Herniation of intervertebral disc into thoracolumbar fracture vertebral body leads to malunion of fracture and decrease of intervertebral space height / 中国骨伤

OBJECTIVE@#To analyze the clinical characteristics of intervertebral disc tissue injury and herniation into the vertebral body in thoracolumbar fracture on fracture healing, vertebral bone defect volume and intervertebral space height.@*METHODS@#From April 2016 to April 2020, a total of 140 patients with thoracolumbar single vertebral fracture combined with upper intervertebral disc injury treated with pedicle screw rod system reduction and internal fixation in our hospital. There were 83 males and 57 females, aged from 19 to 58 years old, with an average age of (39.33±10.26) years old. All patients were followed up regularly 6 months, 12 months and 18 months after surgery. The patients with injured intervertebral disc tissue not herniated into the fractured vertebral body were the control group, and the patients with injured intervertebral disc and herniated into the fractured vertebral body were the observation group. By detecting the thoracolumbar AP and lateral X-ray films, CT and MRI of the thoracolumbar segment at different follow-up time, calculate the changes of the wedge angle of the fractured vertebral body, the sagittal kyphosis angle and the height of the superior adjacent intervertebral space, the changes of the fracture healing and bone defect volume after the reduction of the vertebral body, and the changes of the intervertebral disc degeneration grade. The prognosis was evaluated by visual analogue scale(VAS) and Oswestry disability index(ODI). Finally, the differences of the above results among different groups were comprehensively analyzed.@*RESULTS@#All the patients had normal wound healing without complications. A total of 87 patients received complete follow-up data, at least 18 months after internal fixation. Thoracolumbar AP and lateral X-ray films showed that 18 months after the reduction and internal fixation operation, the vertebral wedge angle, sagittal kyphosis angle and the height of the upper adjacent intervertebral space in the observation group were greater than those in the control group(P<0.05). CT scanning showed that the deformity of the fracture healed 12 months after the vertebral body reduction in the observation group and formed a "cavity" of bone defect connected with the intervertebral space, and its volume was significantly increased compared with that before (P<0.05). MRI scanning showed that the degeneration rate of injured intervertebral discs in the observation group was more serious than that in the control group 12 months after operation(P<0.05). However, there was no significant difference in VAS and ODI score at each time.@*CONCLUSION@#Herniation of injured intervertebral disc tissue hernias into the fractured vertebral body leads to increased bone resorption defect volume around the fracture and forms a malunion "cavity" connected with the intervertebral space. This may be the main reason for the change of vertebral wedge angle, the increase of sagittal kyphosis angle and the decrease of intervertebral space height after removal of internal fixation devices.

Treatment of stage Ⅱ-Ⅲ Kümmell disease with robot-assisted bone cement-augmented pedicle screw fixation / 中国骨伤

OBJECTIVE@#To evaluate the early clinical efficacy of robot-assisted percutaneous short-segment bone cement-augmented pedicle screw fixation in the treatment of stageⅡ-Ⅲ Kümmell disease.@*METHODS@#The clinical data of 20 patients with stageⅡ-Ⅲ Kümmell's disease who underwent robot-assisted percutaneous bone cement-augmented pedicle screw fixation between June 2017 and January 2021 were retrospectively analyzed. There were 4 males and 16 females, aged from 60 to 81 years old with an average age of (69.1±8.3) years. There were 9 cases of stageⅡand 11 cases of stage Ⅲ, all of which were single vertebral lesions, including 3 cases of T11, 5 cases of T12, 8 cases of L1, 3 cases of L2, and 1 case of L3. These patients did not exhibit symptoms of spinal cord injury. The operation time, intraoperative blood loss, and complications were recorded. The position of pedicle screws and the filling and leakage of bone cement in gaps were observed using postoperative CT 2D reconstruction. The data of the visual analogue scale (VAS), Oswestry disability index (ODI), kyphosis Cobb angle, wedge angle of the diseased vertebra, and anterior and posterior vertebral height on lateral radiographs were statistically analyzed preoperatively, 1 week postoperatively, and at the final follow-up.@*RESULTS@#Twenty patients were followed up for 10 to 26 months, with an average follow-up of (16.0±5.1) months. All operations were successfully completed. The surgical duration ranged from 98 to 160 minutes, with an average of (122±24) minutes. The intraoperative blood loss ranged from 25 to 95 ml, with an average of (45±20) ml. There were no intraoperative vascular nerve injuries. A total of 120 screws were inserted in this group, including 111 screws at grade A and 9 screws at grade B according to the Gertzbein and Robbins scales. Postoperative CT indicated that the bone cement was well-filled in the diseased vertebra, and cement leakage occurred in 4 cases. Preoperative VAS and ODI were (6.05±0.18) points and (71.10±5.37)%, respectively, (2.05±0.14) points and (18.57±2.77)% at 1 week after operation, and (1.35±0.11) points and (15.71±2.12) % at final follow-up. There were significant differences between postoperative 1 week and preoperative, and between final follow-up and postoperative 1 week(P<0.01). Anterior and posterior vertebral height, kyphosis Cobb angle, and wedge angle of the diseased vertebra were(45.07±1.06)%, (82.02±2.11)%, (19.49±0.77) °, and (17.56±0.94) ° preoperatively, respectively, (77.00±0.99)%, (83.04±2.02)%, (7.34±0.56) °, and (6.15±0.52) ° at 1 week postoperatively, and (75.13±0.86)%, (82.39±0.45)%, (8.38±0.63) °, and (7.09±0.59) ° at the final follow-up.@*CONCLUSION@#Robot-assisted percutaneous short-segment bone cement-augmented pedicle screw fixation demonstrates satisfactory short-term efficacy in treating stageⅡ-Ⅲ Kümmell's disease as an effective minimally invasive alternative. However, longer operation times and strict patient selection criteria are necessary, and long-term follow-up is required to determine its lasting effectiveness.

