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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 3  |  Issue : 2  |  Page : 55-59

Management of fractures of thoracolumbar spine with pedicle screw fixation


1 Department of Trauma and Orthopaedics, JJM Medical College, Davangere; Department of Trauma and Replacement Orthopaedics, PGH Multispeciality Hospital, Delhi; Department of Trauma and Orthopaedics, Dr. Baba Saheb Ambedkar Medical College, Rohini, Delhi, India
2 Department of Trauma and Orthopaedics, JJM Medical College, Davangere, India
3 Department of Orthopaedics, Ganga Hospital, Coimbatore, Tamil Nadu, India
4 Department of Trauma and Orthopaedics, Dr. Baba Saheb Ambedkar Medical College, Rohini, Delhi, India

Date of Web Publication17-Jun-2016

Correspondence Address:
Himanshu Rohela
House Number A-169, Fourth Floor, A Block, Meera Bagh, New Delhi - 110 087
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2394-2010.184230

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  Abstract 

Objective: The spinal traumas are common and leading problem in orthopedic practice. In this study, we stabilize the cases of the unstable thoracolumbar spine injuries with decompression and pedicular screw instrumentation . Materials and Methods: This study was undertaken in the Department of Orthopedics in CG and Bapuji Hospitals attached to JJM Medical College, Davangere. Twenty adult patients with acute thoracolumbar injuries who gave the consent for surgery admitted during the study period were included as study sample. Patient selection was according to the inclusion and exclusion criteria and was surgically treated with pedicle screw and rod system (ZETA). Results: The standard deviation of the study group was 11.5 with mean age being 41 years. The most common vertebrae involved in this series were between T11 and L2 to the extent up to 50%. The average regional angle during preoperative stage was 16.50 ΁ 5.020 and 4.450 ΁ 4.150 during 1-year postoperative period. The mean difference of vertebral height between pre- and 12 th post-operative week was 8.8 mm, pre- and 24 th post-operative week was 7.95 and pre- and 1-year post-operative period was 7.95. Among all the subjects, 20% resumed the previous level of work or equal level of the physically challenging job. While 35% with little modification resumed the previous level of heavy work after 1 year of follow-up. After same period about 45% of subjects did not entertain any pain, whereas 30% felt occasionally, for which no medication was required. Conclusion: Findings of this study show that pedicle screw-rod instrumentation is an excellent implant system used in treatment of vertebral fractures. There is a very high statistical significant restoration of vertebral body height, mean regional angle and mean anterior wedge angle with this procedure in thoracolumbar fractures. Neurological recovery was seen significantly when all cases with neurological deficits were clubbed together.

Keywords: Bedsore, fractures, lumbar vertebrae, pedicle screw


How to cite this article:
Rohela H, Ravinath T M, Vasudeva J, Mallick T. Management of fractures of thoracolumbar spine with pedicle screw fixation. J Health Res Rev 2016;3:55-9

How to cite this URL:
Rohela H, Ravinath T M, Vasudeva J, Mallick T. Management of fractures of thoracolumbar spine with pedicle screw fixation. J Health Res Rev [serial online] 2016 [cited 2021 Apr 19];3:55-9. Available from: https://www.jhrr.org/text.asp?2016/3/2/55/184230


  Introduction Top


The spinal traumas are common and leading problem in orthopedic practice.

The individuals are at risk of high-energy trauma in the modern era. [1],[2],[3] The fractures to the spine are reported to be around 6% approximately of the trauma patients, of which trauma to spinal cord occurs in around 2.6% with neurological deficit. These patients are also prone to bedsores and pulmonary infections. [4] Thoracolumbar segment is second most commonly involved segment in the spinal cord following spinal injuries followed by cervical segment. It constitutes 30-60% of all spinal injuries. Only 15-20% of the fractures at the thoracolumbar level are associated with neurological injury. [5] Thoracolumbar injuries classically exhibit a bimodal distribution, with peaks among males under 30 years of age and in the geriatric population. [3] The modality of treating the patient is costly since it requires care by highly skilled personnel and the number of bed day's used. [6] The posterior approach is a safe alternative for the surgery as most of the specialists are more experienced. Also, the spine can be stabilized by a posterior approach with many available instruments. [7] The disease progression, which is due to the mechanical instability of vertebral column, can be arrested if it is stabilized by any operative intervention. Case series involving open techniques report blood loss almost twice as much. [8] The posterior approach is a safe alternative for the surgery as most of the specialists are more experienced. Proper placement of transpedicular screws is imperative to prevent injury of the adjacent neural and vascular elements, and helps maximize the amount of bone surrounding the screw and increases screw purchase. [9] Posterolateral fusion and posterior lumbar interbody fusion (PLIF) are of widely accepted fusion techniques. [10] Some of the studies have represented the PLIF as the superior technique, but comparable results of both techniques have shown by other trials. [11],[12]


