• Users Online: 417
  • Print this page
  • Email this page


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 5  |  Issue : 1  |  Page : 18-23

Prospective study of posterior open pedicle screw fixation for posttraumatic thoracolumbar and lumbar burst fractures with spinal injury at a tertiary care center: A short-term clinical and radiological follow-up


Department of Orthopaedics, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India

Date of Submission18-Oct-2021
Date of Decision09-Dec-2021
Date of Acceptance18-Jan-2022
Date of Web Publication15-Mar-2022

Correspondence Address:
Raj Kumar
Department of Orthopaedics, Rajendra Institute of Medical Sciences, Ranchi - 834 009, Jharkhand
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jodp.jodp_27_21

Rights and Permissions
  Abstract 


Background: Fractures of the thoracic and lumbar vertebrae are quite common injuries and their management remains controversial in the literature. The aim of this study was to analyze the clinical and radiological outcomes of posterior open pedicle screw fixation (OPSF) for the treatment of posttraumatic thoracolumbar and lumbar burst fractures with spinal injury. Materials and Methods: This is a prospective study of 24 patients with thoraco-lumbar and lumbar burst fracture treated with OPSF, and each patient was followed up for a minimum period of 1 year. Demographic characteristics, clinical and radiological outcomes, and adverse events were evaluated. Results: There were 70.83% male patients and 54.17% patients were in the age group of 21 to 40 years. Road traffic accident (41.67%) was the most common mechanism of injury and L1 was the most commonly fractured vertebra followed by T12. The average operative time was 125.35 min with a mean intraoperative blood loss of 480.82 mL. There was a significant improvement in Sagital Cobb's angle, vertebral body angle, anterior vertebral body height, and visual analog score at 1 year follow-up. The common postoperative complications were superficial infection, bed sore, and urinary tract infection worsening. Implant loosening was seen only in one case. Conclusions: Patients with thoraco-lumbar and lumbar burst fractures can be effectively managed with OPSF. It allows earlier mobilization and shorter recovery time and hospital stay and has contributed for better neurological outcome when combined with early aggressive and proper physiotherapy.

Keywords: Open pedicle screw fixation, prospective study, tans-pedicular instrumentation, thoraco-lumbar and lumbar burst fracture


How to cite this article:
Kumar R, Das S, Gupta P, Manjhi LB. Prospective study of posterior open pedicle screw fixation for posttraumatic thoracolumbar and lumbar burst fractures with spinal injury at a tertiary care center: A short-term clinical and radiological follow-up. J Orthop Dis Traumatol 2022;5:18-23

How to cite this URL:
Kumar R, Das S, Gupta P, Manjhi LB. Prospective study of posterior open pedicle screw fixation for posttraumatic thoracolumbar and lumbar burst fractures with spinal injury at a tertiary care center: A short-term clinical and radiological follow-up. J Orthop Dis Traumatol [serial online] 2022 [cited 2022 May 24];5:18-23. Available from: https://www.jodt.org/text.asp?2022/5/1/18/339678




  Introduction Top


Spinal trauma is coming up as a common problem in today's orthopedic practice. About 6% of all the fractures involve the spinal column, with approximately 90% of them occurring within the thoracic or lumbar regions.[1] Almost 60% of spinal fractures occur within the thoracolumbar region, with 17% being burst fracture. These injuries are painful and may impact the quality of life, resulting in prolong absence from work and chronic pain, thus having significant socio-economic impact. Nearly one-third of these patients have concomitant neural structure injury and variable neurologic deficit.[2],[3]

These fractures are typically caused by high-energy trauma, such as a car crash or fall from height, and they are more common in men.[4] Elderly people also are in danger for these fractures, because of weakened bone from osteoporosis.[2]

The treatment of such injuries has been controversial. However, the primary goals of treatment for such fractures include protecting the neural elements and preventing deformity and instability. The treatment depends on the individual characteristics of the fracture that range from compression fractures and burst fractures to flexion distraction injuries with fracture dislocation, which may be managed conservatively including bed rest alone, closed reduction of fractures and functional bracing, and surgical managements involving open reduction and internal fixation of the fracture.[2],[5] However, studies have advocated that nonoperative treatments are associated with complications, increased bed occupancy, increased cost of therapy, increased hospital stay hours, and care by trained personnel.[1] Early surgical decompression with instrumentation reduces the duration of hospital stay, facilitates early recovery, and prevents prolonged morbidity, so there is an urgent need for possibilities of surgical stabilization, early mobilization, and rehabilitation of patients. Surgical management should be strongly considered when neurologic deficit or significant deformity or instability is present.[1],[4] With the advent of pedicle screws, more and more fractures are treated with posterior-based surgeries, which regains spinal alignment and provides adequate stability.[1] At our institution, we favor an open approach if there is neurological deficit or neural element compression.

