Objective To review the latest progress in classification system of thoracolumbar fractures and its surgical treatment with posterior approaches. Methods Recent l iterature about classification system of thoracolumbar fractures and its surgical treatment was reviewed. Results For the treatment of thoracolumbar fracture, the surgeon first should decide whether the surgical treatment was necessary. Recently, a new classification system had been developed to help the surgeon make the right decision. The surgical methods included short segment internal fixation and long segment internalfixation with or without fusion, and minimally invasive internal fixation. Conclusion The progress in the surgical treatmentof thoracolumbar fracture will help spinal surgeon decide the necessary surgery beneficial for the patients. The most appropriate and effective surgical method with the minimum damage should be used to treat the fracture. The advantages of non-fusion surgical treatment still need a further study.
ObjectiveTo explore the effectiveness and safety of tranexamic acid (TXA) in anterior approach surgery for thoracolumbar fractures.MethodsFrom January 2017 to January 2020, a total of 68 thoracolumbar fracture patients undergoing anterior approach surgery were included and randomly divided into TXA group (n=33) and control group (n=35). Patients in the TXA group were given a dose of 15 mg/kg of TXA by intravenous infusion during 30 min before skin incision and an additional 15 mg/kg of TXA intravenously at 8 h after the first infusion, while the ones in the control group were given 15 mg/kg of normal saline at the same time. Basic data of the patients were collected. The hemoglobin concentration, hematocrit, coagulation and fibrinolysis indexes of the patients were monitored preoperatively, 24-hour postoperatively, and 72-hour postoperatively. The intraoperative blood loss and wound drainage of the patients were recorded. The incidence of blood transfusion and thrombotic events were collected. Statistical analysis was performed.ResultsThere was no significant difference in age, sex, body mass index, operation time, fracture location distribution, anesthesia classification of American Society of Anesthesiologists, neurologic grade of American Spinal Injury Association, injury time, or length of hospital stay between the two groups (P>0.05). Compared with those in the control group, the total blood loss [(1 398.49±312.24) vs. (1 642.30±357.78) mL, P=0.003], intraoperative blood loss [(432.83±74.76) vs. (486.31±86.51) mL, P=0.008], and wound drainage [(276.73±89.42) vs. (389.24±125.71) mL, P<0.001] in the TXA group reduced. No statistically significant difference was found between the two groups in the preoperative hemoglobin or hematocrit (P>0.05), but the 24-hour postoperative hemoglobin concentration [(112.67±20.59) vs. (102.64±19.41) g/L, P=0.042] and hematocrit [(32.25±4.12)% vs. (30.13±4.28)%, P=0.042] in the TXA group were higher than those in the control group. The incidence of allogeneic blood transfusion in the TXA group was lower than that in the control group (6.1% vs. 25.7%, P<0.05). There was no statistically significant difference in preoperative, 24-hour postoperative, or 72-hour postoperative prothrombin time, international standardized ratio, activated partial prothrombin time, platelet count, fibrinogen, d-dimer, or fibrinogen degradation products between the two groups (P>0.05), and no thrombotic complications were found.ConclusionTXA has good efficacy and safety in the anterior approach surgery for thoracolumbar fractures.
Objective To study the effectiveness of transpedicular intervertebral bone graft and pedicle screws fixation in injured vertebrae for the treatment of thoracolumbar fractures. Methods Between February 2007 and January 2009, 25 patients with thoracolumbar fractures were treated by posterior short-segment fixation combined with transpedicular intervertabral bone graft and pedicle screw fixation in injured vertebrae. There were 18 males and 7 females with a mean ageof 46 years (range, 28-63 years). The injured vertebrae were located at T10 in 1 case, T11 in 2 cases, T12 in 8 cases, L1 in 6 cases, L2 in 6 cases, L3 in 1 case, and L4 in 1 case. According to Denis classification, there were 14 cases of burst fractures and 11 cases of compression fractures. Based on Frankel classifications, 2 cases were rated as grade A, 4 cases as grade B, 8 cases as grade C, 7 cases as grade D, and 4 cases as grade E. The time between injury and operation was 6 hours to 7 days (mean, 4.6 days). The X-ray film was taken to measure the relative height of fractured vertebrae and Cobb angle, and Frankel classification was conducted to evaluate the function recovery of the spinal cord. Results The operations were performed successfully, and incisions healed primarily. All the patients were followed up 12-25 months (mean, 16 months). CT and X-ray films