1. science
2. medicine
3. surgery

OUTCOME OF THORACO-LUMBAR FRACTURE
STABILIZATION BY MOSS MIAMI SPINAL
SYSTEM
(Based on the study at Department of Orthopaedics, Bir Hospital,
From February 2008 to January 2010)
Thesis Submitted to
National Academy Of Medical Sciences
Mahaboudha, Kathmandu, Nepal
In fulfillment of the requirements for the degree of
MASTER OF SURGERY (MS) IN ORTHOPAEDICS &
TRAUMA
By
Dr. Som Bahadur Ale, MBBS (KU)
February 2010
CERTIFICATE FROM THE CO-ORDINATOR
This is to certify that Dr. Som Bahadur Ale has carried out an original research work
entitled “OUTCOME OF THORACO-LUMBAR FRACTURE STABILIZATION
BY MOSS MIAMI SPINAL SYSTEM” under my supervision and guidance. His
observation and work has been checked and verified by me from time to time. This work
is submitted as his thesis for the degree of ‘Master of Surgery in Orthopaedics and
Trauma’ in accordance with the rules and regulations laid down by National Academy of
Medical Sciences.
……………………………………….
Prof. Dr. Ashok Ratna Bajracharya
MS (Ortho), MCh Orth (L’pool), Fellow of spine surgery (USA)
Co-ordinator and HOD,
Department of Orthopaedics and Trauma
National Academy of Medical Sciences.
Bir Hospital,
Kathmandu, Nepal.
CERTIFICATE FROM THE GUIDE
This is to certify that Dr. Som Bahadur Ale has carried out an original research work
entitled “OUTCOME OF THORACO-LUMBAR FRACTURE STABILIZATION
BY MOSS MIAMI SPINAL SYSTEM” under my direct supervision and guidance. His
work has been checked and verified by me from time to time. This work is submitted as
his thesis for the degree of ‘Master of Surgery in Orthopaedics and Trauma’ in
accordance with the rules and regulations laid down by National Academy of Medical
Sciences.
……………………………………….
Prof. Dr. Ashok Ratna Bajracharya
MS (Ortho), MCh Orth (L’pool), Fellow of spine surgery (USA)
Co-ordinator and HOD,
Department of Orthopaedics and Traumatology
National Academy of Medical Sciences.
Bir Hospital,
Kathmandu, Nepal.
DECLARATION
I declare that this thesis work "OUTCOME OF THORACO-LUMBAR FRACTURE
STABILIZATION BY MOSS MIAMI SPINAL SYSTEM" has not been submitted
previously in candidature for any other degree. I authorize National Academy of Medical
Sciences (NAMS) to reproduce this thesis by any means, in total or in parts, at the request
of other institutions or individual for the purpose of scholarly researches.
………………………….
Dr. Som Bahadur Ale
M.B.B.S
DEDICATED TO
ALL THE MEMBERS OF MY FAMILY
AND
TO THOSE PEOPLE WHO LOVE ME
ACKNOWLEDGEMENTS
I am deeply indebted to my distinguished guide, Prof. Dr. Ashok Ratna Bajracharya for
his valuable suggestions and supervision during the whole period of my thesis work. I
wish to express my sincere gratitude for his sustained interest and skillful guidance at
every stage of this work.
It is an honour to express my gratitude to our respected teacher Prof. Dr. Jwala Raj
Pandey who has been a source of inspiration and support at every stage of this work.
I am indebted to my teacher, Prof. Dr. Bachchu Ram K.C for his continuous help and
support.
I also express my gratitude to Prof. Dr. Buland Thapa, Prof. Shree Krishna Giri, Assoc.
Prof. Dr. Ganesh Bahadur Gurung, Assoc. Prof. Dr. Dirgha Raj RC, Col. Dr. Bhanu
Chandra Shah, Asst. Prof. Dr. Pankaj Chand, Asst. Prof. Dr. Bhoj Raj Adhikari, Dr.
Shrawan Thapa, Registrar Dr. Deepak Dutta, Maj. Dr. Amit joshi, Dr. Bishnu Babu
Thapa, Dr. Pramod Joshi, Dr. Rajram Maharjan, Dr. Rajdev Kushwaha, for their valuable
suggestions and encouragement throughout the study.
I specially thank Dr. Angel Magar and Dr. Suvash Shrestha for their valuable support
during the preparation of this study. I would like to express my sincere gratitude for
helping me in the statistical analysis of this study.
I am really thankful to all the teachers and residents of the Department of Anaesthesia and
to all the ward and OPD staffs of Bir Hospital.
I thank my colleagues, Dr. Kiran Khanal, Dr.Nirab Kayastha, Dr. Ramashish Thakur, Dr.
Rojan Tamrakar for being good friends during my entire residency. Without their support,
I would not have been able to tackle all the problems during my thesis work. Similarly, I
thank my friends from sixth and seventh batch of the faculty of Orthopedics, NAMS.
I am very much obliged to all the patients and their families, who gave consent to
participate in this study.
-Dr. Som Bahadur Ale
January 2010
CONTENTS
S. No.
Title
Page No.
1.
Executive summary
1
2.
Introduction
3
3.
Objectives
6
4.
Hypothesis
7
5.
Anatomical considerations
8
6.
Literature review
36
7.
Materials and Methods
62
7.1 Study Design
62
7.2 Place of study
62
7.3 Study period
62
7.4 Sample size
62
7.5 Inclusion criteria
62
7.6 Exclusion criteria
63
7.7 Pre operative work up of patients
63
7.8 Operative technique
67
7.9 Follow up and evaluation
69
8.
Observation and results
74
9.
Discussion
89
10.
Conclusion
94
11.
Recommendations
95
12.
Bibliography
96
13.
Appendices
Appendix 1: Proforma of the study
Appendix 2: Operative procedure photographs
Appendix 3: Master chart
LIST OF FIGURES
Figures
Page No.
Figure 1 : Development of spine ………………………………….……………………. 8
Figure 2 : Denis three column concept of spinal injury ……………………………...... 19
Figure 3 : Denis definitions of types of spinal fracture ……………………………….. 20
Figure 4 : Modified Maegerl (AO/ASIF) classification of thoracolumbar
injuries.…………………………………………………………………….…25
Figure 5 : The mid sagittal diameter of spinal canal……………………………………. 30
Figure 6 : Age of the Patients (%)……………………………………………………….74
Figure 7 : Gender distribution (%)……………………………………………... ……… 75
Figure 8 : Occupation of the patients (%)….………..…………………………….……. 76
Figure 9 : Modes of injury (%)……………………...……………………..…………… 77
Figure 10 : Type of injury (%)…………………………………………………..…….. 78
Figure 11 : Level of injury …………................................................................................ 79
Figure 12 : Neurological involvement ………………………………………………….. 80
Figure 13 : Associated injuries ……………..…..………………………………………. 81
Figure 14: Time interval between Admission and surgery ……………………..…….… 82
Figure 15 : Kyphotic deformity in degrees (%)………………………………………... 84
Figure 16 : Loss of anterior vertebral body height (%) ………………………….….…..85
Figure 17 : VAS pain Score ………………………………………………………...…... 86
LIST OF TABLES
Tables
Page No.
Table 1 :
Denis classification of spinal fracture …………..………………………..
Table 2 :
Vaccaro et al. Thoracolumbar Injury Classification (TLICS) and Injury
21
Severity Score …………………………....................................
22
Table 3 :
McAfee Classification of thoracolumbar spine fractures ……………….
23
Table 4 :
Maegerl AO (Arbeitsgemeinshaft fur Osteosynthesefragen) Classification 24
Table 5 :
Frankel grading of Neurologic deficits in patients with Spinal cord
Injuries:……………………………………………………........................ 27
Table 6 :
ASIA impairment scale ………….………………………………………
27
Table 7 :
Incomplete cord syndromes ………….……………..…………………
28
Table 8:
Denis et al’s pain scale ……………………….…………………………
72
Table 9 :
Denis et al’s work scale ……………………………………………….
72
Table 10 : Bowel and bladder involvement…………………………………..……
81
Table 11 : Regional distribution of associated injuries ………………………………. 82
Table 12 : Complications …………………………………….…………………….… 83
Table 13: Preoperative and post-operative neurological status according to
Frankel’s Grading System………………………………………………
83
Table 14: Corelation between preoperative kyphotic deformity and postoperative
kyphotic deformity …………………………………………………..
84
Table 15: The mean (SD) Loss of anterior vertebral body height preoperatively and
on immediate post operative period ……………………………………... 85
Table 16 : Time of bony fusion …................................................................................... 86
Table 17 : Correlation between VAS pain score on admission, 1st month, 3rd month
and 6th month………………………………..…………………………
Table 18 : Distribution of patients classified by Denis et al’s pain scale……………
87
88
Table 19 : Distribution of patients classified by Denis et al’s work scale…………….. 88
GLOSSARY OF ABBREVIATIONS
NAMS = National Academy of Medical Sciences
T = Thoracic
L = Lumbar
AO= Arbeitsgemeinschaft für Osteosynthesefragen
ASIF = Association for the Study of Internal Fixation
FFH = Fall from height
RTA = Road traffic accident
VAS = Visual analogue scale
ASIA = American spinal injury association
A-P = Anterior posterior
Lat= Lateral
CT = Computerized tomography
MRI = Magnetic resonance imaging
ESR = Erythrocyte sedimentation rate
HIV = Human immunodeficiency virus
HBsAg = Surface antigen for hepatitis B virus
SD = Standard deviation
TL = Thoraco-Lumbar
RGO = Reciprocating gait orthosis
HKAFO = Hip Knee Ankle Foot Orthosis
TLSO=Thoracolumbosacral orthosis
TSRH = Texas Scottish Rite hospital
CD = Cotrel-Du-boussett
1. EXECUTIVE SUMMARY
Thoracolumbar spinal injuries are serious injuries and are occurring among the productive
age group of people. Fractures and fracture dislocations of thoraco-lumbar Spine accounts
for approximately 50% of all vertebral fractures and approximately 40% of spinal cord
injuries. The goal of our treatment is to realign the spine and spinal canal, to relieve pain,
to obtain and maintain spinal stability to prevent or minimize secondary neurological
injury, to decompress directly or indirectly the neural elements and facilitate neurological
recovery as well as early rehabilitation of the patient starting from mobilization to
ambulation where possible.
This prospective interventional type of study was carried out to evaluate the outcome of
thoracolumbar fracture stabilized by Moss Miami spinal system in terms of neurological,
radiological and functional outcome. Thirty two patients were included in the study
initially, but two patients were lost after first follow up. Hence, only thirty patients were
included in the final data analysis.
The mean age of the patient was 26.9 years, majority between 15 to 25 years.
Fall from height was the most common mode of injury in 80% of the patients and
unstable burst fracture was the commonest type of injury in 60% of the patients. Similarly
first lumbar vertebra was the commonest level of injury in 56.3% of the patients. The
mean deformity correction was from 20.4 degree preoperatively to 4.6 degree
postoperatively i.e 15.80 degree. The percentage loss of anterior vertebral body height
was 53% preoperatively 10.13% in immediate post operative period and 12.83% on final
follow up. All had evidence of fusion at a mean of 5.5 months, ranging from 4 to 6
months. Neurologically 18 patients were Frankel grade A with bowel and bladder
1
involvement. Postoperatively 3 patients and 2 patients showed neurological recovery to
Frankel grades B and C respectively. Remaining 11 patients with Frankel grade B, C, D
showed recovery postoperatively by 1 or 2 grades of power.
All the patients (n=30) were followed up at regular intervals and evaluated on
the basis of neurological , radiological and functional outcome. Our results were
comparable to other similar studies done elsewhere.
Though the results in this study of short duration is very satisfactory, further studies on
larger scale and longer period of follow ups are recommended to evaluate the outcome of
thoracolumbar fracture stabilization by Moss Miami spinal system.
2
2. INTRODUCTION
Fractures and dislocations of the spine are serious injuries that mostly occur in productive
age group people. The management and evaluation of these types of injuries have
changed tremendously over the last decade with improvement of imaging technologies
and spinal instrumentation. Numerous internal fixation devices have been developed for
the treatment of unstable thoraco-lumbar spine fracture. Boucher introduced pedicle
screw fixation of the spine in the1950s. Significant advances by Roy Camille, Steffee,
Krag, Luque and the others in biomechanical design and placement technique have led to
a rapid increase in the use of pedicle screw fixation systems. Several problems existing
with multiple hook-screw-rod systems became evident and the development of Moss
Miami spinal instrumentation had the initial goals of solving the problems posed by the
existing systems. Low profile of the implant, minimum number of implants and
instruments, easy to apply closure system and avoidance of damage to bio-mechanically
important structures and stable and 360 degree fusion without anterior access are some of
the advantages which make Moss Miami spinal system a better choice in the management
of the patients with thoracolumbar instability 1.
Unstable thoracolumbar spine injuries requires stabilization to 1) Allow mobilization of
the patient to prevent pulmonary and venous complications 2) To relieve pain 3) To
realign the spine and spinal canal 4) To obtain and maintain spinal stability 5) To prevent
or minimize ‘secondary neurological injury 6) To decompress directly or indirectly the
neural elements 7) To facilitate neurological recovery in incomplete neurological deficit
as well as rehabilitation of the patient starting from mobilization to ambulation where
possible 2 .
3
Thoracic and thoracic-lumbar fractures treatment has long been in controversies. With the
increased knowledge on biomechanics and anatomy of the thoracic-lumbar region,
discussions around treatment have become deeper, especially during the 1980’s and
1990’s. During that period, the use of pedicular screws for fixing those fractures has
grown, because strong advantages were reported, such as good reduction, stabilization,
spinal cord decompression, in addition to enable early mobilization of patients after
surgery. However, there are some disadvantages, mostly inherent to the transpedicular
screws fixation, such as: risks of perforating pedicle canal walls, pedicle fracture and
involvement of nervous roots. Therefore, an accurate evaluation is required regarding
screws positioning on the spine. Magnetic resonance and computed tomography are
excellent imaging tests for evaluating screws on pedicles 3.
Fracture reduction results in an indirect decompression of the neural elements and may
lead to improved neurologic recovery. Nonoperative means usually fail to achieve an
anatomic fracture reduction in the thoracolumbar spine, therefore, early surgical treatment
in patients with partial defect is recommended. Unfortunately, surgical treatment for
complete paraplegic patients does not result in significant neurologic recovery. Early
surgical care in patients with complete paraplegia does decrease the rate of complications,
hospitalization time, and overall costs, however. Other indications for emergent surgical
care are patients with progressive neurologic deficits, open spine fractures, and burns of
the torso with concomitant unstable spine fractures 4.
Timing of surgical intervention and the effect on neurologic outcome remain
controversial. The only accepted indication for emergent surgical treatment in a patient
with a thoracolumbar fracture is progressive neurologic deterioration. This complication
4
is rare, seen in 1% to 2% of cases and may be secondary to fracture displacement,
expanding epidural hematoma, spinal cord oedema or infarction4.
A long term outcome of closed treatment in neurologically intact patients with
thoracolumbar burst fractures was recently reported by Mumford et al. They found that
66% of patients had good or excellent results at a follow-up an average of 2 years later.
Only one patient developed neurologic deterioration (2.1%). Radiagraphic follow-up of
these patients revealed an average increase of kyphosis of 30 and an improvement of the
canal compromise from an initial average of 37% (16% to 66%) to 14% (3% to 40%)
secondary to remodeling 4.
In the majority of comparison studies between surgical and non surgical treatment, it
appears that neurologic recovery is enhanced in surgically treated patients. The choice of
surgical approach and instrumentation requires a thorough understanding of fracture type,
injury level, and degree of neural injury 4. Moss Miami posterior spinal instrumentation is
a new spinal instrumentation introduced, which is a hybrid system using pedicular screws
and rods.
5
3. OBJECTIVES
(a) General Objectives
To evaluate the functional outcome of the stabilization of the traumatic unstable
thoraco- lumbar spinal fractures (T10 – L2) by moss Miami spinal system.
(b)
Specific Objectives
1. To evaluate the role of moss Miami pedicle screw fixation in decreasing the
kyphotic deformity in spinal injuries.
2. To see the neurological outcome and functional recovery of the operated cases
of traumatic unstable thoracolumbar spine.
3. To find out the complications associated with the procedures.
4. To compare the results of this study with similar studies done elsewhere.
5. To study epidemiological data on such fractures including neurological deficit
association.
6
4. HYPOTHESIS
Moss Miami pedicle screw system provides stable, reliable, segmental construct, helps in
immediate rehabilitation of patients after an unstable thoracolumbar spinal injury.
7
5. RELEVENT ANATOMY
The development of spine begins in the third week of gestation and continues until the
third decade of life. Formation of the primitive streak makes the beginning of spinal
development, which is followed by the formation of notochordal process. This process
includes neuro ectodermal, ectodermal and mesodermal differentiation.
