Objective To discuss the effectiveness of anterolateral decompression and three column reconstruction through posterior approach for the treatment of unstable thoracolumbar fracture. Methods Between March 2009 and October 2011, 39 patients with unstable burst thoracolumbar fracture were treated. Of them, there were 32 males and 7 females, with an average age of 43.8 years (range, 25-68 years). The injury causes included falling from height in 17 cases, bruise in 10 cases, traffic accident in 4 cases, and other in 8 cases. The fracture was located at the T10 level in 1 case, T11 in 9 cases, T12 in 6 cases, L1 in 14 cases, L2 in 7 cases, L3 in 1 case, and L4 in 1 case. According to Frankel classification before operation, 5 cases were classified as grade A, 5 as grade B, 9 as grade C, 14 as grade D, and 6 as grade E. Before operation, the vertebral kyphosis Cobb angle was (26.7 ± 7.1)°; vertebral height loss was 37.5% ± 9.5%; and the space occupying of vertebral canal was 73.7% ± 11.3%. The time between injury and operation was 1-4 days (mean, 2.5 days). All patients underwent anterolateral decompression of spinal canal by posterior approach and three column reconstruction. After operation, the vertebral height restoration, correction of kyphosis, decompression of the spinal canal, and the recovery of nerve function were evaluated. Results Increase of paraplegic level, urinary infection, and pressure sore occurred in 1 case, 1 case, and 2 cases, respectively; no incision infection or neurological complications was observed in the other cases, primary healing of incision was obtained. The patients were followed up 12-36 months (mean, 27 months). The patients had no aggravation of pain of low back after operation; no loosening and breaking of screws and rods occurred; no titanium alloys electrolysis and titanium cage subsidence or breakage was observed. The imaging examination showed that complete decompression of the spinal canal, satisfactory restoration of the vertebral height, and good physiological curvature of spine at 2 years after operation. At last follow-up, 1 case was classified as Frankel grade A, 2 as grade B, 2 as grade C, 10 as grade D, and 24 as grade E, which was significantly improved when compared with preoperative one (Plt; 0.05). At immediate after operation and last follow-up, the Cobb angle was (6.3 ± 2.1)° and (6.5 ± 2.4)° respectively; the vertebral height loss was 7.9% ± 2.7% and 8.2% ± 3.0% respectively; and the indexes were significantly improved when compared with preoperative ones (P lt; 0.05). Conclusion The technique of anterolateral decompression and three column reconstruction through posterior approach is one perfect approach to treat unstable thoracolumbar fracture because of complete spinal cord canal decompression, three column reconstruction, and immediate recovery of the spinal stability after operation.
【Abstract】 Objective To study the effectiveness of computer assisted pedicle screw insertion in osteoporotic spinalposterior fixation. Methods Between December 2009 and March 2011, 51 patients underwent pedicle screw fixation using the computer assisted navigation (navigation group), while 41 patients underwent the conventional technique (traditional group). All patients had osteoporosis under the dual-energy X-rays absorptiometry. There was no significant difference in age, gender, bone mineral density, involved segment, preoperative complications, and other general status between 2 groups (P gt; 0.05). The amount of blood loss, the operation time, the rate of the pedicle screw re-insertion, and the postoperative complication were observed. The state of the pedicle screw location was assessed by CT postoperatively with the Richter’s classification and the fusion state of the bone graft was observed using three-dimensional (3-D) CT scans during follow-up. Results A total of 250 screws were inserted in navigation group, and 239 were inserted successfully at first time while the other 11 screws (4.4%) were re-inserted. A total of 213 screws were inserted in traditional group, and 190 were successful at first time while 23 screws (10.8%) were re-inserted. There was significant difference in the rate of screws re-insertion between 2 groups (χ2=6.919, P=0.009). Both the amount of blood loss and the operation time in navigation group were significantly less than those in traditional group (P lt; 0.05). According to Richter’s classification for screw location, the results were excellent in 240 screws, good in 10 screws innavigation group; the results were excellent in 191 screws, good in 21 screws, and poor in 1 screw in traditional group. Significant difference was noticed in the screw position between 2 groups (χ2=7.566, P=0.023). The patients were followed up (7.8 ± 1.5) months in navigation group and (8.7 ± 1.5) months in traditional group. No loosening, extraction, and breakage of the pedicle screw occurred in navigation group, and all these patients had successful fusion within 6 months postoperatively. While in traditional group, successful fusion was shown in the other patients by 3-D CT, except the absorption of bone graft was found in only 1 patient at 6 months after operation. And then, after braking by adequate brace and enhancing the anti-osteoporotic therapy, the bone graft fused at 9 months postoperatively. Conclusion The computer assisted navigating pedicle screw insertion could effective reduce the deviation or re-insertion of the screws, insuring the maximum stabil ity of each screw, mean while it can reduce the exposure time and blood loss, avoiding complication. The computer assisted navigation would be a useful technique which made the pedicle screw fixation more safe and stable in patients with osteoporosis.
