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COMPARATIVE ANALYSIS OF FUNCTIONAL OUTCOME IN THORACOLUMBAR FRACTURES AND DISLOCATIONS FIXED WITH SHORT SEGMENT WITH
INDEX VERTEBRA FIXATION AND LONG SEGMENT SPANNING FIXATION
Dissertation submitted in partial fulfillment of the regulation for the award of M.S DEGREE IN ORTHOPAEDIC SURGERY BRANCH II
MAY 2018
THE TAMIL NADU
DR. MGR MEDICAL UNIVERSITY CHENNAI, TAMIL NADU MADURAI MEDICAL COLLEGE
MADURAI
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CERTIFICATE
This is to certify that the work “COMPARATIVE ANALYSIS OF FUNCTIONAL OUTCOME IN THORACOLUMBAR FRACTURES AND DISLOCATIONS FIXED WITH SHORT SEGMENT WITH INDEX VERTEBRA FIXATION AND LONG SEGMENT SPANNING FIXATION" which is being submitted for M.S. Orthopaedics, is a bonafide work of Dr.G.PRASANTH, Post Graduate Student at Department of Orthopaedics, Madurai Medical College, Madurai.
The Dean ,
Madurai Medical college,
Madurai.
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CERTIFICATE
This is to certify that the work “COMPARATIVE ANALYSIS OF FUNCTIONAL OUTCOME IN THORACOLUMBAR FRACTURES AND DISLOCATIONS FIXED WITH SHORT SEGMENT WITH INDEX VERTEBRA FIXATION AND LONG SEGMENT SPANNING FIXATION" which is being submitted for M.S. Orthopaedics, is a bonafide work of Dr.G.PRASANTH, Post Graduate Student at Department of Orthopaedics, Madurai Medical College, Madurai.
Prof. Dr. P.V.Pugalenthi, M.S Ortho.D.Ortho
Professor and Head, Department of Orthopaedics & Traumatology
Madurai Medical College,
Madurai.
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CERTIFICATE
This is to certify that this dissertation “COMPARATIVE ANALYSIS OF FUNCTIONAL OUTCOME IN THORACOLUMBAR FRACTURES AND DISLOCATIONS FIXED WITH SHORT SEGMENT WITH INDEX VERTEBRA FIXATION AND LONG SEGMENT SPANNING FIXATION" is the bonafide work done by Dr.G.PRASANTH under my direct guidance and supervision in the Department of Orthopaedic Surgery, Madurai Medical College, Madurai-20.
Prof. Dr. R.Sivakumar, M.S Ortho., D. Ortho
Professor and Chief Ortho unit-III
Department of Orthopaedics & Traumatology
Madurai Medical College,
Madurai.
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ACKNOWLEDGEMENT
I am grateful to Prof.Dr.P.V. Pugalenthi, M.S., Ortho, D.Ortho., Professor and Head, Department of Orthopaedic Surgery and Traumatology, Madurai Medical College in guiding me to prepare this dissertation.
I am greatly indebted and thankful to my beloved chief, my guideProf.Dr.R.Sivakumar, M.S.,Ortho, D.Ortho., Ortho-III unit, Department of Orthopaedic Surgery and Traumatology, Madurai Medical College for his invaluable help, encouragement and guidance rendered to me in preparing this dissertation.
I am most indebted and take immense pleasure in expressing my deep sense of gratitude to Prof.Dr.B.Sivakumar M.S. Ortho.,D.ortho, Prof.Dr.R.Arivasan M.S.Ortho., Prof .Dr.V.R.Ganesan M.S.Ortho.,D.Ortho, and Prof.Dr.N.Thanappan M.S.Ortho for their easy accessibility and timely suggestion, which enabled me to bring out this dissertation.
At the very outset I would like to thank Prof.Dr.D.Maruthupandian M.S,F.A.I.S,F.I.C.S,the Dean, Madurai Medical College and Govt. Rajaji Hospital, Madurai for permitting me to carry out this study in this hospital.
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I take immense pleasure to thank my co-guide Dr.K.Senthil Kumar M.S.Ortho.,for his timely help and encouragement.
I also take this opportunity to thank Dr.M.N.Karthi M.S.Ortho., Dr.J.MaheswaranM.S.Ortho.,Dr.T.SaravanaMuthuM.S.Ortho.,Dr.V.A.Prabu M.S.Ortho., Dr.R.Ashok Kumar MS Ortho., Dr.R.Karthik Raja M.S.Ortho., Dr.Gopi Manohar DNB Ortho,Assistant Professors, Department of Orthopaedics, Madurai Medical College, for their timely help and guidance given to me during all stages of the study.
Last but not the least, I express my gratitude to the patients for their kind co-operation.
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DECLARATION
I, Dr.G.PRASANTH , solemnly declare that the dissertation titled“COMPARATIVE ANALYSIS OF FUNCTIONAL OUTCOME IN THORACOLUMBAR FRACTURES AND DISLOCATIONS FIXED WITH SHORT SEGMENT WITH INDEX VERTEBRA FIXATION AND LONG SEGMENT SPANNING FIXATION", has been prepared by me. This is submitted to “The Tamil Nadu Dr. M.G.R. Medical University, Chennai, in partial fulfillment of the regulations for the award of M S degree branch II Orthopaedics.
DR.G.PRASANTH
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PART A
• ACKNOWLEDGEMENT
CONTENTS Page No.
Introduction 10
Aim and Objective 12
Review of Literature 13
Anatomy and classification 15
Radiographic evaluation 32
Treatment 34
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PART -B
CONTENTS Page No.
Methodology 42
Observation & Results 49
Cases 62
Discussion 82
Conclusion 87
ANNEXURES :
a. BIBLIOGRAPHY
b. PATIENT PROFORMA c. CONSENT FORM d. MASTER CHART
e. MODIFIED MACNAB’S CRITERIA AND OSWESTRY DISABILITY INDEX
f. ETHICAL COMMITTEE APPROVAL
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INTRODUCTION
Fractures in the thoracic and lumbar spine accounts for 90% of all spinal fractures. The dorsolumbar junction is unique because of its anatomy and biomechanical environment . Dorsolumbar spine fractures are the commonest cause of traumatic paraplegia . They are most commonly seen in younger patients.
