Management of Thoracolumbar Fracture with Posterior Decompression with Fusion and Fixation by Pedicle Screw and Rod—Our Experience

Introduction

Sixty-four percent of spine fractures occur at the thoracolumbar (TL) junction, usually at T12–L1, and 70% of these occur without immediate neurologic injury. Denis’ 3-column model of the spine attempts to identify computed tomography (CT) criteria of instability of TL spine fractures.[1] This model has generally good predictive value; however, any attempt to create “rules” of instability will have some inherent inaccuracy.[1]

The McAfee classification describes six main types of fractures.[2] A simplified system with four categories as follows: lateral and anterior most common between T6–T8 and T12–L3; lateral X-ray wedging of the vertebral body (VB) anteriorly; no loss of height of posterior VB, and no subluxation; CT spinal canal intactand disruption of the anterior end plate.[2]

Thoracolumbar injuries are the most common spinal injuries.[3] The treatment of unstable fractures and fracture dislocations of TL spine remains controversial.[4] The goal of the treatment of unstable TL injuries is to optimize neural decompression while providing stable internal fixation over the least number of spinal segments.[5] Either anterior–posterior or both approaches can be used to achieve fusion.[6] However, posterior approach is less extensive. Pedicle screw devices allow immediate stable fixation as the screws traverse all the three columns. The pedicle screws are passed one level above and one level below the fractured vertebra via posterior approach.[7]

Injuries to the thoracic and lumbar spine account for > 50% of all spinal fractures and a large portion of acute spinal cord injuries.[8] Given this frequency and the significant impact of these injuries, significant advancements have been made in the surgical treatment of TL trauma. Despite the invention and continued evolution of spinal instrumentation and surgical techniques, medical decision-making in spine trauma remains controversial. Fracture treatment can vary widely, from bracing to invasive 360-degree fusions, based on geographical, institutional, or individual preferences with little scientific basis.[8]

Several classification systems have been developed in an attempt to better define TL trauma and aid treatment decision- making. These systems are typically based on either anatomical structures (Denis 3-column system) or on proposed mechanisms of injury (Ferguson and Allen classification, and the AO system).[1] [9] [10]

Overall, however, there is a paucity of strong data supporting the use of any of these systems. Additionally, there is currently no clear consensus regarding the optimal system for characterizing TL fractures. An ideal system must be simple and reproducible based on commonly identified clinical and radiographic parameters. Current systems are either excessively convoluted, with an impractical number of variables, or are too simple, lacking sufficient detail to provide clinically relevant information. These limitations have yielded classification systems that are difficult to implement, have shown insufficient validity and reproducibility, and have not been widely popular.[10] [11] [12] [13]

• References

• 1 Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine 1983; 8 (08) 817-831
• 2 Chedid MK, Green C. A Review of the management of lumbar fractures with focus on surgical decision making and techniques. Contemp Neurosurg 1999; 21 (11) 1-12
• 3 Yue JJ, Sossan A, Selgrath C. et al. The treatment of unstable thoracic spine fractures with transpedicular screw instrumentation: a 3-year consecutive series. Spine 2002; 27 (24) 2782-2787
• 4 Shafiq K, Iqbal M, Hameed A, Mian JM. Role of transpedicular fixation in thoracolumbar spinal injuries. Neurol Surg 1998; 1: 21-27
• 5 Sar C, Bilen FE. Thoracolumbar flexion-distraction injuries combined with vertebral body fractures. Am J Orthop 2002; 31 (03) 147-151
• 6 Cordista A, Conrad B, Horodyski M, Walters S, Rechtine G. Biomechanical evaluation of pedicle screws versus pedicle and laminar hooks in the thoracic spine. Spine J 2006; 6 (04) 444-449
• 7 Lindsey C, Deviren V, Xu Z, Yeh RF, Puttlitz CM. The effects of rod contouring on spinal construct fatigue strength. Spine 2006; 31 (15) 1680-1687
• 8 National SCI Statistical Center (US). Spinal Cord Injury Facts & Figures at a Glance 2008. Birmingham, AL: The National SCI Statistical Center; 2008
• 9 Ferguson RL, Allen Jr BL. A mechanistic classification of thoracolumbar spine fractures. Clin Orthop Relat Res 1984; (189) 77-88
• 10 Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S. A comprehensive classification of thoracic and lumbar injuries. Eur Spine J 1994; 3 (04) 184-201
• 11 Blauth M, Bastian L, Knop C, Lange U, Tusch G. Inter-observer reliability in the classification of thoraco-lumbar spinal injuries [in German]. Orthopade 1999; 28 (08) 662-681
• 12 Oner FC, Ramos LM, Simmermacher RK. et al. Classification of thoracic and lumbar spine fractures: problems of reproducibility. A study of 53 patients using CT and MRI. Eur Spine J 2002; 11 (03) 235-245
• 13 Wood KB, Khanna G, Vaccaro AR, Arnold PM, Harris MB, Mehbod AA. Assessment of two thoracolumbar fracture classification systems as used by multiple surgeons. J Bone Joint Surg Am 2005; 87 (07) 1423-1429
• 14 Abeil M, Thalgott JS, Weblo JK. Stabilization Technique: Spine AO Principles in the Spine Surgery. Springer Mantra/Candevergy; Germany: 2002: 83-122
• 15 Jun DS, Yu CH, Ahn BG. Posterior direct decompression and fusion of the lower thoracic and lumbar fractures with neurological deficit. Asian Spine J 2011; 5 (03) 146-154