颈椎前路钛板置入内固定后螺钉松动3例

背景：对于保守治疗效果不佳的颈椎病患者及颈椎外伤后椎间盘突出或椎体骨折压迫脊髓出现神经根神经症状者,颈椎前路椎间盘切除、椎体次全切植骨/钛笼固定仍然是其主要治疗方式。 目的：总结颈前路钛板内固定后螺钉松动的原因及防治策略。 方法：纳入41例颈椎病和颈椎损伤患者,根据手术适应证选择经前路颈椎间盘切除、椎体次全切行颈椎前路钛板内固定,内固定后有3例出现螺钉钛板松动,分析其发生原因并提出防治方法,以减少颈前路钛板螺钉松动的发生率。 结果与结论：3例螺钉松动患者均出现不同程度的吞咽困难症状,确诊后2周内行2次手术,调整螺钉位置后重新固定钛板,远期观察患者内固定位置良好,症状缓解。提示适应证及置入方法的选择,内固定器材的合理应用,正确的置入后管理是预防颈前路钛板内固定后螺钉松动的关键。     

Screw fixation of craniocervical junction

In recent years an increase has been observed of the use of screw techniques for the fixation of the craniocervical junction. For clinical use two techniques have been introduced: (1) transarticular screw fixation, and (2) transpedicular screw fixation. In the former the screw is inserted through the C2 lateral mass, the fissure of the C1-C2 joint, and the C1 lateral mass. (2) in the latter the screw is inserted into the C2 pedicle and anchored in C2 vertebral body. Transarticular or pedicle screws can be easily connected to longitudinal elements such as rods or plates, and combined with lateral mass screws of the remaining cervical vertebrae or occipital screws. In comparison to sublaminar wiring or interlaminar clamping the screw techniques: (a) strengthen the stiffness of the construct and speed up fusion, (b) allow fixation in the absence or deficiency of laminae as a result of trauma or laminectomy, and (c) can selectively include only the affected segments. Increased construct stiffness is due to deep anchorage of the screw in bone providing thus a solid grip on the vertebra. Both techniques require preoperative assessment of the course of the vertebral artery using imaging methods. In about 18% of cases abnormal course of the artery precludes screw use. Pedicle screw insertion requires direct control of the medial and superior walls of C2 pedicle with dissector introduced into the vertebral canal, which requires removal of the atlantoaxial ligament. Additional control can be achieved with lateral fluoroscopy. The entry point for transarticular screw is on the lateral mass of the odontoid 2-3 mm laterally to the medial margin of C2 facet and 2-3 mm above the C1/C2 articular fissure. The screw trajectory is 0-10 degrees in horizontal plane and towards the anterior C1 tuberculum in sagittal plane.     

Transpedicular reconstruction of vertebral body height with simultaneous interbody spondylodesis

BACKGROUND AND PURPOSE: Surgical treatment of traumatic spinal injury should include fast and complete decompression of spinal cord and radices wits reduction of broken vertebral body, restoration of physiological spinal curvatures and spondylodesis of injured segments. Restoration of natural spinal curvatures is only possible when the height of broken vertebral body is reconstructed. MATERIAL AND METHODS: Between 1992 and 2001, 75 patients were operated on because of traumatic injuries of thoracolumbar spine in the Ortopaedic and Traumatology Department Skubiszewski Medical University of Lublin. 48 patients had broken vertebral body reduction with simultaneous filling of bone loss with autogenic bone grafts inserted through pediculum. Only in 4 cases posterior spondylodesis was carried out on arches and spinous processes. Transpedicular plasty of 44 broken vertebral bodies was connected with posterior interbody fusion with PLIF technique using graft application to interbody space. RESULTS: The operative protocol presented above allowed for the height of the anterior vertebral wall to be restored on average to 81.5% of the original height. We did not observe either fatigue breakage of the screws or screws loosening with kyphosis recurrence. We did not note serious postoperative complications, including neurological compromise. The operative procedure did not significantly change the neurological status of the patients. In 9 cases we noted neurological improvement: usually by 1 or 2 grades in Frankel's score. CONCLUSIONS: Restoration of the fractured vertebral body with bone grafts combined with posterior interbody spondylodesis effectively prevents the recurrence of the kyphotic deformation.     

