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Anterior stabilization for unstable traumatic thoracolumbar spine burst fractures
Clinical Neurology and Neurosurgery 130 (2015) 86–90
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Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro
Anterior stabilization for unstable traumatic thoracolumbar spine burst fractures Shihao Zhang a , Jai Deep Thakur a , Imad Saeed Khan b , Richard Menger a , Sunil Kukreja a , Osama Ahmed a , Bharat Guthikonda a , Donald Smith a , Anil Nanda a,∗ a b
Department of Neurosurgery—Louisiana State University Health Science Center, Shreveport, USA Department of Neurosurgery—Dartmouth-Hitchcock Medical Center, Lebanon, USA
a r t i c l e
i n f o
Article history: Received 26 September 2014 Received in revised form 16 October 2014 Accepted 28 October 2014 Available online 5 November 2014 Keywords: Thoracolumbar fracture Anterior approach Stabilization Burst fracture Unstable fracture
a b s t r a c t Background: Traumatic injuries to the thoracolumbar spine result in a high incidence of unstable fractures. The goal of the surgical management is to achieve an adequate decompression and stabilization. We have analyzed operative and postoperative features of anterior surgical approaches. Methods: We retrospectively analyzed the medical records of 45 patients that presented with traumatic unstable thoracolumbar fractures who underwent anterior corpectomy with stabilization from January 1999 to January 2009. The neurological status of the patient was defined using the American Spinal Injury Association (ASIA) impairment scale. Results: The average age of the patients was 37.6 years (range: 13–70), with a male-to-female ratio of 1.5:1. Retroperitoneal approach was used in 64.4%, transthoracic in 13.3%, and transthoracic transdiaghragmatic in 22.2%. The average operation time, estimated blood loss (EBL), and length of stay after surgery was 412.3 min, 1098 ml and 9.1 days, respectively. A BMI > 25 was associated with longer operative times (p < 0.02) and higher EBL (p < 0.006). Perioperative complications occurred in 37.7%, (7 major, 10 minor). The mean sagittal angulation improved from 15.5 degree preoperatively to 8.7 degree postoperatively (p < 0.001). Postoperative neurological status remained intact in all patients having preoperative ASIA-E status (n = 18), improved in 7 of 14 patients with ASIA-D, and improved in 1 of 5 patients with ASIA-B preoperative neurological deficit. There were no cases of neurological deterioration postoperatively, and majority of the patient (84.4%) of the patients were discharged home. At latest follow-up (mean 27.2 months) there were no new cases of neurological deficits, and 9 patients had a further improvement of neurological status. Conclusions: Based on our findings, anterior surgical approach appears to be a safe and effective technique for managing traumatic thoracic and lumbar unstable burst fractures. This is also evident that anterior decompression and stabilization achieves a significant correction of kyphotic deformity with a lower risk of neurological deterioration and pseudoarthrosis. © 2015 Published by Elsevier B.V.
1. Introduction Traumatic spinal fractures are one the most frequent types of injuries in the thoracolumbar region [1]. This area transitions from the rigid, kyphotic thoracic spine to the more mobile, lordotic lumbar spine [2]. Burst fractures are described as compression fractures of the anterior and middle columns with retropulsion of bony fragments into the spinal canal [3,4]. These unstable fractures account for 10–20% of all spine injuries at the thoracolumbar junction [3,5].
∗ Corresponding author. Tel.: +1 318 675 6404; fax: +1 318675 6867. E-mail address: [email protected] (A. Nanda). http://dx.doi.org/10.1016/j.clineuro.2014.10.020 0303-8467/© 2015 Published by Elsevier B.V.
Burst fractures often cause neurological deficits, as well as, kyphotic deformity. Optimal treatment remains controversial; however, the goal of treatment remains to improve neurological function, restore kyphotic deformity, and stabilize the fracture [6]. Posterior indirect and direct decompression, anterior decompression, and combined anteroposterior approaches are available surgical treatments [7]. Posterior fixation with pedicle screws segmental instrumentation provides rigid fixations, but canal decompression is often incomplete and limited. Also posterior fixation requires the inclusion of additional adjacent normal levels in order to provide stability and prevent late increases in deformity. Combined anteroposterior approach provides adequate canal decompression with rigid fixations. However, the long operative time and high blood loss
S. Zhang et al. / Clinical Neurology and Neurosurgery 130 (2015) 86–90
increase the risk of surgical morbidity [8]. On the contrary; several authors advocated stand-alone anterior approaches to achieve a direct spinal cord decompression, an effective restoration of sagittal angulation and good functional outcomes [7,9]. The objective of this study was to review our experience with single-stage, anterior decompression with fixation for treatment of unstable traumatic thoracic and lumbar burst fracture. 2. Materials and methods Between 1999 and 2009, all patients who sustained traumatic burst fractures in spine were reviewed. Forty five patients with burst fractures of the thoracolumbar junction were treated with anterior decompression and fusion at Louisiana State University Health Science Center-Shreveport. The procedures were performed by three attending neurosurgeons. The causes of injury were as followed: 26 motor vehicle accidents, 17 falls, and 2 motorcycle accidents. 3. Inclusion criteria Patients with thoracolumbar burst fractures with incomplete neurological injuries that were treated with anterior decompression and fixation were included in this study. Also patients with no neurological deficits but with radiological evidence of mechanical instability were included. Radiological instability consists of one or more of the following: (1) 50% or more loss of vertebral body height as measured on lateral radiography (2) More than 20 degree of kyphosis and (3) greater than 40% of canal compromise as seen on axial CT scan [10,11]. Electronic medical records, operative notes, follow-up clinical notes and radiographic studies were obtained after clearance from the Human Subjects Committee at the Louisiana State University Health Science Center in Shreveport. Data on age, gender, body mass index (BMI), level of injury, kyphotic deformity (both preoperatively and immediately postoperatively), intraoperative blood loss, neurological function (preoperatively and at final follow up), fusion rate, and complications were obtained. Patients with American Spinal Injury Association (ASIA-A) classification, with no motor or sensory functions, are not managed from the anterior approach at our center, thus were excluded from the study. 3.1. Radiographic analysis Pre-operative and immediate post-operative anteroposterior and lateral radiographs were obtained in all patients. Axial CT scans were used to determine the extent of canal compression. The height of vertebral body and Cobb angle were measured on lateral radiographs. The Cobb angle was used to determine the degree of kyphotic deformity and was measured between the inferior endplate of the intact vertebral body above and the superior endplate of the intact vertebral body below [1]. Bony fusion was determined radiographically by two or more of the following: (1) bony formation spanning the disc spaces within the instrumented area (2) no movement on flexion and extension lateral radiographs and (3) solid bony fusion involved the vertebral segment and the adjacent vertebral bodies [8]. 3.2. Clinical outcomes The operation time, estimated blood loss, time of hospital stay, and complications of the operation were evaluated for each patient. The neurological status of the patient was defined using the ASIA impairment scale.
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3.3. Operative technique Left side anterolateral approach (transthoracic or retroperitoneal) was used to expose the fractured vertebrae in all patients. Single level subtotal corpectomy was performed to completely decompress the spinal canal. The dura was visualized from the craniocaudal retraction of the fractured vertebrae and mediolateral retraction from one pedicle to the other. As per the surgeon’s preference, titanium-mesh cage packed with local autograft from fractured vertebrae was used for reconstruction of the spine. Intraoperative fluoroscopy is essential in confirming cage placement and anterior instrumentation with screws and plates.
3.4. Postoperative evaluation Patients were seen at 2 weeks, 3 months, 6 months and 1-year postoperative period. Fusion was assessed with plain radiographs at 3 and 6 months. Patients with persistent pain, progressive kyphosis and having ambiguous fusion status on plain radiographs, were evaluated with CT scan.
3.5. Statistical methods We measured the continuous variable means by using Student ‘t’ test. Associations of two categorical variables were defined by using Pearson chi-square or Fisher exact test as appropriate. IBM SPSS.21 was used for statistical analysis and the p valve < 0.05 was considered to be statistical significance.
4. Results From January 1999 to January 2009, a total of 45 patients sustained a single level thoracolumbar burst fracture underwent an anterolateral approach for decompression and fixation. The mean age of the patients was 37.6 years (range: 13–70), with a male-tofemale ratio of 1.5:1. Retroperitoneal approach was used in 64.4%, transthoracic in 13.3%, and transthoracic transdiaphragmatic in 22.2%. The average operation time, estimated blood loss (EBL) and length of stay after surgery was 412.3 min, 1098.2 ml and 9.1 days, respectively. A BMI > 25was associated with longer operative times (p < 0.02) and higher EBL (p < 0.006). Mean hematocrit of the patients decreased from 32.75 to 27.17 (p = 0.059). There were no cases of neurological deterioration postoperatively. Eighteen patients who were neurologically ASIA-E remained intact after surgery. Thirteen of the 27 patients (48%) with incomplete injuries improved in their neurological exam by time of discharge from the hospital. At latest follow-up (mean: 27.2 months) none of the patients developed neurological deterioration and there were no new onset of neurological deficits. Out of the 27 patients that had neurological deficits, at final follow up 22 (82%) patients had neurological improvement compared to preoperative status (Fig. 1).
4.1. Radiographic results Forty-three out of 45 (96%) patients had stable construct and fusion at last follow up. One patient required posterior fixation for additional stability. We compared the preoperative vs. postoperative Cobb angle to measure the kyphotic variable. The mean preoperative Cobb angle was 15.5 degrees and postoperative was 8.7 degrees (p < 0.001), which indicated significant improvement in the degree of spinal kyphosis postoperatively.
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Fig. 1. 48% patients with incomplete injuries improved in their neurological exam by time of discharge from the hospital and at latest follow-up (mean: 27.2 months) 82% patients had neurological improvement compared to preoperative status.
Fig. 2. Pie chart representing spectrum of complications through anterior approach corpectomy.
4.2. Complications Twelve patients developed some form of perioperative complication. There were no mortalities and no incidences of increased neurological deficits in any of those patients. No intraoperative or late vascular injuries were noted. Two patients demonstrated on radiographic imaging evidence of minor graft movement that did not progress. Dural tear occurred in two cases. Other perioperative complications include one case of pulmonary embolism, one deep vein thrombosis, one urinary tract infection, three superficial wound infections treated with antibiotics, ileus, left diaphragm tear with pneumothorax, and pneumomediastinum (Fig. 2). 5. Discussion Operative approaches for thoracolumbar burst fractures remain controversial [1,4,7,8,12–17]. A review of literature shows many different views on treatment of those types of fractures. The goal of surgical treatment is to improve neurological function, prevent worsening of neurological deficits, decompress the spinal canal, restore vertebral body height, correct the kyphotic deformity, and
facilitate mobilization and rehabilitation. Surgical options include anterior, posterior or combined anterior–posterior approaches to the vertebral body fractures. Anterolateral approach offers direct decompression of the spinal canal and improved spinal kyphotic deformity correction compared to posterior instrumentation [7]. The placement of allograft and anterior instrumentation allows for direct reconstruction of the spinal column and fusion of the column, thus limiting the number of motion segment to be fused. Posterior instrumentation usually requires pedicle screws 2 levels above and below the fracture with fusion rate of around 90% [18]. Short segment posterior instrumentation remains controversial. Tezeren and Kuru reported that 5 out of 9 patients treated with short segment posterior instrumentation in a randomized controlled trial had a correction loss of 10 degrees and 55% failure rate [19]. In our study, only 2 of the 45 patients did not fuse on follow-up, for a fusion rate of 96%. Compared to posterior fixation, several investigators have shown improved kyphosis correction and maintenance of the correction with the anterolateral approach [7,14,17,20]. In thoracolumbar fractures, neurological deficits are usually caused by the impact of trauma as well as compression to the ventral surface of the spinal cord [1]. Anterolateral approach provides direct visualization of the ventral spinal cord during surgical decompression. The studies that directly compare anterior and posterior approaches are relatively few. Esses et al. [5] reported a randomized prospective comparison of these two approaches in 40 patients with a 20 month follow-up. There was no difference in restoring normal sagittal contour. There were 2 implant failures and statistically significant higher blood loss in the anterior surgery group. No functional outcome data were analyzed in that study. Wood et al. [21] performed a randomized prospective comparison of these two approaches in 38 patients with 2 year clinical follow-up. Again, surgical blood loss was higher in the anterior group. Patient outcome and radiographic analysis were equivocal in the two groups but had less complication in the anterior decompression and fixation group. Some studies have shown higher postoperative kyphotic correction and improvement of vertebral height in the combined anterior–posterior approach [15,22]. However, the combined anterior–posterior surgery is associated with higher operative time and blood loss, without an increase improvement in neurological function recovery, fusion healing, pain relief, or work status when compared to anterior surgery or posterior surgery [8,15,23]. These results indicate that there is no advantage of combined procedure since there are better and more cost-effective treatments for unstable thoracolumbar spine fractures. Initially, anterolateral approach for decompression without instrumentation and reconstruction with simple anterior strut had a variable rate of pseudoarthrosis, from 10 to 100% [20,24]. Advancement in anterior thoracolumbar instrumentation, with high rate of fusion, has led to single stage anterolateral decompression and reconstruction as treatment for unstable thoracolumbar fractures. Kostuik [25] reported a series of 49 patients with burst fractures, of which 25 patients underwent anterior decompression and instrumentation. There were no instances of pseudoarthrosis and good clinical outcome with average 1.6 Frankel grade neurological improvement. Kaneda et al. [26] reported 150 patients with thoracolumbar burst fracture and associated neurological deficits that were managed with single-stage anterior spinal decompression, strut graft, and instrumentation. At eight year follow-up, 93% of patients showed successful fusion on radiograph. They also report mean kyphotic deformity correction from 19 degrees to 7 degrees postoperatively without significant loss at last followup. Ninety-five percent of patients have at least one Frankel grade improvement in their neurological function. Sasso et al. [7] reviewed stand-alone single-stage anterior surgical management of three-column thoracolumbar injuries in 39 patients and they
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Table 1 Review of previous reports on anterior approach and stabilization for thoracolumbar fractures. Reference
Number of cases
Mean age (years)
Follow-up y—years m—months
Partial neurological deficit (n)
Neurological improvement (n)
Angle of kyphosis correction Preop/Postop
Fusion rate (%)
40 37 57 20 9 71%
Not specified Not specified Not specified Not specified −/5◦ Loss of correction 7◦ 22◦ /11◦
93.7 ? 97.5 95.9 100 100
26◦ /14.5◦ 27.5◦ /12◦ 19◦ /7◦ 32◦ /11◦ 31◦ /13◦
92 100 93.0 100 91.6
16.8◦ /2.9◦ Not specified 20◦ /6.6◦
96 Not recorded 100
10.5◦ /5◦
95
22.7◦ /7.4◦ Not specified 24.6◦ /17.1◦ (T) 10.6◦ /13.6◦ (L) Not specified 24.2◦ /5.2◦
95 85 92.8
15.5◦ /8.7◦
96
Dunn [38] MacAfee et al. [32] Kostuik [30] Transfeldt et al. [36] Been [22] Haas et al. [29]
48 70 80 49 29 39
26 34 32 35 30.1 28
Not specified 3.4 y (2–8.6 y) Not specified 1–19 y 3.1 y Not specified
Okuyama et al. [33]
19
46
54 m (24–94 m)
40 42 57 43 10 19 grades A/B and 20 grades No deficit
25 15 150 36 12
32 26 39 36.7 43
2y 2y 8 y (5–12 y) 42 m (24–84 m) 22 m (12–30 m)
5 5 148 26 3 Frankel D
25 45 20
34.4 44 43.3
16 m (7–29 m) Not specified 15 m
17 Not specified No deficit
39
42.3 m
No deficit
37.4/40.2* 36 40.3
31.1 m 4 m–6 y 24 m
37 27% 7
16 Not specified No deterioration No deterioration 33 13/20 5
20/80 32/64
50.6 37.8
16.2 m 46.5 m
45
37.6
27.2 m
11 24.5 (Preop ASIA score) 27
7 24.0 (Postop ASIA score) 13
Van Loon et al. [37] Van Loon et al. [37] Kaneda et al. [26] Carl et al. [28] Ghanayem and Zdeblic [20] Schnee and Ansell [34] Schultheiss et al. [35] Madi et al. [31] Wood et al. [21] Sasso et al. [7] Beisse [27] Sasani et al. [4] Lu et al. [23] Lin et al. [1]
20/38 40 220 14
Our study *
No deterioration 5 3 142 26 3 Frankel E
100
Not specified Not specified
Average age for male/female.
reported kyphosis correction from 22.7 degree kyphosis preoperatively to mean of 7.4 degree kyphosis postoperatively with 94% stable construct at last follow up. On similar lines, our study showed significant improvement of kyphosis post-operatively. The results of previous reports on anterior approach for thoracolumbar fracture are summarized in Table 1 [1,4,7,20–23,26–38]. Our study has shown that anterolateral approach is a safe and effective method for treatment for traumatic thoracic and lumbar burst fractures. In our study, no neurological deterioration occurred postoperatively. Thirteen out of 27 patients
(48%) had improvement of at least one ASIA grade on hospital discharge. At final clinical follow-up, 22 patients (82%) had improvement in their neurological function. This is consistent with what is reported in literature. Since neurological deficit is due to ventral compression, direct visualization provides optimal decompression of spinal canal (Fig. 3). Preoperative mean degree of kyphosis was 15.5 which corrected to a mean postoperative 8.7 degrees. The overall improvement of sagittal angulation was improved significantly from preoperative measurements (p < 0.0001).
Fig. 3. A 55 year old male sustained a motor vehicular accident. MRI shows (A) a highly unstable L2 burst fracture with a retropulsed fragment compressing over the spinal cord anteriorly. (B) Immediate postoperative CT scan shows anterior stabilization with restoration of vertebral height and lumbar lordosis. (C) Postoperative CT myelogram reveals an effective decompression achieved. The patient’s neurological status improved from ASIA-D to ASIA-E following the surgery.