Somites form in the mesodermal tissue adjacent to the neural tube (neuroectoderm) and
notochord. They number in 42 to 44 in humans. The somite begins to migrate in
preparation for the formation of skeletal structures. At the same time, the portion of
somites around the notochord separates into sclerotome with loosely packed cells
cephalad and densely packed cells caudally. Each sclerotome then separates at the
junction of the loose and densely packed cells. The caudal dense cells migrate to the
cephalad loose cells of the next more caudal sclerotome. The space where the sclerotome
separates eventually forms the intervertebral disc. As the vertebral bodies form, the
notochord that is in the center degenerates. The only remaining notochordal remnant
forms the nucleus pulposus which is later surrounded by circular fibres of annulus
fibrosus forming the intervertebral disc.
Figure 1. Development of spine
8
The intervertebral disc is a visco-elastic hydrodynamic shock absorbing structure
consisting of vertebral end plates, nucleus pullposus and annulus fibrosus.
Vertebral end plates form an interface between vertebral body and disc. They are made up
of thin plate of bone and a thin layer of hyaline cartilage containing type two collagen
fibres. At early life these end plates have micropores which help in diffusion of nutrients
into the disc and with increasing age the permeability of the pores decreases. Functionally
though it serves to resist compression and can undergo fatigue failure under physiological
prolonged compression stress.
Nucleus pulposus is a hydrated gel of proteoglycans consisting of sulphated
glycosaminoglycans bound to protein core and collagen fibrils. Because of the negatively
charged sulphate groups, water is attracted to the proteoglycan. This proteoglycan water
complex generates hydrodynamic turgor which keeps annular fibres elongated and under
optimum maintaining its height. Nucleus pulposus has no neural innervation.
Annulus fibrosis is a fibrocartilaginous structure arranged in concentric rings. The
collagen in the fibrocartilage structure are arranged in oblique offset from adjacent layer
and the adjacent layers are gummed by proteoglycans. This arrangement of collagen
allows motions in different planes.
In the lumbar and cervical region, the anterior annulus is thick and long while the
posterior annulus is thin and short, producing and maintaining the normal lordosis. The
outer layer of annulus fibrosis has sensory innervation whereas the inner layers are poorly
innervated.
The intervertebral disc in the adult is avascular. Rudert and Tillmann showed vascularity
of the annulus until the age of 20 years and the cartilage endplate until the age of 7 years.
9
The cells within the disc are sustained by diffuse of nutrient through the porous vertebral
endplate. Motion and weight bearing are believed to be helpful in maintain this diffusion.
At birth the vertebral column is convex dorsally, which forms the predominant sagittal
contour. However, when the erect position is acquired, compensatory cervical and lumbar
lordotic curves develop opposite the primary thoracic and sacral kyphotic curves.
The vertebral column comprises 33 vertebrae divided into five sections (seven cervical,
12 thoracic, five lumbar, five sacral, and 4 coccygeal). The sacral and coccygeal vertebrae
are fused, which typically allows for 24 mobile segments. Congenital anomalies and
variations in segmentation are common. The cervical and lumbar segments develop
lordosis as an erect posture is acquired. The thoracic and sacral segments maintain
kyphotic postures, which are found in utero, and serve as attachment points for the rib
cage and pelvic girdle. In general, each mobile vertebral body increases in size when
moving from cranial to caudal. A typical vertebra comprises an anterior body and a
posterior arch that enclose the vertebral canal. The neural arch is composed of two
pedicles laterally and two laminae posteriorly that are united to form the spinous process.
To either side of the arch of the vertebral body is a transverse process and superior and
inferior articular processes. The articular processes articulate with adjacent vertebrae to
form synovial joints. The relative orientation of the articular processes accounts for the
degree of flexion, extension, or rotation possible in each segment of the vertebral column.
The spinous and transverse processes serve as levers for the numerous muscles attached
to them. The vertebral column is composed of alternating bony vertebrae and
fibrocartilaginous disc that are connected by strong ligaments and supported by
musculature that extends from the skull to the pelvis and provides axial support to the
body. The length of the vertebral column averages 72 cm in men and 7 to 10 cm less in
10
women. The vertebral canal extends throughout the length of the column and provides
protection for the spinal cord, conus medullaris, and cauda equina. Nerve and vessels pass
through the intervertebral foramen formed by the superior and inferior border of the
pedicles of adjacent vertebrae.
The transition zone at the thoracolumbar junction makes a significant change from a stiff
thoracic spine to a mobile lumbar spine. This zone of transition across T10 to l2 is related
to the loss of the rib cage as well as the changing orientation of the facet joints. The
thoracolumbar junction also marks a transition zone from the kyphotic thoracic spine to
the lordotic lumbar spine. An additional thoracolumbar consideration is the transition
from the spinal cord to the cauda equina. This usually occurs around the L1-2 interspace5.
ANATOMY OF THE CERVICAL, THORACIC AND LUMBAR
PEDICLES
Karaikovic et al. used CT measurements to study cervical pedicle morphology and found
that C2 and C7 pedicles had larger mean interdiameters than all other cervical vertebrae,
and that C3 had the smallest mean interdiameter. The outer pedicle width-to-height ratio
increased from C2 to C7, indicating that pedicles in the upper cervical spine (C2-4) are
elongated, whereas pedicles in the lower cervical spine (C6-7) are rounded. It also is
crucial to know that cervical pedicles angle medially at all levels, with the most medial
angulation at C5 and the least at C2 and C7. The pedicles slope upward at C2 and C3, are
parallel at C4 and C5 and are angled downward at C6 and C7.
The pedicle cortex is not uniformly thick, and that the medial cortex toward the spinal
cord is almost twice as thick as the lateral cortex.
11
Pedicle dimensions and angles change progressively from the upper thoracic spine
distally. In 2905 pedicle measurements made from T1 to L5, pedicles were widest at L5
and narrowest at T5 in the horizontal plane. The widest pedicles in the sagittal plane were
at T11, and the narrowest were at T1. Because of the oval shape of the pedicle, the
sagittal plane width was generally larger than the horizontal plane width. The largest
pedicle angle in the horizontal plane was at L5. In the sagittal plane, the pedicles angle
caudad at L5 and cephalad at L3-T1. The depth to the anterior cortex was significantly
longer along the pedicle axis than along a line parallel to the midline of the vertebral body
at all levels except T12 and L1.
The thoracic pedicle is a convoluted, three-dimensional structure that is filled mostly with
cancellous bone (62% to 79%). Panjabi et al. showed that the cortical shell is of variable
density throughout its perimeter, and that the lateral wall is significantly thinner than the
medial wall. This seemed to be true for all levels of thoracic vertebrae. A study by Kothe
et al. also showed that the medial wall is thicker than the lateral wall of the thoracic
pedicle, and they found that most pedicle fractures related to screw insertion occurred
laterally.
The pedicles of the thoracic and lumbar vertebrae are tube like bony structures that
connect the anterior and posterior columns of the spine. Medial to the medial wall of the
pedicle lies the dural sac. Inferior to the medial wall of the pedicle is the nerve root in the
neural foramen. The lumbar roots usually are situated in the upper third of the foramen; it
is more dangerous to penetrate the pedicle medially or inferiorly as opposed to laterally or
superiorly.
There are three techniques for localization of the pedicle: (1) the intersection technique,
(2) the pars interarticularis technique, and (3) the mammillary process technique. The
12
intersection technique is perhaps the most commonly used method of localizing the
pedicle. It involves dropping a line from the lateral aspect of the facet joint, which
intersects a line that bisects the transverse process at a spot overlying the pedicle. The
pars interarticularis is the area of bone where the pedicle connects to the lamina. Because
the laminae and the pars interarticularis can be identified easily at surgery, they provide
landmarks by which a pedicular drill starting point can be made. The mammillary process
technique is based on a small prominence of bone at the base of the transverse process.
This mammillary process can be used as a starting point for transpedicular drilling.
Usually the mammillary process is more lateral than the intersection technique starting
point, which also is more lateral than the pars interarticularis starting point. With the help
of preoperative CT scanning at the level of the pedicle and intraoperative radiographs, the
angle of the pedicle to the sagittal and horizontal planes can be determined5.
CIRCULATION OF SPINAL CORD
The main arterial of the spinal cord are:
1.
Anterior spinal artery –is a midline vessel that lies in the anterior median fissure. It is
usually larger than the posterior spinal arteries and runs the whole length of the cord,
it becomes small at places especially in the thoracic region, that it may be considered
absent.
2.
Posterior spinal artery-is usually double forming longitudinal trunks that run through
and behind the posterior nerve rootlets for the whole length of the cord.
3.
Radicular arteries-has an important contribution to reinforce the longitudinal trunks as
they form anastomoses with the anterior and posterior spinal arteries. Their most
characteristic feature is their variability in number and position. Blood incoming from
them may flow up and or down the cord. The largest of the feeder vessels, radicularis
13
magna (the great redicular artery of Adamkiewicz), originates on the left side between
the T9 and T11 vertebral segments and supplies the lower two thirds of the spinal
cord via the anterior spinal artery. When damaged or obstructed, it can result in
anterior spinal artery syndrome with loss of bowel and bladder continence and
impaired motor functions of the legs, sensory function often preserved to a degree.
The blood supply to the spinal cord is rich but the spinal canal is narrowest and the blood
supply is poorest at T4-9. T4-9 should be considered the critical vascular zone of the
spinal cord, a zone in which interference with the circulation is most likely to result in
paraplegia5.
VENOUS DRAINAGE
Dommisse pointed out two sets of veins:
1. Those of the spinal cord, and
2. Batson plexus
The veins of the spinal cord are a small component of the entire system and drain into the
batson plexus.
The batson plexus is a large and complex venous channel which communicates directly
with the venous system draining the head, chest and splanchnic plexus of abdomen. These
veins are valveless and the interconnection allows metastatic spread of neoplastic or
infectious disease from abdomen to the vertebral column5.
14
NEURAL ELEMENTS
The spinal cord is a cylindrical, grayish white structure that begins above at the foramen
magnum, where it is continuous with the medulla oblongata of the brain. It terminates
below in the adult at the level of the lower border of the first lumbar vertebra. In the
young child it is relatively longer and and ends at the upper border of the third lumbar
vertebra. There are cervical and lumbar enlargements in the cord which gives origin to
brachial and lumbosacral plexus respectively.
At the lower border of L1 vertebra the spinal cord tapers off into the conus medullaris
from the apex of which a prolongation of the pia matar, the filum terminale, descends to
be attached to the back of the coccyx. The cord possesses in the midline anteriorly a deep
longitudinal fissure, and on the posterior surface a shallow fissure, the posterior median
sulcus6.
The canal contains the spinal meninges and the spinal cord with its nerve roots. The bony
walls of the canal are separated from the contained meninges by the epidural spaces also
known as the extradural space which contains fat and the veins. The extradural fat
extends laterally into the invertebral foramen with the nerve roots within their dural
sheaths.
The organization of the neural elements is strictly maintained throughout the entire neural
system even within the conus medullaris and cauda equinna distally. It follows a highly
organized pattern with the most cephalad root lying lateral and the most caudal lying
centrally. the motor roots are vertebral at the level. The arachnoid matar holds the roots in
the position.
15
The pedicle is the key to understand surgical anatomy. The relation of the pedicle to the
neural element varies by region within the spinal column. In the cervical region, there are
seven vertebrae but eight cervical roots therefore accepted nomenclature allows each
cervical root exit cephalad to the pedicle of the vertebrae. The relationship changes in
thoracic spine because the eight cervical root exit between C7 and T1 pedicle requiring
T1 root to exit caudal to the pedicle for which it is named the relationship is maintained
throughout the remaining caudal segments. Discs are named in all levels for the vertebral
level immediately cephalad. Similarly relationship exists in lumbar spine.
MECHANISMS OF INJURY
A. Axial compression – within the thoracolumbar region, an axial load commonly
produces a nearly pure compressive load to the vertebral bodies. If the load is sufficient to
produce a bony injury, there initially is failure of the end plate. With increasing loads, a
vertebral body wedge compression fracture is produced with fracturing of the anterior
portion of the body.
B. Flexion – flexion forces generally compress the vertebral body and produce tensile
forces posteriorly. If the posterior osteoligamentous complex remains intact, a stable
injury generally persists. A posterior ligamentous injury is presumed to have occurred to
some degree when more than 50% of the vertebral body height is compromised at the
time of injury.
C. Lateral compression - Lateral compression forces produce injuries similar to those
found after flexion forces, although they occur along the lateral aspect of the vertebral
body. The injuries may be limited to a fracture of the lateral body or they may have an
associated posterior ligamentous disruption, contralateral ligamentous disruption or both.
16
D. Flexion- rotation - Flexion- rotation injuries generally include an anterior bony injury
and the addition of rotational forces leads to an increasingly greater likelihood of
posterior ligamentous and facet capsular failure. Mostly flexion rotation injuries lead to
both anterior and posterior column injuries of the thoracolumbar spinal segment.
E. Shear – pure shear forces often cause significant posterior ligamentous injuries. Shear
forces may produce an anterior, posterior and a lateral listhesis.
F. Flexion- distraction – These injuries are more commonly referred to as seat belt
injuries.
G. Extension – pure extension injuries are rare and present with injury patterns opposite
of those caused by more common flexion injuries and leads to tensile failure beginning
anteriorly with compressive forces applied posteriorly. Most extension injuries are
stable7.
SPINAL STABILITY
Punjabi & white advocate that clinical stability is present when, under normal
physiological load, the spinal column is capable of maintaining its pattern without
displacement so that there is no additional neurological deficient, no major deformity and
no incapacitating pain.
Mechanical instability is defined by the presence of injuries to two or more of the three
columns which allows abnormal motion across the injured spinal segments.
Clinical instability is defined as the loss of ability of spine under physiological loads to
maintain relationship between vertebrae in such a way that there is neither damage nor
subsequent irritation to the spinal cord or nerve roots and without causing incapacitating
17
pain or deformity from structural damage. This can result from trauma, disease, surgery
or combination.
Neurological Instability: Some burst fractures without neurological injury initially are at
risk of developing it at later date. This late onset is from increasing kyphosis, post
traumatic collapse due to osteoporosis.
Classification of thoracolumbar fractures
Holdsworth classification
Holdsworth classified thoracolumbar fractures into five groups according to the
mechanism of injury8.
(1) pure flexion, which causes a stable wedge compression fracture;
(2) flexion and rotation, which produce an unstable fracture-dislocation with rupture of
the posterior ligament complex, separation of the spinous processes, a slice fracture
near the upper border of the lower vertebra and dislocation of the lower articular
processes of the upper vertebra;
(3) extension, which causes rupture of the intervertebral disc and the anterior longitudinal
ligament and avulsion of a small bone fragment from the anterior border of the
dislocated vertebra—this dislocation almost always reduces spontaneously and is
stable in flexion;
(4) vertebral compression, which causes a fracture of the end plate as the nucleus of the
intervertebral disc is forced into the intervertebral body, causing it to burst, with
outward displacement of fragments of the body—because the ligaments remain intact,
this comminuted fracture is stable;
18
(5) Shearing, which results in displacement of the whole vertebra and an unstable fracture
of the articular processes or pedicles.
Denis three column concept of spinal injury
Denis developed a three column concept of spinal injury9.
The anterior column contains the anterior longitudinal ligament, the anterior half of the
vertebral body, and the anterior portion of the annulus fibrosus.
The middle column consists of the posterior longitudinal ligament, the posterior half of
the vertebral body and the posterior aspect of the annulus fibrosus.
The posterior column includes the neural arch, the ligamentum flavum, the facet capsules
and the interspinous ligaments. Denis noted that one or more of the three columns
predictably failed in axial compression, axial distraction or translation from combinations
of forces in different planes.
Figure 2. The spine can be considered as a three-column structure. ( from: Garfin S,
Blair B, Eismont F, Abitbol J. Thoracic and upper lumbar spine injuries.
In: Browner B, Jupiter JB, Levine A, Trafton P, editors. Skeletal trauma.
2nd ed. Philadelphia: W.B. Saunders Company; 1998. p 967--981.)
19
Denis classification of thoracolumbar trauma9
Figure 3. Denis definitions of types of spinal fracture. (From Denis F. The threecolumn spine and its significance in the classification of acute
thoracolumbar spinal injuries. Spine. 1983;8:817-831.)
20
Table 1: Denis classification of spinal fracture
Fracture type
Compression
Mechanism
Flexion
Anterior
Anterior flexion
Lateral
Lateral flexion
Burst
Compression
A
Axial Load
B
Axial Load plus flexion
C
Axial Load plus flexion
D
Axial Load plus rotation
E
Axial Load plus lateral
flexion
Seat-belt type Flexion-distraction
Columns involved
Anterior column compression with or without
Posterior column distraction
Compression
Anterior and middle column compression
with or without Posterior column distraction
Anterior column intact or distracted ;
middle column and Posterior column
distraction
Fracture
Compression,
dislocation
rotation , shear
Flexion rotation
Flexion -rotation
Shear
Flexiondistraction
Any columns can be affected (alone or in
combination)
Shear(anterior-posterior
or posterior –anterior)
Flexion-distraction
Vaccaro et al. Thoracolumbar Injury Classification and Injury Severity
Score
Vaccaro et al. proposed the Thoracolumbar Injury Classification and Injury Severity
Score to assist in the determination of when operative treatment of the thoracolumbar
spine is appropriate. The score is developed from an algorithm in which points are
collected in a sequential evaluation of the injury .The items considered in order are (1) the
fracture mechanism, (2) the integrity of the posterior ligament complex, and (3) the
21
neurological status of the patient. The fracture mechanism is determined from plain
radiographs and CT scans, neurological involvement is determined by physical
examination, and the integrity of the posterior ligamentous complex is determined by the
method most familiar to the examiner, which may include physical examination, plain
radiographs, CT, and MRI. A point value is assigned to each segment of the three injury
components, and these points are totaled7.