It involves most commonly in the region between T11 and L1. Injuries are mostly due to fall from height, motor vehicle accidents and injuries related to occupation and recreational activities.
The treatment usually are either conservative or surgery. Surgery involves either posterior reduction and instrumentation or anterior decompression and instrumentation or combined.Most commonly done procedure is Posterior instrumentation . Most important aim of the management is to mobilise the patient early and rehabilitation. Conservative treatment was used Until 1970. Hippocrates was the first to treat the spinal fractures in the form of bed rest, postural reduction , mobilization, ambulatory bracing and combination of these. The main goal was to mobilize the patient with or without brace early.
Dorsolumbar burst fractures are unstable mostly which requires surgical spinal stabilization to maintain anatomical reduction and stability and also to
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promote early bony fusion and mobilisation. Now most of the dorsolumbar fractures are treated surgically to allow early mobilisation and to avoid the complications of prolonged bed rest.
For the past 20 years, spine surgery has seen a dramatic increase in the operative management. Posterior short segment pedicle screw fixation is usually done for burst fractures. Eventhough early clinical results of this surgery are usually satisfactory, a high failure rate and progressive kyphosis remain a concern.To overcome this in addition to short segment fixation ,pedicle screw is inserted at the fracture site.Long segment fixation is usually reserved for fracture dislocation.Inorder to compare the results of functional outcome of both this study is undertaken.
To
compare analysis of functional outcome in thoracolumbar
fractures and dislocations fixed with long segment spanning fixation
and short segment with index vertebra fixation
, this study was undertaken.12
AIM OF THE STUDY
• To
compare the results of functional outcome in thoracolumbar fractures and dislocations fixed with long segment spanning fixation and short segment with index vertebra fixation
OBJECTIVES OF STUDY
• To
compare the results of functional outcome in thoracolumbar fractures and dislocations fixed with long segment spanning fixation and short segment with index vertebra fixation
• To facilitate early mobilisation of patients and thus helping easy nursing care of patients in order to re-create a stable and pain free spinal column.
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REVIEW OF LITERATURE
In a study by Jong-Jie et al (2010),82 Patients were included and followed up for 2 years.All cases achieved fusion,without vertebral body height loss and implant failure.Improvement of neurological function was observed in patients with incomplete neurological deficit.It concluded that posterior short segment pedicle screw fixation with pedicle screw at the fracture level is a safe and effective therapeutic option to treat thoracolumbar vertebral fractures, which can help to correct the kyphosis and maintain the reduction.
In a study by Tarek ahmed aly(2016),no significant difference was found between short segment and long segment pedicle screw fixation in terms of radiological ,functional outcome,neurologic improvement and implant failure rate.[58]
In a study by Jun li(2016), 455 cases were taken(239 short segment and 216 long segment )eventhough operating time for long segment fixation was prolonged,good radiological outcome and less implant failure in long segment
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fixation was seen but there was no significant difference in clinical outcome between short and long sement fixation.[57]
In a study by Yue zhou and Changing li(2014),four fixation models were used and it concleded that additional pedicle screws at the level of fracture may result in a stiffer construct and less von misses stress for pedicle screws and rods.
In a study by Tezeren G kuru(2005),18 consecutive patient were included with 9 patients treated by short segment and 9 patients with long segment.Measurements of local kyphosis,sagittal index and anterior vertebral body height compression showed that long segment fixation had better outcome at final followup.Also short segment group had 55%failure rate whereras the long segment group had prolonged operative time and increased blood loss.However there was no significant difference between the two groups according to low back outcome score.[32]
In a study by S.Acharya,A.Garg and R.S.Chahal(2012),20 patients were included(10 with short segment and 10 with long segment).postoperative kyphotic correction and restoration of height was measured and results of both the groups were comparable.It concluded that Pedicle screw at the level of fracture in short
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segment provides added stability,better postoperative maintenance of corrected kyphosis at reduced cost of implant and also reduces the duration of surgery and blood loss [56]
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ANATOMY
Most of spinal fractures occur between levels T11 and L2. This thoracolumbar junction is unique since it has a transitional anatomy. Thoracic spine is stabilized by rib cage and costotransverse ligaments which provide resistance to axial rotation and bending moments in coronal and sagittal plane. This provides protection and also relative stiffness for the dorsal spine. But lumbar spine is relatively unprotected and more flexible. The coronal and frontal orientation of the facet joints of thoracic spine restrict mobility both in the flexion and extension plane. But the sagittally oriented lumbar facet joints has increased motion in both flexion and extension plane. Thoracolumbar junction provides less shock-absorbing capacity or potential since it is straighter whereas the kyphosis of the thoracic spine and lordosis of the lumbar spine serves to absorb and dissipate axial loads .[14]
Thoraco lumbar injury-Classification :
Any classification should give the injury identification and clinical ,radiographic characteristics. It also should give information about the severity of injury and give idea regarding the choice of treatment.
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In 1930 Bohler was the first one who classified spinal fractures.
In 1949 Nicoll published the concept given by Watson and Jones regarding stability and ligamentous integrity. In 1963 Holdsworth proposed two column theory.In 1977 Louis proposed the three column concept. In 1983 Dennis based on CT proposed the three column theory.[5]
In the Denis anatomical three-column model ,
1.Anterior column - anterior longitudinal ligament and the anterior half of anulus fibrosus and vertebral body .
2.Middle column -posterior longitudinal ligament and posterior half of the anulus fibrosus and vertebral body.
3.Posterior column -consists of ligamentous and bony structures posterior to the posterior longitudinal ligament.
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In three-column model, thoracolumbar fractures are classified based on the injury to the middle column. Injury to the middle column is considered as a potentially unstable fracture pattern in this three column classification system.
