Objective To investigate the effect of the sequence of intermediate instrumentation with long screws and distraction-reduction on mild to moderate thoracolumbar fractures treated by posterior open and short-segmental fixation. MethodsThe clinical data of 68 patients with mild to moderate thoracolumbar burst fractures who met the selection criteria between January 2016 and June 2019 were retrospectively analyzed. The patients were divided into group ISDRF (intermediate screws then distraction-reduction fixation, 32 cases) and group DRISF (distraction-reduction then intermediate screws fixation, 36 cases) according to the different operation methods. There was no significant difference between the two groups in age, gender, body mass index, fracture segment, cause of injury, and preoperative load-sharing classification score, thoracolumbar injury classification and severity score, vertebral canal occupational rate, back pain visual analogue scale (VAS) score, anterior height of fractured vertebra, and Cobb angle (P>0.05). The operation time, intraoperative blood loss, complications, and fracture healing time were recorded and compared between the two groups. The vertebral canal occupational rate, anterior height of fractured vertebra, kyphosis Cobb angle, and back pain VAS score before and after operation were used to evaluate the effectiveness. Results There was no significant difference in intraoperative blood loss and operation time between the two groups (P>0.05). No vascular or spinal nerve injury and deep infections or skin infections occurred in both groups. At 1 week after operation, the vertebral canal occupational rate in the two groups was significantly improved when compared with that before operation (P<0.05), no significant difference was found in the difference of vertebral canal occupational rate before and after operation and improvement between the two groups (P>0.05). The patients in both groups were followed up 18-24 months, with an average of 22.3 months. All vertebral fractures reached bone union at 6 months postoperatively. At last follow-up, there was no internal fixation failures such as broken screws, broken rods or loose screws, but there were 2 cases of mild back pain in the ISDRF group. The intra-group comparison showed that the back pain VAS score, the anterior height of fractured vertebra, and the Cobb angle of the two groups were significantly improved at each time point postoperatively (P<0.05); the VAS scores at 12 months postoperatively and last follow-up were also improved when compared with that at 1 week postoperatively (P<0.05). At last follow-up, the anterior height of fractured vertebra in the ISDRF group was significantly lost when compared with that at 1 week and 12 months postoperatively (P<0.05), the Cobb angle had a significant loss when compared with that at 1 week postoperatively (P<0.05); the anterior height of fractured vertebra and Cobb angle in DRISF group were not significantly lost when compared with that at 1 week and 12 months postoperatively (P>0.05). The comparison between groups showed that there was no significant difference in the remission rate of VAS score between the two groups at 1 week postoperatively (P>0.05), the recovery value of the anterior height of fractured vertebra in ISDRF group was significantly higher than that in DRISF group (P<0.05), the loss rate at last follow-up was also significantly higher (P<0.05); the correction rate of Cobb angle in ISDRF group was significantly higher than that in DRISF group at 1 week postoperatively (P<0.05), but there was no significant difference in the loss rate of Cobb angle between the two groups at last follow-up (P>0.05). ConclusionIn the treatment of mild to moderate thoracolumbar burst fractures with posterior short-segment fixation, the instrumentation of long screws in the injured vertebrae does not affect the reduction of the fracture fragments in the spinal canal. DRISF can better maintain the restored anterior height of the fractured vertebra and reduce the loss of kyphosis Cobb angle during the follow-up, indicating a better long-term effectiveness.
