J Korean Neurotraumatol Soc.  2008 Jun;4(1):37-42. 10.13004/jknts.2008.4.1.37.

The Surgical Management of Unstable Thoracolumbar Burst Fractures with Anterolateral and Posterior Approach: Comparison of Clinical and Radiological Outcome

• Lee SB
• Yoo DS
• Huh PW
• Kim DS
• Cho KS

• KMID: 1814441
• DOI: http://doi.org/10.13004/jknts.2008.4.1.37

Abstract

OBJECTIVE
The authors evaluate the clinical and radiographic outcome of the management of acute thoracolumbar burst fractures by anterolateral or posterior approach.
METHODS
Thirty four (34) consecutive patients with a single-level traumatic unstable burst fracture at the thoracolumbar junction were surgically treated between Jan. 2004 and Dec. 2006. Twenty one patients were operated on by anterolateral approach, strut graft and fixation with a Kaneda plate. Thirteen patients were treated with posterior approach and transpedicular screw fixation. Clinical and radiographic evaluation was performed on all 34 patients before and after surgery.
RESULTS
There were 34 thoracolumbar burst fractures in 27 male and 7 female patients. Fifty-nine percent (20 of 34) of patients presented with a neurologic deficit. The mean follow-up duration was 18.5 months (range 7-44 months). Preoperative canal encroachment in the anterolateral and posterior groups measured 49.3+/-7.6%, 27.3+/-9% respectively (p=0.001). Preoperative angular deformity in the anterolateral and posterior groups measured 19.4+/-8.4degrees and 12.9+/-4.5degrees respectively. At discharge, angular deformity had been corrected to 10.5+/-7.3degrees and 7.6+/-4.9degrees in both groups, respectively. Preoperative Frankel grade grade in the anterolateral and posterior groups was 3.9+/-1.2, 3.9+/-1.5 respectively (p=0.9). Postoperatively, it had been improved to 4.4+/-1.1, 4.2+/-1.4 in both groups, respectively.
CONCLUSION
Compared with posterior approaches, the anterolateral approach can reduce fusion segment, well maintained the kyphosis correction and decompress the spinal canal completely. The selection of treatment should be based on clinical and radiological finding including neurological deficit.

Keyword

Thoracolumbar burst fracture; Anterolateral approach; Posterior approach

MeSH Terms

Congenital Abnormalities
Female
Follow-Up Studies
Humans
Kyphosis
Male
Neurologic Manifestations
Spinal Canal
Transplants

Figure

• 

  FIGURE 1 The kyphotic angulation. Plain lateral radiograph showing loss in vertebral body (VB) height and kyphotic angulation. It shows change of sagittal Cobb's angle with Kaneda device fixation and posterior screw fusion between preoperative (A), (C) and last follow up (B), (D).

• 

  FIGURE 2 Bar graph showing preoperative, discharge and follow-up Frankel scores. At follow up, improvement in Frankel scores is noted irrespective of the approach (p=0.672). The difference in Frankel scores between the two groups is not significant on admission, discharge or at follow up; however, the improvement in the Frankel score was significant within each group-anterolateral (white bar) (p=0.012) and posterior (black bar) (p=0.014).

• 

  FIGURE 3 Line graph showing deformity angles at admission, discharge, and latest follow up in the anterolateral (solid line) and posterior (dot line) instrumentation groups.

Reference

1. Alanay A, Acaroglu E, Yazici M, Oznur A, Surat A. Short-segment pedicle instrumentation of thoracolumbar burst fractures: does transpedicular intracorporeal grafting prevent early failure? Spine (Phila Pa 1976). 2001; 26:213–217.

2. Alanay A, Yazici M, Acaroglu E, Turhan E, Cila A, Surat A. Course of nonsurgical management of burst fractures with intact posterior ligamentous complex: an MRI study. Spine (Phila Pa 1976). 2004; 29:2425–2431.

3. Bradford DS, McBride GG. Surgical management of thoracolumbar spine fractures with incomplete neurologic deficits. Clin Orthop Relat Res. 1987; 218:201–216.

4. Cantor JB, Lebwohl NH, Garvey T, Eismont FJ. Nonoperative management of stable thoracolumbar burst fractures with early ambulation and bracing. Spine (Phila Pa 1976). 1993; 18:971–976.

5. Carl AL, Tromanhauser SG, Roger DJ. Pedicle screw instrumentation for thoracolumbar burst fractures and fracture-dislocations. Spine (Phila Pa 1976). 1992; 17:S317–S324.

6. Carl AL, Tranmer BI, Sachs BL. Anterolateral dynamized instrumentation and fusion for unstable thoracolumbar and lumbar burst fractures. Spine (Phila Pa 1976). 1997; 22:686–690.

7. Dick JC, Brodke DS, Zdeblick TA, Bartel BD, Kunz DN, Rapoff AJ. Anterior instrumentation of the thoracolumbar spine. A biomechanical comparison. Spine (Phila Pa 1976). 1997; 22:744–750.

8. Dunn HK. Anterior stabilization of thoracolumbar injuries. Clin Orthop Relat Res. 1984; 189:116–124.

9. Frankel HL, Hancock DO, Hyslop G, Melzack J, Michaelis LS, Ungar GH, et al. The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. I. Paraplegia. 1969; 7:179–192.

10. Gertzbein SD. Spine update. Classification of thoracic and lumbar fractures. Spine (Phila Pa 1976). 1994; 19:626–628.

11. Ghanayem AJ, Zdeblick TA. Anterior instrumentation in the management of thoracolumbar burst fractures. Clin Orthop Relat Res. 1997; (355):89–100.

12. Hitchon PW, Goel VK, Rogge T, Grosland NM, Torner J. Biomechanical studies on two anterior thoracolumbar implants in cadaveric spines. Spine (Phila Pa 1976). 1999; 24:213–218.

13. Hitchon PW, Torner JC, Haddad SF, Follett KA. Management options in thoracolumbar burst fractures. Surg Neurol. 1998; 49:619–626. discussion 626-627.

14. Kaneda K, Taneichi H, