A PROSPECTIVE STUDY OF FUNCTIONAL OUTCOME OF DORSO-LUMBAR SPINE FRACTURES TREATED BY POSTERIOR
STABILIZATION WITH PEDICLE SCREW FIXATION Dissertation Submitted to
THE TAMILNADU DR.M.G.R MEDICAL UNIVERSITY CHENNAI-600032. TAMILNADU
in partial fulfilment of the requirement for the award of the degree of
M.S DEGREE IN
ORTHOPAEDIC SURGERY - BRANCH II Registration Number: 221812360
DEPARTMENT OF ORTHOPAEDICS
GOVT MOHAN KUMARAMANGALAM MEDICAL COLLEGE AND HOSPITAL, SALEM
MAY 2021
GOVERNMENT MOHAN KUMARAMANGALAM MEDICAL COLLEGE & HOSPITAL
DECLARATION BY THE CANDIDATE
I, Dr. D. UDAYA KUMAR, solemnly declare that this Dissertation tilted
“A PROSPECTIVE STUDY OF FUNCTIONAL OUTCOME OF DORSO-LUMBAR SPINE FRACTURES TREATED BY POSTERIOR STABILIZATION WITH PEDICLE SCREW FIXATION” is a bonafide work done by me at Govt Mohan Kumaramangalam Medical College and Hospital, Salem, from October 2018 onwards under the guidance and supervision of Prof. Dr. C. KAMALANATHAN M.S.,ORTHO, D.ORTHO, DNB, Professor and HOD, Department of Orthopaedics, Govt Mohan Kumaramangalam Medical College and Hospital, Salem.
I have not submitted this dissertation to any other university for the award of any degree or diploma previously. This dissertation is submitted to The Tamilnadu Dr. M.G.R.
Medical University, Chennai towards partial fulfilment of the rules and regulations for the award of M.S Degree in ORTHOPAEDIC SURGERY (BRANCH – II).
PLACE : Salem Dr. D. UDAYA KUMAR
DATE : Registration Number: 221812360
GOVERNMENT MOHAN KUMARAMANGALAM MEDICAL COLLEGE & HOSPITAL
CERTIFICATE BY GUIDE
This is to certify that this dissertation titled “A PROSPECTIVE STUDY OF FUNCTIONAL OUTCOME OF DORSO-LUMBAR SPINE FRACTURES TREATED BY POSTERIOR STABILIZATION WITH PEDICLE SCREW FIXATION” is a bonafide work done by Dr. D. UDAYA KUMAR, Post graduate student of the Department of Orthopaedics, Govt Mohan Kumaramangalam Medical College and Hospital, Salem under my guidance, in partial fulfilment of the requirement for M.S.ORTHOPAEDIC SURGERY degree Examination of The Tamilnadu Dr.M.G.R Medical University to be held in 2021.
Prof. Dr. C. KAMALANATHAN. M.S.ORTHO,D.ORTHO,DNB., Place: Salem Professor and Head of the Department,
Date: Department of Orthopaedics, Govt Mohan Kumaramangalam Medical
College & Hospital, Salem.
GOVERNMENT MOHAN KUMARAMANGALAM MEDICAL COLLEGE & HOSPITAL
ENDORSEMENT BY THE HEAD OF DEPARTMENT
This is to certify that this dissertation titled “A PROSPECTIVE STUDY OF FUNCTIONAL OUTCOME OF DORSO-LUMBAR SPINE FRACTURES TREATED BY POSTERIOR STABILIZATION WITH PEDICLE SCREW FIXATION”, is a bonafide work done by Dr. D. UDAYA KUMAR, Post graduate student of the Department of Orthopaedics, Govt Mohan Kumaramangalam Medical College and Hospital, Salem, under the guidance and supervision of Prof. Dr. C. KAMALANATHAN M.S., ORTHO, D.ORTHO, Professor and HOD, Department of Orthopaedics, Govt Mohan Kumaramangalam Medical College and Hospital, Salem, in partial fulfilment of the requirement for M.S.ORTHOPAEDIC SURGERY degree Examination of The Tamilnadu Dr.M.G.R Medical University to be held in 2021.
Prof. C. Dr. KAMALANATHAN. M.S.ORTHO, D.ORTHO,DNB.,
Place: Salem Professor and Head of the Department,
Date: Department of Orthopaedics,
Govt Mohan Kumaramangalam Medical College & Hospital, Salem.
GOVERNMENT MOHAN KUMARAMANGALAM MEDICAL COLLEGE & HOSPITAL
ENDORSEMENT BY THE DEAN OF THE INSTITUTION
This is to certify that this dissertation entitled “A PROSPECTIVE STUDY OF FUNCTIONAL OUTCOME OF DORSO-LUMBAR SPINE FRACTURES TREATED BY POSTERIOR STABILIZATION WITH PEDICLE SCREW FIXATION” is a bonafide record of work done by Dr. D. UDAYA KUMAR, under the guidance and supervision of Prof. Dr. C. KAMALANATHAN M.S., ORTHO, D.ORTHO., Professor and HOD, Department of Orthopaedics, Govt Mohan Kumaramangalam Medical College and Hospital, Salem, in partial fulfilment of the requirement for M.S.ORTHOPAEDIC SURGERY degree Examination of The Tamilnadu Dr.M.G.R Medical University to be held in 2021.
Prof. Dr. R. BALAJINATHAN. M.D.,
Place: Salem DEAN
Date: Govt Mohan Kumaramangalam
Medical College and Hospital
Salem, Tamil Nadu, India
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I hereby declare that the Government Mohan Kumaramangalam Medical College Hospital, Salem, Tamil Nadu, India; shall have the rights to preserve, use and disseminate this dissertation / thesis in print or electronic format for academic / research purpose.
Place :Salem
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Date :
Dr. D. UDAYA KUMAR
CERTIFICATE – II
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ACKNOWLEDGEMENT
At the outset I thank the Lord, Almighty, for giving me strength to perform all my duties.
It is indeed a great pleasure to recall the people who have helped me a lot in completion of my dissertation. Naming all the people who have helped me in achieving this goal would be impossible, yet I attempt to thank a few, who have helped me in diverse ways.
I take this opportunity to express my thanks and gratitude to our respected Dean Prof. Dr. R. BALAJINATHAN. M.D., Dean, Govt Mohan Kumaramangalam Medical College Hospital, for having given me permission for conducting this study and providing all the facilities to conduct the study.
It gives me immense pleasure to express my deep sense of gratitude and
indebtedness towards my teacher, inspiration and guide
,Prof. Dr. C. KAMALANATHAN, M.S.,ORTHO, D.ORTHO, DNB.,
Head
of the Department, Department of Orthopaedics, Govt Mohan Kumaramangalam
Medical College Hospital for permitting me to use the clinical materials and for
his valuable suggestions, guidance, great care, motivation, constant
encouragement and attention to the details that he has so willingly shown
throughout the study.