showed good bone graft heal ing and no loosening or breakage of screws and rods. The relative height of fractured vertebrae were 56.8% ± 15.6% at preoperation, 91.2% ± 10.7% immediately after operation, and 89.6% ± 10.3% at 1 year after operation, showing significant differences between preoperation and postoperation (P lt; 0.01), while no significant difference between immediately after operation and 1 year after operation. The Cobb angles were (18.2 ± 2.6), (7.5 ± 1.4), and (8.7 ± 1.1)°, respectively, showing significant differences between preoperation and postoperation (P lt; 0.01), while no significant difference between immediately and 1 year after operation. At 1 year after operation, the neural function in 16 cases was improved 1-3 grades. ConclusionTreatment of thoracolumbar fractures with transpedicular intervertebral bone graft and pedicle screw fixation in injuredvertebrae has satisfactory effectiveness, which can reconstruct vertebral body height, increase the stabil ity of anterior and middle
Objective To develop a deep learning system for CT images to assist in the diagnosis of thoracolumbar fractures and analyze the feasibility of its clinical application. Methods Collected from West China Hospital of Sichuan University from January 2019 to March 2020, a total of 1256 CT images of thoracolumbar fractures were annotated with a unified standard through the Imaging LabelImg system. All CT images were classified according to the AO Spine thoracolumbar spine injury classification. The deep learning system in diagnosing ABC fracture types was optimized using 1039 CT images for training and validation, of which 1004 were used as the training set and 35 as the validation set; the rest 217 CT images were used as the test set to compare the deep learning system with the clinician’s diagnosis. The deep learning system in subtyping A was optimized using 581 CT images for training and validation, of which 556 were used as the training set and 25 as the validation set; the rest 104 CT images were used as the test set to compare the deep learning system with the clinician’s diagnosis. Results The accuracy and Kappa coefficient of the deep learning system in diagnosing ABC fracture types were 89.4% and 0.849 (P<0.001), respectively. The accuracy and Kappa coefficient of subtyping A were 87.5% and 0.817 (P<0.001), respectively. Conclusions The classification accuracy of the deep learning system for thoracolumbar fractures is high. This approach can be used to assist in the intelligent diagnosis of CT images of thoracolumbar fractures and improve the current manual and complex diagnostic process.
Objective To investigate the influence of spinal cord decompression on posterior surgical treatment of thoracolumbar fracture, and to provide the practical basis for the indications of posterior spinal cord decompression Methods The cl inical data were retrospectively analyzed from 170 cases of thoracolumbar fracture treated with posterior surgical treatment between January 2005 and January 2009. There were 119 males and 51 females with an average age of42.7 years (range, 17-68 years). The fracture locations included T11 in 22 cases, T12 in 30 cases, L1 in 57 cases, and L2 in 61 cases. According to Denis classification system, there were 65 cases of compression fractures, 44 cases of burst fractures, 25 cases of flexion-distraction injuries, and 36 cases of fracture-dislocations. The time from injury to operation was 3-8 days (mean, 4.4 days). All the cases were divided into 4 groups according to space-occupying rates of spinal cord: group A, ≤20% (n=32); group B, 21%-40% (n=68); group C, 41%-60% (n=37); and group D, ≥ 61% (n=33). Through statistical analysis, the correlation between space-occupying rates and spinal cord function (Frankel grade) was evaluated, and the necessities of spinal cord decompression was studied in the patients who had neurological symptoms with space-occupying rates under 40%. Results There was no positive correlation between the degree of spinal cord injury and the space-occupying rates of bone fragments broken into the spinal canal. All patients were followed up 13-41 months (mean, 23.5 months). During the follow-up period, no secondary neurological damage occurred in the patients who were not given posterior spinal cord decompression with space-occupying rates under 40% (28 cases). And also in the cohort of patients with neurological symptoms whose space-occupying rates were under 40%, the posterior spinal cord decompression (65 cases) could improve the spinal cord function significantly when compared with no decompression cohort (7 cases), (P lt; 0.05). Conclusion The relative indications of posterior spinal cord decompression for thoracolumbar fracture are as follows: the cases having neurological symptoms with space-occupying rates under 40% and the ones having the neurological symptoms or not with space-occupying rates above 40%.