Objective To evaluate the early cl inical outcomes of subtotal corpectomy and intervertebral bonegrafting through posterior approach alone in the treatment of thoracolumbar burst fracture or thoracolumbar fracturedislocation.Methods Between January 2009 and December 2010, 20 patients with thoracolumbar burst fracture orthoracolumbar fracture dislocation were treated with subtotal corpectomy and intervertebral bone grafting through posteriorapproach alone. There were 14 males and 6 females, with an average age of 36.1 years (range, 19-47 years). Fractures were causedby falling from height in 12 cases, traffic accident in 6 cases, and crushing in 2 cases. According to AO classification, there were10 cases of A3 type, 8 cases of B2 type, and 2 cases of C2 type. Single segment was involved in 8 cases, double segments in 12cases. Twelve cases complicated by fracture dislocation and 6 cases by lateral displacement. All patients had bones occupancyin vertebral canal. The preoperative Cobb angle was (30.2 ± 3.9)°. According to Frankel classification for neurological function,there were 4 cases of grade B, 9 cases of grade C, and 7 cases of grade D at preoperation. The mean time between injury andoperation was 4.5 days (range, 1-12 days). Results All incisions healed by first intention, and no infection occurred.Twenty patients were followed up 8-16 months (mean, 12 months). The interbody fusion time was 6-9 months (mean, 7months). Neurological function recovered 1 to 3 grades: 1 case of grade C, 2 cases of grade D, 17 cases of grade E at last followup.The Cobb angle was (6.5 ± 4.2)° at last follow-up, showing significant difference when compared with preoperative value(t=2.39, P=0.00). No breaking or loosening of screw and implant sinkage occurred. Conclusion A combination of subtotalcorpectomy and intervertebral bone grafting through posterior approach alone has the advantages of complete decompression,restoration of spinal stabil ity, restoration of vertebral body height, high bone healing rate, and good recovery of neurologicalfunction. However, this surgical technique has a relatively large amount of blood loss and high requirements for surgeons.
Objective To evaluate the cl inical effectiveness and advantages of one-stage posterior debridement, bone graft, and internal fixation for thoracic tuberculosis. Methods The data were retrospectively analysed, from 21 cases of thoracic tuberculosis undergoing one-stage posterior debridement, bone graft, and internal fixation between June 2007 andNovember 2009. There were 16 males and 5 females with an average age of 42.2 years (range, 22-73 years). The average disease duration was 13.2 months (range, 7-21 months). The lesions were located at the level of T5, 6 (1 case), T6, 7 (1 case), T8, 9 (4 cases), T9, 10 (3 cases), T10, 11 (5 cases), T11, 12 (6 cases), and T9-11 (1 case). According to the Frankel grading criterion, the neurological function was rated as grade B in 2 cases, grade C in 6 cases, grade D in 10 cases, and grade E in 3 cases. The preoperative Cobb angle was (26.3 ± 9.2)°. The erythrocyte sedimentation rate (ESR) was (35.9 ± 11.2) mm/ 1 hour. Results Thoracic tuberculosis was confirmed in postoperative pathological examination in all 21 cases. All incisions healed primarily without fistules formation. The average follow-up time for 21 patients was 16.2 months (range, 1-3 years). Bony fusion was achieved within 7-12 months (mean, 9 months) without pseudoarthrosis. No loosening and breakage of internal fixation were found, and no local recurrence occurred. The ESR decreased to (25.1 ± 8.9) mm/1 hour at 1 week postoperatively, showing significant difference when compared with preoperative value (t=5.935, P lt; 0.01); it decreased to (14.1 ± 4.6) mm/1 hour at 3 months postoperatively. According to Frankel grade, the neurological function was significantly improved at 1 year after operation (χ2=13.689, P=0.003). The average Cobb angle was (17.1 ± 4.5)° at 1 years postoperatively, showing significant difference when compared with preoperative value (t=7.476, P lt; 0.01). Conclusion One-stage posterior debridement, bone graft, and internal fixation has a good cl inical effectiveness for thoracic tuberculosis with less injury and complete focal cleaning, as well as a goodeffectiveness of spinal canal decompression and kyphosis deformity correction.