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The stand-alone anterior instrumentation allows a shorter motion segment of the spine to be fused compared to long posterior fusion of two levels above and below the fractured vertebrae. Short segment posterior fusion and decompression is another surgical option for thoracic and lumbar burst fractures that also limits the motion segments that are fused. Studies do report a higher rate of construct failure with this approach [7,14,39]. Our study indicates that single level corpectomy with two segment instrumentation was stable with only two patients showing pseduoarthrosis on radiograph imaging at clinical follow up. Only one patient required additional posterior instrumentation for failing anterior construct. Retrospective nature of the study and inclusion of anterior only approaches are the main limitations of this study. 6. Conclusion Anterior surgical approach appears to be a safe and effective technique for managing traumatic thoracic and lumbar unstable burst fractures. Anterior stabilization techniques allow spinal cord decompression under direct visualization and provide a stable fracture construct with incorporation of less motion segments. This is also evident that anterior decompression and stabilization achieves a significant correction of kyphotic deformity with a lower risk of neurological deterioration and pseudoarthrosis. References [1] Lin B, Chen ZW, Guo ZM, Liu H, Yi ZK. Anterior approach versus posterior approach with subtotal corpectomy, decompression, and reconstruction of spine in the treatment of thoracolumbar burst fractures: a prospective randomized controlled study. J Spinal Disord Tech 2011. [2] Zhang S, Wadhwa R, Haydel J, Toms J, Johnson K, Guthikonda B. Spine and spinal cord trauma: diagnosis and management. Neurol Clin 2013;31:183–206. [3] Denis. Spinal instability as defined by the three-column spine concept in acute spinal trauma. Clin Orthop Relat Res 1984;189:65–76. [4] Sasani M, Ozer AF. Single-stage posterior corpectomy and expandable cage placement for treatment of thoracic or lumbar burst fractures. Spine (Phila Pa 1976) 2009;34:E33–40. [5] Esses SI, Botsford DJ, Kostuik JP. Evaluation of surgical treatment for burst fractures. Spine (Phila Pa 1976) 1990;15:667–73. [6] Wood KB, Li W, Lebl DS, Ploumis A. Management of thoracolumbar spine fractures. Spine J 2014;14:145–64. [7] Sasso RC, Best NM, Reilly TM, McGuire Jr RA. Anterior-only stabilization of three-column thoracolumbar injuries. J Spinal Disord Tech 2005;18(Suppl.):S7–14. [8] Danisa OA, Shaffrey CI, Jane JA, Whitehill R, Wang GJ, Szabo TA, et al. Surgical approaches for the correction of unstable thoracolumbar burst fractures: a retrospective analysis of treatment outcomes. J Neurosurg 1995;83: 977–83. [9] Kaneda K, Abumi K, Fujiya M. Burst fractures with neurologic deficits of the thoracolumbar–lumbar spine. Results of anterior decompression and stabilization with anterior instrumentation. Spine (Phila Pa 1976) 1984;9: 788–95. [10] Boerger TO, Limb D, Dickson RA. Does ‘canal clearance’ affect neurological outcome after thoracolumbar burst fractures? J Bone Joint Surg Br 2000;82:629–35. [11] Petersilge CA, Emery SE. Thoracolumbar burst fracture: evaluating stability. Semin Ultrasound CT MR 1996;17:105–13. [12] Dai LY, Jiang SD, Wang XY, Jiang LS. A review of the management of thoracolumbar burst fractures. Surg Neurol 2007;67:221–31 (discussion 231). [13] P. Oprel P, Tuinebreijer WE, Patka P, den Hartog D. Combined anterior-posterior surgery versus posterior surgery for thoracolumbar burst fractures: a systematic review of the literature. Open Orthop J 2010;4:93–100.
[14] Parker JW, Lane JR, Karaikovic EE, Gaines RW. Successful short-segment instrumentation and fusion for thoracolumbar spine fractures: a consecutive 41/2-year series. Spine (Phila Pa 1976) 2000;25:1157–70. [15] Payer M, Sottas C. Mini-open anterior approach for corpectomy in the thoracolumbar spine. Surg Neurol 2008;69:25–31 (discussion 31-22). [16] Ragel BT, Kan P, Schmidt MH. Blood transfusions after thoracoscopic anterior thoracolumbar vertebrectomy. Acta Neurochir (Wien) 2010;152:597–603. [17] Sasso RC, Cotler HB. Posterior instrumentation and fusion for unstable fractures and fracture-dislocations of the thoracic and lumbar spine. A comparative study of three fixation devices in 70 patients. Spine (Phila Pa 1976) 1993;18:450–60. [18] McBride GG. Cotrel–Dubousset rods in surgical stabilization of spinal fractures. Spine (Phila Pa 1976) 1993;18:466–73. [19] Tezeren G, Kuru I. Posterior fixation of thoracolumbar burst fracture: shortsegment pedicle fixation versus long-segment instrumentation. J Spinal Disord Tech 2005;18:485–8. [20] Ghanayem AJ, Zdeblick TA. Anterior instrumentation in the management of thoracolumbar burst fractures. Clin Orthop Relat Res 1997;335:89–100. [21] Wood KB, Bohn D, Mehbod A. Anterior versus posterior treatment of stable thoracolumbar burst fractures without neurologic deficit: a prospective, randomized study. J Spinal Disord Tech 2005;18(Suppl):S15–23. [22] Been HD, Bouma GJ. Comparison of two types of surgery for thoraco-lumbar burst fractures: combined anterior and posterior stabilisation vs. posterior instrumentation only. Acta Neurochir (Wien) 1999;141:349–57. [23] Lu DC, Lau D, Lee JG, Chou D. The transpedicular approach compared with the anterior approach: an analysis of 80 thoracolumbar corpectomies. J Neurosurg Spine 2010;12:583–91. [24] Zdeblick TA, Shirado O, McAfee PC, deGroot H, Warden KE. Anterior spinal fixation after lumbar corpectomy. A study in dogs. J Bone Joint Surg Am 1991;73:527–34. [25] Kostuik JP. Anterior fixation for fractures of the thoracic and lumbar spine with or without neurologic involvement. Clin Orthop Relat Res 1984;189:103–15. [26] 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. [27] Beisse