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Role of operative treatment
Mini-symposium
Thoraco-lumbar Spinal Injuries: Role of Operative Treatment
R. W. Gaines,
W.
G. Humphreys
Introduction and History Clinical experience with non-operative treatment of thoraco-lumbar fractures has been accumulating from spinal centres since World War II in Australia and Great Britain. Meanwhile experience with operative treatment has also been gradually accumulating and techniques have been improving. The initial negative experience recorded by Nicoll’ was widely emphasised and other reports by Guttmann,’ Lewis3 and Roberts4 reported difficulties with early techniques of internal fixation. Only in the late 1970s did reports of decompression and instrumentation with Harrington double distraction rods begin to appear.’ These papers were the first to report large series of very successful results of spinal internal fixation with low rates of failure of the implants. The Harrington rods, developed for use in scoliosis treatment, relied on ligament stretching and elastic recoil of several segments above and below the fracture site for fixation, and thus necessitated long instrumented spinal segments (5-7 segments)for single level injuries. Addition of Luque sublaminar wires to the Harrington rod6 substantially improved skeletal fixation to the uninjured ‘interval’ segments and reduced the incidence of instrumentation failure. The ‘rod-long. fuse-short’ technique’ was used by certain surgeons who recognised the unfortunate liabilities of the Harrington system’s biomechanical method of fixation, and who wished to avoid such a long fusion area. Only recently have two instrumentation systems and operative approaches been developed specifically for spinal fracture fixation to address a single or double Robert W. Gaines MD, FACS, William G Humpbreys MD, University of Missouri Health Sciences Center. Division of Orthopaedic Surgery, Columbia. Missouri, USA.
segment injury with a single or double level of secure skeletal fixation and fusion. The Steffee system and the Kaneda system both are newly introduced instrumentation systems which perform quite well in the hands of their developers, but which still have not been used widely enough for a long enough period to prove their utility world-wide. These systems will be discussed later. The benefits to a patient of surgical management of his thoraco-lumbar fracture or fracture-dislocation can be discussed under three separate headings-a) neurologic. b) structural, and c) rehabilitation
Neurologic Benefits of Operative Intervention Clearly the most important purpose of treatment of thoraco-lumbar spinal injuries is to protect the conus medullaris, cauda equina and nerve roots from additional injury after the primary one and to create a satisfactory environment for healing of the neurologic injury if present. Although many thermal and biochemical treatments have attempted to reduce the injury and improve neurologic recovery. only the removal of mechanical compression from the injured cord or roots (decompression) has been helpful in certain circumstances.8l9 The most obvious case is in the patient with rapidly progressing neural deficit. Emergency removal of bone or disc fragments from the cord and/or roots by various combinations of fracture realignment, fragment reorientation or removal has permitted rapid post-operative neurologic recovery in many patients. This fact has firmly entrenched the patient with rapidly progressive neurologic deficit as the most impelling indication for surgery. l r’. ’ ‘. Currently, a far more difficult question exists regarding surgical treatment for patients with partial
232
THORACO-LUMBAR
SPINAL
INJURIES:
ROLE
OF OPERATIVE
neurologic injury, without progression, who are shown to have bony fragments in the canal by CT scan or MRI. For this group, unfortunately, data still does not exist which proves the benefit to their neural recovery of removing the bone on an acute or semi-acute basis if the spine is stabilised. Without stabilisation, however, many such patients do deteriorate and posttraumatic kyphosis regularly develops. l, l 2-l 3-I4 Despite the lack of proof, however, most American orthopaedic surgeons and neurosurgeons agree that removal of the bone is warranted, either by indirect (fracture reduction) or direct means particularly when there is major canal narrowing in the areas which contain spinal cord and not nerve roots. They also agree that laminectomy (posterior decompression), when bony fragments compress the canal from anteriorly, is of no benefit. One other scenario creates an excellent indication for surgical treatment, i.e. a patient with chronic partial neural injury which has reached a plateau but who has an obvious area of mechanical cord or root compression. Relief of such compression has been of benefit to neural recovery, on occasion, particularly when accompanied by spinal stabilisation and fusion.15
TREATMENT
the amount of neural deficit (complete, incomplete, or none), the quality of the patient’s bone and the extent of bony comminution of the spinal column under the spinal implant which is able to participate in ‘loadsharing’ are additional factors which control the necessity and feasibility of safe early mobilisation following surgical stabilisation. The availability of rehabilitation facilities for the patient and his post-operative environment also strongly influences the decision-making process regarding treatment.
