Video-Assisted Thoracoscopic Minimally Invasive Anterior Interbody Fusion of the T11-T12 Level Using Direct Lateral Interbody Fusion Devices: A Case Report

STUDY DESIGN: Case report OBJECTIVES: To report a case of video-assisted thoracoscopic (VAT) minimally invasive anterior interbody fusion of the T11-T12 level using direct lateral interbody fusion (DLIF) devices. SUMMARY OF LITERATURE REVIEW: Interbody fusion of the thoracolumbar junction (especially T11-T12) is technically challenging from anterior, lateral, or posterior approaches. A VAT anterior interbody fusion approach using DLIF devices is a safe, minimally invasive alternative approach to the thoracolumbar spine. MATERIALS AND METHODS: A 37-year-old male pedestrian was struck by a car sustaining fracture-dislocation at the T11-T12 level. The accident resulted in complete paraplegia of both lower extremities and multiple lower extremity fractures. A classical instrumented posterolateral fusion from T8 to L3 and staged VAT anterior interbody fusion at the T11-T12 level were performed. RESULTS: At one year postoperatively, he was capable of independent ambulation using a wheelchair without back pain, and plain radiographs and CT scans showed a solid fusion at the T11-T12 level. CONCLUSIONS: VAT anterior interbody fusion using DLIF devices provides excellent access to the anterior spinal column with the added benefits of an improved field of view and can be a safe and effective alternative to open thoracotomy in the management of various thoracolumbar junction problems.

The Sagittal Alignment of Spine in Conservatively Treated Osteoporotic Compression Fractures of Thoracolumbar Junction / 대한골다공증학회지

OBJECTIVES: To evaluate the radiological outcomes of conservative treatment for osteoporotic compression fractures in thoracolumbar junction. MATERIALS AND METHODS: 20 osteoporotic compression fracture cases of thoracolumbar junction (group I) which were treated conservatively using TLSO brace were evaluated compared with 20 osteoporotic spine cases (group II), between August 2010 and March 2012. The mean age was 65.3, ranging from 57 to 71 years old. The average follow up period was 27.4, ranging from 17 to 35 months. The bone marrow density (BMD) was recorded at the initial assessment. The lumbar lordotic angles with compression ratios on the initial and the last follow-up plain lateral radiograph were measured, and the sagittal alignments of spine were evaluated. RESULTS: In group I, the average compression ratios initially and at the last follow up were 23.5% and 33.7% respectively, and the average lumbar lordotic angles initially and at the last follow up were 30.8degrees and 22.6degrees respectively. In group II, the average lumbar lordotic angles initially and at the last follow up were 40.3degrees and 39.9degrees respectively. In group I, the compression ratio was significantly increased, and the lumbar lordotic angle was decreased at the final follow up. In group II, the difference of lumbar lordotic angles was not significant statistically. CONCLUSIONS: In most, the osteoporotic compression fractures can be successfully managed conservatively. But, in some cases of thoracolumbar junction, the further collapse of vertebral body and the change of lumbar lordotic angle can be developed, and then sagittal alignment of spine can be disrupted.

Mini-Transthoracic Supradiaphragmatic Approach to the Thoracolumbar Junction

Anterior reconstruction with instrumentation of the thoracolumbar junction (TLJ) offers: 1) the biomechanical advantage of immediate restoration of the load-bearing anterior column and 2) the ideal biological milieu for an optimal arthrodesis. The authors describe the mini-transthoracic supradiaphragmatic (MTTS) approach to the TLJ. Its technical feasibility is compared with that of the traditional transdiaphragmatic and thoracoscopic supradiaphragmatic approaches to this area of the spine. This technique was performed in 21 patients from 2004 to 2006. There were no surgical mortalities. The MTTS approach without the use of a thoracoscope was successfully employed in this study to treat patients with various lesions located at the TLJ. The diaphragmatic opening, even at its smallest diameter, provides excellent views of the operative field and avoids the significant morbidities associated with the traditional transdiaphragmatic approach.

Spinal Cord Tumors of the Thoracolumbar Junction Requiring Surgery: A Retrospective Review of Clinical Features and Surgical Outcome

PURPOSE: A retrospective review of medical records and imaging studies. To investigate characteristic clinical features and surgical outcomes of spinal cord tumors (SCTs) of the thoracolumbar junction (TLJ). The spinal cord transitions to the cauda equina in the TLJ. The TLJ contains the upper and lower motor neurons of the spinal cord and cauda equina. As a result, the clinical features of lesions in the TLJ vary, and these anatomical characteristics may affect surgical outcome. MATERIALS AND METHODS: Pathological diagnosis, clinical features, neurological signs, and surgical outcomes were investigated in 76 patients surgically treated at our institute for SCTs arising from T11 to L2. The patients were divided into epiconus (T11-12, n=18) and conus groups (L1-2, n=58). RESULTS: Patients in the epiconus group had hyperactive deep tendon reflexes (DTRs), while those in the conus group had hypoactive DTRs (p < 0.05). Nine patients were misdiagnosed with intervertebral disc diseases (IVDs) before correct diagnoses were made. It was impossible to definitively determine the exact cause of symptoms in four patients who had both SCTs and IVDs. CONCLUSION: Among SCTs of the TLJ, the epiconus group displayed upper motor neuron syndrome and the conus group displayed lower motor neuron syndrome. SCTs of the TLJ were frequently misdiagnosed as IVDs due to symptomatic similarities. SCTs of the TLJ should be included in differential diagnosis of back and leg pain, and it is highly recommended that routine lumbar magnetic resonance imaging include the TLJ.

