Role of early minimal-invasive spine fixation in acute thoracic and lumbar spine trauma

Abstract

Polytraumatized patients following a severe trauma suffer from substantial disturbances of the immune system. Secondary organ dysfunction syndromes due to early hyperinflammation and late immunparalysis contribute to adverse outcome. Consequently the principle of damage control surgery / orthopedics developed in the last two decades to limit secondary iatrogenic insult in these patients. New percutaneous internal fixators provide implants for a damage control approach of spinal trauma in polytraumatized patients. The goal of this study is to evaluate the feasibility of minimal-invasive instrumentation in the setting of minor and major trauma and to discuss the potential benefits and drawbacks of this procedure.

Materials and methods: The present study is a prospective analysis of 76 consecutive patients (mean age 53.3 years) with thoracolumbar spine fractures following major or minor trauma from August 2003 to January 2007 who were subjected to minimal-invasive dorsal instrumentation using CD Horizon(®) Sextant™ Rod Insertion System and Longitude™ Rod Insertion System (Medtronic(®) Sofamor Danek). Perioperative and postoperative outcome measures including e.g. local and systemic complications were assessed and discussed.

Results: Forty-nine patients (64.5%) suffered from minor trauma (Injury Severity Score <16). Polytraumatized patients (n=27; 35.5%) had associated chest (n=20) and traumatic brain injuries (n=22). For mono- and bisegmental dorsal instrumentation the Sextant™ was used in 60 patients, whereas in 16 longer ranging instrumentations the (prototype) Longitude™ system was implanted. Operation time was substantially lower than in conventional approach at minimum 22.5 min for Sextant and 36.2 min for Longitude™, respectively. Geriatric patients with high perioperative risk according to ASA classification benefited from the less invasive approach and lack of approach-related complications including no substantial blood loss.

Conclusion: Low rate of approach-related complications in association with short operation time and virtually no blood loss is beneficial in the setting of polytraumatized patients regarding damage control orthopedics, as well as in geriatric patients with high perioperative risk. The minimal-invasive instrumentation of the spine is associated with beneficial outcome in a selected patient population.

Keywords: Damage control; minimally invasive; polytrauma; spinal fracture; spinal instrumentation.

Figure 1

Preoperative physical fitness according to ASA classification, demonstrating low physical fitness prior to surgery in the investigated geriatric patient population (aged 70 and above). All polytraumatized patients were found in the younger patient group indicated by ASA Class 4 and 5. (n = patient number; ASA classification, 1 = Class 1; 2 = Class 2; 3 = Class 3; 4 = Class 4; 5 = Class 5)

Figure 2

Classification of thoracolumbar fractures according to Magerl et al reveals stable anterior column fracture Type A 1.2 to be the most frequent stabilized by minimal invasive percutaneous dorsal instrumentation. More severe spine fractures in polytraumatized patients are seen in the younger population group only (n = patient number; A 1 = compression injury of the endplate; A 2 = compression injury and split fracture; A 3 = complete burst fracture; B = flexiondistraction injury)

Figure 3.1

Lateral (A) and AP x-ray (B), mid sagittal T2WI of MRI (C) and CT scan (D) in a 16 years old female patient with flexion-distraction injury and rotatory instability following a horse riding accident

Figure 3.2

Intraoperative photographs show simultaneous insertion of two Sextant Fixators. Use of rod templates to determine the length of the rod (A). Inserted via stab incisions. Conventional rod distractors are used for added distraction force to the posterior wall fragment (B) and Rods are attached to the Sextant Introducer (C). Final approachrelated injury is minimal as demonstrated by these < 2 cm long stab incisions for a bisegmental internal fixator (D)

Figure 3.3

Post operative lateral (A) and AP X-ray (B), sagittal reconstruction CT (C) and axial CT (D) shows anatomic reduction and anterior height restoration. Uneventful recovery and percutaneous implant removal six months post trauma was performed

Figure 4

Mid sagittal T2WI (A) MRI shows flexion-distraction injury of the thoracolumbar spine in a 55 yrs old female with no neural deficit. X-ray of dorsal spine AP and lateral (B,C) shows stabilization with percutaneous longitude Longitude™ implant. Early ambulation without external bracing was achieved on day one post surgery. Wound healing was primary; no substantial complaints were reported on follow-up.

Figure 5

Duration of C-arm fluoroscopy for positioning of pedicle screws and intraoperative verification of correct implant positioning shows mean radiation time of 354 seconds (n = patient number)

Figure 6

Different forms of analgesia in patients following percutaneous minimal-invasive dorsal fusion procedure. Low demand of analgesics in patients following use of minimal-invasive stabilization is demonstrated. Fifty-seven out of 76 patients were sufficiently treated by oral analgesia like NSAIDs, only. In 12 patients treated with additional surgery, initial patient-controlled intravenous analgesia was necessary for pain reduction