Fundamentals of Successful Surgical Spinal Fracture Treatment To ensure a very high percentage of successful spinal reconstructions, certain basic knowledge, certain techniques and equipment are essential. A. Anatomy
and Kinesiology
A very detailed working knowledge of normal human anatomy is the fundamental building block on which successful surgery is based. This must be learned in the cadaver laboratory.
Structural Benefits of Operative Intervention
B. Biomechanics
Like some long bone fractures, reduction of some severely displaced thoraco-lumbar fractures or fracture-dislocations is impossible by closed means due to the extent of displacement or to soft tissue interposition or both. In these injuries, lack of open reduction leads to the functional debits of spinal malunion or nonunion. Also, in some severely displaced injuries, closed manipulation without anesthesia may be too painful to permit adequate realignment without risk of further neural damage and operative reduction may well be safer. The introduction of spinal cord monitoring has made such intraoperative realignment safer. The operative management of the bony injury has completely eliminated the problem of post-traumatic kyphosis from many spinal centres in the United States. Post-traumatic kyphosis is a totally avoidable condition if up-to-date surgical reduction and fusion are applied to difficult injuries.
Detailed understanding of the kinesiology of various motion segments of the spine and the mechanics of load transfer in injured and uninjured spines is essential to understanding post-traumatic deformities, the reasons for implant failure and the rationale behind both anterior and posterior approaches. The inherent liabilities of long fusions are also best understood in this context.
Rehabilitation Benefits of Operative Intervention Clearly the most striking benefit of operative treatment of thoraco-lumbar spinal fractures is that the patient can be allowed out of bed within a few days following the surgery. This early mobilisation may be life saving to multiple trauma victims or older patients for whom early mobilisation may be essential for survival. Early mobilisation, however, is of obviously less benefit to younger patients, who, though restless and bored during recumbency, may medically tolerate the four to eight weeks of bed rest without major morbidity. The patient’s pre-operative physiological make-up,
C. Surgical Techniques Basic concepts of tissue handling, antisepsis and surgical technique are as important in spine surgery as in any other area of reconstructive orthopaedics. In addition, techniques of thoracic surgery (necessary for anterior intra-thoracic or thoraco-abdominal approaches), of general surgery (for retroperitoneal or trans-peritoneal surgery) and neurosurgery (for dural repair) and of vertebrectomy and anterior canal decompression (from the scoliosis surgeon) are fundamental techniques which must be in the armamentarium of the spinal reconstructive surgeon in 1988. Ability to control bleeding from any source, e.g. great vessel, bone, epi or intradural, is fundamental. D. Techniques of Intra-operative
Spinal Manipulation
Techniques of spinal positioning for reduction of deformity, of spinal elongation to reduce spinal shortening and of spinal compression to approximate distracted segments are fundamental parts of scoliosis and spinal fracture treatment. The understanding of
CURRENT
root/foraminal necessary.
and intra-canal neuroanatomy
is also
E. Implunt.~ Only after all of these fundamentals are acquired (AD), does the understanding and application of the various implants begin to become important to the surgeon. The best way to understand how new implants work is to mount them on human or animal cadaver spines on which has been created an experimental fracture. There is no better way of understanding the biomechanics of the repaired spinal segment than this and we recommend it become included in the education of all spinal surgeons of the future.