  Materials and methods Top


We did study in the Department of Orthopedics. Adult patients with acute thoracolumbar injuries admitted to Chigateri General Hospital and Bapuji Hospitals and JJM Medical College, Davangere were included in this study after obtaining their informed, valid written consent. This study was undertaken from July 2010 to September 2012. Clearance from Institutional Ethical Committee was obtained before initiating the study. Twenty adult patients with acute thoracolumbar injuries who gave the consent for surgery admitted during the period of study were included as study sample. A detailed history was obtained for evaluating the mode of trauma, American Spinal Injury Association (ASIA) grading, sensory level and to check for any spinal deformity. They were clinically and radiologically evaluated for ensuring the thoracolumbar fracture. Radiographs antero-posterior and lateral views were obtained and the instability of the spine was confirmed using White and Punjabi criteria of spinal instability. Laboratory investigations were carried out before surgery. Magnetic resonance imaging/computed tomography scan was conducted to evaluate the relationships and instability of the spine. Those patients with unstable spine were explained about advantages and disadvantages of the surgery.

On the operation table, patient was made prone position with accentuated lordosis by a four poster frame. From two levels proximal to the injured segment a midline posterior incision was given to two levels distal to the same. Area of interest exposed, after soft tissue dissection. The dissection extended to expose laterally the transverse process. Assuming two imaginary lines, one horizontal through the transverse process and other vertically through the center of the superior facet, the point they cross each other denotes the pedicle. A hole is made with the trocar at the entry point of the pedicle after removing bone at that site. After introducing K-wire with blunted end through the hole, its position is checked by image intensifier in both the frontal and sagittal plane. After which pedicle probe inserted with clockwise - anticlockwise rotator motion of 30° each, the aim being to pass the probe in the path of least resistance, which represents the center of pedicle. The probe with its markings helps to determine the depth of the pedicle. After confirming its position, the probe passed to 80% of its depth. Then depending upon the size the holes were tapped with either 5.5 mm or 6.25 mm taps. The continuity of the pedicular cortex was checked by passing a pedicle sound to the pedicle through the tapped hole, in all the four quadrants, which also confirms that a solid tube of bone is maintained all around the hole. With inserter, the screws of appropriate length were fixed into the pedicle. By image intensifier screw position confirmed during fixation in both frontal and sagittal planes. After choosing appropriate sized rods, it is contoured by cam action bending instrument in the shape of the templet, which was contoured in the shape of normal curvature of spine by inserting the templet into the slots of the implant. The contoured rods held in the slots of the implant after making the assembly with long rod holders which can be self-locked. Then, the rods are fixed with previously placed implants with screws on inner side and nuts on outer side with the help of combined insertion instrument and the proper engagement of the threads by screws is confirmed. The screws are not tightened. After all the screws are applied, the distraction force was given to the assembly with the help of angled spreader gently by placing prongs between rod and head of the implant until the deformity is corrected. After this, all the screws are tightened. Meticulous hemostasis achieved, drain applied, wound closed in layers, and sterile dressing done.

Intravenous antibiotics (third-generation cephalosporin and aminoglycoside) were given to all the operated patients for 7 days. Then, switched over to oral antibiotics till the removal of sutures, i.e., 12 th postoperative day. Physiotherapy started on 1 st postoperative day. Side to side rolling started on the 2 nd postoperative day. After applying thoracolumbar belt, sitting, and mobilization on wheelchair started on the 3 rd or 4 th postoperative day. The records of neurological and radiological parameters maintained. Physiotherapy and ambulation on wheelchair advised to those patients with the preoperative complete neurological deficit. Those with incomplete neurological deficit preoperatively were advised physiotherapy and gradual ambulation. Postoperative X-rays were kept for record. Follow-up was done on 4 th week clinical, radiological, and neurological examination were done. Evaluation of neurological status with ASIA grading and radiological assessment of deformity was done at the time of admission, 12 th week, 24 th week, and 1 year.

Statistical analysis

The data thus obtained were entered in a spreadsheet and analyzed using SPSS statistical analyzing software version 20, (Windows ms0 excel, IBM Company 2009, California State University, New York). Independent sample t-test for quantitative variables, Chi-square test for categorical observations and paired t-test for paired observations. Value of <0.05 was considered significance level and all the values below it was considered as statistically significant and the same is mentioned under results section.