R. Endoscopic surgery on the thoracolumbar junction of the spine. Eur Spine J 2006;15:687–704. [28] Carl AL, Tromanhauser SG, Roger DJ. Pedicle screw instrumentation for thoracolumbar burst fractures and fracture-dislocations. Spine (Phila Pa 1976) 1992;17:S317–24. [29] Haas N, Blauth M, Tscherne H. Anterior plating in thoracolumbar spine injuries. Indication, technique, and results. Spine (Phila Pa 1976) 1991;16:S100–11. [30] Kostuik JP. Anterior fixation for burst fractures of the thoracic and lumbar spine with or without neurological involvement. Spine (Phila Pa 1976) 1988;13:286–93. [31] Madi K, Dehoux E, Aunoble S, Le Huec JC. Video-assisted mini-thoracotomy for surgical treatment of thoracolumbar junction fractures. Rev Chir Orthop Reparatrice Appar Mot 2005;91:702–8. [32] 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. [33] Okuyama K, Abe E, Chiba M, Ishikawa N, Sato K. Outcome of anterior decompression and stabilization for thoracolumbar unstable burst fractures in the absence of neurologic deficits. Spine (Phila Pa 1976) 1996;21:620–5. [34] Schnee CL, Ansell LV. Selection criteria and outcome of operative approaches for thoracolumbar burst fractures with and without neurological deficit. J Neurosurg 1997;86:48–55. [35] Schultheiss M, Kinzl L, Claes L, Wilke HJ, Hartwig E. Minimally invasive ventral spondylodesis for thoracolumbar fracture treatment: surgical technique and first clinical outcome. Eur Spine J 2003;12:618–24. [36] Transfeldt EE, White D, Bradford DS, Roche B. Delayed anterior decompression in patients with spinal cord and cauda equina injuries of the thoracolumbar spine. Spine (Phila Pa 1976) 1990;15:953–7. [37] van Loon JL, Slot GH, Pavlov PW. Anterior instrumentation of the spine in thoracic and thoracolumbar fractures: the single rod versus the double rod Slot-Zielke device. Spine (Phila Pa 1976) 1996;21:734–40. [38] Dunn HK. Anterior stabilization of thoracolumbar injuries. Clin Orthop Relat Res 1984:116–24. [39] McLain RF, Sparling E, Benson DR. Early failure of short-segment pedicle instrumentation for thoracolumbar fractures. A preliminary report. J Bone Joint Surg Am 1993;75:162–7.
Contents lists available at ScienceDirect
Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro
Anterior stabilization for unstable traumatic thoracolumbar spine burst fractures Shihao Zhang a , Jai Deep Thakur a , Imad Saeed Khan b , Richard Menger a , Sunil Kukreja a , Osama Ahmed a , Bharat Guthikonda a , Donald Smith a , Anil Nanda a,∗ a b
Department of Neurosurgery—Louisiana State University Health Science Center, Shreveport, USA Department of Neurosurgery—Dartmouth-Hitchcock Medical Center, Lebanon, USA
a r t i c l e
i n f o
Article history: Received 26 September 2014 Received in revised form 16 October 2014 Accepted 28 October 2014 Available online 5 November 2014 Keywords: Thoracolumbar fracture Anterior approach Stabilization Burst fracture Unstable fracture
a b s t r a c t Background: Traumatic injuries to the thoracolumbar spine result in a high incidence of unstable fractures. The goal of the surgical management is to achieve an adequate decompression and stabilization. We have analyzed operative and postoperative features of anterior surgical approaches. Methods: We retrospectively analyzed the medical records of 45 patients that presented with traumatic unstable thoracolumbar fractures who underwent anterior corpectomy with stabilization from January 1999 to January 2009. The neurological status of the patient was defined using the American Spinal Injury Association (ASIA) impairment scale. Results: The average age of the patients was 37.6 years (range: 13–70), with a male-to-female ratio of 1.5:1. Retroperitoneal approach was used in 64.4%, transthoracic in 13.3%, and transthoracic transdiaghragmatic in 22.2%. The average operation time, estimated blood loss (EBL), and length of stay after surgery was 412.3 min, 1098 ml and 9.1 days, respectively. A BMI > 25 was associated with longer operative times (p < 0.02) and higher EBL (p < 0.006). Perioperative complications occurred in 37.7%, (7 major, 10 minor). The mean sagittal angulation improved from 15.5 degree preoperatively to 8.7 degree postoperatively (p < 0.001). Postoperative neurological status remained intact in all patients having preoperative ASIA-E status (n = 18), improved in 7 of 14 patients with ASIA-D, and improved in 1 of 5 patients with ASIA-B preoperative neurological deficit. There were no cases of neurological deterioration postoperatively, and majority of the patient (84.4%) of the patients were discharged home. At latest follow-up (mean 27.2 months) there were no new cases of neurological deficits, and 9 patients had a further improvement of neurological status. Conclusions: Based on our findings, anterior surgical approach appears to be a safe and effective technique for managing traumatic thoracic and lumbar unstable burst fractures. This is also evident that anterior decompression and stabilization achieves a significant correction of kyphotic deformity with a lower risk of neurological deterioration and pseudoarthrosis. © 2015 Published by Elsevier B.V.
1. Introduction Traumatic spinal fractures are one the most frequent types of injuries in the thoracolumbar region [1]. This area transitions from the rigid, kyphotic thoracic spine to the more mobile, lordotic lumbar spine [2]. Burst fractures are described as compression fractures of the anterior and middle columns with retropulsion of bony fragments into the spinal canal [3,4]. These unstable fractures account for 10–20% of all spine injuries at the thoracolumbar junction [3,5].
∗ Corresponding author. Tel.: +1 318 675 6404; fax: +1 318675 6867. E-mail address: [email protected] (A. Nanda). http://dx.doi.org/10.1016/j.clineuro.2014.10.020 0303-8467/© 2015 Published by Elsevier B.V.