Current Spinal Implants and Implant Techniques The Wiwd-in Harrington Rods (Fig. 1) This system, though using a long instrumented segment, is a technique which has become the most reliable fracture fixation method around the world. The rod and hook system resists axial loads well in all but the most comminuted injuries, and the wires strikingly improve the weakness of the Harrington system in resisting rotational loads.” Used carefully, the sublaminar wires are very safe and have not caused a single instance of neurological injury in over 150 cases of surgery for spinal deformity or fracture done in our centre during the past 10 years (> 2000 wires).
ORTHOPAEDICS
233
For surgeons unfamiliar with sublaminar wiring, use of spinous process wiring (Drummond Technique) or Edwards sleeves to improve fixation to ‘interval’ vertebrae is necessary. The Jacobs locking rod is also a better implant, although somewhat difficult to apply. The Harrington double distraction system, by itself, is a poor internal fixation device and should be supplemented with one of several techniques which improve its biomechanical performance. The Stefie VSP Sl!stem (Fig. 2) This newly developed system has become the standard implant in our armamentarium for short-segment spinal fracture treatment for all but the most comminuted bony injuries. Reduction of the facture requires a combination of postural reduction (on the operating table), distraction to physiologic length with the Harrington hooks and outriggers, direct canal decompression, and then stabilisation with transpedicular screws attached to paraspinal plates. This system provides the most rigid spinal internal fixation available today and maintains vertebral position while the associated spinal fusion heals. For fractures or fracture-dislocations involving minimal to moderate anterior column injury, where the anterior column can load-share with the implant, the VSP is an ideal implant system. In our series of twenty-four such cases done without decompression, there has not been a single failure during the thirty months of follow-up. Injuries with substantial anterior column comminution generate high screw stresses and must either be supplemented with a second stage strut reconstruction of the anterior column or operated with strut grafting and anterior column internal fixation with the Kaneda device. The Kuneda Device (Figs 3 & 4) Professor Kiyoshi Kaneda has developed an anterior device used to supplement vertebrectomy and anterior strut grafting so that a single stage repair of 1 very
Fig. I-The wired-in Harrington system is an excellent internal fixation device for spinal fractures but requires long-segment internal fixation. This particular case is a nine month follow-up of a fracture-dislocation with mild neurologic deficit which resolved completely with transpedicular decompression.
Fig. Z---Pre- and post-operative radiographsof a teenage boy with a severe fracture-dislocation managed with short segment Instrumentation and intertransverse fusion with Steffee plates. The short segment instrumentation is of obvious benefit to younger patients who will be physically very active.
234
THORACO-LUMBAR
SPINAL
INJURIES:
ROLE
OF OPERATIVE
TREATMENT
Anter;Jr Spinal Instrun.ontation Karjda c Fig. JA-Twenty-seven year old male with Ll burst fracture. Neurological deficit included cauda equina and conus medullaris lesions.
Fig. 3B-Preand post-operative crest grafting and instrumentation
Transverse Loaders
Fig. 3C-Diagrammatic representation of the instrumentation carried out for the patient in Figure 3A.
CTs of patient in Figure 3A. Anterior decompression with the Kaneda device.
cornminuted burst fracture or mildly displaced fracture-dislocation can be repaired over a short segment in a single stage. He has presented very impressive results in his own personal series of over seventy cases. l5 The healing rate is over 95% and the restoration of normal alignment of both the canal and the spinal column is virtually anatomic in the overwhelming majority of cases. Whether other surgeons can also produce this excellent result depends on many factors. However, there is no question that his approach and device have a distinct and important role in the treatment of certain injuries.