Spinal injury treatment-related literatures are sparse from this region and no such study has been undertaken in our hospital setting yet. Therefore, the aim of this study was to analyze the clinical and radiological outcomes of posterior open pedicle screw fixation (OPSF) for the treatment of posttraumatic thoraco-lumbar and lumbar burst fractures with spinal injury.


  Materials and Methods Top


This prospective cohort study was conducted at the Department of Orthopaedics, Rajendra Institute of Medical Sciences, Ranchi, from January 2018 to July 2021. This institute is a referral tertiary care hospital of Jharkhand and is one of the premier medical colleges in the state and India. A total of 24 patients meeting the inclusion criteria were studied. All these patients were managed by posterior OPSF and each case was followed up for a minimum period of 1 year. The study was approved by the institutional ethics committee, and a written informed consent was obtained from all patients before surgical procedure and for participation in the study.

Inclusion criteria

  • Skeletally mature patients (more than 18 years) with no age restriction and no gender restriction
  • Closed thoraco-lumbar and lumbar burst fracture (T10-L5) with The Thoraco-Lumbar Injury Classification and Severity score[6] of ≥4
  • Surgically managed cases.


Exclusion criteria

  • More than one-level spinal injury
  • Multi-organ trauma
  • Pathologic or osteoporotic fractures
  • Poor anesthetic patients
  • Duration of injury more than 2 weeks
  • Pregnant patients
  • Patients not willing to participate in the study.


All patients underwent complete clinico-radiological (X-ray, noncontrast computed tomography, and magnetic resonance imaging spine) examination preoperatively. Detailed neurological examination including tone, bulk, power at different joints, coordination, any abnormal movements, superficial and deep tendon reflexes, sensory deficit, and bowel and bladder involvement was noted. Perianal sensation and bulbo-cavernosus reflex was tested in all patients to differentiate between complete and incomplete cord lesion. After thorough neurological examination, the patients were categorized according to the American Spinal Injury Association (ASIA) impairment scale.[7] After complete preanesthetic routine investigations and anesthetic fitness, all patients underwent surgical intervention. Postoperatively, early mobilization and rehabilitation was encouraged depending on the neurological recovery using orthoses. All patients were protected by a spinal brace during standing, walking, and sitting up straight for 3 months followed by gradual weaning. The patients were encouraged for regular active and passive range of motion and muscle strengthening exercises depending on the neurological status.

The patients were evaluated for demographic characteristics (age and gender); mechanism of injury (MOI); subjective pain perception; operation time; intraoperative blood loss; postoperative hospitalization time; complications; and neurological and radiological (sagittal Cobb's angle [CA] [Figure 1], vertebral body angle [VBA] [Figure 2], anterior vertebral body height [AVBH] [Figure 3]) improvement. The visual analog scores (VAS), AVBH, VBA, and CA were evaluated at preoperation, the 3rd day after surgery, and at 1-year follow-up.
Figure 1: Radiographic image demonstrating measurement of sagital Cobb's angle

Click here to view
Figure 2: Radiographic image demonstrating measurement of vertebral body angle

Click here to view
Figure 3: Radiographic image demonstrating measurement of anterior vertebral body height; (AVBH = b/[{a + c}/2] ×100%)

Click here to view


Surgical technique (posterior approach)

Before the procedure, the patient was placed on a radiolucent table in a prone position after general anesthesia, and adequate padding was done under the iliac crests, thorax, and other bony prominences. The position of the fractured vertebra was determined and marked using the C-arm. After routine sterilization and placement of the drapes, midline incision of required length was made at the surgical level and dissection was carried out by layers till the tip of the spinous processes. Subperiosteally, the paraspinal muscles were detached to the outer edge of the facet, and the bilateral laminars and facet joints were exposed. Using a blunt awl and a pedicle probe, the required number of pedicle screws was implanted sequentially by free hand, and AP and lateral fluoroscopy images were taken to make sure that the screws were placed in their ideal positions. Two rods of appropriate lengths were implanted, and the height of the vertebral body was restored by lengthening the rods appropriately. The locations of the implants were again confirmed by C-arm images. The incision was irrigated and closed over drain placement.[8]

Statistical analysis

All data were entered into a Microsoft excel spreadsheet. Variables with continuous data were reported as the means and standard deviations and frequency as percentage. The statistical analyses were conducted using SPSS version 19 (SPSS Inc., Chicago, IL, USA). The parameters of radiographic evaluation and VAS score were analyzed by the paired t-test. P <0.05 was considered statistically significant.


