To fix the unstable region of sagittal injured unit symmetrically with pedicle screws combined with bone graft fusion for treating thoracolumbar fractures_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

LIANG Chengmin , ZHANG Wei , LIU Bin ,  YU Haiyang , CAO Jie , YIN Wen

Spine and Trauma Ward, Department of Orthopedics, Fuyang People’s Hospital, Fuyang Clinical College of Anhui Medical University, Fuyang Anhui, 236000, P.R.China;

Corresponding author：

YU Haiyang, Email: 15555850166@163.com

Keywords：

Thoracolumbar fracture; unstable region; injured unit; pedicle screw; internal fixation; symmetrically

DOI：

10.7507/1002-1892.201801160

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ObjectiveTo discuss the security and effectiveness of fixing the unstable region of sagittal injured unit symmetrically with pedicle screws combined with bone graft fusion for treating thoracolumbar fractures.MethodsA series of 65 patients with a single level thoracolumbar fracture between November 2011 and November 2015 were included in the study. There were 41 males and 24 females with an average age of 36.7 years (range, 23-60 years). The fracture segments included T₇ 1 case, T₉ in 2 cases, T₁₀ in 4 cases, T₁₁ in 8 cases, T₁₂ in 14 cases, L₁ in 19 cases, L₂ in 13 cases, L₃ in 3 cases, and L₄ in 1 case. According to AO classification, there were 34 cases classified as type A, 27 cases type B, and 4 cases type C. The neurological function was evaluated by American Spinal Injury Association (ASIA) grade score, there were 1 case at grade A, 2 cases grade B, 6 cases grade C, 15 cases grade D, and 41 cases grade E. The thoracolumbar injury severity score (TLICS) was 4 in 9 cases, 5 in 29 cases, 6-8 in 23 cases, 9-10 in 4 cases. The time form injury to operation was 2-12 days (mean, 5.3 days). The fractured vertebra, along with the superior and inferior discs were defined as a injured unit and divided into three parts on the sagittal position: region Ⅰ mainly including the superior disc, cephalic 1/3 of injured vertebra, and posterior ligamentous complex as to oppose; region Ⅱ mainly including the middle 1/3 of injured vertebra, pedicles, lamina, spinous process, and supraspinal ligament; region Ⅲ mainly including the inferior disc, caudal 1/3 of injured vertebra, and posterior ligamentous complex as to oppose. The unstable region was defined as the key injured region of the vertebra. Pedicle screws were fixed symmetrically and correspondingly with bone grafting to treat thoracolumbar fractures. The neurological status, ratio of anterior body height, and sagittal Cobb angle were collected at preoperation, immediate after operation, and last follow-up to evaluate surgical and clinical outcomes.ResultsAll patients accepted operation safely and were followed up 12-24 months (mean, 17.3 months). Cerebrospinal fluid leakage occurred in 3 patients, and cured by symptomatic treatment. There was no complications such as loosening, displacement, and breakage of internal fixator. Bony fusion was achieved in all patients at 10-13 months (mean, 11.4 months) after operation. At last follow-up, according to ASIA grading, 1 case was grade A, 1 grade B, 3 grade C, 9 grade D, and 51 grade E, showing significant difference when compared with preoperative data (Z=–2.963, P=0.014). The ratio of anterior body height at preoperation, immediate after operation, and last follow-up were 53.2%±6.8%, 91.3%±8.3%, 89.5%±6.6% respectively; and the sagittal Cobb angle were (16.3±8.1), (2.6±7.5), (3.2±6.8)° respectively. The ratio of anterior body height and the sagittal Cobb angle at immediate after operation and at last follow-up were significantly improved when compared with preoperative values (P<0.05), but no significant difference was found between at immediate after operation and at last follow-up (P>0.05).ConclusionIt is safe and reliable to treat thoracolumbar fractures under the principle of fixing the unstable region of injured unit symmetrically with pedicle screws combined with bone grafting.

