Volume 8 | Issue 2 | Aug – Sep 2020 | Page: 7-15 | Mrinal B Shetty, Vinayak Venugopal, Jabez Gnany
Authors: Mrinal B Shetty , Vinayak Venugopal , Jabez Gnany 
 Department of Orthopaedics, Father Muller Medical College, Kankanady, Mangalore, Karnataka
Address of Correspondence
Dr. Vinayak Venugopal,
Department of Orthopaedics, Father Muller Medical College, Kankanady, Mangalore, Karnataka
Purpose: The treatment of fracture-dislocations and unstable fractures of the thoracic and lumbar spine has been controversial. Many authors have advised conservative treatment which was labor intensive and associated with complications, increased bed occupancy, increased cost of therapy, increased hospital stay hours, and care by trained personnel. Early surgical indirect decompression with instrumentation reduces the duration of hospital stay, facilitates early recovery, and prevents prolonged morbidity, so there is an urgent need for possibilities of surgical stabilization, early mobilization, and rehabilitation of patients. The surgical decompression can be done anteriorly, posteriorly, or anteroposteriorly. With advent of pedicle screws, more and more fractures are treated with posterior based surgeries with long-segment (LS) fixation which regains spinal alignment and provides adequate stability. Short-segment pedicle screw fixations of thoracolumbar fractures excluding screw fixation at the fractured vertebrae do not provide the necessary stability; hence, additional fixation point with screws in the fractured vertebrae is useful and a safe technique in the treatment of thoracolumbar fractures.
This prospective study aims at comparing the clinical, radiological, and neurological outcomes after surgical decompression and instrumentation by posterior and transpedicular approach in thoracolumbar spinal fractures postoperatively at 1month, 6 months, and 1 year follow-up periods.
Materials and Methods: Adult patients with acute thoracolumbar injuries admitted to Spine Surgery unit, Father Muller Medical Hospital, Mangalore, were taken for this study after obtaining their informed, valid written consent. This is a prospective study from September 2016 to August 2018.
Results: In our study, 50% of population belong to the age group of 31–50 years, 28% belong to the age below 30 years, and 22% belong to the age above 50 years and 92% of population were male and the rest 8% were female. Twenty-nine of them sustained L1 flexion distraction injury which accounts to about 58% of the fracture, the second most common being six patients with D12 flexion distraction injury which accountsfor10% of cases. Three cases each of D11, L2, and L3 flexion distraction injury which accounts for 6% of fracture. One each case of D11 unstable burst fracture, D12 chance fracture, D12 unstable burst fracture,L1 unstable burst fracture, L1 chance fracture, and L3 unstable burst fracture which accounts for 2% of total fractures. Thirty-eight patients had no neurological deficits and categorized under the American Spine Injury Association (ASIA)-E which accounts for 76% of the cases. Seven had neurological deficits, incomplete categorized under ASIA-C which accounts for14% of the cases. Five were categorized under ASIA-D which accounts for 10% of total cases. Preoperatively, an average of 40.09% of vertebral body height was lost which improved in immediate post-operative period to 70.25% and maintained at 70.38% at the end of 1 year. Degree of segmental kyphosis preoperatively was 15.32°, which improved to 6.62° at the end of 1 year. Percentage of canal compromise measurement preoperatively showed an average of 30.38% of spinal canal encroachment. Immediate post-operative assessment showed decompression of canal to 12.64% and 10.00% at the end of 1 year. Preoperatively, an average Oswestry Disability Index score was 44.28% which improved inimmediate post-operative period to 32.52% and15.71% at the end of 1 year which is mildlevel of disability. Preoperatively, average visual analog score was 7 which shows moderate-to-severe pain which improved to 2.92, indicating minimal or no pain at the end of follow-up.
Conclusion: The technique of short-segment pedicle screw fixation with screws in fractured vertebrae is safe as our study did not show worsening of the pre-operative neurological status in any patients with ASIA-C and above. There was adequate indirect decompression of the spinal canal using smaller incision, resulting in lesser operative time, and blood loss. The vertebral body height was satisfactorily reconstructed, kyphotic angle reduced, and the spinal alignment was maintained. The final outcome in terms of improvement of ASIA impairment scale was determined by the initial injury. Incomplete injuries improved by at least one scale as per ASIA. Hence, this is an effective and safe technique which retains the biomechanical stability as compared to the LS fixation while requiring smaller incision, lesser operative time, and less blood loss.
Keywords: Short-segment pedicle screw fixation, Thoracolumbar fracture, Tanspedicular instrumentation.
1. Gertzbein SD. Scoliosis research society. Multicenter spine fracture study. Spine (Phila Pa 1976) 1992;17:528-40.
2. DeWald RL. Burst fractures of the thoracic and lumbar spine. ClinOrthop Res 1984;18:150-61.
3. Soreff J. Assesment of the Result of Traumatic Compression Fractures of the Thoraco-Lumbar Vertebral Bodies. Sweden: Stokhalm, Karoinska Hospital; 1975. p. 27
4. Azam MQ, Sadat-Ali M. The concept of evolution of thoracolumbar fracture classifications helps in surgical decisions. Asian Spine J 2015;9:984-94.
5. Gelb D, Ludwig S, Karp JE, Chung EH, Werner C, Kim T, et al. Successful treatment of thoracolumbar fractures with short-segment pedicle instrumentation. J Spinal Disord Tech 2010;23:293-301.
6. Mclain RF. The biomechanics of long versus short fixation for thoracolumbar spine fractures. Spine(Phila Pa 1976) 2006;31:70-9.