Objective To investigate the feasibility and effectiveness of selective treatment of senile osteoporotic thoracolumbar burst fractures of Denis type B with kyphoplasty and Jack vertebral dilator. Methods Between August 2007 and May 2011, 30 patients (32 vertebra) with osteoporotic thoracolumbar burst fractures of Denis type B were treated with kyphoplasty and Jack vertebral dilator. There were 7 males and 23 females, aged 57-85 years (mean, 76.9 years). The injured vertebrae included T11 in 2 vertebrae, T12 in 11 vertebrae, L1 in 7 vertebrae, L2 in 5 vertebrae, L3 in 3 vertebrae, and L4 in 4 vertebrae. The visual analogue scale (VAS) score, Oswestry disability index (ODI), the anterior and middle height of the vertebral body, and the Cobb angle were assessed before and after operation. Results The operation was completed smoothly in all cases; no cement leakage or intraoperative complication was found. Obvious back pain relief was achieved in all patients after operation. Thirty patients were followed up at 1 week and 6 months after operation. The VAS score was decreased from 8.2 ± 1.3 before operation to 1.5 ± 0.9 at 1 week after operation and 1.9 ± 0.5 at 6 months after operation; the ODI was decreased from 82.4% ± 15.0% to 17.8% ± 9.5% and 23.0% ± 8.6%; the anterior height of the vertebral body was increased from (19.5 ± 3.2) mm to (24.8 ± 3.0) mm and (24.0 ± 2.6) mm; the middle height of the vertebral body was increased from (18.5 ± 3.4) mm to (23.7 ± 3.7) mm and (22.8 ± 3.5) mm; the Cobb angle was decreased from (14.9± 7.5)° to (7.6 ± 6.0)° and (8.3 ± 6.0)°; and there were significant differences in the VAS score, ODI, the anterior and middle height of the vertebral body, and the Cobb angle between at pre- and at post-operation (P lt; 0.05), but no significant difference between at 1 week and at 6 months after operation (P gt; 0.05). Conclusion Kyphoplasty with Jack vertebral dilator for selective treatment of senile osteoporotic thoracolumbar burst fractures of Denis type B can restore the anterior and middle height of the vertebral body, correct the Cobb angle, and relieve pain, and it has good short-term effectiveness and safety.
Objective To investigate the effectiveness and long-term stability of small fenestration vertebral bone grafting and transpedicular bone grafting in the treatment of Denis types A and B thoracolumbar burst fractures. Methods Between January 2012 and February 2014, 50 patients with Denis type A or B thoracolumbar burst fractures were treated with vertebroplasty and pedicle screw rod fixation system, and the clinical data were retrospectively analyzed. Small fenestration vertebral bone grafting by trans-interlaminar approach was used in 30 cases (group A), and bone grafting by unilateral transpedicular approach was used in 20 cases (group B). X-ray and CT examinations of the thoracolumbar vertebrae were performed routinely before and after operation. There was no significant difference in sex, age, cause of injury, time from injury to operation, fracture type, injury segment, and preoperative Frankel classification, the percentage of the anterior body height of the injured vertebra, and visual analogue scale (VAS) score between two groups (P>0.05). There was significant difference in preoperative Cobb angle of kyphosis between two groups (P<0.05). The Cobb angle of kyphosis, the percentage of the anterior body height of the injured vertebra, and the recovery of neurological function were recorded and compared between two groups. Results The patients were followed up for 16-31 months (mean, 19.1 months) in group A and for 17-25 months (mean, 20.2 months) in group B. Primary healing of incisions was obtained in the two groups; no nerve injury and other operative complications occurred. The neurological function was improved in varying degrees in the other patients with neurological impairment before operation except patients at grade A of Frankel classification. The lumbar back pain was relieved in two groups. There was significant difference in VAS score between before operation and at 3 months after operation or last follow-up in two groups (P<0.05), but no significant difference was found between at 3 months and last follow-up in two groups and between two groups at each time point after operation (P>0.05). X-ray examination showed that there was no breakage of nail and bar, or dislocation and loosening of internal fixation during follow-up period. The bone grafts filled well and fused in the fractured vertebra. The vertebral height recovered well after operation. The percentage of the anterior body height of the in-jured vertebra and Cobb angle of kyphosis at 1 week, 3 months, and last follow-up were significantly better than preope-rative ones in two groups (P<0.05), but there was no significant difference between different time points after operation (P>0.05), and between two groups at each time point after operation (P>0.05). Conclusion For Denis types A and B thoracolumbar burst fractures, vertebral bone grafting and pedicle screw internal fixation through interlaminal small fene-stration or transpedicular approach can restore the vertebral height, correct kyphosis, and maintain the vertebral stability, which reduce the risk of complications of loosening and breakage of internal fixators. The appropriate bone grafting approach can be chosen based on the degree of spinal canal space occupying, collapse of vertebral and spinal cord injury.
