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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 14  |  Issue : 4  |  Page : 153-157

Inclusion of the fracture level in short-segment fixation of unstable traumatic thoracolumbar spine fractures


1 Department of Orthopedics, Faculty of Medicine, Al-Azhar University, Damietta, Egypt
2 Department of Neurosurgery, Faculty of Medicine, Al-Azhar University, Damietta, Egypt

Date of Submission29-Jul-2016
Date of Acceptance11-Dec-2016
Date of Web Publication23-Jun-2017

Correspondence Address:
Samir A Elshoura
16-Zin Eldin st-Ragab al Kadey, Al Mahala Al Kobra, Gharbia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-1693.208930

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  Abstract 

Introduction The diagnosis, classifications, and treatment of injuries of the thoracolumbar spine continue to attract controversy.
Objective The present study evaluated the efficacy of treatment of unstable thoracolumbar burst fractures by transpedicular screw fixation including the fractured vertebra.
Patients and methods From January 2013 to March 2015, 40 patients with thoracolumbar burst fracture underwent posterior pedicle screw fixation consecutively in Al-Azhar University Hospital, Damietta.
Results Forty (25 male and 15 female) patients with age ranging between 16 and 66 years (mean 41.8%) were operated upon by posterior transpedicular screw fixation. According to the American Spinal Injury Association scoring system, all patients were grade E. The mean of kyphotic deformities measured preoperatively was 18.4±5.5° and after 12 months of follow-up it was 9.0±4.1°.
Conclusion By applying the transpedicular screw fixation of the unstable fractures of the thoracolumbar spine, a stable fracture fixation can be achieved; this kind of fixation prevents secondary spine deformities.

Keywords: fixation, fracture, short segment, thoracolumbar


How to cite this article:
Elshoura SA, Elsamea MA. Inclusion of the fracture level in short-segment fixation of unstable traumatic thoracolumbar spine fractures. Al-Azhar Assiut Med J 2016;14:153-7

How to cite this URL:
Elshoura SA, Elsamea MA. Inclusion of the fracture level in short-segment fixation of unstable traumatic thoracolumbar spine fractures. Al-Azhar Assiut Med J [serial online] 2016 [cited 2018 Oct 20];14:153-7. Available from: http://www.azmj.eg.net/text.asp?2016/14/4/153/208930




  Introduction Top


The ideal treatment of unstable fractures of the thoracolumbar spine remains controversial. The surgical treatment for thoracolumbar burst fractures aims to restore vertebral column stability and to decompress neural element [1]. Various methods of surgical treatment have achieved these objectives but are fraught with complications [2].

Anterior corpectomy and fixation has given good results, but the risk of morbidity and the technical expertise required precludes its routine use. Posterior fixation offers easy exposure and a less morbid approach, but with a high incidence of implant failure and recurrent kyphosis. Among the many implants available for internal fixation, pedicle screws have proved their superiority, as it is possible with their use to engage all three columns of the spine and effect reduction with a short-segment construct [3].

Because of several problems associated with extensive long-level instrumentation, posterior short-segment instrumentation has been recently preferred for the treatment of thoracolumbar burst [4]. The thoracolumbar region is generally accepted as that part of the spine formed by vertebrae from the 11th thoracic to the second lumbar. Spine fractures, especially fractures accompanied with the spinal cord injury, pose a difficult surgical, social, and economic problem [5],[6].

The three major trauma mechanisms for thoracolumbar spine fractures are rotation/translation, distraction, and compression. Most thoracolumbar burst fractures are stable injuries that can be treated nonsurgically [7].

Regardless of neurologic deficits, unstable burst fracture that has retropulsed bone fragments compromising the canal requires surgical interventions such as decompression of neural structures, correction of spinal deformities, and stabilization [8],[9].

The success of the treatment depends on the initial medical treatment, radiological diagnosis, anatomical reduction, surgical decompression of the spinal canal (if needed), and surgical stabilization. In cases of neurological damage, it is necessary to determine the exact grade of mobility impairment and of sensory functions. The classification of neurological damage in patients with the fractures of thoracolumbar spine is determined according to the American Spinal Injury Association (ASIA) score [9].

In this study, we aimed to evaluate the efficacy of treatment of unstable thoracolumbar burst fractures by transpedicular screw fixation including the fractured vertebra.


