SURGICAL TREATMENT OF THORACIC AND LUMBAR SPINE FRACTURES USING MODERN TECHNOLOGIES*

S.T. Vetrile, A.A. Kuleshov, 2013 SURGICAL TREATMENT OF THORACIC AND LUMBAR SPINE FRACTURES USING MODERN TECHNOLOGIES* S.T. Vetrile, A.A. Kuleshov Central Institute of Traumatology and Orthopaedics n.a. N.N. Priorov, Moscow, Russia The treatment outcomes of 97 patients with thoracic and lumbar spine fractures are presented. The injuries were uncomplicated in 55 cases, while 42 fractures had neurological complications. Stabilization of the spine was achieved with transpedicular fixators (Steffee, CD, Tenor, TSRH) in 86 cases, with Z-plates in 7 cases, and with Luque rods in 4 cases. In case of acute uncomplicated fracture, indirect spinal canal decompression was performed by means of ligamentotaxis. The instrumented fixation was complemented by posterolateral spine fusion. Uncomplicated compression fractures of thoracic spine with spinal canal stenosis were treated by anterior decompression and spinal fixation by a wire mesh filled with autograft, and by Z-plates. The severe neurological symptoms required spinal canal decompression by extensive laminectomy and Urban wedge resection. The displacement of vertebrae was reduced and spinal canal stenosis was totally eliminated in all cases of fracture-dislocation. Chronic posttraumatic and post-laminectomy kyphosis was corrected and fixed with the CDI system through a posterior approach. The differential choice of spine injury treatment yielded good results in 61 % of patients, satisfactory in 32 %, and unsatisfactory in 7 % of patients. Key Words: surgical treatment, thoracic and lumbar spinal fractures. * Vetrile ST, Kuleshov AA. [Surgical Treatment for Thoracic and Lumbar Spine Fractures with Modern Technologies]. Hirurgia pozvonocnika. 2004;(3):33 39. In Russian. Introduction It is a well-known fact that physicians need to solve both orthopedic and neurosurgical problems when treating patients with thoracic and lumbar spine injuries. Significant progress in surgical treatment of thoracic and lumbar spine injuries has been made over the past decade. It is due to the fact that medical tools used for interventions both in the dorsal (various types of transpedicular ixators) and ventral regions of the spine have been designed and introduced into clinical practice. The fundamental aspects of surgical treatment of spinal fractures include spinal cord decompression, reconstruction of the normal shape of the vertebral column and spinal canal, and rigid fixation of an injured segment. Since 1992, transpedicular fixation devices (Steffee system) have been used at the Spine Pathology Department, Central Institute of Traumatology and Orthopaedics; other systems started to be used later as well. 1

The experience in treating patients with both acute fractures and chronic posttraumatic and post-laminectomy iatrogenic kyphotic deformity of the spine is presented in this article. Material and Methods A total of 97 patients with thoracic and lumbar spine fractures underwent surgical treatment. Specialized methods, such as conventional radiography, myelography/ct scanning, MRI, and X-ray densitometry, were used along with clinico-neurological examination. Three main fracture groups were distinguished (according to the classification proposed by F. Denis, 1983): compression fractures 41, burst fractures 43, fracture-dislocations and flexion-distraction fractures 13. In eight patients, spinal fractures were accompanied by osteoporosis (confirmed by the X-ray densitometry data). Seven patients had a severe kyphosis in the thoracolumbar spine after compression fractures of the T12 L1 vertebrae. These patients had previously undergone surgeries in other hospitals; however, dissatisfactory results were obtained (unjustified laminectomy and inadequate metal fixation of the spine). The neurological disorders were assessed according to the procedure proposed by H. Frankel (1969) and modified by D.S. Bradford and G.G. McBride (1987). A total of 11 patients exhibited severe neurological symptoms (types A, B); 31 patients had less pronounced symptoms (types C, D); 55 patients had an uncomplicated spine injury. The following types of metal constructs were used for correction and fixation of the spine: anterior Z-plates (7 cases) and dorsal metal constructs (89 cases). The most commonly used dorsal constructs included either transpedicular fixation devices or the constructs combining transpedicular screws and sublaminar or pedicle hooks (Steffee, Cotrel Dubousset, Tenor, TSRH). In five cases, transpedicular fixation was combined with anterior fixation with mesh containing autografts. In four patients, spinal fixation was performed using the Luque system. The choice of surgical treatment method depended on fracture type and localization, degree of spinal stenosis, character of neurological disorders, and time that has passed since the injury. In patients with acute uncomplicated compression penetrating fractures in