Objective To investigate the amount of bone grafting, bone defect gap residual rates, and biomechanical stability of the injured vertebral body after reduction of thoracolumbar burst fractures, pedicle screw-rods fixation, and bone graft by bilateral pedicle or unilateral spinal canal. Methods Eighteen fresh lumbar spine (L1-5) specimens of calves (aged 4-6 months) were collected to establish the burst fracture model at L3 and divided into 3 groups randomly. After reduction and fixation with pedicle screws, no bone graft was given in group A (n=6), and bone graft was performed by bilateral pedicles in group B (n=6) and by unilateral spinal canal in group C (n=6). The amount of bone grafting in groups B and C was recorded. The general situation of bone defect gaps was observed by the DR films and CT scanning, and the defect gap residual rates of the injured vertebrae were calculated with counting of grids. The compression stiffness was measured by ElectreForce-3510 high precision biological material testing machines. Results The amount of bone grafting was (4.58 ± 0.66) g and (5.72 ± 0.78) g in groups B and C respectively, showing signficant difference (t=2.707, P=0.022). DR films and CT scanning observation showed large bone defect gap was seen in injured vertebrae specimens of group A; however, the grafting bone grains was seen in the “eggshell” gap of the injured vertebral body, which were mainly located in the posterior part of the vertebral body, but insufficient filling of bone graft in the anterior part of the vertebral body in group B; better filling of the grafting bone grains was seen in injured vertebral body of group C, with uniform distribution. The bone defect gap residual rates were 52.0% ± 5.5%, 39.7% ± 2.5%, and 19.5% ± 2.5% respectively in groups A, B, and C; group C was significantly lower than groups A and B (P lt; 0.05), and group B was significantly lower than group A (P lt; 0.05). Flexion compressive stiffness of group C was significantly higher than that of groups A and B (P lt; 0.05), but no significant difference was found between groups A and B (P gt; 0.05). Extension compressive stiffness in group C was significantly higher than that in group A (P lt; 0.05), but no significant difference was found between groups A and B, and between groups B and C (P gt; 0.05). The compression stiffness of left bending and right bending had no significant difference among 3 groups (P gt; 0.05). Conclusion Thoracolumbar burst fracture pedicle screws fixation with bone grafting by unilateral spinal canal can implant more bone grains, has smaller bone defect gap residual rate, and better recovery of flexion compression stiffness than by bilateral pedicles.
Objective To evaluate the effectiveness of spinal canal decompression assisted by unilateral biportal endoscopy (UBE) and percutaneous uniplanar pedicle screw internal fixation in the treatment of lumbar burst fractures with neurological symptoms. Methods Between June 2021 and December 2022, 10 patients with single level lumbar burst fracture with neurological symptoms were treated with spinal canal decompression assisted by UBE and percutaneous uniplanar pedicle screw internal fixation. There were 7 males and 3 females with an average age of 43.1 years (range, 21-57 years). The injured vertebrae located at L1 in 2 cases, L2 in 4 cases, L3 in 3 cases, and L4 in 1 case. There were 7 cases of AO type A3 fractures and 3 cases of AO type A4 fractures. The total operation time, the time of operation under endoscopy, and complications were recorded. Pre- and post-operative visual analogue scale (VAS) score and American Spinal Injury Association (ASIA) scale (grading A-E corresponding to assigning 1-5 points for statistical analysis) were used to evaluate effectiveness. X-ray film and CT were performed to observe the fracture healing, and the ratio of anterior vertebral body height, Cobb angle, and rate of spinal canal invasion were measured to evaluate the reduction of fracture.Results All operations was successfully completed, and the spinal canal decompression and the bone fragment in spinal canal reduction completed under the endoscopy. Total operation time was 119 minutes on average (range, 95-150 minutes), and the time of operation under endoscopy was 46 minutes on average (range, 35-55 minutes). There was no complication such as dural sac, nerve root, or blood vessel injury during operation. All incisions healed by first intention. All patients were followed up 18.7 months on average (range, 10-28 months). The VAS score after operation significantly decreased when compared with that before operation (P<0.05), and further improved at last follow-up (P<0.05). The ASIA scale after operation significantly improved when compared with that before operation (P<0.05), and there was no significant difference (P>0.05) in the ASIA scale between at 1 week after operation and at last follow-up. The imaging examination showed that the screw position was good and the articular process joint was preserved. During follow-up, there was no loosening, fracture, or fixation failure of the internal fixation. The ratio of anterior vertebral body height and Cobb angle significantly improved, the rate of spinal canal invasion significantly decreased after operation (P<0.05), and without significant loss of correction during the follow-up (P>0.05). Conclusion Spinal canal decompression assisted by UBE and percutaneous uniplanar pedicle screw fixation is a feasible minimally invasive treatment for lumbar burst fractures with neurological symptoms, which can effectively restore the vertebral body sequence, as well as relieve the compression of spinal canal, and improve the neurological function.