Objective To explore the failure cause of posterior approach orthopaedic operation of thoracolumbar hemivertebra, and to summary strategies of revision. Methods The cl inical data from 9 cases undergoing posterior approach orthopaedic operation failure of thoracolumbar hemivertebra between June 2003 and June 2008, were retrospectively analyzed. There were 5 males and 4 females with a median age of 12 years (range, 1 year and 10 months to 24 years). All malformations were identified as fully segmented hemivertebra from the original medical records and X-ray films, including 2 cases in thoracic vertebra, 5 cases in thoracolumbar vertebra, and 2 cases in lumbar vertebra. The preoperative scol iotic Cobb angle was (45.4 ± 17.4)°, and kyphotic Cobb angle was (29.8 ± 22.0)°. The reason of primary surgical failure were analyzed and spinal deformity was corrected again with posterior revision. Results All surgeries were finished successfully. The operation time was 3.0-6.5 hours (mean, 4.5 hours), and the perioperative bleeding was 400-2 500 mL (mean, 950 mL). All incisions healed by first intention; no infection or deep venous thrombosis occurred. Numbness occurred in unilateral lower extremity of 1 case postoperatively, and the symptom was rel ieved completely after treatment of detumescence and neural nutrition. All cases were followed up 12-30 months (mean, 18 months). No pseudoarthrosis and implant failure occurred. The X-ray films showed that the bone grafts completely fused within 8-14 months (mean, 11 months) after operation. The Cobb angles of scol iosis and kyphosis at 1 week after operation and the last follow-up were obviously improved when compared with preoperative ones, showing significant differences (P lt; 0.05). No obvious correction loss was observed either in coronal or sagittal plane. Conclusion The failure causes of posterior approach orthopaedic operation are hemivertebra processing, selection of fixation and fusion range, and selection of internal fixation. If the strategies of revision are made after the above-mentioned failure causes are considered, the cl inical results will be satisfactory.
Objective To observe the effectiveness of posterior approaches for the treatment of posterior coronal fractures of tibial plateau, and to analyze the fracture morphology, radiographic features, and the recognition of Schatzker classification. Methods Between June 2003 and June 2009, 23 patients with posterior coronal fractures of tibial plateau were treated surgically by posterior approaches. There were 15 males and 8 females with an average age of 38 years (range, 32-56 years). All patients had closed fractures. Fracture was caused by traffic accident in 15 cases, by sports in 3 cases, and by falling from height in 5 cases. According to Moore classification, there were 10 cases of type I, 9 cases of type II, and 4 cases of type IV. The X-ray films, CT scanning, and three-dimensional reconstruction were performed. The time from injury to operation was 3-14 days (mean, 6 days). Results After operation, 17 cases had anatomical reduction and 6 had normal reduction. Incisions healed by first intention. All cases were followed up 12 to 36 months (mean, 24 months). The average fracture healing time was 7.6 months (range, 6-9 months). No related complication occurred, such as nerve and vessel injuries, failure in internal fixation, ankylosis, traumatic osteoarthritis, and malunion. According to Rasmussen’s criteria for the function of the knee, the results were excellent in 14 cases, good in 7 cases, and fair in 2 cases with an excellent and good rate of 91.3%. Conclusion Posterior coronal fracture of tibial plateau is rare, which has distinctive morphological features, and Schatzker classification can not contain it totally. The advantages of posterior approach include reduction of articular surface under visualization, firm fixation, less complications, and earlier functional exercise, so it is an ideal surgical treatment plan.