  Results Top


This prospective interventional study was undertaken in the Department of Orthopedics in Chigateri General Hospital, Bapuji Hospitals and JJM Medical College, Davangere. This study was undertaken from July 2011 to September 2014. Sample size 20.

The mean anterior wedge angle during preoperative stage was 19.050 ± 06.70, 12 th postoperative week was 5.00 ± 4.60, during 24 th postoperative week was 5.60 ± 4.60 and 1 year postoperative period was 5.40 ± 4.60. The mean difference of anterior wedge angle between pre- and 12 th post-operative week was 14.050, between pre- and 24 th post-operative week was 13.450 and between pre- and 1 year post-operative period was 13.60. The P values corresponding to the same was 0.0001 <0.05. Since P < 0.05, there was a significant difference between pre- and post-operative anterior wedge angles.

The mean vertebral height was 15.2 ± 3.2 mm during the preoperative stage. The mean vertebral height at 12 th postoperative week was 24 ± 5 mm, during 24 th postoperative week was 23.1 ± 4.6 and during 1 year postoperative period was 23.1 ± 4.7 mm. The mean difference of vertebral height between pre- and 12 th post-operative week was 8.8 mm, pre- and 24 th post-operative week was 7.95 and pre- and 1-year post-operative period was [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5] and [Figure 6] 7.95. These differences were statistically significant. The P values corresponding to the same was 0.0001 <0.05.
Figure 1: Case 1 - Preoperative lateral view

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Figure 2: Case 1 - 1 year follow-up lateral view

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Figure 3: Case 2 - Preoperative

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Figure 4: Case 2 - 1 year follow-up lateral view

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Figure 5: Case 3 - Preoperative

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Figure 6: Case 3 - 1 year follow-up lateral view

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  Discussion Top


This study used stabilization of the cases of the unstable thoracolumbar spine injuries with decompression and pedicular screw and rod instrumentation. In this case series, 20% of the patients were able to return to their previous work or physically challenging job, 35% were able to return to previous employment to heavy labor with some restriction, 30% of the patients were unable to return to their previous employment but worked for full time in their new employment and 25% of the patients were unable to return to their full-time work. About 45% of the patients had no pain, 30% had occasional minimal pain with no need for medication, 20% had moderate pain with occasional need for medication and 5% had moderate to severe pain with occasional absence from work and change in activities of daily living. The mean age of the study group was 41 years with a standard deviation of 11.5 years. The mean age of males was 40.8 ± 11.1 years and female's age was 41.1 ± 12.1 years in this study. Razak et al. in their study found that average was 30 years with a male predominance. [13] However, the mean age in this study group was higher compared to these studies. In this study group, 65% of the patients had injury due to fall from height. Alvine et al. noted it as 52% and Razak et al. noted 69% of the injuries due to fall from height. [13] In this study about 55% of the patients had Type A fractures, 30% had Type B fractures, and 15% had Type C fractures in this study. Alvine et al., [14] Sasso et al., [15] Nasser et al. have also noted similar findings. The average regional angle [Table 1] during preoperative stage was 16.50 ± 5.020 and 4.450 ± 4.150 during 24 th postoperative week, Alvine et al., [15] noted that sagittal plane angulation was 12° preoperatively, 1° postoperatively and 6° at follow-up. The ASIA grading for neurological state during preoperative period, 40% were graded as Grade A, 5% as Grade B, 15% as C, 30% as D and 10% as Grade E. During the last follow-up, Grade A was 25%, Grade B was 5%, C was 5%, D was 10% and E was 55%. Alvine et al., [15] noted that neurological improvement was seen in 50% of cases with 40% improving with one grade and 20% with two grades and none had decrease in neurological level. Eighty-five percent of the study group had shown no complications, Pressure sore, screw fracture and screw misplacement were observed in 5% of the study group. Razak et al. [13] noted two instances of hardware loosening and three misplaced pedicle screws. A more recent human study observed significantly increased denervation at the 6-month follow-up. This study is also not without limitations. This is a cross-sectional study where the group for comparison is not used to validate the value of pedicle screws. A standard sample size and sampling technique has not been used. However, the study adds for the current knowledge base of thoracolumbar fractures and its treatment.
Table 1: Measured vertebral regional angle in degrees in the study groupa

