Objective To evaluate the effectiveness of using pedical screw at the fracture level, intervertebral distraction, and Cage insertion by posterior approach to treat thoracolumbar kyphosis caused by old fracture. Methods Between June 2008 and June 2010, 15 cases of thoracolumbar kyphosis caused by old fracture were treated with pedical screw at the fracture level, intervertebral distraction, and Cage insertion by posterior approach. There were 9 males and 6 females with a mean age of 54.6 years (range, 39-65 years). The disease duration was 5 months to 3 years with an average of 1.5 years. Fractured segments included T11 in 1 case, T12 in 4 cases, L1 in 5 cases, and L2 in 5 cases. Ten patients had nerve symptom, according to American Spinal Injury Association (ASIA) grading, 3 cases were classified as grade B, 4 cases as grade C, and 3 cases as grade D, of which 3 cases had sexual and sphincter dysfunction. At preoperation, the Cobb angle was (47.4 ± 10.2)°; the Oswestry disability index (ODI) score was 67.9% ± 6.9%; and the visual analogue scale (VSA) was 8.6 ± 1.4. Results The wounds obtained primary healing. The mean follow-up time was 28 months (range, 13-60 months). X-ray films showed intervertebral bone fusion was obtained within 6-11 months (mean, 10.2 months). No fixation loosening or breaking occurred during follow-up. Kyphosis was corrected, and lumbar back pain was relieved. At 1 year after operation, Cobb angle was significantly corrected to (13.3 ± 7.7)° (t=72.80, P=0.00); ODI score was significantly improved to 25.2% ± 4.6% (t=48.04, P=0.00); VAS score was significantly decreased to 2.3 ± 0.6 (t=26.52, P=0.00). According to ASIA grading in 10 patients with spinal cord injury, the spinal cord function was improved by 1 grade in 8 cases (3 cases from grade B to C, 3 cases from grade C to D, and 2 cases from grade D to E); 3 patients with sexual and sphincter dysfunction recovered in different degrees. Conclusion Using pedical screw at the fracture level, intervertebral distraction, and Cage insertion by posterior approach is an effective method to treat thoracolumbar kyphosis caused by old fracture.
Objective To compare the effectiveness of long- and short-segment posterior pedicle screw fixation for thoracolumbar fracture. Methods Between January 2007 and December 2009, 58 patients with AO type B thoracolumbar fracture underwent posterior pedicle screw fixation. Of 58 patients, 36 received short-segment pedicle fixation (1 upper and 1 lower vertebral bodies of the fractured vertebral body) in group A, and 22 received long-segment pedicle fixation (2 upper and 2 lower vertebral bodies of the fractured vertebral body) in group B. There was no significant difference in age, gender, injury cause, fracture site, preoperative Frankel grade, and disease duration between 2 groups (P gt; 0.05). The operation time, blood loss, complication, anterior vertebra compression rate (AVCR), and Cobb angle were compared between 2 groups. Frankel grade was used to evaluate the neurological function. Results The operation time and blood loss of group B were significantly higher than those of group A (P lt; 0.05). All incisions obtained primary healing. The patients were followed up 17.2 months on average (range, 12-32 months). No complication occurred in the other patients except 1 case having internal fixation failure and 1 case having aggravated kyphosis deformity in group A. The neurological function recovered in a certain degree; Frankel grade at 3 months was significantly improved when compared with preoperative one (P lt; 0.05) in 2 groups, but no significant difference was found between 2 groups (Z=0.09, P=0.36). The AVCR and Cobb angle were significantly lower in 2 groups at immediately after operation and last follow-up than those before operation (P lt; 0.05). The correction rates of AVCR and Cobb angle in group B were significantly higher than those in group A (P lt; 0.05); whereas the correction losses of AVCR and Cobb angle in group B were significantly less than those in group A (P lt; 0.05). Conclusion Long-segment pedicle screw fixation is better than short-segment pedicle screw fixation in the correction of kyphosis and recovery of vertebra body height, especially in the prevention of correction loss in long-term follow-up although it will increase the blood loss and operation time.