I am deeply indebted to all my teachers who have patiently imparted the benefits of their research and clinical experience to me. I owe a great deal of respect and gratitude to Professor and unit heads Prof. Dr.T.M.MANOHAR M.S.,ORTHO, Prof.Dr.R.T.PARTHASARATHY, M.S.,ORTHO., and Prof.Dr.T.KARIKALAN M.S.ORTHO., for their scholarly suggestions and encouragement.
I also express my sincere thanks to my unit Assistant Professors DR. S. KUMAR M.S.ORTHO., DR. P. RADHAKRISHNAN M.S.ORTHO.,
DR. S. JAWAHAR M.S.ORTHO., and DR. R. N. SURESH KUMAR M.S.ORTHO. D.ORTHO, for their invaluable guidance and constant support throughout my study.
I also sincerely thank the Assistant Professors of this department DR. N. KARTHIKEYAN M.S.(ORTHO), DR. L. KUMAR M.S.(ORTHO),
D.ORTHO., DR. P. ARUNANAND MS.(ORTHO), DR.P.CHINNADURAI D.ORTHO., DR. S. SELVAKUMAR MS.(ORTHO), DR.T.SENTHIL
KUMAR D.ORTHO., DR. S. SYED NASER M.S.(ORTHO), D.ORTHO., DR. P. SIVA KUMAR M.S.(ORTHO), DR. K. SATHISH KUMAR
D.ORTHO., DNB(ORTHO), DR. S. MOHAN KUMAR M.S.(ORTHO),
D.ORTHO., and DR. PRASANNA MOORTHY. M.S.(ORTHO), for their
valuable suggestions and help during this study.
I also take this opportunity to thank the Department of Anaesthesiology and Department of radio diagnostics, Operation Theatre Staff nurses, Paramedical and Non-Medical Staff for their continuous support and cooperation. I am also grateful to my fellow post graduates for helping me to complete my study. No amount of words can measure up to the deep sense of gratitude and thankfulness that I feel towards my parents and brother for their valuable help, support and motivation.
My hearty thanks to all my beloved post graduate Seniors, Juniors and CRRI’s for their whole hearted support.
Last but not the least I am profoundly grateful to all the patients and their
relatives for their co-operation and participation in this study.
PLAGIARISM REPORT
TABLE OF CONTENTS
SI.NO TITLE PAGE
NUMBER
1. INTRODUCTION 01
2. AIM OF THE STUDY 03
3. HISTORY AND REVIEW OF LITERATURE 04
4. ANATOMY OF DORSO-LUMBAR SPINE 12
5. BIOMECHANICS OF SPINE 32
6. CLASSIFICATION OF DORSO-LUMBAR SPINE
FRACTURE’S 34
7. MATERIALS AND METHODS 41
8. OBSERVATION AND RESULTS 57
9. DISCUSSION 73
10. CASE ILLUSTRATION 81
11. CONCLUSION 98
12. BIBLIOGRAPHY 99
13.
ANNEXURES 108
I. MASTER CHART 109
II. CONSENT FORM 111
III. CASE PROFORMA 112
LIST OF FIGURES FIGURE
NO
TITLE PAGE
NUMBER
1. Harrington rod 11
2. Steffee plate 11
3. Lugue Rod and wire 11
4. Pedicle screw system 11
5. Vertebral Column 12
6. Intervertebral disc 14
7. Anatomy of thoracic vertebra 15
8. Anatomy of lumbar vertebra 16
9. Pedicle Dimensions 18
10. Entry point for pedicle screw 19
11. The Ligamentous structures of spine; sagittal view 21 12. The Ligamentous structures of spine; posterior view 23
13. Arterial supply of Spinal Cord. 24
14. Arterial supply of Spinal Cord. 25
15. Venous supply of Spinal Cord. 28
16. The Spinal Cord 29
17. Cross section of the Spinal Cord 31
FIGURE NO
TITLE PAGE
NUMBER
18. Denis three column classification 34
19. Denis Compression type fracture 35
20. Denis Burst type fracture 36
21. Denis Flexion-Distraction type 36
22. Denis fracture-dislocation type 37
23. AO Classification 38
24. Load sharing Classification 38
25. McAfee Classification 39
26. ASIA Impairment Scale 43
27. Frankel Grading 44
28. Regional Kyphotic Angle 46
29. Beck’s Index 46
30. CT imaging in Spine fractures 47
31. MRI imaging in Spine fractures 48
32. Intraoperative images of surgical procedures-1 52 33. Intraoperative images of surgical procedures-2 53 34. Intraoperative images of surgical procedures-3 54
LIST OF TABLES
TABLE NO TITLE PAGE
NUMBER 1. Loss of load carrying capacity and the structures
disrupted
33
2. Denis Classification of Dorso-lumbar spine fractures 35 3. Thoracolumbar Injury Classification and Severity Score
(TLICS)
40
4. Denis Pain Scale 56
5. Denis Work Scale 56
6. Age-wise distribution of cases 57
7. Gender-wise distribution of cases. 58
8. Mode of Injury 59
9. Level of Injury 60
10. Type of Fracture 61
11. Intactness of Posterior Longitudinal Ligament (PLL) 62
12. Administration of Steroids 63
13. Pre-operative and Post-operative neurological status of patients
64
14. Post- operative progression of neurological status of all patients
65
15. Comparison of Beck’s index pre- and post-operatively 66
TABLE NO TITLE PAGE NUMBER 16. Comparison of Regional Kyphotic angle pre- and post-
operatively
67
17. Functional outcome based on Denis Pain scale 68 18. Functional outcome based on Denis work scale 69
19. Post-operative Complications 70
20. Associated injuries and its management 72
21. Comparing th e age-wise distribution in various studies 75 22. Comparing the level of injury with other studies 76
23. Comparison of type of fracture 76
24. Comparing Frankel scoring with various studies 77 25. Comparison of Regional Kyphotic angle and mean
correction with other studies
78
26. Comparison of Beck’s index with other studies 79
LIST OF CHARTS
CHART NO
TITLE PAGE
NUMBER
1. Age-wise Distribution of Cases 58
2. Gender-wise Distribution of Cases 58
3. Mode of Injury 59
4. Level of Injury 60
5. Type of fracture 61
6. Intactness of Posterior Longitudinal Ligament (PLL) 62
7. Administration of Steroids 63
8. Pre-operative and Post-operative neurological status of patients
64
9. Comparison of Beck’s index pre- and post-operatively 66 10. Comparison of Regional Kyphotic angle pre- and post-
operatively
67
11. Functional outcome based on Denis Pain scale 68 12. Functional outcome based on Denis work scale 69
13. Post-operative complications 71
14. Comparison of Regional kyphotic angle with other studies
78
15. Comparison of Beck’s index with other studies. 79
ABSTRACT
Introduction and Aim:
Spine fractures have become very common and the numbers are increasing due to increase in use of automobiles and work-place trauma. If left untreated, spine fractures may lead to significant morbidity and mortality. Thoraco-lumbar junction being a junction between the less mobile thoracic and highly mobile lumbar spine, this region is more vulnerable to injury. The main goals of treatment are to stabilize the spine and rehabilitate the patient as much as possible to the pre-injury level. In this study we aim to evaluate the functional and radiological outcome of dorso-lumbar spine fractures treated by posterior stabilization with pedicle screw fixation.
