How To Repair T12 Burst
Indian J Orthop. 2007 October-Dec; 41(iv): 268–276.
Decision-making in burst fractures of the thoracolumbar and lumbar spine
Robert F Heary
Department of Neurological Surgery, University of Medicine and Dentistry of New Jersey, Newark, New Bailiwick of jersey, U.s.
Sanjeev Kumar
Department of Neurological Surgery, University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA
Abstruse
The almost common site of injury to the spine is the thoracolumbar junction which is the mechanical transition junction betwixt the rigid thoracic and the more flexible lumbar spine. The lumbar spine is another site which is more prone to injury. Absence of stabilizing articulations with the ribs, lordotic posture and more sagitally oriented facet joints are the virtually obvious explanations. Burst fractures of the spine account for xiv% of all spinal injuries. Though common, thoracolumbar and lumbar burst fractures present a number of of import treatment challenges. In that location has been substantial controversy related to the indications for nonoperative or operative management of these fractures. Disagreement also exists regarding the choice of the surgical approach. A large number of thoracolumbar and lumbar fractures tin can be treated conservatively while some fractures require surgery. Selecting an appropriate surgical option requires an in-depth understanding of the unlike methods of decompression, stabilization and/or fusion. Anterior surgery has the advantage of the greatest caste of canal decompression and offers the do good of limiting the number of movement segments fused. These advantages come up at the added price of increased time for the surgery and the related morbidity of the surgical approach. Posterior surgery enjoys the advantage of being more familiar to the operating surgeons and can exist an effective approach. However, the limitations of this arroyo include inadequate decompression, recurrence of the deformity and implant failure. Though many of the principles are the same, the treatment of low lumbar burst fractures requires some additional consideration due to the difficulty of approaching this region anteriorly. Avoiding complications of these surgeries are some other of import aspect and can be achieved past following an algorithmic approach to patient assessment, proper radiological examination and precision in decision-making regarding management. A detailed understanding of the mechanism of injury and their unique biomechanical propensities following various forms of treatment can help the spinal surgeon manage such patients effectively and forestall devastating complications.
Keywords: Burst fracture, lumbar fracture, thoracolumbar fracture
Each yr, there are approximately 5 meg new vertebral fractures worldwide.1 In the United States of America, 72.5% of all spinal fractures involve the thoracic or lumbar spines.ii The thoracolumbar junction, due to its mechanical transition zone and the lumbar spine, due to its absence of stabilizing articulations with the ribs, lordotic posture and more than sagitally oriented facet joints, are reasonable explanations for their involvement in spinal injuries.three
In 1963, Holdsworth described flare-up fractures.4 The incidence of burst fractures is maximum at the thoracolumbar junction and occurs ofttimes in high-energy traumas which are most ordinarily associated with falls and traffic accidents.v The treatment of thoracolumbar and lumbar burst fractures has remained controversial due to many different options of nonoperative or operative management.6
Different factors which play vital roles in the direction of such patients include the neurological status, the number of segments involved, the type of the injury and other factors such equally the age of the patient, the quality of bone and associated comorbidities. An algorithmic approach is vital for the initial patient assessment, radiological workup and controlling for ultimate management.
PRELIMINARY Due eastVALUATION
Patients must be immobilized at commencement. Airway, animate and circulation (ABC) must exist stabilized earlier proceeding for the neurological exam. It is non uncommon to accept progression of a neurological deficit. Hence, recording of the baseline neurological status and series assessments thereafter are vital. These should include assessing sensation in each dermatome and at least five muscles or movements should be graded for each extremity. Deep tendon reflexes should also be examined.7 A rectal examination is useful in assessing the anal sphincter tone and perianal sensations. Although spinal shock does not usually last for more than 24 h, it may concluding for days to weeks. Return of the anal wink reflex usually indicates the stop of spinal stupor. A progressive neurological deficit is a widely accepted indication for urgent surgical intervention. The possibility of a spinal fracture cannot be ruled out with a normal neurological examination as the majority of thoracolumbar injuries do non accept associated neurological deficits.2
As the spinal cord can variably finish between T11 to L2, a multifariousness of neurological deficits can consequence from flare-up fractures of the thoracolumbar and lumbar spines ranging from frank spinal string injury to a cauda equine syndrome.