Objective To introduce operation skill of the spinal wedge osteotomy by posterior approach for correction of severe rigid scol iosis and to discuss the selection of the indications and the range of fusion and fixation. Methods Between July 1999 and January 2009, 23 patients with severe rigid scol iosis were treated with spinal wedge osteotomy by posterior approach, including 16 congenital scol iosis, 5 idiopathic scol iosis, and 2 neurofibromatosis scol iosis. There were 11 males and 12 females with a median age of 15 years (range, 8-29 years). Two patients had previous surgery history. The Cobb’s angles of scol iosis and kyphosis before operation were (85.39 ± 13.51)° and (56.78 ± 17.69)°, respectively. The mean spinal flexibil ity was 14.4% (range, 4.7%-22.5%). The trunk shift was (15.61 ± 4.89) mm. The preoperative CT or MRI showed bony septum in the canal in 2 patients. Results The mean operative time was 241 minutes and the mean blood loss was 1 452 mL. The average fused vertebrae were 10.7 segaments (range, 8-14 segaments). The follow-up ranged from 1 to 4 years with an average of 2 years and 6 months. The postoperative Cobb’s angle of scol iosis was (38.70 ± 6.51)°, the average correction rate was 54.7%. The postoperative Cobb’s angle of kyphosis was (27.78 ± 6.01)°, the average correction rate was 51.0%. The trunk shift was improved to (4.69 ± 1.87) mm, the increased height was 5.2 cm on average (range, 2.8-7.7 cm). The Cobb’s angle of scol iosis was (41.57 ± 6.80)° with an average 2.9° loss of correction at the final follow-up; the Cobb’s angle of kyphosis was (30.39 ± 5.94)° with an average 2.6° loss of correction at the final follow-up; the trunk shift was (4.78 ± 2.00) mm at the final follow-up. There were significant differences (P lt; 0.05) in the Cobb’s angles of scol iosis and kyphosis and the trunk shift between preoperation and postoperation, between preoperation and last follow-up. Four cases had pedicle fracture, 1 had L1 nerve root injury, 2 had superior mesenteric artery syndrome, 1 had exudates of incision, and 2 had temporary dysfunction of both lower extremity. Conclusion Spinal wedge osteotomy by posterior approach is a rel iable and safe surgical technique for correcting severe rigid scol iosis. With segmental pedical screw fixation, both the spinal balance and stabil ity can be restored.
Objective To discuss the main points of technique and the range of fusion in posterior operation of spinal stenosis associated with lumbar degenerative kyphosis (LDK). Methods The cl inical data were retrospectively analysedfrom 20 cases of spinal stenosis associated with LDK which were performed posterior operation from February 2001 to February 2008. There were 1 male and 19 females, aged 52-81 years old with an average of 64 years old. The course of disease was 6-10 years. All patients had severe low back pain. According to Frankel’s neurologic function classification, there were 18 cases of grade E and 2 cases of grade D before operation. The apex of LDK included L1 in 3 cases, L2 in 10 and L3 in 7. The operational method was decided according to different characteristics of LDK. All patients were divided into three groups. Group 1 included 6 cases of sciatica and intermittent claudication with worse physical status, the segmental decompression of spinal canal, posterior intervertebral fusion and short transpedical instrument fixation were performed. Group 2 included 8 cases whose Cobb angle of LDK was less than 20°, the segmental decompression of spinal canal, posterior intervertebral fusion and one-level or multilevel lamina osteotomy were performed, instrumentation-assisted correction was used. Group 3 included 6 cases whose Cobb angle of LDK was more than 20°, the canal decompression and one-level transvertebral wedge osteotomy were performed, instrumentation-assisted correction, intervertebral fusion and posterior-lateral fusion were used. Results Incision healedby first intention in all patients. One patient suffered from superior mesenteric artery syndrome at 6 hours after operationand healed after symptomatic management. The neurologic function was improved to grade E at 2 weeks after opeartion. All patients were followed-up 24-54 months (average 26 months). At last follow-up，the Oswestry Disabil ity Index of all patients was 30.5% ± 9.6%; showing significant difference when compared with preoperation (55.9% ± 11.8%, P lt; 0.05). The back pain scoring and leg pain scoring were 2.8 ± 1.6 and 2.4 ± 1.6, respectively according to the Numeric Rating Scale score; showing significant differences when compared with preoperation (7.5 ± 0.5 and 7.3 ± 0.7, P lt; 0.05). The Numeric Rating Scale score and Oswestry Disabil ity Index in all patients were improved obviously when compared with before operation (P lt; 0.05). During the follow-up period, there was no instrumentation failure or correction loss and the fusion rate was up to 100%. Conclusion For spinal stenosis associated with LDK patients, the most important therapic purpose is to improve cl inical symptom through reconstruction lumbar stabil ization and spinal biomechanics l ine in sagittal plane. Overall estimate of the cl inical appearance and imageology character is necessary when making decision of which segments needed to be fixation and fusion. Individual ized treatment strategy may be the best choice.