Table 2.
Vaccaro et al. Thoracolumbar Injury Classification (TLICS) and Injury
Severity Score
Points
Fracture Mechanism
Compression fracture
1
Burst fracture
1
Translation/rotation
3
Distraction
4
Posterior Ligamentous Complex Integrity
Intact
0
Injury suspected/indeterminate
2
Injured
3
Neurological Involvement
Intact
0
Nerve root
2
Cord, conus medullaris, incomplete
3
Cord, conus medullaris, complete
2
Cauda equine
3
22
Patients with scores of 3 or less should do well with nonoperative treatment, whereas
patients with scores of 5 or more require surgery. Nonoperative or operative treatment
may be appropriate for patients with 4 points; clinical qualifiers (e.g., comorbid medical
conditions, multisystem polytrauma, and closed head injury) must be evaluated to
determine if operative treatment is indicated.
McAfee et al. classification
McAfee et al. determined the mechanisms of failure of the middle osteoligamentous
complex and developed a new system based on these mechanisms7.
Table 3: McAfee Classification of thoracolumbar spine fractures
Injury Type
Pathology
Wedge-compression
fracture
Isolated anterior column failure
Stable burst fracture
Anterior and middle-column compression failure, posterior
column intact
Unstable burst fracture
Compressive failure of anterior and middle columns,
disruption of posterior column
Chance fracture
Horizontal vertebral avulsion injury with center of rotation
anterior to vertebral body
Flexion-distraction injury
Compressive failure of anterior column, tensile failure of
posterior column. The center of rotation is posterior to
anterior longitudinal ligament
Translational injuries
Disruption of spinal canal alignment in transverse plane,
shear mechanism common
23
Maegerl
AO
(Arbeitsgemeinshaft
fur
Osteosynthesefragen)
Classification
This Swiss system remains the basis for modern fracture fixation. It classifies
thoracolumbar fractures into 3 major groups, based on the three primary forces applied to
the spine10.
Table 4. Maegerl AO (Arbeitsgemeinshaft fur Osteosynthesefragen) Classification
A. Compression
A1
Wedge
A2
Split or coronal
A3
Burst
B. Distraction
B1
Distraction of the posterior soft tissues (subluxation)
B2
Distraction of the posterior arch (Chance fracture)
B3
` Distraction of the anterior disc (extension spondylolysis)
C. Multi-directional with translation
C1
Anterior-posterior (dislocation)
C2
Lateral (lateral shear)
C3
Rotational (rotational burst)
The AO classification is commonly used, as it provides a comprehensive classification
describing the nature of injury, the degree of instability, and prognostic aspects that are
important for choosing the most appropriate treatment.
24
It is very detailed and descriptive classification system with rationale for determining
treatment and prognosis.
Figure 4. Modified Maegerl (AO/ASIF) classification of thoracolumbar injuries.
(from Gertzbein SD. Spine update. Classification of thoracic and lumbar
fractures. Spine. 1994;19:626-628.)
25
Neurologic classification
American spinal injury Association (ASIA) defines a complete neurologic lesion as an
absence of sensory and motor function below the level of injury including the lowest
sacral segment2. Although patients can be in “spinal shock”, when all reflex activities are
lost, Stauffer et al have demonstrated that a bulbocavernosus reflex returns within 24
hours in 99% of patients, thus indicating the end of spinal shock. Complete injuries have
a less than 3% chance of functional motor recovery if no neurological return is seen
within 24 hours and have no chance of neurological recovery after 24 to 48 hours.
A lesion is incomplete if sensory, motor, or both functions are partially present below the
neurological level of injury. Sacral sensation at the mucocutaneous junction and the
presence of voluntary contraction of the external anal sphincter on digital examination
should be carefully elicited as this may be the only sign of preserved function. Patients
with incomplete neurological injuries are expected to improve, with many regaining the
ability to ambulate.
Spinal Injury
The level of neurological injury is graded at the lowest nerve root level that has at least
antigravity strength. Overall gross function of patients with spinal cord injuries is
assessed by the Frankel classification. This scale has recently been modified by ASIA.
26
Table 5. Frankel grading of Neurologic deficits in patients with Spinal cord Injuries:
Grade
Description
A
Absent motor and sensory function
B
Sensation present, motor function absent
C
Sensation present, motor function active but not useful (grade 2-3/5)
D
Sensation present, motor function active and useful (grade 4/5)
E
Normal motor and sensory function
Table 6. ASIA impairment scale
Grade
Description
A
Complete: No sensory or motor function below level of neurologic deficit
level. Sacral sparing is absent.
B
Incomplete. Sensory but not motor function is preserved below the
neurologic deficit level
C
Incomplete. Motor function is preserved below the neurologic deficit
level, and the majority of key muscles below the neurologic deficit level
has a muscle grade lower than 3
D
Incomplete. Motor function is preserved below the neurologic deficit
level, and the majority of key muscles below the neurologic deficit level,
has a muscle grade higher or equal to 3.
E
Sensory and motor function is normal
27
Table 7. Incomplete cord syndromes
Syndrome
Description
Anterior cord
A lesion that produces variable loss of motor function and of
sensitivity to pain and temperature, while preserving proprioception
Brown-Sequard
A lesion that produces relatively greater ipsilateral proprioceptive and
motor loss and contralateral loss of sensitivity to pain and temperature
Central cord
A lesion, occurring almost exclusively in the cervical region, that
produces sacral sensory sparing and greater weakness in the upper
limbs than in the lower limbs
Dorsal cord
(posterior cord)
A lesion occurring almost in the dorsal sensory column mainly
affecting proprioception
Conus medullaris Injury of the sacral cord (conus) and lumbar nerve roots within the
neural canal, which usually results in an areflexic bladder, bowel, and
lower limbs. Sacral segments may occasionally show preserved
reflexes. E.g., bulbocavernosus and micturition reflexes.
Cauda equina
Injury to the lumbosacral nerve roots within the neural canal resulting
in areflexic bladder, bowel and lower limbs.
Neurological injury of spinal cord
The Primary injuries which occur at the time of injury are contusion, compression, stretch
and laceration. The secondary injuries which occur later as a result of ischaemia, Swelling
that accompany all spinal injuries .Late sequelae
are chronic pain and delayed
neurological deterioration due to spinal deformity, residual spinal compression, scar
formation and post traumatic Syringomyelia4.
28
Radiologic evaluation
Plain radiographs
High quality anteroposterior and lateral radiographs are obtained to evaluate and classify
deformities in Sagittal and coronal planes. The AP film should be examine for loss of
vertebral
height and width of vertebrae, Widening of interpedicular distance , fracture of the
pedicles, laminae, transverse process or rib fractures, malalignment of vertebral bodies or
spinous process without a history of scoliosis. The size of the pedicles of the vertebra
above and below the injured one is assessed for the placement of pedicular screws. The
lateral view is best form of imaging to locate the injury level. The lateral radiograph is
examined for loss of body height, disruption of superior or inferior end plate, posterior
cortical wall fracture with retropulsed bone, fracture of spinous processes, widening of
interspinous distance, subluxation or angulation of vertebral bodies and anterior or
posterior translation.
CT scan
Computerized tomography (CT) better delineates the bony structures once an injury is
identified. A CT scan reveals the integrity of the middle column, the degree of canal
compromise, the intactness of pedicles planned for screw placement as well as
subluxations or fractures of facets and lamina. The presence of two bodies on the same
axial cut of a CT scan may indicate a fracture subluxation or dislocation, but first assure
that the gantry has been angled in parallel to the vertebral endplates. Sagittal
reconstructions are helpful in visualizing flexion--distraction injuries and fracture
dislocations. Contrast CT scan can also diagnose dural tears or root avulsions.
29
Measurement of canal diameter
The Percentage of Spinal Canal Compromise:
a = (1 - x/y) ×100
a = percentage of canal compromise
Figure 5: The mid sagittal diameter of spinal canal.
x = mid-sagittal diameter of spinal canal at the level of injury
y = average mid-sagittal diameter of the spinal canal
(one level above and on level below the level of injury)
Magnetic resonance imaging (MRI)
Magnetic resonance imaging (MRI) can demonstrate spinal cord pathology and the
presence of neural compression. Other soft tissue injuries and the state of the
intervertebral disc can be identified. MRI is indicated in patients with progressive
neurologic deterioration, incongruous neurologic and skeletal injury, and unexplained
neurologic deficit. MRI can also be used to assess the status of the posterior ligamentous
complex. MRI can locate conus. It is useful at thoracolumbar junction due to variable
location of conus medullaris. A low lying conus in upper lumbar burst fracture may be
indicated for decompression. It can diagnose ligamentous instability in absence of bony
injury as well as traumatic syringomyelia. The disadvantages are patients with respiratory
distress, metallic implants.
30
Goals of surgery
The goals of surgery are to reduce fracture and dislocations, stabilize the injured segment
and decompress the neural elements.
Fracture reduction results in an indirect
decompression of the neural elements and may lead to improved neurologic recovery.
Because nonoperative means usually fail to achieve an anatomic fracture reduction in the
thoracolumbar spine, therefore, early surgical treatment in patients with partial defects is
recommended. Unfortunately, surgical treatment for complete paraplegic patients does
not result in significant neurologic recovery. Early surgical treatment in patients with
complete paraplegia does decrease the rate of complications, hospitalization time, and
overall costs, however. Other indications for emergent surgical care are patients with
progressive neurologic deficits, open spine fractures, and burns of the torso with
concomitant unstable spine fractures
Timing of surgery
Timing of surgical intervention and the effect on neurologic outcome remain
controversial. The only accepted indication for emergent surgical treatment in a patient
with a thoracolumbar fracture is progressive neurologic deterioration. This complication
is rare, seen in 1% to 2% of cases and may be secondary to fracture displacement,
expanding epidural hematoma, spinal cord edema, or infarction. In patients with complete
spinal cord injuries or static spinal cord injuries, some authors advocate delaying surgery
for several days to allow resolution of cord oedema whereas other favor early surgical
stabilization. There is no conclusive evidence in the literature that early surgical
decompression and stabilization improve neurological recovery or that neurological
recovery is compromised by a delay of several days.
31
DEFINITIVE TREATMENT
Non operative management
The non operative treatment is recommended for compression fractures with less than
50% loss of anterior column height and less than 30 degrees of kyphosis, stable burst
fractures and bony chance fractures. This treatment includes postural reduction, bed rest,
wearing a thoracolumbar sacral orthosis (TLSO) or a hyperextension orthosis and
observation. The patients are allowed to function and participate in normal activities of
daily living while in the brace. The brace is normally worn fulltime for an average of 3
months.
Non operative treatment is considered to have failed if there is significant progression of
the kyphosis, the development of a neurological deficit or residual painful instability at
the injured segment. These patients generally benefit from operative treatment.
Surgical treatment
The choice of surgical approach and instrumentation requires a thorough understanding of
fracture type, injury level, and degree of neural injury. Patients who have a distractive
injury of the posterior elements that occurs in flexion-distraction injuries, Chance-type
injuries, and fracture-dislocations are best treated with posterior instrumentation. Patients
with unstable burst injuries and incomplete paraplegia associated with high-grade spinal
canal stenosis may benefit in the long term from immediate anterior decompression.
Patients with unstable burst fractures and lesser degrees of canal stenosis are treated by
posterior instrumentation.
32
Indications of operative treatment
A. Absolute indications:
1. Unstable fractures, mechanically & neurologically
2. Progressive neurological deficit
B. Relative indications:
1. Incomplete neurological lesion
2. Kyphotic deformity>20 degree
3. Lateral angulation or scoliosis of 15 degree
4. Translocation >10 degree
5. Loss of vertebral body height >50%
6. Ankylosing spondylitis
There are three components of operative treatment:
a. Stabilization with instrumentation
b. Decompression
c. Fusion
Types of instrumentation
a. Distraction : Harrington, Locking spinal rods
b. Segmental fixation system: Luque rods, TSRHS, Cotrel-Du-bousset (CD)
instrumentation.
c. Pedicle screw system : rod screw, plate screw e.g Moss Miami posterior spinal
instrumentation
Moss Miami posterior spinal instrumentation is a new spinal instrumentation introduced,
which is a hybrid system using pedicular screws and rods.
33
Decompression
The role of decompression also is controversial. Compression of the neural elements by
retropulsed bone fragments can be relieved indirectly by the insertion of posterior
instrumentation or directly by exploration of the spinal canal through a posterolateral or
anterior approach. There is no universal agreement as to indications for each of these.
The posterior decompression of the spinal canal is an indirect approach and generally
involves insertion of posterior instrumentation. This technique uses the distraction
instrumentation and the intact posterior longitudinal ligament to reduce the retropulsed
bone from the spinal canal. Numerous authors have documented excellent results with
this technique, and it is a familiar technique to most orthopaedic surgeons. Problems with
this technique occur if surgery is delayed for three weeks or more because indirect
reduction of the spinal canal cannot be achieved with posterior instrumentation alone. In
addition, severely comminuted fractures with multiple pieces of bone pushed into the
spinal canal and severe canal compromise (>50%) may not be completely reduced by
distraction instrumentation.
The posterolateral technique for decompression of the spinal canal is effective at the
thoracolumbar junction. This procedure involves hemilaminectomy and removal of a
pedicle with a high-speed burr to allow posterolateral decompression of the dura along its
anterior aspect. The posterolateral decompression for thoracolumbar fractures is less
traumatic than thoracolumbar approach for anterior decompression of this area. However,
anterior decompression can be followed by replacement with cage and bone graft whereas
after posterolateral decompression, graft or cage replacement is not possible.
34
The anterior approach allows direct decompression of the thecal sac, but is an unfamiliar
approach to many surgeons. Visceral and vascular structures may be injured, and this
approach carries the greatest risk of potential morbidity. In addition, anterior
decompression and placement of an iliac strut graft provide no immediate stability to the
fracture, unless anterior internal fixation is used. The role of anterior internal fixation
devices is rapidly evolving, and these devices have proved to be safe and beneficial in
achieving spinal stabilization. When anterior and middle column are destroyed, the use of
posterior stabilization procedures as an indirect stabilization in such situation now has
been eliminated with these anterior stabilization.
Early posterior instrumentation is favoured in an attempt to achieve anatomical reduction
of the fracture. If residual neural compression exists, a posterior or posterolateral
decompression is done. Posterior decompression is mandatory in patients with posterior
laminar fractures because of the increased frequency of dural tears with exposed nerve
roots and the possibility of severe posttraumatic arachnoiditis.
Postoperatively, a CT scan of the spine with sagittal reconstructions is obtained through
the injured segment to evaluate further the patency of the spinal canal.
35
6. LITERATURE REVIEW
Sangam SS et al. (2008)1 performed a prospective study in 50 cases to evaluate the role of
Moss Miami pedicle screw fixation in decreasing the deformity and bony union in spinal
injuries and to see the neurological recovery and functional outcome of the operated cases
of traumatic unstable thoracolumbar spine. Fifty patients (48 males and 2 females with
mean age of 29.68years) having traumatic insult to the thoracolumbar spine of less than
two weeks duration resulting in unstable fracture/subluxation or dislocation with
incomplete or complete neurological deficit were included in the study. Spine was fixed
with Moss Miami Spinal System. Roadside accidents (40%) and fall from height (36%)
were the most common mode of injury. There was clustering of trauma around the
thoracolumbar junction i.e.D12 and L1 levels (42%). Mean kyphotic deformity
preoperatively was19 degree and postoperatively it was 3 degree. Majority of the patients
recovered 1 or 2 grades of power according to ASIA Scale. The results were evaluated on
the basis of neurological, radiological and functional outcome and were excellent and
good in 84% cases and poor in 16% cases. Faulty screw placement in 6, nut loosening in
4, and implant pullout in 2, bursitis over implant in 3 and loss of correction in 6 were the
complications related to the system. Moss Miami pedicle screw system provides stable,
reliable, truly segmental construct helps in immediate rehabilitation of patients suffering
from traumatic unstable thoracolumbar spine.