Materials and Methods:
This is a prospective interventional study done at the Department of Orthopaedics at Govt. Mohan Kumaramangalam Medical College and Hospital at Salem, between October 2018 and October 2020. Twenty-five patients with dorso- lumbar spine fractures who were willing to take part in the study were included in this study. All the patients were treated by posterior stabilization with poly-axial pedicle screw fixation. All the patients were followed up for a minimum of 12 months. All 25 patients were available for follow-up till 12 months.
Observation and Results:
The mean age of the study group was 38.4 years, males being most common (68%). The most common mode of injury was fall from height (68%) followed by road traffic accident (32%). The most frequently fractured vertebra was D11 followed by L1 in our study. The most common type of fracture was type A (80%). At the end of one -
year follow-up patients with Frankel A grading did not show any improvement. Out of 2 patients in Frankel C grade, 1 patient improved to Frankel D while the other remained the same. Out of 5 patients in Frankel D, 4 patients improved to Frankel E and 1 patient remained in Frankel D. All the patients in Frankel grade E maintained in Frankel E.
There was no post-operative deterioration of neurological status in any of the patients.
The preoperative Beck’s index was 0.607 which improved to 0.72 at 1-year follow-up.
The preoperative regional kyphotic angle was 16.56° which improved to 10.44° at 1- year follow-up with a mean correction of 6.12°. According to Denis Pain scale 44% of patients had no pain and 36% had occasional pain without need for pain medication at the end of 1 year. According to Denis Work scale 20% of the patients were able to return to their previous work/ heavy work, 24% were able to return to previous sedentary work or heavy work with restrictions and 28% were unable to return to previous work but were able to return to new sedentary work.72% of patients had no complications. 12%
had pressure sore, 8% had superficial infection and 8% has urinary tract infection.
Conclusion:
From our study we conclude that posterior stabilization with pedicle screw and rod system is an excellent option for dorso-lumbar spine fractures. It resulted in good improvement in post-operative regional kyphotic angle and Beck’s index. Also, the post-operative neurological status has improved in a significant number of patients and also the over-all functional outcome of patients according to the Denis pain and Denis work scale has shown improvement.
Keywords: Thoraco-lumbar spine fractures, Pedicle screw fixation, posterior stabilization, Kyphotic angle, Beck’s index.
1
INTRODUCTION
Spine fractures are common occurrences in polytrauma patients. At least 65 to 80% of spine fractures are seen in thoraco-lumbar region [1]. Common causes of spine fracture include fall from height, motor vehicle accident/collision, direct assault etc. They can range from mild anterior wedge compression to burst fracture, translation or distraction injuries depending on mode of injury and force, bone quality of the patient etc.
Fractures involving thoraco-lumbar region have a bimodal distribution involving active young individuals (usually males, less than 40 years) due to high energy trauma or older age group years (usually females, above 50 years) due to trivial trauma in osteoporotic bone.[2] However, most of the osteoporotic fractures in elderly are not diagnosed as they cause compression type of fractures and usually without a neurological deficit. And even after being diagnosed most of such fractures are treated conservatively.
Roughly 20% of spine fractures will present with neurological deficit.[2]
Mortality in paraplegic patients at the end of 1 year is around 4% due to various morbidity related causes. [3] Elderly patients suffer more neurological injury than younger patients and also have a poorer outcome making age a predictive prognostic factor.
Most of the fractures in thoraco-lumbar region involves vertebra D11, D12, L1 and L2 vertebra. This is because the thoracic spine is kyphotic, rigid and stabilized with ribs while the lumbar spine is lordotic and mobile. This transition
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zone is weak, thus experiencing more biomechanical stress and results in fracture when subjected to trauma. [2]
Patients with mild degree of compression fractures without much deformity or displacement and no neurological deficit can be treated conservatively. Whereas, patients with neurological deficit and unstable fracture morphology may need surgical treatment. Posterior decompression and stabilization with pedicle screw fixation are done in such cases. This increases the chances of improving the neurological status of the patient. Surgical stabilization of the spine also helps to mobilize the patient early with better nursing care and thereby reducing the morbidity and mortality associated with prolonged bed ridden patients.
3
AIM
The aim of the study is to evaluate the functional outcome of Dorso-lumbar spine fractures treated by posterior stabilization with pedicle screw fixation.
4
HISTORY AND REVIEW OF LITERATURE
Injury to the spinal cord has been known to man since ancient times. Since spinal cord is encased within the vertebral column, injury to spinal cord does not occur alone but with fracture of the vertebral column. Damage to spinal cord resulting in neurological deficit results in death of patient due to causes associated with morbidity do to prolonged bed rest (like pressure sores, UTI, chest infections, poor nursing care etc). Patients who do not suffer a neurological deficit may develop it late if vertebral column is not adequately stabilized.
Treatment of spinal fractures dates back to Egyptian civilization around 3000 BC, where Edwin Smith in his surgical papyrus has described paraplegia due to injury of the spinal cord. Reduction of spine fracture by traction was first described by Hippocrates (circa 460 – 370 BC). [4]
Paul of Aegina (625 – 690 AD) used windlass to reduce the spine fractures and recommended laminectomy. Malgaigne and Bohler treated spine fracture cases by indirect manipulative anatomical reduction by longitudinal traction and lordosis followed by immobilization in plaster casts and then strengthening exercises.
After the fall of the Roman Empire, practice of medicine declined in the western Europe. whereas the Greek and Roman practices were still going on In Eastern Empire and In the Arabian region by Christian, Jews and Moslem physicians. Avicenna (980 = 1037) followed the principle that spinal fractures associated with paralysis were fatal.[4]
5
In the pre-renaissance period, In the university of Salerno, Roland of Parma (circa 1230) used manual extension to treat spine fractures and established the fact that spine fractures need early treatment, one of the key stones of today's practice.
Laminectomy for spinal injury was established by Ambroise Pare (1564–1598).
In the 18th century, Astley Cooper and Charles Bell further studied the spine Injuries at the London teaching Hospital in the United Kingdom. Astley Cooper (1768–1841) described the clinical manifestations of spinal Injuries and according to his records, his teacher Henry Cline (1750 - 1827) performed the first laminectomy for spine Injuries. Whereas, Charles Bell (1774–1842), was against laminectomy and indulged in a celebrated controversy with Cooper on the subject.
