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The management of thoracolumbar burst fractures: a prospective study between conservative management, traditional open spinal surgery and minimally interventional spinal surgery


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The objective of this study was to assess which patient group had better outcomes for management of single level thoracolumbar spinal fractures. We prospectively collected data on the outcomes of patients having either conservatively managed, traditional open surgery, or minimally interventional surgery (MIS) for treatment of a single level thoracolumbar fracture. All patients had previously asymptomatic spines prior to their fractures and had a single level thoracolumbar burst fracture of more than 20° kyphosis. Fractures treated operatively, either via open surgery or MIS techniques, were corrected to less than 10° of residual kyphosis using a monoaxial pedicle screw construct 2 levels above & 2 levels below the fracture posteriorly only. The metalwork was removed between 6 months and 1 year post operatively to remobilise the spinal segments. All patients were then evaluated at least 6 months after metal work removal and at 18 months post fracture using radiographs and the Oswestry Disability Index (ODI). Those patients treated with MIS techniques demonstrated superior outcomes compared to traditional open techniques and conservative methods of treatment, with significantly reduced hospital stay, better return to work & leisure, and the best chance of restoring their spine to near its pre-injury status. We would recommend MIS techniques as the best way of treating single level thoracolumbar spinal fractures. There is a significant improvement in ODI when treated by MIS over open surgical methods.
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RES E AR C H Open Access
The management of thoracolumbar burst fractures:
management, traditional open spinal surgery and
minimally interventional spinal surgery
Amit Kumar
, Randeep Aujla
and Christopher Lee
The objective of this study was to assess which patient group had better outcomes for management of single
level thoracolumbar spinal fractures. We prospectively collected data on the outcomes of patients having either
conservatively managed, traditional open surgery, or minimally interventional surgery (MIS) for treatment of a single
level thoracolumbar fracture. All patients had previously asymptomatic spines prior to their fractures and had a
single level thoracolumbar burst fracture of more than 20° kyphosis. Fractures treated operatively, either via open
surgery or MIS techniques, were corrected to less than 10° of residual kyphosis using a monoaxial pedicle screw
construct 2 levels above & 2 levels below the fracture posteriorly only. The metalwork was removed between
6 months and 1 year post operatively to remobilise the spinal segments. All patients were then evaluated at least
6 months after metal work removal and at 18 months post fracture using radiographs and the Oswestry Disability
Index (ODI).
Those patients treated with MIS techniques demonstrated superior outcomes compared to traditional open techniques
and conservative methods of treatment, with significantly reduced hospital stay, better return to work & leisure, and the
best chance of restoring their spine to near its pre-injury status. We would recommend MIS techniques as the best way
of treating single level thoracolumbar spinal fractures. There is a significant improvement in ODI when treated by MIS
over open surgical methods.
Keywords: Thoracolumbar fracture; Minimally invasive surgery; Open surgery; Oswestry disability index; Single level
The treatment of thoracolumbar burst fractures of the
spine still excites debate and disagreement. In patients
without neurological deficit, there are those who advo-
cate conservative treatment whatever the instability or
deformity (Chow et al. 1996; Shen et al. 2001; Cantor
et al. 1993). However, some patients are left with signifi-
cant disability when fractures have healed with a signifi-
cant deformity, particularly kyphosis (Xiang-Wang et al.
2008; Shen and Shen 1999). Many would advise fixation
and correction of fractures with kyphosis more than 30°,
and a significant number with deformity less than that
(Xiang-Wang et al. 2008; Shen and Shen 1999; Kim
et al. 2011; Logroscino et al. 2009; Tezeren et al. 2009).
The risk of late collapse in conservatively managed pa-
tients is a risk. Spinal braces are poor at preventing this
and fixation usually avoids this problem (McAfee et al.
1982). There are many that claim that operative fixation
carries a morbidity risk, with significant risk to soft tis-
sues, particularly paraspinal muscles (Kim et al. 2009;
MacNab et al. 1977). Fixation also carries the risk of fail-
ure of correction and loss of position, particularly with
older types of implants and short segment fixation
(Xiang-Wang et al. 2008; Alanay et al. 2001; Tezeren
and Kuru 2005).
Minimally interventional surgery (MIS) seeks to avoid
the soft tissue damage that comes with traditional open
techniques, and allows the benefits of longer constructs
* Correspondence:
Specialist Orthopaedic Registrar, University Hospitals Leicester, Infirmary
Square, Leicester LE1 5WW, UK
Full list of author information is available at the end of the article
a SpringerOpen Journal
© 2015 Kumar et al.; licensee Springer. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons. org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction
in any medium, provided the original work is properly credited.
Kumar et al. SpringerPlus (2015) 4:204
DOI 10.1186/s40064-015-0960-4
(Logroscino et al. 2009; Tezeren and Kuru 2005; Choll
2010; Ringel et al. 2006; Hatta et al. 2009; Smith et al.
2010). MIS techniques, however, have to deliver correc-
tion and stabilisation that is as good as with conven-
tional open techniques, without compromise to implant
placement or increased risk of complications, and allow
easy implant insertion and removal. Such techniques
involve placing pedicle screws through small paraspinal
incisions, preserving the overlying muscles and soft
tissues, then sliding a rod bent to the appropriate shape
under the muscles from one incision to the other before
locking it down into the screws with the appropriate
end-caps, reducing and stabilising the fracture.
To date there have been no prospective trials that
demonstrate the benefits of MIS techniques over others
when correcting or stabilising spinal fractures and none
that directly compares open and MIS techniques using
exactly the same implants for both. Our study looks at
prospectively collected data of the past nine years, which
addresses this.
In total 78 patients met the inclusion criteria for the
study. 30 patients were treate d conservatively, 23 pa-
tients were treated via open operative techniques, and
25 patients were treated via MIS techniques. The total
cohort confirmed a pre-injury ODI score of 0, and had a
single level spinal fracture at T12, L1 or L2, with a local
kyphosis greater than 20°. There were 29 fractures (37%)
involving T12, 41 fractures (53%) involving L1, and 8
fractures (10%) involved L2. The youngest was 18 years
and oldest was 53 years of age at the time of injury.
There was no variance in patient demographics or char-
acteristics between conservative, open conventional sur-
gery or MIS groups (Table 1). The mechanism of injury
and fracture characteristi cs are shown in Table 2 and 3
Analysis of data showed there was no difference in
degree of post-traumatic kyphosis between the groups
(p = 0.79). The re is a significant difference in the t ime
spent in hospital between conser vative treatme nt
(mean 36 days) and any surgical interve ntion (mean
24 days, p < 0.005). There is also a significant difference
in time spent in hospital between the two surgical groups,
with favourable results for MIS (mean 4 days for open
surgery versus mean 2 days for MIS; p < 0.001, Table 4).
In the conservatively managed cohort 8 patients (27%)
did not return to their original occupa tions. 5 (17%) of
these eventually returned to a less demanding occupa -
tion, and 3 (10%) became unemployed. In the conven-
tional surgery group, 4 (17%) patients did not return to
original occupa tion and eventually returned to a less
demanding occupation. For the MIS cohort all patients
returned to their original occupations.