There is no involvement of middle column in compression fractures in which anterior column goes for failure, whereas burst fracture both the anterior and the middle column goes for compression failure. Chance fractures and Chance variantsfailure in distraction, whereas any translation or rotation through the middle column is a characteristic of a fracture-dislocation.[5,6]
In 1994 two new classification were come. The load sharing classification (LSC) coined by McCormack
et and Comprehensive Classification[14].
McCORMACK
CLASSIFICATIONgiving points to
1.The amount of comminution in the fractured vertebral body 2.The amount of kyphosis
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correction needs to restore the sagittal alignment
3.The spread of comminuted fragments in the fractured vertebral body (apposition)
Magrel et al presented Comprehensive classification based on AO fracture classification[8]. It consists of
1. Type A fracture –compression type of injury without posterior lesion 2. Type B fracture - distraction type of injury
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3. Type C fracture- rotational type of injury
Each of these subdivided into three subgroups. At present Denis and Comprehensive classification are used commonly.
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Common pattern of fractures
The most common fracture patterns at the thoracolumbar junctioninclude 1.Anterior wedge compression fractures
2.Burst fractures ( stable ,unstable)
3.Flexion-distractioninjuries ( chance fractures) 4.Fracture- subluxation and dislocations.
Anterior wedge Compression Fractures :
It occurs when vertebral body fails under axial loading.
The anteriorspinal column goes failure in compression, while the middle columnis not involved. The posterior column may remain intact or failin tension, depending on the energy level of the injury. They are usually not associated with neurological deficit .But it can occur when multiple adjacent level fractured .[6]
This type of fracture can be easily diagnosedon plain radiographs and with CT scan. On lateral plain radiographs, it is seen as a wedge-shaped vertebra with loss of anterior body height and no involvement of theposterior vertebral body. The
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height of injured vertebral body should be measured and compared with those at the more cephaladand caudal levels.
These type of compression fractures are considered stable, and can therefore be treated non-operatively. In the setting of normal neurologic function, vertebral body height loss and kyphosis have been used as radiologic parameters to assess the degree of injury. Patients with fractures exhibiting minimal height loss (less than 10%) can usually be safely mobilized without the use of a brace or an external support. Most practitioners consider a compression or wedge fracture with less than 30% or 40% of vertebral body height loss and < 20 degrees to 25 degrees of kyphosis to be inherently stable. So they can be treated in brace. A Jewett hyperextension brace is applied for 6 to 8 weeks. Standing x-rays in the brace should be obtained both initially and at regular follow-up visits to monitor fracture healing and alignment.[44,45]
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If the height loss is > 50% or more than 30 degrees of kyphosis in non- osteoporotic bone strongly suggests the possibility of PLC disruption, which places the patient at risk of increasing kyphotic deformity or neurologic deficit. Inter- spinous widening on lateral x-rays may strengthen this suspicion, and give cause for concern if non-operative management is used. In such cases, posterior stabilization is usually recommended.[28]
Burst fractures :
Because of high energy axial load that results in compression failure of anterior and middle spinal column. The sudden application of high energy axial load will cause vertebral end plate failure and adjacent disc tissue will be driven into the fractured vertebral body. Most of the time fragments will be retropulsed into the spinal canal which will cause the neurological deficit. Like compressionfractures, burst fractures are more common in thoracolumbar spinal segments.[28]
Denis further classified burst fracture into, a type-A fracture involves failure of both the superiorand the inferior end plate, type B involves failure of the superior endplate only, type C involves failure of the inferior end plateonly, type D
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results in an axial loading and rotational injury,and type E results in an axial loading and lateral flexion injury.Type B is the most frequent fracture pattern, followed by typeA. The other types are relatively rare. [5,6]
Most of the burst fractures are having some degree of spinal canal compromise due to retropulsionof any bony fragment.The initial radiographic evaluation should include assessmentof vertebral body height loss and the kyphosis angle on lateralradiographs as well as the interpedicular distanceon anteroposterior radiographs . Computedtomography imaging is useful for measuring thecanal diameter. Magnetic resonance imaging is recommendedfor patients with a neurological deficit. It is very useful to identify spinal cord or cauda equina injury, hemorrhage, or epidural hematoma.[18]
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The patient should be immobilized in Thoracic Lumbar Sacral Orthosis (TLSO). Patient should be followed up by taking X-rays and MRI at every 2 weeks. The TLSO brace should be worn for atleast 2–3 months. The patient should undergo physical therapy to strengthen weakened muscles. Once the fracture and any associated neurological injuries havebeen characterized, spinal stability must be evaluated. [39,41]
Several different systems for determining clinicalspinal stability, including complicated point systems and checklists, havebeen proposed. Determinantsof burst fracture instability common to these systems includea progressive neurological deficit,>50% loss of vertebral body height in association with substantial kyphosis, radiographicevidence of substantial posterior column injury andprogressive kyphosis. These fractures may be treated non operatively, but late progression of kyphosisand spinal stenosis tend to develop.[5]
Flexion-Distraction Injury:
In this type of flexion distraction or Chance fractures the primary vector force acting anterior to the middle column. Middle and posterior column will go for failure in tension. The anterior column may go for failure in tension or
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compression depends on the location of the axis of rotation either at or anterior to the anterior column. They may be purely ligamentous, purely osseous or a combination of both. This type of injuries are more common in motor vehicle accident while using seatbelt. An extremely high rateof intra-abdominal injury (45%) has been observed in associationwith this injury pattern. So the abdominal examination is important for this patient. Overall, the riskof substantial neurological injury in association with a flexion-distractioninjury is 10% to 15%.