Bell on the other hand advocated that the damage to the spinal cord occurred at the moment of Injury and was not due to the continued pressure, stating that operation on spinal column was useless and dangerous and accurate diagnosis in the first instance Is essential. He also stated that the death in paraplegic patients was due to UTI. This view was well received In Britain.
In 19th century, Thomas Curling (1811–1888) described the effects paralysis of the bladder and retention of urine resulting in suppuration of the kidneys, and emphasized that the survival time was proportional to the severity of the infection.
The consequences of renal suppuration in paraplegia was also advocated by Sir William Gull (1816–1890), William Thorburn (1861–1923), and Charles Fagge (1838–1883). [4]
Wilhelm Wagner (1848 - 1900) a general surgeon at a small workers compensation hospital In Königshütte hospital In Upper Silesia, where he spent his
6
entire career accounted the first successful management of spinal Injuries. He demonstrated how a spine Injury patient should be treated practically. Along with his former pupil, Paul Stopler (1865 to 1906) he published a book on Injuries of spine and spinal cord dealing with every aspect of the subject Including, anatomy, pathology of Injury, mechanism of Injury, symptomatology, practical treatment protocol and Indications for surgery. He Included 6 major problems: pressure sores and sepsis, treatment of cervical spine fractures, post traumatic syringomyelia, chest Infections, renal stones leading to real tract sepsis, and the need to mobilize the patient in bed until fracture union. After the healing of fracture, patients were mobilized. Wagner opposed the operative treatment of spine. Initial radiographs were taken to Identify the position of fracture, then he recommended palpation of kyphus to reduce the dislocation. He has also described on how to reduce the fracture of cervical spine, how bladder should be managed, frequent position changing of patients to prevent sores. He was able to successfully treat patients with spinal Injuries and was able to mobilize them. All of his works were carried out alone in municipal hospital without an academic position.
Nearly around the same time, Theodor Kocher (1841–1917), professor of surgery at Bern, also was Involved In treating spinal Injuries. He carried out extensive research but his work was mainly on an anatomical and physiological basis. It is impossible to determine from his writings how many patients with spinal injuries he treated and whether they were successfully discharged home.
The textbooks by Kocher (1896) and Wagner and Stolper (1898) became the standard reference work and were referred to by subsequent writers.
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Until the first world war, the number of spine injury cases were less and thus it was difficult to collect data of series of cases and study them. During the world war I, several cases were reported and dedicated multimodality treatment units were developed for spine injury cases. Especially the United Kingdom, France and Germany saw an overwhelming number of cases, which helped in better understanding of management of spine injury cases. When world war I ended, there was a sharp decline in the number of cases and resulting in closure of all the military hospitals along with them, the spine units, with all the physicians returning to their regular work. Germany, was then a superpower in economic and medical world, was a place of evolution of spine injury management. With rise of Nazi to power, less emphasis was made on modern medicine and medical training. This led to shift of development of treatment of spinal injuries to united states of America.
Charles Frazier (1870–1936), who has been taking care of spine injury patients in the first world war has written a book on spinal injuries. It was a major textbook on managing spine injury cases not only quoting the cases that was treated by him but also other physicians including 717 cases of spine injury from world literature. His work also included translating several research papers on spine injury from German and French, and a detailed statistical analysis of result of surgery, prognosis, life expectancy, discharge and rehabilitation of patients.
Donald Munro (1889–1973), who was an assistant of Frazier, was known to be the father of treatment of paraplegia. He later became professor of neurosurgery In Harvard neurological unit at Boston city hospital.
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In 1939 George Riddoch (1888–1947) was appointed consultant neurologist to the army with the rank of brigadier, with second world war setting In.
Anticipating several casualties with spine Injuries from the experience of working in first world war, multiple spine Injury treating units were set up In the European countries and the United States of America.
Later, after the introduction of safe surgical anaesthesiology, antiseptic technique and development of special neurosurgical intensive care units, more importance was given to surgical approach for treating spine injury patients.
One of the earliest surgical intervention to spine injury was by Hadra, who treated cervical spine fracture due to Pott’s disease by using a silver wire loop around the spinous process in figure of eight formation. This laid the foundation for internal fixation of spine fractures, improving recovery of patients several folds.
This was further advanced by Hibbs in 1922 who performed the posterolateral arthrodesis, in which the spinous process was decorticated and used as autograft to contact the caudal process and simultaneously decorticating the articular surfaces resulting in interlaminar fusion. Autopsies performed on such patients after their death showed a solid fusion of vertebra indicating the success of the procedure, making it the predominant procedure for the next 50 years.
Wiring techniques were followed for several years, until 1943 when Tourney Introduced the facet screw to fasten the recovery and avoiding long term bracing, casting and Immobilization. This technique was further modified and expanded by King, who presented his work in 1948.
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In the late 1950s, there was a need to treat an Increasing number of neuromuscular scoliosis that was caused by paralytic poliomyelitis, when Harrington Introduced his spinal Instrumentation set using steel rods attached to hooks to correct deformity by compression and distraction. Later It was Improvised and used to treat other types of scoliosis and stabilization of spinal trauma also.
Placing pedicle screws were thought to be too dangerous, which was first accomplished by Boucher along with Harrington and Tullos in 1959.
In 1982, Steffee began using his segmental spine plate fixation system with variable screw placement system.
In 1986, Luque used his wire and rod fixation system which was a posterior fixation system that better maintained sagittal contouring. The following year Cotrel and Dubousset began using a pedicle screw system with bent rods that follow the natural curvature of spine.
However, in 1990s, the FDA (food and drugs administration) asked manufacturers to stop promotion of bone screws as pedicle screws because of limited data on the efficacy of Pedicle screws. This resulted in lawsuits filed against manufacturers, surgeons and governing societies (like the American association of neurological surgeons, the North American spine society and the American academy of orthopaedic surgeons) for the use of pedicle screws. As a result, spine Implant manufacturers and surgeons were criminalized. A cohort study was then conducted to study the efficacy of pedicle screw fixation in thoracic, lumbar and sacral spine fusion by orthopaedicians and neurosurgeons which showed high rates of fusion. After prolonged debate and discussion FDA recommended pedicle screws
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be changed from class III to class II. In 1998, 4 years later, it was again reclassified, after which there was a rapid development and upgradation of pedicle screws leading to Its wide usage in current clinical practice.
In 2000, Razak et al studied 26 patients operated between 1994-1998 with short segment posterior instrumentation. the mean kyphotic angle improved from 20° to 7° immediate post-operatively and then to 9° at last follow-up. 64% of patients with neurological deficit showed improvement by at least 1 Frankel grade.
They concluded that short-segment fixation with decompression and fusion was effective in treating unstable thoracolumbar fractures.[21]
In 2011, AWY Young et al, studied 19 patients who underwent posterior stabilization with pedicle screw fixation. The results of this study showed a favourable outcome in radiological correction and achieving a stable construct.