the thoracolumbar spine, posterior transpedicular fixation with simultaneous elimination of traumatic kyphosis by ligamentotaxis was performed. No revision of the spinal canal was typically required. Intraoperative myelography allowed one to reliably assess the degree of retention or elimination of spinal canal stenosis. In order to perform corporodesis, fenestration and removal of an injured disc was conducted through a posterolateral approach followed by incorporation of an autograft into the interbody space. In five cases, surgery procedures in the lumbar spine were performed through an anterior approach only, using Z-plates combined with autograft corporodesis. Uncomplicated compression fractures of the T7 and T11 vertebra occurred in two and one cases, respectively. However, complete compression of the anterior subarachnoidal space by an injured disc and a bone fragment was detected based on the data obtained by specialized methods (myelography/ct scanning and MRI). In this case, anterior decompression of the spinal canal was performed via partial excision of an injured vertebral body and an intervertebral disc. In two cases, spinal fixation was performed using a mesh containing autograft and a Z-plate; in one case, 18-year-old patient P. underwent corporodesis using an autograft and a Z-plate (Fig. 1). In patients with acute complicated burst fractures with mild or moderate degrees of neurological disorders (type D), closed decompression, or if there were no interventions in the spinal canal, an indirect decompression (reduction of fragments and restoration of the canal shape via distraction and lordosis formation) 2

a b Fig. 1 MRI and radiograms of the 18-year-old patient P.: a MRI before the surgery: compression fracture of the Т11 vertebra, with compression of the anterior subarachnoidal space; b radiograms after the surgery: discectomy of Т10 Т11, partial resection of the Т11 body, corporodesis of Т10 T12 with an autograft and fixation with a Z-plate was preferentially carried out. In case of complicated fractures of the lower lumbar vertebrae, preference was given to laminectomy and Urban wedge resection through a posterior approach, since the decompression maneuver via ligamentotaxis typically failed, since the posterior longitudinal ligament below the L3 vertebra was poorly pronounced. In patients with severe neurological symptoms (types A, B, C), the indications for decompression by extensive laminectomy and resection of the pedicles to remove the Urban wedge and the injured disc increased. The surgery was finished by metal fixation of the spine and interbody fusion. The revision of the contents of the dural sac and drainage of the intracerebral hematoma was conducted in two patients; sutures were put on pachymeninx in one female patient. In two patients with a complete fracture-dislocation in the thoracic spine, there was a complete anatomic interruption both of the spinal cord and spinal meninges. In this case, resection of the broken vertebral body, dislocation reduction, and metal fixation of the spine combined with posterior spine fusion were performed (intraoperative halo traction was conducted when performing dislocation reduction). The integrity of spinal meninges was not restored because of extensive crushing (up to 2 cm) of their edges in both the proximal and distal spinal cord and significant contraction of the proximal spinal cord. In this case, at least two vertebrae had to be resected in order to restore the anatomic integrity of the dural sac, which was considered unjustified. Clinical example. A 17-year-old patient K. had a fracture-dislocation of the T7 T8 vertebrae as a result of car accident. The admitted patient was in critical condition and had an abrupt kyphotic deformity in the thoracic spine. The neurological status included lower paraplegia with the loss of all types of sensitivity and pelvic organ dysfunction. According to the radiography data, the frontal view (Fig. 2a) shows a multifragmental fracture of the T8 vertebra, lateroposition of the T7 to the right; the lateral view shows a complete anterior dislocation of the T7 vertebra (Fig. 2b). After the examination, a halo ring was applied and access to the posterior spinal regions (T1 L1 vertebrae) was ensured. A rupture of T7 T8 ligament structures and fracture of T8 articular processes were revealed; the T7 vertebra body was displaced forward and rightwards; the T8 arch is not connected to the vertebral body. The arch of the T8 vertebral body was removed. Revision of the spinal canal was performed; an anatomic interruption of the spinal meninges and spinal cord was detected. The proximal end of the spinal cord was visualized in the spinal cavity near the T6 T7 vertebrae. The distal fragment of the meninges and the spinal matter was crushed within 2.5 3.0 cm. The halo ring 3