Selecting the Correct Approach The level of sophistication of surgical spinal fracture management has rapidly developed in many centres
Device with the
was carried out along with full-thickness
iliac
during the past decade and now allows repair of even the most severe injuries over short segments. Successful surgery obtains benefits of cord and root decompresrestoration and patient sion, spinal column rehabilitation. However, the improvements in surgical treatment have not replaced conservative treatment for many patients. Whether to use the surgical approach or to rely on conservative treatment depends on many factors. These include: the anatomy of the bony injury, the neural injury, the associated injuries and the hospital and post-surgical facilities and implants available for operation, aftercare, and rehabilitation. One essential part, however, is the experience of the operating surgeon in applying the technique he uses to the patient at hand. ‘The best’ approach to a given patient is the one
CURRENT
ORTHOPAEDICS
235
2. Guttmann L 1969 Spinal Deformities in Traumatic Paraplegics and Tetraplegics Following Surgical Procedures. Paraplegia 7 :38-49 3. Lewis J, McKibbin B 1974 The Treatment of Unstable Fracture-Dislocations of the Thoraco-Lumbar Spine Accompanied by Paraplegia. Journal of Bone and Jount Surgery 56B : 603-612
Fig. &Two years after surgery showing good graft consolidation and satisfactory placement of the implants following surgical reconstruction of the patient in Figure 3A.
which permits the best healing of the bony and neural injury with the least morbidity. Given the interplay of the many variables which determine the final outcome, there is probably no other area of orthopaedics which requires more judgement. Certainly, however, the best candidates for operative treatment, given ideal surgical techniques, are patients with incomplete or progressing neural injury, severely cornminuted and displaced fractures to avoid non-union or malunion and to eliminate post-traumatic deformity, and in totally paraplegic patients for the rehabilitation benefits.
References 1. Nicoll E A 1949 Fractures of the Dorso-Lumbar Spine. Journal of Bone and Joint Surgery 3 1B : 376-394
4. Roberts P H 1969 Internal Metallic Splintage in the Treatment of Traumatic Paraplegia. Injury 1: 4-l I P R, Erwin W D 1978 Results of 5. Dickson J M. Harrington Reduction and Stabilization of the Severely Fractured. Unstable Thoracic and Lumbar Spine. Journal of Bone and Joint Surgery 60A : 799-805 of 6. Gaines R W, Breedlove R F, Munson G 1984 Stabilization Thoracic and Thoracolumbar Fracture Dislocations with Harrington Rods and Sublaminar Wires. Clinical Orthopaedics and Related Research 189: 195-203 7. Jacobs R R. Asher M A, Snider R K 1980 Thoracolumbar Spine Injuries. Spine 5 : 463~.477 8. Jelsma R. 1982 Surgical Treatment of Thoracolumhsr Fractures. Surgical Neurology 18: 156-166 9. O’L.aoire S A. Thomas D G T 1981 Surgery in Incomplete Spinal Cord Injury Surgical Neurology 17: I?- 15 IO. Guttmann L 1949 Surgical Aspects of the Treatment of Traumatic Paraplegia. Journal of Bone and Joint Surgery 3 I B : 399-403 G 1982 Segmental II. Luque E R, Cassls N. Ramirer-Wiella Spinal Instrumentation in the Treatment of Fracture\ of the Thoracolumbar Spine. Spine 7 :312-3 I7 12. Osebold W R, Weinstein S R, Sprague B L I98 IThoracolumbar Spine Fractures. Spine 6: 13 34 of the 13. Stranger J K 1947 Fracture-Dislocations Thoracolumbar Spine. Journal of Bone and Joint Surgery ‘9:107--118 14. Soreff J. Axdorph G, Bylund P 1982 Treatment of Patients with Unstable Fractures of the Thoracic and Lumbar Spine. Acta Orthopaedica Scandinavica 53 :369-381 15. Kaneda K. Abumi K, Fujiya. A 1984 Burst Fractures with Neurologic Deficits of the Thoraco-Lumbar Spine. Spine 9:788%795 16 Kelly R P, W hitesides, T E 1968 Treatment of Lumbodorsal Fracture/Dislocations. Annals of Surgery 167 :705-7 I6 17 Munson G. Satterlee C. Hammond S, Betten R, Gaines R W 1984 Experimental Evaluation of Harrington Rod Fixation Supplemented with Sublaminar Wires in Stabilizing Thoracolumbar Fracture-Dislocations. Clinical Orthopaedics 189 97-101,
Thoraco-lumbar Spinal Injuries: Role of Operative Treatment
R. W. Gaines,
W.