Stambough JL et al. (1997)2 published an article on posterior instrumentation for
thoracolumbar trauma. Clin Orthop Relat Res. 1997 Feb; (335):73-88. The majority of
thoracolumbar spine fractures and fracture dislocations may be considered acute sagittal
plane deformities. Unstable thoracolumbar spine injuries require stabilization to (1) allow
mobilization of the patient to prevent pulmonary and venous complications; (2) to relieve
36
pain; (3) to realign the spine and spinal canal, and (4) to decompress directly or indirectly
the neural elements. Posterior spinal instrumentation is a safe, available, familiar, and
effective method to achieve these goals. Posterior spinal instrumentation techniques used
rod hook systems or screw rod and screw plate systems. Most of these unstable injuries
can be managed using these well established techniques without the need for additional
combined or staged anterior spinal surgery.
Mikles MR et al. (2004)3 published an article on posterior instrumentation for
thoracolumbar fractures. 2004 Nov-Dec;12(6):424-35. Thoracolumbar fractures are
relatively common injuries. Numerous classification systems have been developed to
characterize these fractures and their prognostic and therapeutic implications. Recent
emphasis on short, rigid fixation has influenced surgical management. Most compression
and stable burst fractures should be treated nonsurgically. Neurologically intact patients
with unstable burst fractures that have >25 degrees of kyphosis, >50% loss of vertebral
height, or >40% canal compromise often can be treated with short, rigid posterior fusions.
Patients with unstable burst fractures and neurologic deficits require direct or indirect
decompression. Advances in understanding both biomechanics and types of fixation have
influenced the development of reliable systems that can effectively stabilize these
fractures and permit early mobilization.
Lin HS et al. (2002)11 conducted a prospective study to review their experience in treating
thoracolumbar fractures with Moss Miami System and vertebra anterior distraction device
Twenty-eight patients with thoracolumbar fractures admitted in the Department of
Trauma and Reconstructive Surgery (Unfallkrankenhause, Berlin, Germany) were treated
by posterior fixation with Moss Miami system and anterior decompression, followed by
autologous bone grafting and anterior distraction device stabilizing implant. Death
37
occurred in none of the cases and no patients exhibited signs of neurologic damages both
intraoperatively and postoperatively, with the only exception that disruption of the dura
mater of the spinal cord occurred in 1 case intraoperatively. Follow-up study lasting for a
mean period of 11.8 months was conducted in all the cases, which found that the position
of Moss Miami system and implanted ADD remained unchanged in 24 cases, in
comparison with their position as shown by postoperative imaging data. In 3 cases,
however, ADD was inlaid in the vertebral body, with an angle correction loss of which
was less than 5 degrees. Lateral obliquity and displacement of ADD was found in 1 case.
Of the 5 incomplete paraplegic patients, 3 achieved complete habilitation of neurologic
function and 2 had partial improvement. Moss Miami system and anterior distraction
device constitute good modalities in treating thoracolumbar fractures, with such merits as
thorough decompression of the spinal canal, reliable fixation to allow early force loading
with less correction loss of the angle, and are therefore suitable for treating unstable
thoracolumbar fractures.
Kaya RA et al. (2004)12 performed a prospective study on modified transpedicular
approach for the surgical treatment of severe thoracolumbar or lumbar burst fractures.
Conventional transpedicular decompression of the neural canal requires a considerable
amount of lamina, facet joint and pedicle resection. The authors assumed that it would be
possible to remove the retropulsed bone fragment by carving the pedicle with a highspeed drill without destroying the vertebral elements contributing to spinal stabilization.
In this way, surgical treatment of unstable burst fractures can be performed less
invasively. The purpose of this study is to demonstrate both the possibility of neural canal
decompression through a transpedicular approach without removing the posterior
vertebral elements, which contribute to spinal stabilization and the adequacy of posterior
stabilization of severe vertebral deformities after burst fractures. Twenty-eight
38
consecutive patients with complete or incomplete neurological deficits as a result of the
thoracolumbar burst fractures were included in this study. All patients had severe spinal
canal compromise (mean, 59.53%+/-14.92) and loss of vertebral body height (mean,
45.14%+/-7.19). Each patient was investigated for neural canal compromise, degree of
kyphosis at fracture level and fusion after operation by computed tomography and direct
roentgenograms taken preoperatively, early postoperatively and late postoperatively. The
neurological condition of the patients was recorded in the early and late postoperative
period according to Benzel-Larson grading systems. The outcome of the study was
evaluated with regard to the adequate neural canal decompression, fusion and reoperation
percents and neurological improvement. Modified transpedicular approach includes
drilling the pedicle for removal of retropulsed bone fragment under surgical microscope
without damaging the anatomic continuity of posterior column. Stabilization with pedicle
screw fixation and posterior fusion with autogenous bone chips were done after this
decompression procedure at all 28 patients included in this study. Twenty-three of 28
patients showed neurological improvement. The percent of ambulatory patients was
71.4% 6 months after the operation. The major complications included pseudoarthrosis in
five patients (17.8%), epidural hematoma in one (3.5%) and inadequate decompression in
one (3.5%). These patients were reoperated on by means of an anterior approach. Of the
five pseudoarthrosis cases, two were the result of infection. Although anterior
vertebrectomy and fusion is generally recommended for burst fractures causing canal
compromise, in these patients adequate neural canal decompression can also be achieved
by a modified transpedicular approach less invasively.
Yue JJ et al. (2002)13 conducted a 3 year consecutive series on the treatment of unstable
thoracic spine fractures with transpedicular screw instrumentation. The treatment of
unstable thoracic spine fractures remains controversial. Theoretical biomechanical
39
advantages of transpedicular screw fixation include three-column control of vertebral
segments and fixation of a vertebral segment in the absence of intact posterior elements.
Additionally, pedicle screw constructs may obviate the need for neural canal dissection
and potential neural element impingement by intracanal instrumentation. A 3-year
consecutive series was performed to evaluate the use of transpedicular screw fixation in
the treatment of unstable thoracic spine injuries. This study was performed to evaluate the
efficacy of transpedicular screw fixation in the upper, middle, and lower thoracic spine.
The use of rod/hook and rod/wiring techniques has been evaluated in the treatment of
thoracic spine injuries. To date, a study evaluating the safety and efficacy of pedicle
screw instrumentation in the upper, middle, and lower thoracic spine has not been
reported. Thirty-two patients with 79 individual vertebral injury levels (T2-L1) treated
with transpedicular spinal stabilization and bone fusion were evaluated during a 3-year
consecutive series from 1998 to 2001. Patient charts, operative reports, preoperative and
postoperative radiographs, computed tomography scans, and postoperative follow-up
examinations and radiographs were reviewed from the time of surgery to final follow-up
assessment. Radiographic measurements included: sagittal index, Gardner segmental
kyphotic deformity, and compression percentage. A total of 252 pedicle screws were
placed, of which 222 were placed in segments T2-L1. Clinical examination and plain
radiographs were used to determine the presence of a solid fusion. Fracture healing and
radiographic stabilization occurred at an average of 4.8 months after the initial operation.
There were no reported cases of hardware failure, loss of reduction, or painful hardware
removal. Two hundred fifty-two transpedicular screws were successfully placed without
intraoperative complications. The mean preoperative sagittal index was 13.9 degrees,
whereas the mean follow-up was 5.25 degrees (P < 0.001). The mean final correction of
sagittal index achieved was 8.65 degrees, or a 62.2% improvement. The mean Gardner
40
segmental kyphotic angle was 15.9 degrees, whereas the mean follow-up angle was 10.6
degrees (P < 0.0005). The mean compression percentage was 35.4, and at follow-up was
27.4 (P < 0.07). In carefully selected instances, pedicle screw fixation of upper, middle,
and lower thoracic and upper thoracolumbar spinal injuries is a reliable and safe method
of posterior spinal stabilization. Transpedicular screw fixation may offer superior threecolumn control in the absence of posterior element integrity and obviates the need for
intracanal placement of hardware. Transpedicular instrumentation provides rigid fixation
for upper, middle, and lower unstable thoracic spine injuries and produces early pain-free
fusion results. These results provide evidence that with appropriate preoperative
radiographic evaluation of pedicular size and orientation using computed tomography as
well as radiograph assessment, transpedicular instrumentation is a safe and effective
alternative in the treatment of unstable thoracic (T2-L1) spinal injuries.
Knop C et al. (2000)14 conducted a prospective study on surgical treatment of injuries of
the thoracolumbar transition: Operation and roentgenlogic findings .The authors report on
a prospective multicenter study with regard to the operative treatment of acute fractures
and dislocations of the thoracolumbar spine (T10-L2). The study should analyze the
operative methods currently used and determine the results in a large representative
collective. This investigation was realized by the working group "spine" of the German
Trauma Society. Between September 1994 and December 1996, 682 patients treated in 18
different traumatology centers in Germany and Austria were included. Part 2 describes
the details of the operative methods and measured data in standard radiographs and CT
scans of the spine. Of the patients, 448 (65.7%) were treated with posterior, 197 (28.9%)
with combined posterior-anterior, and 37 (5.4%) with anterior surgery alone. In 72% of
the posterior operations, the instrumentation was combined with transpedicular bone
grafting. The combined procedures were performed as one-stage operations in 38.1%. A
41
significantly longer average operative time (4:14 h) was noted in combined cases
compared to the posterior (P < 0.001) or anterior (P < 0.05) procedures. The average
blood loss was comparable in both posterior and anterior groups. During combined
surgery the blood loss was significantly higher (P < 0.001; P < 0.05). The longest
intraoperative fluoroscopy time (average 4:08 min) was noticed in posterior surgery with
a significant difference compared to the anterior group. In almost every case a "Fixateur
interne" (eight different types of internal fixators) was used for posterior stabilization. For
anterior instrumentation, fixed angle implants (plate or rod systems) were mainly
preferred (n = 22) compared to non-fixed angle plate systems (n = 12). A decompression
of the spinal canal (indirect by reduction or direct by surgical means) was performed in
70.8% of the neurologically intact patients (Frankel/ASIA E) and in 82.6% of those with
neurologic deficit (Frankel/ASIA grade A-D). An intraoperative myelography was added
in 22% of all patients. The authors found a significant correlation between the amount of
canal compromise in preoperative CT scans and the neurologic deficit in Frankel/ASIA
grades. The wedge angle and sagittal index measured on lateral radiographs improved
from -17.0 degrees and 0.63 (preoperative) to -6.3 degrees and 0.86 (postoperative). A
significantly (P < 0.01) stronger deformity was noted preoperatively in the combined
group compared to the posterior one. The segmental kyphosis angle improved by 11.3
degrees (8.8 degrees with inclusion of the two adjacent intervertebral disc spaces). A
significantly better operative correction of the kyphotic deformity was found in the
combined group. In 101 (14.8%) patients, intra- or postoperative complications were
noticed, 41 (6.0%) required reoperation. There was no significant difference between the
three treatment groups. Of the 2264 pedicle screws, 139 (6.1%) were found to be
misplaced. This number included all screws, which were judged to be not placed in an
optimal direction or location. In seven (1.0%) patients the false placement of screws was
42
judged as a complication, four (0.6%) of them required revision. The multicenter study
determines the actual incidence of thoracolumbar fractures and dislocations with
associated injuries and describes the current standard of operative treatment. The efforts
and prospects of different surgical methods could be demonstrated considering certain
related risks. The follow-up of the population is still in progress and the late results
remain for future publication.
Lutaka AS et al. (2006)15 evaluated if computed tomography is a good analysis method
for pedicular screws positioning and the potential complications of surgically passing
them. Nineteen patients have been studied, totaling 134 screws, during the period ranging
from November 2002 to February 2005, regarding X-ray, tomography and pre- and
postoperative neurological function analyses. As a result, there were two cases of injury
on pedicle’s lateral wall at the tomography image, with no clinical repercussion to
patients. Regarding neurological deficit, no patient showed a worse condition. Six
patients presented with an improved neurological status. We concluded that computed
tomography is an excellent imaging test for evaluating pedicular screws, and this kind of
fixation was safe and showed low morbidity rates, allowing an early mobilization of the
patient.
Khan I et al.6 conducted a study on Thoracolumbar junction injuries and their
management with pedicle screws to evaluate the use of pedicle screw fixation in
earthquake injured thoracolumbar spine. Nineteen patients with posttraumatic instability
of lower thoracic or upper lumbar spine were included in the study. White and Panjabi
criteria was used to assess spinal instability. All patients underwent open reduction and
internal fixation by posterior approach. Pedicles were localized using detailed anatomical
landmarks and intraoperative imaging. . Local bone was used as bone graft. The
43
neurological status of the patients and any other complications were noted up to one year.
There were 19 patients with unstable thoracolumbar junction injuries who were managed
with pedicle screws and rods. Females were more affected (F:M ratio was 8.5:1). Wedge
compression was the commonest. None of the patients deteriorated after surgery. There
were 20 Frankel improvements in 18 patients (1.11 Frankel on average) with neurological
deficit whereas 1 patient in Frankel E remained in the same grade on subsequent followups. There was one patient with wound infection and one patient developed DVT. None
of the patients developed bedsores.
Pedicle screw fixation is a useful choice for thoracolumbar junction injuries for achieving
reduction and stability in both anterior and posterior column injuries, without affecting
extra motion segments.
Butt MF et al. (2007)17 published an article on Management of unstable thoracolumbar
spinal injuries by posterior short segment spinal fixation. Fifty patients with
thoracolumbar fractures were treated operatively between July 2000 and December 2001.
The average age of the patients was 33.6 years (range: 20–50 years), 36 were males and
14 were females and the follow-up averaged 59 months (range: 49–68 months). A fall
from a height, usually a tree, was the most common cause of injury. Twenty six patients
had unstable burst fractures and 13 had translational injury. There were 15 patients with
complete neurological deficit, 17 had partial neurological lesions, while 18 had no
neurological deficit. All patients were treated by posterior short segment fixation (Steffee
VSP). The average pre-operative kyphotic angle was 21.48°, which improved to 12.86° in
the immediate post-operative period. The loss of kyphosis averaged 3.46° (0–26°) at the
final follow-up. The average pre-operative anterior vertebral body height was 44.7%
(range: 36–90%), which improved to 72.0% (range: 55–97%) in the immediate post-
44
operative period. The loss of body height averaged 3.0% (range: 1–15%) at the final
follow-up. No neurological deterioration was seen, and in 24 cases a one grade or better
improvement was observed. The mean pain score was 1.6, and the mean functional score
was 2.8. We found that the application of posterior instrumentation resulted in a
reasonable correction of the deformity with a significant reduction in recumbencyassociated complications; there were, however, significant other complications.
Khan AA et al. (2008)18 performed a retrospective study to report the surgical outcome of
thoracolumber fractures treated with short-segment pedicle instrumentation. A
retrospective review of all surgically managed thoracolumbar fractures during two years
was performed. 84 surgically managed patients were instrumented by the short-segment
technique. Patient’s charts, operation notes, preoperative and postoperative radiographs,
computed tomographic scans, magnetic resonance imaging was done. Neurological
findings (Frankel functional classification), and follow-up records up to 6 months were
reviewed. Transpedicular fixation was performed in 84 cases including 52 male and 32
female with male to female ratio 1.6:1.Mean±SD of age was 40±13.75 years (range15–
60). The level of injuries was different in different age groups. Outcome was assessed on
Frankel grading. No patient showed an increase in neurological deficit. Most of the
patients showed improvement to the next grade. Screw breakage occurred in 8 cases, bed
sores in 16 cases and deep vein thrombosis in 3 cases. Misplaced screw in 5 cases. Eight
cases got wound infection and concluded that although long term follow-up evaluation
needs to verified, the short term follow-up results suggest a favourable outcome for shortsegment instrumentation. The development of transpedicular screw fixation techniques
and instrumentation systems has brought short-segment instrumentation into general
clinical practice.
45
Achakzai N et al. (2009)19 performed a study to evaluate the clinical accuracy and safety
of placement of pedicle screws in thoracolumbosacral spine without per-operative
imaging. Forty consecutive patients with thoracolumbosacral spine instability were
operated using transpedicular screws from T9 to S1 by a single surgeon from January December 2008. Among these forty patients, the cause of instability was trauma (60%),
tuberculosis (32.5%) and spondylolisthesis (7.5%). All forty patients underwent pedicle
screws placement at different levels by using free hand technique taking into account
anatomical land marks, specific pedicle entry points and angulations in sagittal and
coronal planes.
A total of 170 screws were inserted at different levels, as follows: T9 (n=2), T10 (n=6),
T11 (n=10), T12 (n=34), L1 (n=22), L2 (n=36), L3 (n=16), L4 (n=23), L5 (n=13), S1
(n=8). Post-operative plain radiographs (AP, Lateral) confirmed 12 (7.06%) violated
screws and concluded that Pedicle screws placement in thoracolumbosacral spine with a
free hand technique seems to be accurate, reliable and reasonably safe when performed in
a step wise manner taking into account anatomical landmarks. It reduces operative time
and saves the surgical team from radiation hazards as well.
Marin F et al. (2001)20 conducted a prospective clinical trial on anterior Decompression
and Fixation versus Posterior Reposition and Semi rigid Fixation in the Treatment of
Unstable
Burst
Thoracolumbar
Fracture.
Twenty-five
patients
with
unstable
thoracolumbar fracture underwent either anterior decompression and fixation (n=13) or
posterior reposition and semirigid fixation by hook-rod with pedicle screw fixation
(n=12), depending on the type of implants available at the time of operation.