With regard to the ODI, our results showed that there
is a significant difference between MIS (ODI = 4) and
conventional open treatment (ODI = 14) at all ODI time
scales (p < 0.0001). There is an even greater difference
between MIS (ODI = 4) and conservatively treated pa-
tients (ODI = 32) (p < 0.0001) for both 18 and 30 months.
At 30 months follow up the ODI scores failed to im-
prove and were unchanged in all groups (Table 4). The
MCID for t he ODI at 30 months for conser vative,
conventional surgery and MIS are 4.5, 2.8 and 1.7
The degree of corre ction achieved using the two surgi-
cal techniques showed no significant difference (p = 0.8).
Patients whom underwent conventional open surgery
had a mean kyphosis of 3.5° after correction. This was
an 87% improvement on their initial post traumatic
Table 1 Demographics and patient characteristics for the
three treatments groups for single level spinal fractures
Demographics Conservative (%) Open surgery (%) MIS (%)
Number of patients 30 23 25
Mean age (range) 31 (2152) 29 (1949) 31 (1853)
Gender M:F 19:11 15:8 14:11
Manual occupation 12 (40) 10 (44) 11 (44)
16 (53) 11 (47) 12 (48)
Sports person 2 (7) 2 (9) 2 (8)
Table 2 Incidences of different mechanism/place of
injuries for the spinal fractures treated conservatively or
by different surgical methods
Mechanism of injury Conservative (%) Open surgery (%) MIS (%)
Road traffic accident 12 (40) 10 (44) 11 (44)
Sporting injury 8 (27) 5 (22) 6 (24)
Industrial injury 4 (13) 4 (17) 4 (16)
Domestic injury 6 (20) 4 (17) 4 (16)
Table 3 Fracture characteristics for the spinal fracture
groups treated conservatively or by different surgical
Conservative (%) Open surgery (%) MIS (%)
T12 12 (40) 9 (39) 8 (32)
L1 15 (50) 12 (52) 14 (56)
L2 3 (10) 2 (9) 3 (12)
Magerl Type A 19 (63) 9 (39) 11 (44)
Magerl Type B 11 (37) 14 (61) 14 (56)
Mean Post-Traumatic
Kyphosis (degrees)
24 (2027) 26 (2033) 26 (2134)
Kumar et al. SpringerPlus (2015) 4:204 Page 2 of 10
kyphosis (see Table 5 and Figure 1). The MIS cohort had
a mean corrected kyphosis of 3.7°, giving an 86% im-
provement. The residual kyphosis after removal of
metalwork remained the same as after fixation.
There was no significant difference in improvement in
kyphosis of patients with Magerl Type A (p = 0.6) or
Type B (p = 0.4) fractures between the Open surgery
group and MIS group. There was no significant change
in kyphosis in those patients managed conservatively
from post-traumatic to final degree of kyphosis (P > 0.5).
The mean operative time for both surgical groups
(conventional open and MIS) was 120 minutes. The
mean blood loss was 80mls for the MIS group and
550mls for the conventio nal open group. No patients
required blood transfusion post operatively in either
surgical group.
In the conservative group, 6 patients had a kyphosis that
deteriorated further (mean 5°, 3-8°) during the follow-up
period with 5 patients requiring subs equent procedures
to correct post-traumatic kyphosis. These patients
underwent anterior reconstructive techniques to restore
stability and kyphosis. The other complication that did
exist in 4 patients was a transient bowel ileus. All cases
resolved spontaneously without treatment and its occur-
rence likely to be related to bed rest. Only one patient
had loss of correction (3°) in conventional open opera-
tive group and one patient had a post-operative wound
infection that settled with antibiotics. There were no
complications in the MIS group.
There were no cases of venous-thromboembolism
(DVT or PE). All patients received mechanical prophy-
laxis and when deemed safe commenced on low molecu-
lar weight heparin after 5 days while recumbent.
Patients had mechanical prophylaxis also during surgery
and were mobilised post-operatively as soon as safely
possible. This was a universal departmental policy.
Patients treated with bed rest had regular pressure
areas checks and log-rolls to avoid decubitus ulcers.
There were no incidences of other medical complica-
tions such as chest infection or res piratory problems.
We feel our incidence of VTE was low as the cohort
consisted of young fit patient s with little other medical
co-morbidities and the spine injury as their only injury.
Non-operative management of stable thoracolumbar
spinal fractures has been advocated even in the pres ence
of kyphotic collapse (C how et al. 1996; Shen et al. 2001;
Cantor et al. 1993). Our results show that correction of
these fractures offers significant benefit to patients in
terms of ODI scores, return to work, time spent in hos-
pital and secondary complications. If the spine is left
with a deformity after fracture, then this has significant
effects on spinal balance and the vertebral levels above
and below (Xiang-Wang et al. 2008; Shen and Shen
1999). The older the patient, the less able the spine will
be to compensate, and even in younger patients one
would expect the spine to decompensate in later years
with consequent disa bility. We believe that fractured
spines should be treated like any other bony injury i.e.
to reduce, hold and rehabilitate, and that an unreduced
deformed fracture is likely to cause disability.
Traditional open operations on the spine do lead to a
legacy of soft tissue damage, particularly from stripping
the posterior paraspinal muscles away from the spine
(MacNab et al. 1977). A fusion adds an additional mech-
anical insult by creating a permanent stiff segment with
stress transfer to other levels. If no fusion is carried out,
then damage to those paraspinal muscles results in func-
tional loss as those muscle groups are required to sup-
port and move those segments (MacNab et al. 1977;
Choll 2010). Many surgeons try to limit the soft tissue
damage caused by restricting the number of segments
spanned by any construct to one level above and below
the fractured vertebra. Short segment fixations such as
these from the posterior aspect alone have a significant
Table 4 Time spent in hospital in days, time taken to
return to work in months, and ODI at all time scales
Open surgery
MIS (Range)
Time in hospital (days) 36 (10104) 4 (27) 2 (14)
Time to return to work
9 (324) 4 (0.5-9) 2 (0.1-6)
ODI prior to metalwork
n/a 14 (426) 4 (010)
ODI at 18 months 32 (1246) 14 (426) 4 (010)
ODI at 30 months 32 (1246) 14 (426) 4 (010)
Table 5 Showing the degree of kyphosis pre and post
Fracture kyphosis Conservative Open surgery MIS
Mean in degrees
Initial post- traumatic 24 (2027) 26 (2033) 26 (2134)
Post treatment 25 (2032) 4 (08) 4 (07)
Initial post- traumatic
Magerl Type A
23 22 23
Post treatment Magerl
Type A
23 2 3
Initial post- traumatic
Magerl Type B
25 28 28
Post treatment Magerl
Type B
25 4 4
Kumar et al. SpringerPlus (2015) 4:204 Page 3 of 10
incidence of loss of correction and metalwork failure
(Xiang-Wang et al. 2008; Alanay et al. 2001; Tezeren
and Kuru 2005). Anterior procedures provide greater
structural supp ort to short segment posterior constructs
such as these, but carry a significant complication risk
and morbidity (Kim et al. 2009). Anterior procedures for
thoracolumbar fractures also means taking down the
diaphragm and violating the chest, which is best avoided
if possible, particularly if patients have concomitant
chest trauma. Stabilising the spine in these patients how-
ever has marked benefits for the recovery from associ-
ated trauma to other organs (Bellabarba et al. 2010).