G. Humphreys
Introduction and History Clinical experience with non-operative treatment of thoraco-lumbar fractures has been accumulating from spinal centres since World War II in Australia and Great Britain. Meanwhile experience with operative treatment has also been gradually accumulating and techniques have been improving. The initial negative experience recorded by Nicoll’ was widely emphasised and other reports by Guttmann,’ Lewis3 and Roberts4 reported difficulties with early techniques of internal fixation. Only in the late 1970s did reports of decompression and instrumentation with Harrington double distraction rods begin to appear.’ These papers were the first to report large series of very successful results of spinal internal fixation with low rates of failure of the implants. The Harrington rods, developed for use in scoliosis treatment, relied on ligament stretching and elastic recoil of several segments above and below the fracture site for fixation, and thus necessitated long instrumented spinal segments (5-7 segments)for single level injuries. Addition of Luque sublaminar wires to the Harrington rod6 substantially improved skeletal fixation to the uninjured ‘interval’ segments and reduced the incidence of instrumentation failure. The ‘rod-long. fuse-short’ technique’ was used by certain surgeons who recognised the unfortunate liabilities of the Harrington system’s biomechanical method of fixation, and who wished to avoid such a long fusion area. Only recently have two instrumentation systems and operative approaches been developed specifically for spinal fracture fixation to address a single or double Robert W. Gaines MD, FACS, William G Humpbreys MD, University of Missouri Health Sciences Center. Division of Orthopaedic Surgery, Columbia. Missouri, USA.
segment injury with a single or double level of secure skeletal fixation and fusion. The Steffee system and the Kaneda system both are newly introduced instrumentation systems which perform quite well in the hands of their developers, but which still have not been used widely enough for a long enough period to prove their utility world-wide. These systems will be discussed later. The benefits to a patient of surgical management of his thoraco-lumbar fracture or fracture-dislocation can be discussed under three separate headings-a) neurologic. b) structural, and c) rehabilitation
Neurologic Benefits of Operative Intervention Clearly the most important purpose of treatment of thoraco-lumbar spinal injuries is to protect the conus medullaris, cauda equina and nerve roots from additional injury after the primary one and to create a satisfactory environment for healing of the neurologic injury if present. Although many thermal and biochemical treatments have attempted to reduce the injury and improve neurologic recovery. only the removal of mechanical compression from the injured cord or roots (decompression) has been helpful in certain circumstances.8l9 The most obvious case is in the patient with rapidly progressing neural deficit. Emergency removal of bone or disc fragments from the cord and/or roots by various combinations of fracture realignment, fragment reorientation or removal has permitted rapid post-operative neurologic recovery in many patients. This fact has firmly entrenched the patient with rapidly progressive neurologic deficit as the most impelling indication for surgery. l r’. ’ ‘. Currently, a far more difficult question exists regarding surgical treatment for patients with partial
232
THORACO-LUMBAR
SPINAL
INJURIES:
ROLE
OF OPERATIVE
neurologic injury, without progression, who are shown to have bony fragments in the canal by CT scan or MRI. For this group, unfortunately, data still does not exist which proves the benefit to their neural recovery of removing the bone on an acute or semi-acute basis if the spine is stabilised. Without stabilisation, however, many such patients do deteriorate and posttraumatic kyphosis regularly develops. l, l 2-l 3-I4 Despite the lack of proof, however, most American orthopaedic surgeons and neurosurgeons agree that removal of the bone is warranted, either by indirect (fracture reduction) or direct means particularly when there is major canal narrowing in the areas which contain spinal cord and not nerve roots. They also agree that laminectomy (posterior decompression), when bony fragments compress the canal from anteriorly, is of no benefit. One other scenario creates an excellent indication for surgical treatment, i.e. a patient with chronic partial neural injury which has reached a plateau but who has an obvious area of mechanical cord or root compression. Relief of such compression has been of benefit to neural recovery, on occasion, particularly when accompanied by spinal stabilisation and fusion.15
TREATMENT
the amount of neural deficit (complete, incomplete, or none), the quality of the patient’s bone and the extent of bony comminution of the spinal column under the spinal implant which is able to participate in ‘loadsharing’ are additional factors which control the necessity and feasibility of safe early mobilisation following surgical stabilisation. The availability of rehabilitation facilities for the patient and his post-operative environment also strongly influences the decision-making process regarding treatment.