Neurologically injured patients were operated on within the first 8 hours and
neurologically intact patients within the first 2 days after the fracture. Neurological
46
improvement was assessed according to the American Spinal Injury Association grading
scale and the Prolo economic/function outcome scale. We also recorded operation time,
blood loss, cosmetic outcome, hospital stay and cost, complications, and donor site pain.
There were no significant differences between the two groups in either neurological
improvement (p=0.86) or favorable economic or function outcome (p=0.54 and p=0.53,
respectively). The operation time was shorter in the posterior approach group than in the
anterior approach group (median 174 min, range 130-215, vs median 250 min, range 200295, respectively, p<0.001). The blood loss was smaller in the posterior approach group
(median 750 mL, range 500-1,100, vs median 1,362 mL, range 1,150-1,500, in the
anterior approach group; p<0.001). The posterior approach group also had better esthetic
outcome, lower hospital cost, lower complication rate, and no donor site pain and
concluded that Both surgical techniques were equally effective in neurological
improvement and functional outcome. Posterior surgery can be recommended in
emergency neurodecompression and fixation of unstable thoracolumbar fractures because
of the shorter operation time and smaller blood loss.
Parker JW et al. (2000)21 performed a retrospective review of all the surgically managed
spinal fractures at the University of Missouri Medical Center during the 41/2-year period
from January 1989 to July 1993. Of the 51 surgically managed patients, 46 were
instrumented by short-segment technique (attachment of one level above the fracture to
one level below the fracture). The other 5 patients in this consecutive series had multiple
trauma. These patients were included in the review because this was a consecutive series.
However, they were grouped separately because they were instrumented by long-segment
technique because of their multiple organ system injuries. The choice of the anterior or
posterior approach for short-segment instrumentation was based on the Load-Sharing
Classification published in a 1994 issue of Spine. The purpose of this review was to
47
demonstrate that grading comminution by use of the Load-Sharing Classification for
approach selection and the choice of patients with isolated fractures who are cooperative
with spinal bracing for 4 months provide the keys to successful short-segment treatment
of isolated spinal fractures. The current literature implies that the use of pedicle screws
for short-segment instrumentation of spinal fracture is dangerous and inappropriate
because of the high screw fracture rate. Charts, operative notes, preoperative and
postoperative radiographs, computed tomography scans, and follow-up records of all
patients were reviewed carefully from the time of surgery until final follow-up
assessment. The Load-Sharing Classification had been used prospectively for all patients
before their surgery to determine the approach for short-segment instrumentation. Denis’
Pain Scale and Work Scales were obtained during follow-up evaluation for all patients.
All patients were observed over 40 months except for 1 patient who died of unrelated
causes after 35 months. The mean follow-up period was 66 months (51/2 years). No
patient was lost to follow-up evaluation. Prospective application of the Load-Sharing
Classification to the patients’ injury and restriction of the short-segment approach to
cooperative patients with isolated spinal fractures (excluding multisystem trauma
patients) allowed 45 of 46 patients instrumented by the short-segment technique to
proceed to successful healing in virtual anatomic alignment and concluded that the LoadSharing Classification is a straightforward way to describe the amount of bony
comminution in a spinal fracture. When applied to patients with isolated spine fractures
who are cooperative with 3 to 4 months of spinal bracing, it can help the surgeon select
short-segment pedicle-screw-based fixation using the posterior approach for less
comminuted injuries and the anterior approach for those more comminuted. The choice of
which fracture–dislocations should be strut grafted anteriorly and which need only
48
posterior short-segment pedicle-screw-based instrumentation also can be made using the
Load-Sharing Classification.
Tae-Sob Shin et al. (2007)22 published a literature on Short-segment Pedicle
Instrumentation of Thoracolumbar Burst-compression Fractures; Short Term Follow-up
Results .The purpose of this study is to report the short term results of thoracolumbar
burst and compression fractures treated with short-segment pedicle instrumentation. A
retrospective review of all surgically managed thoracolumbar fractures during six years
was performed. The 19 surgically managed patients were instrumented by the shortsegment technique. Patients' charts, operation notes, preoperative and postoperative
radiographs (sagittal index, sagittal plane kyphosis, anterior body compression, vertebral
kyphosis, regional kyphosis), computed tomography scans, neurological findings (Frankel
functional classification), and follow-up records up to 12-month follow-up were
reviewed. No patients showed an increase in neurological deficit. A statistically
significant difference existed between the patients preoperative, postoperative and followup sagittal index, sagittal plane kyphosis, anterior body compression, vertebral kyphosis
and regional kyphosis. One screw pullout resulted in kyphotic angulation, one screw was
misplaced and one patient suffered angulation of the proximal segment on follow-up, but
these findings were not related to the radiographic findings. Significant bending of screws
or hardware breakage were not encountered.
Although long term follow-up evaluation needs to verified, the short term follow-up
results suggest a favorable outcome for short-segment instrumentation. When applied to
patients with isolated spinal fractures who were cooperative with 3-4 months of spinal
bracing, short-segment pedicle screw fixation using the posterior approach seems to
provide satisfactory result.
49
Celebi L et al. (2004)23 evaluated the results of short-segment posterior instrumentation of
thoracolumbar burst fractures and investigated correlations between radiographic and
functional results as well as factors that affected correction losses.48 patients (30 males,
18 females; mean age 40±14 years; range 18 to 67 years) who underwent short-segment
posterior instrumentation with pedicle screws and fusion were reviewed. The most
common involvement was at L1 in 18 patients (37.5%), followed by T12 in 11 patients
(22.9%). According to the Frankel grading system, six patients had complete, 14 patients
had incomplete neurologic deficits. The Cobb angles were measured, and canal
remodeling was assessed by computed tomography. Modified functional results were
derived using the Denis pain and work scales. The mean follow- up was 21.7±9.1 months
(range 12 to 48 months). The mean correction in the Cobb angle was 18.2±8.6° (p<0.01),
the mean correction loss was 7.4±5.7° (p<0.01), and the mean canal remodeling was
51.3±9.3% (p<0.001). There was a significant correlation between Cobb angle correction
and correction loss (r=0.38, p<0.01). An intraoperative correction of greater than 15° was
significantly associated with a greater correction loss (p<0.05). Patients with a correction
loss of more than 10° had a significantly poorer Denis pain score and modified functional
result (p<0.05). Modified functional results were excellent in 16 patients (33.3%), good in
23 patients (47.9%), fair in seven patients (14.6%), and poor in two patients (4.2%). At
final follow- ups, the Cobb angle was not correlated with functional results (p>0.05). All
the patients having incomplete neurologic deficits improved by at least 1 Frankel grade
and concluded that an intraoperative correction exceeding 15° is significantly associated
with a greater correction loss, which in turn has a significantly adverse effect on
functional results.
Li-Yang Dai et al. (2009)24 conducted a controlled clinical trial to define the effect of
fusion on lumbar spine and patient-related functional outcomes. From2000 to 2002,
50
seventy-three consecutive patients with a single-level Denis type-B burst fracture
involving the thoracolumbar spine and a load-sharing score of £6 were managed with
posterior pedicle screw instrumentation. The patients were randomly assigned to
treatment with posterolateral fusion (fusion group, n = 37) or without posterolateral
fusion (non fusion group, n = 36). The patients were followed for at least five years after
surgery and were assessed with regard to clinical and radiographic outcomes. Clinical
outcomes were evaluated with use of the Frankel scale, the motor score of the American
Spinal Injury Association, a visual analog scale, and the Short Form-36 (SF-36)
questionnaire. Radiographic outcomes were assessed on the basis of the local kyphosis
angle and loss of kyphosis correction. No significant difference in radiographic or clinical
outcomes was noted between the patients managed with the two techniques. Both
operative time and blood loss were significantly less in the nonfusion group compared
with the fusion group (p < 0.05). Twenty-five of the thirty-seven patients in the fusion
group still had some degree of donor-site pain at the time of the latest examination.
Posterolateral bone-grafting is not necessary when a Denis type-B thoracolumbar burst
fracture associated with a load-sharing score of £6 is treated with short-segment pedicle
screw fixation.
Yousry Eid et al. (1999)25 conducted a study to report the results of short segment pedicle
screw fixation in unstable fracture of the thoracolumbar spine with or without
neurological deficits. Out of seventeen patients, all were males. The thoracolumbar
junction was affected in 64.7% of cases. Radiologically, 60% of patients had burst
fractures. The cob method was used to measure the degree of kyphotic deformity. All the
patients were operated upon after an average of 3.2 days. The procedure included
reduction of the deformity. Short segment pedicle screw fixation using the Varifix version
of the Wiltse system was used. Decompression was done when needed. Postoperatively,
51
an intensive rehabilitation started as soon as possible. By the end of the final follow up
period, which averaged about 21 months, the overall results were satisfactory in 13
patients (76.4%). Satisfactory results were obtained in all patients with burst fractures and
only 42.8 % of patients with fracture – dislocation. In all patients with neurological
deficits, a variable degree of recovery has occurred. The degree of kyphotic deformity has
been corrected significantly on the immediate postoperative x rays and remained so
throughout the period of follow up. They concluded that pedicle screw fixation of a short
segment (two motion segments) for unstable thoracolumbar fractures gives satisfactory
results. This is true provided that adequate restoration of the neural canal is achieved
either directly or indirectly. The addition of posterior fusion of the stabilized segments
would improve the overall results, especially for the more unstable injuries with fracture –
dislocations.
Altay M et al. (2007)26 performed a retrospective study was to compare the outcomes of
the SS- and long-segment posterior fixation (LSPF) in unstable thoracolumbar junction
burst fractures (T12–L2) in Magerl Type A fractures. The patients were divided into two
groups according to the number of instrumented levels. Group I included 32 patients
treated by SSPF (four screws: one level above and below the fracture), and Group II
included 31 patients treated by LSPF (eight screws: two levels above and below the
fracture). Clinical outcomes and radiological parameters (sagittal index, and canal
compromise) were compared according to demographic features, localizations, loadsharing classification (LSC) and Magerl subgroups, statistically. The fractures with more
than 10° correction loss at sagittal plane were analyzed in each group. The groups were
similar with regard to age, gender, LSC, SI, and CC preoperatively. The mean follow-ups
were similar for both groups, 36 and 33 months, respectively. In Group II, the correction
values of SI, and CC were more significant than in Group I. More than 10° correction loss
52
occurred in six of the 32 fractures in Group I and in two of the 31 patients in Group II.
SSPF was found inadequate in patients with high load sharing scores. Although
radiological outcomes (SI and CC remodeling) were better in Group II for all fracture
types and localizations, the clinical outcomes (according to Denis functional scores) were
similar except Magerl type A33 fractures. We recommend that, especially in patients,
who need more mobility, with LSC point 7 or less with Magerl Type A31 and A32
fractures (LSC point 6 or less in Magerl Type A3.3) without neurological deficit, SSPF
achieves adequate fixation, without implant failure and correction loss. In Magerl Type
A33 fractures with LSC point 7 or more (LSC points 8–9 in Magerl Type A31 and A32)
without severe neurologic deficit, LSPF is more beneficial.
Korovessis P et al. (2006)27 carried out a randomized, blinded, controlled trial on
Combined Anterior Plus Posterior Stabilization Versus Posterior Short-Segment
Instrumentation and Fusion for Mid-Lumbar (L2-L4) Burst Fractures with a mean 46 to
48-month follow-up in a hospital in Greece. 40 patients (78% men) with L2 to L4 lumbar
Type-A3 burst fractures caused by a fall from a height or a traffic accident. Inclusion
criteria were a Magerl classification of A3 with a combined load-sharing score of ≤6, a
single-level injury, and a fracture that had occurred within the previous week. Exclusion
criteria were multiple trauma, severe osteoporosis, spinal deformity, degenerative or other
spinal stenosis, or previous spinal or abdominal surgery. Follow-up was 100%. Patients
were allocated to combined anterior (including partial corpectomy) and posterior
stabilization with use of a mesh cage filled with autologous iliac bone graft and SSTF,
including 1 vertebra above and below the fractured vertebra (n = 20), or to posterior SSTF
alone (n = 20). Main outcome measures: Operative outcomes (time, blood loss, and
hospital stay), loss of correction (Gardner angle), neurologic deterioration (Frankel
53
grade), pain (visual analogue scale [VAS]), and functional outcome (Short Form-36 [SF36]).
Patients who received combined surgery had a longer operative time, more blood loss,
and a longer hospital stay than patients who received posterior SSTF alone. The Gardner
angle loss of correction was 2° in the combined surgery group and 5° in the group that
had posterior SSTF alone. The Gardner angle was significantly correlated with spinal
canal encroachment in the posterior SSTF alone group before surgery (p < 0.01), after
surgery (p < 0.01), and at the time of final follow-up (p < 0.001), while the correlation
was only significant with the combined surgery group at the time of final follow-up (p <
0.001). No neurologic deterioration occurred after surgery in either group. At the time of
follow-up, the Frankel grade was correlated with spinal canal clearance in patients who
received posterior SSTF alone (p < 0.02). VAS scores did not differ between groups; SF36 scores in the domains of bodily pain and physical function improved in the posterior
SSTF alone group. VAS and SF-36 scores were not correlated with loss of kyphotic angle
correction or anterior or posterior vertebral body height ratio in either group.
Conclusions: In patients with burst fractures of the second, third, and fourth lumbar
vertebrae, combined anterior and posterior short segment transpedicular fixation (SSTF)
was associated with longer operative times, more blood loss, and a longer hospital stay
than posterior SSTF alone. Although some increased loss of correction occurred in the
group that had posterior SSTF alone, the SF-36 scores were better.
James JY et al. (2002)28 reported the results of pedicle screw fixation in unstable upper,
middle, and lower thoracic and thoracolumbar spine injuries .Eighteen patients with 28
individual vertebral injury levels (T3 to L1), treated with transpedicular posterolateral
spinal fusion with autologous bone graft, were evaluated during a 3-year consecutive
54
series from 1997 to 2000. Charts, operative reports, preoperative and postoperative
radiographs, CT scans, and postoperative follow-up reports and radiographs were
reviewed from the time of the surgical procedure to the final follow-up assessment.
Patients treated with anterior and posterior fusion were excluded. Postoperatively, all
patients were placed in appropriate external bracing. A complete neurologic examination
was performed on admission and at a follow-up and graded according to the modified
Frankel classification. The fracture type was classified according to the OTA
classification system. On admission, anteroposterior and lateral radiographs were
obtained with the patient lying on a bed, whereas all other radiographs were made with
the patient in a standing or seated position. The following parameters were measured
manually on lateral radiographs by three different examiners, and the mean value was
used for statistical analysis: sagittal index (SI), Gardner segmental kyphotic deformity
(GSKD), and compression percentage (CP). Eighteen patients, 13 men and 5 women
(mean age, 41.3 years, range, 21 to 76), with 28 individual vertebral injury levels (T3 to
L1) were reviewed. The median follow-up was 18 months (range, 10 to 30). The causes
of injury were high-energy trauma in 16 and pathologic lesion in 2. The levels of injury
were T1 to T4 (5), T5 to T8 (10), T9 to T12 (7), and L1 (5). Flexion and extension
radiographs were used to determine the presence of a solid fusion. Fusion occurred at an
average of 3.8 months after the initial operation. There were no reported cases of implant
failure or loss of reduction. Fracture types consisted of 25 compression fractures (14
A3.3, 1 A3.2, 9 A3.1, and 1 A1.1) and 1 flexion subluxation with rotation fracture (C2.1).
Associated injuries consisted of various neurologic deficiencies recorded with the
modified Frankel classification, with no patient regressing in Frankel grade after surgical
reduction and fixation. The mean preoperative SI was 13.9°, and the mean at follow-up
was 5.25° (P <0.001). The mean final correction of SI achieved was 8.65°, or a 62.2%
55
improvement. The mean preoperative GSKD angle was 15.9°, and the mean at follow-up
was 10.6° (P <0.0005). The mean final correction in Gardner angle was 5.3°, or a 33.3%
improvement. The mean preoperative CP was 35.4, and the mean follow-up CP was 27.4
(P <0.07). The mean final correction in CP was 8, or a 22.5% correction. Pedicle screw
fixation of thoracic and thoracolumbar spinal injuries is a reliable and safe method of
posterior spinal stabilization. Advantages include three-dimensional correction in the
presence and/or absence of posterior elements, early mobilization, and indirect spinal
canal decompression. Transpedicular instrumentation provides rigid fixation for upper,
middle, and lower unstable thoracic and thoracolumbar spine injuries and appears to
produce early pain-free fusion results. These results will provide more evidence that
transpedicular instrumentation is safe and effective in the treatment of unstable thoracic
and thoracolumbar spinal injuries.
