内固定术后置钉椎压缩性骨折患者于广州市增城区人民医院采用椎体成形术治疗。术后观察有无骨水泥渗漏、再次骨折及内固定松动断裂;收集手术前、术后3天、术后1月、术后3月、术后6月、术后12月患者疼痛视觉模拟评分（VAS）、椎体压缩率及Cobb 角。结果 所有患者随访12个月。仅1例发生骨水泥渗漏,无椎体再次骨折,无内固定松动断裂。术后腰背部VAS评分、椎体压缩率及Cobb 角相比术前具有统计学差异（P<0.05）。术后1月和术后3月、术后6月、术后12月对比,腰背部VAS评分、椎体压缩率及Cobb 角相比无统计学差异（P>0.05）。结论 椎体成形术用于治疗胸腰椎内固定术后置钉椎压缩性骨折可明显缓解腰背部疼痛,预防再次骨折、内固定松动断裂,是一种有效的治疗方法。     

Non neurologic burst thoracolumbar fractures fixation: Case-control study

Study designBurst fractures not associated with any neurological deficits are frequent but not therapeutic agreement on their management is available to date. This case-control study was conducted to try to help guide therapeutic decision in the treatment of such fractures.Materials and methodsThis case-control study includes consecutive retrospective evaluation of 25 case-patients treated by posterior short-segment fixation associated with kyphoplasty (SFK) in the treatment of A3 thoracolumbar unstable fractures, as compared to a control-group composed of 82 patients treated by long-segment (LF) pedicle screws.ResultsSFK patients bled significantly less than the LF patients (p = 0.04). Assessment of deformation progression, vertebral height restoration and reduction of the regional kyphotic angle in the SFK and LF groups revealed no statistically significant superiority of one approach on another. In contrast, the height of endplates was significantly increased in the SFK group (p = 0.006). The patients’ pain levels were significantly improved in the SFK group (p = 0.002). However, patients from the SFK group stood earlier postoperatively (1.7 vs 3.7 days, p = 0.001).ConclusionWe believe that SFK in vertebral fractures is as efficient as LF for bone consolidation and spine stabilization. In addition, SFK patients may use fewer analgesics.     

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。     

The phenomenon and efficiency of ligamentotaxis after dorsal stabilization of thoracolumbar burst fractures

Thirty-six consecutive patients with burst fractures of the thoracolumbar spine and with a fractured posterior vertebral surface dislocated into the spinal canal without neurological symptoms were treated with the AO internal fixator. Computed tomography-aided planimetry of the spinal canal was undertaken preoperatively and within 1 week postoperatively to elucidate the effect of kyphosis correction and distraction on spinal canal widening (ligamentotaxis). The stenosis of the spinal canal area (SCA) was reduced from 29% preoperatively to 19% postoperatively (+10%) of the estimated original area, and the stenosis of the mid-sagittal diameter (MSD) reduced from 31 to 23% (+8%). The widening of the SCA was greater at the level of L1/L2 (+13%) than at L3/L4 (+6%). High preoperative canal compromise was associated with greater absolute spinal canal widening. Large trapezoid-shaped fragments resisted reduction by ligamentotaxis. Even though the effect of ligamentotaxis after operative treatment with the internal fixator was proven, a certain stenosis of the spinal canal remains in most cases. Especially for patients with fracture-related neurological symptoms, ligamentotaxis alone does not seem sufficient for the requested spinal decompression. Even an exact analysis of preoperative CT scans under consideration of the fracture level will not always allow an exact prognosis of the expected effect of ligamentotaxis.     

Burst fracture of the fifth lumbar vertebra: results of posterior internal fixation and transpedicular bone grafting

Burst fractures of the fifth lumbar vertebra are rare, and there are only a few reports on this subject, which is characterised by its unique anatomical and biomechanical features. This retrospective analysis reports on ten patients whose fractures of L5 were stabilised with a short internal fixator in combination with a posterior fusion as well as transpedicular bone grafting. The average follow-up period was 22 months. Radiometric data were surveyed and compared to the functional results. The height of the fractured vertebra remained nearly unchanged throughout the course. Loss of lordosis of 4 degrees in the upper disc space and 4 degrees in the lower disc space were observed postoperatively. At the time of follow-up, the values of segmental lumbar lordosis were significantly below the preoperative level. The narrowing of the neural canal was reduced from 57% to 28% with the surgical intervention. However, there was no correlation between the functional and the radiological outcome. Neurological deficits were documented in two patients, which declined during the course. There were no severe postoperative complications. The results of the present study demonstrate that the described surgical procedure in fractures of the fifth lumbar vertebra does not promote an anatomic restoration of the fractured vertebra, nor of the segmental lordosis. However, the clinical results do not correlate with the radiological outcome. Nonoperative treatment with early mobilisation without external support seems to be the treatment of choice.     

经骨折椎椎弓根直接复位固定治疗胸腰椎爆裂性骨折

目的探讨胸腰椎爆裂性骨折经骨折椎椎弓根直接复位固定的可行性及原理。方法2001年6月～2005年11月手术治疗胸腰椎单节段爆裂性骨折患者24例,男16例,女8例；平均年龄32．5岁。骨折部位：T_(11) 2例,T_(12) 9例,L_1 11例,L_2 2例。按ASIA脊髓神经功能障碍分级标准：A级1例,B级2例,C级5例,D级3例,E级13例。按椎管阻塞面积分为4度：Ⅰ度3例,Ⅱ度9例,Ⅲ度10例,Ⅳ度2例。手术方法：骨折椎及相邻的上、下椎体经椎弓根置入螺钉后,按固定区的正常矢状面形态将棒预弯；旋转预弯棒,利用中间螺钉作为支点,将骨折椎向前推顶,纠正伤椎后突畸形及水平移位；上、下椎弓根钉撑开,行后外侧植骨。结果所有患者获得3～34个月(平均21个月)随访,伤椎高度恢复至正常的93．6%,水平移位恢复至正常的0．6%,矢状面Cobb角由术前26．5°恢复至术后的3．1°。椎管面积由术前的44．6%增加至术后的92．1%。骨折椎体愈合满意,不完全神经损伤手术后脊髓神经功能有1～2级的恢复。无神经损伤及加重等并发症。结论经骨折椎椎弓根螺钉固定是安全可靠的方法；对骨折直接复位和固定可提高复位质量,改善固定强度及应力分布。     

上腰椎爆裂型骨折外侧入路的手术方法

目的: 介绍上腰椎爆裂型骨折外侧入路的手术方法。方法: 沿骶棘肌外缘切口, 分离暴露L1、2、3横突, 切除横突、椎弓根、椎体后缘和突出的椎间盘, 减压硬膜管, 并同时作椎体间植骨骨水泥固定。结果: 50例患者均能达到脊髓前减压彻底和椎体间植骨融合稳定的目的。截瘫和下肢神经症状的恢复根据Frankel标准, 一般均能恢复 1~2个档次。结论: 上腰椎爆裂型骨折外侧入路的手术方法, 能达到脊髓前减压彻底和椎体间植骨融合稳定的目的。