Dorsal Short-Segment Fixation for Unstable Thoracolumbar Junction Fractures

OBJECTIVE: This study is to evaluate the efficacy of dorsal short-segment fixation in unstable thoracolumbar junction fractures. METHODS: The cases of 20 patients who underwent dorsal short-segment fixation were reviewed retrospectively. Clinical outcomes were analysed using Sonntag's pain level, work status, and neurological scale according to the modified Frankel classification. Radiological outcomes were analysed using Mumford's anterior body compression(%), canal compromise ratio, and Cobb's kyphotic angle. RESULTS: At the latest clinical follow-up (average=14.6 months), there were 19 (95.0%) in group I and 1 patient (5.0%) in II in pain level35). The postoperative work status were 17 (85.0%) in group I, 2 patients (10.0%) in II, and 1 patient (5.0%) in V. Surgery brought to improve the neurologic status. In success group (19 cases, 95%), the average canal compromise ratio was reduced from 0.57 (+/-0.07) to 0.05 (+/-0.08) (P<0.05), the average anterior body compression (%) was reduced from 41% (+/-17) to 18% (+/-14) (P<0.05), and the average preoperative kyphotic angle was 20.0 degrees (+/-9.0), and corrected to 5.7 degrees (+/-7.1) postoperatively, and progressed to 7.8 degrees (+/-6.2) at the latest follow-up. There was a case of implantation failure in an elderly osteoporotic patient. CONCLUSION: Although there are limitations in the patient number and follow-up period, the present study favors dorsal short-segment fixation for selective cases in unstable thoracolumbar junction fractures.

Posterolateral Fusion for Unstable Thoracolumbar Junction / 대한척추외과학회지

STUDY DESIGN: A retrospective study of patients with a posterolateral spinal fusion for an unstable thoracolumbar junction. OBJECTIVES: To evaluate the efficacy of a posterolateral spinal fusion for an unstable thoracolumbar junction. SUMMARY OF LITERATURE REVIEW: Posterolateral spinal fusions are well documented for their efficacy in the lumbar and lumbosacral spine, and have also been applied to the thoracolumbar junction in the lumbar area. The thoracolumbar junction, however, is a little different from the lumbar spine, in its anatomical and biomechanical aspects, and posterolateral fusions have not been well evaluated in these respects. MATERIALS AND METHODS: Fourteen consecutive patients, who had posterolateral spinal fusions, with instrumentation for an unstable condition, including T12-L1 segment, and followed for more than one year, were included. In 11 patients, all the fractures had been decompressed posteriorly, for degenerative conditions in 2, and for a neoplastic pathology in the other one. The radiographs concerning the lateral fusion mass were reviewed according to Lenke's classification, the change in the segmental sagittal angle of the fused segment and the fixation failure of the instrumentation. The medical records relating to the neurological recovery were reviewed using the modified Frankel grading, and the overall clinical results of treatment by the Kirkaldy-Willis criteria. RESULTS: All patients disclosed big, bilateral and solid fusion masses, with the exception of one patient who revealed a big, solid fusion mass on one side, and small, thin fusion mass on the other. No patient revealed more than 3 degrees of mobility on flexion-extension lateral radiographs, any evidence of fixation failure of the instrumentation. The neurological recovery, by the modified Frankel grading system, showed an average 1.3 improvement. The clinical results were excellent in 6, good in 6 and fair in 2 patients, with no poor results. CONCLUSIONS: A posterolateral spinal fusion can be effectively applied in an unstable thoracolumbar junction, such as in the lumbar and lumbosacral spine, provided there is precise preparation of the graft beds, enough bone grafts and correction of the excessive kyphotic angle by the compression fixation of the posterior instrumentation.

One Stage Three Column Fixation by Posterior Approach in Thoracolumbar Junction Lesion

For a thoracolumbar junction lesion, there are many approaches according to pathology. A combined anterior and posterior approach can give anterior and posterior fixation with adequate neural decompression in three column lesion like a metastatic tumor or primary malignant lesion. But it can cause a serious complication of vascular or visceral injury especially during anterior approach. Author developed a new approach which can give a rigid fixation at anterior and posterior column simultaneously by posterior approach. This method has advantages of both anterior and posterior approach and associated with minimized postoperative morbidity. By this method good three column stabilization and adequate neural decompression can be achieved immediately. Three cases of malignant spinal tumors and two cases of complicated spine fracture were operated by this approach. Among three tumor cases, two patients showed rapid recovery of their impending paraparesis. All patients had excellent clinical results and good stabilities of spinal column without any complications.