Nasser MG et al. (2001)29 conducted a prospective study to evaluate the posterior screw
instrumentation for management of unstable thoracolumbar spine injuries. Diapason
pedicular screw rod system was used in 37 patients that had unstable thoracolumbar spine
injuries twenty four patients were neurologically intact while the remaining 13 patients
had neurological deficit. Magerl’s classification, modified frankel grade different
measurements of structural deformities with various imaging modalities was used in
preoperative assessment. Reduction technique, neural structure decompression and
stabilization of the spine were evaluated. The outcome after a minimum of six months
from the surgical procedure was discussed and analyzed. The complications encountered
were investigated. Faulty implant placements, failure of reduction, neurological deficit
were encountered. Posterior neural arch fracture, marked spinal canal encroachment and
gross soft tissue failure were risk factors. Its relation to pre operative assessment,
operative technique and postoperative management were reviewed. Certain precautions
56
and modification of the technique were suggested to improve the final outcome of such
demanding injuries.
George MW et al. (2010)30 conducted a study to evaluate the biomechanical
characteristics of spinal instrumentation constructs in a human unstable thoracolumbar
burst fracture model simulated by corpectomy. The objective of the study was to compare
the biomechanical characteristics of short-segment posterior instrumentation, with and
without crosslinks, in a human unstable burst fracture model simulated by corpectomy.
Six fresh frozen human spines (T10–L2) were potted to isolate the T11–L1 segments, and
biomechanically tested in axial rotation, lateral bending, flexion, and extension. A custom
spine testing system was used that allows motion with 6 degrees of freedom. After testing
was completed on intact specimens, a corpectomy was performed at T12 to simulate an
unstable burst fracture with loss of anterior and middle column support. Short-segment
transpedicular instrumentation was then performed from T11 to L1. Each specimen was
retested with 1, 2, or no crosslinks. Construct stiffness and motion data were analyzed
with each intact specimen serving as its own internal control. Torsional stiffness in axial
rotation was significantly increased (P < 0.05) in short-segment fixation constructs with 1
and 2 crosslinks, but none was restored to the preinjury baseline level. Significant
reductions in standardized motion were also achieved with 1 and 2 crosslinks compared
to no crosslinks (P < 0.05), but they remained greater than baseline. Crosslinks
significantly increased stiffness and decreased motion in lateral bending, beyond the
baseline level (P < 0.05). In flexion, all constructs had significantly decreased stiffness
and increased motion compared to the intact specimen (P < 0.05), with crosslinks
providing no additional benefit. Conversely, none of the constructs demonstrated a
significant change in extension compared to baseline (P > 0.05). When attempting to load
the constructs to failure, screw pullout was seen in all specimens. Crosslinks, when added
57
to short-segment posterior fixation, improve stiffness and decrease motion in axial
rotation, but do not restore baseline stability in this corpectomy model. Short-segment
posterior fixation is also inadequate in restoring stability in flexion with injuries of this
severity. Short-segment posterior instrumentation alone can achieve baseline stability in
lateral bending, and crosslinks provide even greater stiffness.
Acosta FL et al.31 carried out a study to compare the biomechanical performance of the
following 3 fixation strategies for spinal reconstruction after decompression for an
unstable thoracolumbar burst fracture: 1) short-segment anterolateral fixation; 2)
circumferential fixation; and 3) extended anterolateral fixation. Thoracolumbar spines
(T10–L4) from 7 donors (mean age at death 64 6 6 years; 1 female and 6 males) were
tested in pure moment loading in flexion–extension, lateral bending, and axial rotation.
Thoracolumbar burst fractures were surgically induced at L-1, and testing was repeated
sequentially for each of the following fixation techniques: short-segment anterolateral,
circumferential, and extended anterolateral. Primary and coupled 3D motions were
measured across the instrumented site (T12–L2) and compared across treatment groups.
Circumferential and extended anterolateral fixations were statistically equivalent for
primary and off axis range-of-motions in all loading directions, and short-segment
anterolateral fixation offered significantly less rigidity than the other 2 methods. The
results of this study strongly suggest that extended anterolateral fixation is
biomechanically comparable to circumferential fusion in the treatment of unstable
thoracolumbar burst fractures with posterior column and posterior ligamentous injury. In
cases in which an anterior procedure may be favored for load sharing or canal
decompression, extension of the anterior instrumentation and fusion one level above and
below the unstable segment can result in near equivalent stability to a 2-stage
circumferential procedure.
58
Leferink VJM et al. (2002)32 performed a prospective study to evaluate the functional
outcome of operatively treated patients with a thoracolumbar burst fracture, operatively
treated with pedicle screw internal fixation, transpedicular cancellous bone grafting, and
dorsal spondylodesis. Ventral fusion was not pursued. The aim of the study is to develop
insight in the impairments in these patients, and also in their ability to participate in daily
living, in their possibilities to return to work and in their quality of life as defined by the
World Health Organization (WHO) in the International Classification of Function,
Disability and Health (ICF). Patients operated for a type A fracture (Comprehensive
Classification CC) of the thoracolumbar spine (T10-L4) between 1993 and 1998 in the
University Hospital Groningen, the Netherlands, aged between 18 and 60 years, without
neurological deficit, were included in the study. Exclusion criteria were spinal disorders
in the medical history (including low back pain previously treated by a medical
specialist), pathological fractures and insufficient command of the Dutch language. The
Medical Ethics Committee of the University Hospital Groningen approved the study
protocol (Nr. 99/12/206). Within these criteria a group of 35 patients could be identified.
Eleven patients did not respond, four refused to join the study, and one patient agreed to
participate in the study, but did not show up at several appointments. Eventually nineteen
patients joined the study. The mean age of the respondents was 40.5 years (range 24-57,
SD 10.3), ten patients were male and nine were female. Etiologic factors were traffic
accidents (n=3), accidental fall from height (n=10) and accidents of sports (horse riding,
motor sports and parachute jumping) (n=6). Fracture levels are merely T12 and L1 and
the CC of the typeA fractures shows 68% A3 fractures. Three patients had multiple
fractures at other locations. In all patients the Injury Severity Score (ISS) was derived
from the codes of the 9th version of the International Classification of Diseases (ICD-9)
[12]. Mean ISS was 10.6 (range 9-22). One patient suffered from diabetes mellitus, two
59
from cardiovascular ischaemic disease and two from chronic obstructive pulmonary
disease. Respondents did not differ in fracture severity, co-morbidity, age & gender from
non respondents.
Lukas R et al. (2006)33 conducted a study to evaluate the indications and results of the
surgical treatment of thoracolumbar fractures. Total of 64 patients (22 women and 42
men, with a mean age of 43 years) with unstable spinal fractures treated operatively in
2001 in our institution. Patients with multiple fractures, osteoporosis and spinal cord
injury were not included in this study. Three subgroups were identified according to the
surgical approach. 1) 22 patients operated through anterior approach. 2) 22 patients were
operated by combined anterior-posterior approach. 3) 20 patients treated by isolated
posterior approach. All patients were preoperatively investigated by plain X-ray, CT and
MRI. Classification was performed after complete imaging. Patients with posterior
column intact were indicated for anterior approach and patients with posterior column
injury were indicated for posterior approach. The extent and severity of damage in
anterior column was classified according to LSC in all cases. Six and more points in this
classification meant that anterior approach must be added to the surgical treatment. The
patients were followed for at least 22 months after operation. Transpedicular fixator,
when applied exclusively, was routinely removed after fracture was healed. The endplates angle of the fractured vertebra was assessed after operation and at the end of
follow-up. Type B fractures were most frequent in our series and occurred in 29 patients.
Neither instrumentation failure nor any significant loss of reduction was observed in the
first and second groups. In the third group, mean loss of reduction was 3.1°.Progress in
imaging technologies provokes the changes in use of traditional classification schemes.
They concluded that adequate imaging examination (X-ray, CT, and MRI) is crucial for
accurate fracture classification including prognostic aspects. Classification viewed in this
60
fashion is the adequate guideline for the selection of the operative approach. Properly
selected surgical approach is effective in the prevention of operative treatment failure.
Lee SH et al. (2009)34 conducted a study to compare the effect of fixation level and
variable duration of postoperative immobilization on the outcome of unstable
thoracolumbar burst fractures treated by posterior stabilization without bone grafting.
A randomized, prospective, and consecutive series was conducted at a tertiary level
medical center. Thirty-six neurologically intact (Frankel type E) thoracolumbar burst
fracture patients admitted at our institute between February 2003 and December 2005
were randomly divided into three groups. Group I (n = 15) and II (n = 11) patients were
treated by short-segment fixation, while Group III ( n = 10) patients were treated by longsegment fixation. In Group I ambulation was delayed to 10th-14th postoperative day,
while group II and III patients were mobilized on third postoperative day. Anterior body
height loss (ABHL) percentage and increase in kyphosis as measured by Cobb's angle
were calculated preoperatively, postoperatively, and at follow-up. Denis Pain Scale and
Work Scales were obtained during follow-up. Mean follow-up was 13.7 months (range 327 months). At the final follow-up the mean ABHL was 4.73% in group I compared with
16.2% in group II and 6.20% in group III. The mean Cobb's angle loss was 1.8° in group I
compared with 5.91° in group II and 2.3° in group III. The ABHL difference between
groups I and II was significant (P = 0.0002), while between groups I and III was not
significant (P = 0.49). The short-segment fixation with amenable delayed ambulation is a
valid option for the management of thoracolumbar burst fractures, as radiological results
are comparable to that of long-segment fixation with the advantage of preserving
maximum number of motion segments.
61
7. Materials and Methods
7.1 Study Design
A Prospective observational study.
7.2 Place of study
This work has been carried out in the orthopaedic departments of Bir Hospital, Shree
Birendra Hospital.
7.3 Study period
The case study was conducted over a period of two years from February 2008 to January
2010.
7.4 Sample size
A total of thirty two patients were enrolled in this study initially, but two patients were
lost after first follow up. Hence, only thirty patients were included in the final data
analysis.
7.5 Inclusion criteria
All the patients having traumatic insult to the thoracolumbar spine of less than three
weeks duration resulting in unstable fracture/subluxation or dislocation with or without
neurological deficit were included in the study.
Criteria for the instability of the thoracolumbar injuries during the study:
1. Loss of vertebral body height by more than 50%
2. Kyphotic deformity of 30 degree
3. Progressive neurological deficit.
4. Involvement of two or more of the Denis’ three columns.
62
7.6 Exclusion criteria
1. Age below 15 years and above 70 years.
2. Fractures above tenth thoracic vertebra (T10) and below second lumbar vertebra
(L2).
3. Non traumatic paraplegic patients.
4. Open spinal fractures.
5. Any established pre existing deformity of Spine.
6. Immunocompromised patient
7. Patients on anticoagulant therapy or uncorrected coagulopathy.
8. Co-morbid conditions which are contraindicated for surgery.
ETHICAL CONSIDERATION
Prior to start of study, formal ethical clearance was obtained from the Institutional
Review Board, NAMS. The aims and objectives of the study along with the procedure
and the consequences were thoroughly explained in easily understandable language to the
patients and the patient party at the time of enrollment of each case. Informed written
consent was taken from the patient himself or herself and close relative just before the
procedure. All the collected data were kept confidential.
7.7 Pre operative work up of patients
A detailed proforma was filled up with identification of the patients including address,
occupation, telephone number, a complete history with special attention to mode of
injury, duration of trauma, and pre injury ambulatory status was recorded along with the
co morbid conditions if any. In local examination the deformity, disability, distal
neurovascular status, and other associated injuries were recorded.
63
Laboratory investigations including Haemoglobin, Total Count, Differential Count,
ESR, blood grouping, blood glucose level, renal function tests, routine urine examination
and screening for HIV and HBsAg were done for all the patients.
A thorough radiological investigation was done to define the fracture morphology that
includes plain Roentgenograms of the injured part- Anteroposterior and Lateral views.
Specialized investigations like computer tomography was also done routinely whereas
magnetic resonance imaging scan was done as and when required.
The patients and the attendants were informed about the type of injury, and the outcomes.
An informed written consent was obtained from the patient himself or herself if possible
or from the closest relatives.
Patients were kept nil per orally for at least 8 hours before surgery. All the surgeries
were performed on routine basis by Consultants according to the strict guidelines of
thesis protocol.
Neurological exam
A complete neurological examination of the patient (sensory as well as motor) was done
at the time of admission. Patients having neurological deficit were carefully turned to
right or left lateral position and examined for anal wink reflex, tone of anal sphincter and
sensation in the perianal area to determine the completeness of the lesion. The
examination was repeated after twenty four to forty eight hours to look for any signs of
improvement. The neurological status was assessed according to American Spinal Injury
Association Score (ASIA Score for motor and sensory examination, and ASIA
Impairment Scale for the patients with spinal cord injury).
64
Components of the ASIA Examination
ASIA Motor Grading
ASIA Sensory Exam
Sensory Exam
Motor Grading Scale
– 28 sensory “points”
6 point scale (0-5) …..(avoid +/-’s)
– Test light touch & pin prick/pain
0 = no active movement
Importance of sacral pin testing
1 = muscle contraction
•
3 point scale (0,1,2)
2 = movement thru ROM w/o gravity
•
“optional”: proprioception & deep
3 = movement thru ROM against gravity
pressure (“present vs. absent”)
4 = movement against some resistance
deep anal sensation recorded (“present
5 = movement against full resistance
•
vs. absent”
American Spinal Injury Association (ASIA) impairment scale
Grade
Description
A
Complete: No sensory or motor function below level of neurologic deficit
level. Sacral sparing is absent.
B
Incomplete. Sensory but not motor function is preserved below the neurologic
deficit level
C
Incomplete. Motor function is preserved below the neurologic deficit level,
and the majority of key muscles below the neurologic deficit level has a muscle
grade lower than 3
D
Incomplete. Motor function is preserved below the neurologic deficit level,
and the majority of key muscles below the neurologic deficit level, has a
muscle grade higher or equal to 3.
E
Sensory and motor function is normal
65
ASIA Examination
•
Motor Examination
Motor level of injury
10 “key” muscles (5 upper & 5 lower ext)
Lowest normal level with 3/5
C5-elbow flexion
L2-hip flexion
C6-wrist extension
L3-knee extension
C7-elbow extension
L4-ankle
*4/5 acceptable with pain,
deconditioning
Higher muscles have normal (5/5) dorsiflexion
motor
C8-finger flexion
• Each muscle has 2 roots innervating it T1-finger abduction
L5-toe extension
S1-ankle PF
• Motor Index Score (MIS) = total 100 Sacral exam: voluntary anal contraction
pts
(present/absent)
66
7.8 Operative technique for Moss Miami instrumentation:
Other additional surgical procedures e.g. decompression, reduction of fracture, fracture
dislocation, or dislocation etc were added to this operative procedure and carried out as
per standard technique if required.
Anaesthesia - General anaesthesia.
Position of the patient:
The patient is placed prone on a padded spinal operating table with bolsters placed
longitudinally under the patient’s sides to allow the abdomen to be entirely free.
Approach - Posterior midline approach.
Fracture site is identified using bony landmarks as guide i.e the highest point of iliac crest
is in the L4-5 interspace or the spinous processes are counted down from C7. Make a
midline longitudinal incision over the area to be exposed one spinous process above the
area to be instrumented and one below the area to be instrumented.
Dissection is deepened in the midline using the electrocautery knife through the fat and
superficial and thoracolumbar fascia in line with the skin incision until the tips of the
spinous processes is reached. The posterior elements are exposed subperiosteally by
reflecting the paraspinal muscles (erector spinae) laterally to the tips of the transverse
processes using Cobb subperiosteal elevators on each side. Dissect down the spinous
process and along the lamina to the facet joint. Muscles from the lamina are srtipped
laterally on to the transverse processes. Each segment is packed with a taped sponge
immediately after exposure to lessen bleeding. After satisfactory exposure of the posterior
elements, a roentgenogram is obtained to confirm proper localization of the intended
level. Keep the dissection open with self retaining retractors. The fracture site is identified
and subluxation or dislocation if present is reduced manually.
67
The entry point is at the intersection of lines drawn through middle of inferior articular
facet and middle of insertion of transverse processes. Provisional pins are then inserted.
Check X- rays are taken anteroposterior and lateral views to confirm their accurate
placement. On anteroposterior view, the pin should lie end on within the round or oval
pedicle shadow. On lateral view, the pin should be inside the pedicle and directed towards
upper third of vertebral body parallel with the end plates.
The preparation of pedicle for screw placement includes first creating the tract by owl
introduction with a wriggling movement. The direction of introduction is vertical.
Transverse plane (coronal / medial) angulation decreases as one descends caudally in the
spine until the lumbar region. The angle increases as the lumbar spine descends. Medial
angulation at T1 is 10 degrees, at T12 it is 5 degrees, at L1 it is 5 to 10 degrees while this
angle increases by 5 degrees per level from L1 to the sacrum. These directions are
required to match the direction of pedicles. Owl is inserted to the required depth which is
usually predetermined by measuring on the lateral view roentgenogram so that the
penetration crosses middle of the vertebral body.