RADIOLOGICAL EXAMINATION
Obtaining an anteroposterior (AP) and lateral patently radiograph of the suspected involved segment is the standard practice for the initial cess of the patient [Figure 1.1.] Withal, plain radiographs sometimes fail to demonstrate some of the of import aspects of the spinal fractures. Recently, computerized tomography (CT) scanning is beingness increasingly utilized in conjunction with plain radiographs. A CT scan provides more diagnostic information than plain radiographs regarding the extent of bony injury.8 Another advantage of the CT scan is its ability to meliorate assess the degree of culvert compromise [Figure ane.two.] James et al., (2005), documented that laminar and articular process fractures are typically missed on plain radiographs and are best visualized on axial CT scans.nine However, it is our exercise to obtain AP and lateral plain films of the region if an injury is suspected as these radiographs are useful for preoperative planning and postoperative followups. In improver, subtle changes in the soft tissues or between the posterior elements can alert the physician to areas requiring further examination. Kyphotic and translation injuries can be visualized on sagittal and coronal reconstructions. Vertebral trunk pinnacle, disc spaces, inter-pedicular distances and inter-spinous process intervals must be noted and compared betwixt the injured and the non-injured levels. Still, CT scans have a limited role in visualizing soft-tissue injuries which include disc herniations, epidural or subdural hematomas, ligamentous injuries and spinal cord parenchymal injury.3
Lateral plain film radiograph (a) demonstrates a 17% loss of height at L1 and a fifty% loss of tiptop at L2. AP plain picture (b) radiograph demonstrates a focal translation at the level of the L1-L2 subluxation causing a coronal plane deformity. An inferior vena caval filter is visualized
Axial CT scan (a) paradigm at the level of the L2 pedicles demonstrates a 70% compromise of the spinal culvert expanse by a large retropulsed fragment of the vertebra. Of note, the L1 vertebra had a 55% loss of spinal culvert area. The patient was operated for -AP spinal reconstruction: Anterior surgery includes corpectomies of L1 and L2, placement of a stackable carbon fiber muzzle filled with autograft bone anteriorly from T12 - L3 and stabilization with a Kaneda screw-rod construct. Posteriorly the stabilization with bilateral pedicle screws at T11 and L4, bilateral hooks at T12 and L3, two rods with 2 crossconnectors and generous amounts of autologous iliac crest os graft was done. (b) Centric CT scan at the level of the T11 pedicles demonstrates well-positioned pedicle screws which approach the far bony cortex of the T11 vertebra. Axial CT scan (c) at the level of the L3 pedicles demonstrates the inferior Kaneda screws which are placed across the vertebra to achieve bicortical fixation. Centric CT scan (d) through the L2 level which shows the pedicle-to-pedicle decompression of the spinal culvert with the carbon cobweb cage filled with autograft
Magnetic resonance (MR) imaging has the ability to visualize the soft-tissue components of spinal injuries.three Its utility for the thoracolumbar junction is important due to the variable location of the conus medullaris in the adult population.9 Biomedical implants, such as cardiac pacemakers and aneurysm clips, are contraindications for MR imaging. Nosotros reserve MR imaging for patients with a neurological arrears or in whom the integrity of the posterior ligamentous complex is questionable. For such patients, the short tau inversion recovery (STIR) sequence is particularly valuable for detecting acutely injured soft tissues. In patients who cannot undergo an MR imaging study, a myelogram followed past a postal service-myelogram CT scan is a reasonable alternative imaging study.
CLASSIFICATION
Many unlike classification systems have been proposed for thoracolumbar and lumbar burst fractures. Holdsworth proposed a two-column model of spinal stability by separating the spine into an anterior weight-bearing column of the vertebral body and a posterior tension-bearing column of the posterior ligamentous complex (PLC). He termed burst fractures as unstable if the PLC was disrupted.4 Denis (1983) described a 3-column classification of spinal fractures. He proposed that injury to the middle column i.eastward. the posterior portion of the vertebral body, posterior longitudinal ligament and posterior disc was sufficient to create instability.10 He besides classified unstable fractures into three types: mechanical (onest degree), neurological (2nd caste) or combined mechanical/neurological (iiird degree). In 1994, McAfee et al. proposed another classification and treatment scheme. He classified the injuries based on how the middle column failed, with burst fractures exhibiting center column failure in pinch. He also distinguished between burst fractures with and without PLC disruption.11 A burst fracture with PLC disruption is considered to be unstable. It is widely accepted that the posterior ligaments take probably failed if at that place is greater than 30° of kyphosis and/or 50% of vertebral body height loss on obviously radiographs.
McCormack et al., also in 1994, proposed another classification which was based on the load-sharing basis. They specifically designed their classification based on the relevance to thoracolumbar outburst fractures. They used a point-based system which grades the corporeality of vertebral body comminution, displacement of fracture fragments and the degree of kyphosis.12 The aim of this load-sharing organisation was to predict the failure of short-segment posterior fixation for a burst fracture every bit information technology suggests that injuries with high scores should undergo supplemental inductive cavalcade support.
MECHANISM OF INJURY
Due to gravity in the upright posture, an axial load is exerted on the vertebral column and the body's center of gravity passes anterior to the thoracic spine, through the thoracolumbar junction, posterior to the lumbar spine and through the sacral promontory. With sudden acceleration or deceleration, an increase in centric loads, with or without flexion or extension, can atomic number 82 various components of the vertebral column to neglect. Multiple fracture lines propagate due to axial loading of the vertebral trunk in burst fractures which tin can lead to discontinuity of the posterior vertebral body and the adjacent pedicles. The explosive nature of a burst fracture can lead to variable degrees of vertebral body retropulsion into the culvert too.