Fundamentals of Successful Surgical Spinal Fracture Treatment To ensure a very high percentage of successful spinal reconstructions, certain basic knowledge, certain techniques and equipment are essential. A. Anatomy
and Kinesiology
A very detailed working knowledge of normal human anatomy is the fundamental building block on which successful surgery is based. This must be learned in the cadaver laboratory.
Structural Benefits of Operative Intervention
B. Biomechanics
Like some long bone fractures, reduction of some severely displaced thoraco-lumbar fractures or fracture-dislocations is impossible by closed means due to the extent of displacement or to soft tissue interposition or both. In these injuries, lack of open reduction leads to the functional debits of spinal malunion or nonunion. Also, in some severely displaced injuries, closed manipulation without anesthesia may be too painful to permit adequate realignment without risk of further neural damage and operative reduction may well be safer. The introduction of spinal cord monitoring has made such intraoperative realignment safer. The operative management of the bony injury has completely eliminated the problem of post-traumatic kyphosis from many spinal centres in the United States. Post-traumatic kyphosis is a totally avoidable condition if up-to-date surgical reduction and fusion are applied to difficult injuries.
Detailed understanding of the kinesiology of various motion segments of the spine and the mechanics of load transfer in injured and uninjured spines is essential to understanding post-traumatic deformities, the reasons for implant failure and the rationale behind both anterior and posterior approaches. The inherent liabilities of long fusions are also best understood in this context.
Rehabilitation Benefits of Operative Intervention Clearly the most striking benefit of operative treatment of thoraco-lumbar spinal fractures is that the patient can be allowed out of bed within a few days following the surgery. This early mobilisation may be life saving to multiple trauma victims or older patients for whom early mobilisation may be essential for survival. Early mobilisation, however, is of obviously less benefit to younger patients, who, though restless and bored during recumbency, may medically tolerate the four to eight weeks of bed rest without major morbidity. The patient’s pre-operative physiological make-up,
C. Surgical Techniques Basic concepts of tissue handling, antisepsis and surgical technique are as important in spine surgery as in any other area of reconstructive orthopaedics. In addition, techniques of thoracic surgery (necessary for anterior intra-thoracic or thoraco-abdominal approaches), of general surgery (for retroperitoneal or trans-peritoneal surgery) and neurosurgery (for dural repair) and of vertebrectomy and anterior canal decompression (from the scoliosis surgeon) are fundamental techniques which must be in the armamentarium of the spinal reconstructive surgeon in 1988. Ability to control bleeding from any source, e.g. great vessel, bone, epi or intradural, is fundamental. D. Techniques of Intra-operative
Spinal Manipulation
Techniques of spinal positioning for reduction of deformity, of spinal elongation to reduce spinal shortening and of spinal compression to approximate distracted segments are fundamental parts of scoliosis and spinal fracture treatment. The understanding of
CURRENT
root/foraminal necessary.
and intra-canal neuroanatomy
is also
E. Implunt.~ Only after all of these fundamentals are acquired (AD), does the understanding and application of the various implants begin to become important to the surgeon. The best way to understand how new implants work is to mount them on human or animal cadaver spines on which has been created an experimental fracture. There is no better way of understanding the biomechanics of the repaired spinal segment than this and we recommend it become included in the education of all spinal surgeons of the future.
