Clinical study of Wiltse approach with fulcrum reduction technique in the treatment of AO-A type thoracolumbar fractures_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

 WEN Ganjun ^1,2 , JIANG Diqin ¹ , ZHOU Zhisen ¹ , TENG Fanwen ¹ , ZHAO Yunfang ¹

1. Department of Orthopedics, Dongguan East Central Hospital, Dongguan Guangdong, 523573, P. R. China;
2. The First Clinical Medical College of Guangzhou University of Traditional Chinese Medicine, Guangzhou Guangdong, 510405, P. R. China;

Corresponding author：

WEN Ganjun, Email: 413697236@qq.com

Keywords：

Wiltse approach; fulcrum reduction technique; thoracolumbar fracture; internal fixation

DOI：

10.7507/1002-1892.202110030

Video：

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Objective To investigate the effectiveness of Wiltse approach with fulcrum reduction technique and pedicle internal fixation in the treatment of AO-A type thoracolumbar fractures. Methods The clinical data of 16 patients with AO-A type thoracolumbar fractures treated with Wiltse approach with fulcrum reduction technique and pedicle internal fixation between September 2013 and January 2019 were retrospectively analyzed. There were 9 males and 7 females, the age ranged from 38 to 60 years, with an average age of 50.7 years. Causes of injury included 9 cases of falling from height, 3 cases of traffic accidents, 3 cases of falling, and 1 case crushed by heavy objects. Fractured segment involved T₁₁ in 2 cases, T₁₂ in 5 cases, L₁ in 7 cases, and L₂ in 2 cases. There were 6 cases of type A1, 3 cases of type A2, 5 cases of type A3, and 2 cases of type A4 according to AO fracture classification. The operation time, intraoperative blood loss, and removal time of internal fixator were recorded. Before operation, immediately after operation, before and after removal of internal fixator, the local kyphotic angle (LKA), anterior vertebral height (AVH), and posterior vertebral height (PVH) of fractured vertebral body were measured; visual analogue scale (VAS) score of back pain were evaluated before operation, at 3 days after operation, before and after removal of internal fixator. Results The operation time of the patients was 50-95 minutes, with an average of 70.7 minutes; the intraoperative blood loss was 50-230 mL, with an average of 132.9 mL; the internal fixator was removed after 18-30 months, with an average of 23.6 months. All patients were followed up 20-32 months, with an average of 25.6 months. No incision infection, hematoma, and other surgery-related complications, and internal fixator rupture residual complications occurred. All 16 patients achieved satisfactory reduction results. Immediate postoperative LKA, AVH, and PVH were significantly improved when compared with preoperative ones (P<0.05). There was a certain degree of reduction loss before internal fixator removal, and the difference in LKA was significant (P<0.05), but the difference in AVH and PVH were not significant (P>0.05). There was a certain degree of reduction loss after internal fixator removal, but only the difference in AVH was significant (P<0.05), and there was no significant difference in LKA and PVH (P>0.05). The VAS score of the back pain significantly improved at 3 days after operation and before internal fixator removal when compared with preoperative score (P<0.05). The pain after internal fixator removal was significantly worse than that before internal fixator removal (P<0.05). Conclusion The Wiltse approach with fulcrum reduction technique and pedicle internal fixation in the treatment of AO-A thoracolumbar fractures has a short operation time, less intraoperative blood loss, and the posterior soft tissue and other structures are well protected during the operation. It can provide satisfactory clinical reduction results.

Citation： WEN Ganjun, JIANG Diqin, ZHOU Zhisen, TENG Fanwen, ZHAO Yunfang. Clinical study of Wiltse approach with fulcrum reduction technique in the treatment of AO-A type thoracolumbar fractures. Chinese Journal of Reparative and Reconstructive Surgery, 2022, 36(3): 310-314. doi: 10.7507/1002-1892.202110030 Copy

1.	Hu R, Mustard CA, Burns C. Epidemiology of incident spinal fracture in a complete population. Spine (Phila Pa 1976), 1996, 21(4): 492-499.
2.	Gertzbein SD. Scoliosis Research Society. Multicenter spine fracture study. Spine (Phila Pa 1976), 1992, 17(5): 528-540.
3.	Wood K, Buttermann G, Mehbod A, et al. Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit. A prospective, randomized study. J Bone Joint Surg (Am), 2003, 85(5): 773-781.
4.	Wiltse LL, Bateman JG, Hutchinson RH, et al. The paraspinal sacrospinalis-splitting approach to the lumbar spine. J Bone Joint Surg (Am), 1968, 50(5): 919-926.
5.	黎庆初, 尹刚辉, 张忠民, 等. 微创Wiltse入路与传统后正中入路手术治疗双节段腰椎管狭窄症的疗效比较. 中国脊柱脊髓杂志, 2012, 22(9): 812-817.
6.	Chen ZD, Wu J, Yao XT, et al. Comparison of Wiltse’s paraspinal approach and open book laminectomy for thoracolumbar burst fractures with greenstick lamina fractures: a randomized controlled trial. J Orthop Surg Res, 2018, 13(1): 43. doi: 10.1186/s13018-018-0743-z.
7.	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): 2028-2037.
8.	Tian NF, Wu YS, Zhang XL, et al. Fusion versus nonfusion for surgically treated thoracolumbar burst fractures: a meta-analysis. PLoS One, 2013, 8(5): e63995. doi: 10.1371/journal.pone.0063995.
9.	Barbagallo GM, Yoder E, Dettori JR, et al. Percutaneous minimally invasive versus open spine surgery in the treatment of fractures of the thoracolumbar junction: a comparative effectiveness review. Evid Based Spine Care J, 2012, 3(3): 43-49.
10.	Boerger TO, Limb D, Dickson RA. Does ‘canal clearance’ affect neurological outcome after thoracolumbar burst fractures? J Bone Joint Surg (Br), 2000, 82(5): 629-635.
11.	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.
12.	Meves R, Avanzi O. Correlation among canal compromise, neurologic deficit, and injury severity in thoracolumbar burst fractures. Spine (Phila Pa 1976), 2006, 31(18): 2137-2141.
13.	Walker CT, Xu DS, Godzik J, et al. Minimally invasive surgery for thoracolumbar spinal trauma. Ann Transl Med, 2018, 6(6): 102. doi: 10.21037/atm.2018.02.10.
14.	Sun ZF, Yang KX, Chen HT, et al. A novel entry point for pedicle screw placement in the thoracic spine. J Biomed Res, 2018, 32(2): 123-129.
15.	Phan K, Rao PJ, Mobbs RJ. Percutaneous versus open pedicle screw fixation for treatment of thoracolumbar fractures: Systematic review and meta-analysis of comparative studies. Clin Neurol Neurosurg, 2015, 135: 85-92.
16.	Kawaguchi Y, Yabuki S, Styf J, et al. Back muscle injury after posterior lumbar spine surgery. Topographic evaluation of intramuscular pressure and blood flow in the porcine back muscle during surgery. Spine (Phila Pa 1976), 1996, 21(22): 2683-2688.
17.	Chung WH, Eu WC, Chiu CK, et al. Minimally invasive reduction of thoracolumbar burst fracture using monoaxial percutaneous pedicle screws: Surgical technique and report of radiological outcome. J Orthop Surg (Hong Kong), 2020, 28(1): 2309499019888977. doi: 10.1177/2309499019888977.
18.	Moore TA, Steinmetz MP, Anderson PA. Novel reduction technique for thoracolumbar fracture-dislocations. J Neurosurg Spine, 2011, 15(6): 675-677.

