COMPARATIVE ANALYSIS OF FUNCTIONAL OUTCOME IN...

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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.

3

CERTIFICATE

This is to certify that the work “COMPARATIVE ANALYSIS OF



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



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.

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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

43

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

44

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

45

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.

46

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.

47

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

48

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.

51

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

53

After long segment spanning

posterior instrumentation with

transpedicular screws and rod After skin closure

Posterior approach in prone position

54

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

55

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



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

59

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.

60

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.

76

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

62

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

64

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

65

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

1213

DIAGNOSIS

No.of cases

Diagnosis No.of cases Percentage

Dislocation 12 48%

Burst 13 52%

Total 25 100

66

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

68

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

TLICS

No.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

69

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

70

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

72

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

2829303132333435

Long Short

32.31 31.99

OSWESTRY DISABILITY INDEX AT FINAL FOLLOWUP

Mean

73

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

75

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


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

79

PREOP XRAY CT MRI

AT FINAL FOLLOWUP

IMMEDIATE POSTOP

80

Case 4(S.NO 24)


AGE/SEX:25/M

DIAGNOSIS:D12 BURST# PROCEDURE:SHORT SEGMENT


TLICS:6

PREOP XRAY

81

CT

IMMEDIATE POSTOP

AT FINAL FOLLOWUP

82

Case 5(S.NO.19)


AGE/SEX:45/M

DIAGNOSIS:L1 BURST# PROCEDURE:SHORT SEGMENT


83

PREOP XRAY

CT

MRI

IMMEDIATE POSTOP

84

AGE/SEX:45/M

DIAGNOSIS:D12 BURST # PROCEDURE:SHORT SEGMENT

AT FINAL FOLLOWUP


Case 6(S.NO 17)

85

TLICS: 5 FUNCTIONAL OUTCOME: GOOD

MRI

IMMEDIATE POSTOP

AT FINAL FOLLOWUP

PREOP XRAY

86

AGE/SEX:43/M

DIAGNOSIS:D10-D11#DISLOCATION PROCEDURE:LONG SEGMENT


Case 7(S.NO 9)

87

TLICS: 8 FUNCTIONAL OUTCOME:FAIR

CT

MRI

IMMEDIATE POSTOP

AT FINAL FOLLOWUP

PREOP XRAY

88

AGE/SEX:30/M

DIAGNOSIS:L2-L3 #DISLOCATION PROCEDURE:LONG SEGMENT

TLICS: 9 FUNCTIONAL OUTCOME: FAIR


MRI

Case 8(S.NO 4)

89

CT

IMMEDIATE POSTOP

PREOP XRAY

90

AGE/SEX:20/M


Case 9(S.NO 18)

AT FINAL FOLLOWUP

91

DIAGNOSIS:D12 BURST # PROCEDURE:SHORT SEGMENT

TLICS: 6 FUNCTIONAL OUTCOME:GOOD

CT MRI

IMMEDIATE POSTOP

PREOP XRAY

92

Case 10(S.NO 12)

AT FIN AL FOLLOWUP


93

AGE/SEX:32/M

DIAGNOSIS:D12 BURST# PROCEDURE:SHORT SEGMENT

TLICS: 7 FUNCTIONAL OUTCOME: FAIR

PREOP

XRAY

CT

IMMEDIATE POSTOP

94

AT FINAL FOLLOWUP


95

DISCUSSION

The dorsolumbar injuries of the spine are the most common in whole of

spinal trauma.The anatomy of the Dorsolumbar spine makes it highly vulnerable to

high-energy trauma associated with motor-vehicle accidents and falls .Main

objectives of initial evaluation and diagnosis include injury characterization and

identifying any neurological deficit. The goal of treatment is to obtain pain free

stable spine and maximum restoration of function.

Thoracolumbar junction is the commonest site of the spinal injuries with

52% occurring between T11 & L1 (Burgoss et al 1988;krauss et al 1975).

Spinal injuries are more common in younger individuals. They are most

commonly caused by fall from height and motor vehicle accidents (Carpenter et al

1991). More common in sports activities in adolescents (Hubard et al 1974). Four

fold increased risk is seen in males than females in many of the studies.

