Decompression by mini-open posterior approach assisted with microscope for thoracolumbar burst fracture with severe spinal canal stenosis_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

ZHANG Bin ^1,2 , ZOU Hua ¹ , KONG Weijun ¹ , WANG Chong ¹ , WU Fujun ¹ , YE Sheng ¹ ,  WANG Xin ¹ ,  AO Jun ¹

1. Department of Orthopaedics, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou, 563003, P.R.China;
2. Department of Spinal Surgery, Guizhou Orthopedic Hospital, Guiyang Guizhou, 550002, P.R.China;

Corresponding author：

WANG Xin, Email: lchwx@aliyun.com; AO Jun, Email: Ao00jun@163.com

Keywords：

Thoracolumbar burst fracture; severe spinal canal stenosis; minimal invasive; microscope

DOI：

10.7507/1002-1892.201711052

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ObjectiveTo investigate the effectiveness of posterior microscopic mini-open technique (MOT) decompression in patients with severe spinal canal stenosis resulting from thoracolumbar burst fractures.MethodsThe clinical data of 28 patients with severe spinal canal stenosis caused by thoracolumbar burst fractures, who were treated by posterior microscopic MOT, which performed unilateral or bilateral laminectomy, poking reduction, intervertebral bone graft via spinal canal, and percutaneous pedicle screw fixation between January 2014 and January 2016 were retrospectively analyzed. There were 21 males and 7 females with a mean age of 42.1 years (range, 16-61 years). The involved segments included T₁₁ in 1 case, T₁₂ in 4 cases, L₁ in 14 cases, and L₂ in 9 cases. According to AO classification, there were 19 cases of type A3, 9 of type A4. According to American Spinal Injury Association (ASIA) grading, 12 cases were grade C, 13 grade D, and 3 grade E. The time between injury and operation was 3-7 days (mean, 3.6 days). To evaluate effectiveness, the changes in the visual analogue scale (VAS), percentage of anterior height of injured vertebrae, Cobb angle, rate of spinal compromise (RSC), and ASIA grading were analyzed.ResultsAll patients were performed procedures successfully. The operation time was 135-323 minutes (mean, 216.4 minutes). The intraoperative blood loss was 80-800 mL (mean, 197.7 mL). The hospitalization time was 10-25 days (mean, 12.5 days). The incisions healed primarily, without wound infection, cerebrospinal fluid leakage, or other early complications. All the 28 patients were followed up 12-24 months (mean, 16.5 months). No breakage or loosening of internal fixation occurred. All fractures healed, and the healing time was 3-12 months (mean, 6.5 months). Compared with preoperative ones, the percentage of anterior height of injured vertebrae, Cobb angle, and RSC at immediate after operation and at last follow-up and the VAS scores at 1 day after operation and at last-follow were significantly improved (P<0.05). There was no significant difference in the percentage of anterior height of injured vertebrae and Cobb angle between at immediate after operation and at last follow-up (P>0.05). But the RSC at immediate after operation and VSA score at 1 day after operation were significantly improved when compared with those at last follow-up (P<0.05). The ASIA grading at last follow-up was 1 case of grade C, 14 grade D, and 13 grade E, which was significantly improved when compared with preoperative ones (Z=3.860, P=0.000).ConclusionMOT is an effective and minimal invasive treatment for thoracolumbar AO type A3 and A4 burst fractures with severe spinal canal stenosis, and it is beneficial to early rehabilitation for patients.

Citation： ZHANG Bin, ZOU Hua, KONG Weijun, WANG Chong, WU Fujun, YE Sheng, WANG Xin, AO Jun. Decompression by mini-open posterior approach assisted with microscope for thoracolumbar burst fracture with severe spinal canal stenosis. Chinese Journal of Reparative and Reconstructive Surgery, 2018, 32(4): 468-475. doi: 10.7507/1002-1892.201711052 Copy