  Results Top


Seventy four patients with spinal injury were admitted during the study period, from which 45 patients were identified with thoraco-lumbar and lumbar fracture. Of these, 31 patients underwent surgical management. Twenty four patients of the 31 fulfilling the inclusion criteria were studied. All of the studied patients were followed up for a mean time of 22.91 ± 8.85 months (ranging from 12 to 42 months).

Baseline characteristics of patients

The demographic and clinical characteristics of 24 patients are summarized in [Table 1]. There were 17 male (70.83%) and 7 female (29.17%) patients with a mean age of 38.94 years (range: 19–65 years). Majority of the patients (n = 12, 50%) were in the age group of 21 to 40 years followed by 41 to 60 years (n = 8, 33.33%). Road traffic accident (RTA) was the most common mode of injury that occurred in 10 (41.67%) patients followed by fall from height in 7 (29.17%) patients. Among the fractured vertebrae, L1 (n = 6, 25%) had the highest frequency followed by T12 (n = 5, 20.83%), L2 (n = 4, 16.67%), T11 and L3 (n = 3 each, 12.5%), T10 (n = 2, 8.33%), and L4 (n = 1, 4.17%).
Table 1: Demographic and clinical characteristics of the study patients

Click here to view


Operative indexes

The average operation duration was 125.35 ± 17.95 min (range: 104–143 min) min and the intraoperative blood loss was 480.82 ± 131.13 mL (range: 315–720 mL). Three patients needed blood transfusion during the surgery. The average postoperative hospital stay was 9.65 ± 4.48 days (range: 5–16 days) [Table 2].
Table 2: Operative Indices of the patients

Click here to view


Radiologic parameters

Statistical analysis of data [Table 3] showed significant difference in the sagittal CA, fractured VBA, and AVBH on preoperative and final follow-up of 12 months (all P < 0.05). The average preoperative sagittal CA was 23.82° immediate postoperative was 8.68° and at 1-year follow-up was 13.73°, with an average correction of 10.09°. The average preoperative VBA was 17.19°, immediate postoperative was 8.51° and at 1-year follow-up was 10.30°, with an average correction of 6.89°. The average AVBH (percentage of normal) was 60.18% before surgery and 87.90% at 1-year follow-up, yielding an average vertebral body height restoration of 27.72%.
Table 3: Radiological parameters of the cases

Click here to view


Effectiveness parameter

Before operation, VAS score for back pain was 7.85, on 3-day postoperative was 3.61 and at 1 year was 2.15, showing a significant difference of VAS scores at the 1-year follow-up (P < 0.05) [Table 4].
Table 4: Visual analog score of the study population

Click here to view


As shown in [Table 5], majority of the patients (n = 11, 45.83%) were having ASIA Grade C followed by Grade D (25%) and Grade B (20.83%). On final follow-up, 1 (4.17%) patient from Grade A improved to Grade C and 1 (4.17%) to Grade B; 3 (12.5%) patients from Grade B improved to Grade D and 2 (8.33%) to Grade C; 7 (29.17%) patients from Grade C improved to Grade E and 3 (12.5%) to Grade D; and 5 (20.83%) out of 6 patients improved from Grade D to Grade E.
Table 5: Changes in neurological status (American Spinal Injury Association Grading System) in the study population

Click here to view


Postoperative complications

Three patients (12.5%) had developed superficial infection in the early postoperative period, who were treated with higher antibiotics and regular dressing. None of the patients had deep infection. Three patients (12.5%) developed Grade II bed sore over sacrum during the follow-up period which were managed by nonoperative wound care. Two (8.33%) had developed worsening of urinary tract infection (UTI) which was managed by intermittent catheterization, bladder wash, and antibiotics. One patient (4.17%) had developed hardware failure (implant loosening) after a period of 13 months, which was treated by implant removal and intermittently, brace was advised. None of the patient had complications of neurological deterioration, chest infection, or deep-vein thrombosis (DVT) [Table 6].
Table 6: Postoperative complications

Click here to view



  Discussion Top


Spinal fracture is a serious injury. Surgical treatment of thoraco-lumbar fractures traditionally has been performed mainly using an open midline approach involving fixation of the fracture with a pedicle screw-rod system associated with posterolateral bony fusion.[3] In this study, we evaluated the effectiveness of OPSF for treating thoraco-lumbar and lumbar burst fractures with spinal injuries.

