Objective To investigate the surgical method and prel iminary cl inical result of managing the patient with lumbar burst fracture but not suitable for single-level fixation and fusion surgery with the reservation of the fractured vertebral body and the anterior decompression. Methods From September 2007 to December 2008, 11 patients with lumbar burst fracture underwent the removal of the posterior superior corner of the injured vertebral body, the removal of the inferior intervertebral disc adjacent to the injured vertebral body, bone graft fusion, and internal fixation. There were 8 males and3 females aged 21-48 years old (average 29.4 years old). All the fractures caused by fall ing from high places. Imaging exams confirmed all the fractures were Denis type B burst fracture. The fracture level was at the L1 in 4 cases, the L2 in 4 cases, the L3 in 2 cases, and the L4 in 1 case. Before operation, the nerve function was graded as grade B in 4 cases, grade C in 3 cases, and grade D in 4 cases according to Frankel scales; the visual analogue scale (VAS) was (7.30 ± 0.98) points; lateral X-ray films displayed the kyphosis Cobb angel was (24.94 ± 12.21)°; the adjacent superior and inferior intervertebral disc height was (12.78 ± 1.52) mm and (11.68 ± 1.04) mm, respectively; CT scan showed the vertebral canal sagittal diameter was (9.56 ± 2.27) mm; CT three-dimensional reconstruction revealed that the intact part of the injured vertebra was less than 50% vertebra body height and the fracture l ine crossed the pedicle. The time from injury to operation was 3-11 days (average 4.8 days). The neurological and radiological evaluations were carried out immediately and 3 months after operation, respectively, and compared with the condition before operation. Results All the patients successfully underwent the surgery. The wound all healed by first intention. All the patients were followed up for 6-18 months (average 14 months). All the patients had a certain degree of nerve function recovery. The Frankel scales in all the patients were increased by 1-2 grade immediately and 3 months after operation. The VAS score was (2.80 ± 1.49) points immediately after operation and (1.54 ± 0.48) points 3 months after operation, suggesting there were significant differences among three time points (P lt; 0.05). The vertebral canal sagittal diameter was significantly enlarged to (18.98 ± 4.82) mm immediately after operation and was (19.07 ± 4.37) mm 3 months after operation. The Cobb angle was (7.78 ± 4.52)° immediately after operation and (8.23 ± 3.57)° 3 months after operation. There were significant differences between before and after operation (P lt; 0.05). For the adjacent superior and inferior intervertebral disc height, there was no significant difference when the value immediately or 3 months after operation was compared with that of before operation (P gt; 0.05). X-ray films and CT scan 3 months after operation showed good internal fixation without theoccurrence of loosing and displacement. Conclusion For the treatment of lumbar burst fracture, the method of reserving the injured vertebral body and anterior decompression can decompress the vertebral canal and shorten the duration for bony fusion.
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 effect of preventing the loss of correction and vertebral defects after thoracolumbar burst fractures treated with recombinant human bone morphogenetic protein 2 (rhBMP-2) and allogeneic bone grafting in injured vertebra uniting short-segment pedicle instrumentation. Methods A prospective randomized controlled study was performed in 48 patients with thoracolumbar fracture who were assigned into 2 groups between June 2013 and June 2015. Control group (n=24) received treatment with short-segment pedicle screw instrumentation with allogeneic bone implanting in injured vertebra; intervention group (n=24) received treatment with short-segment pedicle screw instrumentation combining with rhBMP-2 and allogeneic bone grafting in injured vertebra. There was no significant difference in gender, age, injury cause, affected segment, vertebral compression degree, the thoracolumbar injury severity score (TLICS), Frankel grading for neurological symptoms, Cobb angle, compression rate of anterior verterbral height between 2 groups before operation (P>0.05). The Cobb angle, compression rate of anterior vertebral height, intervertebral height changes, and defects in injured vertebra at last follow-up were compared between 2 groups. Results All the patients were followed up 21-45 months (mean, 31.3 months). Bone healing was achieved in 2 groups, and there was no significant difference in healing time of fracture between intervention group [(7.6±0.8) months] and control group [(7.5±0.8) months] (t=0.336, P=0.740). The Frankel grading of all patients were reached grade E at last follow-up. The Cobb angle and compression rate of anterior verterbral height at 1 week after operation and last follow-up were significantly improved when compared with preoperative ones in 2 groups (P<0.05). There was no significant difference in Cobb angle and compression rate of anterior verterbral height between 2 groups at 1 week after operation (P>0.05), but the above indexes in intervention group were better than those in control group at last follow-up (P<0.05). At last follow-up, there was no significant difference of intervertebral height changes of internal fixation adjacent upper position, injured vertebra adjacent upper position, injured vertebra adjacent lower position, and internal fixation adjacent lower position between 2 groups (P>0.05). Defects in injured vertebra happened in 18 cases (75.0%) in control group and 5 cases (20.8%) in intervention group, showing significant difference (χ2=14.108, P=0.000); and in patients with defects in injured vertebra, bone defect degree was 7.50%±3.61% in control group, and was 2.70%±0.66% in intervention group, showing significant difference (t=6.026, P=0.000). Conclusion Treating thoracolumbar fractures with short-segment pedicle screw instrumentation with rhBMP-2 and allogeneic bone grafting in injured vertebra can prevent the loss of correction and vertebral defects.