Treatment of spinal burst fractures with pedicle screw fixation at high altitude area / 中国骨伤

OBJECTIVE@#According to the characteristics of spinal burst fractures in high-altitude areas and the local medical conditions, to explore the clinical efficacy of short-segment fixation with pedicle screws combined with screw placement in injured vertebrae in the treatment of thoracolumbar burst fractures.@*METHODS@#From August 2018 to December 2021, 12 patients with single-vertebral thoracolumbar burst fractures without neurological symptoms were treated with injured vertebral screw placement technique, including 7 males and 5 females;aged 29 to 54 years old, with an average of(42.50±7.95) years old;6 cases of traffic accident injury, 4 cases of high fall injury, 2 cases of heavy object injury;2 cases of T11, 4 cases of T12, 3 cases of L1, 2 cases of L2, and 1 case of L3. In the operation, screws were first placed in the upper and lower vertebrae of the fracture, pedicle screws were placed in the injured vertebra, and connecting rods were installed, and the fractured vertebral body was reset by positioning and distraction. Visual analogue scale (VAS) and Japanese Orthopedic Association (JOA) scoring were used to evaluate the changes in pain and quality of life of patients, and the kyphotic correction rate and correction loss rate of the injured segment were measured by X-ray.@*RESULTS@#All operations were successful without significant intraoperative complications. All 12 patients were followed up, the duration ranged from 9 to 27 months, with an mean of (17.75±5.79) months. VAS at 3 days after operation was significantly higher than that at admission (t=6.701, P=0.000). There was significant difference in JOA score between 9 months after operation and at admission (t=5.085, P=0.000). Three days after operation, Cobb angle was (4.42±1.16)°, and the correction rate was (82±5)% compared with (25.67±5.71)° at admission. Cobb angle was (5.08±1.24) °at 9 months after operation, with a corrected loss rate of (16±13)%. No loosening or breakage of internal fixation was found.@*CONCLUSION@#Under the high-altitude hypobaric and hypoxic environment, the effect of the operation should be ensured while reducing the trauma. The application of the technique of placing screws on the injured vertebra can effectively restore and maintain the height of the injured vertebra, with less bleeding and shorter fixed segments, which is an effective method.

Analysis of the clinical effect of percutaneous pedicle screw fixation combined with transpedicular bone grafting in the treatment of thoracolumbar fracture / 中国骨伤

OBJECTIVE@#To investigate the clinical efficacy of percutaneous screw fixation combined with minimally invasive transpedicular bone grafting and non-bone grafting in the treatment of thoracolumbar fractures.@*METHODS@#From Janury 2021 to June 2022, 40 patients with thoracolumbar fracture were divided into the experimental group and the control group. There were 26 patients in the experimental group, including 21 males and 5 females with an aberage age of (47.3±12.3) years old, who underwent percutaneous pedicle screw fixation combined with transpedicular autogenous bone grafting. In the control group, 14 patients received percutaneous pedicle screw fixation only. including 7 makes and 7 females with an average age of (50.2±11.2) years old. The operative time, intraoperative blood loss, anterior height ratio of injured vertebrae, Cobb angle, visual analogue score (VAS), MacNab scores, loosening or broken of the implants. were compared and analyzed.@*RESULTS@#There was no significant difference in operation time, intraoperative blood loss, VAS and anterior height ratio of injured vertebrae between the two groups. Compared with the preoperative results, VAS and anterior height ratio of injured vertebrae were improved statistically(P<0.05). For Cobb angle of injured vertebra, there was no significant difference between the two groups before surgery (P=0.766). While at 1 week, 3 months and 12 months after surgery, there were statistically differences between the two groups (P values were 0.042, 0.007 and 0.039, respectively). The Cobb angle of injured vertebrae one year after operation was statistically decreased in both groups compared with that before surgery (P<0.001). One year after surgery, the excellent and good rate of Macnab scores was 96.15% in the experimental group and 92.86% in the control group, and there was no statistical differences between the two groups (P=0.648). There was one patient in the control group suffering superficial wound infection on the third day, which was cured by dressing change and anti-infection treatment. There were no postoperative screw loosening and broken in both groups.@*CONCLUSION@#The two surgical methods have the advantages of less trauma, less pain and quicker recovery, which can restore the height of the injured vertebra, reconstruct the spinal sequence and reduce the fracture of the vertebral body. Transpedicular autogenous bone grafting can increase the stability of the fractured vertebra and maintain the height of the vertebra better after surgery, thus reducing the possibility of complications such as kyphosis, screw loosening and broken.

Effectiveness of one-stage posterior eggshell osteotomy and long-segment pedicle screw fixation for ankylosing spondylitis kyphosis combined with acute thoracolumbar vertebral fracture / 中国修复重建外科杂志