The comprehensive classification arrangement by Magerl, which has further been modified by the AO group, has classified burst fractures. Blazon A injuries are axial compression injuries. Type B injuries are lark injuries including flexion-lark injuries. Blazon C injuries are unstable three-column injuries with rotation in the anteroposterior projection. According to this classification, all burst fractures are pinch fractures and may be stable or unstable. Hence, it is important to differentiate Type A-3 fractures from Type C-1 fractures (where all three columns fail leading to a college caste of instability). Although these nomenclature systems provide some guidelines to the many varieties of thoracolumbar burst fractures, different combinations do exist, requiring careful assessment to define the mechanical failure that has occurred at the site of the injury.
The most unstable variant of the burst fracture is where significant kyphosis (more than than 30°) is nowadays, with or without 50% of vertebral torso height loss, on plain radiographs. These injuries are typically associated with posterior ligamentous injury or horizontal posterior element fracture. This injury blazon, is clinically suspected by marked posterior tenderness, bruising or a palpable gap at the interspinous level. In unstable burst fractures, the inductive and middle columns fail under axial compression and the posterior column fails due to tension.
PRINCIPLES OF SURGICAL TREATMENT
The 3 basic components of surgical treatment of thoracolumbar and lumbar burst fractures include neural decompression, stabilization and fusion. A coherent and logical rationale must be followed in guild to attain the desired results. However, it is always advisable to make individualized decisions in every case.
NEUROLOGICAL DECOMPRESSION
The need for neural decompression can broadly be divided into two groups of patients- one with neurological deficit and the other without it.
1. Patients with neurological arrears
Surgery is usually considered as the primary line of treatment for these patients with the goal of achieving decompression of the neural elements. It has been documented in the past that neurological recovery post-obit decompression has a better prospect than the recovery seen after conservative treatment.6 The methods of decompression tin can vary depending on the personal choice and feel of the operating surgeon. Nonetheless, information technology has been reported that greater neurological improvement tin be accomplished following anterior decompression as compared to posterior or posterolateral.13 Kaneda et al., (1984), documented that anterior decompression results in a maximum canal decompression.14 Bradford et al., reported an boilerplate 25.9% of residual canal compromise following posterior surgery compared to less than i% after anterior decompression.xv Belanger et al. 2005, reported that fifty-fifty in cases of long standing compression, anterior decompression can consequence in modest improvements in neurological function.16 In our practice, we usually perform posterior surgery for cases with consummate motor-sensory American Spinal Injury Association (ASIA) class A spinal cord injuries (SCI). The extent of instrumentation is usually 2 or iii levels above and two levels below.
Cases with partial neural deficits are ideal candidates for anterior decompression as they have the greatest adventure for neurological recovery. Posterior decompression solitary using laminectomy does not upshot in an constructive decompression of the neural elements.6 Nonetheless, it is not the absolute indication for the surgery. Patients with progressively increasing neurological deficit may exist considered every bit an absolute indication for the surgery. In patients with entrapped nerve roots, laminectomy is usually performed in addition to an anterior decompression to release the nerve roots.17 For cases with incomplete neurological injuries (ASIA classes B-D) with significant ventral bony compression (50% or more on axial CT browse), no motor deficit with only bowel and bladder dysfunction or significant kyphotic deformity, we prefer anterior surgery. Yet, in the majority of cases, either an inductive or a posterior approach is reasonable.
The choice of approach primarily depends on the experience and preference of the operating surgeon and his/her results. In our practice, we have a multidisciplinary team which enables us to safely perform ventral surgery in the astute post-injury period. In our experience, blood loss, neurological outcomes and overall management morbidity and mortality have been very low from either approach. The employ of postoperative CT scans has demonstrated very expert canal decompression and improvement of sagittal airplane alignment when inductive surgery is performed for pregnant burst fractures with either meaning canal compromise or significant kyphosis at the level of the injury [Figure ane.3]. The most of import cistron determining the operative arroyo is the individual surgeon's own outcomes which atomic number 82 to the best neurological and functional outcomes. In the overwhelming majority of patients, successful decompression and stabilization/fusion can be accomplished by either arroyo.
Sagittal reconstruction of a CT scan (a) of the aforementioned patient as fig ane.1 & 1.2 demonstrating expert positioning of the stackable carbon fiber muzzle with complete decompression of the spinal canal. Kaneda screws are seen at T12 and L3. Coronal reconstruction of a CT (b) scan demonstrating good positioning of the stackable carbon fiber muzzle and the Kaneda spiral-rod fixation device. AP plain picture radiograph (c) obtained two years after surgery demonstrates solid fusion and first-class alignment. Lateral plain film radiograph (d) at two years postoperatively demonstrates preservation of sagittal alignment. At v years post-injury, the patient was neurologically intact with normal bowel and bladder role. She was gainfully employed and despite a solid T11-L4 fusion, she was able to forwards bend and touch her toes with her knees fully extended. She required no pain medications
For cases with astringent three-cavalcade instability and preserved neurological function we accept establish it necessary to perform both anterior and posterior surgery (AP) [Figure ane.1–1.3.] In medically stable, younger patients, we routinely perform the AP surgeries under a single anesthetic session. For less stable patients, staged surgeries with two split operations are occasionally necessary.