Objective To evaluate the early cl inical outcomes of subtotal corpectomy and intervertebral bonegrafting through posterior approach alone in the treatment of thoracolumbar burst fracture or thoracolumbar fracturedislocation.Methods Between January 2009 and December 2010, 20 patients with thoracolumbar burst fracture orthoracolumbar fracture dislocation were treated with subtotal corpectomy and intervertebral bone grafting through posteriorapproach alone. There were 14 males and 6 females, with an average age of 36.1 years (range, 19-47 years). Fractures were causedby falling from height in 12 cases, traffic accident in 6 cases, and crushing in 2 cases. According to AO classification, there were10 cases of A3 type, 8 cases of B2 type, and 2 cases of C2 type. Single segment was involved in 8 cases, double segments in 12cases. Twelve cases complicated by fracture dislocation and 6 cases by lateral displacement. All patients had bones occupancyin vertebral canal. The preoperative Cobb angle was (30.2 ± 3.9)°. According to Frankel classification for neurological function,there were 4 cases of grade B, 9 cases of grade C, and 7 cases of grade D at preoperation. The mean time between injury andoperation was 4.5 days (range, 1-12 days). Results All incisions healed by first intention, and no infection occurred.Twenty patients were followed up 8-16 months (mean, 12 months). The interbody fusion time was 6-9 months (mean, 7months). Neurological function recovered 1 to 3 grades: 1 case of grade C, 2 cases of grade D, 17 cases of grade E at last followup.The Cobb angle was (6.5 ± 4.2)° at last follow-up, showing significant difference when compared with preoperative value(t=2.39, P=0.00). No breaking or loosening of screw and implant sinkage occurred. Conclusion A combination of subtotalcorpectomy and intervertebral bone grafting through posterior approach alone has the advantages of complete decompression,restoration of spinal stabil ity, restoration of vertebral body height, high bone healing rate, and good recovery of neurologicalfunction. However, this surgical technique has a relatively large amount of blood loss and high requirements for surgeons.
ObjectiveTo study the effectiveness of posterior laminotomy decompression and bone grafting via the injured vertebrae for treatment of thoracolumbar burst fractures. MethodsBetween November 2010 and November 2012, 58 patients with thoracolumbar burst fractures were treated by posterior fixation combined with posterior laminotomy decompression and intervertebral bone graft in the injured vertebrae. There were 40 males and 18 females with a mean age of 48 years (range, 25-58 years). According to Denis classification, 58 cases had burst fractures (Denis type B); based on neurological classification of spinal cord injury by American Spinal Injury Association (ASIA) classifications, 5 cases were rated as grade A, 18 cases as grade B, 20 cases as grade C, 14 cases as grade D, and 1 case as grade E. Based on thoracolumbar burst fractures CT classifications there were 5 cases of type A, 20 cases of type B1, 10 cases of type B2, and 23 cases of type C. The time between injury and operation was 10 hours to 9 days (mean, 7.2 days). The CT was taken to measure the space occupying of vertebral canal. The X-ray film was taken to measure the relative height of fractured vertebrae for evaluating the vertebral height restoration, Cobb angle for evaluating the correction of kyphosis, and ASIA classification was conducted to evaluate the function recovery of the spinal cord. ResultsThe operations were performed successfully, and incisions healed primarily. All the patients were followed up 12-18 months (mean, 15 months). CT showed good bone graft healing except partial absorption of vertebral body grafted bone; no loosening or breakage of screws and rods occurred. The stenosis rates of fractured vertebral canale were 47.56%±14.61% at preoperation and 1.26%±0.62% at 1 year after operation, showing significant difference (t=24.46, P=0.00). The Cobb angles were (16.98±3.67)° at preoperation, (3.42±1.45)° at 1 week after operation, (3.82±1.60)° at 1 year after operation, and (4.84±1.70)° at 3 months after removal of internal fixation, showing significant differences between at pre-and post-operation (P < 0.05). The relative heights of fractured vertebrae were 57.10%±6.52% at preoperation, 96.26%±1.94% at 1 week after operation, 96.11%±1.97% at 1 year after operation, and 96.03%±1.96% at 3 months after removal of internal fixation, showing significant differences between at pre-and post-operation (P < 0.05). At 1 year after operation, the neural function was improved 1-3 grades in 56 cases. Based on ASIA classifications, 1 case was rated as grade A, 4 cases as grade B, 10 cases as grade C, 23 cases as grade D, and 20 cases as grade E. ConclusionTreatment of thoracic and lumbar vertebrae burst fractures by posterior laminotomy decompression and bone grafting via the injured vertebrae has satisfactory effectiveness, which can reconstruct vertebral body shape and height with spinal cord decompression and good vertebral healing. It is a kind of effective solution for thoracolumbar burst fracture.