In this study, 24 patients with thoraco-lumbar and lumbar burst fracture with spinal injuries were followed up for an average duration of 22.91 months. There were 70.83% male and 29.17% female patients with a mean age of 38.94 years. Majority of the patients (50%) were in the age group of 21 to 40 years followed by 41 to 60 years (33.33%). RTA was the most common mode of injury occurred in 41.67% patients followed by (29.17% patients) fall from height. Among the fractured vertebrae, L1 (25%) had the highest frequency followed by T12 (20.83%) and L2 (16.67%). In a study of fifty patients by Shetty et al.,[1] 92% of the patients were male and the remaining were female. Fifty percent of the patients belonged to 31–50 years of age followed by 28% who were below 30 years. Nearly 58% of the patients sustained injury of L1 and 12% had injury of D12. The most common MOI in Panteliadis et al.'s study was fall from height which accounted for 65.5% followed by RTA in 16.4%.[9]

In our study, the average operation duration was 125.35 min, the intraoperative blood loss was 480.82 mL, and the average postoperative hospital stay was 9.65 days. In a study by Kumar et al., the average operation time was 115.26 min, the intraoperative blood loss was 444.33 mL, and the average postoperative hospital stay was 6.6 days, which is less when compared with the present study.[2] Wang et al.'s study had an average operation time, intraoperative blood loss, and hospital stay of 180 min, 591.5 mL, and 20.7 days, respectively, which is more when compared with the present study.[10] Ajay and Vijayakumar's study had an average operation time, intraoperative blood loss, and hospital stay of 103.48 min, 159.80 mL, and 13.12 days, respectively.[4]

For postoperative recovery, preoperative and postoperative imaging findings were analyzed [Figure 4]. In this study, we achieved significant correction of sagittal CA and fractured VBA and significant restoration of AVBH at 1-year follow-up. The average correction of CA was 10.09° and VBA was 6.89°; and the average restoration of AVBH was 27.72%. In Ajay and Vijayakumar's study, the average correction of CA was 9.96°, VBA was 9.12°, and the average restoration of AVBH was 28.6%, which is comparable to our study.[4] Wang et al.'s study had an average correction of CA and VBA of 6.2° and 8.5°, respectively, with an average restoration of AVBH of 24.3%, which is less when compared with the present study.[10]
Figure 4: Films of a 33 year-old male with D12 burst fracture caused by road traffic accident and treated with open pedicle screw fixation. Preoperative images: (a) Antero-posterior and lateral radiograph; (b and c) computed tomography scan: sagittal and axial views; (d and e) magnetic resonance imaging film: sagittal and axial views. Postoperative images: (f) Antero-posterior and lateral radiograph; (g) computed tomography scan: sagittal view

Click here to view


VAS for back pain and neurological status are also indicators of efficacy of surgery. In our study, there was a significant decrease of VAS from 7.85 in preoperative to 2.15 at 1-year follow-up. In Wang et al.'s study, VAS of 8.3 in preoperative period decreased to 1.4 at the final follow-up.[10] Shetty et al.'s study had an average preoperative VAS of 7.53, which decreased to 2.92 at 1-year follow-up.[1] Decreased postoperative pain may lead to earlier mobilization, shorter recovery time, shortened hospital stay, and reduced hospital costs. In addition, early mobilization due to reduced postoperative erative pain and early initiation of aggressive and proper physiotherapy have contributed for better neurological outcome.[2]

In this study, the patients having incomplete lesions of the spinal cord showed more neurological improvement than the complete lesion of the spinal cord. Two (8.33%) patients did not improve, 11 patients (45.83%) improved by one grade and 12 patients (50%) improved by two grades. Twelve patients (50%) improved fully to Grade E. In Singh et al.'s study, 18 (27%) patients did not improve, 34 patients (51%) improved by one grade, 8 patients (12%) improved by two grades, and 6 patients (9%) improved by three grades. Twelve patients (18.2%) improved fully to Grade E.[11],[12] The interval between injury and surgery has impact on neurological outcome. In Chadha and Bahadur's study, patients of early surgery group showed more neurological improvement than that of the patients of late surgery group.[13]

Complication is a very important factor for assessing surgical safety. In this study, three patients developed superficial wound infection in the early postoperative period, grade 2 bed sore over sacral region in three patients, worsening of urinary tract infection (UTI) in two patients, and implant loosening in one patient. None of the patient in our study had complication of deep-vein thrombosis or neurological deterioration. In Kumar et al.'s study on 15 patients, there were two cases of wound infection, two of bed sore, and one of worsening of UTI.[2] El-Shehaby et al.'s study reported the failure of implant in five patients (10.9%), while Xu et al. noted the presence of instrumentation failure in 16.2% of cases. [14],[15] Shetty et al.'s study reported UTI in five patients, while no case had surgical site infection, worsening of neurological status, or implant failure.[1]


