Evaluation of vertebral shortening and interbody fusion with short segment pedicle screw fixation for unstable thoracolumbar fractures

Abstract

Background: Various operative procedures have been described for the treatment of traumatic paraplegia caused by unstable thoracolumbar fractures. We prospectively evaluated interbody fusion (IBF) with SS-PSF in these cases with regard to clinico-radiological outcome with the objectives: (1) Does IBF and short segment pedicle screw fixation (SS-PSF) prevent progression of kyphotic angle after surgery? (2) Can this procedure be safely performed in the setting of acute trauma?.

Methods: Sixteen patients suffering from traumatic paraplegia caused by acute unstable thoracolumbar fractures were enrolled prospectively and underwent IBF with SS-PSF. They were evaluated for magnitude of shortening in spine, progression of kyphotic angle, and neurological improvement by American spinal injury association scale (ASIA).

Results: Out of total sixteen, 14 patients were ASIA grade A and 2 were grade C, at the time of presentation. Thirteen out of these 14 remained grade A and one improved to B. Both the patients who had grade C involvement at the time of presentation improved to grade D at one-year follow-up. The mean blood loss was 750 ml (range; 650 ml-1150 ml). Mean kyphotic angle decreased from 20.6° (range; 13° to 37°) preoperatively to 6.2° (range; 3° to 10°) at postoperative day 2 (p = 0.002). Its mean value after 6 months was 6.5° (range; 3° to 11°). The procedure resulted in mean spinal column shortening of 18 mm (range; 16 mm-22 mm) in the spinal column. All the patients achieved bony union by a mean duration of 3.9 months (range; 3 months-6 months).

Conclusions: IBF with SS-PSF has the shortest possible instrumented construct for thoracolumbar junction fusion done by posterior approach. The interbody fusion for unstable thoracolumbar junction fractures prevents the progression of kyphotic angle post-operatively.

Level of evidence: Level 4.

Fig. 1

A 25-years-old man who fell from height and presented with complete paraplegia: (A) lateral view radiograph showing unstable L1 vertebral body fracture; (B) sagittal view; (C) axial view; and (D) 3-D reconstructed image of NCCT showing fracture anatomy and comminution in detail.

Fig. 2

(A) Intra-operative image showing all 4 pedicle screws with a temporary rod on one side in place. Spinous process, lamina, and facet joint are seen removed exposing the dura; and (B) Intra-operative image after shortening procedure.

Fig. 3

Line diagram of vertebral body fracture (A) before; and (B) after IBF.

Fig. 4

(A) Lateral view radiograph showing vertebral shortening procedure; (B) sagittal view NCCT obtained 3 months post-operatively showing initiation of healing; (C) sagittal view NCCT obtained 6 months post-operatively showing anterior fusion.

Fig. 5

A 30-years-old man who fell from height and presented with complete paraplegia: (A) lateral view radiograph showing unstable L1 vertebral body fracture; (B) NCCT mid-sagittal view showing retropulsion of vertebral body; (C) MRI sagittal view showing resultant cord compression; and (D) lateral view radiograph showing vertebral shortening, SS-PSF and IBF procedure at 3 months follow-up.

Fig. 6

A 35-years-old man who fell from height and presented with complete paraplegia: (A) lateral view radiograph showing unstable T12 vertebral body fracture; (B) NCCT mid-sagittal view showing retropulsion of vertebral body; (C) lateral view radiograph showing vertebral shortening, SS-PSF and IBF procedure; (D) NCCT mid-sagittal view at 5 months follow-up showing IBF.