1.	Dai J, Lin H, Niu S, et al. Correlation of bone fragments reposition and related parameters in thoracolumbar burst fractures patients. Int J Clin Exp Med, 2015, 8(7): 11125-11131.
2.	Park MS, Moon SH, Yang JH, et al. Neurologic recovery according to the spinal fracture patterns by Denis classification. Yonsei Med J, 2013, 54(3): 715-719.
3.	Li C, Zhou Y, Wang H, et al. Treatment of unstable thoracolumbar fractures through short segment pedicle screw fixation techniques using pedicle fixation at the level of the fracture: a finite element analysis. PLoS One, 2014, 9(6): 99156.
4.	Ellingson BM, Salamon N, Holly LT. Imaging techniques in spinal cord injury. World Neurosurg, 2014, 82(6): 1351-1358.
5.	Fessler RG, O’Toole JE, Eichholz KM, et al. The development of minimally invasive spine surgery. Neurosurg Clin N Am, 2006, 17(4): 401-409.
6.	Samartzis D, Shen FH, Perez-Cruet MJ, et al. Minimally invasive spine surgery: a historical perspective. Orthop Clin North Am, 2007, 38(3): 305-326.
7.	Foley KT, Holly LT, Schwender JD. Minimally invasive lumbar fusion. Spine (Phila Pa 1976), 2003, 28(15 Suppl): S26-35.
8.	Hashimoto T, Kaneda K, Abumi K. Relationship between traumatic spinal canal stenosis and neurologic deficits in thoracolumbar burst fractures. Spine (Phila Pa 1976), 1988, 13(11): 1268-1272.
9.	Mohanty SP, Bhat NS, Abraham R, et al. Neurological deficit and canal compromise in thoracolumbar and lumbar burst fractures. J Orthop Surg (Hong Kong), 2008, 16(1): 20-23.
10.	Wolter D. Recommendation for the classification of spinal injuries. Unfallchirurg, 1985, 88(11): 481-484.
11.	袁文. 胸腰椎骨折外科治疗相关问题探讨. 中华创伤杂志, 2006, 22(1): 8-10.
12.	Meves R, Avanzi O. Correlation between neurological deficit and spinal canal compromise in 198 patients with thoracolumbar and lumbar fractures. Spine (Phila Pa 1976), 2005, 30(7): 787-791.
13.	Dickerman RD, Reynolds AS, Tackett J, et al. Percutaneous pedicle screws significantly decrease muscle damage and operative time: surgical technique makes a difference! Eur Spine J, 2008, 17(10): 1398.
14.	Vanek P, Bradac O, Konopkova R, et al. Treatment of thoracolumbar trauma by short-segment percutaneous transpedicular screw instrumentation: prospective comparative study with a minimum 2-year follow-up. J Neurosurg Spine, 2014, 20(2): 150-156.
15.	Xu BS, Xu HW, Yuan QM, et al. Thoracic endoscopic‐assisted mini‐open surgery for thoracic and thoracolumbar spinal cord compression. Orthop Surg, 2016, 8(4): 523-526.
16.	Kuang L, Wang B, Lu GH. Transforaminal lumbar interbody fusion versus mini-open anterior lumbar interbody fusion with oblique self-anchored stand-alone Cages for the treatment of lumbar disc herniation: a retrospective study with 2-year follow-up. Spine (Phila Pa 1976), 2017, 42(21): E1259-E1265.
17.	Pingel A, Castein J, Kandziora F. Anterior monosegmental stabilization and fusion of an incomplete cranial burst fracture in the thoracolumbar spine via a mini-open, thoracoscopically assisted transthoracic approach. Eur Spine J, 2017, 26(Suppl 3): 431-432.
18.	Theologis AA, Ehsan T, Paul T, et al. Anterior corpectomy via the mini-open, extreme lateral, transpsoas approach combined with short-segment posterior fixation for single-level traumatic lumbar burst fractures: analysis of health-related quality of life outcomes and patient satisfaction. J Neurosurg Spine, 2016, 24(1): 60-68.