OBJECTIVE@#To explore the safety and effectiveness of one-stage posterior eggshell osteotomy and long-segment pedicle screw fixation in the treatment of ankylosing spondylitis kyphosis combined with acute thoracolumbar vertebral fracture.@*METHODS@#A clinical data of 20 patients with ankylosing spondylitis kyphosis combined with acute thoracolumbar spine fracture, who were treated with one-stage posterior eggshell osteotomy and long-segment pedicle screw fixation between April 2016 and January 2022, was retrospectively analyzed. Among them, 16 cases were male and 4 cases were female; their ages ranged from 32 to 68 years, with an average of 45.9 years. The causes of injury included 10 cases of sprain, 8 cases of fall, and 2 cases of falling from height. The time from injury to operation ranged from 1 to 12 days, with an average of 7.1 days. The injured segment was T 11 in 2 cases, T 12 in 2 cases, L 1 in 6 cases, and L 2 in 10 cases. X-ray film and CT showed that the patients had characteristic imaging manifestations of ankylosing spondylitis, and the fracture lines were involved in the anterior, middle, and posterior columns and accompanied by different degrees of kyphosis and vertebral compression; and MRI showed that 12 patients had different degrees of nerve injuries. The operation time, intraoperative bleeding, intra- and post-operative complications were recorded. The visual analogue scale (VAS) score and Oswestry disability index (ODI) were used to evaluate the low back pain and quality of life, and the American spinal cord injury association (ASIA) classification was used to evaluate the neurological function. X-ray films were taken, and local Cobb angle (LCA) and sagittal vertical axis (SVA) were measured to evaluate the correction of the kyphosis.@*RESULTS@#All operations were successfully completed and the operation time ranged from 127 to 254 minutes (mean, 176.3 minutes). The amount of intraoperative bleeding ranged from 400 to 950 mL (mean, 722.5 mL). One case of dural sac tear occurred during operation, and no cerebrospinal fluid leakage occurred after repair, and the rest of the patients did not suffer from neurological and vascular injuries, cerebrospinal fluid leakage, and other related complications during operation. All incisions healed by first intention without infection or fat liquefaction. All patients were followed up 8-16 months (mean, 12.5 months). The VAS score, ODI, LCA, and SVA at 3 days after operation and last follow-up significantly improved when compared with those before operation ( P<0.05), and the difference between 3 days after operation and last follow-up was not significant ( P>0.05). The ASIA grading of neurological function at last follow-up also significantly improved when compared with that before operation ( P<0.05), including 17 cases of grade E and 3 cases of grade D. At last follow-up, all bone grafts achieved bone fusion, and no complications such as loosening, breaking of internal fixation, and pseudoarthrosis occurred.@*CONCLUSION@#One-stage posterior eggshell osteotomy and long-segment pedicle screw fixation is an effective surgical procedure for ankylosing spondylitis kyphosis combined with acute thoracolumbar vertebral fracture. It can significantly relieve patients' clinical symptoms and to some extent, alleviate the local kyphotic deformity.

Effectiveness of sagittal top compression reduction technique in treatment of thoracolumbar vertebral fractures / 中国修复重建外科杂志

OBJECTIVE@#To investigate the effectiveness of sagittal top compression reduction technique in the treatment of thoracolumbar vertebral fractures.@*METHODS@#A retrospective analysis was conducted on the clinical data of 59 patients with thoracolumbar vertebral fractures who met the selection criteria and were admitted between November 2018 and January 2022. Among them, 34 patients were treated with sagittal top compression reduction technique (top pressure group), and 25 patients were treated with traditional reduction technique (traditional group). There was no significant difference in baseline data between the two groups ( P>0.05), including gender, age, fracture segment, cause of injury, AO classification of thoracolumbar vertebral fractures, thoracolumbar injury classification and severity (TLICS) score, American Spinal Injury Association (ASIA) grading, surgical approach, preoperative vertebral body index, height ratio of the anterior margin of injured vertebra, injured vertebra angle, segmental kyphosis angle, visual analogue scale (VAS) score, and Oswestry disability index (ODI). The operation time, intraoperative blood loss, and incidence of complications between the two groups were recorded and compared. After operation, VAS score and ODI were used to evaluate effectiveness, and X-ray and CT examinations were performed to measure imaging indicators such as vertebral body index, height ratio of the anterior margin of injured vertebra, injured vertebra angle, and segmental kyphosis angle.@*RESULTS@#There was no significant difference in operation time and intraoperative blood loss between the two groups ( P>0.05). No complication such as dural sac, nerve root, or vascular injury was found during operation, and all incisions healed by first intention. Patients in both groups were followed up 6-48 months, with an average of 20.6 months. No loosening, breakage, or failure of internal fixation occurred during follow-up. The imaging indicators, VAS score, and ODI of the two groups significantly improved at 1 week and last follow-up when compared to preoperative ones ( P<0.05). At last follow-up, the VAS score and ODI further significantly improved when compared to 1 week after operation ( P<0.05). At 1 week after operation and last follow-up, the vertebral body index, segmental kyphosis angle, injured vertebra angle, and ODI in the top pressure group were significantly better than those in the traditional group ( P<0.05). There was no significant difference in VAS score and height ratio of the anterior margin of injured vertebra between the two groups at 1 week after operation ( P>0.05), but the two indicators in the top pressure group were significantly better than those in the traditional group at last follow-up ( P<0.05).@*CONCLUSION@#The treatment of thoracolumbar vertebral fractures with sagittal top compression reduction technique can significantly improve the quality of vertebral reduction, and is superior to traditional reduction techniques in relieving pain and improving spinal function.

Mechanisms of mid-thoracic spine fracture/dislocation due to falls during horse racing: A report of two cases / 中华创伤杂志(英文版)

We reported two cases of jockeys who sustained fracture/dislocation of the mid-thoracic spine due to traumatic falls during horse racing. We examined the injury mechanism based upon the patients' diagnostic images and video footage of races, in which the accidents occurred. Admission imaging of patient 1 (a 42 years old male) revealed T5 burst fracture with bony retropulsion of 7 mm causing complete paralysis below T5/6. There existed 22° focal kyphosis at T5/6, anterolisthesis of T5 relative to T6, T5/6 disc herniation, cord edema and epidural hemorrhage from T4 through T6, and cord injury from C3 through C6. Admission imaging of patient 2 (a 23 years old male) revealed T4/5 fracture/dislocation causing incomplete paralysis below spinal level. There existed compression fractures at T5, T6, and T7; 4 mm anterior subluxation of T4 on T5; diffuse cord swelling from T3 through T5; comminuted fracture of the C1 right lateral mass; right frontal traumatic subarachnoid hemorrhage; and extensive diffuse axonal injury. The injuries were caused by high energy flexion-compression of the mid-thoracic spine with a flexed posture upon impact. Our results suggest that substantially greater cord compression occurred transiently during trauma as compared to that documented from admission imaging. Video footage of the accidents indicated that the spine buckled and failed due to abrupt pocketing and deceleration of the head, neck and shoulders upon impact with the ground combined with continued forward and downward momentum of the torso and lower extremities. While a similar mechanism is well known to cause fracture/dislocation of the cervical spine, it is less common and less understood for mid-thoracic spine injuries. Our study provides insight into the etiology of fracture/dislocation patterns of the mid-thoracic spine due to falls during horse racing.