7. Mahar A, Kim C, Wedemeyer M, Mitsunaga L, Odell T, Johnson B, et al. Short-segment fixation of lumbar burst fractures using pedicle fixation at the level of the fracture. Spine (Phila Pa 1976) 2007;32:1503-7.
8. Guven O, Kocaoglu B, Bezer M, Aydin N, Nalbantoglu U. The use of screw at the fracture level in the treatment of thoracolumbar burst fractures. J Spinal Disord Tech 2009;22:417-21.
9. Jonathan-James T, Chen J, Mitsunaga M. Short same-segment fixation of thoracolumbar burst fractures. Spine J 2010;10:109-14.
10. Moon M, Choi W, Sun D, Chae J, Ryu J, Chang H, et al. Instrumented ligamentotaxis and stabilization of compression and burst fractures of dorsolumbar and mid-lumbar spines. Indian J Orthop 2007;41:346-53.
11. Huang W. Efficacy analysis of pedicle screw internal fixation of fractured vertebrae in the treatment of thoracolumbar fractures. ExpTher Med 2013;5:678-82.
12. Wang L, Li J, Wang H, Yang Q, Lv D, Zhang W, et al. Posterior short segment pedicle screw fixation and TLIF for the treatment of unstable thoracolumbar/lumbar fracture. J MusculoskeletDisord 2014;15:1-11.
13. Patil RP, Joshi V. Comparative study between short segment open versus percutaneous pedicle screw fixation with indirect decompression in management of acute burst fracture of thoracolumbar and lumbar spine with minimal neurological deficit in adults. J Spine 2016;5:1-5.
14. Bensch FV, Koivikko MP, Kiuru MJ, Koskinen SK. The incidence and distribution of burst fractures. EmergRadiol 2006;12:124-9.
15. Harrington PR. The history and development of Harrington instrumentation. ClinOrthopRelat Res 1973;93:110-2.
16. Zhao Q, Gu X, Yang H, Liu Z. Surgical outcome of posterior fixation, including fractured vertebra, for thoracolumbar fractures. Neurosciences 2015;20:362-7.
17. Wang J. Treatment of thoracolumbar vertebrate fracture by transpedicular morselized bone grafting in vertebrae for spinal fusion and pedicle screw fixation. J Huazhong Univ Sci Technol Med Sci 2008;28:322-6.
18. Kim BG, Dan JM, Shin DE. Treatment of thoracolumbar fracture. Asian Spine J 2015;9:133-46.
19. Gurwitz GS, Dawson JM, McNamara MJ, Federspiel CF, Spengler DM. Biomechanical analysis of three surgical approaches for lumbar burst fractures using short-segment instrumentation. Spine (Phila Pa 1976) 1993;18:977-82.
20. Farookhi MR. Inclusion of the fracture level in short segment fixation of thoracolumbar fractures. Eur Spine J 2010;19:1651-6.
21. Machino M, Yukawa Y, Nakashima H, Kato F. Posterior/anterior combined surgery for thoracolumbar burst fractures–posterior instrumentation with pedicle screws and laminar hooks, anterior decompression and strut grafting. Spinal Cord 2011;49:573-9.
22. Canbek U, Karapinar L. Posterior fixation of thoracolumbar burst fractures: Is it possible to protect one segment in the lumbar region?. Eur J OrthopSurgTraumatol 2014;24:459-65.
23. Wilcox RK, Boerger TO, Allen DJ, Barton DC, Limb D, Dickson RA, et al. A dynamic study of thoracolumbar burst fractures. J Bone Joint Surg 2003;85:2184-9.
24. Sjöström L, Jacobsson O, Karlström G, Pech P, Rauschning W. Spinal canal remodelling after stabilization of thoracolumbar burst fractures. Eur Spine J 1994;3:312-7.
25. Wessberg P, Wang Y, Irstam L, Nordwall A. The effect of surgery and remodelling on spinal canal measurements after thoracolumbar burst fractures. Eur Spine J 2001;10:55-63.
26. Fairbank JC, Pynsent PB. The Oswestry disability index. Spine (Phila Pa 1976) 2000;25:2940-53.
27. Zou J, Zhang L, Shi J, Gan M. Treatment of thoracolumbar burst fractures: Short-segment pedicle instrumentationversus kyphoplasty. ActaOrthopBelg 2013;79:718-25.
28. Glassman S, Gornet MF, Branch C, Polly D, Peloza J, Schwender JD, et al. MOS short form 36 and Oswestry disability index outcomes in lumbar fusion: A multicenter experience. Spine J 2006;6:21-6.
29. Singh R, Rohilla RK, Kamboj K, Magu NK, Kaur K. Outcome of pedicle screw fixation and monosegmental fusion in patients with fresh thoracolumbar fractures. Asian Spine J 2014;8:298-308.
30. Canto FR. Low thoracic and lumbar burst fractures: Radiographic and functional outcomes. Eur Spine J 2007;16:1934-43.
31. Chadha M, Bahadur R. Steffee variable screw placement system in the management of unstable thoracolumbar fractures: A third world experience. Injury 1998;29:737-47.
|How to Cite this article: Shetty MB, Venugopal V, Gnany J | Study of Functional and Radiological Outcome of Short-Segment Pedicle Screw Fixation for Thoracolumbar Fractures with use of Pedicle Screws in Fractured Vertebrae | Journal of Karnataka Orthopaedic Association | August-September 2020; 8(2): 7-15.|