Because of the more fluid nature of the dural sac of the cauda equina, lumbar flare-up fractures with neurological deficits accept been reported to be at a higher risk. If this injury is left untreated, it can lead to neural element herniations, entrapment, epidural or subdural hematoma, cerebrospinal fluid leak and even pseudomeningocele.18
Another approach for inductive decompression is the lateral extracavitary approach. This arroyo has the advantage of providing access to both the anterior and posterior elements using a unmarried dorsal incision. A hockey stick-shaped incision can provide access to the area below the paraspinal muscles to allow for lateral visualization of the thecal sac. Ventral autopsy exposes the lateral border of the injured vertebral body for fragment removal and reconstruction. Even so, this arroyo is technically demanding with a very loftier charge per unit of complications. Resnick et al. documented a complication rate as high as 55% with this approach.xix We normally recommend this approach in older patients, morbidly obese patients or medically unstable patients who may be unable to withstand a thoracotomy for pulmonary reasons.
Neurological deficits have been reported in approximately l% of cases with lumbar burst fractures.10 Treatment of low lumbar (L3 to L5) burst fractures is technically dissimilar compared to that of thoracolumbar (T10 to L2) fractures. Corpectomy via an inductive approach is usually possible for lower lumbar fractures but becomes increasingly hard with each lower level. Low lumbar surgeries performed anteriorly tin can be difficult at times due to the iliopsoas musculus which hinders both the decompression as well the fusion. Aggressive autopsy of this muscle can lead to postoperative hip flexor weakness. It is our preference to operate via a posterior arroyo when the construct extends to and beyond the L4 level.
Timing of surgery
The optimal timing of the decompression is another critical attribute of the surgery. A progressive neurological deficit is one of the few indications for immediate surgery to care for a thoracolumbar or lumbar flare-up fracture. Notwithstanding, most of the studies in this regard have demonstrated no direct correlation betwixt the timing of surgery and the amount of neurological recovery.6 ,20 Mirza et al. (1999), in their retrospective study, found improved neurological recovery with surgery within 72 h as compared to surgery within x to xiv days.21 Often, early on surgery can exist more difficult than late due to local soft-tissue atmospheric condition, increased operative blood loss and associated visceral or skeletal injuries especially via an inductive approach. The operative trauma from decompression of an acutely edematous spinal cord tin can itself atomic number 82 to farther neurological trauma.6
Neurological deficit is primarily determined by the degree of trauma which occurred to the neural elements at the fourth dimension of affect. Cauda equina injuries are less likely to take complete neurological arrears, primarily due to its anatomy, when compared to conus medullaris or spinal string injuries.13 A complete injury has no motor, sensory or bladder/bowel role distal to the fractured level when spinal shock has resolved, which usually occurs past 48 h.6 ,xx The role of serial examinations over a period of at to the lowest degree 2 days comes into play to make up one's mind this. Decompression of such cases, with a complete injury, is unlikely to result in neurological recovery;6 even so, the benefits of surgical stabilization can facilitate rehabilitation in these situations. Controversy still remains regarding decompressing the neural elements at the caudal aspect of the spinal cord which may subtract the development of postal service-traumatic syringomyelia.
2. Patients without neurological deficit
Hu et al. (1996), reported that the majority of cases with thoracolumbar and lumbar flare-up fractures are neurologically intact.two Cases with no neurological deficit may exist managed conservatively. Cases with a mechanically unstable burst fracture, divers past a disrupted PLC, without any neurological deficit, should be considered as unstable as they are at high take chances for neurological decline without surgical stabilization.
Information technology is important to make up one's mind the integrity of the PLC in this grouping of patients. Information technology is widely accepted that the posterior ligaments have probably failed if there is greater than 30° of kyphosis and/or fifty% of vertebral trunk height loss. However, unlike studies in the past have reported that fifty-fifty with these positive signs many patients can be successfully treated conservatively.22 ,23 Recently, MR imaging has been used to determine the continuity of the PLC.
Once PLC disruption is confirmed, stabilization and fusion should be considered for neurologically intact patients. The presence of substantial culvert compromise is indication plenty for decompression as well. Some surgeons consider an indirect decompression, past distracting a posterior pedicle-screw construct, safer than anterior decompression. However, a risk of neural injury is at that place during manipulation and removal of retropulsed os fragments. Furthermore, posterior distraction maneuvers can lead to relative kyphosis with worsening of the global sagittal spinal balance. Wood et al. (2005), suggested removal of sufficient vertebral body to allow insertion of a strut without inbound the spinal canal.24 There is some concern regarding leaving bone fragments in the canal. However, at that place is hardly whatever clinical data to support this business. Cantor et al., reported that resorption of the fragments occurs over time with both braces and posterior stabilization alone.25 It is our practice to perform a pedicle-to-pedicle decompression of all os fragments when anterior surgery is performed.