19.	Kalra RR, Schmidt MH. The role of a miniopen thoracoscopic-assisted approach in the management of burst fractures involving the thoracolumbar junction. Neurosurg Clin N Am, 2017, 28(1): 139-145.
20.	胡龙驹, 冯新民, 陈鹏涛, 等. 后路椎板开窗减压加对侧椎板植骨融合治疗胸腰椎爆裂性骨折伴不全瘫. 中国矫形外科杂志, 2012, 20(22): 2039-2042.
21.	敖俊, 辛志军, 陈方, 等. 两种植骨法对胸腰椎爆裂骨折复位后骨缺损空隙残存率及压缩刚度的影响. 中国修复重建外科杂志, 2013, 27(8): 974-979.
22.	Damodaran O, Lee J, Lee G. Microscope in modern spinal surgery: advantages, ergonomics and limitations. ANZ J Surg, 2013, 83(4): 211-214.
23.	敖俊, 兰美兵, 薛鹏举, 等. 脊柱胸腰段椎内静脉丛的应用解剖学研究. 中国现代医学杂志, 2013, 23(28): 29-32.
24.	Hussey RW, Rossier AB, Sarkarati M. An algorithm or treatment plan for acute spinal cord injury. J Am Paraplegia Soc, 1983, 6(2): 27-32.
25.	关骅, 唐和虎. 脊髓损伤早期康复. 中国康复理论与实践, 2000, 6(4): 179-183.
26.	Maynard FM Jr, Bracken MB, Creasey G, et al. International standards for neurological and functional classification of spinal cord injury. American Spinal Injury Association. Spinal Cord, 1997, 35(5): 266-274.
27.	Bains RS, Althausen PL, Gitlin GN, et al. The role of acute decompression and restoration of spinal alignment in the prevention of post-traumatic syringomyelia: case report and review of recent literature. Spine (Phila Pa 1976), 2001, 26(17): E399-402.
28.	Shi R, Liu H, Zhao X, et al. Anterior single segmental decompression and fixation for Denis B type thoracolumbar burst fracture with neurological deficiency: thirty-four cases with average twenty-six month follow-up. Spine (Phila Pa 1976), 2011, 36(9): E598-605.
29.	Xu GJ, Li ZJ, Ma JX, et al. Anterior versus posterior approach for treatment of thoracolumbar burst fractures: a meta-analysis. Eur Spine J, 2013, 22(10): 2176-2183.
30.	Mahar A, Kim C, Wedemeyer M, et al. Short-segment fixation of lumbar burst fractures using pedicle fixation at the level of the fracture. Spine (Phila Pa 1976), 2007, 32(14): 1503-1507.
31.	敖俊, 王震, 覃建朴, 等. 胸腰段和腰椎椎体矢状骨折线的CT影像学分析. 实用医学杂志, 2013, 29(1): 4-6.
32.	许效坤, 左炳光. 后路短节段固定治疗胸腰椎骨折是否需要融合? 中国骨与关节损伤杂志, 2012, 27(9): 820-821.
33.	Farcy JP, Weidenbaum M, Glassman SD. Sagittal index in management of thoracolumbar burst fractures. Spine (Phila Pa 1976), 1990, 15(9): 958-965.
34.	Sjöström L, Jacobsson O, Karlström G, et al. Spinal canal remodelling after stabilization of thoracolumbar burst fractures. Eur Spine J, 1994, 3(6): 312-317.
35.	Miyashita T, Ataka H, Tanno T. Clinical results of posterior stabilization without decompression for thoracolumbar burst fractures: is decompression necessary? Neurosurg Rev, 2012, 35(3): 447-455.
36.	Merom L, Raz N, Hamud C, et al. Minimally invasive burst fracture fixation in the thoracolumbar region. Orthopedics, 2009, 32(4): 273-275.
37.	Weiner BK, Kilgore WB. Bacterial shedding in common spine surgical procedures: headlamp/loupes and the operative microscope. Spine (Phila Pa 1976), 2007, 32(8): 918-920.
38.	Bible JE, O’Neill KR, Crosby CG, et al. Microscope sterility during spine surgery. Spine (Phila Pa 1976), 2012, 37(7): 623-627.
39.	Basques BA, Golinvaux NS, Bohl DD, et al. Use of an operating microscope during spine surgery is associated with minor increases in operating room times and no increased risk of infection. Spine (Phila Pa 1976), 2014, 39(22): 1910-1916.