Citation： LIANG Chengmin, ZHANG Wei, LIU Bin, YU Haiyang, CAO Jie, YIN Wen. To fix the unstable region of sagittal injured unit symmetrically with pedicle screws combined with bone graft fusion for treating thoracolumbar fractures. Chinese Journal of Reparative and Reconstructive Surgery, 2018, 32(7): 920-926. doi: 10.7507/1002-1892.201801160 Copy

1.	Tee JW, Chan CH, Fitzgerald MC, et al. Epidemiological trends of spine trauma: an Australian level 1 trauma centre study. Global Spine J, 2013, 3(2): 75-84.
2.	Kumar A, Aujla R, Lee C. The management of thoracolumbar burst fractures: a prospective study between conservative management, traditional open spinal surgery and minimally interventional spinal surgery. Springerplus, 2015, 4: 204.
3.	Kim BG, Dan JM, Shin DE. Treatment of thoracolumbar fracture. Asian Spine J, 2015, 9(1): 133-146.
4.	Vaccaro AR, Oner C, Kepler CK, et al. AOSpine thoracolumbar spine injury classification system: fracture description, neurological status, and key modifiers. Spine (Phila Pa 1976), 2013, 38(23): 2028-2037.
5.	Vaccaro AR, Lehman RA Jr, Hurlbert RJ, et al. A new classification of thoracolumbar injuries: the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status. Spine (Phila Pa 1976), 2005, 30(20): 2325-2333.
6.	Pellisé F, Barastegui D, Hernandez-Fernandez A, et al. Viability and long-term survival of short-segment posterior fixation in thoracolumbar burst fractures. Spine J, 2015, 15(8): 1796-1803.
7.	Koh YD, Kim DJ, Koh YW. Reliability and Validity of Thoracolumbar Injury Classification and Severity Score (TLICS). Asian Spine J, 2010, 4(2): 109-117.
8.	Pneumaticos SG, Karampinas PK, Triantafilopoulos G, et al. Evaluation of TLICS for thoracolumbar fractures. Eur Spine J, 2016, 25(4): 1123-1127.
9.	Park WM, Park YS, Kim K, et al. Biomechanical comparison of instrumentation techniques in treatment of thoracolumbar burst fractures: a finite element analysis. J Orthop Sci, 2009, 14(4): 443-449.
10.	Park SR, Na HY, Kim JM, et al. More than 5-year follow-up results of two-level and three-level posterior fixations of thoracolumbar burst fractures with load-sharing scores of seven and eight points. Clin Orthop Surg, 2016, 8(1): 71-77.
11.	McLain RF. The biomechanics of long versus short fixation for thoracolumbar spine fractures. Spine (Phila Pa 1976), 2006, 31(11 Suppl): S70-S79.
12.	张文武, 申勇, 姚晓光, 等. 后路长节段椎弓根螺钉固定治疗胸腰椎骨折的疗效评价. 中国矫形外科杂志, 2014, 22(6): 487-492.
13.	Formica M, Cavagnaro L, Basso M, et al. Which patients risk segmental kyphosis after short segment thoracolumbar fracture fixation with intermediate screws? Injury, 2016, 47 Suppl 4: S29-S34.
14.	Uzumcugil O, Dogan A, Yetis M, et al. Results of ‘two above- one below approach’ with intermediate screws at the fracture site in the surgical treatment of thoracolumbar burst fractures. Kobe J Med Sci, 2010, 56(2): E67-E78.
15.	Norton RP, Milne EL, Kaimrajh DN, et al. Biomechanical analysis of four-versus six-screw constructs for short-segment pedicle screw and rod instrumentation of unstable thoracolumbar fractures. Spine J, 2014,14(8): 1734-1739.
16.	Chou PH, Ma HL, Wang ST, et al. Fusion may not be a necessary procedure for surgically treated burst fractures of the thoracolumbar and lumbar spines: a follow-up of at least ten years. J Bone Joint Surg (Am), 2014, 96(20): 1724-1731.
17.	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(5): 1033-1041.
18.	Jindal N, Sankhala SS, Bachhal V. The role of fusion in the management of burst fractures of the thoracolumbar spine treated by short segment pedicle screw fixation: a prospective randomised trial. J Bone Joint Surg (Br), 2012, 94(8): 1101-1106.
19.	Chen JX, Goswami A, Xu DL, et al. The radiologic assessment of posterior ligamentous complex injury in patients with thoracolumbar fracture. Eur Spine J, 2017, 26(5): 1454-1462.
20.	Yacoub AR, Joaquim AF, Ghizoni E, et al. Evaluation of the safety and reliability of the newly-proposed AO spine injury classification system. J Spinal Cord Med, 2017, 40(1): 70-75.
21.	Joaquim AF, de Almeida Bastos DC, Jorge Torres HH, et al. Thoracolumbar injury classification and injury severity score system: a literature review of its safety. Global Spine J, 2016, 6(1): 80-85.

