Outcome analysis of surgically managed unstable burst fracture
Keywords:Burst fracture, TSM-Bone graft, Anterior decompression, Neurological deficit
Background:Burst fractures are common injuries of dorsolumbar spine. In indicated cases, surgery is the treatment of choice. Significant controversy exists regarding surgical intervention for these fractures. Posterior decompression, anterior decompression and instrumentation, and combined anterior decompression and posterior instrumentation have been recommended in various studies. Here we are going to evaluate unstable burst fractures of thoracic and lumbar spine treated by isolated anterior decompression and instrumented fusion with TSM-Bone graft composite.
Methods: Prospective study of thirty-six cases of unstable fracture of thoracic and lumbar spine treated in Sri Ramachandra Medical centre from January 2011 to January 2014. The inclusion criteria were burst fractures of thoracic or lumbar spine complete or incomplete neurological deficit and burst fractures of thoracic or lumbar spine without neurological deficit but with mechanical instability. The exclusion criteria were pathological fractures, chance fracture, stable burst, wedge compression and osteoporotic compression fractures. The results were analyzed during the follow-up using the Pain – Visual analogue scale, Fusion status and radiographic parameter – K-angle .For pain score were given as 3,2,1 for absent, moderate and severe pain respectively. Regarding fusion status score of 3,2,1 were given when fusion was good, fair and no sign of fusion respectively.
Results:Mean pre-operative K-angle was 28o. Average loss of correction at final follow up was 3o.Mean correction of K-angle was 140.Moderate to severe loss of correction of K- angle was observed in 4 patients. Mild to moderate pain in 5 patients treated with analgesics. Average TSM subsidence was 3mm.
Conclusions:Bone graft composite provides stable biomechanical support to deficient anterior column in burst fractures and allows early rehabilitation and mobilization. Neural recovery may occur after anterior decompression, stabilization and fusion with TSM-Bone graft composite in dorsolumbar burst fractures with incomplete cord injury.
Haher TR, Bergman M, O'Brien M, Felmly WT, Choueka J, Welin D. The effect of the three columns of the spine on instantaneous axis of rotation in flexion and extension. Spine. 1991;16(8 Suppl):S312-8.
Haher TR, O'Brien M, Felmly WT, Welin D, Perrier G, Choueka J. Instantaneous axis of rotation as a function of the three columns of the spine. Spine. 1992;17(6Suppl):S149-54.
Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine. 1983;8(8):817-31.
White A, Punjabi M. Clinical biomechanics of spine. 2nd edition. Philadelphia : Lippincott-Raven, 1990.
McCormack T, Karikovic E, Gaines RW. Load sharing classification of spine fractures. Spine. 1994;19:1741-4.
Bridwell KH, Lenke LG, McEnery KW, Baldus C, Blanke K. Anterior fresh frozen structural allografts in the thoracic and lumbar spine. Do they work if combined with posterior fusion and instrumentation in adult patients with kyphosis or anterior column defects? Spine. 1995;20(12):1410-8.
Kuklo TR, Polly DW, Owens BD, Zeidman SM, Chang AS, Klemme WR. Measurement of thoracic and lumbar fracture kyphosis: evaluation of intra observer, interobserver, and technique variability. Spine. 2001;26(1):61-5;
Zielke K, Pellin B. New instruments and implants for supplementation of the Harrington system. Z Orthop Ihre Grenzgeb. 1976;114(4):534-7.
Dunn HK. Anterior stabilization of thoracolumbar injuries. Clin Orthop Relat Res. 1984;(189):116-24.
Kostuik JP. Anterior fixation for fractures of the thoracic and lumbar spine with or without neurologic involvement. Clin Orthop Relat Res. 1984;(189):103-15.
Kaneda K, Abumi K, Fujiya M. Burst fractures with neurologic deficits of the thoracolumbar-lumbar spine. Results of anterior decompression and stabilization with anterior instrumentation. Spine. 1984;9(8):788-95.
Hashimoto T, Kaneda K, Relationship between traumatic spinal canal stenosis and neurologic deficits in thoracolumbar burst fractures. Spine. 1988;13(11):1268-72.
Breig A. The therapeutic possibilities of surgical bioengineering in incomplete spinal cord lesions. Paraplegia. 1972;9(4):173-82.
Harrington PR, Tullos HS. Reduction of severe spondylolisthesis in children. South Med J. 1969;62(1):1-7
Brightman RP, Miller CA, Rea GL, Chakeres DW, Hunt WE. Magnetic resonance imaging of trauma to the thoracic and lumbar spine. The importance of the posterior longitudinal ligament. Spine. 1992;17(5):541-50.
Keene JS, Fischer SP, Vanderby R Jr, Drummond DS, Turski PA. Significance of acute posttraumatic bony encroachment of the neural canal. Spine. 1989;14(8):799-802.
Eck KR, Bridwell KH, Ungacta FF, Lapp MA, Lenke LG, Riew KD. Analysis of titanium mesh cages in adults with minimum two-year follow-up. Spine. 2000;25(18):2407-15.
Fehlings MG, Tator CH. An evidence-based review of decompressive surgery in acute spinal cord injury: rationale, indications, and timing based on experimental and clinical studies. J Neurosurg. 1999;91(1 Suppl):1-11.
Edelker DK, Asher MA, Neef JR. Survivor analysis of VSP spine instrumentation in the treatment of thoraco lumbar and lumbar burst fractures. Spine. 1991;16:428-32.