1. Dai J, Lin H, Niu S, et al. Correlation of bone fragments reposition and related parameters in thoracolumbar burst fractures patients. Int J Clin Exp Med, 2015, 8(7): 11125-11131.
2. Park MS, Moon SH, Yang JH, et al. Neurologic recovery according to the spinal fracture patterns by Denis classification. Yonsei Med J, 2013, 54(3): 715-719.
3. Li C, Zhou Y, Wang H, et al. Treatment of unstable thoracolumbar fractures through short segment pedicle screw fixation techniques using pedicle fixation at the level of the fracture: a finite element analysis. PLoS One, 2014, 9(6): 99156.
4. Ellingson BM, Salamon N, Holly LT. Imaging techniques in spinal cord injury. World Neurosurg, 2014, 82(6): 1351-1358.
5. Fessler RG, O’Toole JE, Eichholz KM, et al. The development of minimally invasive spine surgery. Neurosurg Clin N Am, 2006, 17(4): 401-409.
6. Samartzis D, Shen FH, Perez-Cruet MJ, et al. Minimally invasive spine surgery: a historical perspective. Orthop Clin North Am, 2007, 38(3): 305-326.
7. Foley KT, Holly LT, Schwender JD. Minimally invasive lumbar fusion. Spine (Phila Pa 1976), 2003, 28(15 Suppl): S26-35.
8. Hashimoto T, Kaneda K, Abumi K. Relationship between traumatic spinal canal stenosis and neurologic deficits in thoracolumbar burst fractures. Spine (Phila Pa 1976), 1988, 13(11): 1268-1272.
9. Mohanty SP, Bhat NS, Abraham R, et al. Neurological deficit and canal compromise in thoracolumbar and lumbar burst fractures. J Orthop Surg (Hong Kong), 2008, 16(1): 20-23.
10. Wolter D. Recommendation for the classification of spinal injuries. Unfallchirurg, 1985, 88(11): 481-484.
11. 袁文. 胸腰椎骨折外科治疗相关问题探讨. 中华创伤杂志, 2006, 22(1): 8-10.
12. Meves R, Avanzi O. Correlation between neurological deficit and spinal canal compromise in 198 patients with thoracolumbar and lumbar fractures. Spine (Phila Pa 1976), 2005, 30(7): 787-791.
13. Dickerman RD, Reynolds AS, Tackett J, et al. Percutaneous pedicle screws significantly decrease muscle damage and operative time: surgical technique makes a difference! Eur Spine J, 2008, 17(10): 1398.
14. Vanek P, Bradac O, Konopkova R, et al. Treatment of thoracolumbar trauma by short-segment percutaneous transpedicular screw instrumentation: prospective comparative study with a minimum 2-year follow-up. J Neurosurg Spine, 2014, 20(2): 150-156.
15. Xu BS, Xu HW, Yuan QM, et al. Thoracic endoscopic‐assisted mini‐open surgery for thoracic and thoracolumbar spinal cord compression. Orthop Surg, 2016, 8(4): 523-526.
16. Kuang L, Wang B, Lu GH. Transforaminal lumbar interbody fusion versus mini-open anterior lumbar interbody fusion with oblique self-anchored stand-alone Cages for the treatment of lumbar disc herniation: a retrospective study with 2-year follow-up. Spine (Phila Pa 1976), 2017, 42(21): E1259-E1265.
17. Pingel A, Castein J, Kandziora F. Anterior monosegmental stabilization and fusion of an incomplete cranial burst fracture in the thoracolumbar spine via a mini-open, thoracoscopically assisted transthoracic approach. Eur Spine J, 2017, 26(Suppl 3): 431-432.
18. Theologis AA, Ehsan T, Paul T, et al. Anterior corpectomy via the mini-open, extreme lateral, transpsoas approach combined with short-segment posterior fixation for single-level traumatic lumbar burst fractures: analysis of health-related quality of life outcomes and patient satisfaction. J Neurosurg Spine, 2016, 24(1): 60-68.