Cement augmented pedicle screw combined with vertebroplasty for the treatment of Kümmell's disease with type Ⅲ / 中国骨伤

OBJECTIVE@#To explore clinical effect of cement-augmented pedicle screw combined with vertebroplasty in treating Kümmell disease with type Ⅲ.@*METHODS@#From January 2015 to December 2018, 37 patients with type Ⅲ Kümmell disease were retrospectively analyzed, including 11 males and 26 females, aged from 61 to 84 years old with an average of (68.6±4.2) years old, and the courses of disease ranged from 2 to 10 months with an average of(6.5±2.3) months. Nine patients were grade C, 20 patients were grade D and 8 patients were grade E according to Frankle grading. All patients were treated by cement-augmented pedicle screw combined with vertebroplasty. Operation time, blood loss, postoperative drainage, hospital stay and complicationswere observed after oeprtaion. Visual analogue scale(VAS), Oswestry Disability Index(ODI), height of anterior vertebral body, Cobb angle before and after operation were compared.@*RESULTS@#All patients were followed up from 12 to 60 months with an average of (22.4±10.9) months. Operation time was (240.9±77.4) min, blood loss was (315.0±149.2) ml, postoperative drainage was (220.8±72.0) ml, hospital stay was (12.6±4.7) days. One patient occurred incision redness and 1 patient occurred infection after opertaion. No loosening of bone cement occurred. Postopertaive VAS and ODI were lower than that of before opertaion(@*CONCLUSION@#Cement-augmented pedicle screw combined with vertebroplasty is a safe and effective method for the tretament of Kümmell disease with type Ⅲ.

Operative versus Non-Operative Management of Traumatic Thoracolumbar Injuries according to the AO Spine Thoracolumbar Spine Injury Classification System

Introduction The AOSpine Thoracolumbar Spine Injury Classification (AOSTSIC) system has been proposed to better characterize injury morphologies and improve the classification of thoracolumbar (TL) spine trauma. However, the indications for surgical treatment according to the AOSTSIC system are still debated. Additionally, the proposed Thoracolumbar AOSpine Injury Score (AOSIS) is quite complex, which may preclude its use in daily practice. The objective of this reviewis to discuss the AOSTSIC systemand its indications for initial nonoperative versus surgical management of acute TL spine trauma. Methods We analyzed the literature for each injury type (and subtype, when pertinent) according to the AOSTSIC system as well as their potential treatment options. Results Patients with AOSTSIC subtypes A0, A1, and A2 are neurologically intact in the vast majority of the cases and initially managed nonoperatively. The treatment of A3- and A4-subtype injuries (burst fractures) in neurologically-intact patients is still debated with great controversy, with initially nonoperative management being considered an option in select patients. Surgery is recommended when there are neurological deficits or failure of nonoperativemanagement,with the role of magnetic resonance findings in the Posterior Ligamentous Complex (PLC) evaluation still being considered controversial. Injuries classified as type B1 in neurologically-intact patients may be treated, initially, with nonoperative management, provided that there are no ligamentous injury and non-displacing fragments. Due to severe ligamentous injury, type-B and type-C injuries should be considered as unstable injuries that must be surgically treated, regardless of the neurological status of the patient. Conclusions Until further evidence, we provided an easy algorithm-based guide on the spinal trauma literature to help surgeons in the decision-making process for the treatment of TL spine injuries classified according to the new AOSTSIC system.

Lesiones toracolumbares en la práctica de acrobacia en tela: Reporte de casos / Thoracolumbar spine injury associated with aerial silk practice. Case reports

Introducción: La acrobacia en tela es una práctica circense con muchos adeptos en la población urbana. Consiste en sostenerse en altura tomado por dos extremos de tela, para realizar posturas fijas y cambiar entre ellas mediante deslizamiento y caídas. La práctica profesional no está libre de lesiones. Objetivo: Conocer la naturaleza de la lesión, reconocer los factores predisponentes de lesión y las medidas de prevención utilizadas, evaluar la cinemática, clasificar la lesión y analizar el tratamiento. Materiales y Métodos: Se incluyeron seis pacientes. Se evaluaron la estructura física personal, la cinemática de la caída, los sistemas de protección, la clasificación de las fracturas según la nueva clasificación AO, el cuadro neurológico, el tratamiento y las complicaciones. Resultados: La muestra incluyó a 6 mujeres, con un promedio de edad de 24 años y un índice de masa corporal de 19,29. Caída de 3,08 m de altura, cuatro con colchoneta <5 cm. Las lesiones principales fueron: 6 A1, 4 B2 y 1C. No se observaron déficits neurológicos. Cuatro pacientes fueron sometidas a cirugía. Conclusiones: La práctica de acrobacia en tela es una actividad circense de reciente aparición global. Las mujeres están más expuestas a las lesiones. El entrenamiento riguroso y el empleo de elementos de seguridad son necesarios para evitar las lesiones. No se observó un patrón único de lesión, la causa fue multifactorial. El tratamiento indicado depende de la lesión vertebral. Nivel de Evidencia: IV

Introduction: Aerial silk is a circus practice that has become very popular in urban populations. It involves hanging from two pieces of fabric in order to make fixed positions and change between them by sliding and dropping from different heights. The professional practice is not free of injuries. Objective: To learn the nature of the injury, to recognize the injury predisposing factors and the safety measures used, to study the kinematics, to classify the injury, and to analyze the treatment. Materials and Methods: Six patients were included. The evaluation included individual body structure, drop kinematics, safety measures, classification of fractures according to the new AO classification, neurological symptoms, treatment, and complications. Results: The study included six female patients, averaging 24 years, a body mass index of 19.29 and a fall from 3.08m, 4 of which included mattress <5cm. The main injuries classification resulted in 6 A1, 4 B2 and 1 C. No neurological deficit was found. Four patients underwent surgical treatment. Conclusions: Aerial silk is a circus activity that has recently become a worldwide practice. Women are more exposed. Rigorous training and the use of safety elements are necessary to avoid injuries. We did not observe a unique pattern of injury, because of its multifactorial cause. The therapeutic decision-making is related to the spinal injury. Level of Evidence: IV