Objective To discuss the effectiveness of anterolateral decompression and three column reconstruction through posterior approach for the treatment of unstable thoracolumbar fracture. Methods Between March 2009 and October 2011, 39 patients with unstable burst thoracolumbar fracture were treated. Of them, there were 32 males and 7 females, with an average age of 43.8 years (range, 25-68 years). The injury causes included falling from height in 17 cases, bruise in 10 cases, traffic accident in 4 cases, and other in 8 cases. The fracture was located at the T10 level in 1 case, T11 in 9 cases, T12 in 6 cases, L1 in 14 cases, L2 in 7 cases, L3 in 1 case, and L4 in 1 case. According to Frankel classification before operation, 5 cases were classified as grade A, 5 as grade B, 9 as grade C, 14 as grade D, and 6 as grade E. Before operation, the vertebral kyphosis Cobb angle was (26.7 ± 7.1)°; vertebral height loss was 37.5% ± 9.5%; and the space occupying of vertebral canal was 73.7% ± 11.3%. The time between injury and operation was 1-4 days (mean, 2.5 days). All patients underwent anterolateral decompression of spinal canal by posterior approach and three column reconstruction. After operation, the vertebral height restoration, correction of kyphosis, decompression of the spinal canal, and the recovery of nerve function were evaluated. Results Increase of paraplegic level, urinary infection, and pressure sore occurred in 1 case, 1 case, and 2 cases, respectively; no incision infection or neurological complications was observed in the other cases, primary healing of incision was obtained. The patients were followed up 12-36 months (mean, 27 months). The patients had no aggravation of pain of low back after operation; no loosening and breaking of screws and rods occurred; no titanium alloys electrolysis and titanium cage subsidence or breakage was observed. The imaging examination showed that complete decompression of the spinal canal, satisfactory restoration of the vertebral height, and good physiological curvature of spine at 2 years after operation. At last follow-up, 1 case was classified as Frankel grade A, 2 as grade B, 2 as grade C, 10 as grade D, and 24 as grade E, which was significantly improved when compared with preoperative one (Plt; 0.05). At immediate after operation and last follow-up, the Cobb angle was (6.3 ± 2.1)° and (6.5 ± 2.4)° respectively; the vertebral height loss was 7.9% ± 2.7% and 8.2% ± 3.0% respectively; and the indexes were significantly improved when compared with preoperative ones (P lt; 0.05). Conclusion The technique of anterolateral decompression and three column reconstruction through posterior approach is one perfect approach to treat unstable thoracolumbar fracture because of complete spinal cord canal decompression, three column reconstruction, and immediate recovery of the spinal stability after operation.
Objective To study the effectiveness of transpedicular intervertebral bone graft and pedicle screws fixation in injured vertebrae for the treatment of thoracolumbar fractures. Methods Between February 2007 and January 2009, 25 patients with thoracolumbar fractures were treated by posterior short-segment fixation combined with transpedicular intervertabral bone graft and pedicle screw fixation in injured vertebrae. There were 18 males and 7 females with a mean ageof 46 years (range, 28-63 years). The injured vertebrae were located at T10 in 1 case, T11 in 2 cases, T12 in 8 cases, L1 in 6 cases, L2 in 6 cases, L3 in 1 case, and L4 in 1 case. According to Denis classification, there were 14 cases of burst fractures and 11 cases of compression fractures. Based on Frankel classifications, 2 cases were rated as grade A, 4 cases as grade B, 8 cases as grade C, 7 cases as grade D, and 4 cases as grade E. The time between injury and operation was 6 hours to 7 days (mean, 4.6 days). The X-ray film was taken to measure the relative height of fractured vertebrae and Cobb angle, and Frankel classification was conducted to evaluate the function recovery of the spinal cord. Results The operations were performed successfully, and incisions healed primarily. All the patients were followed up 12-25 months (mean, 16 months). CT and X-ray films showed good bone graft heal ing and no loosening or breakage of screws and rods. The relative height of fractured vertebrae were 56.8% ± 15.6% at preoperation, 91.2% ± 10.7% immediately after operation, and 89.6% ± 10.3% at 1 year after operation, showing significant differences between preoperation and postoperation (P lt; 0.01), while no significant difference between immediately after operation and 1 year after operation. The Cobb angles were (18.2 ± 2.6), (7.5 ± 1.4), and (8.7 ± 1.1)°, respectively, showing significant differences between preoperation and postoperation (P lt; 0.01), while no significant difference between immediately and 1 year after operation. At 1 year after operation, the neural function in 16 cases was improved 1-3 grades. ConclusionTreatment of thoracolumbar fractures with transpedicular intervertebral bone graft and pedicle screw fixation in injuredvertebrae has satisfactory effectiveness, which can reconstruct vertebral body height, increase the stabil ity of anterior and middle