A Clinical Analysis of the Patients with Thoracolumbar Vertebral Junction Fracture

To clarify the prognostic factors influencing clinical outcome, the authors retrospectively analyzed 50 cases of thoracolumbar vertebral junction fracture treated at our hospital between September 1989 and October 1992. The age of the patients ranged from 23 to 75 years(median 49 years) and the male-to-female ratio was 33:17. Falling was the major mode of injury(m=27). The kyphotic angle between fractured vertebrae and the ratio of neural canal encroachment was measured in a simple X-ray and a computed tomography(CT) of the thoracic spine. An ANOVA test was performed to evaluate the predicting factors to determine the final outcome. The kyphotic angle and loss of height of vertebral body were not significantly correlated with the neurological status of the patients. However, the ratio of the compromised area of the neural canal was closely correlated with the neurological outcome(p value<0.05). The worst prognosis was found in patients with fracture-dislocation. In conclusion, it is suggested that early surgical intervention must be considered in the neurologically compromised patients whose CT demonstrates neural canal encroachment by bony fragments.

A Clinical Analysis of the Patients with Thoracolumbar Vertebral Junction Fracture

To clarify the prognostic factors influencing clinical outcome, the authors retrospectively analyzed 50 cases of thoracolumbar vertebral junction fracture treated at our hospital between September 1989 and October 1992. The age of the patients ranged from 23 to 75 years(median 49 years) and the male-to-female ratio was 33:17. Falling was the major mode of injury(m=27). The kyphotic angle between fractured vertebrae and the ratio of neural canal encroachment was measured in a simple X-ray and a computed tomography(CT) of the thoracic spine. An ANOVA test was performed to evaluate the predicting factors to determine the final outcome. The kyphotic angle and loss of height of vertebral body were not significantly correlated with the neurological status of the patients. However, the ratio of the compromised area of the neural canal was closely correlated with the neurological outcome(p value<0.05). The worst prognosis was found in patients with fracture-dislocation. In conclusion, it is suggested that early surgical intervention must be considered in the neurologically compromised patients whose CT demonstrates neural canal encroachment by bony fragments.

Operative Treatment Of Burst Fracture On The Thoracolmbar Junction / 대한정형외과학회잡지

We analyzed 41 cases of burst fractures on the thoracolumbar junction which were operated with Kaneda and Cotrel-Dubousset implant at Chosun University Hospital between 1989 and 1993. The purpose of this study was to evaluate the radiologic sign, the amount of reduction, complications, and functional results. The results were as follows: 1. According to McGrorys Criteria to evaluate the posterior superior vertebral body angle of burst fractures, 33 out of 41 cases(80.5%) were positive and the average angle degree was 107.6°. 2. The average postoperative kyphotic correction was 15.4° in the Kaneda group and 13.8° in the C-D group. The average loss of correction at follow-up examination was 5° in the Kaneda group and 4.8° in the C-D group. 3. Indirect reduction was achieved in 10 cases(50%) and we obtained a good indirect reduction even though canal compromise was over 50%. 4. The pain at operative site was much more severe in the Kaneda group(6 cases) than in the C-D group(2 cases) and both groups experienced 2 cases each of implant failure. 5. According to Denis' pain and work scale, 28 cases(63.8%) had good and excellent, 8 cases had fair and 5 cases had poor results. In summary we recommend doing 1) a posterior instrumentation first for stability and indirect reduction, if it is not a severe neurologic symptom and 2) anterior decompression if it is a severe or progressive neurologic symptom.

Anterolateral Instrumentation and Spinal Stabilization in the Treatment of Fractures of the Thoracolumbar Area

In the treatment of fractures of the thoracolumbar junctiion area, surgical intervention was performed when posterior part of veretbral body, posterior structure supporting ligaments were involved and body compression more than 40%. Number of cases satisfying above criteria were seven between Aug. 1990 and Jun. 1991. Age distribution ranged from 15 to 57 years. Sex ratio was 4:3(F:M). Four patients presented with nerve root sign, one patient with cauda equina signs, and two patients were normal neurologically. In all cases, spinal canal decompression, internal instrument fixation, and bone fusion with iliac bone were performed via anterolateral approach. After surgical treatment, neurological deficits disappeared and kyphotic angle returned to normal range of thoracolumbar junction area in all cases. Percentage of body compression was improved from preop. 55% to postop. 21% in average. According to above results, we concluded that anterior instrumental fixation combined with bone fusion using iliac bone was supperior to posterior approach in providing biomechanical stability and decompression of protruding ventral bone fragments.