Fijación transpedicular percutánea versus técnica abierta en pacientes con fracturas toracolumbares tipo A / Percutaneous versus open technique transpedicular fixation in patients with thoracolumbares type A fractures

Resumen: Introducción: Las técnicas de fijación transpedicular percutánea son una herramienta emergente en el tratamiento del trauma espinal, sin embargo, su uso no es totalmente aceptado. Objetivo: Comparar resultados en pacientes con fractura vertebral traumática que fueron tratados con cirugía de fijación transpedicular percutánea versus fijación transpedicular abierta. Material y métodos: De Enero a Diciembre de 2016, 15 pacientes con fractura vertebral traumática fueron divididos aleatoriamente en dos grupos: el grupo A fue de seis pacientes tratados con fijación transpedicular percutánea y el grupo B fue de seis pacientes tratados con fijación transpedicular con técnica abierta; tres pacientes fueron eliminados. Se evaluó el sangrado transoperatorio, el dolor postoperatorio con la escala visual análoga a las 24 horas y a las dos semanas del postoperatorio; también se evaluó el índice de discapacidad de dolor lumbar Oswestry a seis semanas, además de tres, seis, 12 y 24 meses del postoperatorio. Resultado: El seguimiento fue de 24 meses. Se reportaron diferencias estadísticamente significativas en el sangrado transoperatorio (p 2.43E-05), EVA al primer día (p < 0.0003), EVA a las dos semanas (p = 0.01); también en el cuestionario de discapacidad de dolor lumbar Oswestry a las seis semanas (p = 0.0007), tres meses (p = 0.005), seis meses (p = 0.005), 12 meses (p = 0.01) y 24 meses (p = 0.004). No se observaron diferencias significativas con respecto al tiempo operatorio (p = 0.12). Discusión: En nuestro trabajo encontramos que el sangrado transoperatorio, dolor postoperatorio y discapacidad funcional son significativamente menores en el grupo de fijación transpedicular percutánea.

Abstract: Introduction: Percutaneous transpedicular fixation techniques are an emerging tool in the treatment of spinal trauma, however, their use is not fully accepted. Objective: Compare results in patients with traumatic vertebral fracture, treated with percutaneous transpedicular fixation surgery versus open transpedicular fixation. Material and methods: From January to December 2016, 15 patients with traumatic vertebral fracture were randomly divided into 2 groups, group A were six treated with percutaneous transpedicular fixation, group B were treated with open technique transpedicular fixation, three patients were eliminated. Transoperative bleeding, postoperative pain with the 24-hour and two-week postoperative visual scale, the six-week Oswestry lumbar pain disability index, and three, six, 12 and 24 months of postoperative control were evaluated. Results: The follow-up was 24 months. Statistically significant differences in transoperative bleeding (p 2.43E-05), EVA on the first day (p < 0.0003), EVA at two weeks (p = 0.01) were reported in the Oswestry lumbar pain disability questionnaire at six weeks (p = 0.0007), three months (p = 0.005), six months (p = 0.005), 12 months (p = 0.01) and 24 months (p = 0.004), no significant differences were observed with respect to operating time (p = 0.12). Discussion: In our work we find that transoperative bleeding, postoperative pain and functional disability are significantly minor in the percutaneous transpedicular fixation group.

Lesión dural asociada a fracturas de charnela toracolumbar y lumbares con compromiso del muro posterior: Relación con las variables del sistema de clasificación AOSpine / Thecal sac injury secondary to burst fractures of the thoracolumbar and lumbar spine, and its association with the AOSpine Classification System variables

Introducción: Las lesiones del saco dural con atrapamiento de la cauda equina entre los fragmentos óseos pueden estar asociadas con fracturas toracolumbares. Objetivo: Realizar un análisis retrospectivo de las variables clínico-radiográficas y el sistema de clasificación AOSpine y la posibilidad de lesión dural asociada en una serie de fracturas toracolumbares por estallido, tratadas en nuestro Centro. Materiales y Métodos: Estudio retrospectivo, observacional de una serie de pacientes con fracturas toracolumbares con compromiso del muro posterior operados en nuestra institución, entre enero de 2012 y diciembre de 2017. Resultados: Se incluyeron 46 pacientes, 16 casos con lesión del saco dural asociada. Las variables porcentaje de ocupación del canal, distancia interpedicular, ángulo del fragmento retropulsado y déficit neurológico asociado mostraron diferencias estadísticamente significativas según la comparación en función de la presencia o ausencia de lesión dural (p = 0,046, p = 0,007, p = 0,046 y p = 0,004, respectivamente). Conclusiones: Según nuestros resultados, la lesión dural traumática podría ser contemplada en la planificación del tratamiento de fracturas toracolumbares ante fragmentos voluminosos del muro posterior con ángulo agudo, compromiso severo del canal raquídeo, distancia interpedicular elevada y daño neurológico asociado, tal como se propone en la bibliografía. Nivel de Evidencia: IV

Introduction: Fractures of the thoracolumbar spine can trigger thecal sac injuries due to the impingement of the cauda equina between bone fragments. Objective: To carry out a retrospective analysis of clinical and radiological variables, the AOSpine Classification System and the possibility of secondary thecal sac injury in a series of thoracolumbar burst fractures treated at our center. Materials and Methods: A retrospective, observational study of a series of patients with thoracolumbar fractures with compromise of the posterior vertebral body wall, who underwent surgery at our center between January 2012 and December 2017. Results: Forty-six patients were included, 16 of which had secondary thecal sac injury. The differences in the variables-percentage of spinal canal involvement, interpedicular distance, angle of the retropulsed fragment, neurological deficit and type C fractures-were statistically significant according to the comparison made with the presence or absence of thecal sac injury (p=0.046, p=0.007, p=0.046, p=0.004, p=0,001 respectively). Conclusions: This study suggests that traumatic thecal sac injury could be suspected when managing burst fractures with prominent fragments in the posterior vertebral body wall, acute angle of the retropulsed fragment, severe compression of the spinal canal, wide interpedicular distance, neurological deficit and fracture displacement (fracture type C according to the AOSpine Classification System). Level of Evidence: IV