Conversely, the presence of the hallmark transabdominal or anterior chest wall band of ecchymosis in conjunction with an intra-abdominal injury should highlight the strong possibility of an underlying spinal injury. Even with careful evaluation, the diagnosis is often missed or delayed. Abdominal evaluation should include CT scanning, ultrasound and/or deep peritoneal lavage. Laparotomy with intestinal repair and/or staged diversion takes precedence over spinal injuries, as it is a life- saving procedure. Strict spinal precautions should be maintained at all times, however, to avoid further displacement and potentially neurologic decline when a patient has a flexion-distraction injury and a neurologicalinjury. Magnetic resonance imaging is useful for identifyingongoing neural element compression and to rule out an epiduralhematoma. A computed tomography scan with sagittal reconstructionsis recommended to confirm the fracture pattern and to ascertainthat
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there is no comminution of the middle spinal column. Thisdistinction is important when planning surgical treatment, asthe compression forces that would be necessary to reduce a flexion-distraction injurymay be contraindicated if the middle column is disrupted inorder to prevent middle column retropulsion. The magnetic resonanceimages and computed tomography scans with sagittal reconstructionare also valuable for identifying injury involved eitherbone or ligamentous, as this determines the likelihood of theinjury healing in a brace. The selection and timingof treatment depend in part on the presence of associated intraabdominalinjuries as well as on the neurological profile.[28]
There are few indications for non-operative management of flexion- distraction injuries of the thoracolumbar spine. Some injuries occur primarily through bone. In this setting, provided that the fracture can be reduced and maintained in a brace or cast and the patient is neurologically intact, non-operative
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treatment can be effective. Anderson et al recommended that nonsurgical treatment should be attempted in neurologically intact patients with less 15 degrees of kyphosis provided the injury is primarily bony. X-ray follow-up should be frequent to ensure that the reduction is maintained. External immobilization is recommended for a minimum of 3 months. But most of the flexion-distraction injuries need surgical stabilization.[24]
Fracture –Dislocation:
Fracture-dislocations are high energy injuries due to complex shearing force.
These are extremely unstable and involve disruption of all the three spinal
columns. Usually it is associated with complete neurological deficit.
They are easily recognized on plain radiographs. Any horizontal translation or rotation through the injury level should raise the suspicion that a fracture- dislocation is present. Computed tomography is useful for planning surgical treatment as it identifies incompetent osseous structures and aids in the selection of the implant size. In the less common case of an incomplete neurologicalinjury, magnetic resonance imaging should be performed to characterize ongoing neural element compression and the nature of injury of the spinal cord and cauda equina.
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SPINAL CORD INJURIES
It varies from complete cord injury to incomplete one.
Incomplete Spinal Cord Injury:
An incomplete spinal cord injury means some amount of neurology is intact below the injury site. It is important as (1) the greater the sparing of motor and sensory functions distal to the injury, the greater the expected recovery; (2) the more rapid the recovery, the greater the amount of recovery; and (3) when new recovery ceases and a plateau is reached, no further recovery can be expected . It is described below as
• Spinal contusions
Spinal contusion is the commonest type of cord injury. Cord is just contused but not severed due to inflammation and bleeding near the injury.
The most common type of spinal cord injury. It will result in temporary block of all functions of the cord. Usually it will resolve within 24-48 hrs.[28]
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• Anterior cord syndrome
It is due to damage to the anterior areas of spinal cord which results in compete motor loss and loss of temperature and pain. It occurs mostly in hyper flexion injuries which leads to bony or disc fragments compressing the anterior spinal artery. Deep touch, position sense, and vibratory sensation is preserved.
Prognosis for recovery is bad.
• Posterior cord syndrome
It commonly occurs in extension type of injuries. It affects the posterior column of the cord. So it results in loss of deep touch and vibration sense and position sense. This syndrome is rare.
• Brown-Sequard syndrome-
Sensation and movement are lost on same side but pain and temperature will be lost on opposite side of the bodybelow the level of injury . It occurs due to injury to the right or left side of the spinal cord.
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• Mixed syndrome
Usually it is a combination of several syndromes. It describes the small percentage of incomplete spinal cord injuries that do not fit one of the previously described syndromes
• Conus medullaris syndrome
This type of syndrome occurs when injury happened between T11 and L2 because cord ends at L1. So Injury to the sacral cord or conus and lumbar nerve roots occur. It results in bladder and bowel areflexia, and motor loss of lower extremities. Bulbocavernous reflex and perianal wink will be absent.
Motor function may be spared some times between L1 and L4 if nerve roots are escaped from the injury.
• Cauda equina syndrome,
It is a lower motor neuron type of injury and incomplete one. It occurs when injury occurs beyond L1 vertebra and injury between the conus and the lumbosacral nerve roots. It will lead to areflexic bladder, bowel, and asymmetry motor and sensory loss of lower limbs and absence of bulbocavernosus reflex, anal wink and all modalities of reflex activity in the lower limbs are absent.[36]
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Pre hospital care and Assessment in Emergency department:
Prehospital care
First aid is very important for any spine fractures. The short and long-term outcomes for patients with a dorsolumbarspine fracture depends upon pre hospital care. Extrication and transportation of trauma patientson a backboard and adherence to Advanced Trauma Life Support(ATLS) protocols for resuscitation have been credited for much of this improvement. Breathing and circulation should be focused.
In hospital resuscitation
Hypotension and bradycardia indicates patient in spinal shock. So it should be differentiated from hypovolemic shock. Fluid and oxygen therapy is important in intial stage.
Examination of the patient
Examination should be done thoroughly and other injuries should be ruled out. Examination of a patient with a possible spine fracture should begin with visual inspection of the back. The presence and location of lacerations, abrasions,ecchymoses, and swelling provide clues about the mechanism of injury.
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Palpation of the spine for localized tenderness,spinous process gaps, step-offs,and malalignment may provide evidenceof spinal instability.