Adawi MM et al, 2019 conducted a prospective study involving 36 patients with single level thoracolumbar fractures. The study concluded that posterior short segment pedicle screw fixation with screw in fractured vertebra is a viable option for treating single level fractures establishing satisfactory functional and radiological outcome with minimal loss of postoperative Cobb angle and vertebral body height at the end of the follow-up.
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Fig 1: Harrington rod Fig 2: Steffee plate Fig 3: Lugue Rod and wire
Fig 4: Pedicle Screw system
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ANATOMY OF THE SPINE The vertebral column:
The human vertebral column is made up of 33 vertebrae which includes 7 cervical vertebrae, 12 thoracic vertebrae, 5 lumbar vertebrae, 5 sacral vertebrae, and 4 coccygeal vertebrae. The sacral and coccygeal vertebrae are fused, while the remaining 24 are mobile.
The vertebral column is not straight but has acquired curvatures. Curvature with convexity anteriorly is called lordosis and convex posteriorly is called kyphosis.
The cervical and lumbar segments are lordotic while the thoracic and sacral segments are kyphotic when an erect posture is acquired. The thoracic segment allows attachment of rib cage while the sacral segments allows the attachment of pelvic girdle.
Fig 5: Vertebral Column
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The vertebra:
The 24 mobile vertebrae increase in size from cranial to caudal. Each typical vertebra is made up of an anterior vertebral body and a posterior arch enclosing the spinal cord. The posterior arch is made up of two pedicles laterally and two lamina that unite at the midline. From the midline posteriorly arises the spinous process and, on either side, or arch arises a transverse process. The arch also contains two superior and two inferior articular facets. These facets articulate with the vertebra above and below. Orientation of these articular facets account for flexion, extension or rotation of spinal segments. The spinous and transverse processes serve as levers for the attachment of paraspinal muscles.
The vertebral column encloses a canal known as the vertebral canal that protects the spinal cord, conus medullaris, and the cauda equina.
The facet joints:
Each vertebra is connected to the vertebra above and below by facets making the facet joints. These facet joints are synovial type of joints, thus having an articular cartilage, a synovial membrane and a joint capsule. The synovial joints are innervated by the posterior primary rami. On the other hand, the vertebral bodies are joined by structures known as intervertebral discs. Intervertebral discs are present between all the vertebral bodies, except the first and the second cervical vertebrae.
The intervertebral disc:
The intervertebral discs are strong and deformable, making them to serve as shock absorber and also help in movements and weight bearing of spine. Each intervertebral disc has a vertebral endplate above and below. The centre portion
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contains the nucleus pulposus which is surrounded by a fibrous ring called the annulus fibrosus, forming a secondary cartilaginous joint or symphysis at each level.
The vertebral end plate is a 1-mm thick sheet of cartilage (fibrocartilage and hyalin cartilage), with proportion of fibrocartilage keeps increasing with age. The central nucleus pulposus is mucoid in nature containing majority of water (70 to 90%), and remaining dry weight is composed of proteoglycans (65%) and collagens (15 to 20%). [5] The nucleus pulposus is surrounded by annulus fibrosus, which is mainly made up of collagen that is arranged in 12 concentric lamellae in alternating orientation in each layer to withstand multidirectional strain. The annulus contains majority of water (60 to 70%) and the remaining dry weight is made up of collagen
Fig 6: Intervertebral disc
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(50 to 60%) and proteoglycans (20%). As ageing occurs the water and proteoglycans decrease. The intervertebral discs are avascular in nature, and depend on diffusion from the endplate blood vessels for nutrition.
Fig 7: Anatomy of thoracic vertebra
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The Pedicles:
Since pedicle screw has evolved into an important tool for posterior instrumentation in both traumatic and degenerative conditions, it is very much essential to understand the anatomy of the pedicles. This not only helps to
Fig 8: Anatomy of lumbar vertebra
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understand the biomechanics and attaining a stable fixation, but also helps in avoiding possible complications during surgery.
In our study, we deal only with dorso-lumbar fractures and their fixation, we mainly focus on the anatomy of pedicles of dorsal and lumbar vertebra.
The pedicles of the thoracic and lumbar vertebrae are tubelike bony structures that connect the anterior and posterior columns of the spine. The transverse and the vertical diameters of pedicles and their angle of inclination vary progressively from the upper thoracic vertebra distally. It is very much essential to understand this in order to get a good pedicle screw purchase without damaging the surrounding structures.
Studies have showed that the transverse diameter of the pedicles are widest at the level of L5 and the narrowest at the level of T5. Likewise, considering the vertical diameter, the widest is at the level of T11 and the narrowest is at the level of T1. The vertical diameters are generally larger than the horizontal diameters giving the pedicles a vertical oval shape. The angle inclined by the pedicles in the horizontal plane was maximum at L5 level. Whereas in sagittal plane the pedicles angle caudad at L5 and cephalad at L3 to T1. [5]
The depth of the anterior cortex of the vertebral body was longer along the axis of the pedicle than along a line parallel to the midline at all levels except T12 and L1.
The thoracic pedicles are made up of mainly cancellus bone and the cortical lining of the pedicles have a varying density, lateral wall being significantly thinner than the medial wall.
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Intraoperative anatomy of pedicles:
The reference point for insertion of pedicle screw is the space between the superior and inferior facets (pars interarticularis) and the middle of the transverse process. The thoracic and the lumbar pedicles connect the anterior body and posterior arch segments, altogether forming a ring structure enclosing the spinal cord. The dural-sac within which the spinal cord is present lies just medial to the medial wall of pedicle. The neural foramen which contains the nerve root lied just inferior to the medial wall of the pedicle. The lumbar nerve roots are present in the upper 2/3rd of the neural foramen. Therefore, this makes penetration of the pedicle medially and inferiorly more dangerous than laterally and superiorly.
c- Vertical diameter of pedicle d- Transverse diameter of pedicle
e- Angle of inclination of pedicle in transverse plane
Fig 9: Pedicle Dimensions
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Keeping in mind the crucial structures that are located in proximity to the pedicles and possible variations in the anatomy, it is very much recommended to do a thorough pre-operative imaging – X-ray AP and Lateral view, a 3D reconstruction CT of spine along with axial and sagittal section and an MRI to study the status of cord and nerve roots. Intra-operative fluoroscopy can also be used as a reliable guide for pedicle screw insertion in normal spinal anatomy. But there can be confusion and misleading in patients with pre-existing spinal disorders like scoliosis. Hence, a thorough knowledge of spinal anatomy is essential.
Intro-operative identification and localization of pedicles can be done by 3 techniques.
Fig 10: Entry point for pedicle screw
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1. The intersection technique: It is the most commonly employed method. A vertical line is drawn along the lateral border of the facet and a horizontal line is drawn bisecting the transverse process. The point of intersection of these two lines lies over the pedicle.