  Patients and methods Top


In this study, 40 patients were hospitalized with the diagnosis of traumatic thoracolumbar spinal fracture without post-traumatic neurologic deficit in the Neurosurgical and Orthopedic Departments of Al-Azhar University Hospital, Damietta. They were operated upon with posterior short-segment instrumentation with inclusion of the fractured segment between January 2013 and March 2015. Informed consents were taken from the patients of all ethical issues.

Preoperative assessment

Patients were clinically evaluated for type of injury and extent of neurological deficit (ASIA grade) ([Table 1]). Anteroposterior and lateral plain radiographs, MRI, and 3D-computed tomography (CT) scans were carried out in all patients. The segmental kyphosis angle was measured on lateral radiographs as the angle between the superior end plate of the first uninvolved vertebra proximal to the affected segment and the first uninvolved vertebra distal to the affected segment. On the basis of CT and MRIs of the patients, we evaluated intracanal fragments, the presence of pedicle and laminar fractures, posterior ligamentous complex status, and the presence of medullary edema.
Table 1 Asia Impairment Scale [9]

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Operative technique

Our surgical procedure was attempted to reach the retropulsed bone fragments through performing both laminectomy and in some cases minimal facetectomy. In prone position, we made a midline skin incision to expose the laminae 1 or 2 levels above and below the injured levels. We performed blunt dissection until the facet joints on both sides were seen. After routine laminectomy then, we could push the retropulsed bone fragments down into the fractured vertebral body to their rightful position in the burst vertebral body. The manipulation was done with great care to avoid damage to the neural structures. This was a crucial procedure to decompress the neural canal without removal of the retropulsed bone fragments. After the posterior decompression and bone fragment repositioning, the transverse processes, laminae of above and below level, and other posterior bony surfaces were decorticated for posterolateral fusion. Then, we carried out the classical short-segment pedicle screw instrumentation (transpedicular screw and rod instruments). Finally, we embedded a sufficient amount of harvested bone fragments in the posterolateral sides of the column (posterolateral fusion).

Follow-up

The outcome was evaluated with ASIA scale after 3, 6 months, and 1 year following surgery. Plain radiography, both anteroposterior and lateral views, and 3D-CT were performed postoperatively. The segmental kyphosis angle and the extent of collapse were measured on lateral radiographs at each visit. The presence of fusion was determined from two plain radiographs and was verified with CT scan.


  Results Top


Forty (25 male and 15 female) patients with age ranging between 16 and 66 years (41.8±11.3 years) were operated upon by posterior transpedicular screw fixation. According to the ASIA scoring system, all patients were grade E. The distribution of fracture level was as shown in [Figure 1].
Figure 1 (a) Plain x-ray for male patient 24ys old presented by low back pain after road traffic accident level of L1. (b) Preoperative MRI with sagital T2 image show a fracture at leel L1 patient is neurological intact. (c) Postoperative plain x ray showing transpedicular fixation including the fractured vertebra.

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The causes of these fractures were fall in 30 (75%) patients and motor vehicle accidents in 10 (25%) patients.

Surgical outcome

Postoperative hospitalization: The average postoperative hospitalization was 7 days (range: 3–12 days).

Follow-up: The average follow-up period was 6.5 months (range: 1–12 months).

Radiological outcome: Preoperatively, most patients experienced loss of more than 45% of the vertebra body’s height and compromise of more than 22% in canal. No statistically significant correlation appeared between the canal compromise and loss of vertebral body height (P>0.05) ([Figure 2]).
Figure 2 (a,b) Plain x-ray for female patient 22ys old presented by low back pain after falling from height fracture L 3. (c) Preoperative MRI with sagital T2 image show a fracture at level L3, (d) Axial cut T2 image. (e) Postoperative plain x ray showing transpedicular fixation including the fractured vertebra. (f) Lateral view. (g) Three months postoperative.

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Dural tear occurred in three patients, with one patient having postoperative cerebrospinal fluid leak. Superficial wound infection occurred in two patients, and they responded to antibiotic treatment (third-generation cephalosporins). No patient experienced neurological worsening. No screw breakage was detected at postoperative follow-up.


  Discussion Top


In general, the treatment of thoracolumbar vertebral fractures is highly controversial. The vertebral stability after fracture constitutes an important part of the conflict [10].

Short-segment pedicle screw fixation has emerged as the treatment of choice for a patient with a burst fracture of the thoracolumbar spine. Pedicle screws have a high pull-out and cut-out strength and can withstand high stresses without failure. They can therefore achieve and maintain reduction of a short segment. Despite these advantages, they are unable to prevent anterior collapse, especially in a highly comminuted fracture. Late complications such as implant failure with recurrent kyphosis can be troublesome [11].