Current Spinal Implants and Implant Techniques The Wiwd-in Harrington Rods (Fig. 1) This system, though using a long instrumented segment, is a technique which has become the most reliable fracture fixation method around the world. The rod and hook system resists axial loads well in all but the most comminuted injuries, and the wires strikingly improve the weakness of the Harrington system in resisting rotational loads.” Used carefully, the sublaminar wires are very safe and have not caused a single instance of neurological injury in over 150 cases of surgery for spinal deformity or fracture done in our centre during the past 10 years (> 2000 wires).
ORTHOPAEDICS
233
For surgeons unfamiliar with sublaminar wiring, use of spinous process wiring (Drummond Technique) or Edwards sleeves to improve fixation to ‘interval’ vertebrae is necessary. The Jacobs locking rod is also a better implant, although somewhat difficult to apply. The Harrington double distraction system, by itself, is a poor internal fixation device and should be supplemented with one of several techniques which improve its biomechanical performance. The Stefie VSP Sl!stem (Fig. 2) This newly developed system has become the standard implant in our armamentarium for short-segment spinal fracture treatment for all but the most comminuted bony injuries. Reduction of the facture requires a combination of postural reduction (on the operating table), distraction to physiologic length with the Harrington hooks and outriggers, direct canal decompression, and then stabilisation with transpedicular screws attached to paraspinal plates. This system provides the most rigid spinal internal fixation available today and maintains vertebral position while the associated spinal fusion heals. For fractures or fracture-dislocations involving minimal to moderate anterior column injury, where the anterior column can load-share with the implant, the VSP is an ideal implant system. In our series of twenty-four such cases done without decompression, there has not been a single failure during the thirty months of follow-up. Injuries with substantial anterior column comminution generate high screw stresses and must either be supplemented with a second stage strut reconstruction of the anterior column or operated with strut grafting and anterior column internal fixation with the Kaneda device. The Kuneda Device (Figs 3 & 4) Professor Kiyoshi Kaneda has developed an anterior device used to supplement vertebrectomy and anterior strut grafting so that a single stage repair of 1 very
Fig. I-The wired-in Harrington system is an excellent internal fixation device for spinal fractures but requires long-segment internal fixation. This particular case is a nine month follow-up of a fracture-dislocation with mild neurologic deficit which resolved completely with transpedicular decompression.
Fig. Z---Pre- and post-operative radiographsof a teenage boy with a severe fracture-dislocation managed with short segment Instrumentation and intertransverse fusion with Steffee plates. The short segment instrumentation is of obvious benefit to younger patients who will be physically very active.
234
THORACO-LUMBAR
SPINAL
INJURIES:
ROLE
OF OPERATIVE
TREATMENT
Anter;Jr Spinal Instrun.ontation Karjda c Fig. JA-Twenty-seven year old male with Ll burst fracture. Neurological deficit included cauda equina and conus medullaris lesions.
Fig. 3B-Preand post-operative crest grafting and instrumentation
Transverse Loaders
Fig. 3C-Diagrammatic representation of the instrumentation carried out for the patient in Figure 3A.
CTs of patient in Figure 3A. Anterior decompression with the Kaneda device.
cornminuted burst fracture or mildly displaced fracture-dislocation can be repaired over a short segment in a single stage. He has presented very impressive results in his own personal series of over seventy cases. l5 The healing rate is over 95% and the restoration of normal alignment of both the canal and the spinal column is virtually anatomic in the overwhelming majority of cases. Whether other surgeons can also produce this excellent result depends on many factors. However, there is no question that his approach and device have a distinct and important role in the treatment of certain injuries.