Objective To assess the effectivness of different bone graft fusion ways in the treatment of thoracolumbar burst fractures. Methods Between June 2000 and June 2009, 126 cases of thoracolumbar burst fractures were treated by onestageposterior short segment internal fixation combined with bone graft fusion. All patients had acute spine and spinal injuryat the levels of T11-L2, who were with different degrees of neural function injury (below Frankel grade D). The patients were randomly divided into 3 groups and were treated respectively by centrum combined with interbody bone graft fusion (group A), posterolateral bone graft fusion (group B), and ring bone graft fusion (group C) combined with posterior short segment pedicle instrumentation. The changes of the Cobb angle, correction loss of Cobb angle, bone fusion rate, internal fixation failure rate, Oswestry Disabil ity Index (ODI), and Frankel grade of the fracture vertebral were observed after operation to evaluate the effectiveness of different bone graft fusion ways. Results All 126 cases were followed up 24-32 months (mean, 28 months). The operation time and bleeding volume in group C were significantly larger than those in groups A and B (P lt; 0.05), but no significant difference was found between groups A and B (P gt; 0.05). At 2 years after operation and last follow-up, the Cobb angle and correction loss in group B were significantly larger than those in groups A and C (P lt; 0.05), but there was no significant difference between groups A and C (P gt; 0.05). At last follow-up, the bone fusion rate and internal fixation failure rate were 100% and 0 in group A, 78.6% and 21.4% in group B, and 97.5% and 0 in group C; there were significant differences between group B and groups A, C (P lt; 0.05), but no significant difference was found between groups A and C (P gt; 0.05). ODI and Frankel grade were obviously improved after operation, showing significant differences between preoperation and last follow-up (P lt; 0.05) in 3 groups, between group B and groups A, C (P lt; 0.05), but no significant difference was found between groups A and C (P gt; 0.05). Conclusion The centrum combined with interbody bone graft fusion is best in 3 bone graft fusion ways because of its optimum bone fusion and according with human body biomechanics mechanism. Back outboard bone graft fusion may not a appropriate bone fusion way because of its high internal fixation failure rate and not according with human body biomechanics mechanism. The ring bone graft fusion may not be an indispensable bone fusion way because of its common bone fusion ratio and lower cost-performance ratio.