Anterior retropharyngeal plate screw fixation with bilateral anterior transarticular screws for odontoid fractures ... a new comprehensive technique

Introduction: A certain group of odontoid fractures (Anderson and D’ Alonzo Type-2) are usually offered surgical treatment. Common surgical option is an anterior odontoid screw. Some of the fractures are not suitable for anterior odontoid screw (anterior oblique, displaced distal fragments and those with atlantoaxial instability) and these are usually offered posterior transarticular screws (Magerl’s) or posterior atlantoaxial screw rod/plate fixation (Goel-Harms technique). Posterior surgery involves atlantoaxial fixation with an indirect attempt to reduce and fuse the fracture . Posterior surgery has a risk of injury to the vertebral arteries, hemorrhage from the paravertebral venous plexus and the C2 root ganglion.

Methods: A direct anterior submandibular retropharyangeal approach with open reduction and fixation (ORIF) using a customized variable screw placement (VSP) plate was used to realign and fix the fracture fragments in compression mode under direct vision. Twenty patients of type-II odontoid fractures (unsuitable for anterior odontoid screw) underwent an anterior retropharyngeal approach with anterior variable screw position (VSP) plate and screw fixation and eight amongst them, who had associated atlantoaxial instability underwent additional bilateral anterior transarticular screws.

Results: All patients treated by this technique had 100% fracture site bone union without any implant failure. Longest follow-up has been for 3 years.

Conclusion: Anterior retropharyangeal approach allows direct fracture fragment realignment under vision with an opportunity to fix in compression mode using the VSP plate, which ensures early fusion across the type-II odontoid fracture. Any associated instability can be treated by additional bilateral anterior transarticular screws. The approach is simple and safe without any risk to the vertebral arteries and biomechanically appealing.     

三种置钉方法在下颈椎经椎弓根螺钉置入过程中的比较

背景：目前各种下颈椎椎弓根置钉方法的准确率报道不一,特别是国内常用的椎板部分切除置钉法、Abumi法、管道疏通法缺乏比较。 目的：探讨下颈椎(C3~7)经椎弓根螺钉内固定的可行性,比较椎板部分切除置钉法、Abumi法、管道疏通法在置钉满意率、出血量、置钉时间、并发症等方面的差异。 方法：选择60例需颈后路经椎弓根螺钉内固定治疗的下颈椎疾患病例,随机分成3组,各置入椎弓根螺钉80枚,分别采用椎板部分切除置钉法、Abumi法及管道疏通法。术中计算各方法置钉时间、出血量;出院前观察置钉满意率及在颈椎椎弓根四壁损伤例数的构成比;比较C3~7每一节段的椎弓根外侧壁损伤发生率。 结果与结论：椎板部分切除组、Abumi组及管道疏通组置钉时间依次递减(P < 0.05),置钉满意率依次递增(P < 0.05)。3组间置钉出血量及颈椎椎弓根四壁损伤例数的构成比差异无显著性意义(P > 0.05),椎弓根损伤好发生于外壁。C4、C5节段外壁损伤发生率明显高于C3、C6、C7。提示管道疏通法在经颈后路椎弓根螺钉内固定常规置钉法中优势明显。     

