Spinal canal remodeling after stabilization of thoracolumbar burst fractures

Bone fragments in the spinal canal after thoracolumbar burst fractures causing spinal canal narrowing is a frequent phenomenon. Efforts to remove such fragments are often considered. The aim of this study was to evaluate the spinal canal remodeling after posterior instrumentation and fusion. 24 patients with unstable thoracolumbar burst fractures were treated in Mansoura Emergency Hospital by transpedicular instrumentation and fusion using autogenous iliac bone graft. There were 16 males and 8 females, their age ranged from 18 to 54 years with a mean age of 34 years. 16 patients had burst fracture at L1 level, 4 patients had fracture of L2, 2 patients had fracture of T12 and another 2 patients had fracture of T11 level. Preoperative CT scan was done routinely for all the patients and sometimes with sagittal reformat to evaluate the pattern of the fracture and the degree of canal compromise. Also detailed neurological evaluation for the patients was achieved and documented. 15 patients had partial neurological insult while 9 patients were neurologically intact. The type of neurological deficit in all patients was scored on the scale of Frankel et al. Spinal canal cross sectional areas [CSA] were measured preoperatively, within 1 week postoperatively and at least 2 years after surgery. The results showed that the preoperative canal encroachment averaged 48.83% [range 30%-72%] of the estimated original area. The 16 patients with neurological deficit had significantly more severe initial canal encroachment [mean 53%] than those who were neurologically intact [mean 41%]. Postoperatively, canal encroachment had decreased to a mean of 33.87% [range 18-55%], at the end of follow-up, canal encroachment was further reduced by resorption of bone fragments to a mean of 12.08% [range 0-32%]. Our results showed statistically significant difference in spinal canal areas postoperatively and at the end of follow-up suggesting effective remodeling of the spinal canal after surgical treatment of thoracolumbar burst fractures with posterior instrumentation and fusion. All patients with neurological deficits improved, and only 4 patients had residual neurological affection. our study shows that canal enlargement during surgery is caused by indirect effects when the spine is distracted and put into lordosis. Remodeling will occur if there is residual narrowing. Acute intervention into the spinal canal, as well as subsequent anterior surgery because of residual bone, should be limited

Significance of thoracolumbar spinal canal dimensions in prediction of neurologic injury in patients with burst fractures

The relation between the spinal canal dimensions and its association with neurologic sequelae after cervical spine injuries has been established. A similar relation at the thoracolumbar spine is debated in the literature. The aim of this work is to determine the relation between the spinal canal dimensions and their association with neurologic sequale after thoracolumbar burst fractures. In a prospective study between January 1999 and December 2001, 48 patients with thoracolumbar burst fractures [T11-L2] 22 with neurologic deficit and 26 without neurologic deficit were included in our study. There were 30 males and 18 females, their age ranged from 18 to 62 years with a mean age of 37 years. Computed tomographic [CT] scans were done for all the patients to evaluate the pattern of the fracture and to measure the sagittal, the transverse diameters and the surface areas of the spinal canal at the level of injury, as well as one level above and one level below the fracture level. The type of neurological deficit in all patients was scored on the scale of Frankel et al 1969. All the patients with burst fractures of the thoracolumbar junction, with and without neurologic deficit, were compared in sagittal diameter, transverse diameter, sagittal-to-transverse diameter ratio and cross sectional area [CSA]. Statistical analysis was performed using Student s t-test. We found that the ratio of sagittal-to-transverse diameter at the level of injury was significantly smaller in patients with neurological deficit than those without a neurologic deficit. The mean transverse diameter at the level of injury was significantly larger in patients with neurological deficit than in the neurologically intact patients. The surface area of the canal at the level of the injury was significantly smaller in patients with neurological deficit than in those without a deficit. There was no significant statistical relation between spinal canal measurements above and below the level of injury with the neurologic deficit. We concluded that. There were no anatomic factors at the thoracolumbar junction that predisposed to neurologic injury after burst fracture, however the shape and the size of the canal after injury were predictive of neurologic deficit