Selecting the Correct Approach The level of sophistication of surgical spinal fracture management has rapidly developed in many centres
Device with the
was carried out along with full-thickness
iliac
during the past decade and now allows repair of even the most severe injuries over short segments. Successful surgery obtains benefits of cord and root decompresrestoration and patient sion, spinal column rehabilitation. However, the improvements in surgical treatment have not replaced conservative treatment for many patients. Whether to use the surgical approach or to rely on conservative treatment depends on many factors. These include: the anatomy of the bony injury, the neural injury, the associated injuries and the hospital and post-surgical facilities and implants available for operation, aftercare, and rehabilitation. One essential part, however, is the experience of the operating surgeon in applying the technique he uses to the patient at hand. ‘The best’ approach to a given patient is the one
CURRENT
ORTHOPAEDICS
235
2. Guttmann L 1969 Spinal Deformities in Traumatic Paraplegics and Tetraplegics Following Surgical Procedures. Paraplegia 7 :38-49 3. Lewis J, McKibbin B 1974 The Treatment of Unstable Fracture-Dislocations of the Thoraco-Lumbar Spine Accompanied by Paraplegia. Journal of Bone and Jount Surgery 56B : 603-612
Fig. &Two years after surgery showing good graft consolidation and satisfactory placement of the implants following surgical reconstruction of the patient in Figure 3A.
which permits the best healing of the bony and neural injury with the least morbidity. Given the interplay of the many variables which determine the final outcome, there is probably no other area of orthopaedics which requires more judgement. Certainly, however, the best candidates for operative treatment, given ideal surgical techniques, are patients with incomplete or progressing neural injury, severely cornminuted and displaced fractures to avoid non-union or malunion and to eliminate post-traumatic deformity, and in totally paraplegic patients for the rehabilitation benefits.
References 1. Nicoll E A 1949 Fractures of the Dorso-Lumbar Spine. Journal of Bone and Joint Surgery 3 1B : 376-394
4. Roberts P H 1969 Internal Metallic Splintage in the Treatment of Traumatic Paraplegia. Injury 1: 4-l I P R, Erwin W D 1978 Results of 5. Dickson J M. Harrington Reduction and Stabilization of the Severely Fractured. Unstable Thoracic and Lumbar Spine. Journal of Bone and Joint Surgery 60A : 799-805 of 6. Gaines R W, Breedlove R F, Munson G 1984 Stabilization Thoracic and Thoracolumbar Fracture Dislocations with Harrington Rods and Sublaminar Wires. Clinical Orthopaedics and Related Research 189: 195-203 7. Jacobs R R. Asher M A, Snider R K 1980 Thoracolumbar Spine Injuries. Spine 5 : 463~.477 8. Jelsma R. 1982 Surgical Treatment of Thoracolumhsr Fractures. Surgical Neurology 18: 156-166 9. O’L.aoire S A. Thomas D G T 1981 Surgery in Incomplete Spinal Cord Injury Surgical Neurology 17: I?- 15 IO. Guttmann L 1949 Surgical Aspects of the Treatment of Traumatic Paraplegia. Journal of Bone and Joint Surgery 3 I B : 399-403 G 1982 Segmental II. Luque E R, Cassls N. Ramirer-Wiella Spinal Instrumentation in the Treatment of Fracture\ of the Thoracolumbar Spine. Spine 7 :312-3 I7 12. Osebold W R, Weinstein S R, Sprague B L I98 IThoracolumbar Spine Fractures. Spine 6: 13 34 of the 13. Stranger J K 1947 Fracture-Dislocations Thoracolumbar Spine. Journal of Bone and Joint Surgery ‘9:107--118 14. Soreff J. Axdorph G, Bylund P 1982 Treatment of Patients with Unstable Fractures of the Thoracic and Lumbar Spine. Acta Orthopaedica Scandinavica 53 :369-381 15. Kaneda K. Abumi K, Fujiya. A 1984 Burst Fractures with Neurologic Deficits of the Thoraco-Lumbar Spine. Spine 9:788%795 16 Kelly R P, W hitesides, T E 1968 Treatment of Lumbodorsal Fracture/Dislocations. Annals of Surgery 167 :705-7 I6 17 Munson G. Satterlee C. Hammond S, Betten R, Gaines R W 1984 Experimental Evaluation of Harrington Rod Fixation Supplemented with Sublaminar Wires in Stabilizing Thoracolumbar Fracture-Dislocations. Clinical Orthopaedics 189 97-101,