前置与上置重建钢板固定锁骨中段骨折生物力学性能比较**☆

背景：锁骨中段粉碎性骨折采用切开复位内固定时,其钢板放置方法尚有争议,须经研究证实重建钢板前置与上置的生物力学差异,从而为临床治疗提供有效指导。 目的：比较前置与上置重建钢板固定锁骨中段骨折的生物力学性能。 方法：采集12具成人新鲜锁骨标本(共24根),致中段锁骨粉碎骨折,分别采用6孔钢板固定并将标本随机分为3组：钢板上置组(n=9)：重建钢板经塑形后,固定于锁骨骨折标本上方,保证骨折线两端均有3枚螺钉;钢板前置组(n=9)：重建钢板经塑形后,固定于锁骨骨折标本上方,保证骨折线两端均有3枚螺钉;正常标本组(n=6)：无任何干预措施。测试各组试件的生物力学特性,并进行比较。 结果与结论：三点弯曲强度、扭转强度和刚度测量表明,钢板上置组和钢板前置组与正常标本组相比,差异无显著性意义(P > 0.05);而拉伸试验表明,钢板前置组内固定抗拉强度和刚度优于钢板上置组(P < 0.05);抗拔力亦明显优于钢板上置组(P < 0.05);同时钢板前置组内固定应力遮挡小,明显优于钢板上置组(P < 0.05)。提示钢板前置是治疗锁骨中段粉碎性骨折的一种可靠治疗方法。 关键词：锁骨骨折;中段骨折;重建钢板;前置;上置;生物力学     

Acrylic bone cement use for internal spondylodesis in neurosurgical operations

Vertebral column stabilization relying on performing of surgical internal spondylodesis with acrylic bone cement (methylmethacrylate, MMA) was carried out in 27 cases treated surgically in Department and Clinic of Neurosurgery in Poznań from 1996 to 1999. The age of patients was 16-69 (mean age 50.29 +/- 15.29) years. Male patients predominated (2:1). The vertebral lesion was caused by neoplasm (55% of cases), degenerative disease (26%), trauma (19%). Pathological changes were found in cervical region in 16 (59%), in thoracic region in 6 (22%) and in lumbar region in 5 (19%) patients. The anterior surgical approach to vertebral column was chosen in 17 (63%), posterolateral approach in 8 (30%) and posterior approach in 2 (7%) patients. Bone acrylic cement was used for reconstruction of vertebral body damaged by neoplasm or trauma, whereas it substituted the removed intervertebral disc or vertebral body in degenerative diseases. The acrylic cement graft in all cases maintained the proper anterior and medial vertebral column alignment. Semiliquid acrylic cement was used for filling of defects after tumour removal in thoracic and lumbar vertebral bodies. Acrylic cement graft was properly prepared in cuboid form and was inserted into the intervertebral spaces in patients with trauma or degenerative diseases. In all cases involving bone acrylic cement, stabilization of the vertebral segment was completed by metallic implants (cervical plates, "Z" plates, intrapedicular screws and rods). No postoperative complications (wound infections or implant dislocation) were observed. Postoperative, neurological signs were intensified in 3 cases (12%) and were regressive. Mortality rate was 4%. This type of internal spondylodesis makes possible to restore the anterior and medial columns and immobilisation of the proper vertebral segments.     

术中CT导航在上颈椎螺钉固定手术中的应用

目的 为降低椎动脉、神经损伤和螺钉位置偏差等风险,探索应用术中CT实时导航技术完成上颈椎螺钉置入.方法 应用术中CT实时导航技术完成螺钉置入,9例患者中7例颅颈交界区畸形,1例C1～2巨大神经鞘瘤,1例C1～3椎板巨大血管性病变行上颈段螺钉固定,共置钉42枚.结果 根据Madawi定义的合理螺钉位置,9例共置钉42枚,位置满意,其中1例颅颈交界畸形患者二侧高跨椎动脉,1例-侧高跨椎动脉,共3枚C2螺钉为以往螺钉技术的相对禁忌证.所有患者无椎动脉、脊髓或神经损伤,没有穿破骨皮质,复位满意,固定牢靠.结论 使用术中CT三维影像实时导航,可以安全、准确地完成上颈段螺钉固定.