Thoracolumbar burst fractures tin can exist associated with lamina fractures and tin can have dural tears and/or entrapped nerve roots.26 Laminectomy and reduction of the displaced roots, along with dural repair, in the neurologically intact patient, is even so considered controversial. Nonetheless, we have institute that using conscientious microdissection techniques, this approach is both safety and efficacious. Exploration and repair should be taken upward in patients with a proven neurological deficit.
CONSERVATIVE TREATMENT
Bourgeois handling has a limited function in established cases with neurological deficit and instability. In cases without neurological arrears and instability, nonoperative handling may play a role. Even so, this handling is associated with increased risk for complications such as decubitus ulcers, deep vein thrombosis and pneumonia6 due to prolonged recumbency.
SouthTABILIZATION AND FUSION
Instability in thoracolumbar and lumbar flare-up fractures is commonly caused by PLC disruption. The role of instrumentation is to restore firsthand stability and correct the deformity. But in the long term, solid fusion has to exist accomplished to prevent the failure of the instrumentation. Without solid fusion, the implants will somewhen fail due to instrumentation fatigue failure which occurs from cyclic loading. Successful fusion requires a bone graft or bone graft substitute that has some essential characteristics such as osteogenicity (usually provided by bone cells), osteoinducitivity (the ability to activate and sustain the cascade of biochemical processes that lead to bony healing) and osteoconductivity (the power to provide a scaffold to which the new bone can adhere to and propagate).27
ANTERIOR SouthTABILIZATION AND FUSION
In the initial menstruum of inductive instrumentation, adaptations of Harrington rod devices were used. However, with the evolution of the Kaneda instrumentation, a major footstep forward was taken for the treatment of thoracolumbar outburst fractures. The basic instrumentation has two screws placed through a staple into the intact suprajacent and infrajacent vertebral bodies which are and then connected to two cross-linked rods. The major advantage of the system is the ability to apply these screws as anchors for distracting the corpectomy site to allow better strut graft placement14 as well as superior rigidity compared to the plate systems. In addition, sagittal aeroplane correction of the kyphosis which typically is seen with burst fractures is able to be best accomplished by placement of a strut into the anterior column. Kaneda devices have nigh twice the stiffness of posterior constructs with axial compressive and torsional loading.28 All the same, the scenario has changed over a period of time due to innovative designs and techniques of the newer plate-spiral systems and they announced to exist as or more stable than some of the dual-rod screw instrumentations.29 Other advantages of inductive stabilization include its ability to limit fusion to the level above and beneath the injured site.
Following corpectomy, the site must be filled with a cage and/or bone graft which tin can sustain axial compressive loads and maintain kyphotic correction. Os graft choices include autograft (ordinarily bone from the corpectomy or the iliac crest), allograft or cages filled with morselized autograft or allograft. Nosotros prefer to use autologous graft due to its osteogenic, osteoinductive and osteoconductive properties. Any kyphosis, if present, must be maximally corrected prior to placement of the cage. Slight distraction of the corpectomy site using the screw-staple ballast or a Kaneda-type device can facilitate this correction.
The graft should be placed as close to the anterior vertebral body as possible. Optimally, it should exist centered along the endplates to ensure even distribution of the compressive loads. Centric compression tin then be delivered using the vertebral trunk screws to ensure a tight interference fit between the endplates and the muzzle or the bone graft. This will reduce the graft dislodgement.
Immediate stability can be maximized with bicortical screw buy. After placing the strut, it is of import to neutralize any interruption in the operating tabular array before securing the rods as this will avoid a coronal plane deformity. Cantankerous-connectors play an important role in dual rod-screw systems every bit they improve the resistance to rotational, torsional and angle forces. One of the major disadvantages of the inductive approach is the increased morbidity and it must exist weighed confronting its advantages.
POSTERIOR STABILIZATION AND FUSION
Lately, pedicle screws have largely replaced the hooks and wires for posterior stabilization due to the biomechanical advantages, peculiarly in the thoracolumbar and lumbar regions. Pedicle screws provide iii-cavalcade fixation as well.14 Another advantage of pedicle screws is their ability to restore stability with fewer anchoring points which can spare motion segments.
Although some studies accept suggested short-segment fixation, this strategy may issue in loftier rates of construct failure in many cases.30 ,31 In our practise nosotros commonly musical instrument two levels in a higher place and below the injured segment for highly unstable fractures. However, cases with less severe instability can be managed with simply i level higher up and below. Curt-segment pedicle screw stabilization can be combined with anterior instrumentation as well.30 However, short-segment fixation is more durable in the low lumbar spine primarily due to larger pedicle sizes and anatomical lordotic alignment. Dickman et al. suggested that to maintain this lordotic curve, the rods must be contoured to avoid the sequelae of flat-dorsum syndrome.32 In situ angle has been found to weaken the screw-bone interface and is not advised.30
Pedicle screw placement is technically demanding and carries the potential gamble for nerve root, spinal cord or vascular injury if the cortical borders are breached.33 A careful planning and intraoperative imaging are of enormous assistance in ensuring that screws are placed correctly. Screw breakage may occur more oftentimes with smaller diameter screws compared to larger ones.32 Ultimately, the size of the screw is adamant past measuring the maximal transverse pedicle diameter on preoperative CT or MR images.