Burst fractures often cause neurological deficits, as well as, kyphotic deformity. Optimal treatment remains controversial; however, the goal of treatment remains to improve neurological function, restore kyphotic deformity, and stabilize the fracture [6]. Posterior indirect and direct decompression, anterior decompression, and combined anteroposterior approaches are available surgical treatments [7]. Posterior fixation with pedicle screws segmental instrumentation provides rigid fixations, but canal decompression is often incomplete and limited. Also posterior fixation requires the inclusion of additional adjacent normal levels in order to provide stability and prevent late increases in deformity. Combined anteroposterior approach provides adequate canal decompression with rigid fixations. However, the long operative time and high blood loss
S. Zhang et al. / Clinical Neurology and Neurosurgery 130 (2015) 86–90
increase the risk of surgical morbidity [8]. On the contrary; several authors advocated stand-alone anterior approaches to achieve a direct spinal cord decompression, an effective restoration of sagittal angulation and good functional outcomes [7,9]. The objective of this study was to review our experience with single-stage, anterior decompression with fixation for treatment of unstable traumatic thoracic and lumbar burst fracture. 2. Materials and methods Between 1999 and 2009, all patients who sustained traumatic burst fractures in spine were reviewed. Forty five patients with burst fractures of the thoracolumbar junction were treated with anterior decompression and fusion at Louisiana State University Health Science Center-Shreveport. The procedures were performed by three attending neurosurgeons. The causes of injury were as followed: 26 motor vehicle accidents, 17 falls, and 2 motorcycle accidents. 3. Inclusion criteria Patients with thoracolumbar burst fractures with incomplete neurological injuries that were treated with anterior decompression and fixation were included in this study. Also patients with no neurological deficits but with radiological evidence of mechanical instability were included. Radiological instability consists of one or more of the following: (1) 50% or more loss of vertebral body height as measured on lateral radiography (2) More than 20 degree of kyphosis and (3) greater than 40% of canal compromise as seen on axial CT scan [10,11]. Electronic medical records, operative notes, follow-up clinical notes and radiographic studies were obtained after clearance from the Human Subjects Committee at the Louisiana State University Health Science Center in Shreveport. Data on age, gender, body mass index (BMI), level of injury, kyphotic deformity (both preoperatively and immediately postoperatively), intraoperative blood loss, neurological function (preoperatively and at final follow up), fusion rate, and complications were obtained. Patients with American Spinal Injury Association (ASIA-A) classification, with no motor or sensory functions, are not managed from the anterior approach at our center, thus were excluded from the study. 3.1. Radiographic analysis Pre-operative and immediate post-operative anteroposterior and lateral radiographs were obtained in all patients. Axial CT scans were used to determine the extent of canal compression. The height of vertebral body and Cobb angle were measured on lateral radiographs. The Cobb angle was used to determine the degree of kyphotic deformity and was measured between the inferior endplate of the intact vertebral body above and the superior endplate of the intact vertebral body below [1]. Bony fusion was determined radiographically by two or more of the following: (1) bony formation spanning the disc spaces within the instrumented area (2) no movement on flexion and extension lateral radiographs and (3) solid bony fusion involved the vertebral segment and the adjacent vertebral bodies [8]. 3.2. Clinical outcomes The operation time, estimated blood loss, time of hospital stay, and complications of the operation were evaluated for each patient. The neurological status of the patient was defined using the ASIA impairment scale.
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3.3. Operative technique Left side anterolateral approach (transthoracic or retroperitoneal) was used to expose the fractured vertebrae in all patients. Single level subtotal corpectomy was performed to completely decompress the spinal canal. The dura was visualized from the craniocaudal retraction of the fractured vertebrae and mediolateral retraction from one pedicle to the other. As per the surgeon’s preference, titanium-mesh cage packed with local autograft from fractured vertebrae was used for reconstruction of the spine. Intraoperative fluoroscopy is essential in confirming cage placement and anterior instrumentation with screws and plates.
3.4. Postoperative evaluation Patients were seen at 2 weeks, 3 months, 6 months and 1-year postoperative period. Fusion was assessed with plain radiographs at 3 and 6 months. Patients with persistent pain, progressive kyphosis and having ambiguous fusion status on plain radiographs, were evaluated with CT scan.
3.5. Statistical methods We measured the continuous variable means by using Student ‘t’ test. Associations of two categorical variables were defined by using Pearson chi-square or Fisher exact test as appropriate. IBM SPSS.21 was used for statistical analysis and the p valve < 0.05 was considered to be statistical significance.
4. Results From January 1999 to January 2009, a total of 45 patients sustained a single level thoracolumbar burst fracture underwent an anterolateral approach for decompression and fixation. The mean age of the patients was 37.6 years (range: 13–70), with a male-tofemale ratio of 1.5:1. Retroperitoneal approach was used in 64.4%, transthoracic in 13.3%, and transthoracic transdiaphragmatic in 22.2%. The average operation time, estimated blood loss (EBL) and length of stay after surgery was 412.3 min, 1098.2 ml and 9.1 days, respectively. A BMI > 25was associated with longer operative times (p < 0.02) and higher EBL (p < 0.006). Mean hematocrit of the patients decreased from 32.75 to 27.17 (p = 0.059). There were no cases of neurological deterioration postoperatively. Eighteen patients who were neurologically ASIA-E remained intact after surgery. Thirteen of the 27 patients (48%) with incomplete injuries improved in their neurological exam by time of discharge from the hospital. At latest follow-up (mean: 27.2 months) none of the patients developed neurological deterioration and there were no new onset of neurological deficits. Out of the 27 patients that had neurological deficits, at final follow up 22 (82%) patients had neurological improvement compared to preoperative status (Fig. 1).
4.1. Radiographic results Forty-three out of 45 (96%) patients had stable construct and fusion at last follow up. One patient required posterior fixation for additional stability. We compared the preoperative vs. postoperative Cobb angle to measure the kyphotic variable. The mean preoperative Cobb angle was 15.5 degrees and postoperative was 8.7 degrees (p < 0.001), which indicated significant improvement in the degree of spinal kyphosis postoperatively.
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Fig. 1. 48% patients with incomplete injuries improved in their neurological exam by time of discharge from the hospital and at latest follow-up (mean: 27.2 months) 82% patients had neurological improvement compared to preoperative status.