Abstract：

Objective For improvement of safety, avoiding the risk of injury of vertebral artery and nerve tissue, intraoperative CT guided placement of screws in upper cervical spine were performed.Methods Brain LAB Vector Vision system in conjunction with iCT were used for image guidance.42 screws were placed at C1, C2 levels using this technique in 9 patients, including 7 cases of craniovertebral junction malformation, 1 case of C1～2 giant schwannoma, and 1 case of C1-3 giant lamina vascular lesion.Results According to Madawi's definition of rational placement of screw, all 42 screws were placed satisfactorily.For 3 C2 screws, including 1 case of both side and 1 case of one side of high riding vertebral arteries, the placement of them was relative contraindication for traditional techniques.There was no injury of vertebral artery, spinal cord or nerves resulted from the placement of screws.There was no bony breach.Conclusions Intraoperative navigation by 3 -dimensional CT image guidance is helpful for safe and accurate placement of screws in upper cervical spine.     

Thoracolumbar fracture dislocation: a study of 30 patients

Open reduction and wiring of the spinous processes were carried out in patients with a thoracolumbar fracture dislocation. Clinical and X-ray examinations were performed on 30 patients 5 or more years following operation. At the time of the initial examination, an anterior angulation of 30 degrees or more was noted in 18 patients, but only in 4 cases at the time of the follow-up examination. Anterior displacement of the vertebral bodies was seen in 30 patients, but it was found to be normal in 26 patients at the time of follow-up. There were 7 patients with lateral angulation of 5 degrees or more, but only 2 patients at the time of follow-up. Lateral displacement of 5 mm or more was observed in 10 patients, but only 3 patients could be seen at the time of follow-up. In comparison with spinal instrumentation with the use of large long metallic materials, wiring of the spinous processes has several advantages such as limited surgical invasion, firm fixation, no effect on spinal mobility and no need for repeat surgery for removal of metallic materials. It is an adequate alternative method for the internal fixation of rotational fracture dislocations of the thoracolumbar region of the spine, without fracture of the posterior wall of the vertebral body and pedicle fracture.     

The Management of Bilateral Interfacetal Dislocation with Anterior Fixation in Cervical Spine : Comparison with Combined Antero-Posterior Fixation

Objective

Combined antero-posterior fixation has been a standard method for bilateral interfacetal dislocation in cervical spine. The purpose of this study is to evaluate the efficacy and complication of anterior cervical stabilization in treatment of bilateral interfacetal dislocation.

Methods

A total of 65 cases of traumatic bilateral interfacetal dislocation in cervical spine who were managed in our institution, from Mar. 1997 to Feb. 2006, were included in this study. Closed reduction was tried in all cases before operation. If closed reduction was accomplished successfully, only anterior cervical fixation was performed (Group I), and attempted to place screws bicortically as possible with unicortical screws. If failed, posterior open reduction with fixation was first tried, followed by anterior cervical fixation (Group II). All patients were evaluated for neurological outcome and radiological evidence of healing.

Results

The Group I included 47 patients and the Group II, 18 patients. The improvement of Frankel grade and increase of mean cervical lordosis angles were not statistically different between two groups. Screw-plate system used did not influence the outcome. On follow up, solid bone fusion was evident and there were no cases of instability in both groups.

Conclusion

Our study demonstrated that anterior cervical fixation on BID is safe and effective in comparison with combined antero-posterior cervical fixation.     