a b c d e f Fig. 2 Radiograms and skiagrams of 17-year-old patient K.; dislocation of the T7 vertebra, multifragmental fracture of the T8 vertebra: a frontal view prior to surgery; b lateral view prior to surgery; c frontal view after the resection of the T8 vertebral body and dislocation reduction; d lateral view after the surgery; e patient s appearance prior to surgery; f patient s appearance after the surgery traction of the proximal spinal region was performed; numerous T8 vertebral body fragments were detected. Under the conditions of continuous lateral traction of the spine, fragments of the T8 vertebral bodies were removed; thus, total spondylectomy of the T8 vertebra was performed. Next, the dislocation of the proximal spine was reduced; the Tenor system was mounted on the posterior spinal elements using transpedicular screws and pedicle and laminar hooks; contraction at the level of the injury was performed; and the T7 T9 vertebral bodies were drawn closer to one another until tight contact (shortening spondylectomy was performed). The resected arch and bone fragments of the T8 vertebral body were broken down into smaller fragments and placed along the posterior spinal elements; the wound was tightly closed layer by layer; the halo ring was removed; the control radiogram showed the dislocation reduction and the restoration of the normal shape of the spine (Figs. 2c, d, e). The patient has adapting to using a wheelchair within one month; he was also using a spinal support of Leningrad type for three months; no external immobilization was subsequently required. In patients with fractures due to osteoporosis, stabilizing surgery with the longer metal fixation of the spine (3 4 segments) was conducted; laminar hooks were used along with transpedicular screws. Long-term drug therapy for osteoporosis was performed in all cases. Chronic pain syndrome with progressive local deformation of the spine was an indication for surgery. Worsening of neurological symptoms (in 5 cases) and a severe cosmetic defect (in 2 cases) were indications for surgery in patients with chronic fractures and severe kyphotic deformation. The dural sac was isolated from the scars through a posterior approach and the vertebral body on the apex of the kyphosis was isolated extrapleurally from two sides (a metal construct had been preliminarily mounted on the posterior spinal elements on one side); the apical vertebral body was then removed (virtually the spondylectomy) followed by correction of kyphosis through straightening the rod of the CD system. The interbody defect at the site of the removed body was replaced by an autograft or a mesh with autograft; the rod was 4

then fixed on the other side. Thus, this procedure was similar to that performed by L. Tomita in patients with metastatic spinal lesions [8]. Results The treatment results were assessed radiographically and clinically. Improved radiographic indices (degree of compression of the anterior region of a vertebral body, local kyphosis angle) have been observed in groups of patients with acute compression and burst fractures during the postoperative period. No significant changes in vertebral body height were observed in patients with chronic compression fractures of the lower lumbar spine who underwent surgeries through the posterior approach. An analysis of the results of surgical correction of traumatic spinal deformity has demonstrated that the time between injury and treatment had the crucial effect on the degree of correction of the angular deformation: correction of kyphosis was insignificant even four weeks after the trauma occurred. The displacement of a vertebral body was completely eliminated in all the patients with fracture-dislocations in the thoracic and lumbar spine. In patients with chronic kyphotic deformation of the spine following laminectomy, the pathological kyphosis was either eliminated or considerably reduced (it was 70 100 deg. prior to the surgery) and the spinal meningeal tension was eliminated. At the remote period, loss of correction in three cases resulted mainly from the subsidence of vertebral bodies after compression fractures in individuals with systemic osteoporosis. In the group of patients with burst fractures, the subsidence of the vertebral body and interbody space was observed in two cases; patients had no complaints related to spinal pain (the mean follow-up period was 6 years). In one case, the loss of correction was caused by breakage of two lower screws of the Steffee system, after which kyphotic deformation increased significantly. This female patient underwent wedge resection on the apex of the deformation through the bilateral posterolateral approach, reposition, and fixation using the Steffee system at four levels; pathological kyphosis was eliminated; no recurrent deformation was observed during the 2-year follow-up period. The use of the Luque system for spinal fixation in four cases has demonstrated that it was less efficient as compared to the transpedicular systems. This can be attributed to the fact that the use of the Luque system does not ensure reliable stability during