Objective To evaluate the cl inical outcomes of anterior decompression, bone graft and internal fixation in treating fourth lumbar burst fractures with il iac fenestration. Methods From February 2001 to May 2006, 8 cases of fourth lumbar burst fractures were treated by anterior decompression, correction, reduction, il iac autograft, Z-plate internal fixation with il iac fenestration. Of them, there were 7 males and 1 female, aging 24-46 years with an average of 29.3 years, including 3 cases of Denis type A and 5 cases of Denis type B. The decompression, intervertebral height were compared betweenpreoperation and postoperation by CT scanning. According to Frankel assessment for neurological status, 2 cases were at grade C, 5 at grade D and 1 at grade E before operation. Four cases had different degrees of disturbance of sphincter. Time from injury to operation was 8 hours to 11 days. The preoperative height of the anterior border of the L4 vertebral body was (13.8 ± 2.3) mm, the Cobb angel of fractured vertebral body was (13.2 ± 2.5)°, the vertebral canal sagittal diameter of L4 was (10.6 ± 3.5) mm. The bone graft volume was (7.5 ± 1.3) cm3 during operation. Results Operations were performed successfully. The mean operative time was (142 ± 25) minutes and the mean amount of blood loss was (436 ± 39) mL. The incisions obtained heal ing by first intention after operation. Two cases suffered donor site pain and recevied no treatment. The follow-up time of 8 cases was from 21 months to 52 months (mean 24.5 months). At one week after operation, the height of the anterior border of the L4 vertebral body was (32.5 ± 2.6) mm, the Cobb angel of fractured vertebral body was (6.8 ± 3.7)°, and the vertebral canal sagittal diameter of L4 was (19.8 ± 5.1) mm, showing significant difference when compared with those of preoperation (P lt; 0.01). At the final follow-up, the results showed that the pressure was reduced sufficiently, all autograft fused well, the neurological status improved at Frankel grade from C to D in 1 patient, from D to E in 3 patients, but the others had no improvement. In 4 patients who had disturbance of sphincter, 3 restored to normal and 1 was better off. Conclusion Cl inical outcomes of anterior surgery for fourth lumbar burst fractures with il iac fenestration are satisfactory. It can facil icate operation, reduce the pressure sufficiently, maintenance intervertebral height and recover the neurological function.
ObjectiveTo compare the effective of short-segment pedicle instrumentation with bone grafting and pedicle screw implanting in injured vertebra and cross segment pedicle instrumentation with bone grafting in injured vertebra for treating thoracolumbar fractures. MethodsA prospective randomized controlled study was performed in 40 patients with thoracolumbar fracture who were in accordance with the inclusive criteria between June 2010 and June 2012. Of 40 patients, 20 received treatment with short-segment pedicle screw instrumentation with bone grafting and pedicle screw implanting in injured vertebra in group A, and 20 received treatment with cross segment pedicle instrumentation with bone grafting in injured vertebra in group B. There was no significant difference in gender, age, affected segment, disease duration, Frankel grade, Cobb angle, compression rate of anterior verterbral height, visual analogue scale (VAS) score, and Japanese Orthopaedic Association (JOA) score between 2 groups before operation (P>0.05). The operation time, blood loss, Cobb angle, compression rate of anterior vertebral height, loss of disc space height, Frankel grade, VAS and JOA scores were compared between 2 groups. ResultsThere was no significant difference in the operation time and blood loss between 2 groups (P>0.05). Primary healing of incision was obtained in all patients, and no early complication of infection or lower limb vein thrombus occurred. Forty patients were followed up 12-16 months (mean, 14.8 months). No breaking or displacement of internal fixation was observed. The improvement of Frankel grading score was 0.52±0.72 in group A and 0.47±0.63 in group B, showing no significant difference (t=0.188, P=0.853) at 12 months after operation. The Cobb angle, compression rate of anterior verterbral height, and VAS score at 1 week and 12 months, and JOA score at 12 months were significantly improved when compared with preoperative ones in 2 groups (P<0.05). No significant difference was found in Cobb angle, disc space height, VAS score, and JOA score between 2 groups at each time point (P>0.05), but the compression rate of anterior verterbral height in group A was significantly lower than that in group B (P<0.05). The loss of disc space height next to the internal fixation or the injured vertebra was observed in 2 groups at 12 months, but showing no significant difference (P>0.05). ConclusionCompared with cross segment pedicle instrumentation, short-segment pedicle screw instrumentation with bone grafting and pedicle screw implanting in injured vertebra can recover and maintain the affected vertebra height in treating thoracolumbar fractures, but it could not effectively prevent degeneration of adjacent segments and the loss of kyphosis correction degree.
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 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 explore an improved surgical approach to the superior posterior partial resection of the fractured vertebral body followed by the single segmental fusion to treat lumbar burst fracture and to evaluate its preliminary clinical application. Methods From June to October 2006, 4 patients (2 males, 2 females; age, 17-39 years) with Denis B type lumbar burst fracture underwent the superior posterior partial resection of the fractured vertebral body followed by the single segmental fusion. The fracture occurred in 2 patients at L1 and 2 at L2. According to the Frankel scales assessment, before operation, 2patients were at Grade B and the other 2 at Grade C, and the visual analogue scale (VAS) was 7.00±0.82. Radiological evaluation was performed, which revealed the kyphosis Cobb angel of 22.94±11.21°, the adjacent superior and the inferiorintervertebal disc heights of 12.78±1.52 mm and 11.68±1.04 mm, espectively, and the vertebral canal sagittal diameter of 9.56±2.27 mm on the computer tomography (CT) scan. The neurological and the radiological evaluations were also made immediately and 3 months after operation. Results The anterior single segmental decompression and fusion operations were performed successfully in all the patients. The average operating time was 166±29 min and the average amount of blood loss was 395± 54 ml. The Frankel scales assessment showed that at the time immediately after operation, one of the 2 Grade B patients had an improvement to Grade C, but the other patient had no improvement. One of the 2 Grade C patientshad an improvement to Grade D, but the other patient had no improvement. Three months after operation, the 2 Grade B patients had an improvement to Grade C. The 2 grade C patients had an improvement to Grade D or E. The VAS score was significantly decreased to 3.50±1.29 after operation and to 1.25±0.50 3 months later （P＜0.05）. The vertebral canal sagittal diameter was significantly increased to 19.76±3.82 mm (Plt;0.01), but it was maintained to 19.27±3.41 mm3 months later, with no significant difference（Pgt;0.05）. The patients’ kyphosis Cobb angle was significantly improved to 8.71±5.41° (P＜0.05) , but it was maintained to 9.52±5.66° 3 months later, with no significant difference（Pgt;0.05）. The heights of the adjacent discs remained unchanged. No complication was observedduring and after operation, and the radiological and the CT scanning evaluations 3 months later showed no failure of the internal fixation. Conclusion The superior and posterior partial resection of the fractured vertebral body followedby the single segmental fusion can effectively decompress the vertebral canal and maintain the spine stability in treatment of the Denis B type fracture thoughthe longterm effectiveness requires a further follow-up.
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 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.
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。