利用图像存储传输系统数据库构建下颈椎椎弓根模型及其临床意义

背景：下颈椎椎弓根钉内固定技术具有良好的生物力学强度、三维稳定性和植骨融合率。然而,由于下颈椎解剖结构复杂且个体差异性大,常导致螺钉置入困难,复位风险高。 目的：利用图像存储传输系统结合64排CT片及X射线片于内固定前精确测量下颈椎后方解剖学结构,指导下颈椎内固定过程中椎弓根置钉。 方法：51例下颈椎疾患病例利用图像存储传输系统测量定位法行颈椎椎弓根内固定。同时对比同期开展治疗的两种不同方案的颈椎内固定患者：解剖置钉法26例,管道疏通法17例。以Andrew椎弓根螺钉CT位置分级标准评价3组患者的置钉准确率。 结果与结论：图像存储传输系统测量定位组置钉准确率显著高于其他两组(P < 0.05),图像存储传输系统测量定位组病例均未发现脊髓、椎动脉、神经等组织损伤。提示应用图像存储传输系统结合64排CT及X射线片内固定前测量,能够指导内固定过程中安全置入颈椎椎弓根螺钉,置钉效果明显强于传统的解剖置钉法及管道疏通法。     

颈椎后路螺钉-钛棒(板)内固定技术:初步临床报告

目的 报告利用螺钉-钛棒（板）固定技术治疗各种原因引起的颈椎不稳的初步临床结果。方法 作者1年来行颈椎后路螺钉-钛棒（板）技术内固定9例，其中齿突样骨引起的C1～C2不稳2例，手术后进行性颈椎后凸2例，颈椎管狭窄2例，C3-C4滑脱1例，C6～C7外伤滑脱2例。分别采用C1侧块、C2椎弓根螺钉、C3～C5侧块螺钉、C2-T2椎弓根螺钉植入技术，然后连接钛棒或钛板完成固定。9例病人共植入螺钉59枚。结果 所有病人在1周内带外支架进行活动，除1例因拒绝治疗死亡外，其余病人在1个月及1年后复查均未见内固定物移位。结论 颈椎后路螺钉-钛棒（板）固定为安全可靠的技术，可以术后即刻获得牢固内固定，为下一步治疗创造有利条件。     

An anterior expandable titanium cage in Mycobacterium avium vertebral osteomyelitis

Mycobacterial infection is most commonly caused by Mycobacterium tuberculosis. M. avium and M. intracellulare are two other organisms within the Mycobacteria group often classified together as the mycobacterium avium-intracellulare complex (MAC). MAC is of low virulence and usually causes disease in immunocompromised patients such as those with the human immunodeficiency virus. Isolated vertebral osteomyelitis secondary to MAC infection is rare with only 18 previous reports, only one of which required surgical intervention. There is increasing evidence that vertebral body osteomyelitis with other pathogens can be treated with decompression, debridement and reconstruction with titanium vertebral body cages in the setting of active infection. We present a 70-year-old Caucasian male with a pathological fracture of T6 vertebral body and a kyphosis of 60° and MRI findings consistent with granulomatous osteomyelitis. Vertebrectomies of T5 and T6 were performed and an expandable titanium cage was inserted with supplementary lateral fixation using plate and screws. This is the first report of a single-stage decompression and fusion with a titanium vertebral body cage for active MAC vertebral osteomyelitis.     

Minimally invasive central corpectomy for ossified posterior longitudinal ligament in the cervical spine

Minimally invasive central corpectomy (MICC) for cervical segmental ossified posterior longitudinal ligament (OPLL) is described. The procedure of MICC includes upper- or lower-half central corpectomy of the involved cervical spine, transdiscal decompression of the adjacent disc level, dissection and partial removal of the OPLL, removal of the OPLL behind the vertebral body via these windows, and fusion with cylindrical titanium cages. Anterior plate fixation is not necessary. From January 2008 to December 2009 we surgically treated three patients with cervical OPLL by MICC. All three patients showed remarkable improvement of their symptoms within a few days after the operation. No neurological or radiological complication was observed during that period. MICC is beneficial in avoiding complete corpectomy and long fusion, usage of an anterior plate, and usage of a large external orthosis. MICC also reduces the risk of postoperative esophageal perforation due to a screw backing out of the plate.     