vertical loading; there is a demand for the longer (multilevel) fixation of the spine (at least 5 6 segments) and in penetration of wire sutures into the spinal canal. Because of these drawbacks, we subsequently abandoned the use of the Luque system. However, it should be mentioned that no unsatisfactory results have been obtained when using this system. In two cases, stabilization using the Luque system was performed after the spinal cord decompression surgeries in patients with complicated spinal injury; a significant regression of the neurological symptoms was reported for these patients. The restoration of the shape of the spinal canal was assessed using the intraoperative myelography and postoperative CT data. The restoration was attained by 17.5 % on average (from 42.5 to 25 % canal stenosis) in the case of indirect decompression by ligamentotaxis in patients with acute uncomplicated fractures. In patients with fracture-dislocations, spinal stenosis was completely eliminated in all cases. The treatment outcomes were clinically assessed on the basis of changes in pain syndrome, restoration of the lost functions, and the dynamics of neurological disorders (table). In patients with complicated fractures, no significant regression of neurological symptoms has been observed in four cases only (two patients had complete anatomic interruption of the spinal cord and its meninges, and two other ones had hematomyelia). In the remaining cases, either partial or complete regression of neurological symptoms was observed. Among the patients with pelvic organ 5

Table Assessment of therapy outcomes (five-grade scale) Grade Pain Function Neurology Data obtained by instrumental diagnostic methods (according to Denis) (according to Denis) (according to Frankel) (radiography, CT, MRI) 5 Р1 W1 E consistent fusion, complete deformation correction, retention of the adjacent vertebral motor segments, absence of spinal stenosis 4 Р2 W2 D3 consistent fusion, residual nonprogressive deformation (up to 20 deg.), fixation of several non-injured segments, absence of spinal stenosis 3 Р3 W3 D2 fibrotic block, residual nonprogressive deformation (up to 30 deg.), absence of degenerative changes in the adjacent vertebral motor segments, spinal stenosis up to reasonable values 2 Р4 W4 D1 pseudoarthrosis, deformation over 30 deg., degenerative changes in the adjacent vertebral motor segments, spinal stenosis up to reasonable values 1 Р5 W5 A, B, C increasing deformation with the involvement of the adjacent vertebral motor segments, pseudoarthrosis, increased degree of stenosis of the spinal canal and intervertebral foramina Р1 no pain; Р2 infrequent mild pain requiring no treatment; Р3 moderate pain that sometimes requires drug therapy but does not affect the vital capacity; Р4 pain with intensity varying from moderate to severe, which requires drug therapy and sometimes results in disability; Р5 chronic pain regardless of drug therapy; W1 returning to the previous workplace; W2 returning to the previous workplace with limited physical activity; W3 returning to work with less hard conditions (change of profession); W4 individuals efficient when working part-time; W5 completely disabled individuals. dysfunction, complete and partial restoration was observed in six and three individuals, respectively; the function of pelvic organs did not restore in four patients. The total score for all the indices yields the numerical score for evaluating the treatment outcome: 17 20 good results; 12 16 satisfactory results; and below 11 unsatisfactory results. According to the complex clinical and radiographic evaluation of treatment outcome, good results were achieved in 61 % of patients; satisfactory and unsatisfactory results were achieved in 32 and 7 % of patients, respectively. 6

Conclusions The use of modern technologies makes it possible to completely solve the orthopedic problems in patients with severe spinal injuries and partially solve the neurological problems. Various types of transpedicular or anterior fixation devices make it considerably easier to solve the orthopedic problem in patients with traumatic spine injuries. The optimal method for treating this category of patients is to possibly solve all the problems during a single surgery. Surgeries for uncomplicated compression fractures combined with stenosis of the anterior regions of the spinal canal are preferentially performed through an anterior approach. In particular, this is valid for patients with fractures localized in the thoracic spine. Many researchers consider it necessary to employ two-stage surgical treatment [5 7, 9] through the anterior and posterior approaches individually in patients with fractures in the thoracolumbar region with significant body damage. The two-stage surgical treatment was performed in five patients. In the remaining cases, osteoplasty after the transpedicular spinal fixation was performed either through the posterolateral approach if there was no interventions