MIS offers the benefit s of longer segment posterior
correction and fixation without the damage to soft tis-
sues and paraspinal muscles that traditional open sur-
gery involv es (Choll 2010; Hatta et al. 2009; Smith et al.
2010). The fractured segment is stable once healed
(Lindsey et al. 1993; Wang et al. 2006) and allows sec-
ondary removal of metalwork to remobilise those seg-
ments spanned (Kim et al. 2011). MIS techniques allow
this withou t further soft tissue trauma. MIS techniques
must satisfy certain criteria if they are to show benefit.
There must be no compromise when using these tech-
niques , and the surgeon must be able to achieve every-
thing that would be attained with open surgery.
Implants must be able to be placed as reliably and accur-
ately as with open techniques. Fractures and deformity
must be able to be reduced as well and reliably as with
open techniques. The desired outcome should be
achieved as well as with open techniques. Our study
demonstrates that our techniques achieve this, and that
our techniques are safe, reliable and reproducible.
Another issue is equipment and its availability. There
are now a number of different systems available on the
market for MIS techniques, but virtually all rely on tubes
attached to the pedicle scr ews to guide and seat the rods
allowing reduction into the pedicle screw. These systems
all have a disadvantage, because they can only be used
with polyaxial screws to allow for pedicle screw angle
variation. This is because a tube attached to the screw
head magnifies this variation, and polyaxiality is there-
fore required to align the screws/tubes to allow passage
of the rod. This means that with these systems, the ped-
icle screw itself cannot be used as a vehicle to reduce a
fracture or deformity. Our techniques do not have this
disadvantage, because we have adapted a system de-
signed for open surgery directly for MIS techniques. The
reduction is carried out directly into the screw head on
the surface of the bone, which means that we can use
monoaxial or solid screws. When the reduction clamps
are applied, this allows the unit to behave like a Schanz
pin/screw, thereby permit ting strong reliable active cor-
rection of the fracture and deformity with the pedicle
Our conservative methods of treatment were standard
and part of an agreed departmental protocol. Patients
were assessed for brace tolerance, pressure areas and
compliance (although all patients assured us they were
complying), psychological factors (espe cially with bed
rest) and problems with immobility (DVT/PE, pressure
areas, bowel & bladder habit, chest problems). We have
an aggressive physiotherapy protocol with regular roll-
ing, in bed exercises & chest protocols. These protocols
are comprehensive and regularly reviewed to ensure best
There was a clear difference in return to work between
open and conservative groups in our paper in contrast
to the paper by Wood et al. In their paper, they found
no difference in return to work between surgical and
conservative methods (Wood et al. 2003). All of our pa-
tients who underwent MIS returned to work. This may
be related to our young patient cohor t. The mean ages
Figure 1 Chart showing mean kyphosis (degrees) post treatment.
Kumar et al. SpringerPlus (2015) 4:204 Page 4 of 10
of our patients has been stated whereas solely an age
range of 1866 years was mentioned in the paper of
Wood et al.
Additionally, the paper by Wood et al. does not have
the degree of kyphosis that our patients did. In their
paper, the average degree of kyphosis pre-op was 10° and
post- surgery (Wood et al. 2003). Most surgeons
would accept a pre-op kyphosis post injury of 10° but
this is patient dependent. This also may indicate less vio-
lence in their patients, more stable fractures, and that
the degree of kyphosis plays more of a part than their
paper might perhaps gives credit to.
One would expect that for their cohort of patients
with such a low degree of deformity that operative treat-
ment would not be expected to confer an advantage.
The patients in our study, by contrast, represent an en-
tirely different group. In relation to this, the ODI scores
in their paper was 20.75 at final follow up in the opera-
tive group, and 10.7 for the conservative group (Wood
et al. 2003). Our ODI scores are much lower for our
MIS group at 4 point s, and higher for our conservative
group at 32 points, which may reflect the greater degree
of viole nce involved and the effects of a greater degree
of post-traumatic kyphos is. Our MCID scores were
smaller than previous studies for the ODI due to narrow
standard deviations (Copay et al. 2008; Ostelo et al.
2008; Hagg et al. 2003).
We accept that the limitations of our study include
the lack of variability in patients within the cohort. We
have adopted strict inclusion criteria to try and make pa-
tient groups a s comparable as possible. Patients were
not random ised to treatment but were given the option
after full discussion of the risks and benefits with the
senior author of treatment options of surgery and con-
servative treatment. Additionally this is a study of short
term follow up and longer term outcome data is re-
quired to assess the long term sequelae of such injuries.
To date there has been no study to directly compare
MIS techniques with open techniques using the exactly
the same equipment for each. Our non-randomised,
comparative study conclusively addresses this, and
shows the benefits of MIS techniques. The advantages of
correcting spinal fractures with a significant deformity
over conservative methods where that deformity is left is
evident. We would, therefore, advocate tha t these frac-
tures are corrected via MIS techniques, as described
Patients and methods
We have been prospectively collecting data on all single
level thoracolumbar burst fractures since January 2003
to 2012.
All fractures in the study were single level and in-
volved a degree of local kyphosis of 20° or greater. All
fractures were at either T12, L1 or L2 vertebrae and
were of Magerl classification type A or type B grade
(Magerl et al. 1994) without any evidence of neurological
compromise (Figure 2a & b).
Additional inclusion criteria were patients of working
age and in employment or full time education. All pa-
tients had no history of any back or spinal complaint
and had no prior spinal surgery. Of the several groups ,
30% of patients smoked and 5 % had diabetes. None had
osteoporosis or any other medical condition that would
affect their outcome. They were all asked to fill out an
Oswestry Disability Index (ODI) form regarding their
pre-accident spinal history upon admission to confirm
this. All patients underwent an MRI scan at time of ad-
mission to en sure there was no significant spinal path-
ology elsewhere. All patients were neurologically normal
clinically and radiologically. All patients had their spinal
injury as their only injury. This was to ensure that when
assessing patients there would be no confounding
Figure 2 Radiograph showing a single level L1 fracture at time of injury a. Lateral b. Antero-posterior.
Kumar et al. SpringerPlus (2015) 4:204 Page 5 of 10
Figure 4 Clinical photo showing pedicle screw finder insertion through minimally invasive techniques.
Figure 3 Clinical photo showing pedicle screw insertion through minimal skin incision.
Kumar et al. SpringerPlus (2015) 4:204 Page 6 of 10
Figure 5 Clinical photo showing insertion of rod through small incisions.
Figure 6 Clinical photo showing extent of MIS exposure.
Kumar et al. SpringerPlus (2015) 4:204 Page 7 of 10
variables from other injuries that would skew or affect
the results. There were, therefore, no multiply injured
patients in the study.
On admission, patients were informed of the treat-
ment options along with risks by the senior author.