Depending on the type of spinal injury, associated spinal and non spinal

injuries occur in upto 50% of patients (Cotler et al 1986,Court-Brown 1988). Intra

96

thoracic injuries in 20% of patients while intra abdominal injuries in 10% patients

and associated skeletal injuries in upto 20% of the patients. In our study,calcaneal

fractures were most commonly seen.

Transpedicular screws and rod system is currently the standard in fixation

of thoracolumbar spine. Long segment spanning fixation with two levels above and

below the fracture is a method which provides good stability but motion between

adjacent segments cannot be preserved.Posterior surgery with a short segment

stabilization allows early mobilization. Posterior surgery corrects deformity but

post operative vertebral collapse common , which leads to post surgical kyphosis.

To prevent this, inclusion of fractured vertebra in short segment fixation is

done. In our series,patients underwent either posterior short segment fixation with

inclusion of fractured vertebra or long segment spanning fixation with two level

above and below the fracture. Ligamentotaxis was done in all fractures and

dislocations with intact neurology utilizing the partially intact posterior

ligamentous complex(PLC). Posterior decompression was done in patients with

neurological deficit. In our study ,we have not encountered loss of kyphotic

correction in any of the cases.

97

Post-operative ASIA grade improved in patients with incomplete paraplegia

at three months after surgery which were comparable with most of the

studies.There was no new onset or deterioration of neurological deficit .

Radiologically,mean kyphotic angle in long segment group preoperatively

was 26.8 degrees which was reduced to 5.84 degrees postoperatively and mean

kyphotic angle in short segment group preoperatively was 21.4 degrees which was

reduced to 4.75 degrees.But there was loss of kyphotic correction in long segment

group during followup.

Posterior transpedicular screw fixation initially was reported by Boucher in

1959. Since then, modern instrumentation systems have been developed. These

systems control segmental motions in three dimensions, preserve motion segments,

avoid long fusions, and provide a more stable construct .Short-segment posterior

fixation is the most common and simple treatment, offering the advantage of

incorporating fewer motion segments in the fusion . A review of the literature

showed that Short-segment posterior fixation alone led upto 54% incidence of

implant failure and re-kyphosis in the long-term follow-up, and 50% of the patients

with implant failure had moderate-to-severe pain. To prevent this, several

techniques have been developed like short segment with inclusion of fracture

vertebra , long-segment spanning posterior fixation and bone grafting.

98

Altay et al.(2007) reported that use of four pairs of screws (two above and

two below) to lengthen the level arm of the construct would probably not only

enhance the stability but also allow effective reduction of kyphotic deformity.[61].

Tezeren and Kuru(2005) , in their study comparing short segment versus long

segment fixation in thoracolumbar burst fractures, demonstrated that long segment

instrumentation is an effective way to manage thoracolumbar burst fractures.

However, long segment instrumentation prolonged the operative time and

increased the amount of blood loss significantl[32]. In our study,Operative time

and amount of blood loss is increased in long segment fixation well comparable to

the above study.

Carl et al.(1992) also reported that segmental transpedicular fixation two

levels above the kyphosis should be used at the thoracolumbar junction where

compressive forces act more anteriorly. Therefore, they prefered to put the pedicle

screw two levels above the fracture site in order to prevent progressive kyphosis as

well as hard ware failure. On the other hand preferring one level fixation distal to

fracture site was to preserve the motion segment as much as possible in the lumbar

level.[62]

99

Butt et al.(2007) , reported success of short segment pedicle screw fixation

in thoracolumbar burst fractures; however, the 40% hardware failure rate that they

reported is worrisome.[63]

Gurr and McAfee(1976) found that two-levels above and below the

injured level in an unstable calf spine model provided more stiffness than the intact

spine. In the present study, long posterior fixation significantly improved stability

compared to intact and injured conditions in all loading modes.[47]