  Conclusions Top


Our results suggest that OPSF demonstrate favorable clinical and radiological outcomes for the treatment of thoraco-lumbar and lumbar burst fractures with spinal injury. It allows earlier mobilization, shorter recovery time with better neurological recovery, good pain control, and fewer complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shetty MB, Venugopal V, Gnany J. Study of functional and radiological outcome of short-segment pedicle screw fixation for thoracolumbar fractures with use of pedicle screws in fractured vertebrae. J Karnataka Orthop Assoc 2020;8:7-15.  Back to cited text no. 1
    
2.
Kumar R, Sarkar B, Ifthekar S, Mittal S, Kandwal P, Azam Q. Analysis of outcome of percutaneous versus open pedicle screw fixation in the treatment of thoraco-lumbar spine fractures: A prospective comparative study. Int J Res Orthop 2021;7:343-50.  Back to cited text no. 2
    
3.
Defino HL, Costa HR, Nunes AA, Nogueira Barbosa M, Romero V. Open versus minimally invasive percutaneous surgery for surgical treatment of thoracolumbar spine fractures – A multicenter randomized controlled trial: Study protocol. BMC Musculoskelet Disord 2019;20:397.  Back to cited text no. 3
    
4.
Ajay MB, Vijayakumar AV. Comparative study between conventional open spine pedicle screw fixation surgery and minimally invasive percutaneous pedicle screw fixation in the management of thoracolumbar spine fracture in adult. Int J Ortho Sci 2016;2:154-9.  Back to cited text no. 4
    
5.
Tian F, Tu LY, Gu WF, Zhang EF, Wang ZB, Chu G, et al. Percutaneous versus open pedicle screw instrumentation in treatment of thoracic and lumbar spine fractures: A systematic review and meta-analysis. Medicine (Baltimore) 2018;97:e12535.  Back to cited text no. 5
    
6.
Lee JY, Vaccaro AR, Lim MR, Oner FC, Hulbert RJ, Hedlund R, et al. Thoracolumbar injury classification and severity score: A new paradigm for the treatment of thoracolumbar spine trauma. J Orthop Sci 2005;10:671-5.  Back to cited text no. 6
    
7.
Roberts TT, Leonard GR, Cepela DJ. Classifications in brief: American Spinal Injury Association (ASIA) impairment scale. Clin Orthop Relat Res 2017;475:1499-504.  Back to cited text no. 7
    
8.
Wu H, Wang CX, Gu CY, Zhang ZY, Tong S, Yan HD, et al. Comparison of three different surgical approaches for treatment of thoracolumbar burst fracture. Chin J Traumatol 2013;16:31-5.  Back to cited text no. 8
    
9.
Panteliadis P, Musbahi O, Muthian S, Goyal S, Montgomery AS, Ranganathan A. A comparison of three different methods of fixation in the management of thoracolumbar fractures. Int J Spine Surg 2018;12:1-7.  Back to cited text no. 9
    
10.
Wang B, Fan Y, Dong J, Wang H, Wang F, Liu Z, et al. A retrospective study comparing percutaneous and open pedicle screw fixation for thoracolumbar fractures with spinal injuries. Medicine (Baltimore) 2017;96:e8104.  Back to cited text no. 10
    
11.
Singh R, Rohilla RK, Kamboj K, Magu NK, Kaur K. Outcome of pedicle screw fixation and monosegmental fusion in patients with fresh thoracolumbar fractures. Asian Spine J 2014;8:298-308.  Back to cited text no. 11
    
12.
Defino HL, Canto FR. Low thoracic and lumbar burst fractures: Radiographic and functional outcomes. Eur Spine J 2007;16:1934-43.  Back to cited text no. 12
    
13.
Chadha M, Bahadur R. Steffee variable screw placement system in the management of unstable thoracolumbar fractures: A third world experience. Injury 1998;29:737-42.  Back to cited text no. 13
    
14.
El-Shehaby A, Saoud K, Elayouty A, Elkhatib E, Eshra M, Al- Shatoury H, et al. Comparison of long segment fixation versus short segment fixation with pedicle screws at the level of the fracture in the management of Thoracolumbar fractures. Egypt Spine J 2013;5:47-52.  Back to cited text no. 14
    
15.
Xu BS, Tang TS, Yang HL. Long-term results of thoracolumbar and lumbar burst fractures after short-segment pedicle instrumentation, with special reference to implant failure and correction loss. Orthop Surg 2009;1:85-93.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusions
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed380    
    Printed4    
    Emailed0    
    PDF Downloaded3    
    Comments [Add]    

Recommend this journal