Patients who opted for conservative treatment were
either treated with bed rest for up to 3 months if their
spinal injury was deemed to be unstable, followed by
TLSO bracing for 3 months; or if their injury was
deemed to be stable, by TLSO bracing alone for
3 months. Stability was assessed by a MRI and CT scan
of the spine along with standing radiographs in the
brace. All patients underwent a functional rehabilitation
programme for at least 1 year after injury.
Patients who opted for surgery were treated by open
techniques until end of 2006, and via MIS techniques
from 2007 until the present day. All fractures were fixed
by a construct of pedicle screws inserted into the verte-
brae at the 2 levels above the fractured vertebra and the
2 levels below it (Figures 3, 4, 5 and 6) (Logroscino et al.
2009; Tezeren and Kuru 2005). Decompression was not
required and there was no instrumentation into the frac-
tured vertebra itself, with no transpedicular grafting
(Alanay et al. 2001). No fusion was attempted across any
part of the construct as treatment was aimed for fracture
correction and not fusion (Kim et al. 2011; Tezeren
et al. 2009; Jindal et al. 2012). Additionally fusion would
add to the operative time, blood loss and morbidity and
ultimately prevent remobilisation of the spinal segment.
All fractured vertebrae were corrected to less than 10° of
residual kyphosis and the instrumentation used was the
same for both open and MIS techniques. We used the
Camlok S-Rad 90 system (Stryker GmBh) for all cases,
with mono-axial (solid) screws throughout in both open
and MIS cases (Figures 7).
All surgically treated patients were mobilised immedi-
ately post-operatively without any secondary bracing,
and were monitored regularly po st-operatively. After the
Figure 7 Radiograph showing stabilisation and degree of kyphosis correction a. Lateral b. Anterio-posterior.
Figure 8 Radiograph of lower thoracic and lumbar vertebrae 12 months after stabilisation and correction a. Lateral b. Anterio-posterior.
Kumar et al. SpringerPlus (2015) 4:204 Page 8 of 10
removal of sutures at 2 weeks, patients were seen at 3
and 6 months post operatively with standing radiographs
prior to implant removal. As this was a corrective pro-
cedure for sagittal mal-alignment not involving fusion,
all implants were removed between 6 months and 1 year
after surgery to remobilise the stabilised segments once
the fractured vertebra had healed (Kim et al. 2011;
Tezeren et al. 2009; Jindal et al. 20 12) (Figure 8). Im-
plant removal was achieved via MIS methods. If the pa-
tient had undergone open surgery, then although the old
scar was opened, the implants were removed by muscle
splitting portholes, the rods being slid out from under-
neath the muscles from the top portholes, to spare the
muscles further violation from a midline approach. If
the patient had had MIS techniques, then the old inci-
sions were used and the implants were removed via the
same muscle sparing techniques as above. This ensured
that there was no mor bidity or further trauma caused to
the paraspinal muscles by implant removal.
Patients were subsequently assessed for length of stay
in hospital, and time to discharge post-surgery. All pa-
tients were assessed regarding return to work status, and
return to sporting or leisure pursuits. Complications,
loss of correction of deformity, and the need for second-
ary procedures were also recorded.
All patients were followed up 12 weeks post injury,
6 weeks and 3 months post discharge with standing
radiographs of the spine. All patients filled out an ODI
assessment at follow up 18 months post-injury (i.e. at
least 6 months after implant removal in those who had
had surgery) and another ODI a further year later
(30 months post-injury). Patients underwent standin g ra-
diographs finally at 6 months post hardware removal.
All post-treatment radiographs were analysed by the
senior author (CL). Statistica l analysis was performed
and analysed independently on SPSS V8.0 software for
windows (SPSS inc, Chicago, Illinois). MannWhitn ey U
and unpaired t-tests were used to assess differences
between the groups. Minimally clinically important dif-
ferences (MCID) were calculated using distribution
based methods involving half of the standard deviation.
Our study had local ethical approval in line with our
research and audit department and as set out by the
National Institution for Health Research (NIHR). Patients
followed an appropriate consent procedure for their inclu-
sion in the study.
Competing interests
The authors declare that they have no competing interests.
Authors contributions
AK lead the data collection and analysis, along with the study write up and
interpretation of results. RA analysed the data collected along with preparation
of results for the study. CL collected the data from the study and was behind
the study design and write up of the project. All authors read and approved the
final manuscript.
Author details
Specialist Orthopaedic Registrar, University Hospitals Leicester, Infirmary
Square, Leicester LE1 5WW, UK.
Consultant Orthopaedic & Spinal Surgeon,
Lincoln County Hospital, Greetwell Road, Lincoln LN2 5QY, UK.
Received: 21 January 2015 Accepted: 1 April 2015
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Kumar et al. SpringerPlus (2015) 4:204 Page 10 of 10
... While literature supports that cannulated screws are associated with reduced blood loss in posterior fusion [13], this is typically attributed to the surgical approach resulting in reduced soft tissue damage and not the implant design [14]. Cannulated screws are most utilised in minimally invasive, percutaneous procedures, distinct to our centre which uses them in an open approach. ...
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We aim to delineate whether there is increased blood loss with the use of cannulated pedicle screws compared to solid pedicle screws in patients undergoing posterior spinal fusion. A single-centre retrospective case-control study was undertaken on patients undergoing PSF for spinal fractures. Cannulated screw fixation was compared with solid screw fixation. Intraoperative blood loss was estimated using pre and postoperative haemoglobin levels, recorded estimated blood loss and cell saver reports. Anticoagulation, blood product administration, operative time and number of levels fused were assessed. A total of 64 cases, 32 in each cohort, were included in the analysis. Overall mean haemoglobin reduction from pre- to post-operative was 2.82 ± 1.85 g/L per screw inserted in the cannulated group, compared to a haemoglobin decrease of 2.81 ± 1.521 g/L per screw inserted in the solid screw group (p = 0.971). Total estimated intraoperative blood loss was 616.3 + 355.4 mL in the cannulated group, compared to 713.6 + 473.5 mL in the solid screw group (p = 0.456). Patients with preoperative thrombocytopenia had a transfusion rate of 0.5 ± 0.71 units/patient compared to 0.04 ± 0.19 units/patient in patients with normal platelet levels (p < 0.005). The differences in blood loss observed between cannulated and solid pedicle screws are non-significant overall. The largest predictor for need of transfusion was pre-operative thrombocytopenia, regardless of the type of screw used.
... Furthermore, we observed that patients with burst fractures had an increased tendency of being crippled/bedbound at the preoperative stage and had increased spinal canal occlusion as observed in MRI as compared to other fracture subtypes. Kumar et al. suggested that the injury to surgery interval is important as it determines the efficacy of ligamentotaxis [16]. The efficacy of the ligamentotaxis has been shown to decrease after traumatic injury within 72 hours. ...