1. Hu R, Mustard CA, Burns C. Epidemiology of incident spinal fracture in a complete population. Spine (Phila Pa 1976), 1996, 21(4): 492-499.
2. Gertzbein SD. Scoliosis Research Society. Multicenter spine fracture study. Spine (Phila Pa 1976), 1992, 17(5): 528-540.
3. Wood K, Buttermann G, Mehbod A, et al. Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit. A prospective, randomized study. J Bone Joint Surg (Am), 2003, 85(5): 773-781.
4. Wiltse LL, Bateman JG, Hutchinson RH, et al. The paraspinal sacrospinalis-splitting approach to the lumbar spine. J Bone Joint Surg (Am), 1968, 50(5): 919-926.
5. 黎庆初, 尹刚辉, 张忠民, 等. 微创Wiltse入路与传统后正中入路手术治疗双节段腰椎管狭窄症的疗效比较. 中国脊柱脊髓杂志, 2012, 22(9): 812-817.
6. Chen ZD, Wu J, Yao XT, et al. Comparison of Wiltse’s paraspinal approach and open book laminectomy for thoracolumbar burst fractures with greenstick lamina fractures: a randomized controlled trial. J Orthop Surg Res, 2018, 13(1): 43. doi: 10.1186/s13018-018-0743-z.
7. 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): 2028-2037.
8. Tian NF, Wu YS, Zhang XL, et al. Fusion versus nonfusion for surgically treated thoracolumbar burst fractures: a meta-analysis. PLoS One, 2013, 8(5): e63995. doi: 10.1371/journal.pone.0063995.
9. Barbagallo GM, Yoder E, Dettori JR, et al. Percutaneous minimally invasive versus open spine surgery in the treatment of fractures of the thoracolumbar junction: a comparative effectiveness review. Evid Based Spine Care J, 2012, 3(3): 43-49.
10. Boerger TO, Limb D, Dickson RA. Does ‘canal clearance’ affect neurological outcome after thoracolumbar burst fractures? J Bone Joint Surg (Br), 2000, 82(5): 629-635.
11. 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.
12. Meves R, Avanzi O. Correlation among canal compromise, neurologic deficit, and injury severity in thoracolumbar burst fractures. Spine (Phila Pa 1976), 2006, 31(18): 2137-2141.
13. Walker CT, Xu DS, Godzik J, et al. Minimally invasive surgery for thoracolumbar spinal trauma. Ann Transl Med, 2018, 6(6): 102. doi: 10.21037/atm.2018.02.10.
14. Sun ZF, Yang KX, Chen HT, et al. A novel entry point for pedicle screw placement in the thoracic spine. J Biomed Res, 2018, 32(2): 123-129.
15. Phan K, Rao PJ, Mobbs RJ. Percutaneous versus open pedicle screw fixation for treatment of thoracolumbar fractures: Systematic review and meta-analysis of comparative studies. Clin Neurol Neurosurg, 2015, 135: 85-92.
16. Kawaguchi Y, Yabuki S, Styf J, et al. Back muscle injury after posterior lumbar spine surgery. Topographic evaluation of intramuscular pressure and blood flow in the porcine back muscle during surgery. Spine (Phila Pa 1976), 1996, 21(22): 2683-2688.
17. Chung WH, Eu WC, Chiu CK, et al. Minimally invasive reduction of thoracolumbar burst fracture using monoaxial percutaneous pedicle screws: Surgical technique and report of radiological outcome. J Orthop Surg (Hong Kong), 2020, 28(1): 2309499019888977. doi: 10.1177/2309499019888977.
18. Moore TA, Steinmetz MP, Anderson PA. Novel reduction technique for thoracolumbar fracture-dislocations. J Neurosurg Spine, 2011, 15(6): 675-677.

Chinese Journal of Reparative and Reconstructive Surgery

Clinical study of Wiltse approach with fulcrum reduction technique in the treatment of AO-A type thoracolumbar fractures

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