Various treatment methods ranging from conservative treatment to early surgical treatment have been used. The most important factor determining the treatment strategy is whether the patient has a neurological injury and, if yes, whether it is progressive or not. As the concepts and definitions have not yet been agreed upon, different treatment approaches have evolved and continue to evolve [12].

The aim of the treatment of spinal fractures is to achieve a painless, balanced, and stable spine, healthy neurological function, the highest degree of spinal motion, and to enable the patient to move in a short period of time [13].

Surgery provides spinal alignment and allows a better reduction of the fracture fragments. Canal width is more efficiently preserved regarding preventing a damage to neurological functions. It also prevents complications developing secondary to plaster cast or long-term bed rest. Because of its ability to provide a high degree of stability, patients can be mobilized earlier. Hence, rehabilitation can be initiated earlier. Posterior surgery is performed primarily in the treatment of burst fractures without neurological deficit [14].

With the effects of lordosis and posterior distraction force applied during posterior decompression, intracanal tissues are expected to be displaced anteriorly [15].

McLain et al. [16] detected early failure of this technique. In a retrospective study of 28 patients, Sanderson and colleagues performed short-segment posterior instrumentation without fusion in one level above and below the fractured vertebra and followed up the patients for 2 years. Implant failure was screw breakage in four patients (prevelation is 14%) [17].

In a prospective randomized study, Alanay et al. [18] evaluated the efficacy of transpedicular grafting and established that similar results were obtained with and without grafting.

In a prospective clinical study, Wang and colleagues compared the results of surgical treatment with and without fusion in thoracolumbar burst fractures. In that study, a total of 58 patients who were neurologically intact, with a kyphosis angle greater than 20° and a canal narrowing and collapse in vertebral height of greater than 50%, were enrolled. As a result of that study, no marked difference was observed in kyposis angles between the two groups. Radiographic parameters were found to be statistically better in the nonfusion group. Implant failure was screw breakage in eight patients (prevalence 13.7%), five of whom were in the fusion group, whereas three were in the nonfusion group. The authors suggested that the short-term outcomes of short-segment pedicular fixation without fusion in the treatment of thoracolumbar fractures were satisfactory. In addition, they suggested that the advantages of nonfusion surgery included the absence of donor-site-related problems, preservation of motion segments, decreased blood loss, and the shortened duration of the surgery [19].

Liu and colleagues published the results of a 5-year prospective randomized clinical study of 73 patients who underwent posterior short-segment fixation with and without fusion for thoracolumbar burst fractures. Among radiological results, local kyphosis angle and loss of kyphosis angle correction were taken as the basis. As a result, no radiological or clinical differences were detected between the two groups. The duration of the operation and blood loss were found to be statistically significantly lower in the nonfusion group (P<0.05) [20].

Dai and colleagues reported that pain was observed but not considered to be a major problem. However, they emphasized that the presence of these findings is irrefutable. Consequently, they reported that posterolateral bone grafting was necessary when posterior short-segment fixation was performed in selected patients (Dennis type B patients with a load sharing score of <6). Posterolateral bone grafting was done in all of our patients [21].


  Conclusion Top


By applying the transpedicular screw fixation of the unstable fractures of the thoracolumbar spine, a stable fracture fixation can be achieved. Therefore, early ambulation, rapid return to work, and less rehabilitation costs could be achieved. This kind of fixation prevents secondary spine deformities.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Knop C, Bastian L, Lange U, Oeser M, Zdichavsky M, Blauth M. Complications in surgical treatment of thoracolumbar injuries. Eur Spine J 2002; 11:214–226.  Back to cited text no. 1
    
2.
Floman Y. Posterior instrumentation in the management of thoracolumbar injuries. In: Argenson C, editor. Thoracolumbar spine. New York, NY: Raven Press; 1993:279–306.  Back to cited text no. 2
    
3.
Cho DY, Lee WY, Sheu PC. Treatment of thoracolumbar burst fractures with polymethyl methacrylate vertebroplasty and short-segment pedicle screw fixation. Neurosurgery 2003; 53:1354–1360.  Back to cited text no. 3
    
4.
Lee YS, Sung JK. Long-term follow-up results of short-segment posterior screw fixation for thoracolumbar burst fractures. J Korean Neurosurg Soc 2005; 37:416–421.  Back to cited text no. 4
    