2. Pars interarticularis method: It is the point between the superior and the inferior facets of the vertebra and also it marks the point where the pedicle joins the lamina. This point is easily identified intraoperatively.
3. The mamillary process method: mamillary process is a small prominence at the base of the transverse process. This can also be taken as the entry point for pedicle screw insertion.
Of the three points mentioned above, the pars interarticularis point is the most medial, lateral to which is the intersection point and the most lateral point is the mamillary process.[5] The points mentioned are only to be considered for making the entry for pedicle screws. The angle in which the screws must be proceeded vary with the level of the vertebra being fixed and is determined with preoperative images and better confirmed under fluoroscopic guidance.
The Ligaments of the spine:
The ligaments of the spine play a crucial role in supporting the stability of the vertebral column and in reinforcing the vertebral joints. They are uniaxial in nature and resist the tensile forces and also buckle when they are subjected to compression. The ligaments can be broadly placed in two groups, the continuous and the segmental ligaments.
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The continuous ligaments run along the length of the vertebral column:
1. The Anterior Longitudinal ligament 2. The Posterior Longitudinal ligament 3. The Supraspinous ligament
The segmental ligaments connect two vertebrae at each segment:
1. The Interspinous ligaments 2. The Ligamentum Flavum 3. The Intertransverse ligaments
Fig 11: The Ligamentous structures of spine; sagittal view
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1. The Anterior Longitudinal Ligament:
The Anterior Longitudinal Ligament extends from the base of skull to the upper part of the sacrum running anterior to the vertebral body. The ligament is attached to the anterior aspect of the vertebral body and the Intervertebral disc. It Is broader at the vertebral body and narrower at the Intervertebral disc.
2. The Posterior Longitudinal ligament:
Similar to anterior longitudinal ligament the posterior longitudinal ligament runs from the base of skull up-to the coccyx along the posterior aspect of the vertebral body. they are also attached to the vertebral body and the Intervertebral disc. The posterior longitudinal ligaments are less developed in lumbar region.
Unlike their anterior counterpart, the posterior longitudinal ligament Is broader at the Intervertebral disc and narrower at the vertebral body.
3. The Supraspinous ligament:
Extends from the ligamentum nuchae and run along the tip of the spinous processes up-to the sacrum. They are broader and more significant in the lumbar region.
4. The Ligamentum Flavum:
Also known as the yellow ligament (flavum = yellow, due to high content of elastin) connect the lamina of the 2 adjacent vertebrae. They attach to the antero- inferior aspect of the upper lamina to the postero-superior aspect of the lower lamina.
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5. Interspinous ligaments:
These ligaments are attached to the adjacent spinous processes from root till the apes. They are thin and long in the thoracic region, thick and broad at lumbar region.
6. Intertransverse ligaments:
These ligaments attach to the adjacent transverse processes.
Fig 12: The Ligamentous structures of spine; posterior view
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The blood supply of the spinal cord:
The spinal cord is supplied mainly by 3 arteries; One anterior median longitudinal arterial trunk and a pair of posterolateral trunks near the posterior nerve rootlets.
The longitudinal arterial canals are reinforced by several radicular arteries (also known as the medullary feeders).
Fig 13: Arterial supply of Spinal Cord.
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There are approximately 2 to 17 radicular arteries anteriorly and 6 to 25 radicular arteries posteriorly. Major supplier of these radicular arteries in the cervical region are the vertebral arteries and in the thoracic and lumbar region is the aorta. Artery of Adamkiewicz is the largest of the medullary feeder of lumbar segment of spinal cord, usually present on the left side between levels T9 to T11 in 80% of the individuals. In the sacral region the radicular arteries are supplied by the lateral sacral, the fifth lumbar, the iliolumbar, and the middle sacral arteries.
This supplementary source of blood supply from the vertebral and posterior inferior cerebellar arteries in cervical region and the sacral radicular arteries from the lateral sacral arteries that travel along the distal root of cauda equina has a reversible blood flow that possibly can adjust the blood volume based on the metabolic demands.
Fig 14: Arterial supply of Spinal Cord.
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At the level of each vertebra, a pair of segmental arteries arise that supply the extra and intraspinal structures. The aorta gives rise to the thoracic and the lumbar segmental arteries. The vertebral arteries and the costo-cervical and thyrocervical trunks give rise to the segmental arteries of the cervical region. In some 60% of the population an additional branch arises from the ascending pharyngeal branch of the external carotid artery. The lateral sacral arteries, the 5th lumbar, the iliolumbar and the middle sacral arteries give rise to the sacral segmental arteries. The segmental arteries in turn divide into several branches before supplying the spinal cord, at the level of the intervertebral foramen, known as the point of distribution, forming a second anastomotic network in the loose connective tissue within the spinal canal.
This anastomotic network is seen throughout the spinal cord, more in the cervical and lumbar levels. This rich anastomotic network helps in maintaining the circulation even after ligation of segmental arteries.
From the longitudinal vessels and the segmental vessels, the blood flows via 3 arterial rings that form the anastomoses. The internal arterial circle around the cord surrounded by another arterial circle in the extradural space and the outer most circle in the extra-vertebral soft tissue. This rich anastomosis helps in maintaining the circulation of spinal cord intact even when there is a damage to anterior longitudinal vessel. Since the spinal canal is narrowest between T4 to T9, this is a critical vascular zone where paraplegia is likely when circulation is disturbed.
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The venous system is more complex and variable than the arterial system.
There are 2 sets of venous system, the veins of the spinal cord and the veins of the Batson’s network, which is a large and complex venous channel that extends from the base of the skull to the coccyx. It drains directly into the superior and the inferior vena cava and the azygos system. The veins of the spinal cord drains into the Batson’s plexus. Similar to the longitudinal arteries, there are anterior and posterior longitudinal veins.
Batson’s plexus is composed of the
1. The extradural vertebral venous plexus;
2. The extra-vertebral venous plexus (including the segmental veins of neck, intercostal veins, azygos communication, lumbar veins and communication system with the IVC.);
3. The veins of the bony structure of the vertebral column.
Batson’s plexus plays an important role in disseminating neoplastic and infectious disease from the pelvis to the vertebral column.
While operating on the spine the following points are to be kept in mind regarding preservation of the blood supply to the spinal cord. 1. Ligating spinal arteries only if necessary, for exposure. 2. Ligate the segmental arteries closed to the aorta than the foramen. 3. Ligate only on one side leaving the opposite side segmental vessel intact to maintain the circulation. 4. Limit the dissection to single level when possible so as to not disturb and maintain the collateral circulation from adjacent levels.
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Fig 15: Venous supply of Spinal Cord.
