Comparison of operative versus nonoperative treatment of lumbar burst fractures.

The outcomes of traumatic two- and three-column lumbar burst fracture patients treated operatively and nonoperatively were investigated with respect to treatment complications, resumption of employment, and quality of life. Data were obtained from hospital records, radiographs, and written questionnaires. Of 93 patients diagnosed with lumbar fracture between January 1987 and December 1989, 22 met the criteria for study (12 operative, ten nonoperative). Exclusion was based on single-column compression or chance fractures, neurologic compromise, and nontraumatic fractures. The patient groups had distinctly different fracture patterns based on degree of anterior column compression (ACC). Trends toward significant differences in kyphotic angulation and canal compromise were noted. There were no preoperative complications. Varying modes of external immobilization were used in both groups. One patient in each group used narcotic medications for pain at final follow-up evaluation. When comparing the operatively and nonoperatively treated lumbar burst fracture patients in this study group, no significant difference in treatment outcome was established. Nonoperative treatment remains a viable alternative to operative intervention in selected lumbar burst fracture patterns.

Influence of pedicle fixation on postoperative pain.

From October 1988 through November 1990, 29 lumbar and lumbosacral spine fusion patients, 11 instrumented and 18 noninstrumented, were observed. Seventeen were men and 12 were women, with a mean age of 42.6 years (range, 22-83). The narcotic equivalent (NE) in milligrams/kilogram/day of medication used was analyzed. Age, sex, height, and weight were compared to the type, dose, mode, and duration of medication administration. Morphine was the reference point narcotic at 1.0:1.0. Levels fused, use of instrumentation, and prior surgery were related to NE. No significant differences in age, total body weight, height, levels fused, or hospital stay were established. There were 89.6% of patients over the ideal body weight by a mean 17.47 kg or 38.3 lb. The mean population NE was 3.76 mg/kg/day. Prior surgery patients tended to request narcotics intramuscularly for a longer period, while older patients tended to receive less medication. Patient obesity was related to lower NE. This study could not demonstrate a decrease in postoperative pain as it relates to the amount of narcotic medication received with the use of pedicle instrumentation.

Randomized trial comparing single dose versus fractionated irradiation for prevention of heterotopic bone: a preliminary report.

Radiation therapy has been shown to prevent heterotopic bone formation in high risk patients undergoing total hip replacement. A number of doses have been used without a randomized trial comparing one dose regimen against another. A prospective randomized trial was undertaken comparing 10 Gy in 5 fractions versus 8 Gy in 1 fraction. Forty-seven patients have been randomized at the time of this evaluation with 37 patients eligible for analysis. The pre-operative, immediate post-operative and 2 month post-operative radiographs were graded. At the time of this analysis, 17 patients were randomized to the 8 Gy arm with 20 patients in the 10 Gy arm. Patients were treated with limited fields so as to only cover the area at risk for development of heterotopic bone to prevent adverse effects on biologic fixation of uncemented implants. When comparing the pre-operative, operative, and 2 month post-operative radiographs, only four patients (1 patient in the 8 Gy arm and 3 patients in the 10 Gy arm), had an increase in the score. No patient had an increase in score to a clinically significant level, usually grade 3 or 4. These preliminary results appear to show that 8 Gy in a single fraction can be as effective as 10 Gy in 5 fractions in preventing heterotopic bone in susceptible individuals. Further follow-up of the remaining patients may confirm this.

Guidelines for the management of lumbosacral spondylolisthesis associated with scoliosis.

Lumbosacral spondylolisthesis, when it is associated with scoliosis, presents special problems which require special consideration in management. Lumbosacral spondylosisthesis associated with a major thoracic curve, presents two separate problems. Treatment of the lumbosacral spondylolisthesis depends upon the severity of the lesion and symptoms. The thoracic curve is treated as required, depending upon the severity of the scoliosis and the stage of spinal maturation. Lumbosacral spondylolisthesis associated with a thoracolumbar or lumbar curve requires treatment of the curves above, along with the spondylolisthesis. Do not fuse the lumbosacral joint in an uncorrected position.