目的 觀察后路環形減壓治療胸腰椎爆裂骨折術后2～5年的臨床療效及并發癥發生情況。 方法 回顧性分析2007年1月－2011年3月23例胸腰椎椎體爆裂骨折患者資料，23例患者存在骨折壓迫硬膜合并神經癥狀，均予后路環形減壓。術后定期隨訪，采用日本骨科協會評估治療分數、美國脊髓損傷協會脊髓損傷分級評定臨床療效及神經功能改善情況，通過影像學資料觀察脊柱Cobb角變化情況。 結果 23例患者手術順利，經過2～5年的隨訪，出現術后腦脊液漏3例，尿路感染5例，經對癥處理后好轉。 結論 經椎弓根內側行椎體后壁切除，可良好減壓，避免神經擠壓繼發加重損傷，有利于神經功能恢復。
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.
ObjectiveTo investigate the efficacy and safety of over-bending rod reduction and fixation technique via posterior approach in the treatment of unstable fresh thoracolumbar burst fracture.MethodsA clinical data of 27 patients with unstable fresh thoracolumbar burst fracture, who were met the inclusive criteria and admitted between January 2018 and October 2019, was retrospectively analyzed. There were 15 males and 12 females with an average age of 41.8 years (range, 26-64 years). The fractures were caused by falling from height in 14 cases, traffic accident in 8 cases, and crushing by a heavy objective in 5 cases. The interval between injury and operation was 1-7 days (mean, 3.2 days). The injured fracture was located at T10 in 1 case, T11 in 3 cases, T12 in 6 cases, L1 in 7 cases, L2 in 7 cases, and L3 in 3 cases. According to AO classification, there were 11 cases of type A3, 7 cases of type B, and 9 cases of type C. Neurological function was rated as grade A in 3 cases, grade B in 7 cases, grade C in 5 cases, and grade D in 12 cases according to the American Spinal Injury Association (ASIA) grading. All cases were treated by over-bending rod reduction and fixation technique via posterior approach, and 16 cases were combined with limited fenestration decompression. The evaluation indicators consisted of operation time, intraoperative blood loss, the compression ratio of the anterior vertebral height, the invasion rate of the injured vertebra into the spinal canal, the Cobb angle of segmental kyphosis, visual analogue scale (VAS) score, and Oswestry Disability Index (ODI).ResultsThe operation time was 67-128 minutes (mean, 81.6 minutes), and the intraoperative blood loss was 105-295 mL (mean, 210 mL). All patients were followed up 12-23 months (mean, 17.2 months). A total of 178 pedicle screws were implanted during operation, and the accuracy of the implantation was 98.9% (176/178). The compression ratios of the anterior vertebral height at the early postoperatively and last follow-up were significantly increased when compared with preoperative one (P<0.05), and the invasion rate of the injured vertebra into the spinal canal, Cobb angle, VAS score, and ODI were significantly lower than those preoperatively (P<0.05). Except that the ODI at last follow-up was significantly lower than that of the early postoperative period (P<0.05), there was no significant difference between the last follow-up and the early postoperative period for other indicators (P>0.05). At last follow-up, the neurological function was rated as grade A in 1 case, grade B in 2 cases, grade C in 4 cases, grade D in 9 cases, and grade E in 11 cases according to the ASIA grading, showing significant difference when compared with that before operation (Z=–3.446, P=0.001).ConclusionOver-bending rod reduction and fixation technique can effectively restore vertebral height, reset the invaded vertebral block, and selectively perform limited decompression and posterolateral bone grafting to ensure the completeness of intravertebral decompression and stability, which is one of the effective methods to treat unstable fresh thoracolumbar burst vertebral fracture.