Fusion is facilitated by decorticating all exposed bony elements provided they are present. Interspinous ligaments should be resected to facilitate fusion between these bony surfaces. Nosotros recommend that large amounts of autologous os graft, harvested from the iliac crest, should be placed over the exposed surfaces. Utilise of allograft bone should exist reserved for cases where autologous bone is not bachelor due to diverse medical reasons. On the other hand, allograft bone, demineralized bone matrix (DBM) and recombinant growth factors can be used alone as an alternative or in combination with autograft. Yet, none of these substitutes provide all three basic backdrop of autograft bone. Bone morphogenetic proteins (BMP) have excellent osteoinductive activity as noted in both preclinical beast studies and in homo trials.34 Nonetheless, some authors take suggested that large doses of BMP have been required to induce adequate bone formation in humans.35 Another concern with BMP is that a single dose of the recombinant protein may non be sufficient for an adequate osteoinductive response, especially in cases where there is compromised bone stock and vascularity.36 The cost of BMP is as well very high. Probably the biggest concern for BMP is the excessive and uncontrolled bone growth. Lately there has been a lot of interest in the use of bone marrow as an adjunct to the spinal fusion procedure forth with autograft or allograft. In 1998, Connolly reported fourscore% healing rate for numerous skeletal healing problems using marrow grafting.37
Recently, the use of osteoblast progenitor cells separated from the patient'due south bone marrow has shown promising results. The technique provides a less invasive method to augment local bone graft, allograft and osteoblast progenitor cells at the fusion site to achieve successful fusion.
It is our exercise to adopt the posterior arroyo for patients with ASIA Class A injuries. This avoids the additional morbidity of the anterior approach. Resection of i or more pedicles may assist to facilitate the decompression as well.
Loss of correction is one of the most common complications of posterior stabilization of thoracolumbar outburst fractures. In these cases, fractures tend to collapse leading to kyphosis. We prefer anterior fixation for such cases. In cases where only posterior instrumentation is undertaken, an boosted level above and below can exist included to resist the forces which favor kyphosis.
ANTERIOR-POSTERIOR (AP) STABILIZATION AND FUSION
One of the most compelling indications for AP stabilization and fusion is the very unstable fracture or fractures/subluxation with intact neurological status or incomplete spinal string injury. Information technology is our practice to undertake both the surgeries on the aforementioned day to expedite rehabilitation and recovery. Notwithstanding, the primary deciding gene for this is the medical condition and age of the patient. Anterior-posterior surgery increases the physiologic demands on the already compromised patient due to the increased claret loss and operative fourth dimension. The benefits of the combined AP surgery start the risks by adequate decompression, stabilization and fusion in a patient with a highly unstable spine injury and intact neurological function. The surgery itself is as described in the separate anterior and posterior stabilization sections.
POSTOPERATIVE CONSIDERATIONS
An firsthand neurological evaluation should be washed upon arrival in the recovery room and portable supine AP and lateral radiographs should exist obtained. Thromboembolic stockings and sequential compression devices should be continued throughout the recovery period. If bear witness of a deep vein thrombosis or pulmonary embolus is detected, placement of a Greenfield filter is preferable to systemic anticoagulation in the early postoperative period. Suction drains are usually removed on the tertiary postoperative day. Our exercise is to obtain a CT scan for a more than detailed cess of the location of all spinal implants and to appraise the adequacy of the bony decompression. Non-steroidal antiinflammatory drugs should exist avoided in the postoperative period. Glassman et al., reported adverse affects on spinal fusion with the utilize of these agents.38 Concrete therapy should be started as soon as possible.
CONCLUSION
The almost common site of injury to the spine is the thoracolumbar junction which is the mechanical transition junction between the rigid thoracic and the more flexible lumbar spine. The near widely accustomed form of instability has been proposed past Denis.10 He proposed that injury to the middle column i.e. the posterior portion of the vertebral trunk, posterior longitudinal ligament and posterior disc was sufficient to create instability. He also classified unstable fractures into three types: mechanical (1st degree), neurological (2nd caste) or combined mechanical/neurological (threerd degree). A disrupted PLC usually leads to mechanically unstable burst fracture. Cases with no neurological deficit tin oftentimes exist managed conservatively. Nonoperative handling options have a limited part in patients with neurological deficits. It is of import to follow an algorithmic approach in the initial patient assessment, radiological workup and ultimate decision-making for management. Selection of an appropriate surgical direction and approach requires an in-depth analysis of the different bachelor methods of decompression, stabilization and fusion. We ordinarily perform posterior surgery for cases with ASIA Class A type of SCI. The extent of instrumentation is usually ii or three levels above and ii levels below. For cases with incomplete injury with significant ventral bony compression (fifty% or more on axial CT scan), no motor deficit with only bowel and bladder dysfunction or significant kyphotic deformity, we prefer anterior surgery. Yet, in the majority of cases, either an anterior or a posterior arroyo is reasonable.