Objective To analyze the imaging characteristics of vertebral " shell” phenomenon of thoracolumbar fractures after posterior reduction and to explore the relationship between vertebral " shell” and fracture healing. Methods Between January 2013 and December 2015, the clinical data of 116 patients with thoracolumbar fractures treated with posterior pedicle screw-rod system reduction and internal fixation were analyzed retrospectively. There were 72 males and 44 females, aged 22-66 years (mean, 43 years). Injury causes were traffic accident in 24 cases, falling from height in 54 cases, bruise in 38 cases. Fracture segment located at T11 in 5 cases, T12 in 38 cases, L1 in 52 cases, L2 in 21 cases. There were 51 cases of compressive fracture and 65 cases of burst fracture. The sagittal Cobb angle ranged from 8 to 27°, with an average of 15°. Degree of preoperative spinal compression ranged from 20% to 75%, with an average of 44%. Bone density measurement showed that normal bone mass in 30 cases, bone loss in 40 cases, osteoporosis in 41 cases, and severe osteoporosis in 5 cases. The number, pathological characteristics, and imaging regularity of the vertebral " shell” phenomenon were observed and analyzed by logistic regression. Results All patients were followed up 11-18 months with an average of 13 months. A total of 72 cases of vertebral " shell” phenomenon mainly located in the vertebral anterior column and the end plate near the weak area (54/72, 75.0%). Most of them were in the irregular shape (50/72, 69.5%). The vertebral fracture line was related to the shape of the vertebral body and the displacement of the vertebral body after reduction. The outcome of the " shell” can be divided into disappeared type, reduced type, and collapse type, the volume of vertebral " shell” and its outcome were the risk factors for vertebral fracture healing. Conclusion The incidence of vertebral " shell” and nonuion of thoracolumbar fractures after posterior reduction are high. The main influencing factors are vertebral " shell” outcome and size.
ObjectiveTo explore the effectiveness percutaneous monoaxial screw combined with polyaxial pedical screw for treating thoracolumbar fracture by comparing with simple polyaxial pedicle screw fixation. MethodsBetween January 2012 and June 2014, 56 cases of thoracolumbar fractures were treated by percutaneous pedicle screw fixation, the clinical data were retrospectively analyzed. Of 56 cases, 30 were treated with percutaneous monoaxial screw combined with percutaneous polyaxial pedical screw fixation (group A), 26 patients with only percutaneous polyaxial pedicle screw fixation (group B). There was no significant difference in gender, age, body mass index, injury causes, time from injury to admission, involved segments, fracture type, and preoperative American Spinal Injury Association (ASIA) stage, visual analogue scale (VAS), the anterior height of the injured vertebrae, Cobb angle, and sagittal index between 2 groups (P>0.05). The operation time, intraoperative blood loss, and complications were recorded and compared between the 2 groups. The VAS score was used to evaluate the improvement of the pain. The sagittal kyphosis Cobb angle, the anterior height of the injured vertebrae, sagittal index, and the average correction (difference between 3 days after oeration and preoperation) and loss degrees (difference between last follow-up and 3 days after operation) were measured on the X-ray films at preoperation, 3 days after operation, and last follow-up. ResultsIncision healing at stage I was obtained, no related complications occurred. The operation time and intraoperative blood loss showed no significant difference between 2 groups (P>0.05). The patients were followed up 20-42 months (mean, 32 months) in group A and 21-44 months (mean, 30 months) in group B. VAS score of group A was significantly lower than that of group B at 3 days after operation (t=-2.277, P=0.027), but no significant difference was found at last follow-up (t=-0.289, P=0.774). X-ray examination showed good position of internal fixation, with no broken nails or exit of nail. There were significant differences in the anterior height of the injured vertebrae, Cobb angle, and sagittal index between at preoperation and at 3 days and last follow-up, and between at 3 days and last follow-up in 2 groups (P<0.05). The anterior height of the injured vertebrae, Cobb angle, and sagittal index of group A were significantly better than those of group B at 3 days and last follow-up (P<0.05), and correction degree were significantly higher than those of group B (P<0.05), but loss degree was not significant between 2 groups (P>0.05). ConclusionPercutaneous monoaxial screw combined with polyaxial pedicle screw fixation is better than simply polyaxial pedicle screw in effects of treating thoracolumbar fracture under the premise of strictly holding indications.