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Introduction The treatment of unstable thoracolumbar burst fractures and fracture dislocations of the thoracolumbar spine remains ever evolving. Anterior or posterior approaches both have equal efficacy, but the posterior approach has been preferred in our study due to its ease of application, less extensile nature, and reduced intra-operative bleeding. Posterior approaches can employ short-segment fixation or long-segment fixation techniques. Long segment fixation may need implant removal later to increase mobility in nonfusion surgeries. The thoracolumbar segment is a transition zone where the thoracic spine is a less flexible zone, and the lumbar spine is a more flexible zone. Lumbar motion is important to preserve. Hence, we proposed to study spinal fixation two levels above and one level below the fracture for stabilization. This may provide increased stability along with preservation of the motion segment at the lumbar level. Methods We retro-prospectively reviewed the results of unstable thoracolumbar junction fractures with incomplete or intact neurology in 34 consecutive cases operated with alternate two above and one below fixation approach between June 2018 and June 2019 at our institute. Five cases were excluded due to incomplete follow up and the remaining 29 patients were included in the study. Regular follow-up in the postoperative period at three, six, and 12 months was conducted. Data analysis was done by SPSS software version 22 (IBM Corp., Armonk, NY). Results Twenty-nine patients were included in the study out of which 16 were males and 13 were females. The average age was 36.31±1.46 years (range, 14-60 years). The average follow-up duration was 14.31 months. The average injury to surgery interval was 7.17±7.31 days (range, 1-30 days). On analysis via paired t-test, pre-operative kyphotic angle (mean=20.06±8.34º) improved to immediate post-operative (mean=8.44±5.76º, p=0.0001). The postoperative kyphotic angle at 12 months follow-up showed significant stability (Mean=14.13±5.27º, p=0.0001). A median average pre-operative neurological compromise was ASIA score C and Frankel Grade C and the median average disability was an ODI score of 61%-80%. At the end of 12 months of follow-up the median average neurological compromise improved to ASIA Score D and Frankel Grade D and the median average disability improved to an ODI score of 21%-40%. Conclusion Two levels above and one level below hybrid pedicle screw fixation with decompression for the treatment of unstable thoracolumbar fractures with partial and intact neurology was successful within the limited time frame we had for follow-up in preserving progressive post-operative kyphosis, preserving one-motion segment, improving the neurological outcome and disability of the patients without any major complications.
... The reason is that the tube connected to screw head amplifies this variation, and polyaxiality is therefore required to align the screws/tubes to allow passage of the rod. Due to its multidirectional screw head, the polyaxial screws cannot be used as a tool to reduce fractures or deformities [21] . Moreover, in patients treated with polyaxial screws, a loss of fracture correction was observed during follow-up, it could be due to movement between the head and the arm of the screw [22] . ...
Objectives: Percutaneous pedicle screw fixation (PPSF) has been a common surgery for treating thoracolumbar and lumbar fractures. Many studies have reported PPSF is associated with poor reduction. We present a reliable method by using short-segment monoaxial percutaneous screws and instrumentational maneuvers to reduce the spine. This study aimed to evaluate radiological and clinical results of this method of reduction compared to traditional polyaxial screws method in treating thoracolumbar and lumbar fractures. Methods: From February 2015 to February 2021, 64 patients with thoracolumbar and lumbar fractures in our department were retrospectively reviewed and divided into experimental group and control group according to different treatment methods. The experimental group was treated with short-segment monoaxial percutaneous screws (which were inserted at the adjacent vertebrae one level above, one level below the fracture, and the fractured vertebra) and instrumentational maneuvers method, while the control group was treated with traditional polyaxial screws method. The operation time was recorded. Visual analogue scale (VAS) and Oswestry disability index (ODI) were assessed as the clinical outcomes. The anterior height of the injured vertebra(AVH), the kyphosis cobb angle and the vertebral wedge angle were used to evaluate the fracture radiological reduction. Results: A total of 64 patients were enrolled including 31 in the experimental group and 33 in the control group. There were no significant difference in operation time, AVH, the kyphosis cobb angle,the wedge angle of injured vertebra,VAS and ODI score between the two groups in preoperation. In each group, there were significant differences in the AVH, the kyphosis cobb angle and wedge angle of injured vertebra between preoperation and immediate postoperation. In each group, there were significant differences in VAS and ODI score between the preoperation and last follow-up. The total correction rates of AVH,the kyphosis cobb angle and the wedge angle of injured vertebra were significantly higher in the experimental group than those in the control group, while the loss of correction was significantly lower than the control. Conclusions: The reduction technique using monoaxial percutaneous screws and instrumentational maneuvers for thoracolumbar and lumbar fractures exhibited better radiological results and satisfying functional outcomes when compared to traditional polyaxial screws.
... A Jewett brace was provided on discharge and patients were followed up 1 week and 3 months after discharge, which included radiography to assess the extent of kyphosis. 26 Another UK study 27,28 refers to an aggressive physiotherapy protocol with regular bed rolling, in-bed exercises and chest protocols, with patients assessed for brace tolerance. ...
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Background There is informal consensus that simple compression fractures of the body of the thoracolumbar vertebrae between the 10th thoracic vertebra and the second lumbar vertebra without neurological complications can be managed conservatively and that obvious unstable fractures require surgical fixation. However, there is a zone of uncertainty about whether surgical or conservative management is best for stable fractures. Objectives To assess the feasibility of a definitive randomised controlled trial comparing surgical fixation with initial conservative management of stable thoracolumbar fractures without spinal cord injury. Design External randomised feasibility study, qualitative study and national survey. Setting Three NHS hospitals. Methods A feasibility randomised controlled trial using block randomisation, stratified by centre and type of injury (high- or low-energy trauma) to allocate participants 1 : 1 to surgery or conservative treatment; a costing analysis; a national survey of spine surgeons; and a qualitative study with clinicians, recruiting staff and patients. Participants Adults aged ≥ 16 years with a high- or low-energy fracture of the body of a thoracolumbar vertebra between the 10th thoracic vertebra and the second lumbar vertebra, confirmed by radiography, computerised tomography or magnetic resonance imaging, with at least one of the following: kyphotic angle > 20° on weight-bearing radiographs or > 15° on a supine radiograph or on computerised tomography; reduction in vertebral body height of 25%; a fracture line propagating through the posterior wall of the vertebra; involvement of two contiguous vertebrae; or injury to the posterior longitudinal ligament or annulus in addition to the body fracture. Interventions Surgical fixation: open spinal surgery (with or without spinal fusion) or minimally invasive stabilisation surgery. Conservative management: mobilisation with or without a brace. Main outcome measure Recruitment rate (proportion of eligible participants randomised). Results Twelve patients were randomised (surgery, n = 8; conservative, n = 4). The proportion of eligible patients recruited was 0.43 (95% confidence interval 0.24 to 0.63) over a combined total of 30.7 recruitment months. Of 211 patients screened, 28 (13.3%) fulfilled the eligibility criteria. Patients in the qualitative study ( n = 5) expressed strong preferences for surgical treatment, and identified provision of information about treatment and recovery and when and how they are approached for consent as important. Nineteen surgeons and site staff participated in the qualitative study. Key themes were the lack of clinical consensus regarding the implementation of the eligibility criteria in practice and what constitutes a stable fracture, alongside lack of equipoise regarding treatment. Based on the feasibility study eligibility criteria, 77% (50/65) and 70% (46/66) of surgeons participating in the survey were willing to randomise for high- and low-energy fractures, respectively. Limitations Owing to the small number of participants, there is substantial uncertainty around the recruitment rate. Conclusions A definitive trial is unlikely to be feasible currently, mainly because of the small number of patients meeting the eligibility criteria. The recruitment and follow-up rates were slightly lower than anticipated; however, there is room to increase these based on information gathered and the support within the surgical community for a future trial. Future work Development of consensus regarding the population of interest for a trial. Trial registration Current Controlled Trials ISRCTN12094890. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 25, No. 62. See the NIHR Journals Library website for further project information.