Objective To investigate the efficacy of the pedicle screw fixation and allograft bone in posterior spinal fusion for the treatment of thoracolumbar vertebral fractures. Methods From September 2006 to March 2008, 105 cases of thoracolumbar vertebral fractures were treated with allograft bone in posterior spinal fusion after the pedicle screw fixation,including 75 males and 30 males aged 15-65 years (mean 37 years). The mixture which consisted of spinous process and vertebral plate sclerotin and homogeneity variant bone was used as bone graft to implant into articular process and processus transversus space or vertebral plate space. The time from injury to surgery varied from 8 hours to 21 days, with an average of 3 days. There were 52 cases of fall ing injuries from height, 35 cases of traffic accident injuries, 11 cases of bruise injuries and 7 cases of tumbl ing injuries. Before operation, the primary cl inical symptoms of patients included local pain combined with l imitation of activity, 30 cases compl icated by various degrees of spinal cord and nerve root functional disturbance. According to Mcaffee classification, there were 7 cases of flexion depressed fractures, 86 cases of blow-out fractures, 9 cases of Chance fractures and 3 cases of dislocation-fracture. According to Frankel grade, there were 11 cases of grade A, 2 cases of grade B, 7 cases of grade C, 10 cases of grade D and 75 cases of grade E. The X-ray examination of all patients denoted that the bodies of injuryed vertebra were compressed and wedge-shaped, and the CT scan showed that 98 cases had spinal stenosis. After 2 weeeks and 3, 6, 12 months, the X-ray films were taken to evaluate bone graft fusion. The Cobb angle was measured. The recovery of nerve function was analyzed. Results The operation time was 55-180 minutes (mean 90 minutes) and the blood loss was 100-900 mL (mean 200 mL). All patients achieved heal ing by first intention with no compl ication. After operation, 93 cases were followed up for 6-15 months with an average of 11 months. Except for 11 patients who were at grade A before operation, one to two grade recover was observed in other patients. The average Cobb angle of injury segment was improved from preoperative 32.1° to postoperative 5.2°. The height of anterior border of injuried vertebral body was recovered from the preoperative average compressed remaining height 61.5% to postoperative 96.8%. The vestigial degree of canal is spinal is anteroposterior diameter was recovered from preoperative 65.7% to postoperative 89.9%. Imageology examination showed that all the patient achieved bone union within 6 months. The fusion rate of bone graft in spinal fusion was 100%. No loosening and breaking of nails occurred. Conclusion Pedicle fixators can restore and fix the thoracolumbar fractures, and the combination of autograft and allograft bone transplantation is a safe, rel iable and effective method.
Objective To review the latest progress in classification system of thoracolumbar fractures and its surgical treatment with posterior approaches. Methods Recent l iterature about classification system of thoracolumbar fractures and its surgical treatment was reviewed. Results For the treatment of thoracolumbar fracture, the surgeon first should decide whether the surgical treatment was necessary. Recently, a new classification system had been developed to help the surgeon make the right decision. The surgical methods included short segment internal fixation and long segment internalfixation with or without fusion, and minimally invasive internal fixation. Conclusion The progress in the surgical treatmentof thoracolumbar fracture will help spinal surgeon decide the necessary surgery beneficial for the patients. The most appropriate and effective surgical method with the minimum damage should be used to treat the fracture. The advantages of non-fusion surgical treatment still need a further study.