Endoscopic microsurgery in herniated cervical discs

The purpose of this study was to make public our results using endoscopic microsurgery in herniated cervical discs. This technique allows us to avoid complications due to conventional exposure, as is the case in traditional approaches. This study was carried out from January 1991 to January 1998. One hundred and seventy-one patients should have undergone traditional surgery for 296 herniated cervical discs. They were, instead, treated by using endoscopic microsurgical techniques. In 273 herniations the surgical procedure was performed by a paramidline right anterior approach, and in 23 herniations by a paramidline posterior approach, with a working sleeve of 4.6 mm outer diameter in both cases. In the anterior approach the tube was firmly placed against the anterior longitudinal ligament and the edge of the anterior part of the vertebral bodies. The neurovascular structures were placed lateral to the working sleeve and the visceral structures were placed medial to the working sleeve. Then, under endoscopic coaxial control, removal of the herniated part was performed, through the intervertebral discs, with microsurgical instruments. In the posterior approach, the tube was placed instead between the inferior and superior lamina, then under the nerve root up to the herniation, which was removed. This posterior approach was used only in the lateral disc herniations. There were no incidents or major complications following these operations. After one month the success rate was 94.7%, after three months 95.9%, after six months 96.4% and after one year 97%. There were no cases of relapse during the follow-up period of these patients. This study suggests that for herniated cervical discs, the endoscopic microsurgical technique is an extremely advantageous and safe method. Moreover, longer follow-up periods and an increased number of patients treated with this procedure should further confirm the usefulness of this technique.     

Anterior versus combined anterior and posterior fixation/fusion in the treatment of distraction-flexion injury in the lower cervical spine.

This study compared the results of combined anterior and posterior fixation/fusion with those of anterior fixation/fusion alone through a retrospective review of 50 patients with a distraction flexion injury of the cervical spine. Group A (n=28) had unilateral facet joint subluxation or dislocation (Allen stage I or II) and anterior fixation/fusion alone. Group B (n=10) had bilateral dislocation (Allen stage III) and anterior fixation/fusion alone. Group C (n=5) had unilateral subluxation or dislocation and combined anterior and posterior fixation/fusion. Group D (n=7) had bilateral dislocation or total dislocation (Allen stage III or IV) and combined anterior and posterior fixation/fusion. The following parameters were analyzed: the change in the vertebral height and Cobb's angle, neurologic recovery, fusion time, fusion rate, surgery time, and the rate of complications. The mean fusion time was 3.75+/-2.10, 6.00+/-2.82, 3.60+/-1.34, and 3.85+/-2.26 months in groups A, B, C, and D, respectively. Group B had a significantly longer mean fusion time than groups A and D (Mann-Whitney U-test, P=0,012, P=0.014). There was a significant difference in the operation time between groups A and B and groups C and D. There were no significant differences in the changes in vertebral height and Cobb's angle, fusion rate, and neurologic recovery. The complications encountered were three cases of distal screw loosening in group A (n=2) and B (n=1), and three cases of delayed union in group A (n=2) and B (n=1). There were no complications in groups C and D. In those with a bilateral dislocation, the fusion time was increased when only anterior fixation/fusion had been performed but the clinical results, such as neurologic recovery and complications, were similar in the four groups. Overall, anterior fixation/fusion alone in a bilateral dislocation is recommended as an alternative method.     