Peters et al.(2014), in their biomechanical study comparing short segment

versus long segment fixation, found that long posterior fixation was the stiffest

with and without anterior column augmentation in all loading conditions. The use

of screws two above and two below has shown to not only enhance the stability but

also allow effective reduction of kyphotic deformity. However, short posterior

fixation alone has also shown to provide good clinical and radiological outcomes

for certain fractures, particularly in the more lordotic middle and lower lumbar

spine, where the compressive forces act more posterior. [59]

Katonis et al.(1976) found that one-level above and one-level below the

fracture in the lumbar area formed a rigid construct with no correction loss. In this

100

study, we compared patients treated with posterior approach using short segment

pedicle screw with index vertebra fixation with those treated with long segment

spanning fixation to study the effectiveness of fixation in preventing postoperative

development of kyphosis and hardware failure and also for evaluation of functional

outcome. To our knowledge, this is one of the study comparing short segment with

index vertebra fixation and long segment spanning fixation for the treatment of

thoracolumbar fractures and dislocations. [60]

The most important purpose of the surgical management of thoracolumbar

fractures is to minimize the change in the patients’ lives. Pain relief and

radiological correction are major outcome criteria for surgical treatment of

thoracolumbar burst fractures from the patients’ perspective. Modified macnab

scale and Oswestry disability index was used to assess the improvement of back

pain in posterior short segment fixation and long segment fixation treated patients

during the follow-up periods which ranged from 6months to 1 year. Long-term

pain relief significantly improved in both treatment groups in all studies. Among

the included studies, the results showed that there was no significant difference in

pain reduction between the two groups.

101

Our study suggests that there was no significant difference in kyphosis

between short segment fixation and long segment fixation groups at last follow up,

no progression of kyphosis occurs in both groups.Implant breakage was found in

one case with long segment fixation but patient is able to do his activities and his

functional outcome was good.Superficial infection was observed in one case in

long segment but it settled well with i.v antibiotics and regular dressing.In long

segment fixation,duration of surgery is prolonged and amount of blood loss is also

more when compared to short segment fixation.No significant difference in

functional outcome in short segment group with index vertebra fixation when

compared to long segment spanning fixation.

102

CONCLUSION

Advantages of surgical stabilization of unstable dorsolumbar fractures in terms of

restoration or preservation of neurological function, achievement of pain-free

fracture site, early mobilization, and thereby fewer complications associated with

prolonged bed rest.Radiological loss of kyphosis was very less in short segment

with index vertebra fixation when compared to long segment spanning fixation

however the study period is short to draw conclusion.

In long segment spanning fixation, even though the amount of blood

loss is more,operating time is prolonged and complications rate were high there is

no significant difference in functional outcome between short segment pedicle

screw with index vertebra fixation when compared to long segment spanning

fixation.However considering the operating time,blood loss and neurological

recovery,short segment with index vertebra fixation is a better alternative to long

segment spanning fixation in treating thoracolumbar fractures and dislocations.

103

ANNEXURES

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111

PROFORMA

Name: age/sex: ip no: Unit: phone num:

Address:

Mechanism of injury:

Co morbidities: dm/ht/tb/epilepsy/ba

Date of admission : Date of sugery: Date of discharge:

Surgery details:

Type of surgery(short segment or long segment):

Implants used: No of screws: Operative time: Amount of blood loss:

Postop complications:

Infection: implant failure

PARAMETERS AT THE

TIME

OF

ADMISS

ON

IMMEDIAT

E POSTOP

1st

MONTH

FOLLO

W

UP

3rd

MONTH

FOLLO

WUP

6th

MONTH

FOLLOW

UP

1

YEAR

FOLLO

W

UP

MODIFIED

MCNAB’S

SCALE

OSWESTRY

DISABILITY

INDEX

112

CONSENT FORM

FOR OPERATION/ANAESTHESIA

I_________ Hosp. No.______ in my full senses hereby give my full

consent for ______ or any other procedure deemed fit which is a diagnostic

procedure / biopsy / transfusion / operation to be performed on me / my son /

mydaughter / my ward_____age under any anaesthesia deemed fit. The

nature,risks andcomplications involved in the procedure have been explained to me

in my own language and to my satisfaction. For academic and scientific purpose

the operation/procedure may be photographed or televised.