Objective To explore the correlation between the inserting angle of vertebral screws and the extent of post-operative lateral angulation instantly in sugery via anterior approach for thoracolumbar fractures. Methods The cl inical data were from 172 patients consecutively treated with surgery via anterior approach in thoracic and lumbar fractures betweenMay 2004 and January 2008. These cases included 124 males and 48 females at the age of 15-70 years old (mean 39 years old). One fracture were located at T11, 37 at T12, 88 at L1, 30 at L2, 15 at L3, 3 at L4. One segment was involved in 170 cases and two segments in 2 cases. According to Frankel assessment for neurological status, there were 19 cases of grade A, 24 cases of grade B, 45 cases of grade C, 53 cases of grade D, and 31 cases of grade E. The time from injury to operation was 2-30 days (median 8 days). According to the coronal Cobb angle instantly after surgery, the patients were divided into three groups: 0-5° group, 5-10° group and over 10°group. Every group was further divided into four subgroups according to the type of the internal fixation instruments: Z-plate subgroup, Antares subgroup, Profile subgroup and single screw rod (SSR) subgroup. Radiograph images were used to evaluate the coronal Cobb angle and inserting angle between the screws and end-plates. The screws were named as A, B, C and D in vertebral bodies from the cephal ic to the caudal portion. The angles between the superior endplate and the screws A, B were named as angles A, B, and the angles between the inferior endplate and the screws C, D were named as angles C, D. The differences were compared between the screw’s inserting angle A+D (or/and B+C) and the post-operative coronal Cobb angle instantly, and l inear regression analysis was done. The satisfaction survey was acommpl ished. Results Surfacialinfection occurred in 1 patient at 7 days and incision healed well after debridement; other incisions healed by first intention. A total of 172 cases were followed up for 6-49 months (mean 39 months). The degree of satisfaction was 3-10 points, median 8.5 points. Various degrees of neurological function recovered in final follow-up except patients for Frankel A grade. The mean coronal Cobb angles were (0.75 ± 3.91)° for pre-operatively, (3.17 ± 4.07)° for instantly post-operatively and (3.46 ± 4.21)° at last follow-up; showing statistically differences between pre-operatively and instantly post-operatively, between pre-operatively and at last follow-up (P lt; 0.05). Comparing the screw’s inserting angle A+D (or/and B+C) and the coronal Cobb angle, there was statistically significant difference between Z-Plate subgroup and other subgroups in 0-5° group (P lt; 0.05), and there were no statistically significant differences between other subgroups in each group (P gt; 0.05). Except the screw’s inserting angle A+D (Z-Plate and SSR subgroups) and angle B+C (Antares subgroup) in 0-5° group, the post-operative coronal Cobb angle correlated closely with the screw’s inserting angle A+D (or/and B+C) in other subgroups of 3 groups. Conclusion Nonparallel ism between the vertebral screws and the correlative end plate is one of the main causes of post-operative spinal lateral angulation.
Objective To investigate the biomechanical characteristics of self-developed distraction reduction fixation system (DRFS) and to evaluate its cl inical effect on thoracolumbar vertebrate fracture. Methods Twelve fresh porcine spines were prepared for the biomechanical test. The stiffness of each intact specimen were recorded on forward bending (20°),backward bending (10°), lateral bending (30°) and axial rotation (20°), and then specimens of fracture dislocation were made by cuneiform osteotomy of L3 vertebral body and excision of posterior facet joints. Finally, DRFS internal fixation was performed on each specimen. The stiffness of specimens in fracture dislocation and after DRFS fixation were measured during the same movements mentioned above, respectively. The cl inical effect of DRFS on thoracolumbar vertebrate fracture in 31 patients (aged 17-46 years with an average of 32.1) from April 1998 to October 2002 was summarized. Fracture types were classified according to Denis classification: 2 patients suffered simple compressed fracture, 16 burst fracture, and 13 fracture dislocation, including 2 cases of T11, 11 cases of T12, 14 cases of L1 and 4 cases of L2. Frankel and X-ray examination were adopted to assess the results. Results The stiffness during forward bending, backward bending, lateral bending and axial rotation in the fracturedislocation state was markedly lower than that of the corresponding movements of the intact porcine spines (P lt; 0.05). After DRFS, the stiffness during various movements increased to the level that significantly higher than that in the fracture-dislocation state (P lt; 0.05), and the stiffness during backward bending was of significant difference (P lt; 0.05), but without significant difference during the rest three movements (P gt; 0.05) when compared to that in intact spines. Regarding cl inical observation, the operation time was 2.2-4.1 hours (2.7 hours on average) and blood loss was 250-600 mL (450 mL on average). The patients were followed up for 5-20 months (10.2 months on average). The heal ing time for fracture was 5-11months (8 months onaverage). The mean anterior and posterior heights of the injured vertebrate recovered from 46.2% ± 7.5% and 76.4% ± 2.4% preoperatively to 89.8% ± 4.6% and 94.1% ± 1.5% postoperatively (P lt; 0.05).The median point height also raised from 60.8% ± 6.4% to 90.7% ± 2.9% (P lt; 0.05). The Cobb’s angle decreased from (26.3 ± 5.9)° to (5.2 ± 1.8)° (P lt; 0.05), and all the sl ipped vertebrates were well repositioned. Spine function was assessed by Frankel classification as follows: 2 of 5 Class A preoperatively improved to Class B postoperatively, and the other 3 remained unchanged ; 4 of 6 from B to C, and the other 2 to D; 6 of 13 from C to D, and the other 7 to E; and 7 from D to E. Conclusion DRFS is capable of providing sufficient stabil ity, meeting the requirement of the spine physical activity without any obvious side effect. DRFS, as a handy, safe and effective technique in cl inical practice, is featured by satisfying functions of distraction, reposition and fixation.