PLIF in thoracolumbar trauma: technique and radiological results

Abstract

Patients with fractures from the 11th thoracic to the 5th lumbar vertebra had a reconstruction of the anterior column with monocortical iliac crest autograft by using a single dorsal approach. The loss of correction was observed using X-rays pre- and post-operatively, at 3 months and after implant removal (IR). Successful fusion was assessed using computed tomography after the implant removal. To assess the loss of correction and intervertebral fusion rate of this technique. There are still controversial discussions about the treatment modalities of spine lesions, especially in cases of burst fractures. Dorsal, combined and ventral procedures are reported with different assets and drawbacks. We want to present a method to restore the weight-bearing capability of the anterior column using a single dorsal approach. From 2001 to 2005, a total of 100 patients was treated with this technique at our department. Follow-up examination was possible in 82 patients. The X-rays and CT scans were proofed for loss of correction and fusion rate. The anterior column has been restored using a monocortical strut graft via a partial resection of the lamina and the apophyseal joint on one side to access the disc space. The dorsal reduction has been achieved using an angular stable pedicle screw system. The mean follow-up time was 15 months (range 8-39); 67 patients had a CT scan at follow-up and 83% showed a 360 degrees fusion. The average post-operative loss of correction was 3.3 degrees (range 0-21). The average duration of operation was 192 min (range 120-360) and the mean blood loss was 790 ml (range 300-3,400 ml). Regarding the complications we did not have any deep wound infections. We had two epidural haematomas postoperatively with a neurological deterioration that had to be revised. We were able to decompress the neurological structures and restore the weight-bearing capability of the anterior column in a one-stage procedure. So we think that this technique can be an alternative procedure to combined operations regarding the presented radiological results of successful fusion and loss of correction.

Fig. 1

Segmental angle was measured between both endplates adjacent to the fused segment in the lateral view

Fig. 2

a Intraoperative photo shows the interspinal spreader in position. The transforaminal approach to the disc space is lateral to the dural sac. b An incomplete cranial burst fracture (A3.1.1) of L1 is instrumented bisegmentally. The arrow shows the transforaminal approach with resection of the upper articular process and the posterior rim of the vertebral body. The monocortical bone graft is brought in, in longitudinal direction and shows good contact with the endplates. CT scan after the IR shows successful intervertebral and posterior fusion with satisfactory alignment

Fig. 3

The initial correction and the following loss of correction in diagram

Fig. 4

A 24-year-old male who had a fall from a height during the landing procedure in paragliding. He suffered a A3.2.1 fracture of the 2nd lumbar vertebra with horizontal fracture of the spinous process. The spinal canal is completely narrowed by a posterior wall fragment. On admission he showed a complete paraplegia that did not recover. The posterior fragment was resected and monocortical strut grafts were put in place. The patient was instrumented bisegmentally. The CT scan after IR showed successful intervertebral fusion. The loss of correction was 4.5°

Fig. 5

A 25-year-old female who fell from a horse. She was neurologically intact. a and b CT scans showed a incomplete cranial burst fracture. The screws were set very close to the graft bed and the bone blocks did not have good contact with the endplates. c After a superior loss of correction CT scans showed only partial intervertebral fusion. There was no sufficient fusion to the fracture area. d After IR there was an additional loss of correction and intevertebral fusion occurred in the posterior intervertebral area