Comparison of short-segment monoaxial and polyaxial pedicle screw fixation combined with intermediate screws in traumatic thoracolumbar fractures: a finite element study and clinical radiographic review

OBJECTIVES: No studies have compared monoaxial and polyaxial pedicle screws with regard to the von Mises stress of the instrumentation, intradiscal pressures of the adjacent segment and adjacent segment degeneration. METHODS: Short-segment monoaxial/polyaxial pedicle screw fixation techniques were compared using finite element methods, and the redistributed T11-L1 segment range of motion, largest maximal von Mises stress of the instrumentation, and intradiscal pressures of the adjacent segment under displacement loading were evaluated. Radiographic results of 230 patients with traumatic thoracolumbar fractures treated with these fixations were reviewed, and the sagittal Cobb's angle, vertebral body angle, anterior vertebral body height of the fractured vertebrae and adjacent segment degeneration were calculated and evaluated. RESULTS: The largest maximal values of the von Mises stress were 376.8 MPa for the pedicle screws in the short-segment monoaxial pedicle screw fixation model and 439.9 MPa for the rods in the intermediate monoaxial pedicle screw fixation model. The maximal intradiscal pressures of the upper adjacent segments were all greater than those of the lower adjacent segments. The maximal intradiscal pressures of the monoaxial pedicle screw fixation model were larger than those in the corresponding segments of the normal model. The radiographic results at the final follow-up evaluation showed that the mean loss of correction of the sagittal Cobb's angle, vertebral body angle and anterior vertebral body height were smallest in the intermediate monoaxial pedicle screw fixation group. Adjacent segment degeneration was less likely to be observed in the intermediate polyaxial pedicle screw fixation group but more likely to be observed in the intermediate monoaxial pedicle screw fixation group. CONCLUSION: Smaller von Mises stress in the pedicle screws and lower intradiscal pressure in the adjacent segment were observed in the polyaxial screw model than in the monoaxial pedicle screw fixation spine models. Fracture-level fixation could significantly correct kyphosis and reduce correction loss, and adjacent segment degeneration was less likely to be observed in the intermediate polyaxial pedicle screw fixation group.

Fracturas vertebrales en niños con osteogénesis imperfecta tipo I / Vertebral fractures in children with Type I Osteogenesis imperfecta

La Osteogénesis imperfecta (OI) es una enfermedad hereditaria del tejido conectivo, que se caracteriza principalmente por fragilidad ósea, deformidad y alteración del crecimiento. La OI tipo I (OI tipo I) es la más frecuente, leve y clínicamente homogénea. Su mayor complicación es la presencia de fracturas vertebrales, asociadas a morbilidad esquelética y cardiopulmonar. Objetivo: Caracterizar clinicamente una cohorte de niños con OI tipo I. Pacientes y Método: Se examinó una cohorte histórica de pacientes menores de 20 años mediante la revisión de fichas clínicas, rescatando las características demográficas, clínicas, bioquímicas y radiológicas. Resultados: Se incluyeron 67 pacientes, 55% varones, 69% de la Región Metropolitana. La edad media de diagnóstico fue de 2,9 años, el 70% de los pacientes presentó fracturas vertebrales de predominio torácico, y el 50% lo hizo antes de los 5 años. Un 15% presentó fracturas al momento del diagnóstico, siendo en ellos el diagnóstico de OI tipo I cerca de los 5 años. Los parámetros metabólicos óseos estuvieron en rangos adecuados durante el seguimiento, sin cambios significativos al diagnóstico de las fracturas vertebrales, excepto una disminución de la ingesta recomendada de calcio. Conclusiones: En este estudio, la OI tipo I presenta un diagnóstico precoz, principalmente en preescolares, y se asocia a alta frecuencia de fracturas vertebrales. La disminución en la ingesta de calcio demostrada al momento de la primera fractura requiere especial atención en estos pacientes.

Osteogenesis imperfecta (OI) is an hereditary disease affecting conective tissue, mainly associated to growth retardation and pathological fractures. OI type I (OI type I), is the mildest, most often, and homogeneous in its fenotype. Vertebral fractures are the most significant complications, associated to skeletical and cardiopulmonary morbidity. Objectives: To characterize clinically a cohort of children with OI type I. Patients and Methods: A cohort of OI type I children younger than 20 year old was evaluated. Demographic, clinical, biochemical and radiological data were registered. Results: Sixty seven patients were included, 55% male, 69% resident in the Metropolitan Region. The mean age of diagnose was 2.9 years, 70% presented vertebral fractures on follow-up, mostly thoracic, and 50% before the age of 5 years. Fifty percentage presented vertebral fractures at diagnose, which was about the age of 5 years. Bone metabolic parameters were in the normal range, without significant change at the moment of vertebral fractures. Calcium intake was found to be below American Academy of Pediatrics recommendations at the time of the first fracture. Conclusions: In this study OI type I has an early diagnose, and vertebral fractures show a high incidence, mostly in toddlers. Calcium intake was found to be below reccomended values, and should be closely supervised in these patients.

Corporectomía por acceso único posterior con colocación de caja expandible y fijación transpedicular en fracturas toracolumbares / Posterior corpectomy, transpedicular fixation and expandable cage placement in thoracolumbar fractures

Resumen: Objetivo: Evaluar el resultado de la corporectomía por acceso único posterior con colocación de caja expandible y fijación transpedicular en pacientes con fracturas toracolumbares. Material y métodos: Estudio retrospectivo en el que se evaluaron ocho pacientes con fracturas por estallido entre Mayo de 2011 y Mayo de 2014, quienes fueron tratados de manera quirúrgica mediante corporectomía, colocación de caja expandible y fijación transpedicular con abordaje posterior. El estado neurológico fue valorado a través de la escala de ASIA prequirúrgico y postquirúrgico a un año de evolución y se midió la corrección angular de las deformidades. Resultados: El estudio comprendió cinco personas de sexo masculino y tres de sexo femenino, con un promedio de edad de 38 años (de 24 a 58 años). Todos los pacientes presentaron fracturas por estallido del cuerpo vertebral, uno de ellos con componente rotacional. A los ocho se les realizó solamente la corporectomía de un nivel vertebral. El tiempo quirúrgico promedio fue de 236 minutos (rango: 195-330 min). El sangrado quirúrgico en promedio fue de 1,731 ml. Conclusión/Discusión: Los pacientes que se sometieron a corporectomía por vía posterior mostraron resultados clínicos favorables, sin presentar lesiones neurológicas o lesiones asociadas al procedimiento, por lo que esta técnica puede ser una opción terapéutica al disminuir las complicaciones de una vía anterior o de un doble abordaje.