The selection of approach primarily depends on the operating surgeon and his/her results. The optimal timing of the decompression is critical. A progressive neurological deficit is one of the indications for firsthand surgery to treat a thoracolumbar or lumbar burst fracture. While anterior surgery has the reward of achieving excellent canal decompression and the do good of short segment fusion, this is achieved at the cost of increased approach-related morbidity. Posterior surgery has the advantage of existence an effective approach associated with less morbidity. At the same time, it lacks the do good of short segment stabilization and fusion. Other limitations of this approach are the possibility of achieving inadequate decompression or construct failure leading to recurrence of deformity. Anterior-posterior stabilization and fusion should be undertaken for very unstable fracture or fractures/subluxation with intact neurological status or incomplete spinal string injury. Finally, the decision regarding the type and arroyo of the surgery should be individualized based on the type of the injury and medical condition of the patient.
Footnotes
Source of Support: Nil
Disharmonize of Interest: None.
REFERENCES
one. Melton LJ, 3rd, Thamer M, Ray NF, Chan JK, Chesnut CH, 3rd, Einhorn TA, et al. Fractures attributable to osteoporosis: Report from the National Osteoporosis Foundation. J Os Miner Res. 1997;12:sixteen–23. [PubMed] [Google Scholar]
2. Hu R, Mustard CA, Burns C. Epidemiology of incident spinal fracture in a complete population. Spine. 1996;21:492–9. [PubMed] [Google Scholar]
3. Flanders AE. Thoracolumbar trauma imaging overview. Instructional Grade Lectures. 1999;48:429–31. [PubMed] [Google Scholar]
4. Holdsworth FW. Fractures, dislocations and fracture/dislocation of the spine. J Bone Joint Surg Br. 1963;45:6–20. [Google Scholar]
5. Bensch FV, Koivikko MP, Kiuru MJ, Koskinen SK. The incidence and distribution of burst fractures. Emerg Radiol. 2006;12:124–9. [PubMed] [Google Scholar]
six. Benzel EC, Larson SJ. Functional recovery after decompressive operation for thoracic and lumbar spine fractures. Neurosurgery. 1986;nineteen:772–eight. [PubMed] [Google Scholar]
7. Holdsworth F. Fractures, dislocations and fracture-dislocations of the spine. J Bone Articulation Surg Am. 1970;52:1534–51. [PubMed] [Google Scholar]
8. McCulloch PT, France J, Jones DL, Krantz W, Nguyen TP, Chambers C, et al. Helical computer tomography alone compared with obviously radiographs with adjunct computed tomography to evaluate the cervical spine after high-free energy trauma. J Bone Joint Surg Am. 2005;87:2388–94. [PubMed] [Google Scholar]
9. James SH, Alexander RV, Kevin TF. Trauma surgery: Thoracic and thoracolumbar spine. In: Benzel EC, editor. Spine surgery: Techniques, complication avoidance and direction. 2nd ed. volume 1. Elsevier, Inc: Philadelphia; 2005. pp. 544–62. [Google Scholar]
x. Denis F. The 3 cavalcade spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine. 1983;8:817–31. [PubMed] [Google Scholar]
11. McAfee PC, Bohlman HH, Yuan HA. The value of computed tomography in thoracolumbar fractures: An analysis of ane hundred sequent cases and a new classification. J Bone Joint Surg Am. 1985;67:89–104. [PubMed] [Google Scholar]
12. McCormack T, Karaikovic Due east, Gaines RW. The load sharing nomenclature of spine fractures. Spine. 1994;19:1741–4. [PubMed] [Google Scholar]
thirteen. Gertzbein SD. Scoliosis enquiry society: Multicenter spine fracture study. Spine. 1992;17:528–xl. [PubMed] [Google Scholar]
xiv. Kaneda M, Abumi One thousand, Fujiya Yard. Burst fractures with neurologic deficits of the thoracolumbar-lumbar spine: Results of anterior decompression and stabilization with anterior instrumentation. Spine. 1984;9:788–95. [PubMed] [Google Scholar]
15. Bradford DS, McBride GG. Surgical management of thoracolumbar spine fractures with incomplete neurologic deficits. Clin Orthop Relat Res. 1987;218:201–16. [PubMed] [Google Scholar]
16. Belanger TA, Roh JS, Hanks SE, Kang JD, Emery SE, Bohlman HH. Ossification of the posterior longitudinal ligament: Results of inductive cervical decompression and arthrodesis in 60-one north american patients. J Bone Articulation Surg Am. 2005;87:610–5. [PubMed] [Google Scholar]