... Consistent with our findings of an average EQ-5D index of 0.7, Deml et al. reported the same mean EQ-5D index of 0.7 at a 1.7-year follow-up after anterior column reconstruction of the thoraco-lumbar spine with a new modular PEEK vertebral body replacement device in 48 cases [28]. [29]. There was no evidence of neurological compromise in their collective and no additional injuries were reported, therefore representing a different collective with less severe injured patients. ...
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Abstract Background For the treatment of unstable thoraco-lumbar burst fractures, a combined posterior and anterior stabilization instead of a posterior-only instrumentation is recommend in the current literature due to the instability of the anterior column. Data on restoring the bi-segmental kyphotic endplate angle (BKA) with expandable vertebral body replacements (VBR) and on the mid- to long-term patient-reported outcome measures (PROM) is sparse. Methods A retrospective cohort study of patients with traumatic thoraco-lumbar spinal fractures treated with an expandable VBR implant (Obelisc™, Ulrich Medical, Germany) between 2001 and 2015 was conducted. Patient and treatment characteristics were evaluated retrospectively. Radiological data acquisition was completed pre- and postoperatively, 6 months and at least 2 years after the VBR surgery. The BKA was measured and fusion-rates were assessed. The SF-36, EQ-5D and ODI questionnaires were evaluated prospectively. Results Ninety-six patients (25 female, 71 male; age: 46.1 ± 12.8 years) were included in the study. An AO Type A4 fracture was seen in 80/96 cases (83.3%). Seventy-three fractures (76.0%) were located at the lumbar spine. Intraoperative reduction of the BKA in n = 96 patients was 10.5 ± 9.4° (p
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Background: Thoracolumbar burst fractures are a common traumatic vertebral fracture in the spine, and pedicle screw fixation has been widely performed as a safe and effective procedure. However, after the stabilization of the thoracolumbar burst fractures, whether or not to remove the pedicle screw implant remains controversial. This review aimed to assess the benefits and risks of pedicle screw instrument removal after fixation of thoracolumbar burst fractures. Methods: Data sources, including PubMed, EMBASE, Cochrane Library, Web of Science, Google Scholar, and Clinical, were comprehensively searched. All types of human studies that reported the benefits and risks of implant removal after thoracolumbar burst fractures, were selected for inclusion. Clinical outcomes after implant removal were collected for further evaluation. Results: A total of 4051 papers were retrieved, of which 35 studies were eligible for inclusion in the review, including four case reports, four case series, and 27 observational studies. The possible risks of pedicle screw removal after fixation of thoracolumbar burst fractures include the progression of the kyphotic deformity and surgical complications (e.g., surgical site infection, neurovascular injury, worsening pain, revision surgery), while the potential benefits of pedicle screw removal mainly include improved segmental range of motion and alleviated pain and disability. Therefore, the potential benefits and possible risks should be weighed to support patient-specific clinical decision-making about the removal of pedicle screws after the successful fusion of thoracolumbar burst fractures. Conclusions: There was conflicting evidence regarding the benefits and harms of implant removal after successful fixation of thoracolumbar burst fractures, and the current literature does not support the general recommendation for removal of the pedicle screw instruments, which may expose the patients to unnecessary complications and costs. Both surgeons and patients should be aware of the indications and have appropriate expectations of the benefits and risks of implant removal. The decision to remove the implant or not should be made individually and cautiously by the surgeon in consultation with the patient. Further studies are warranted to clarify this issue. Level of evidence: level 1.
Background /aim: We compared the clinical and radiological outcomes and complications of patients treated for thoracolumbar burst fractures via temporary percutaneous osteosynthesis or open definitive arthrodesis. Methods A retrospective case-control study was performed including patients treated between 2017 and 2019 for a burst fracture of the thoracolumbar junction, either with percutaneous osteosynthesis (case group) or open arthrodesis (control group). Clinical, functional, and radiographic results were analyzed and compared between treatment groups. Results We included 112 patients (56 osteosynthesis/56 arthrodesis, p = 1) in our study. The mean follow-up and mean age were 20 ± 3 months (20 ± 2 / 20 ± 3, p = 1), and 41 ± 10 years (40 ± 11 / 42 ± 10, p = .3), respectively. Fracture level was L1/L2 in 75% and T11/T12 in 25% of patients. The osteosynthesis group showed significantly shorter operative times (104 ± 20 min / 176 ± 18 min, p < .01) and inpatient stays (11.6 ± 1.5 days / 15.6 ± 3.8 days, p < .01). Both groups showed similar correction over kyphosis angle at final follow-up (5.8º ± 2.8º / 6º ± 0.2°, p = .57), but the osteosynthesis group showed increased segment mobility after hardware removal (3.8º ± 1.2º / 0.9º ± 0.3°, p < .01). There were no significant differences in complications, although the osteosynthesis group showed significantly lower need for blood transfusion (21% / 43%, p = .02). Conclusions Both methods of treatment yielded good clinical and radiological results with similar complication rates. Temporary osteosynthesis seems to be more beneficial than open arthrodesis because it requires shorter operative time and hospitalization, causes less bleeding, and facilitates spinal movement.
Background: The objective of this study is to compare percutaneous techniques (MIS) with the open technique in terms of angle correction, long-term maintenance and clinical results. Methods: The authors collected a prospective database of thoraco-lumbar fractures treated with posterior stabilization without fusion from 2013 to 2019. The statistical analysis has been carried out retrospectively. The patients were classified into Open and MIS group. To compare the two population, samples, treatments and mitigate the differences between the groups, the propensity score (PS) matching was used. Results: 108 patients with thoraco-lumbar fractures were included. After performing the PS, 21 patients were obtained in the open group and 28 in the MIS group. For operative and perioperative parameters there were no differences in number of patients with posterior decompression, number of instrumented segments, number of total screws, operative time and complications. Postoperative hemoglobin was similar in both groups. However, in the open group a greater loss of hemoglobin was observed; as well as, higher analgesia requirements and length of stay. No statistically significant differences were observed in neurological status in both groups in the preoperative, postoperative period and at follow-up. The Cobb angle showed no differences at admission comparing both groups. A similar angle correction was observed with both surgeries, but in open surgery there was a statistically significant loss of correction. Conclusions: We observed in this study that the MIS technique for the treatment of thoracolumbar fractures is as effective as the open technique in terms of angle correction; and demonstrated that is better in its maintenance over time. Clinical results were at least as good as with the open technique.