Fig. 2. Pie chart representing spectrum of complications through anterior approach corpectomy.
4.2. Complications Twelve patients developed some form of perioperative complication. There were no mortalities and no incidences of increased neurological deficits in any of those patients. No intraoperative or late vascular injuries were noted. Two patients demonstrated on radiographic imaging evidence of minor graft movement that did not progress. Dural tear occurred in two cases. Other perioperative complications include one case of pulmonary embolism, one deep vein thrombosis, one urinary tract infection, three superficial wound infections treated with antibiotics, ileus, left diaphragm tear with pneumothorax, and pneumomediastinum (Fig. 2). 5. Discussion Operative approaches for thoracolumbar burst fractures remain controversial [1,4,7,8,12–17]. A review of literature shows many different views on treatment of those types of fractures. The goal of surgical treatment is to improve neurological function, prevent worsening of neurological deficits, decompress the spinal canal, restore vertebral body height, correct the kyphotic deformity, and
facilitate mobilization and rehabilitation. Surgical options include anterior, posterior or combined anterior–posterior approaches to the vertebral body fractures. Anterolateral approach offers direct decompression of the spinal canal and improved spinal kyphotic deformity correction compared to posterior instrumentation [7]. The placement of allograft and anterior instrumentation allows for direct reconstruction of the spinal column and fusion of the column, thus limiting the number of motion segment to be fused. Posterior instrumentation usually requires pedicle screws 2 levels above and below the fracture with fusion rate of around 90% [18]. Short segment posterior instrumentation remains controversial. Tezeren and Kuru reported that 5 out of 9 patients treated with short segment posterior instrumentation in a randomized controlled trial had a correction loss of 10 degrees and 55% failure rate [19]. In our study, only 2 of the 45 patients did not fuse on follow-up, for a fusion rate of 96%. Compared to posterior fixation, several investigators have shown improved kyphosis correction and maintenance of the correction with the anterolateral approach [7,14,17,20]. In thoracolumbar fractures, neurological deficits are usually caused by the impact of trauma as well as compression to the ventral surface of the spinal cord [1]. Anterolateral approach provides direct visualization of the ventral spinal cord during surgical decompression. The studies that directly compare anterior and posterior approaches are relatively few. Esses et al. [5] reported a randomized prospective comparison of these two approaches in 40 patients with a 20 month follow-up. There was no difference in restoring normal sagittal contour. There were 2 implant failures and statistically significant higher blood loss in the anterior surgery group. No functional outcome data were analyzed in that study. Wood et al. [21] performed a randomized prospective comparison of these two approaches in 38 patients with 2 year clinical follow-up. Again, surgical blood loss was higher in the anterior group. Patient outcome and radiographic analysis were equivocal in the two groups but had less complication in the anterior decompression and fixation group. Some studies have shown higher postoperative kyphotic correction and improvement of vertebral height in the combined anterior–posterior approach [15,22]. However, the combined anterior–posterior surgery is associated with higher operative time and blood loss, without an increase improvement in neurological function recovery, fusion healing, pain relief, or work status when compared to anterior surgery or posterior surgery [8,15,23]. These results indicate that there is no advantage of combined procedure since there are better and more cost-effective treatments for unstable thoracolumbar spine fractures. Initially, anterolateral approach for decompression without instrumentation and reconstruction with simple anterior strut had a variable rate of pseudoarthrosis, from 10 to 100% [20,24]. Advancement in anterior thoracolumbar instrumentation, with high rate of fusion, has led to single stage anterolateral decompression and reconstruction as treatment for unstable thoracolumbar fractures. Kostuik [25] reported a series of 49 patients with burst fractures, of which 25 patients underwent anterior decompression and instrumentation. There were no instances of pseudoarthrosis and good clinical outcome with average 1.6 Frankel grade neurological improvement. Kaneda et al. [26] reported 150 patients with thoracolumbar burst fracture and associated neurological deficits that were managed with single-stage anterior spinal decompression, strut graft, and instrumentation. At eight year follow-up, 93% of patients showed successful fusion on radiograph. They also report mean kyphotic deformity correction from 19 degrees to 7 degrees postoperatively without significant loss at last followup. Ninety-five percent of patients have at least one Frankel grade improvement in their neurological function. Sasso et al. [7] reviewed stand-alone single-stage anterior surgical management of three-column thoracolumbar injuries in 39 patients and they
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Table 1 Review of previous reports on anterior approach and stabilization for thoracolumbar fractures. Reference
Number of cases
Mean age (years)
Follow-up y—years m—months
Partial neurological deficit (n)
Neurological improvement (n)
Angle of kyphosis correction Preop/Postop
Fusion rate (%)
40 37 57 20 9 71%
Not specified Not specified Not specified Not specified −/5◦ Loss of correction 7◦ 22◦ /11◦
93.7 ? 97.5 95.9 100 100
26◦ /14.5◦ 27.5◦ /12◦ 19◦ /7◦ 32◦ /11◦ 31◦ /13◦
92 100 93.0 100 91.6
16.8◦ /2.9◦ Not specified 20◦ /6.6◦
96 Not recorded 100
10.5◦ /5◦
95
22.7◦ /7.4◦ Not specified 24.6◦ /17.1◦ (T) 10.6◦ /13.6◦ (L) Not specified 24.2◦ /5.2◦
95 85 92.8
15.5◦ /8.7◦
96
Dunn [38] MacAfee et al. [32] Kostuik [30] Transfeldt et al. [36] Been [22] Haas et al. [29]
48 70 80 49 29 39
26 34 32 35 30.1 28
Not specified 3.4 y (2–8.6 y) Not specified 1–19 y 3.1 y Not specified
Okuyama et al. [33]
19
46
54 m (24–94 m)
40 42 57 43 10 19 grades A/B and 20 grades No deficit
25 15 150 36 12
32 26 39 36.7 43
2y 2y 8 y (5–12 y) 42 m (24–84 m) 22 m (12–30 m)
5 5 148 26 3 Frankel D
25 45 20
34.4 44 43.3
16 m (7–29 m) Not specified 15 m
17 Not specified No deficit
39
42.3 m
No deficit
37.4/40.2* 36 40.3
31.1 m 4 m–6 y 24 m
37 27% 7
16 Not specified No deterioration No deterioration 33 13/20 5
20/80 32/64
50.6 37.8
16.2 m 46.5 m
45
37.6
27.2 m
11 24.5 (Preop ASIA score) 27
7 24.0 (Postop ASIA score) 13
Van Loon et al. [37] Van Loon et al. [37] Kaneda et al. [26] Carl et al. [28] Ghanayem and Zdeblic [20] Schnee and Ansell [34] Schultheiss et al. [35] Madi et al. [31] Wood et al. [21] Sasso et al. [7] Beisse [27] Sasani et al. [4] Lu et al. [23] Lin et al. [1]
20/38 40 220 14
Our study *
No deterioration 5 3 142 26 3 Frankel E
100
Not specified Not specified
Average age for male/female.