Abstract: Objective: The objective is to evaluate the outcome of vertebral corpectomy and placement of an expandable cage in patients with thoracolumbar fractures, using a posterior-only approach. Material and methods: A retrospective, case series study in the period from May 2011 to May 2014, in which eight patients with thoracolumbar burst fractures were treated surgically with corpectomy of fractured spinal body, placement of expandable box and fixation with transpedicular system, via posterior-only approach. Neurologic examination was done pre- and postoperatively with the ASIA score in a one year span. The angular deformity correction was also measured. Results: The mean age was 38 years (24 to 58 years); five male and three female patients. All the patients had burst fracture, one of them with aggregate rotational component. Only one vertebral level was worked with corpectomy in all patients. Mean surgical time was 236 minutes (195-330 min). Mean surgical bleeding was 1,731 ml. Conclusion/Discussion: Patients who underwent posterior approach corpectomy showed favorable clinical results. None presented neurological damage or surgical-related injury. This technique can be a useful option to avoid complications related to anterior vertebral approach or double approach.

Reliability of the AO Classification of thoracolumbar fractures compared to TLICS and Magerl / Confiabilidade da Classificação AO de fraturas toracolombares em comparação com TLICS e Magerl / Fiabilidad de la Clasificación AO de fracturas toracolumbares en comparación con TLICS y Magerl

ABSTRACT Objective: To test the reliability of the new AO/2013 classification compared with AO/Magerl and TLICS. Methods: Four spine surgeons retrospectively and blindly evaluated imaging and clinical data from 98 patients with thoracolumbar fractures. Results: Using the Kappa coefficient, we obtained the best reproducibility for the AO/2013 classification compared to the other two, represented by Kappa coefficient of 0.690. We could also obtain, with good reproducibility among the evaluators (Kappa 0.690), the most common subtypes of AO/2013 classification with indication for surgery. Conclusion: We believe that the new AO/2013 classification has proven to be a good communication tool among spine surgeons with good reproducibility, but more studies should be conducted in several centers in order to be consolidated and so that the prognosis between the types of injury is better understood.

RESUMO Objetivos: Testar a confiabilidade da nova classificação AO/2013 com relação às classificações AO/Magerl e TLICS. Métodos: Foram avaliados retrospectivamente exames de imagem e dados clínicos de 98 pacientes com fraturas toracolombares por quatro cirurgiões de coluna vertebral, de modo cego. Resultados: Utilizando o coeficiente Kappa, obtivemos a melhor reprodutibilidade para a classificação AO/2013 quando comparada com as outras duas, representada por um índice Kappa de 0,690. Pudemos obter também, com boa reprodutibilidade entre os avaliadores (Kappa 0,690), os subtipos mais comuns da classificação AO/2013 com indicação de cirurgia. Conclusão: Acreditamos que a nova classificação AO/2013 demonstrou ser uma ótima ferramenta de comunicação entre os cirurgiões de coluna, com boa reprodutibilidade, porém mais estudos devem ser realizados em diversos centros para que seja consolidada e que o prognóstico entre os tipos de lesão seja mais bem compreendido.

RESUMEN Objetivos: Comprobar la fiabilidad de la nueva clasificación AO/2013 en relación con las clasificaciones AO/Magerl y TLICS. Métodos: Se evaluaron de forma retrospectiva imágenes y datos clínicos de 98 pacientes con fracturas toracolumbares por cuatro cirujanos de columna, a ciegas. Resultados: Utilizando el coeficiente Kappa, se obtuvo la mejor reproducibilidad para la clasificación AO/2013 en comparación con las otras dos, representada por un índice Kappa de 0,690. Hemos sido capaces de obtener también, con buena reproducibilidad entre evaluadores (Kappa 0,690), los subtipos más comunes de la clasificación AO/2013 con indicación para cirugía. Conclusión: Creemos que la nueva clasificación AO/2013 resultó ser una gran herramienta de comunicación entre los cirujanos de columna, con buena reproducibilidad, pero más estudios deben llevarse a cabo en varios centros para que se consolide y que el pronóstico entre los tipos de lesiones sea más bien comprendido.

Severe Lateral Thoracic Fracture-Dislocation without Neurological Deficit ­ Case Report

Introduction A case report of a thoracic fracture-dislocation (T11­T12) without neurological deficit is presented. Objective Report the diagnosis and treatment of a traumatic severe fracture with lateral dislocation at the thoracolumbar junction without neurological deficit. Background Fracture-dislocation of the thoracic spine without neurological deficit is a rare lesion. We retrieved only 15 cases reported in the literature. Surgical treatment with spinal decompression, fusion and realignment is the treatment of choice. Case A 40-year-old man suffered a bicycle accident and was admitted with severe back pain but neurologically intact. He was treated with a wide laminectomy and spinal cord decompression followed by correction of his deformity using pedicle screw instrumentation and rod maneuvers. Results After three days, the patient was able to walk, and after one month he had just mild back pain, but was neurologically intact, and was able to return to his usual daily activities. After six months, he was neurologically intact and performing routine physical activities. Conclusions Fracture-dislocation of the thoracic spine without neurological deficit is a rare injury. A good outcome can be obtained with modern spinal stabilization surgical techniques, avoiding late neurological deterioration.