Axial compressive/flexion moderate forces on the anterior spinal elements may cause vertebral compression fractures (VCF), compromising the anterior column of the spine, reducing vertebral body height and leading to characteristic wedge-shaped deformity. 60% to 75% of VCFs are located in the thoracolumbar junction (T12 – L2) due to mechanical forces upon the transition from the relatively fixed thoracic to the relatively mobile lumbar spine. Compression force spinal fractures vary in literature according to the classification system in use, resulting in controversial treatment options.Type A fracture patterns of AO classification are eligible for non-operative treatment provided the posterior complex is intact and there are no neurologic complications. That includes both simple compressive and burst fractures. The aim of this study is to investigate the long-term consequences of non-operative treated compressive thoracolumbar fractures regarding posttraumatic deformity, chronic back pain, and functional status.A retrospective study of 75 patients withstable (compressive and burst type A AO) spinal fractures of the thoracolumbar spine (T12-L2) without neurological symptoms and treated non-operativelywas conducted.Post traumatic regional kyphosis,Visual Analogue Scale (VAS) and the Oswestry Disability Index (ODI) were used to evaluate deformity progression, pain and alteration of the quality of life during follow up. There was no significant correlation between magnitude of posttraumatic regional kyphosis, sex, pain score and disability index. Statistically significant correlation between patients age and disability index was revealed.
Spinal cord injury (SCI) is a debilitating condition which often leads to a severe disability and ultimately impact patient's physical, psychological, and social well-being. The management of acute SCI has evolved over the couple of decades due to improved understanding of injury mechanisms and increasing knowledge of disease. Currently, the early management of acute SCI patient includes pharmacological agents, surgical intervention and newly experimental neuroprotective strategies. However, many controversial areas are still surrounding in the current treatment strategies for acute SCI, including the optimal timing of surgical intervention, early versus delayed decompression outcome benefits, the use of methylprednisolone. Due to the lack of consensus, the optimal standard of care has been varied across treatment centres. The authors have shed a light on the current updates on early treatment approaches and neuroprotective strategies in the initial management of acute SCI in order to protect the early neurologic injury and reduce the future disability.
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Background: To our knowledge, a prospective, randomized study comparing operative and non-operative treatment of a thoracolumbar burst fracture in patients without a neurological deficit has never been performed. Our hypothesis was that operative treatment would lead to superior long-term clinical outcomes. Methods: From 1994 to 1998, forty-seven consecutive patients (thirty-two men and fifteen women) with a stable thoracolumbar burst fracture and no neurological deficit were randomized to one of two treatment groups: operative (posterior or anterior arthrodesis and instrumentation) or non-operative treatment (application of a body cast or orthosis). Radiographs and computed tomography scans were analyzed for sagittal alignment and canal compromise. All patients completed a questionnaire to assess any disability they may have had before the injury, and they indicated the degree of pain at the time of presentation with use of a visual analog scale. The average duration of follow-up was forty-four months (minimum, twenty-four months). After treatment, patients indicated the degree of pain with use of the visual analog scale and they completed the Roland and Morris disability questionnaire, the Oswestry back-pain questionnaire, and the Short Form-36 (SF-36) health survey. Results: In the operative group (twenty-four patients), the average fracture kyphosis was 10.1° at the time of admission and 13° at the final follow-up evaluation. The average canal compromise was 39% on admission, and it improved to 22% at the final follow-up examination. In the non-operative group (twenty-three patients), the average kyphosis was 11.3° at the time of admission and 13.8° at the final follow-up examination after treatment. The average canal compromise was 34% at the time of admission and improved to 19% at the final follow-up examination. On the basis of the numbers available, no significant difference was found between the two groups with respect to return to work. The average pain scores at the time of the latest follow-up were similar for both groups. The pre-injury scores were similar for both groups; however, at the time of the final follow-up, those who were treated non-operatively reported less disability. Final scores on the SF-36 and Oswestry questionnaires were similar for the two groups, although certain trends favored those treated without surgery. Complications were more frequent in the operative group. Conclusion: We found that operative treatment of patients with a stable thoracolumbar burst fracture and normal findings on the neurological examination provided no major long-term advantage compared with non-operative treatment.
In view of the current level of knowledge and the numerous treatment possibilities, none of the existing classification systems of thoracic and lumbar injuries is completely satisfactory. As a result of more than a decade of consideration of the subject matter and a review of 1445 consecutive thoracolumbar injuries, a comprehensive classification of thoracic and lumbar injuries is proposed. The classification is primarily based on pathomorphological criteria. Categories are established according to the main mechanism of injury, pathomorphological uniformity, and in consideration of prognostic aspects regarding healing potential. The classification reflects a progressive scale of morphological damage by which the degree of instability is determined. The severity of the injury in terms of instability is expressed by its ranking within the classification system. A simple grid, the 3-3-3 scheme of the AO fracture classification, was used in grouping the injuries. This grid consists of three types: A, B, and C. Every type has three groups, each of which contains three subgroups with specifications. The types have a fundamental injury pattern which is determined by the three most important mechanisms acting on the spine: compression, distraction, and axial torque. Type A (vertebral body compression) focuses on injury patterns of the vertebral body. Type B injuries (anterior and posterior element injuries with distraction) are characterized by transverse disruption either anteriorly or posteriorly. Type C lesions (anterior and posterior element injuries with rotation) describe injury patterns resulting from axial torque. The latter are most often superimposed on either type A or type B lesions. Morphological criteria are predominantly used for further subdivision of the injuries. Severity progresses from type A through type C as well as within the types, groups, and further subdivisions. The 1445 cases were analyzed with regard to the level of the main injury, the frequency of types and groups, and the incidence of neurological deficit. Most injuries occurred around the thoracolumbar junction. The upper and lower end of the thoracolumbar spine and the T10 level were most infrequently injured. Type A fractures were found in 66.1%, type B in 14.5%, and type C in 19.4% of the cases. Stable type A1 fractures accounted for 34.7% of the total. Some injury patterns are typical for certain sections of the thoracolumbar spine and others for age groups. The neurological deficit, ranging from complete paraplegia to a single root lesion, was evaluated in 1212 cases.(ABSTRACT TRUNCATED AT 400 WORDS)
The Fixateur interne has been proposed for limited pedicle fixation of thoracolumbar spine fractures with the assumption that motion in the nontraumatized spinal segments could be maintained. To date, no data exist that both localize and quantitate spinal mobility about the fractured vertebra. Voluntary maximum lateral flexion and extension radiographs were obtained on patients with unstable thoracolumbar spine fractures at a minimum of 2 years after Fixateur Interne instrumentation (implant was removed after 1 year). Residual intersegmental motion was measured at levels adjacent to both the vertebra fracture and the fixation. Fifty-nine patients were reviewed, and the posterior vertebral body angle demonstrated a mean total sagittal motion of 2.98[degrees]. Cephalad and caudal to the fractured vertebra, a mean of 1.34[degrees] and 3.08[degrees], respectively, of residual motion was noted; cephalad and caudal to the previously instrumented segment a mean of 3.22[degrees] and 6.88[degrees], respectively, was measured. The authors conclude that residual mobility is most evident at the caudal end of the instrumented segment, removed from the fractured vertebra. The level with end plate disruption becomes essentially ankylosed, with or without a fusion. (C) Lippincott-Raven Publishers.