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The Spinal Cord:
The spinal cord extends up-to L2 vertebra in adults and L3 vertebra in neonates where it terminates as the conus medullaris. From the conus medullaris it extends as thin fibrous cord up-to first coccygeal segment known as the filum terminale. [5]
Fig 16: The Spinal Cord
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The spinal cord like the brain is enclosed in three layers (the dura mater, the arachnoid and the pia mater from outer to inside). The cerebrospinal fluid occupies the sub-arachnoid space between the arachnoid and the pia-mater, in continuation with the brain and helps in serving as a buffer in absorbing shocks and injuries.
The spinal cord has 2 enlargements, the cervical and the lumbar enlargement corresponding to the brachial and the lumbar plexus.
The spinal nerves exit from the spinal cord at each level. In the cervical segment the spinal nerves C2 to C7 exit above the pedicles for which they are named (for example, the C5 nerve root exits the foramen between C4 and C5 vertebra). The C8 nerve root exits the foramen between the C7 and T1pedicles. All other nerve roots from T1 onwards exit below the pedicle for which they are named (for example, L1 nerve root exits through the foramen between L1 and L2.
As we already saw the spinal cord ends at L2 level in adult, the cord is shorter than the spinal column. Thus, the nerves should travel vertically downwards before they exit the spinal canal.
The spinal nerves leave the cord through roots, the dorsal sensory root and the ventral motor root that combine to form the mixed nerve before leaving the canal. The dorsal nerve root has a ganglion located near the foramen known as dorsal nerve root ganglion, which is the synaptic junction for the ascending cell bodies.
This ganglion is sensitive to pressure and heat and caused dysesthetic pain when handled.
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Fig 17: Cross section of the Spinal Cord
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BIO-MECHANICS OF SPINE
Understanding the biomechanics of spine is very much essential to further study the factors that cause instability in a trauma, and to ascertain the stable method of fixation.
Movements at spine can be either translational movements or angular movements. The translational movements, especially the antero-posterior and the mediolateral are very restricted. Thus, the actual movements under physiological conditions in a spine are the angular movements. The flexion-extension movements about the x-axis in sagittal plane, the lateral flexion about the z-axis in frontal plate and the rotation about the y-axis.
The thoracic spine is much stiffer than the lumbar spine due to the articulation of ribcage and the intervertebral discs that are thinner than the lumbar spine.
Rotational movement about the vertical axis is the greatest movements at the thoracic spine (75°), whereas the flexion-extension and lateral flexion are highly restricted. On the other hand, at the lumbar spine, the flexion-extension and the lateral flexion are greatest and rotation movements (10°) are restricted due to the orientation of the facets and the anterior portion of the annulus. [6]
Several studies have been conducted to study the factors that strengthen the spinal column and factors that leads to instability.
Kelly and Whitesides found out that compressive loads on spine were mainly supported by the vertebral bodies and discs, and on the other hand the tensile forces were tackled by the ligamentous structures that stabilize the spine. [7]
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Jacobs et al studied that the amount of compressive force transmitted at the thoracic-lumbar junction was around 400N. The centre of gravity is anterior to the spinal column, resulting in flexion. When a person bends forward to 90° at the hip, in addition to the 400N, the shear force increased to 120NM. [8]
When fixing a spine fracture, the system must be rigid enough to withstand this load under physiological conditions.
Haher et al while studying the load carrying capacity of spine at thoraco- lumbar junction analysed the loss of load carrying capacity when certain elements of the spine are disrupted. The conclusion of his study is tabulated below. [9]
Table 1: Loss of load carrying capacity and the structures disrupted.
Structure disrupted Loss of Load carrying capacity
Anterior Column 30%
Anterior and Middle Column 70%
Posterior Column 65%
Annulus 80% (loss of rotatory stability)
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CLASSIFICATION OF DORSO-LUMBAR FRACTURES:
Several classification systems have evolved over years for classifying the Dorso-lumbar fractures. Briefly, Nicoll classified spine fractures into stable and unstable types. Later, Holdsworth modified the classification based on two columns the anterior (the vertebral bodies, intervertebral discs and their associated ligaments) and the posterior column (the neural arch, pedicles, facets and the posterior ligaments).
Later Denis modified this and divided the spine into three columns. The anterior column (comprising of anterior portion of the vertebral body, disc and ALL), the middle column (comprising of posterior portion of the vertebral body, disc and PLL) and the posterior column (comprising of the neural arch, pedicles, facets and the posterior ligaments). [10]
Fig 18: Denis three column classification
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Based on the three columns, he classified fractures into 4 major types: the compression type, the burst type, seat-belt type and the fracture-dislocation. The table below shows the types of fractures and the status of the three columns in each type. [10]
Table 2: Denis Classification of Dorso-lumbar spine fractures
Type of fracture Anterior Column Middle Column Posterior Column
Compression Compression None
None or Distraction (severe)
Burst Compression Compression None
Seat-belt type None or
Compression Distraction Distraction Fracture
dislocation
Compression Rotational shear
Distraction Rotational shear
Distraction Rotational shear
Denis compression type fracture:
Denis Compression type A # Both superior &
inferior end plates.
B # superior end plate C # inferior end plate D # anterior body
Fig 19: Denis compression type fracture
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Denis Burst type Fracture:
Denis Burst type fracture A # Both superior &
inferior end plates.
B # superior end plate C # inferior end plate D Rotational deformity E Lateral translation
Denis Flexion- Distraction type fracture:
Denis Flexion- Distraction type A Bony involvement in one
segment
B Soft tissue involvement in one segment
C Bony involvement in two segments
D Soft tissue involvement in two segments
Fig 21: Denis Flexion-Distraction type fracture
Fig 20: Denis Burst type fracture
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Denis Fracture-Dislocation type fractures:
Denis Fracture-Dislocation type
A Bony involvement in one segment
B Soft tissue involvement in one segment
C Two level injuries
AO Classification:
AO/Magerl classification which divided fractures based on the force that was applied to the spinal column. The AO system though is more inclusive is less practical and hard to be used in day to day practice due to the complex alpha- numeric scoring protocol.
AO/ Magerl system A Compression B Distraction
C Rotational/ Torsional
Fig 22: Denis Fracture-Dislocation type fracture
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Load-sharing classification by McCormack et al:
In load-sharing classification by McCormack et al, vertebral body is assessed for comminution, displacement of fragments and post-traumatic kyphosis. By assigning points, fractures that need short-segment posterior fixation can be identified. [11]
Fig 23: AO Classification
Fig 24: Load Sharing Classification
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McAfee Classification:
McAfee studied the X-rays and CT of 100 dorso-lumbar fractures and divided them into 6 groups namely, Wedge-compression, stable burst fracture, unstable burst fracture, chance fracture, flexion-distraction injury and translational injuries. [12]
Though there are several classification systems, the decision making whether to operate a spine fracture or not was still difficult. Vaccaro et al [13] then gave a point system known as the Thoracolumbar Injury Severity Score (TLISS) using three parameters, (1) Mechanism of injury interpreted from imaging studies, (2) the integrity of Posterior Longitudinal Ligament and (3) the neurological status of the patient. This was later modified to Thoracolumbar Injury Classification and severity
Fig 25: McAfee Classification
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score (TLICS) [14] in which the mechanism of injury was replaced by fracture morphology.