Objective To assess the effectiveness of percutaneous pedicle screw fixation and minimally invasive decompression in the same incision for type A3 thoracolumbar burst fracture. Methods Between May 2014 and February 2016, 43 cases of type A3 thoracolumbar burst fracture with or without nerve symptoms were treated with pedicle screw fixation and neural decompression. Of them, 21 patients underwent percutaneous pedicle screw fixation and minimally invasive decompression in the same incision (percutaneous group), and the other 22 patients underwent traditional open surgery (open group). There was no significant difference in gender, age, cause of injury, fractures level, preoperative American Spinal Injury Association (ASIA) grade, thoracolumbar injury classification and severity (TLICS) score, load-sharing classification, height of injury vertebrae, kyphotic Cobb angle, and spinal canal encroachment between 2 groups (P>0.05). The length of soft tissue dissection, operation time, intraoperative blood loss, postoperative drainage, X-ray exposure times, and incision visual analogue scale (VAS) score at 1 day after operation were recorded and compared. At last follow-up, Japanese Orthopaedic Association (JOA) score and low back pain VAS score were recorded and compared respectively. The ASIA grade recovery was evaluated; the height of injury vertebrae, kyphotic Cobb angle, and spinal canal encroachment were assessed postoperatively. Results Percutaneous group was significantly better than open group in the length of soft tissue dissection, intraoperative blood loss, postoperative drainage, and incision VAS at 1 day after operation (P<0.05), but no significant difference was found in operation time between 2 groups (P>0.05); however, X-ray exposure times of open group were significantly better than that of percutaneous group (P<0.01). The patients were followed up 12 to 19 months (mean, 15.1 months) in 2 groups. All patients achieved effective decompression. No complications of iatrogenic neurological injury and internal fixation failure occurred. The height of injury vertebrae, kyphotic Cobb angle, and spinal canal encroachment of the fractured vertebral body were significantly improved at 3 days after operation when compared with preoperative ones (P<0.05), but no significant difference was found between 2 groups (P>0.05). At last follow-up, JOA score and low back pain VAS score of percutaneous group were significantly better than those of open group (P<0.05). The neurological function under grade E was improved at least one ASIA grade in 2 groups, but no significant difference was shown between 2 groups (Z=0.480, P=0.961). Conclusion Percutaneous pedicle screw fixation and minimally invasive decompression in the same incision for type A3 thoracolumbar burst fracture has satisfactory effectiveness. And it has the advantages of minimal trauma, quick recovery, safeness, and reliableness.
Objective To evaluate the effectiveness and the value of balloon kyphoplasty in treating aged osteoporosis thoracolumbar vertebrae burst fracture. Methods Between January 2003 and January 2008, 36 thoracolumbar vertebrae burst fracture patients were treated. There were 15 males and 21 females with an average age of 65.4 years (range, 59-72 years). Fourteen cases had no obvious history of trauma, 19 had a history of sl ight trauma, and 3 had a history of severe trauma. Forty vertebral bodies were involved, including 1 T7, 3 T9, 8 T10, 10 T12, 9 L1, 7 L2, and 2 L4. All patients displayed local pain and osteoporosis by bone density measurement with no neurological symptom of both lower limbs. Balloon kyphoplasty through unilateral (31 cases) or bilateral (5 cases) vertebral pedicles with polymethylmethacrylate was performed at the injection volume of (3.46 ± 0.86) mL per vertebral body. Before and after operation, the anterior height and posterior height of fractured vertebral body and the sagittal displacement were measured. Results Two cases had intraoperative cerebrospinal fluid leakage; 1 case had no remission of waist-back pain and pain was released after symptomatic treatment. All 36 patients were followed up 2.3 years on average (range, 1.5-4.0 years). No cement leakage was found with good diffusion of cement on X-ray film. The restoration of the height of vertebral bodies was satisfactory without nerve compression symptoms and other compl ications. The Visual Analogue Score at last follow-up (2.34 ± 1.03) was significantly lower than that of preoperation (6.78 ± 1.21), (P lt; 0.05). The compressive percentage of anterior height (19.80% ± 1.03%) of fractured vertebral body after operation was significantly lower than that before operation(25.30% ± 2.50%), (P lt; 0.05). There was no significant difference in posterior compressive percentage and sagittal displacement between pre- and post- operation (P gt; 0.05). Conclusion Based on roentgenographic scores, balloon kyphoplasty is selectively used to treat aged osteoporosis thoracolumbar vertebrae burst fracture, and the radiographic and cl inical results were satisfactory.
Objective To evaluate the method of the allogenous boneplate reconstructing the spinal channel and grafting in treatment of thoracolumbar burst fracture with paraplegia. Methods Thirty-six patients with thoracolumbar burst fracture with paraplegia were included in this study. Their ages ranged from 18 to 56 (average, 38). The vertebral injury involvedT11 in 3 patients，T12 in 10 patients，L1 in 14 patients，L2 in 7 patients，and L3 in 2 patients. Neurological deficits were classified by the Frankel grading. There were 9 patients in grade A, 11 patients in grade B, 13 patients in grade C, and 3 patients in grade D. All the patients were treatedwith the anterior approach, decompression of the spinal channel, interbody graft, and internal fixation. The grafting materials consisted of the allogenous femoral bone plate that was degreased in advance and implanted in the intervertebral posterior region, with cut ribs and bone mills during the decompression. Results Postoperative CT scanning showed clearance of the spinal cord compression and expansion of the spine channel. During the follow-up period averaged 2 years, almost all the patients showed an improvement in the neurological function. Spinal fusion occurred in 32 patients. There was no screw loosened or broken. Only 1 patient failed to achieve the fusion. Conclusion The anterior approach, allograft bone plate reconstructing the spine channel is a safe and effective method in treatment of the thoracolumbar burst fracture with paraplegia, which may be a replacement of the autogenous illiac bone graft.
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.