Treatment of nonunion of the humerus using the Ilizarov external fixator

Sixteen patients with nonunited humeral shaft fractures were treated from January 1999 to December 2001 using the Ilizarov method of monofocal compression. 14 were males and 2 were females, their ages ranged between 22 and 55 years with a mean age of 34. All of them had at least one previous surgery, 8 cases had plate fixation, 4 cases were treated with external fixator and the other 4 cases had intramedullary fixation. Seven nonunions were hypertrophic, and 9 were atrophic. Seven cases were infected nonunion. The combined circular-semicircular modification from Cattaneo et al was used with wires and 5 mm unilateral self tapping Shanz pins. The average follow-up period was 12 months. Union was obtained in 15 cases with an average consolidation time of 4 months. Apart from superficial pin tract infection seen in most of the cases, there was no nerve injuries or other significant complications. The results show that Ilizarov method is a reliable method for the treatment of humeral nonunion, even after multiple previous surgeries or in the event of infection

Unstable lower cervical spine injuries results of posterior lateral mass plate fixation

Thirty patients with unstable lower cervical spine injuries were treated from January 1998 to December 2001 using posterior lateral mass plating and autogenous iliac hone graft. There were 25 males and 5 females, the average patient age was 37.73 years [range 18-60 years]. The average duration of follow-up was 15.18 months [range 6 to 43 months]. The cause of trauma was motor vehicle accidents in 18 patients, a fall from height in 9 patients and diving into a shallow water in 3 cases. Eight patients had associated injuries, three of them suffered head injuries, 2 cases had pelvic fractures. 2 cases had femoral shaft fractures and one patient had forearm fracture. Thirty patients met the criteria for posterior cervical plating and fusion having cervical instability. Eleven patients had unilateral facet dislocation at one level, four patients had bilateral facet dislocation at one level, 13 patients had fracture dislocations either at one or two levels, and Two patients had burst fracture at one Level. Neurologically, 10 patients were neurologically free complaining of neck pain only, 8 patients had a one level root injury, 4 patients had anterior cord syndrome. 3 patients had Brown Sequard syndrome, and 5 patients had complete cord injury. The final functional results were assessed using Bohlman and Anderson criteria. No patient's neurological function deteriorated after surgery. All the patients with radicular symptoms relieved and all incomplete spinal cord injuries improved at least one ASIA Level. All the patients had solid fusion and good alignment based on flexion and extension radiographs at follow-up. Although one patient had implant failure in the form of backing out of the screws, non had an increased deformity and all progressed to sound fusion. Extension of the fusion mass beyond the instrumented levels was evident in 12 patients. There were no neurologic or vascular complications related to screws fixation. Posterior Cervical plating with lateral mass fixation and bone grafting offers a reliable method of achieving fusion, with minimal bracing and more rapid functional recovery in the treatment of fractures and dislocations of the lower cervical spine

Evaluation of the results of external fixation of femoral shaft fractures in children

Thirty-four patients with 35 femoral shaft fractures were treated using the AO unilateral external fixator after reductionfrom 1999 through 2000. Thirteen girls and 21 boys were the material of this study. The average patient age at presentation was 9.5 years [range 6-14 years]. There were 16 children with multiple injuries whereas 18 children had isolated femoral shaft fractures. All the fractures were followed until union, with an average time of external fixation of 75 days. The average follow-up was 1.5 years. All the fractures healed without additional surgical intervention. There was minimal angulation at the fracture site with an average of 4.5 degrees in the anteroposterior plane and 4.6 degrees in the lateral plane. Although pin tract infection was common [10 cases], nine of them resolved with a broad-spectrum oral antibiotics, only one patient required inpatient intravenous antibiotics. No patient developed osteomyelitis. 24 patients had clinically equal leg lengths, 9 patients had clinically less than 10 mm of inequality and only one patient had 15 mm discrepancy. We had no re-fractures after removal of the fixator, We agree with previous reports that external fixation remains a viable option for the treatment of femoral shaft fractures in children with multiple injuries. It is also an effective means of treating isolated femoral shaft fractures in the pediatric population