Objective To evaluate surgical results of the titanium screwplate internal fixation in treatment of the lower cervical fracture dislocation. Methods From September 2001 to March 2006, 31 patients(24 males, 7 females; age range, 2063 years) with the lower cervical fracturedislocation were treated in our department. The injuries were caused by a road accident in 25 patients, a high crash in 4, and a heavy object crash in 2. The fracture dislocation occurred in the following cervical segments:C3(1 patient),C4(5 patients), C5(12 patients), C6(10 patients), and C7(3 patients). The disease course ranged from 1 to 23 days. The associated spinal nerve root injury occurred in 29 patients. The Frankle scaling revealed that 14 patients were at Grade A, 3 at Grade B, 7 at Grade C, 3 at Grade D, and 2 at Grade E (associated nerve root injury with hand and shoulder numbness). The 29 patients underwentthe spinal cord decompression, the grafting fusion of the small joints, and thelateral mass titanium screwplate internal fixation; 2 patients without nerve injury underwent only the grafting fusion of the small joints and the lateral mass titanium screwplate internal fixation. The bone fusion, cervical vertebra movement, and internal fixation condition were observed by the X-ray examinations postoperatively. The nerve function recovery was evaluated by the Frankle scaling system. Results The followedup in all the patients for 6months to 4 years revealed that the small joint fusion time was 36 months, with an average of 3.6 months. The cervical X-ray films showed that there was no instability or fracture looseness of the internal fixation at 6 months. Among the 29 patients with the spinal nerve root injury, 14 were at Grade A preoperatively but 13 were improved at Grade B and 1 at Grade C postoperatively; 3 were at Grade B preoperatively but 2 were improved at Grade C and 1 at Grade D postoperatively; 7 were at Grade C preoperatively but 3 were improved at Grade D and 4 at Grade E postoperatively; 3 at Grade D preoperatively but all the 3 were improvedat Grade E postoperatively; 2 were at Grade E preoperatively and remained unchanged postoperatively. In the 2 patients with only the nerve root injury, numbness disappeared soon after operation. Conclusion This posteriorapproach has two advantages: the mobility range of the cervical vertebra can preserved to the greatest extent because of the short segment fixation; the betterstability can obtained because of the titanium screwplate internal fixation on the cervical jointcolumn to prevent the hyperextension and hyperflexion. Therefore, the titanium screwplate internal fixation on the cervical lateral massis an effective treatment of the lower cervical fracture dislocation.
ObjectiveTo explore a better segment of fixation and fusion for high-grade spondylolisthesis. MethodsA total of 21 patients with high-grade spondylolisthesis who had undergone reduction and posterior instrumented fusion between July 2007 and March 2012, were retrospectively reviewed. All cases underwent posterior spinal canal decompression, Schanz screws fixation and reduction, and intervertebral and posterolateral fusion. The concept of "unstable zone" and the feature of spinal deformity helped us to identify the most appropriate segment to fuse. The pre/post-operative differences on slip percentage, pelvic incidence (PI) and lumbosacral angle were compared and analyzed. The nerve function was evaluated by physical examination and neurological Frankel grade. The Visual Analogue Scale (VAS) and Oswestry Disability Index were used to assess clinical and functional outcomes of lower limbs. Bone fusion was assessed using CT reconstruction. ResultsAll patients were followed up between 12 and 48 months. The clinical and radiological outcomes such as VAS scores and PI angle were all improved compared with that of preoperative, and the differences were all statistically significant (P<0.05). ConclusionFor children with severe spondylolisthesis, if not combined with structural scoliosis, the fixation and fusion level should be up to the upper vertebra which PI angle>60°, and try to protect the posterior longitudinal ligament complex in case adjacent segments become instability or even slip. For adults with severe spondylolisthesis, if not combined with other spinal disorders such as severe osteoporosis, only mono-segmental fusion is recommended after reduction. If the slipped vertebrae could not be reduced to Meyerding gradeⅠ, two or more segments would need to be fixed and fused.