17. Keenen TL, Anthony J, Benson DR. Dural tears associated with lumbar outburst fractures. J Orthop Trauma. 1990;four:243–5. [PubMed] [Google Scholar]
eighteen. Silvestro C, Francaviglia Due north, Bragazzi R, Piatelli 1000, Viale GL. On the predictive value of radiological signs for the presence of dural lacerations related to fractures of the lower thoracic or lumbar spine. J Spinal Disord. 1991;4:49–53. [PubMed] [Google Scholar]
19. Resnick DK, Benzel EC. Lateral extracavitary approach for thoracic and thoracolumbar spine trauma: Operative complications. Neurosurgery. 1998;43:796–803. [PubMed] [Google Scholar]
20. Bradford DS, Akbarnia BA, Winter RB, Seljeskog EL. Surgical stabilization of fracture and fracture dislocations of the thoracic spine. Spine. 1977;2:185–96. [Google Scholar]
21. Mirza SK, Krengel WF 3rd, Chapman JR, Anderson PA, Bailey JC, Grady MS, et al. Early versus delayed surgery for acute cervical spinal cord injury. Clin Orthop Relat Res. 1999;359:104–14. [PubMed] [Google Scholar]
22. Rechtine GR. Nonsurgical treatment of thoracic and lumbar fractures. Instr Course Lect. 1999;48:413–six. [PubMed] [Google Scholar]
23. Hitchon PW, From AM, Brenton Medico, Glaser JA, Torner JC. Fractures of the thoracolumbar spine complicating ankylosing spondylitis. J Neurosurg. 2002;97:218–22. [PubMed] [Google Scholar]
24. Woods KB, Bohn D, Mehbod A. Anterior versus posterior treatment of stable thoracolumbar outburst fractures without neurologic arrears. J Spinal Disord Tech. 2005;18:S15–23. [PubMed] [Google Scholar]
25. Cantor JB, Lebwohl NH, Garvey T, Eismont FJ. Non-operative direction of stable thoracolumbar burst fractures with early airing and bracing. Spine. 1993;xviii:971–six. [PubMed] [Google Scholar]
26. Cammisa FP, Jr, Eismont FJ, Green BA. Dural laceration occurring with burst fractures and associated laminar fractures. J Os Articulation Surg Am. 1989;71:1044–52. [PubMed] [Google Scholar]
27. Burkus JK. Surgical treatment of the painful motion segment: matching engineering with indications. Spine. 2005;thirty:S7–15. [PubMed] [Google Scholar]
28. Shono Y, McAfee PC, Cunningham BW. Experimental study of thoracolumbar burst fractures. Spine. 1994;19:1711–22. [PubMed] [Google Scholar]
29. Brodke DS, Gollogly South, Bachus KN, Alexander Mohr R, Nguyen BK. Anterior thoracolumbar instrumentation: Stiffness and load sharing characteristics of plate and rod systems. Spine. 2003;28:1794–801. [PubMed] [Google Scholar]
xxx. 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;75:162–7. [PubMed] [Google Scholar]
31. Ferguson RL, Allen BL., Jr A mechanistic classification of thoracolumbar spine fractures. Clin Orthop Relat Res. 1983;189:77–88. [PubMed] [Google Scholar]
32. Dickman CA, Fessler RG, MacMillan M, Haid RW. Transpedicular spiral-rod fixation of the lumbar spine: Operative technique and outcome in 104 cases. J Neurosurg. 1992;77:860–70. [PubMed] [Google Scholar]
33. Heary RF, Bono CM, Black M. Thoracic pedicle screws: Postoperative computerized tomography scanning cess. J Neurosurg. 2004;100:325–31. [PubMed] [Google Scholar]
34. Reddi AH. Initiation of fracture repair by bone morphogenetic proteins. Clin Orthop Relat Res. 1998;355:S66–72. [PubMed] [Google Scholar]
35. Govender S, Csimma C, Genant HK, Valentin-Opran A, Amit Y, Arbel R, et al. Recombinant human bone morphogenetic protein-two for treatment of open tibial fractures: A prospective, controlled, randomized written report of four hundred and l patients. J Os Articulation Surg Am. 2002;84:2123–34. [PubMed] [Google Scholar]
36. Lieberman JR, Ghivizzani SC, Evans CH. Gene transfer approaches to the healing of bone and cartilage. Mol Ther. 2002;six:141–7. [PubMed] [Google Scholar]
37. Connolly JF. Clinical use of marrow osteoprogenitor cells to stimulate osteogenesis. Clin Orthop Relat Res. 1998;355:S257–66. [PubMed] [Google Scholar]
38. Glassman SD, Rose SM, Dimar JR, Puno RM, Campbell MJ, Johnson JR. The effect of postoperative nonsteroidal antiinflammatory drug assistants on spinal fusion. Spine. 1998;23:834–8. [PubMed] [Google Scholar]
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2989512/
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