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The neurological examination is important for knowing the severity of injury as well as deciding the treatment option. It should include assessment of spinalcord function as well as assessment of nerve root and peripheralnerve integrity. The spinal cord terminates as conus medullaris atL1 vertebral body in adults sometimes it may extend upto L2 vertebra. So it varies from damage to the terminal spinal cord, conus medullaris, cauda equina, and thoracolumbar nerve roots. Radiculopathy is identified by a dermatomal patternof paresthesias or sensory alterations with or without myotomal weakness and hyporeflexia. A more diffuse distribution of lower-extremity paresthesias, weakness, and reflex loss may signify acute injuryto the cauda equina, conus medullaris, or spinal cord. The bulbocavernosusreflex should be evaluated to assess for spinal shock. In theabsence of this reflex, loss of sensorimotor function may be temporarily due to spinal shock and may not necessarily reflect a complete neurological injury. The presence of rectal tone and perineal pinprick sensation is very important for diagnosing incomplete involvement the cord as well as for prognostic purposes too. [36]
Role of steroids
All patients with a confirmed spinal cord injury should receive a high dose of methylprednisolone intravenously, beginning with a bolus of 30 mg/kg over one
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hour and continued at an infusionat a rate of 5.4 mg/kg/hr according to NASCIS protocol. [28]
Spinal cord injury grading
Frankel system and the American Spinal Injury Association (ASIA) are commonly used for grading spinal cord injury.It plays a major role in determining treatment and ultimate prognosis for manypatients following thoracolumbar spinal trauma.[28]
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RADIOGRAPHIC-EVALUATION:
PLAIN XRAYS
Atleast two views should be taken. Anteroposterior and lateral radiographs of the cervical, thoracic,and lumbar spine should be taken. Because of the high prevalence of contiguous and noncontiguous associated spinal fractures, comprehensive radiographic evaluation,including the entire cervical, thoracic, lumbar, and sacral spine, is recommended for any patient who has sustained a
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high-energyinjury and in whom a spinal injury is suspected. In AP view we have to look interpedicular distance and inter spinous distance. Coronal translational deformity should be looked. In lateral view posterior vertebral line and sagittal malalignment and vertebral body height and Cobbs angle should be seen.
COMPUTED TOMOGRAPHY
Computed tomography will give fine details about bony injuries. CT scanning is the next step afterplain radiographic evaluation. Axial fine cuts and sagittalsections are useful for identifying fracture patterns and the degree of compromise of the spinal canal. The canal diameter of the fractured vertebra should be measured. It will give details about vertebral body comminution.
MAGNETIC RESONANCE IMAGING
MRI is very important for identifying cord involvement and ligamentous complex involvement. It will give fine details about canal compromise and cord changes and epidural hematomas. And it will give details about PLC integrity. It is important for deciding the treatment. Thepresence of gas shadow indicates flexion-
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distractioninjury. When a patient has a neurologicaldeficit, however, magnetic resonance imaging is recommendedto identify any ongoing spinal cord compression, evaluate cordanatomy.[18]
TREATMENT :
The treatment goal in spinal fractures is to mobilise the patient early and to obtain stable vertebral column with maximum spine mobility and good neurological function. The most important factors to consider the treatmentfor patients are general condition , neurologicalstatus, spinal stability, degree of deformity, and associatedinjuries. Recently Vaccaro score is very useful to decide the treatment.
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Thoracolumbar Injury Classifcation and severity Score (TLICS score, Vaccaro score):
• FRACTURE MECHANISM
Compression fracture 1
Burst 2
Translation 3
Distraction 4
• NEUROLOGICAL INVOLEMENT
Intact 0
Nerve root 2
Cord,conus medullaris,incomplete 3
Cord,conus medllaris,complete 2
Cauda equine 3
• POSTERIOR LIGAMENTOUS COMPLEX INTEGRITY
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Intact 0
Injury suspected/indeterminate 2
Injured 3
1.Score less than 3 –it is a stable fracture so it can be treated conservatively 2.Score 5 or more –it is a unstable one. So it should be treated surgically.
3.Score 4- conservative or operative
Non operative treatment:
Until 1970 non-operative treatment was used for spine fractures. Patients were treated by distraction, and reduction and rest on scamnum (low bench).Non operative treatment usually consists of bed rest, postural reduction, direct mobilization , ambulatory bracing and combination of these.
Most of the compression fractures are stable injuries treated nonoperatively in a thoracolumbar orthosis for approximately twelve weeks. Burst fractures are more unstable with some degree of canal compromise. The amount of collapse of the vertebral body and kyphotic angle and the posterior column integrity are key
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factors to decide the treatment whether surgical or non-surgical .Neurological worsening with substantial canal compromise often needs surgical decompression and stabilization. [45]
The treatment of flexion-distraction injuries largely depends on the predominant type of tissue injury.Pure Chance fractures with only bony involvement often will heal reliably if immobilized in a hyperextension orthosis, especially in an immature patient. But ligamentous involvement needs surgical stabilization. Fracture –Dislocation injuries are highly unstable. It needs surgical stabilization.
Nonoperative treatment - advantages:
The principal advantage are the avoidance of operative morbidity, including postoperative infection, iatrogenic neurological injury, failure of instrumentation, and complications related to anesthesia. Secondary issues include deformity correction, minimizing motion loss,and facilitating rapid rehabilitation.
Conservative methods can be used in stable injuries with intact neurology.
The patient should be followed up regularly to identify any instability or worsening of neurology. In cases of neurological deficit and unstable fractures surgical stabilization and decompression is usually done.[39,41,45]
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Surgical management:
Treatment is based on considering several factors . The patient's age, general health, occupation, lifestyle and body habitus are integral to obtain a satisfactory outcome. Most of the young patients needs aggressive surgical treatment due to high energy trauma.
There are three surgical approaches for dorsolumbar spine fractures.
Anterior and posterior as well as combined surgical approaches.
Anterior instrumentation can be done for most compression and burst fractures limited to the anterior and middle columns without involvement of the posterior column. But surgical related complications are high. Morbidity and mortality is high.
A posterior approach with instrumentation fromtwo or three levels cephalad to the injury to two levels caudad to (long segment fixation) it is an acceptable alternative procedure, but it involves fusing a more extensive portion of the spine.
A posterior short-segment fusion with instrumentation and utilization of pedicle screw fixation from one level cephalad to the injury to one level caudal to it is the recent concept for treating spine fractures. In the presence of three column involvement, a combined anteroposteriorfusion often provides the greatest degree
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of iatrogenic spinalstability. Because of the nature of instability ,fracture- dislocations and flexion-distraction injuries are best approached from the back initially, with posterior stabilization, followed by an anterior decompression and reconstruction if needed.[28]
If there is complete neurological injury, surgery is recommended to provide immediate spinal stability, and facilitating more rapid rehabilitation. In this case, posterior approach is the ideal one with the goal of restoring sagittal and coronal alignment and stability.