Date:

Signature/Thumb Impression

of Patient/Guardian

Name:

Designation Guardian Relation ship

Full address

113

MASTER CHART S.NO

NAME AGE/SEX

IP NO MODE OF INJURY

DIAGNOSIS AO TYPE TLICS PROCEDURE DONE

MODIFIED MACNAB CRITERIA AT FINAL FOLLOWUP

1 DHARMARAJ 28/

M

4294/1

6

FALL

FROM HEIGHT

D12-L1 #DISLOCATION C2 8 LONG

SEGMENT

FAIR

2 MURUGAN 23/M

6993/17

FALL FROM HEIGHT

L2 BURST# A4 8 LONG SEGMENT

GOOD

3 NAGASAMY 65/M

6430/17

RTA D10-D11# DISLOCATION C2 8 LONG SEGMENT

GOOD

4 PANDI

MURUGAN

30/M

3205/16

FALL FROM HEIGHT

L2-L3#DISLOCATION C2 9 LONG SEGMENT

FAIR

5 PAVITHRA 20/F 8556/17

FALL FROM HEIGHT

D12-L1#DISLOCATION C2 8 LONG SEGMENT

FAIR

6 PRABHAKARAN 35/M

5467/16

FALL FROM HEIGHT

D11 BURST# A4 7 LONG SEGMENT

GOOD

7 RAJA 50/M

12755/17

FALL FROM HEIGHT


GOOD

8 RAMACHANDRAN 55/M

12543/17

FALL FROM HEIGHT


FAIR

9 SANKAR GANESAN 43/M

14187/17

FALL FROM HEIGHT

D10-D11#DISLOCATION C2 8 LONG SEGMENT

FAIR

10

SENGODIRAJA 40/M

8234/16

FALL FROM HEIGHT


LOST FOLLOWUP

114

11

RAKIBUL ISLAM 27/M

8342/16

FALL FROM HEIGHT

D11-D12#DISLOCATION C2 8 LONG SEGMENT

LOST FOLLOWUP

12

PANDI 32/M

10421/17

FALL FROM HEIGHT


FAIR

13

KANAGARAJ 37/M

10255/17

RTA D11-D12 #DISLOCATION C2 8 LONG SEGMENT

FAIR

14

MOHAN 48/M

6785/16

FALL FROM HEIGHT

D12-L1#DISLOCATION C2 7 SHORT SEGMENT

FAIR

15

BALAMURUGAN 36/M

3256/16

FALL FROM HEIGHT

D12 BURST# A4 5 SHORT SEGMENT

GOOD

1

6

MOHAN 46/

M

7162/1

7

FALL

FROM HEIGHT

D12 BURST# A4 6 SHORT

SEGMENT

FAIR

17

SELVAM 45/M

6951/17

FALL FROM HEIGHT

D11-D12 #DISLOCATION C2 5 SHORT SEGMENT

GOOD

18

PONNAR 20/M

10121/17

FALL FROM HEIGHT


GOOD

19

SENTHIL KUMAR 45/M

9041/17

FALL FROM HEIGHT

L1 BURST# A4 7 SHORT SEGMENT

GOOD

20

SRINIVASAN 26/M

11504/16

FALL FROM HEIGHT

D10-D11#DISLOCATION C2 8 SHORT SEGMENT

LOST FOLLOWUP

21

NATHIYA 21/F 9254/16

FALL FROM HEIGHT

L1 BURST # A4 7 SHORT SEGMENT

GOOD

22

MUTHUVEL 22/M

11521/16

FALL FROM HEIGHT


GOOD

115

23

POTHUMPONNU 45/F 9047/16

FALL FROM HEIGHT

L1 BURST # A4 7 SHORT SEGMENT

LOST FOLLOWUP

24

SIVABALAN 25/M

7402/16

FALL FROM HEIGHT


GOOD

25

PITCHAIRAJA 23/M

3255/16

FALL FROM

HEIGHT


GOOD

116

ETHICAL COMMITTEE APPROVAL CERTIFICATE

117

PLAGIARISM CERTIFICATE

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