5.
Mahar A, Kim C, Wedemeyer M. Short-segment fixation of lumbar burst fractures using pedicle fixation at the level of the fracture. Spine (Phila Pa 1976) 2007; 32:1503–1507.  Back to cited text no. 5
    
6.
Parker JW, Lane JR, Karaikovic EE, Gaines RW. Successful short-segment instrumentation and fusion for thoracolumbar spine fractures: a consecutive 41/2-year series. Spine (Phila Pa 1976) 2000; 25:1157–1170.  Back to cited text no. 6
    
7.
Wang ST, Ma HL, Liu CL. Is fusion necessary for surgically treated burst fractures of the thoracolumbar and lumbar spine? A prospective, randomized study. Spine (Phila Pa 1976) 2006; 31:2646–2652.  Back to cited text no. 7
    
8.
Kim GW, Jang JW, Hur H. Predictive factors for a kyphosis recurrence following short-segment pedicle screw fixation including fractured vertebral body in unstable thoracolumbar burst fractures. J Korean Neurosurg Soc 2014; 56:230–236.  Back to cited text no. 8
    
9.
Kanna RM, Shetty AP, Rajasekaran S. Posterior fixation including the fractured vertebra for severe unstable thoracolumbar fractures. Spine J 2015; 15:256–264.  Back to cited text no. 9
    
10.
Gurwitz GS, Dawson JM, McNamara MJ, Federspiel CF, Spengler DM. Biomechanical analysis of three surgical approaches for lumbar burst fractures using short-segment instrumentation. Spine (Phila Pa 1976) 1993; 18:977–982.  Back to cited text no. 10
    
11.
Yung AW, Thng PL. Radiological outcome of short segment posterior stabilization and fusion in thoracolumbar acute fractures. Ann Acad Med Singapore 2011; 40:140–144.  Back to cited text no. 11
    
12.
Liao JS, Fan KF, Chen WJ, Chen LH, Kao HK. Transpedicular bone grafting following short segment posterior instrumentation for acute thoracolumbar burst fractures. Orthopedics 2009; 32:493.  Back to cited text no. 12
    
13.
Sasso RC, Renken K, Hanson D, Cotler HB, Reuben JD. Unstable traumatic thoracolumbar burst fractures anteriorly versus short segment posterior fixation. J Spinal Disord Tech 2006; 19:242–248.  Back to cited text no. 13
    
14.
Korovessis P, Baikousis A, Zacharatos S, Hadjipavlou A, Repantis T. Combined anterior plus posterior stabilization versus posterior short segment instrumentation and fusion of midlumbar burst fractures. Spine 2006; 31:859–868.  Back to cited text no. 14
    
15.
Gelb D, Ludwig S, Karp JE. Successful treatment of thoracolumbar fractures with short segment pedicle instrumentation. J Spinal Disord Tech 2010; 23:293–301.  Back to cited text no. 15
    
16.
McLain RF, Sparling E, Benson DR. Early failure of short segment pedicle instrumentation for thoracolumbar fractures. A preliminary report. J Bone Joint Surg Am 1993; 75-A:162–167.  Back to cited text no. 16
    
17.
Sanderson PL, Fraser RD, Hall DJ. Short segment fixation of thoracolumbar burst fractures without fusion. Eur Spine J 1999; 8:495–500.  Back to cited text no. 17
    
18.
Alanay A, Acaroglu E, Yazisi M, Aksoy C, Surat A. The effect of transpedicular intracorporeal grafting in treatment of thoracolumbar fractures on canal remodeling. Eur Spine J 2001; 10:512–516.  Back to cited text no. 18
    
19.
Wang H, Li C, Liu T, Zhao WD, Zhou Y. Biomechanical efficacy of monoaxial or polyaxial pedicle screw and additional screw insertion at the level of the fracture, in lumbar burst fracture. An experimental study. Indian J Orthop 2012; 46:395–401.  Back to cited text no. 19
    
20.
Liu S, Li H, Liang C. Monosegmental transpedicular fixation for selected patients with thoracolumbar burst fractures. J Spinal Disord Tech 2009; 22:38–44.  Back to cited text no. 20
    
21.
Dai LY, Jiang LS, Jiang SD. Posterior short segment fixation with or without fusion for thoracolumbar burst fractures. A five to seven year prospective randomized study. J Bone Joint Surg Am 2009; 91:1033–1041.  Back to cited text no. 21
    


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