Neural Decompression:
There are several types of decompression.
1.Direct anterior decompression 2. Posterior decompression
A) Indirect posterior decompression by ligamentotaxis
B) Postero lateral decompression ( transpedicular, costotransversectomy) C) Laminectomy
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Spinal canal decompression needed whenthere is neural compression and neurological deficit with spine fractures. Although the extent of canal compromise at the time of the initial evaluation has been associated in some studies with the severity of theneurological deficit, the timing of surgical decompression hasnot been well correlated with the degree of neurological recovery. [36]
However, most investigators agreethat progressive neurological deterioration is an indication for surgical intervention.Many surgeons also recommend surgical decompression for a patientwith a stable incomplete neurological deficit when there isevidence of ongoing compression of the neural elements. In most of the patients, the site of the neural compressionis located anteriorly, so anterior approach is the ideal one. Laminectomy alone further disrupts theposterior supporting spinal elements, which leads to additionalinstability at the fracture site so failure rate is high.
Sometimes posterolateral or transpedicular approach may be employed to gain access to compressing anterior bonefragments through the posterior approach.
A posterior surgical approach may be used in certain cases to indirectly decompress the spinal canal through distraction instrumentation and ligamentotaxis. The ligamentotaxis effect of a posterior indirect decompression is
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based on the integrity of Sharpey fibers or annular ligament attachments to the displaced fracture fragments. By means of posterior instrumentation, the distraction force will reduce the fragment from the canal into the vertebral body.
sometimes posterior distraction also tends to aggravate any preexisting kyphosis.The efficacy of indirect decompression is greater when surgeryis performed within 72 hours after the traumatic event. This technique may be less effective in the setting of canal compromiseof >70%, which is associated with a higher prevalence ofannular ligament disruption. By transpedicular decompression, anterior vertebral body can be addressed very well.[28,24]
Stabilization :
Most of the unstable thoracolumbar fractures needs surgical stabilization. The goal is to get a stable spine for early mobilization and early rehabilitation. It consists of either
1. long segment spanning fixation
2. short segment with index vertebra fixation
The advantages of early surgical stabilization of unstable fractures will give improved fracture reduction, preservation of neurological function, early mobilization, and fewer complications associated with prolonged bed rest.
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Early fusion techniques with Harrington hook and rod constructs were suboptimal because of length of fusion from five or six motion segments and they are also less reliable in the middle and lower lumbar regions.the long with short fusion techniques were developed to reduce number of motion segments requiring fusion.it involves fusing the two level which are adjacent to fractured vertebra while spanning cephalad and caudad levels with pedicle screws.but the results were poor due to arthritic changes of unfused segments and progressive kyphosis following rod removal and reappearance of pain.hence this technique has fallen out of favour and fixation without fusion is recommended as a routine.[13,15]
The modern pedicle screw-basedsystems allow more reliable rigid fixation .Long segment spanning fixation(by fixing two levels above and two levels below the fracture site) can be done which provides good stability .As previouslymentioned, short-segment fixation with pedicle screw instrumentation(from a level cephalad to the fracture site to a level caudad to it) is a recent concept to preserve the motion.Short segment with index vertebra fixation is inclusion of fracture vertebra which helps in achieving better intra-operative reduction of deformity,does not interfere with fracture healing,maintains the reduction and associated with low failure rates.
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METHODOLOGY
AIM:
• To compare the results of functional outcome in thoracolumbar fractures and dislocations fixed with short segment with index vertebra fixation and long segment spanning fixation.
OBJECTIVE:
• To analyse and compare the results of functional outcome in thoracolumbar fractures and dislocations fixed with long segment spanning fixation and short segment with index vertebra fixation
• To facilitate early mobilisation of patients and thus helping easy nursing care of patients in order to provide a stable and pain free spinal column.
STUDY DESIGN: Prospective
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INCLUSION CRITERIA:
• Patients with age 20 – 60 yrs
• Patients with TLICS(thoracolumbar injury classification and severity score) score>4
• Patients with AO classification type A4 and C2
EXCLUSION CRITERIA:
• Patients with age <20 and >60 yrs
• Patients with co-morbid conditions not permitting for surgery
• Patients with associated injuries like pelvic injury, head injury.
MATERIALS & METHODS
The prospective study was done in patients with Post Traumatic dorsolumbar fractures and dislocations in the Department of Orthopaedics, Madurai Medical College & Govt. Rajaji Hospital, TamilNadu. Twenty five patients were treated surgically between August 2015 to September 2017 and
49
followed for a period of 12 months.Of these four patients were lost followup and hence twenty one cases were included in the study and followed for a period of 1 year.
First assessment of a patient included the history of injury, the mode of injury, a thorough clinical and neurological examination, and status of the stability.
Then, priorities included resuscitation of patient, and treatment of life-threatening injuries before stabilization of the spinal injuries.
The skeletal system was examined to rule out associated injuries. The patient's spine was examined for any swelling, contusion, tenderness, haematoma, gibbus or step off. Full neurological examination (sensation, motor, anal tone)was done and documented. Protection of the spinal column was given immediately.
Daily neurological examination was done. Pattern & level of neurological injury were identified and noted.
Antero posterior and lateral plain X rays, CT scans, and MRI were taken to identify all injuries and to assess the severity and nature of the injury. Neural canal
50
and pedicle were identified in CT scan. Soft tissue injuries and cord changes were identified in MRI. The level and type of fractures were classified according to AO Magrel classification and ThoracoLumabar Injury Classification Score (TLICS) was calculated.The indications for surgical intervention were TLICS score more than four.
The patient and his/her relatives were explained in detail about the nature of injury, severity of injury, the possible outcomes of non-surgical/surgical management and the importance of rehabilitation.
The patients under the effect of general anesthesia were positioned on the prone position and antero-posterior & lateral c-arm views were taken to determine the direction of the pedicles, end plates and disc spaces. All patient underwent either short segment posterior stabilization with index vertebra fixation or long segment spanning fixation using Moss Miami rods and pedicle screws.
