versión On-line ISSN 2309-8309
SA orthop. j. vol.8 no.2 Pretoria ene. 2009
J DavisI; RN DunnII
IRegistrar, Department of Orthopaedics, Tygerberg Hospital
IIConsultant Spine and Orthopaedic Surgeon, Head: Spine Services, Groote Schuur Hospital
This article reports on the radiographic outcome of unstable thoracolumbar fractures managed with short segment posterior instrumentation as standalone treatment.
Short segment posterior instrumentation is the method of choice for unstable thoracolumbar injuries in our unit. It is considered to be adequate treatment in cases with an intact posterior longitudinal ligament, and Gaines score below 7; as well as fracture dislocations, and seatbelt-type injuries, without loss of bone column bearing integrity.
Sixty-five consecutive patients undergoing this surgery were studied. Patients were divided into two main cohorts, namely the 'Fracture group' (n=40) consisting of unstable burst fractures and unstable compression fractures; and the 'Dislocation group' (n=25) consisting of fracture dislocations and seatbelt-type injuries. The groups reflect similar goals in surgical treatment for the grouped injuries, with reduction in loss of sagittal profile and maintenance thereof being the main aim in the fracture group, appropriately treated with Schantz pin constructs; and maintenance in position only in the dislocation group, treated with pedicle screw constructs.
Data were reviewed in terms of complications, correction of deformity, and subsequent loss of correction with associated instrumentation failure. Secondly, factors influencing the aforementioned were sought, and stratified in terms of relevance.
Average follow-up was 278 days for the fracture group and 177 days for the dislocation group. There was an average correction in kyphotic deformity of 10.25 degrees. Subsequent loss in sagittal profile averaged 2 degrees (injured level) and 5 degrees (thoracolumbar region) for the combined fracture and dislocation group. The only factor showing a superior trend in loss of reduction achieved was the absence of bone graft (when non-fusion technique was employed). Instrumentation complications occurred in two cases (bent connection rod, and 10 degrees loss in regional sagittal profile following 2 degrees of reduction respectively). These complications represent 3.07% hardware failure in total.
CONCLUSION: Short segment posterior instrumentation is a safe and effective option in the treatment of unstable thoracolumbar fractures as a standalone measure.
“Full text available only in PDF format”
1. Oxland TR, Lin R, Panjabi M. Three-dimensional mechanical properties of the thoracolumbar junction. J Orthop Res 1992;10(4):573-80. [ Links ]
2. Frei H, Oxland TR, Nolte LP. Thoracolumbar spine mechanics contrasted under compression and shear loading. J Orthop Res 2002;20(6):1333-8. [ Links ]
3. Esses SI, Botsford DJ, Kostuik JP. Evaluation of surgical treatment of burst fractures. Spine 1990;15:667-73. [ Links ]
4. Gertzbein SD. Scoliosis research society. Multicentre spine fracture study. Spine 1992;17:528-40. [ Links ]
5. Jacobs RR, Casey MP. Surgical management of thoracolumbar spinal injuries. General principles and controversial considerations. Clin Orthop 1989:22-35. [ Links ]
6. Kostuik JP. Anterior fixation for burst fractures of the thoracic and lumbar spine with or without neurological involvement. Spine 1988;13:286-93. [ Links ]
7. McAfee PC, Bohlman HH, Yuan HA. Anterior decompression of traumatic thoracolumbar fractures with incomplete neurological deficit using retroperitoneal approach. J Bone Joint Surg (Am) 1985;67:89-104. [ Links ]
8. Riska EB, Myllenen P, Bostman O. Anterolateral decompression for neural involvement in thoracolumbar fractures. A review of 85 cases. J Bone Joint Surg (Br) 1987;69:704-8. [ Links ]
9. Shono Y, McAfee PC, Cunningham BW: Experimental study of thoracolumbar burst fractures. A radiographic and biomechanical analysis of anterior and posterior instrumentation systems. Spine 1994;19:1711-22. [ Links ]
10. Kirkpatrick JS. Thoracolumbar fracture management: Anterior approach. J Am Acad Orthop Surg 2003;11:355-63. [ Links ]
11. Kaneda K, Taneichi H, Abumi K, Hashimoto T, Satoh S, Fujiya M. Anterior decompression and stabilization with the Kaneda device for thoracolumbar burst fractures associated with neurological deficits. J Bone Joint Surg Am 1997;79:69-83. [ Links ]
12.Sasso RC, Best NM, Reilly TM, McGuire RA Jr. Anterior-only stabilization of three-column thoracolumbar injuries. J Spinal Disord Tech 2005;18(suppl):S7-S14. [ Links ]
13. Wessberg P, Wang Y, Irstam L, Nordwall A. The effect of surgery and remodeling on spinal canal measurements after thoracolumbar burst fractures. Eur Spine J 2001;10:55-63. [ Links ]
14. Alanay A, Acoroglu E, Yazici M, Aksoy C, Surat A. The effect of transpedicular intracorporeal grafting in the treatment of thoracolumbar burst fractures on canal remodeling. Eur Spine J 2001;10:512-6. [ Links ]
15. Tezeren G, Kuru I. Posterior fixation of thoracolumbar burst fracture: Short segment pedicle fixation versus long-segment instrumentation. J Spinal Disord Tech 2005;18:458-88. [ Links ]
16. Wilke HJ, Kemmerich V, Claes LE, Arand M. Combined antero-posterior spinal fixation provides superior stabilization to a single anterior or posterior procedure. J Bone Joint Surg Br 2001;83:609-17. [ Links ]
17.Been HD, Bouma GJ. Comparison of two types of surgery for thoracolumbar burst fractures: Combined anterior and posterior stabilization vs. posterior instrumentation only. Acta Neurochir (Wien) 1999;141:349-57. [ Links ]
18. Oner Cumher F, van der Rijt R, Lino M, Ramos P, Dhert WJA, Verbout AJ. Changes in disc space after fractures of the thoracolumbar spine. J Bone Joint Surg Br 1998;80B(5):833-9. [ Links ]
19.Wang S, Ma H, Liu C, Yu W, Chang M, Chen T, Wood KB. Is fusion necessary for surgically treated burst fractures of the thoracolumbar and lumbar spine? Spine 2006;31(23):2646-53. [ Links ]
20. Boden SD. Overview of the biology of lumbar spine fusion and principles for selecting a bone graft substitute. Spine 2002;27:26-31. [ Links ]
21.Hassan D, Haw Chou Lee, Eldin E, Karaikovic, Robert W.Gaines Jr. Decision making in thoracolumbar fractures. Neurology India 2005;53(4):534-41. [ Links ]
22. Rechtine GR, Cahill D, Chrin AM. Treatment of thoracolumbar trauma: comparison of complications of operative versus nonoperative treatment. J Spinal Disord 1999;12(5):406-9. [ Links ]
Dr RN Dunn
Head of Spinal Services
Division of Orthopaedic Surgery
University of Cape Town
PO Box 30086
Tel: (021) 404-5108; Fax: 086 671 5294