on the spinal canal or through the posterior approach if laminectomy was required in patients with a complicated spinal injury. Surgeries are preferentially conducted through the posterior approach in patients with significant damage in the anterior and posterior columns of the spine or with fracture-dislocations. Despite significant displacement of the spinal segments, dislocation was successfully eliminated in almost all cases; however, the dislocation was not reduced in patients with extremely significant spinal displacement [4]. Corporodesis can also be performed through the posterior approach in patients with a complicated injury or with fracture-dislocations, when extensive laminectomy including the removal of the damaged disc and the Urban wedge resection [1]. Patients with spinal fractures due to osteoporosis impose the most significant problem for treatment. Only the patients with pronounced pain syndrome and with compression fractures at the same levels were operated. In this case, the spine was fixed within significant length; hooks were used along with transpedicular screws for fixation. Minimally invasive methods with percutaneous injection of cement to the vertebral body pedicles are the most promising ones for treating this category of patients [10]. The greatest problems are associated with patients with chronic posttraumatic and post-laminectomy kyphotic spinal deformity. The reason for that is that correcting vertebrotomy needs to be performed in order to eliminate the pathological kyphosis, requiring mobilization of the anterior and posterior spinal regions [2, 3]. Circular spinal mobilization through the posterior approach was performed using L. Tomita s procedure. The possibility of restoring the spinal cord function if there is anatomic interruption of the spinal cord or a pronounced hematomyelia is a complex problem. However, the timely and adequate spinal cord decompression and spinal stabilization allows one to attain partial or complete regression of neurological disorders in cases of spinal cord compression or contusion, when no significant cell death (apoptosis) occurs. References 1. Aganesov AG, Meskhi KT, Nikolaev AP, et al. [Surgical treatment of complicated spinal injury in acute period]. Vestnik Travmatologii i Ortopedii im. N.N. Priorova. 2003;(3):48 53. In Russian. 2. Dulaev AK, Orlov VP, Nadulich KA, et al. [Results of surgical treatment of patients with chronic complicated and uncomplicated compression fractures of thoracic and lumbar vertebrae]. Proceedings of the VII Russian Congress of Traumatologists and Orthopaedists, vol. 1, Novosibirsk, 2002:75. In Russian. 7

3. Dulaev AK, Nadulich KA, Vasilevich SV, et al. [Analysis of the results of correction of the posttraumatic kyphotic deformation of the thoracic spinal region]. Proceedings of the Republican Scientific and Practical Conference Organization of Neurotraumatological Care in Patients with Spinal Injuries, Minsk, 2004:43 45. In Russian. 4. Karp VN, Yashinina YuA. [Classification of closed injuries of the spine and spinal cord]. Neyrohirurgiya. 2003;(3):46 48. In Russian. 5. Makarevich SV, Voronovich IR, Petrenko AM, et al. [One- and two-stage surgical interventions for splintered fractures of the thoracic and lumbar vertebrae using transpedicular fixation]. Proceedings of the Republican Scientific and Practical Conference Organization of Neurotraumatological Care in Patients with Spinal Injuries, Minsk, 2004:77 80. In Russian. 6. Ramikh EA, Atamanenko MT. [Surgical methods for treating thoracic and lumbar spinal fractures]. Vestnik Travmatologii i Ortopedii im. N.N. Priorova. 2003;(3):43 48. In Russian. 7. Rerikh VV, Borzykh OK. [Ventral segmental fixation in patients with fractured thoracic and lumbar vertebrae]. Proceedings of the VII Russian Congress of Traumatologists and Orthopaedists, vol. 1, Novosibirsk, 2002:103 104. In Russian. 8. Tomita L, Kavakhara Kh, Baba Kh, et al. [Total en bloc spondylectomy for solitary metastases of the spine]. Vestnik Travmatologii i Ortopedii im. N.N. Priorova. 1996;(2):11 18. In Russian. 9. Usikov VD, Usikov VV. [Surgical treatment in patients with spine and spinal cord injuries: results of surgical treatment in patients with chronic complicated and uncomplicated compression fractures of the thoracic and lumbar vertebrae]. Proceedings of the VII Russian Congress of Traumatologists and Orthopaedists, vol. 1, Novosibirsk, 2002:116 117. In Russian. 10. Polikeit A, Nolte LP, Ferguson SJ. The effect of vertebroplasty on the load transfer in an osteoporotic functional spinal unit. EuroSpine 2003. 5th Annual Meeting of the Spine Society of Europe. Prague, 2003:58 59. Corresponding author: Stepan Vetrile ul. Priorova 10, Moscow, 125299 Russia, Central Institute of Traumatology and Orthopaedics, cito-spine@mail.ru Stepan Timofeyevich Vetrile, MD, DMsc, Prof.; Aleksandr Alekseyevich Kuleshov, MD, DMsc, Central Institute of Traumatology and Orthopaedics n.a. N.N. Priorov, Moscow, Russia. 8