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Instruments and Implants
52
SURGICAL TECHNIQUE
All patients were placed in prone position over radiolucent table. A standard posterior midline approach was used for exposure. For short segment with index vertebra fixation,Pedicle screws were inserted into the vertebra one level above and below the fractured vertebra and pedicle screw inserted at the fracture site under fluoroscopic control at the intersection point of transverse process and facet joint.
For long segment spanning fixation, Pedicle screws were inserted into the vertebra two levels above and two levels below the fractured vertebra under fluoroscopic control at the intersection point of transverse process and facet joint.
End on view is obtained under image intensifier to verify that the screw is
within the pedicle.After connecting the rods and screws, distraction force was applied using distractor forceps to restore lordosis and anterior body height.
Decompression was done in all cases with neurological deficit.ound closure was done in layers
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After long segment spanning
posterior instrumentation with transpedicular screws and rod
After skin closure
Posterior approach in prone position
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POST OPERATIVE PROTOCOL
• On the second postoperative day, Patients were encouraged to sit upright with brace support
• 3rd POD – 1st EOT , 6th POD-2nd EOT, 9th POD – 3rd EOT
• 11th POD- suture removal done
• In neurological deficit patients ,Bladder , bowel and back care done.
• Initial 3months – Mobilisation with brace , increasing the activities gradually
• After 3 months – patient can resume his routine activities
For functional assessment , Modified macnab’s criteria and Oswestry disability index used in all patients pre operatively , immediate post op , 3rd month , 6th month and 12 months followup.
crest
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Modified macnab’s criteria
Excellent:no pain,no restriction of mobility,return to normal work and level of activity
Good:occasional non radicular pain ,relief of presenting symptoms,able to return to modified work
Fair:some improved functional capacity,still handicapped and/or unemployed
Poor:continued objective symptoms of root involvement,additional operative intervention needed at index level irrespective of length of postoperative followup
Oswetry disability index
Section 1 – Pain intensity
I have no pain at the moment The pain is very mild at the moment The pain is moderate at the moment The pain is fairly severe at the moment The pain is very severe at the moment
The pain is the worst imaginable at the moment Section 2 – Personal care (washing, dressing etc)
56 I can look after myself normally without causing extra pain I can look after myself normally but it causes extra pain It is painful to look after myself and I am slow and careful I need some help but manage most of my personal care I need help every day in most aspects of self-care I do not get dressed, I wash with difficulty and stay in bed Section 3 – Lifting
I can lift heavy weights without extra pain I can lift heavy weights but it gives extra pain
Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently placed eg. on a table Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned I can lift very light weights
I cannot lift or carry anything at all Section 4 – Walking*
Pain does not prevent me walking any distance Pain prevents me from walking more than 1 mile Pain prevents me from walking more than ½ mile Pain prevents me from walking more than 100 yards I can only walk using a stick or crutches
I am in bed most of the time Section 5 – Sitting
I can sit in any chair as long as I like
57 I can only sit in my favourite chair as long as I like Pain prevents me sitting more than one hour Pain prevents me from sitting more than 30 minutes Pain prevents me from sitting more than 10 minutes Pain prevents me from sitting at all
Section 6 – Standing
I can stand as long as I want without extra pain I can stand as long as I want but it gives me extra pain Pain prevents me from standing for more than 1 hour Pain prevents me from standing for more than 30 minutes Pain prevents me from standing for more than 10 minutes Pain prevents me from standing at all
Section 7 – Sleeping
My sleep is never disturbed by pain My sleep is occasionally disturbed by pain Because of pain I have less than 6 hours sleep Because of pain I have less than 4 hours sleep Because of pain I have less than 2 hours sleep Pain prevents me from sleeping at all
Section 8 – Sex life (if applicable)
My sex life is normal and causes no extra pain My sex life is normal but causes some extra pain My sex life is nearly normal but is very painful
58 My sex life is severely restricted by pain
My sex life is nearly absent because of pain Pain prevents any sex life at all
Section 9 – Social life
My social life is normal and gives me no extra pain My social life is normal but increases the degree of pain
Pain has no significant effect on my social life apart from limiting my more energetic interests eg, sport Pain has restricted my social life and I do not go out as often
Pain has restricted my social life to my home I have no social life because of pain
Section 10 – Travelling
I can travel anywhere without pain
I can travel anywhere but it gives me extra pain Pain is bad but I manage journeys over two hours Pain restricts me to journeys of less than one hour
Pain restricts me to short necessary journeys under 30 minutes Pain prevents me from travelling except to receive treatment
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INTERPRETATION OF RESULTS:
0% to 20%: minimal disability: The patient can cope with most living activities.
Usually no treatment is indicated apart from advice on lifting sitting and exercise.
21%-40%: moderate disability: The patient experiences more pain and difficulty with sitting, lifting and standing. Travel and social life are more difficult and they may be disabled from work. Personal care, sexual activity and sleeping are not grossly affected and the patient can usually be managed by conservative means.
41%-60%: severe disability: Pain remains the main problem in this group but activities of daily living are affected. These patients require a detailed investigation.
61%-80%: crippled: Back pain impinges on all aspects of the patient's life. Positive intervention is required.
81%-100%: These patients are either bed-bound or
exaggerating their symptoms.
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OBSERVATION AND RESULTS:
I.AGE DISTRIBUTION
In our study among 25 patients,highest number is seen in the age between 36-45 years(40%) ,followed by 28% in the age <25 years and 24% between 26-35 years.
7 6
10
2 0
2 4 6 8 10 12
< 25 26 - 35 36 - 50 > 50 AGE DISTRIBUTION
No.of cases
61
Age in years Long Percentage Short Percentage
< 25 2 15.3% 5 41.6%
26 - 35 5 38.4% 1 8.3%
36 - 50 4 30.7% 6 50%
> 50 2 15.3% 0 0%
Total 13 100 12 100
0 1 2 3 4 5 6
< 25 26 - 35 36 - 50 > 50 2
5
4
2 5
1
6
0 AGE VS PROCEDURE
Long Short
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II.SEX DISTRIBUTION
In our study,almost 88% of the cases(22 patients) were males and only 3patients(12%)were females.