Objective To investigate the effectiveness of injured vertebra fixation with inclined-long pedicle screws combined with interbody fusion for thoracolumbar fracture dislocation with disc injury. Methods Between January 2017 and June 2022, 28 patients with thoracolumbar fracture dislocation with disc injury were underwent posterior depression, the injured vertebra fixation with inclined-long pedicle screws, and interbody fusion. There were 22 males and 6 females, with a mean age of 41.4 years (range, 22-58 years). The causes of injury included falling from height in 18 cases, traffic accident in 5 cases, and bruise in 5 cases. Fracture segment included 1 case of T11, 7 cases of T12, 9 cases of L1, and 11 cases of L2. According to the American Spinal Injury Association (ASIA) scale, the spinal injuries were graded as grade A in 4 cases, grade B in 2 cases, grade C in 11 cases, and grade D in 11 cases. Preoperative spinal canal encroachment ratio was 17.7%-75.3% (mean, 44.0%); the thoracolumbar injury classification and severity score (TLICS) ranged from 9 to 10 (mean, 9.9). Seventeen patients were associated with other injuries. The time from injury to operation ranged from 1 to 4 days (mean, 2.3 days). The perioperative indicators (operation time, intraoperative blood loss, and the occurrence of complications), clinical evaluation indicators [visual analogue scale (VAS) score and Oswestry Disability Index (ODI)], radiologic evaluation indicators [anterior vertebral height ratio (AVHR), kyphosis Cobb angle (KCA), intervertebral space height (ISH), vertebral wedge angle (VWA), displacement angle (DA), and percent fracture dislocation displacement (PFDD)], neurological function, and interbody fusion were recorded. Results The operation time was 110-159 minutes (mean, 130.2 minutes). The intraoperative blood loss was 200-510 mL (mean, 354.3 mL). All incisions healed by first intention, and no surgical complications such as wound infection or hematoma occurred. All patients were followed up 12-15 months (mean, 12.7 months). The chest and lumbar pain significantly relieved, VAS scores and ODI after operation were significantly lower than those before operation, and further decreased with the extension of postoperative time, with significant differences (P<0.05). At last follow-up, the ASIA classification of neurological function of the patients was grade A in 3 cases, grade B in 1 case, grade C in 1 case, grade D in 10 cases, and grade E in 13 cases, which was significantly different from preoperative one (Z=−4.772, P<0.001). Imaging review showed that AVHR, KCA, ISH, VWA, DA, and PFDD significantly improved at 1 week, 3 months and last follow-up (P<0.05). There was no significant difference between different time points after operation (P>0.05). At last follow-up, according to the modified Brantigan score, all patients achieved good intervertebral bone fusion, including 22 complete fusion and 6 good intervertebral fusion with a few clear lines. No complications such as internal fixation failure or kyphosis occurred during follow-up.Conclusion The injured vertebra fixation with inclined-long pedicle screws combined with interbody fusion is an effective treatment for thoracolumbar fracture dislocation with disc injury, which can correct the fracture dislocation, release the nerve compression, restore the injured vertebral height, and reconstruct spinal stabilization.
A new method of anterior decompression for thoracolumbar fractures with paralysi s in six cases was reported. In a follw-up of one to five months, was shown that the neurological functions in all six cases has improved ⅡⅢ rank in Frankl classification. The author believe that the method has the following advantages, such as: less trauma from operation; the level and the limit of decompression could be made without Xray during the operation; usually only 1/5 to 1/4 of the vertebral body was excised so that the stability of the spine was not disturbed, and the obvious favourable results.
Objective To design a new extracorporeal reduction device for percutaneous pedicle screw fixation of thoracolumbar fractures (short for “new reduction device”), and to evaluate its effectiveness. Methods According to the mechanism of thoracolumbar fractures and biomechanics characteristic of reduction, a new reduction device was designed and used in a combination with long U-shaped hollow pedicle screw system. Between January 2014 and January 2016, 36 patients (group A) with single segment thoracolumbar fracture without neurological complications underwent percutaneous pedicle screw fixation, and the clinical data were compared with those of another 39 patients (group B) with thoracolumbar fracture underwent traditional open pedicle screw fixation. There was no significant difference in gender, age, cause of injury, classification of fractures, segments of fractures, injury to operation interval, height percentage of injury vertebrae, and kyphotic angle between 2 groups (P>0.05). The 2 groups were compared in terms of operation time, length of incision, intraoperative blood loss, drainage volume, visual analogue scale (VAS) at postoperative 24 hours, fluoroscopy frequency, ambulation time, height percentage of injury vertebrae, kyphotic angle and correction. Results Group A was significantly better than group B in the operation time, length of incision, intraoperative blood loss, drainage volume, VAS score at postoperative 24 hours, and ambulation time (P<0.05). However, fluoroscopy frequency of group B was significantly less than that of group A (P<0.05). All patients were followed up 11.2 months on average (range, 7-15 months). There was no intraoperative and postoperative complications of iatrogenic nerve injury, infection, breakage of internal fixation. Mild pulling-out of pedicle screws occurred in 1 case of group A during operation. The kyphotic angle and height percentage of the fractured vertebral body were significantly improved at 3 days after operation when compared with preoperative ones (P<0.05), but no significant difference was found between 2 groups at 3 days after operation (P>0.05). Conclusion Minimally invasive extracorporeal reduction device for percutaneous pedicle screw fixation is an effective and safe treatment of thoracic vertebrae and lumbar vertebrae fractures, because of little trauma, less bleeding, and quicker recovery.