A classification should allow the identification of any injury by means of a simple algorithm based on easily recognizable and consistent radiographic and clinical characteristics. In addition, it should provide a concise and descriptive terminology, information regarding the severity of the injury, and guidance as to the choice of treatment and should serve as a useful tool for future studies.
The posterior paravertebral muscles of the lumbar spine are supplied segmentally by the posterior primary rami of the lumbar and sacral nerves. Electromyographic examination of these muscles is used to seek evidence of specific lumbar and sacral nerve root compromise. An anatomic study of the posterior rami and their branches has demonstrated that these nerves are very liable to be damaged during a routine posterior surgical approach to the lumbar spine. In a clinical and electromyographic study of 113 patients, all of whom underwent posterior lumbar spinal surgery, it was shown that some measure of denervation of the paravertebral muscles occurred in 96% of cases. Denervation was shown to persist for many years following surgery, and reservation was only partial. It was concluded that diagnostic electromyography of the paraspinal muscles in a postsurgical patient is of no value. (C) Lippincott-Raven Publishers.
The purpose of this study was to determine whether patients with a burst fracture of the thoracolumbar spine treated by short segment pedicle screw fixation fared better clinically and radiologically if the affected segment was fused at the same time. A total of 50 patients were enrolled in a prospective study and assigned to one of two groups. After the exclusion of three patients, there were 23 patients in the fusion group and 24 in the non-fusion group. Follow-up was at a mean of 23.9 months (18 to 30). Functional outcome was evaluated using the Greenough Low Back Outcome Score. Neurological function was graded using the American Spinal Injury Association Impairment Scale. Radiological outcome was assessed on the basis of the angle of kyphosis. Peri-operative blood transfusion requirements and duration of surgery were significantly higher in the fusion group (p = 0.029 and p < 0.001, respectively). There were no clinical or radiological differences in outcome between the groups (all outcomes p > 0.05). The results of this study suggest that adjunctive fusion is unnecessary when managing patients with a burst fracture of the thoracolumbar spine with short segment pedicle screw fixation.
Systematic Review. To determine whether early spinal stabilization in thoracolumbar spine trauma decreases morbidity and mortality. The role of early spinal stabilization through surgical means may have a number of benefits. These include reduced morbidity and mortality because of more rapid mobilization afforded by spinal column stabilization and a reduction in the incidence and severity of sepsis and respiratory failure. There are several potential disadvantages of early surgery. The most strongly debated is the potential that the additional physiologic injury may result in an unintended increase in morbidity and mortality caused by worsening of existing injuries, such as with pulmonary or intracranial trauma. This problem may be compounded by increased hemorrhage and resulting hypotension. Operating in the presence of missed or underestimated associated injuries or under less-than-ideal conditions relative to the complexity of the surgery and resources required is also a potential disadvantage. A systematic review of the English-language literature was undertaken for articles published between January 1990 and December 2008. Electronic databases and reference lists of key articles were searched to identify published studies examining the timing of thoracolumbar fracture fixation. Two independent reviewers assessed the strength of literature using the Grading of Recommendations Assessment, Development, and Evaluation criteria, assessing quality, quantity, and consistency of results. Disagreements were resolved by consensus. A total of 68 articles were initially screened, and 9 ultimately met the predetermined inclusion criteria. These studies demonstrated that early stabilization of thoracic fractures reduced the mean number of days on a ventilator, the number of days in intensive care unit and in hospital, and reduced respiratory morbidity compared with late stabilization. This effect, other than the length of hospital stay, was not seen with stabilization of lumbar fractures. There is not enough evidence to determine the effect of the timing of stabilization on mortality in thoracolumbar fractures. Ideally, patients with unstable thoracic fractures should undergo early (<72 hours) stabilization of their injury to reduce morbidity and, possibly, mortality.
Prospective registry. The objective of this study was to examine patient outcomes using a mini-open, lateral approach for the treatment of traumatic thoracic and lumbar fractures. The high-quality published studies that examine treatment methods for acute traumatic thoracic and lumbar fractures are few and a few that are present contain insufficient samples to make broad conclusions. Despite this, we know that conventional surgical techniques often include large, morbid exposures. More recent advancements in less invasive surgical techniques have greatly decreased the associated morbidities of conventional approaches, namely, thoracotomy. A total of 52 patients were treated at 1 of 2 institutions for traumatic thoracic or lumbar fractures with a mini-open lateral approach for corpectomy. Patients were prospectively followed for clinical outcomes, with treatment and in-hospital complications collected retrospectively. The majority of patients (94.2%) presented with traumatic burst fractures with instability and neurologic deficit. Patients were treated with mini-open, lateral corpectomies from T7 to L4, the majority at T12 and L1, and were followed 2 years after surgery. Supplemental internal fixation was used in all patients: 75% anterolateral plating and 46.1% transpedicular fixation (11 [21.2%] patients with combined). Median operative time, estimated blood loss, and hospital stay were 128 minutes, 300 mL, and 4 days, respectively. Complications were observed in 13.5% of patients and no reoperations occurred. Neurologic status, assessed using American Spinal Injury Association categorization, improved significantly postoperatively, with 73% of patients either completely neurologically intact or with only slight residual deficits (American Spinal Injury Association E or D). No patient experienced neurologic deterioration. Expandable wide-footprint titanium cages were used in 34.6% of patients, which resisted radiographic subsidence seen in some patients treated with expandable cylindrical titanium cages. The mini-open lateral approach for thoracic and lumbar corpectomy was shown to be safe and effective in this series while avoiding many of the associated morbidities of thoracotomies for anterior column reconstruction and open posterior approaches.
Literature review. To describe the scientific basis of minimally invasive spine surgery as it relates to posterior lumbar surgery. Minimally invasive spine (MIS) surgery is predicated on several basic principles: (1) avoid muscle crush injury by self-retaining retractors; (2) do not disrupt tendon attachment sites of key muscles, particularly the origin of the multifidus muscle at the spinous process; (3) use known anatomic neurovascular and muscle compartment planes; and (4) minimize collateral soft tissue injury by limiting the width of the surgical corridor. Literature review. The conventional midline posterior approach for lumbar decompression and fusion violates these key principles of MIS surgery. The tendon origin of the multifidus muscle is detached, the surgical corridor is exceedingly wide, and significant muscle crush injury occurs through the use of powerful self-retaining retractors. The combination of these events leads to well-described changes in muscle physiology and function. MIS surgery is performed using table-mounted tubular retractors that focus the surgical dissection to a narrow corridor directly over the surgical target site. The path of the surgical corridor is selected on the basis of anatomic planes, specifically avoiding injury to the musculotendinous complex and the neurovascular bundle. With these relatively simple modifications to surgical technique, significant improvements in intraoperative blood loss, postoperative pain, surgical morbidity, return of function, among others, have been achieved. However, MIS techniques remain technically demanding and a significant complication rate has been observed during the initial learning curve of the procedures.