Table 3: Thoracolumbar Injury Classification and Severity Score (TLICS) Morphology
Compression 1
Burst 2
Translational/Rotational 3
Distraction 4
Neurological status
Intact 0
Nerve-root injury 2
Spinal cord or conus medullaris injury - complete 2 Spinal cord or conus medullaris injury - Incomplete 3
Cauda Equina 3
Posterior ligamentous complex
Intact 0
Indeterminate 2
Disrupted 3
Based on the total score obtained,
if the score is < 3 non-operative treatment score is 4 indeterminate (surgeon’s choice) score is > 5 operative treatment.
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MATERIALS AND METHODS
This is a prospective interventional study done at the department of Orthopaedics in Govt. Mohan Kumaramangalam Medical College and Hospital at Salem, between October 2018 and October 2020. This study was conducted after obtaining proper clearance from the institutional ethical committee.
Collection of data:
This study includes 25 patients attending the emergency department at Govt.
Mohan Kumaramangalam Medical College and Hospital, and diagnosed as Dorso- lumbar spine fractures.
The following data were collected: detailed history of trauma, pre-operative clinical status, intra operative complications, post-operative clinical status, post- operative complications, duration of stay in the hospital, early ambulance of the patient, patient satisfaction, cost effectiveness, loss of work days and post-operative long term follow up.
Inclusion criteria:
1. Patients with unstable Dorso-Lumbar spine fractures including Poly trauma patients.
2. Age >15 & < 70 years
3. With or Without neurological deficit
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Exclusion criteria:
1. Age <15 or > 70 years
2. Associated with head injuries needing neurosurgical interventions.
3. Associated with injuries to spine other than Dorso-lumbar spine.
4. Associated with pre-existing deformities of spine.
5. Patients not willing to participate in the study.
6. Pathological fractures
7. Patients medically unfit for surgery.
Pre-operative evaluation:
Patients who were brought to emergency department with history of trauma were evaluated and those suspected to have spine injuries were admitted and proper history regarding mode of injury was obtained.
Preoperative clinical examination included a thorough examination of associated injuries to other segments of spine, other long bones, calcaneum or pelvis.
If any other associated fractures were noted. They were addressed accordingly.
Associated head injury, chest wall injury and abdominal injury, if present was treated accordingly with the concerned specialist.
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Neurological Examination:
Detailed neurological examination is very essential to determine the presence of neurological deficit, identify the level of injury, whether complete or incomplete, involvement of bladder etc. This helps in planning treatment and gives idea about the prognosis of treatment. The state of spinal shock should be evaluated and sacral sensory sparing should be kept in mind, which indicates incomplete spinal cord injury.
American spinal injury association (ASIA) impairment scale was used in our study to document the neurological status of the patients.
Fig 26: ASIA Impairment Scale
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Radiological evaluation:
I. X-rays:
Initial evaluation as the patient was brought to emergency department and suspected to have dorso-lumbar spine injury were subjected to plain AP and Lateral views of the entire spine, so that associated injuries in other levels of spine is not missed. Also x-rays of other suspected bony injuries and chest were taken.
In AP view, any abnormality of spine was observed, like irregularities or widening of inter-pedicular distance etc. Lateral view gives more details regarding fracture morphology, degree of kyphosis, loss of vertebral body height, retropulsion of fragments, increase in interspinous distance suggestive of disruption of Posterior
Fig 27: Frankel Grading
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ligamentous complexes. The following parameters were calculated in lateral view of plain X-ray of injured spine.
1. Regional Kyphotic angle (α):
In X-ray lateral view, a line is drawn along the superior endplate of the intact vertebra above the fractured vertebra and another line along the inferior endplate of intact vertebra below the fractured vertebra. Perpendicular lines were drawn from these two lines to intersect each other. The angle of intersection is the kyphotic angle. There is no specific range for kyphotic angle. With fracture and increased kyphosis of thoracic spine, the angle increases and after surgical correction the angle decreases indicating the effectiveness of fixation.
2. Beck’s index (or Sagittal Index):
In X-ray lateral view, anterior and posterior vertebral body heights of the fractured vertebra is measured. The ratio of the anterior and posterior vertebral body height of the fractured vertebra is known as the Beck’s index. The value less than 1 indicates the anterior vertebral body height is less than the posterior and value greater than 1 indicated that the anterior vertebral body height is more than the posterior. Value =1 indicates the anterior and posterior vertebral body heights are equal.
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Fig 28: Regional Kyphotic angle
Fig 29: Beck’s Index
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II. Computed Tomography (CT):
All the patients were subjected to CT scan of the involved spine, to better study the morphology of the fracture. CT gives us more details regarding the fracture fragments, fracture of posterior elements that may not be clear in x-rays. Axial view can give us adequate information on canal diameter, retropulsion of fragments into the canal, the size of pedicle etc. it can also pick up subtle fractures in segments above or below, that are missed on X-rays. Also, the length and the diameter of the pedicle screw to be used can be pre-operatively assessed with CT axial cuts.
Fig 30: CT imaging in Spine fractures
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III. Magnetic Resonance Imaging (MRI):
All the cases were pre-operatively evaluated with MRI to evaluate the soft tissue components of the spine.
The intactness of Posterior longitudinal ligaments can be determined which helps us to define the prognosis of the injury. The level of damage to spinal cord, cord oedema, hematoma, damage to other ligamentous structures etc can be evaluated. Other associated disc herniations can be identified in levels above and below also.
Fig 31: MRI imaging in Spine fractures
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Initial Management:
The patient when received in emergency department was stabilized and resuscitated. Initial neurological status was recorded for further follow-up and for planning treatment. After basic investigations and X-rays have been taken with caution not to further increase the damage, IV steroids were given. All patients suspected to have spine injuries were shifted on spine boards only.
Intravenous injection of Methylprednisolone was given according to NACIS III guidelines. Loading dose of 30mg/Kg of inj. Methylprednisolone in NS over 20 minutes followed by maintenance dose of 5.4mg/Kg/hr for 24 hours if patient presented within 3 hours of injury or for 48 hours if patient presented between 3 hrs to 8 hrs after injury. [15]
Other associated fractures were given splints accordingly. Other associated injuries to chest wall, abdomen, head etc were treated with the guidance of specific specialists.
If the patient full-filled the inclusion criteria, proper consent was obtained and patient was included in the study.
Routine investigations and pre-anaesthetic assessment were obtained and patient was posted for posterior stabilization with pedicle screw fixation for dorso- lumbar spine fractures.
