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Abstract
Objectives
To understand the necessity of additional posterior decompression when treating a patient with posterior fusion for thoracolumbar fractures with a neurologic deficit.
Summary of Literature Review
Additional posterior decompression is still controversial when treating a patient with posterior fusion for thoracolumbar fractures with neurologic a deficit.
Materials and Methods
40 patients who underwent posterior fusion surgery for thoracolumbar fractures with a neurologic deficit were evaluated. The posterior fusion group (Group 1) included 23 patients (M:F=14:9), and the posterior decompression with laminectomy and posterolateral fusion group (Group 2) included 17 patients (M:F=9:8). According to the Frankel grade, the most common neurologic deficit was grade D in both groups. Unstable burst fractures were the most commonly observed fractures in both groups according to the McAfee classification. A radiographic evaluation was carried out along with a comparison of the spinal canal encroachment and the kyphotic angle. We evaluated neurologic improvement as the clinical criterion.
Results
The l-kyphotic angle at last follow-up was smaller than the preoperative kyphotic angle in both groups. The preoperative canal encroachment was 53.4% (Group 1) and 59.8% (Group 2). Further, neurologic improvement was observed in 19 cases (Group 1) and 14 cases (Group 2). There was no significant difference in the proportion of cases with neurologic improvement between the two groups (improvement in 19 cases in Group 1 and in 14 cases in Group 2) (p<0.05). Further, the preoperative canal encroachment, kyphotic angle, and final neurologic improvement showed no significant correlations between the two groups (p>0.05).
REFERENCES
1. Zdeblick TA, Sasso RC, Vaccaro AR, Chapman JR, Har-ris MB. Surgical treatment of thoracolumbar fractures. Instr Course Lect. 2009; 58:639–44.
2. Mohanty SP, Venkatram N. Does neurological recovery in thoracolumbar and lumbar burst fractures depend on the extent of canal compromise? Spinal Cord. 2002; 40:295–9.
3. Frankel HL, Hancock DO, Hyslop G, et al. The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. I. Paraple-gia. 1969; 7:179–92.
4. Rath SA, Kahamba JF, Kretschmer T, Neff U, Richter HP, Antoniadis G. Neurological recovery and its influencing factors in thoracic and lumbar spine fractures after surgical decompression and stabilization. Neurosurg Rev. 2005; 28:44–52.
5. Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S. A comprehensive classification of thoracic and lumbar injuries. Eur Spine J. 1994; 3:184–201.
6. Harrington RM, Budorick T, Hoyt J, Anderson PA, Tencer AF. Biomechanics of indirect reduction of bone retropulsed into the spinal canal in vertebral fracture. Spine (Phila Pa 1976). 1993; 18:692–9.
7. Bradford DS, McBride GG. Surgical management of thoracolumbar spine fractures with incomplete neurologic deficits. Clin Orthop Relat Res. 1987. 201–16.
8. Hu SS, Capen DA, Rimoldi RL, Zigler JE. The effect of surgical decompression on neurologic outcome after lumbar fractures. Clin Orthop Relat Res. 1993. 166–73.
9. Bohlman HH, Eismont FJ. Surgical techniques of anterior decompression and fusion for spinal cord injuries. Clin Orthop Relat Res. 1981. 57–67.
10. McAfee PC, Bohlman HH, Yuan HA. Anterior decompression of traumatic thoracolumbar fractures with incomplete neurological deficit using a retroperitoneal approach. J Bone Joint Surg Am. 1985; 67:89–104.
11. Handel SF, Twiford TW Jr., Reigel DH, Kaufman HH. Posterior lumbar apophyseal fractures. Radiology. 1979; 130:629–33.
12. Lindahl S, Willen J, Irstam L. Computed tomography of bone fragments in the spinal canal. An experimental study. Spine (Phila Pa 1976). 1983; 8:181–6.
13. Benson DR. Unstable thoracolumbar fractures, with emphasis on the burst fracture. Clin Orthop Relat Res. 1988. 14–29.
14. Mimatsu K, Katoh F, Kawakami N. New vertebral body impactors for posterolateral decompression of burst fracture. Spine (Phila Pa 1976). 1993; 18:1366–8.
15. McAfee PC, Yuan HA, Lasda NA. The unstable burst fracture. Spine (Phila Pa 1976). 1982; 7:365–73.
16. Muralidhar BM, Hegde D, Hussain PS. Management of unstable thoracolumbar spinal fractures by pedicle screws and rods fixation. J Clin Diagn Res. 2014; 8:121–3.
17. Huler RJ. Thoracolumbar spine fracture. (in. Frmoyer JW, editor. The adult spine-principles and practice 2nded. Place, Published: Lippincott-Raven;1997. p. 1473. ).
18. Lee CS, Choi JS, Kim YC, et al. Survival analysis of posterior short fusion in thoracolumbar fracture; Significance of load sharing score and bone mineral density. J Kor Spine Surg. 2001; 8:113–9.
19. Starr JK, Hanley EN Jr. Junctional burst fractures. Spine (Phila Pa 1976). 1992; 17:551–7.
20. Benson DR, Burkus JK, Montesano PX, Sutherland TB, McLain RF. Unstable thoracolumbar and lumbar burst fractures treated with the AO fixateur interne. J Spinal Disord. 1992; 5:335–43.
21. Gertzbein SD, Court-Brown CM, Marks P, et al. The neurological outcome following surgery for spinal fractures. Spine (Phila Pa 1976). 1988; 13:641–4.
22. Oner FC, Wood KB, Smith JS, Shaffrey CI. Therapeutic decision making in thoracolumbar spine trauma. Spine (Phila Pa 1976). 2010; 35:S235–44.
23. Reinhold M, Knop C, Beisse R, et al. Operative treatment of traumatic fractures of the thoracic and lumbar spinal column. Unfallchirurg. 2009; 112:294–316.
Fig. 1.
A 43-year-old male patient with an L2 flexion-distraction injury and Frankel grade C neurologic deficit. Preoperative X-ray and sagittal and axial computed tomography (CT) images showed a 40% canal compromise, and magnetic resonance imaging (MRI) showed neural compression and L1–2 interspinous ligament rupture (A– D). After posterior instrumentation and fusion, the X-ray showed fracture reduction (E) and the axial CT image showed an 18% canal compromise (F). The 1.5-year follow-up X-ray (G) showed that the patient's neurologic deficit improved to Frankel grade D.
Fig. 2.
A 52-year-old female patient with a T12, L2 unstable burst fracture, and Frankel grade C neurologic deficit. Preoperative X-ray and sagittal and axial CT images showed a T12: 70%, L2: 80% canal compromise, and MRI showed neural compression and posterior ligament complex injury (A–E). After posterior decompression and fusion, X-ray showed fracture reduction (E) and the axial CT image showed canal decompression (F– H). The 2-year follow-up X-ray (I) showed that the patient's neurologic deficit had improved to Frankel grade D.
Table 1.
Summarized data on thoracolumbar fracture with neurologic deficit.
Table 2.
Changes of kyphotic angle(°) between two group.
| Pre-op(°) | Impo∗(°) | Last follow up(°) | p-value | |
|---|---|---|---|---|
| Group A | 22.1(17∼35) | 2.5(0∼6) | 3.3(0∼7) | <0.05 |
| Group B | 24.5(19∼38) | 1.6(0∼5) | 2.0(0∼6) | <0.05 |
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