reported kyphosis correction from 22.7 degree kyphosis preoperatively to mean of 7.4 degree kyphosis postoperatively with 94% stable construct at last follow up. On similar lines, our study showed significant improvement of kyphosis post-operatively. The results of previous reports on anterior approach for thoracolumbar fracture are summarized in Table 1 [1,4,7,20–23,26–38]. Our study has shown that anterolateral approach is a safe and effective method for treatment for traumatic thoracic and lumbar burst fractures. In our study, no neurological deterioration occurred postoperatively. Thirteen out of 27 patients
(48%) had improvement of at least one ASIA grade on hospital discharge. At final clinical follow-up, 22 patients (82%) had improvement in their neurological function. This is consistent with what is reported in literature. Since neurological deficit is due to ventral compression, direct visualization provides optimal decompression of spinal canal (Fig. 3). Preoperative mean degree of kyphosis was 15.5 which corrected to a mean postoperative 8.7 degrees. The overall improvement of sagittal angulation was improved significantly from preoperative measurements (p < 0.0001).
Fig. 3. A 55 year old male sustained a motor vehicular accident. MRI shows (A) a highly unstable L2 burst fracture with a retropulsed fragment compressing over the spinal cord anteriorly. (B) Immediate postoperative CT scan shows anterior stabilization with restoration of vertebral height and lumbar lordosis. (C) Postoperative CT myelogram reveals an effective decompression achieved. The patient’s neurological status improved from ASIA-D to ASIA-E following the surgery.
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The stand-alone anterior instrumentation allows a shorter motion segment of the spine to be fused compared to long posterior fusion of two levels above and below the fractured vertebrae. Short segment posterior fusion and decompression is another surgical option for thoracic and lumbar burst fractures that also limits the motion segments that are fused. Studies do report a higher rate of construct failure with this approach [7,14,39]. Our study indicates that single level corpectomy with two segment instrumentation was stable with only two patients showing pseduoarthrosis on radiograph imaging at clinical follow up. Only one patient required additional posterior instrumentation for failing anterior construct. Retrospective nature of the study and inclusion of anterior only approaches are the main limitations of this study. 6. Conclusion Anterior surgical approach appears to be a safe and effective technique for managing traumatic thoracic and lumbar unstable burst fractures. Anterior stabilization techniques allow spinal cord decompression under direct visualization and provide a stable fracture construct with incorporation of less motion segments. This is also evident that anterior decompression and stabilization achieves a significant correction of kyphotic deformity with a lower risk of neurological deterioration and pseudoarthrosis. References [1] Lin B, Chen ZW, Guo ZM, Liu H, Yi ZK. Anterior approach versus posterior approach with subtotal corpectomy, decompression, and reconstruction of spine in the treatment of thoracolumbar burst fractures: a prospective randomized controlled study. J Spinal Disord Tech 2011. [2] Zhang S, Wadhwa R, Haydel J, Toms J, Johnson K, Guthikonda B. Spine and spinal cord trauma: diagnosis and management. Neurol Clin 2013;31:183–206. [3] Denis. Spinal instability as defined by the three-column spine concept in acute spinal trauma. Clin Orthop Relat Res 1984;189:65–76. [4] Sasani M, Ozer AF. Single-stage posterior corpectomy and expandable cage placement for treatment of thoracic or lumbar burst fractures. Spine (Phila Pa 1976) 2009;34:E33–40. [5] Esses SI, Botsford DJ, Kostuik JP. Evaluation of surgical treatment for burst fractures. Spine (Phila Pa 1976) 1990;15:667–73. [6] Wood KB, Li W, Lebl DS, Ploumis A. Management of thoracolumbar spine fractures. Spine J 2014;14:145–64. [7] Sasso RC, Best NM, Reilly TM, McGuire Jr RA. Anterior-only stabilization of three-column thoracolumbar injuries. J Spinal Disord Tech 2005;18(Suppl.):S7–14. [8] Danisa OA, Shaffrey CI, Jane JA, Whitehill R, Wang GJ, Szabo TA, et al. Surgical approaches for the correction of unstable thoracolumbar burst fractures: a retrospective analysis of treatment outcomes. J Neurosurg 1995;83: 977–83. [9] Kaneda K, Abumi K, Fujiya M. Burst fractures with neurologic deficits of the thoracolumbar–lumbar spine. Results of anterior decompression and stabilization with anterior instrumentation. Spine (Phila Pa 1976) 1984;9: 788–95. [10] Boerger TO, Limb D, Dickson RA. Does ‘canal clearance’ affect neurological outcome after thoracolumbar burst fractures? J Bone Joint Surg Br 2000;82:629–35. [11] Petersilge CA, Emery SE. Thoracolumbar burst fracture: evaluating stability. Semin Ultrasound CT MR 1996;17:105–13. [12] Dai LY, Jiang SD, Wang XY, Jiang LS. A review of the management of thoracolumbar burst fractures. Surg Neurol 2007;67:221–31 (discussion 231). [13] P. Oprel P, Tuinebreijer WE, Patka P, den Hartog D. Combined anterior-posterior surgery versus posterior surgery for thoracolumbar burst fractures: a systematic review of the literature. Open Orthop J 2010;4:93–100.
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