19. Kalra RR, Schmidt MH. The role of a miniopen thoracoscopic-assisted approach in the management of burst fractures involving the thoracolumbar junction. Neurosurg Clin N Am, 2017, 28(1): 139-145.
20. 胡龙驹, 冯新民, 陈鹏涛, 等. 后路椎板开窗减压加对侧椎板植骨融合治疗胸腰椎爆裂性骨折伴不全瘫. 中国矫形外科杂志, 2012, 20(22): 2039-2042.
21. 敖俊, 辛志军, 陈方, 等. 两种植骨法对胸腰椎爆裂骨折复位后骨缺损空隙残存率及压缩刚度的影响. 中国修复重建外科杂志, 2013, 27(8): 974-979.
22. Damodaran O, Lee J, Lee G. Microscope in modern spinal surgery: advantages, ergonomics and limitations. ANZ J Surg, 2013, 83(4): 211-214.
23. 敖俊, 兰美兵, 薛鹏举, 等. 脊柱胸腰段椎内静脉丛的应用解剖学研究. 中国现代医学杂志, 2013, 23(28): 29-32.
24. Hussey RW, Rossier AB, Sarkarati M. An algorithm or treatment plan for acute spinal cord injury. J Am Paraplegia Soc, 1983, 6(2): 27-32.
25. 关骅, 唐和虎. 脊髓损伤早期康复. 中国康复理论与实践, 2000, 6(4): 179-183.
26. Maynard FM Jr, Bracken MB, Creasey G, et al. International standards for neurological and functional classification of spinal cord injury. American Spinal Injury Association. Spinal Cord, 1997, 35(5): 266-274.
27. Bains RS, Althausen PL, Gitlin GN, et al. The role of acute decompression and restoration of spinal alignment in the prevention of post-traumatic syringomyelia: case report and review of recent literature. Spine (Phila Pa 1976), 2001, 26(17): E399-402.
28. Shi R, Liu H, Zhao X, et al. Anterior single segmental decompression and fixation for Denis B type thoracolumbar burst fracture with neurological deficiency: thirty-four cases with average twenty-six month follow-up. Spine (Phila Pa 1976), 2011, 36(9): E598-605.
29. Xu GJ, Li ZJ, Ma JX, et al. Anterior versus posterior approach for treatment of thoracolumbar burst fractures: a meta-analysis. Eur Spine J, 2013, 22(10): 2176-2183.
30. Mahar A, Kim C, Wedemeyer M, et al. Short-segment fixation of lumbar burst fractures using pedicle fixation at the level of the fracture. Spine (Phila Pa 1976), 2007, 32(14): 1503-1507.
31. 敖俊, 王震, 覃建朴, 等. 胸腰段和腰椎椎体矢状骨折线的CT影像学分析. 实用医学杂志, 2013, 29(1): 4-6.
32. 许效坤, 左炳光. 后路短节段固定治疗胸腰椎骨折是否需要融合? 中国骨与关节损伤杂志, 2012, 27(9): 820-821.
33. Farcy JP, Weidenbaum M, Glassman SD. Sagittal index in management of thoracolumbar burst fractures. Spine (Phila Pa 1976), 1990, 15(9): 958-965.
34. Sjöström L, Jacobsson O, Karlström G, et al. Spinal canal remodelling after stabilization of thoracolumbar burst fractures. Eur Spine J, 1994, 3(6): 312-317.
35. Miyashita T, Ataka H, Tanno T. Clinical results of posterior stabilization without decompression for thoracolumbar burst fractures: is decompression necessary? Neurosurg Rev, 2012, 35(3): 447-455.
36. Merom L, Raz N, Hamud C, et al. Minimally invasive burst fracture fixation in the thoracolumbar region. Orthopedics, 2009, 32(4): 273-275.
37. Weiner BK, Kilgore WB. Bacterial shedding in common spine surgical procedures: headlamp/loupes and the operative microscope. Spine (Phila Pa 1976), 2007, 32(8): 918-920.
38. Bible JE, O’Neill KR, Crosby CG, et al. Microscope sterility during spine surgery. Spine (Phila Pa 1976), 2012, 37(7): 623-627.
39. Basques BA, Golinvaux NS, Bohl DD, et al. Use of an operating microscope during spine surgery is associated with minor increases in operating room times and no increased risk of infection. Spine (Phila Pa 1976), 2014, 39(22): 1910-1916.

Chinese Journal of Reparative and Reconstructive Surgery

Decompression by mini-open posterior approach assisted with microscope for thoracolumbar burst fracture with severe spinal canal stenosis

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