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  Conclusion Top


The findings of this study show that pedicle screw-rod instrumentation is an excellent implant system used in the treatment of vertebral fractures. There is a very high statistical significant restoration of vertebral body height, mean regional angle and mean anterior wedge angle with this procedure in thoracolumbar fractures. Neurological recovery was seen significantly when all cases with neurological deficits were clubbed together. However, in patients who presented with ASIA Type A neurological deficit, this procedure did not improve neurological status statistically, but easy mobilization was possible due to stabilization of the spine and rendered the patient for adequate nursing care. Complications related directly to pedicle screw-rod instrumentation like pedicle screw breakage, pressure sore, and misplacement of screws are comparable with other studies. Early the interventions better the prognosis. This study is also not without limitations. This is cross-sectional study where the group for comparison is not used to validate the value of pedicle screws. A standard sample size and sampling technique has not been used. However, the study adds for the current knowledge base of thoracolumbar fractures and its treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Chapman JR, Mirza SK. Rockwood, Green Fractures in Adults. 5 th ed., Vol. 2.  Philadelphia:Lippincott Williams and Wilkins; 2001. p. 1295-466.  Back to cited text no. 1
    
2.
Benson DR, Keenen TL. Evaluation and treatment of trauma to the vertebral column. J Bone Joint Surg 1990;39:577-88.  Back to cited text no. 2
    
3.
Leventhal MR. Fractures, dislocations, and fracture dislocations of spine. In: Canale ST, editor. Campbell′s Operative Orthopedics. 9 th ed., Vol. 3. Mosby-year book, Inc. Missouri; 1998. p. 2747-79.  Back to cited text no. 3
    
4.
Guttman L. Spinal Cord Injuries - Comprehensive Management and Research. Oxford: Blackwell Scientific Publications; 1976. p. 137-76.  Back to cited text no. 4
    
5.
Benson DR. Keenen TL. Evaluation and Treatment of Trauma to the Vertebral Column. Journal of Bone and Joint Surgery 1990;39:557-8.  Back to cited text no. 5
    
6.
Watson-Jones R: "Fractures and Joint Injuries"; ED.J.B Wilson, Edinburgh: Churchill Livingstone 1982. p. 789-92.  Back to cited text no. 6
    
7.
Bucholz RW, Heckman JD. Rockwood and Greens Fractures in adults: 5 th ed., vol. 2. Lippincott Williams and Wilkins; 2001. p. 1293-1466.  Back to cited text no. 7
    
8.
Takaso M, Nakazawa T, Imura T, Okada T, Toyama M, Ueno M, et al. Two-year results for scoliosis secondary to Duchenne muscular dystrophy fused to lumbar 5 with segmental pedicle screw instrumentation. J Orthop Sci 2010;15:171-7.  Back to cited text no. 8
    
9.
Erkan S, Hsu B, Wu C, Mehbod AA, Perl J, Transfeldt EE. Alignment of pedicle screws with pilot holes: Can tapping improve screw trajectory in thoracic spines? Eur Spine J 2010;19:71-7.  Back to cited text no. 9
    
10.
Winn HR. Pediatric spondylolisthesis. In: Reames D, editor. Textbook of Neurological Surgery. 6 th ed. Philadelphia: Elsevier Saunders; 2011. p. 2932-46.  Back to cited text no. 10
    
11.
Ye YP, Xu H, Chen D. Comparison between posterior lumbar interbody fusion and posterolateral fusion with transpedicular screw fixation for isthmic spondylolithesis: A meta-analysis. Arch Orthop Trauma Surg 2013;133:1649-55.  Back to cited text no. 11
    
12.
Habib H. Posterolateral fusion versus posterior interbody fusion in adult lumbar isthmic spondylolisthesis. Menoufia Med J 2014;27:191-6.  Back to cited text no. 12
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13.
Razak M, Mahmud MM, Hyzan MY, Omar A. Short segment posterior instrumentation, reduction and fusion of unstable thoracolumbar burst fractures - A review of 26 cases. Med J Malaysia 2000;55 Suppl C: 9-13.  Back to cited text no. 13
    
14.
Alvine GF, Swain JM, Asher MA, Burton DC. Treatment of thoracolumbar burst fractures with variable screw placement or Isola instrumentation and arthrodesis: Case series and literature review. J Spinal Disord Tech 2004;17:251-64.  Back to cited text no. 14
    
15.
Sasso RC, Cotler HB, Reuben JD. Posterior fixation of thoracic and lumbar spine fractures using DC plates and pedicle screws. Spine (Phila Pa 1976) 1991;16 3 Suppl: S134-9.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

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