Once the tract has been created, it is tapped. Then 5 mm screw of appropriate length
introduced till the screw head is well seated on the entry point. Screws are placed in the
additional segments. When screws have been placed in all the segments to be
instrumented connecting rod of appropriate length and contour clamped to the screws one
on each side using inner and outer nuts. Innies and outies are tightend at one end on either
side with the triple tightner. Other end tightening is done only after applying appropriate
distraction or compression. Connectiong rods are then stabilized with a cross link fixed in
prestressed state. Wound closed in layers over a suction drain and a sterile compressive
dressing applied.
68
7.9 Follow up and evaluation
The patients were kept on bed rest initially then rehabilitation was started as soon as the
general condition allowed. Mobilization and ambulation done with thoracolumbosacral
orthosis (TLSO) for three months. Patients were encouraged to sit with the orthosis.
Early ambulation and rehabilitation was encouraged. The haemoglobin levels, any post
operative complications, the length of hospital stay were recorded. The post operative
check x-ray was done to assess the correct placement of implants and amount of
correction. Bladder training started and catheter removed in due course.
Postoperative neurological assessment was done at the first week of surgery, after one
month and then after six months from the surgery. In patients with partial recovery
walking was encouraged by providing walking aid in the form of calipers. Clinical
examination and plain radiographs used to determine the presence of a solid fusion. Even
paraplegics are encouraged to walk with reciprocating gait orthosis (RGO) a kind of hip
knee ankle foot orthosis (HKAFO). Follow up was done at 1 month, 3 months ,six
months, one and two years from the date of surgery.
Assessment on
a. Neurological- Assessment was done using ASIA Score for motor and sensory
examination as well as ASIA Impairment Scale.
b. Radiological: Radiographic measurements in Lateral view- kyphotic angle,
vertebral body height.
c. Functional outcome- visual analogue pain score, Denis pain scale and Denis work
scale
69
Patient charts, operative reports, pre operative and post operative radiographs, computed
tomography scans and postoperative follow up examinations and radiographs were
reviewed from the time of surgery to final follow up examinations.
Visual analogue scale was used to assess the pain expressed by the patients.
(0to 10 –cm scale, 0 for no pain and 10 for intolerable pain)
Numerical Scale
0
1
2
3
4
5
6
7
8
9
10
No
Worst pain
pain
imaginable
Visual Analog Scale
No
Worst
pain
pain
Directions: Ask the patient to indicate on the line where the pain is in
relation to the two extremes. Qualification is only approximate; for
example, a midpoint mark would indicate that the pain is approximately
half of the worst possible pain.
Categorical Scale
None (0)
Mild (1-3)
Moderate (4-6)
Severe (7-10)
The VAS score is becoming widely used. Its main disadvantage is that it is not readily
understood by everyone but with proper explanation it’s difficult to understand and
usually is applicable in daily practice. In the preferred embodiment, the discrete intervals
identified by the markings of the range of pain descriptors are identified by numerical
70
pain descriptors. The numerical pain descriptors are numbered from 0 to 10 in increments
of 1.
In our study we also have asked the patients to grade the degree of pain on a VAS score
before and at various intervals after the posterior stabilization by Moss Miami spinal
instrumentation.
The numerical pain descriptors correspond to verbal pain descriptors as follows:
Numerical pain
Verbal
Descriptors
0
Pain Descriptors
No pain
1
Mild pain that you are aware of but not bothered by
2
Moderate pain that you can tolerate without
medication
3
Moderate pain that is discomforting and requires
medication
4-5
More severe and you begin to feel antisocial
6
Severe pain
7-9
Intensely severe pain
10
Most Severe pain; you might contemplate suicide
over it
71
Table 8. Denis et al’s pain scale
Grade
Criteria
1
No pain
2
Occasional , minimal pain : no need for medication
3
Moderate pain, Occasional medication, no interruption
of work or activities of daily living
4
Moderate to severe pain Occasional absences from
work, significant in activities of daily living
5
Constant severe pain, chronic medication
Table 9. Denis et al’s work scale
Grade
Criteria
1
Return to employment (heavy loader) or physically
demanding activities
2
Able to return to previous employment (sedentary)
Or return to heavy labor with lifting restrictions
3
Unable to return to previous employment but working
full time at a new job
4
Unable to return to full time work
5
No work , completely disabled
72
DATA ANALYSIS AND STATISTICAL ANALYSIS
Data were analyzed using SPSS (Statistical package for social science) software
program, version 17.
Comparison of qualitative variables were done by Chi-square test and quantitative by ttest. Values of P =< 0.05 was considered significant with confidence interval of 95%
throughout the study.
73
8. Observation and results
Out of thirty two patients with unstable thoracolumbar spinal fractures, two patients were
lost in subsequent follow up, so they were excluded from the study. Hence only thirty
cases were analyzed for final result. The results and observations are as follows.
8.1 Age distribution
The minimum age of the patients in the study was 17 years and the maximum was 48
years. Most of the patients were in 15 to 25 years of age group (46.7%) and least number
of patients in 46 to 55 years age group (3.4%). The mean age was 26.9 years.
Figure 6: Age of the Patients (%)
74
8.2 Gender distribution
Out of 30 total number of cases, 26 (87%) were male and 4 (13%) were female at the
ratio of 6.5:1.
Figure 7: Gender distribution (%)
75
8.3 Occupation:
60% of the patients were farmers, 23% were laborers, 7% were involved in household
activities, 7% students and 3% social worker.
Figure 8: Occupation of the patients (%)
76
8.4 Modes of injury
80% (26 patients) sustained injury due to fall from height where as 20 %( 6 patients)
sustained injury by Road traffic accidents.
Figure 9: Modes of injury (%)
77
8.5 Types of injury
Unstable burst fracture (60%) was the most common type of injury followed by Wedge
compression fracture (33%) and translational injuries 7%.
Figure 10: Type of injury (%)
78
8.6 Level of injury
First lumbar vertebra was the most common level of injury. Out of 30 patients, 17
patients had first lumbar vertebral fracture.
Figure 11: Level of injury
79
8.7 Neurological involvement
Out of 30 total number of cases, 29 (97%) had neurological
involvement and 1(3%) had no neurological involvement.
Figure 12: Neurological involvement (%)
80
8.8 Bowel and bladder involvement
Out of 30 cases in the study, bowel and bladder involvement was
present in 25 (83.3%) patients and absent in 5 (16.7%) patients.
Table 10. Bowel and bladder involvement
Bowel and bladder involvement
No. of patients
Proportion (%)
Yes
25
83.3
No
5
16.7
Total
30
100
8. 9 Associated injuries
20 (66.7%) patients had associated injuries whereas 10 (13.3%) patients had only the
thoracolumbar vertebral fractures.
Figure 13: Associated injuries
81
8.10 Regional distribution of associated injuries
14 (70%) patients had associated injuries in the upper limbs and 6 (30%) had
injuries in the lower limbs.
Table11. Regional distribution of associated injuries
Region
No. of patients
Percent (%)
Upper limb
14
70%
Lower limb
6
30%
Thorax
0
0
Total
20
100%
8.11 Time interval between Admission and surgery
The time interval between admission and surgery was 7 days in 5 patients, between 8th to
14 th day was 23 patients and after 14 days in 2 patients.
Figure 14: Time interval between admission and surgery
82
8.12 Complications
Out of 30 cases which were followed up for complete two years, 7 patients developed
complications. There were 1 faulty screw placement, 1 loss of correction, 2 bed sores
and 3 urinary tract infections.
Table 12. Complications
Complications
Number of cases
Faulty screw placement
1
Loss of correction
1
Bed sores
2
Urinary tract infection
3
Total
7
8.13 Preoperative and post-operative neurological status according to
Frankel’s Grading System.
Out of 30 patients, 18 were Frankel grade A patients .surprisingly 2 recovered to Frankel
grade C. similarly others in Frankel grade B, C and D recovered to 1 or 2 grades of
power.
Table 13: Preoperative and post-operative neurological status according to
Frankel’s Grading System.
Frankel
Grade
Postoperative
Preoperative
A
B
C
D
Final follow up
E
A
B
C
D
13
3
2
-
3
3
A
18
13
4
1
-
-
B
7
-
-
6
1
-
C
2
-
-
-
1
1
D
2
-
-
-
1
1
E
1
-
-
-
1
83
E
1
1
-
-
2
-
-
1
8.14 Kyphotic deformity in degrees
Mean kyphotic deformity was 20.4 degree preoperatively and 4.6
degree postoperatively and the correction by 15.80 degree.
Figure 15: Kyphotic deformity in degrees (%)
20
15
10
5
0
Pre‐operative
Number of
patients (%)
Post‐operative
Number of
patients (%)
8.15 The mean Preoperative kyphotic deformity was 20.4 degree (6.8) and the mean
postoperative kyphotic deformity decreased to 4.6 (4.9) and was statistically
significant (P<0.001).
Table 14. Corelation between preoperative kyphotic deformity and postoperative
kyphotic deformity.
Group
Pre
Operative
Mean
deformity
in degrees
Std.
Deviation
20.4
6.8
Average difference
between pre Op and
Post Op deformity
15.8
Post
Operative
4.6
4.9
84
Paired t-test
CI at 95%
confidence
P value
13.3 - 18.3
<0.001
8.16 Loss of anterior vertebral body height in percentage
The percentage loss of anterior vertebral body height was 53% preoperatively 10.13% on
immediate post operative period and 12.83% on final follow up.
Figure 16: Loss of anterior vertebral body height (%)
53%
10.13%
12.83%
8.17 The mean (SD) percentage loss of anterior vertebral body height was 53%
(1.5) preoperatively which decreased to 10.13% on immediate post operative period
was statistically significant (P<0.001)
Table 15. The mean (SD) Loss of anterior vertebral body height preoperatively and
on immediate post operative period
Group
Pre Operative
Immediate Post
Operative
Loss of
height
Std.
Deviation
53
1.5
Mean
difference
42.8
10.1
1.9
85
95% confidence
interval paired t-test
P-value
42.01 - 43.72
<0.001
8.18 Bony Fusion
Out of 30 patients, all had evidence of fusion at a mean of 5.5 months, with a minimum
of four months and a maximum of six months period.
Table 16. Time of Bony Fusion
Months
Number of Patients
Percent
At 4 months
6
20%
At 5 months
12
40%
At 6 months
12
40%
Total
30
100%
8.19 VAS pain Score
The VAS pain score on admission was 8.06, which decreased to 3.5 on 1 month, 1.8 on
3 month and 0.86 on sixth month.
Figure 17: VAS pain score
86
8.20 Correlation between VAS pain score on admission, 1st month, 3rd
month and 6th month
The mean VAS score at admission was 8.06 (1.14) and the mean VAS score at 1 month
decreased to 3.5 (0.56) and1.8 (0.86) which was statistically significant (P<0.001).
Table17. Correlation between VAS pain score on admission, 1st month, 3rd month
and 6th month
VAS pain score
Assessment
time
Number
Std
Mean Deviation
Mean
difference
Minimum
Maximum
At
admission
30
8.06
1.14
6
10
At 1 month
30
3.5
5.41
2
32
At 1 month
30
3.5
5.41
2
32
At 3 month
30
1.8
0.56
1
3
At 3 month
30
1.8
0.56
1
3
At 6 month
30
0.86
0.51
0
87
2
4.6
PPaired
value
t-test
95% CI
2.7 6.5
1.7
-0.35 3.68
0.93
0.72 1.15
<0.00
1
<0.00
1
<0.00
1
8.21 Distribution of patients classified by Denis et al’s pain scale
Out of 30 patients classified by Denis et al’s pain scale, 17 patients were in grade 1, 10
patients in grade 2, 3 patients in grade 3.
Table 18 Distribution of patients classified by Denis et al’s pain scale
Grade
Criteria
Patients
1
No pain
17
2
Occasional , minimal pain : no need for medication
10
3
Moderate pain, Occasional medication, no interruption of
work or activities of daily living
3
4
Moderate to severe pain Occasional absences from work,
significant in activities of daily living
0
8.22 Distribution of patients classified by Denis et al’s work scale
Out of 30 patients classified by Denis et al’s work scale, 6 patients were in grade 1, 2 in
grade 2, 10 in grade 3, 4 in grade 4 and 10 patients in grade 5.
Table 19 Distribution of patients classified by Denis et al’s work scale
Grade
Criteria
Patients
1
Return to employment (heavy loader) or physically
demanding activities
6
2
Able to return to previous employment (sedentary)
Or return to heavy labor with lifting restrictions
2
3
Unable to return to previous employment but working
full time at a new job
10
4
Unable to return to full time work
4
5
No work , completely disabled
10
Total
30
88
9. DISCUSSION
Fractures and fracture dislocations of the thoracolumbar spine are common spinal
injuries. In developed countries such injuries mainly occur in association with motor
vehicle accidents and falls
43,44
, while in the developing world they are primarily the
result of a fall from a height 43,50 .
In our study, the large numbers of patients (46.7%) were within the productive age group
ranging from 15 to 25 years with male predominance (87%). The reason behind this is
because men are mainly engaged in the activities outside the house in this part of world,
and most of them are involved in farming (60%).
The advantage of operating these injuries is the immediate stabilization of the injured
spine and an indirect or direct decompression of the neural structures. Operative
stabilization enables early mobilization and rehabilitation without a heavy and
uncomfortable cast and clearly shortens the hospital stay
42, 43, 44
. The indication for an
operative stabilization in patients with unstable spine injuries and complete paraplegia is
to achieve early neurological restoration, overcome damaged spinal segments
anatomically and accomplish firm and stable fixation for early rehabilitation.
At our hospital short segment fixation with or without fusion has replaced the earlier
methods of fixation, such as Harrington instrumentation and Luque fixation. Short
segment fixation immobilizes less motion segments, so the mobility of the spinal column
is hardly affected. Operative stabilization of the patients reported in this study was based
on the radiological criteria of more than 50% loss of vertebral height and kyphotic
deformity of >20°, as has been adopted by many surgeons 3,5, 42.
89
We used McAfee’s system to classify the fractures after radiological evaluation. The most
common fracture pattern in our study was unstable burst fracture (60%), as revealed in
the CT scan by subluxation of one or more facet joints, fracture of one or more neural
arches or gross displacement of the neural elements. The second most common pattern
was wedge compression fractures (33%), usually at the thoracolumbar junction followed
by translational injuries (7%). The CT reconstruction characteristically showed the
malalignments. Unstable burst fractures and, in particular, translational injuries were
associated with severe neurological involvement. Nam-Hyun et al. 49 also reported a high
degree of neurological involvement in patients with posterior element involvement – i.e.
burst fractures and rotational injuries. Most of our patients with severe neurological
involvement (80%) had a fall from tall trees while felling branches for firewood.
In the present study patients showed clustering of the spinal injuries at the first lumbar
vertebra (L1) level. Other studies show clustering of thoracolumbar trauma around D12
and L1.Weyns et al. 64 showed 60% injuries over D12- L1, Viale et al.65 55% and Carl et
al. 82%
43
at D12- L1 junction. The increased affliction of the thoracolumbar junction in
the trauma can be due to more than one specific reason. Firstly this is the junctional area
between relatively fixed thoracic spine which is also protected by thoracic rib cage to
freely mobile unprotected lumbar spine. Therefore such a junctional area is most
vulnerable to injury during falls, road traffic accidents etc. Secondly this area represents
the transition from the normal thoracic kyphosis to the lumbar lordosis. Furthermore
patients having injuries at this level has poor neurological status due to fact that the spinal
cord usually ends at the lower border of L1 or the upper border of the L2, and spinal cord
and conus medullaris show poor neurological recovery as compared to cauda equina
which almost behaves as do peripheral nerves.
90
We assessed the neurological status according to the Frankel grading and ASIA
Impairment Scale and majority of patients (60 % of the total number) in our study were
having complete neurological deficit i.e. ASIA Impairment Scale A. Neurological
recovery has been reported with early stabilization of thoracolumbar spinal fractures
44
.
The highest recovery rates have been reported for patients operated on within 8 hours of
the initial trauma, while high remission rates have been reported for patients operated on
within 48 hours of the initial trauma. After this time there is no significant difference in
the neurological outcome with respect to the timing of operation after the trauma. The
earliest we were able to stabilize a spine was 7 days after the initial trauma – primarily
because of the late presentation of the patients as most of the patients were from remote
areas and non-availability of facilities for emergency stabilization of the spine in our
hospital. The maximum number of patients (23 out of 30 patients) we operated was on the
second week. The pattern of neurological recovery in our patients, however, is not
discouraging despite this delay. Of the 11 patients with incomplete neurological deficit
(i.e. Frankel grade B, C, and D), two grades of improvement were observed in 40% (4/11)
of the patients and one grade of improvement was observed in 60%. Even in the 18
patients with complete neurological lesion, one and two grades of improvement were seen
in three and two patients, respectively.
In the present study, 20 (66.7%) patients had associated injuries whereas 10 (13.3%)
patients had only the thoracolumbar vertebral fractures. 14 (70%) patients had associated
injuries in the upper limbs and 6 (30%) had injuries in the lower limbs.