Sex No.of cases
Percentage
Male 22 88%
Female 3 12%
Total 25 100
22 3
SEX DISTRIBUTION
Male Female
63
0 2 4 6 8 10 12
Male Female
12
1 10
2
GENDER VS PROCEDURE
Long Short
Sex Long Percentage Short Percentage
Male 12 92.3% 10 83.33%
Female 1 7.6% 2 16.66%
Total 13 100 12 100
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III.MODE OF INJURY
In our study,most common mechanism of injury is fall from height which constitutes almost 92%(22 patients)of the patients followed by RTA in 8% of cases.
Mode of Injury No.of cases Percentage Fall from Height 23 92%
RTA 2 8%
Total 25 100
23 2
MODE OF INJURY
Fall from Height RTA
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IV.DIAGNOSIS
In our study,most commonly seen fracture pattern is burst fractures which is een in 52% (13 patients)of the
cases and followed by fracture dislocation in 12 cases(48%).
10 11 12 13 14 15 16
Dislocation Burst 12
13 DIAGNOSIS
No.of cases
Diagnosis No.of cases Percentage
Dislocation 12 48%
Burst 13 52%
Total 25 100
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V.VERTEBRAL LEVEL
In our study,D12 and L1 level was the most common vertebral level involved comprising almost 64% of cases.
Diagnosis No.of cases Percentage
D10 - D 11 3 12%
D 11 1 4%
D11 - 12 3 12%
D 12 6 24%
D12 - L1 5 20%
L1 5 20%
L2 1 4%
L2 - L3 1 4%
Total 25 100
0 1 2 3 4 5 6
D10 - D 11
D 11 D11 - 12
D 12 D12 - L1
L1 L2 L2 - L3
3
1
3
6
5 5
1 1
DIAGNOSIS
No.of cases
67
VI.AO TYPE
In our study,according to AO classification A4(complete burst)was the most common type which accounted for 52%
of cases.
10 11 12 13 14 15
A4 C2
13
12 AO TYPE
No.of cases
AO Type No.of cases Percentage
A4 13 52%
C2 12 48%
Total 25 100
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VII.TLICS SCORE
In our study, thoracolumbar injury severity score of 7 and 8 constituted 80% of the cases.
0 5 10
T5 &
6
7 8 T9
4
10 10
1
TLICSNo.of cases
TLICS No.of cases Percentage
5 2 8%
6 2 8%
7 10 40%
8 10 40%
T9 1 4%
Total 25 100
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VIII.PROCEDURE
In our study,long segment was done in 13 cases and short segment was done in 12 cases.
10 11 12 13 14 15
Long Short 13
12 PROCEDURE DONE
No.of cases
Procedure Done No.of cases Percentage
Long 13 52%
Short 12 48%
Total 25 100
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IX.MODIFIED MACNAB CRITERIA
In our study,in long segment 72.7% of the patients were good(8 cases) and in short segment 70% of the cases were good(7 cases).In long segment,27.7% of the patients were fair(3 cases) and in short segment 30% of the cases were fair(3 cases).
MODIFIED MACNAB CRITERIA AT
FINAL FOLLOWUP Good
Percentage
Fair
Percentage Lost followup
Long 8 72.7% 3 27.27% 2
Short 7 70% 3 30% 2
Total 15 100 6 100 4
p value 0.730 Not significant
71
8
3
2 7
3
2
0 1 2 3 4 5 6 7 8 9
Good Fair Lost followup MODIFIED MACNAB CRITERIA AT FINAL
FOLLOWUP
Long Short
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X.OSWESTRY DISABILITY INDEX
In our study,the mean of oswestry disability index in long segment is 32.31 and mean in short segment is 31.99.P VALUE is 0.956 which is not significant
OSWESTRY DISABILITY INDEX AT FINAL
FOLLOWUP Mean SD p value
Long 32.31 12.04
Short 31.99 13.78 0.956
Not significant
28 29 30 31 32 33 34 35
Long Short 32.31 31.99
OSWESTRY DISABILITY INDEX AT FINAL FOLLOWUP
Mean
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XI.COMPLICATIONS
In our study, among the 25 patients , one patient had rod breakage but the patient had no pain and no neurological deficit and functional outcome is good. Patient resumed his activities.
One patient had superficial wound infection which was treated with antibiotics and dressing. Among the patients with
neurological deficit, no patient had bed sore. Remaining 23 patients had no complications.
0 1 2
Long Short 2
0 COMPLICATIONS
No.of cases
Complications No.of cases
Long 2(18.1%)
Short 0
p value 2 / 13 vs 0/12
0.497 Not Sig
74 AGE/SEX:50/M
DIAGNOSIS:D12 BURST# PROCEDURE:LONG SEGMENT TLICS:7 FUNCTIONAL OUTCOME:GOOD
D
Case 1(S.NO 7)
PREOP XRAY
CT
IMMEDIATE POSTOP XRAY
MRI
CASES
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FUNCTIONAL OUTCOME AT FOLLOWUP FINAL FOLLOWUP
X-RAYAT 1 YEAR
76 PREOP XRAY
CT
MRI
IMMEDIATE POSTOP AGE/SEX:65/M
DIAGNOSIS:D10-D11 #DISLOCATION PROCEDURE:LONG SEGMENT TLICS:8 FUNCTIONAL OUTCOME:GOOD
Case 2(S.NO 3 )
77
AT FINAL FOLLOWUP
FUNCTIONAL OUTCOME AT FINAL FOLLOWUP
78
Case 3(S.NO 1)
AGE/SEX:28/M
DIAGNOSIS:D12BURST# PROCEDURE:LONG SEGMENT TLICS:8 FUNCTIONAL OUTCOME:FAIR
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PREOP XRAY CT MRI
AT FINAL FOLLOWUP
IMMEDIATE POSTOP