Introdução Apresentamos um relato de caso de fratura-luxação torácica (T11­T12) com grande deslocamento lateral entre os corpos vertebrais, sem déficit neurológico. Objetivo Relatar o diagnóstico e tratamento de uma fratura-luxação grave na junção toracolombar com preservação da função neurológica. Dados Fratura-luxação da coluna torácica sem déficit neurológico é uma lesão rara. Apenas 15 casos relatados na literatura foram encontrados em nossa revisão. O tratamento de escolha se faz com descompressão medular, realinhamento e estabilização. Caso Um homem de 40 anos sofreu um acidente de bicicleta e foi admitido com dorsalgia severa, mas neurologicamente intacto. Ele foi tratado com ampla laminectomia e descompressão medular e, depois, correção da deformidade com parafusos pediculares lombares e manobras de realinhamento. Resultados Após três dias, o paciente estava apto a caminhar, e após um mês, tinha apenas leve dorsalgia e estava neurologicamente intacto, podendo retomar suas atividades de vida diária. Após seis meses da cirurgia, mantinha-se neurologicamente estável e realizando atividades físicas regularmente. Conclusão Fratura-luxação com deslocamento vertebral grave da coluna torácica sem déficit neurológico é uma lesão rara. Um bom desfecho pode ser obtido com técnicas modernas de estabilização da coluna e redução da lesão, evitando deterioração neurológica.

A retrospective study evaluating the correlation between the severity of intervertebral disc injury and the anteroposterior type of thoracolumbar vertebral fractures

OBJECTIVE: To evaluate the correlation between the severity of intervertebral disc injury and the anteroposterior type of thoracolumbar vertebral fractures. METHODS: Fifty-six cases of thoracolumbar vertebral fractures treated in our trauma center from October 2012 to October 2013 were included in this study. The fractures were classified by the anteroposterior classification, whereas the severity of intervertebral disc injury was evaluated using magnetic resonance imaging. The Spearman correlation coefficient was used to analyze the correlation between the severity of intervertebral disc injury and the anteroposterior type of thoracolumbar fractures, whereas a χ2 test was adopted to measure the variability between different fracture types and upper and lower adjacent disc injuries. RESULTS: The Spearman correlation coefficients between fracture types and the severity of the upper and lower adjacent disc injuries were 0.739 (PU<0.001) and 0.368 (PL=0.005), respectively. It means that the more complex Arbeitsgemeinschaft für Osteosynthesefragen (AO) classifications are the disc injury is more severe. There was also a significant difference in the severity of injury between the upper and lower adjacent discs near the fractured vertebrae (p<0.001). CONCLUSIONS: In thoracolumbar spinal fractures, the severity of the adjacent intervertebral disc injury is positively correlated with the anteroposterior fracture type. The injury primarily involves intervertebral discs near the fractured end plate, with more frequent and severe injuries observed in the upper than in the lower discs. The presence of intervertebral disc injury, along with its severity, may provide useful information during the clinical decision-making process.

Surgical treatment of Denis type B thoracolumbar burst fracture with neurological deficiency by paraspinal approach

We aimed to describe the surgical technique and clinical outcomes of paraspinal-approach reduction and fixation (PARF) in a group of patients with Denis type B thoracolumbar burst fracture (TLBF) with neurological deficiencies. A total of 62 patients with Denis B TLBF with neurological deficiencies were included in this study between January 2009 and December 2011. Clinical evaluations including the Frankel scale, pain visual analog scale (VAS) and radiological assessment (CT scans for fragment reduction and X-ray for the Cobb angle, adjacent superior and inferior intervertebral disc height, and vertebral canal diameter) were performed preoperatively and at 3 days, 6 months, and 1 and 2 years postoperatively. All patients underwent successful PARF, and were followed-up for at least 2 years. Average surgical time, blood loss and incision length were recorded. The sagittal vertebral canal diameter was significantly enlarged. The canal stenosis index was also improved. Kyphosis was corrected and remained at 8.6±1.4o (P>0.05) 1 year postoperatively. Adjacent disc heights remained constant. Average Frankel grades were significantly improved at the end of follow-up. All 62 patients were neurologically assessed. Pain scores decreased at 6 months postoperatively, compared to before surgery (P<0.05). PARF provided excellent reduction for traumatic segmental kyphosis, and resulted in significant spinal canal clearance, which restored and maintained the vertebral body height of patients with Denis B TLBF with neurological deficits.

More than 5-Year Follow-up Results of Two-Level and Three-Level Posterior Fixations of Thoracolumbar Burst Fractures with Load-Sharing Scores of Seven and Eight Points

BACKGROUND: The development of pedicle screw-based posterior spinal instrumentation is recognized as one of the major surgical treatment methods for thoracolumbar burst fractures. However, the appropriate level in posterior segment instrumentation is still a point of debate. To assesses the long-term results of two-level and three-level posterior fixations of thoracolumbar burst fractures that have load-sharing scores of 7 and 8 points. METHODS: From January 1998 to May 2009, we retrospectively analyzed clinical and radiologic outcomes of 45 patients with thoracolumbar burst fractures of 7 and 8 points in load-sharing classification who were operated on using two-level posterior fixation (one segment above and one segment below: 28 patients, group I) or three-level posterior fixation (two segments above and one segment below: 17 patients, group II). Clinical results included the grade of the fracture using the Frankel classification, and the visual analog score was used to evaluate pain before surgery, immediately after surgery, and during follow-up period. We also evaluated pain and work status at the final follow-up using the Denis pain scale. RESULTS: In all cases, non-union or loosening of implants was not observed. There were two screw breakages in two-level posterior fixation group, but bony union was obtained at the final follow-up. There were no significant differences in loss of anterior vertebral body height, correction loss, or change in adjacent discs. Also, in clinical evaluation, there was no significant difference in the neurological deficit of any patient during the follow-up period. CONCLUSIONS: In our study, two-level posterior fixation could be used successfully in selected cases of thoracolumbar burst fractures of 7 and 8 points in the load-sharing classification.