During the surgery we did not observe any major intraoperative complications. However,
reduction of the fracture or the dislocation was problematic and difficult to achieve in
patients in whom surgery was delayed for more than a week due to one or the other
91
reason like onset of healing process with callus formation etc. The improvements
observed in the radiological parameters (anterior vertebral body height, kyphotic
deformity) measured in the immediate post-operative period and at the final follow-up
are, comparable with those reported elsewhere 42, 43, 44. The loss of initial correction after
pedicle screw fixation has been reported by many authors. Although a good correction of
kyphosis and restoration of vertebral body height is achieved by surgery, most is lost
during the long-term follow-up period.
In a study Esses et al.62 had the average preoperative kyphotic angle of 18.2 degrees and
average post operative 3.5 degrees, Carl et al.43 reported average improvement of 7.3
degrees in kyphosis postoperatively and average loss of correction of 6.5 degrees at
follow up examination, thus only one degree of correction was attained. A study by
McNamara et al.63 showed the average progression of kyphosis by 8.7 degrees in the
operated cases from postoperative period to the final follow up. In the present study, the
immediate post operative kyphosis was 4.6 degrees and that was maintained at the final
follow-up which may be due to delayed ambulation of the patients and use of braces, thus
allowing for proper spinal stabilization and fracture consolidation
Bony fusion was achieved in 30/30 (100 %) of our cases whereas Sasso et al.39 has
reported a 95.6% arthodesis rate with dynamic compression plates and pedicle screws in
23 patients. Sengupta et al. showed similar fusion rates with iliac crest or local bone in a
single level fusion but less morbidity in case of local bone. We also used autogenous iliac
crest bone as graft in all cases.
A number of complications have been reported for transpedicular spinal fixation.
Blumenthal et al. noted an overall complication rate of 6% with the Wiltse pedicle screw
system
61
. As with all surgical implants, failure of the instrumentation with subsequent
92
loss of reduction is of utmost concern. We had a single case of implant failure in the form
of loosening of screw leading to loss of reduction. Krag et al.37 has suggested segmental
pedicle fixation two levels above the kyphosis to avoid implant failures in the form of
loose, bent and broken screws. We believe that this technique should be used at the
thoracolumbar junction where compression forces act more anteriorly. Another pediclerelated concern, which has been reported to occur in between 10 and 28.8% of cases 37, is
screw misplacement. Knop C et al.14 found 139 out of 2264 screws (6.1%) to be
misplaced with open technique but only 0.6% required revision. Two of our screws, as
evident from post-operative radiographs, were misplaced, and all eventually failed.
No life-threatening complication occurred in our series. Shafiq as well as Olumide used
external orthosis for three months. We also advised wearing thoraco lumbar orthosis for
three months.
Early (within hours of the initial trauma) or immediate (within 48 hours) stablisation and
indirect or direct decompression is a distant dream in our surgical set-up, even delayed
stablisation of the unstable spine has benefits. However, the number of complications
remains worrisome; this is particularly true with respect to hardware failure.
Our objective of the spinal surgery in these patients was deformity correction and early
rehabilitation and thus obviating the complications of prolonged recumbency and we find
the result in this context encouraging. Hence transpedicular screw fixation by Moss
Miami pedicle screw system provides stable, reliable, truly segmental construct, helps in
immediate rehabilitation of patients suffering from traumatic unstable thoracolumbar
spine.
93
10. CONCLUSION
Fractures and fracture dislocations of the spine are serious injuries and are occurring
mostly among productive age group people. Therefore their absence from the work can
cost a lot to the patient, the patient’s family and the nation as a whole. So early treatment
and rehabilitation leading to early return to work can minimize the loss. The management
and evaluation of these types of injuries have changed dramatically over the last decade
due to improvement of imaging technologies and spinal instrumentation.
A prospective observational study was carried out in our set up to assess the functional
outcome of thoracolumbar fracture stabilization by Moss Miami spinal system. The
results showed that Moss Miami pedicle screw system provides stable, reliable, segmental
construct, helps in immediate rehabilitation of patients. It is a short segment fixation, so
avoids unnecessary fixation of additional healthy motion segments above and below. It is
versatile to stabilize the injured segment in compression or distraction mode and can
correct deformity in coronal, sagittal and rotational planes. From this study we came to
conclusion that transpedicular screw fixation offer superior three-column control and as it
is placed entirely outside the vertebral canal therefore avoids potential risk of neural
element impingement by intracanal instrumentation of other systems.
94
11. RECOMMENDATIONS
Regarding the use of Moss Miami spinal instrumentation in unstable thoracolumbar
spinal injuries, following recommendations can be made.
1. Moss Miami spinal instrumentation can be used for posterior fixation in unstable
thoraco-lumbar spinal fractures.
2. Accurate placement of pedicular screws can be improved by fluoroscopic guidance.
3. As this study was carried in small number of patients, a further study with a large
number of patients is recommended.
4. A longer follow up is recommended to assess the long term complications, as this
study was done over a short period.
95
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103
Appendix 1
PROFORMA OF THE THESIS
TITLE: “OUTCOME OF THORACO-LUMBAR FRACTURE STABILIZATION
BY MOSS MIAMI SPINAL SYSTEM.”
a. PERSONAL RECORD:
I.P. No. :
Name:
Age: ……years
Contact Address:
Sex:
M
F
Occupation:
Phone No.:
Date of admission:
Final Diagnosis:
Mobile no. :
Date of discharge:
b. HISTORY:
Chief Complaints:
Mode of injury:
Fall
RTA
Sports
Physical assault
Others:………………………...…
Date & Time of Injury:
Mechanism of injury:
Past History:
Medical/Surgical co-morbidities:
Treatment history:
Yes;
No; If yes,
specify……………………………………………….
Others (Family History/ Drug allergies/ Personal history):
c. Physical Examination
(i) Vitals: Pulse-…….beats/min B.P-………. mm/Hg Temp.-……R.R-……./min
(i)
Chest
CVS
Abdomen
Systemic examination:
(ii)
Local examination of Spine:
(iii)
Neurological examination: American Spinal Injury Association
A
B
C
D
(a) Sensory examination: Upper & Lower extremities:
Dermatome
C2
C3
C4
C5
C6
C7
C8
T1
T2
T3
T4
T5
T6
T7
T8
T9
T10
T11
T12
L1
L2
L3
L4
L5
S1
S2
S3
S4-5
Light touch
Right
Left
Pin prick
Right
Left
Temperature
Right
Left
E
(b) Motor examinations:
Motor
parameters
Upper extremity
Lower extremity
Right
Right
Left
Left
Bulk
Tone
Power: according to Medical Research Council (MRC) grading
Upper extremity
Lower extremity
Right Left
Right
C5: Elbow flexors
L2: Hip flexors
C6: Wrist extensor
L3: Knee extensors
C7: Elbow extensors
L4: Ankle
dorsiflexors
C8: Finger flexors (distal
phalanx of middle finger)
L5: Long toe
extensors
T1: Finger abductors
(little finger)
S1: Ankle plantar
flexors
Reflexes:
Upper extremity
Right
Left
Lower extremity
Right
Left
Biceps
Knee
Triceps
Ankle
Supinator
Plantar
Ankle
clonus
(c) Others:
Reflexes:
Abdominal (T8-T12)
Present
Absent
Cremasteric (T12-L1)
Present
Absent
Bulbocavernous (S3-S4)
Present
Absent
Anal wink (S2-S4)
Present
Absent
Bladder:
Automatic
Bowel:
Continence
Autonomous
Incontinence
Atonic
Left
(iv)
A
B
C
ASIA Impairment scale:
Complete
No motor or sensory function in the lowest sacral
segment (S4 & S5)
Incomplete Sensory function below neurologic level and in S4-S5, no
motor function below neurologic level
Incomplete Motor function is preserved below neurologic level and
more than half of the key muscle groups below
neurologic level have a muscle grade <3
D
Incomplete Motor function is preserved below neurologic level and at
least half of the key muscle groups below neurologic
level have a muscle grade = 3
E
Normal
(V)
Sensory and motor function is normal
Pre operative investigations:
a. Haematology
Haemoglobin-
ESR-
Total CountDifferential
count
Neutrophils
Lymphocytes
EosinophilsMonocytesBasophils-
b. Biochemistry
Blood Sugar F/R
Urea
Creatinine
Sodium
Potassium
c. Screening tests
HIV
HBsAg
Anti HCV
(i)
Radiological examination:
i.
Chest:
ii. Spine:
Radiological evaluation of injured vertebra:
Antero-Posterior
Vertebral Height
Interpedicular
distance
Laminae
Lateral
Wedging
Kyphotic angle
Pedicles
Percentage of
Compression
Retropulsion
Lateral Shift
Spinous Process
Scoliosis
Interspinous
distance
End Plates
End Plates
Superior
Inferior
(ii)
CT scan:
(iii)
MRI:
Superior
Inferior
d. OPERATIVE RECORD:
Place of operation
Date of operation
Post op diagnosis
Surgeon
Anaesthetic
Assist 1
Anaesthesia
Assist 2
Antibiotics
Op started at
Completed at
Intraoperative blood loss:
Intraoperative blood Transfusion
Intraoperative complications :
Total duration:
1st post op day
Date:
Temp.-
Pulse-
C/O:
B.P-
R.R-
Dressing:
Post op investigations
Advice:
Plan:
2nd post op day
Date:
Temp.-
Pulse-
C/O:
B.P-
R.R-
Dressing
Advice:
Plan:
Post op investigations
3rd post op day
Date:
Temp.-
Pulse-
C/O:
B.P-
R.R-
Dressing
Advice:
Plan:
Discharge summary:
Date:
Follow up:
S.N
Description
1.
Chief complaints
2
Local
examination
3
ASIA score
4
Ant vertebral
body height
5
Kyphotic
deformity
7
VAS pain score
8
Denis pain scale
9
Denis work scale
1 month
3 months
6months
1year
2 years
CONSENT FORM
I ……………………….. resident of…………………..… give my consent for participation
in the research study on “
OUTCOME OF THORACO-LUMBAR SPINAL
FRACTURE STABILIZATION WITH MOSS MIAMI SPINAL SYSTEM “conducted
by Dr. Som Bahadur Ale.
I have been well explained about the nature of the research study and the possible
consequences that may arise from the procedure. I am also aware that I have all the rights to
withdraw my participation from the above mentioned study whenever I wish to do so.
Thumb print
(Right)
(Left)
………………………….
(Signature)
Name:
Address:
Date:
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Appendix 2
OPERATIVE PROCEDURE PHOTOGRAPHS
Marking for skin incision
Midline posterior approach
R
Subcutaneous dissection
Candle sticks inserted
Exposure of Posterior elements
Checked under image intensifier
Awl used to create tract in pedicles
Tapping done
Screw of appropriate length introduced
connecting rod clamped to the screws
Innies and outies are tightened at one end
Similar process is repeated in other end
On either side with triple tightner
after adequate distraction.
[Type a quote from the document
Connecting rods stabilised with a cross bar
Screws of cross bar tightened
fixed in prestressed state.
Posterior Instrumentation
drain
Wound closed in layers over a suction
2 weeks after Operation
Case illustration
Case 1
on TLSO and HKAFO after 3 months of surgery
Case 2
on Thoracolumborsacral orthosis after 1 month of surgery
Pre-operative and Post-operative Radiographs:
Case no. 1
Pre-operative radiographs -Antero-posterior and lateral views
Post operative radiograph AP view
view
Post operative radiograph Lat
Case no.2
Pre-operative radiographs -Antero-posterior and lateral views
Post-operative radiographs -Antero-posterior and lateral views
U/L
L/L
U/L
U/L
L/L
U/L
U/L
L/L
U/L
10
12
10
12
11
13
12
12
10
10
15
8
10
8
10
10
10
10
12
13
10
8
8
8
8
8
8
8
10
10
13
12
13
12
13
12
13
13
15
12
15
10
12
12
12
13
12
12
15
15
14
12
12
13
13
13
13
13
13
12
5 10 3
5 9 3
4 8 3
4 7 2
5 6 2
5 7 2
6 9 3
4 8 3
6 10 3
5 8 2
6 7 2
6 9 2
5 9 3
6 9 2
5 8 3
4 8 3
5 6 2
5 8 2
6 7 2
5 7 2
6 7 2
4 10 32
6 9 3
6 8 2
5 9 3
4 6 2
6 8 3
5 8 2
6 8 3
6 9 3
2
1
2
1
2
2
3
2
1
2
2
2
2
3
2
1
2
1
2
1
2
2
2
2
2
1
2
1
2
2
0
1
1
1
0
1
1
1
1
1
1
1
1
1
1
0
1
0
1
0
2
1
1
1
1
0
1
1
1
2
1
2
1
2
1
2
2
1
3
1
2
2
1
1
1
1
2
2
2
3
2
1
1
1
1
3
1
2
1
1
1
2
4
2
5
5
1
5
1
5
4
5
1
1
5
5
4
5
5
5
1
F/u period
51
54
53
54
55
54
53
52
51
54
53
55
50
53
53
50
54
53
53
53
56
55
51
53
53
54
53
51
53
53
VAS on admission
3
7
3
3
3
3
5
3
5
3
1
5
1
3
3
5
5
3
3
3
3
3
5
30
3
5
5
3
5
5
Denis work scale
L/L
L/L
U/L
20
17
17
31
20
20
10
25
31
10
8
28
10
22
17
28
20
17
26
17
23
19
27
31
17
19
31
20
20
10
Denis pain scale
U/L
L/L
U/L
U/L
U/L
U/L
U/L
7
14
14
7
8
7
8
14
21
14
21
7
7
8
8
14
10
9
8
8
8
10
14
14
14
8
8
14
9
10
Time of bony union
Associated injuries
U/L
VAS 6mth
Y
Y
y
Y
Y
Y
Y
Y
Y
N
N
Y
Y
Y
N
Y
N
Y
Y
N
N
Y
Y
N
Y
Y
N
N
N
Y
VAS 3mth
UB
UB
UB
UB
UB
wc
UB
UB
wc
UB
wc
wc
UB
UB
wc
UB
wc
UB
wc
UB
T
wc
UB
UB
wc
wc
UB
UB
UB
T
associated injuries
type of injury
B/B involvment
N
Y
Y
Y
Y
Y
N
N
Y
Y
N
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
VAS1 mth
E
C
A
C
A
A
C
D
A
A
E
Y
A
A
A
A
E
D
A
A
A
B
C
B
C
B
B
C
A
D
Loss of ant vertebral body
ht at FFU
C
B
A
B
A
B
C
D
A
A
E
B
A
A
B
A
D
B
A
A
A
A
A
A
A
A
A
A
A
B
Post op Frankel gr
Pre op Frankel gr
level
L2
D12,L1
D12
L1
L1
L1
L1
D12
L1
L1
L1
L2
L1
L1
L1
D12,L1
L1
D12
l1
D11,D12
D12
L1
D11,D12
L2
L1
L1
L2
L1
L1
L2
Immediate post op Loss of
ant vertebral body ht
RTA1
fall
Fall
Fall
fall
fall
fall
Log
fall
fall
RTA1
RTA2
Rta
fall
Fall
fall
RTA2
Log
fall
fall
fall
fall
fall
fall
fall
fall
fall
fall
fall
fall
Loss of ant vertebral body
ht
Leader
farmer
labour
Housewife
Labour
farmer
farmer
labour
Labour
farmer
student
housewife
labour
farmer
labour
farmer
student
labour
farmer
farmer
farmer
farmer
farmer
farmer
farmer
farmer
farmer
farmer
farmer
farmer
post op kyphotic deformity
Chitwan
okhaldhunga
Nuwakot
Siraha
Mahottari
Tanahu
kavre
ktm
Dhading
Ilam
ktm
ktm
Birjung
Dhading
Dhading
Jumla
ktm
ktm
gorkha
kavre
Nuwakot
Ramechap
Lamjung
kaski
chitwan
ktm
okaldhunga
ktm
Nuwakot
nawalparasi
MOI
occupation
address
sex
M
M
M
F
M
M
F
M
M
M
M
F
M
M
M
F
M
M
M
M
M
M
M
M
M
M
M
M
M
M
Pre op kyphotic deformity
48
35
32
17
20
21
19
24
24
28
19
28
22
24
26
30
20
28
22
24
22
27
28
27
29
35
30
38
36
24
Time interval
padam bdr chhetri
Bir bdr magar
Duba tamang
Puran kumari rai
Indrajit Mukhiya
Kumar ale
laxmi shrestha
sonam lama
Ram tamang
krishna rai
suman stha
rita karki
manish gupta
Hari majhi
ramesh chaudhary
Yanzi sherpa
Bikal sharma
Bal bdr dhimal
Husman thapa
Ram dulal
jeevan B.K
padam basnet
Bikash gurung
Bijaya moktan
Bhuvan thapa
Bimal shrestha
galzen sherpa
shreeram bhattarai
Dayaram dahal
jit bdr sinjali
Age
Name
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
2 years
2 years
2 years
2 years
2 years
2 years
2 years
2 years
2 years
2 years
2 years
2 years
2 years
2 years
2 years
2 years
2 years
2 years
2 years
2 years
2 years
2 years
2 years
2 years
2 years
2 years
2 years
2 years
2 years
2 years