显微镜下经口腔复位内固定术治疗颅底凹陷合并寰枢椎脱位

目的 探讨经口腔入路松解、复位内固定术在颅底凹陷合并寰枢椎脱位治疗中的应用价值,并评价其有效性及安全性.方法 对3 例不可复性寰枢椎脱位患者实施显微镜辅助下经口腔入路松解、复位内固定术,术中以经口腔复位内固定钛板作为前方固定,自体颗粒骨植骨.采用日本骨科协会(JOA)17 分评分系统进行手术前后颈脊髓神经功能评价,MRI 及X 线判断术后寰枢间距及延髓颈髓角改善程度.结果 3 例患者手术平均时间为130 min(110、130 和150 min);平均出血量为150 ml(100、200 和150 ml).术后CT 检查显示,3 例患者内固定钛板及12 枚椎弓根钛钉固定理想、无松动迹象,颅底凹陷及寰枢关节脱位得到不同程度纠正;颈脊髓神经功能明显改善,JOA评分改善率分别为75.00%、40.00%和56.25%,平均改善率为57.08%,平均JOA 评分改善率评级为良好.其中1 例患者术后并发颅内感染,经对症治疗痊愈.结论 显微镜辅助下经口腔入路松解、复位内固定术治疗颅底凹陷合并寰枢椎脱位具有一定临床应用价值.     

Lateral approach corpectomy and reconstruction after anterior longitudinal ligament release in cases with fixed kyphosis: A technical note and a preliminary case series

Lateral approach corpectomy is a useful surgical technique for adult spinal deformity with vertebral deformity. However, in cases with anterior ankylosing over adjacent vertebrae, it is hard to achieve ideal correction without posterior column resection. To minimize surgical invasiveness, we have developed a method for lateral approach corpectomy and reconstruction after anterior longitudinal ligament release (LCRA) in such cases. The aim of the current study is to describe LCRA, and investigate surgical invasiveness, sagittal correction and perioperative complications in this surgery. The subjects were three patients (all female, average age 69.0 years old) with adult spinal deformity with severe fixed kyphosis who underwent LCRA and posterior fixation with pedicle screws. The primary disease was osteoporotic vertebral fracture in all patients. The operative levels were T12 in 2 cases and L2 in 1 case. The operative time and estimated blood loss were 442.3 ± 51.9 min and 875.7 ± 397.5 mL, respectively. Local kyphotic deformity was well corrected from 54.2 ± 4.3° preoperatively to 10.1 ± 3.7° in these surgeries (p < 0.001). There were surgical complications of dural tear and postoperative hemothorax in one case each. These outcomes suggest that LCRA gives good sagittal correction in cases with fixed kyphosis after osteoporotic vertebral fracture, and that this method is a viable surgical option for correction of fixed kyphosis.     

In vitro simulation of intraoperative vertebroplasty applied for pedicle screw augmentation. A biomechanical evaluation

Background and purpose

The purpose of this study was to evaluate the effect of an in vitro simulation of intraoperative vertebroplasty on embedded pedicle screws resistance to pullout. This method involved an application of acrylic cement into the vertebral bodies only after pedicle screws implementation.

Thoracic hyperextension injury with opening wedge distraction fracture in DISH -consideration of surgical strategy based on intraoperative pathological findings-

Diffuse idiopathic skeletal hyperostosis (DISH) is a well-recognized disease characterized by calcifications and ossifications of the entheses mainly in the spine. Patients with DISH are prone to sustaining spinal injuries even after minor trauma because of the long-lever arm mechanism induced by any type of force acting on the rigid yet brittle spine. The number of cases of trauma in DISH-affected spines is predicted to increase during the coming decades because of an increase in DISH-related comorbidities. Generally, posterior fixation with spinal instrumentation spanning three levels above and below the injured site is regarded as a standard treatment for hyperextension fractures of the thoracolumbar spine in patients with DISH. However, no consensus has been reached regarding whether additional anterior fixation is needed for hyperextension injuries with remarkable vertebral body wedge. We experienced one case of hyperextension injury at the thoracic level in patient with DISH. A remarkable remodeling phenomenon in the fractured vertebral body was intraoperatively noticed, which was pathologically confirmed. This is the first report to have confirmed pathologically new bone formation in the anterior column wedge despite the fact that only 1 month had passed since the first injury. Although whether additional anterior fixation is needed for hyperextension injuries with remarkable vertebral body wedge is controversial, this report supports that posterior fixation alone might be an adequate treatment.