Objective To compare the cl inical effects of indirect decompression versus open decompression to vertebral canal in treatment of thoracolumbar burst fractures without neurologic deficit. Methods From April 2004 to June 2008, 52 cases of thoracolumbar burst fracture without neurologic deficit underwent posterior exposition, reduction and fixation with Atlas Fixator (AF) instrumentation. There were 34 males and 18 females with an average age of 43.1 years (range, 31-63 years). The affectd locations were T11 in 5 cases, T12 in 24 cases, L1 in 16 cases, and L2 in 7 cases. The time from injury to operation was 3-8 days (4.4 days on average). All cases were devided into indirect decompression group (group A) and open decompression group (group B). There were no statistically significant differences (P gt; 0.05) in sex, age, affect site, and disease course between two groups. The operative time, blood loss were recoded. Preoperatively, immediately postoperstively and at last follow-up, the height of the fracture vertebra and the Cobb angle were obtained from X-ray pictures and were statistically analysed. Radiographic parameters on computed tomography (CT) pictures were used to get the encroachment rate of vertebral canal. Results The operative time was (87.3 ± 7.9) minutes and (125.3 ± 13.6) minutes, and the blood loss was (273.7 ± 23.4) mL and (512.6 ± 37.7) mL in groups A and B, respectively; showing statistically significant differences (P lt; 0.05). The average follow-up time was 17.4 months (range, 11-31 months) in group A and 19.9 months (range, 12-33 months) in group B. All wounds achieved primary heal ing postoperatively without deaths and spinal cord injuries. Postoperative compl ications in group B included 3 cases of screws loosening, 1 case of screw breakage, and 3 cases of low back pain, and were given symptomatic management. There were no statistically significant differences (P gt; 0.05) in the height of the fracture vertebra, the Cobb angle andthe encroachment rate of vertebral canal preoperatively or postoperstively between two groups. There were statistically significant differences (P lt; 0.05) in the above three parameters between preoperation and postoperation in two groups, but there were no statistically significant differences (P gt; 0.05) in the spinal correction between two groups. The losing-rate of spinal correction of the height of the fracture vertebra and the Cobb angle of group A was lower than group B, showing statistically significant differences (P lt; 0.05). Conclusion The short-term results of two decompression styles in treatment of thoracolumbar burst fractures without neurologic deficit were satisfactory, but indirect decompression has more merits than open decompression: shorter operative time, less blood loss, lower losing-rate of spinal correction, and better stabil ization of vertebral column.
ObjectiveTo investigate the effectiveness of posterior microscopic mini-open technique (MOT) decompression in patients with severe spinal canal stenosis resulting from thoracolumbar burst fractures.MethodsThe clinical data of 28 patients with severe spinal canal stenosis caused by thoracolumbar burst fractures, who were treated by posterior microscopic MOT, which performed unilateral or bilateral laminectomy, poking reduction, intervertebral bone graft via spinal canal, and percutaneous pedicle screw fixation between January 2014 and January 2016 were retrospectively analyzed. There were 21 males and 7 females with a mean age of 42.1 years (range, 16-61 years). The involved segments included T11 in 1 case, T12 in 4 cases, L1 in 14 cases, and L2 in 9 cases. According to AO classification, there were 19 cases of type A3, 9 of type A4. According to American Spinal Injury Association (ASIA) grading, 12 cases were grade C, 13 grade D, and 3 grade E. The time between injury and operation was 3-7 days (mean, 3.6 days). To evaluate effectiveness, the changes in the visual analogue scale (VAS), percentage of anterior height of injured vertebrae, Cobb angle, rate of spinal compromise (RSC), and ASIA grading were analyzed.ResultsAll patients were performed procedures successfully. The operation time was 135-323 minutes (mean, 216.4 minutes). The intraoperative blood loss was 80-800 mL (mean, 197.7 mL). The hospitalization time was 10-25 days (mean, 12.5 days). The incisions healed primarily, without wound infection, cerebrospinal fluid leakage, or other early complications. All the 28 patients were followed up 12-24 months (mean, 16.5 months). No breakage or loosening of internal fixation occurred. All fractures healed, and the healing time was 3-12 months (mean, 6.5 months). Compared with preoperative ones, the percentage of anterior height of injured vertebrae, Cobb angle, and RSC at immediate after operation and at last follow-up and the VAS scores at 1 day after operation and at last-follow were significantly improved (P<0.05). There was no significant difference in the percentage of anterior height of injured vertebrae and Cobb angle between at immediate after operation and at last follow-up (P>0.05). But the RSC at immediate after operation and VSA score at 1 day after operation were significantly improved when compared with those at last follow-up (P<0.05). The ASIA grading at last follow-up was 1 case of grade C, 14 grade D, and 13 grade E, which was significantly improved when compared with preoperative ones (Z=3.860, P=0.000).ConclusionMOT is an effective and minimal invasive treatment for thoracolumbar AO type A3 and A4 burst fractures with severe spinal canal stenosis, and it is beneficial to early rehabilitation for patients.