1. Tee JW, Chan CH, Fitzgerald MC, et al. Epidemiological trends of spine trauma: an Australian level 1 trauma centre study. Global Spine J, 2013, 3(2): 75-84.
2. Kumar A, Aujla R, Lee C. The management of thoracolumbar burst fractures: a prospective study between conservative management, traditional open spinal surgery and minimally interventional spinal surgery. Springerplus, 2015, 4: 204.
3. Kim BG, Dan JM, Shin DE. Treatment of thoracolumbar fracture. Asian Spine J, 2015, 9(1): 133-146.
4. Vaccaro AR, Oner C, Kepler CK, et al. AOSpine thoracolumbar spine injury classification system: fracture description, neurological status, and key modifiers. Spine (Phila Pa 1976), 2013, 38(23): 2028-2037.
5. Vaccaro AR, Lehman RA Jr, Hurlbert RJ, et al. A new classification of thoracolumbar injuries: the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status. Spine (Phila Pa 1976), 2005, 30(20): 2325-2333.
6. Pellisé F, Barastegui D, Hernandez-Fernandez A, et al. Viability and long-term survival of short-segment posterior fixation in thoracolumbar burst fractures. Spine J, 2015, 15(8): 1796-1803.
7. Koh YD, Kim DJ, Koh YW. Reliability and Validity of Thoracolumbar Injury Classification and Severity Score (TLICS). Asian Spine J, 2010, 4(2): 109-117.
8. Pneumaticos SG, Karampinas PK, Triantafilopoulos G, et al. Evaluation of TLICS for thoracolumbar fractures. Eur Spine J, 2016, 25(4): 1123-1127.
9. Park WM, Park YS, Kim K, et al. Biomechanical comparison of instrumentation techniques in treatment of thoracolumbar burst fractures: a finite element analysis. J Orthop Sci, 2009, 14(4): 443-449.
10. Park SR, Na HY, Kim JM, et al. More than 5-year follow-up results of two-level and three-level posterior fixations of thoracolumbar burst fractures with load-sharing scores of seven and eight points. Clin Orthop Surg, 2016, 8(1): 71-77.
11. McLain RF. The biomechanics of long versus short fixation for thoracolumbar spine fractures. Spine (Phila Pa 1976), 2006, 31(11 Suppl): S70-S79.
12. 张文武, 申勇, 姚晓光, 等. 后路长节段椎弓根螺钉固定治疗胸腰椎骨折的疗效评价. 中国矫形外科杂志, 2014, 22(6): 487-492.
13. Formica M, Cavagnaro L, Basso M, et al. Which patients risk segmental kyphosis after short segment thoracolumbar fracture fixation with intermediate screws? Injury, 2016, 47 Suppl 4: S29-S34.
14. Uzumcugil O, Dogan A, Yetis M, et al. Results of ‘two above- one below approach’ with intermediate screws at the fracture site in the surgical treatment of thoracolumbar burst fractures. Kobe J Med Sci, 2010, 56(2): E67-E78.
15. Norton RP, Milne EL, Kaimrajh DN, et al. Biomechanical analysis of four-versus six-screw constructs for short-segment pedicle screw and rod instrumentation of unstable thoracolumbar fractures. Spine J, 2014,14(8): 1734-1739.
16. Chou PH, Ma HL, Wang ST, et al. Fusion may not be a necessary procedure for surgically treated burst fractures of the thoracolumbar and lumbar spines: a follow-up of at least ten years. J Bone Joint Surg (Am), 2014, 96(20): 1724-1731.
17. 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(5): 1033-1041.
18. Jindal N, Sankhala SS, Bachhal V. The role of fusion in the management of burst fractures of the thoracolumbar spine treated by short segment pedicle screw fixation: a prospective randomised trial. J Bone Joint Surg (Br), 2012, 94(8): 1101-1106.
19. Chen JX, Goswami A, Xu DL, et al. The radiologic assessment of posterior ligamentous complex injury in patients with thoracolumbar fracture. Eur Spine J, 2017, 26(5): 1454-1462.
20. Yacoub AR, Joaquim AF, Ghizoni E, et al. Evaluation of the safety and reliability of the newly-proposed AO spine injury classification system. J Spinal Cord Med, 2017, 40(1): 70-75.
21. Joaquim AF, de Almeida Bastos DC, Jorge Torres HH, et al. Thoracolumbar injury classification and injury severity score system: a literature review of its safety. Global Spine J, 2016, 6(1): 80-85.

Chinese Journal of Reparative and Reconstructive Surgery

To fix the unstable region of sagittal injured unit symmetrically with pedicle screws combined with bone graft fusion for treating thoracolumbar fractures

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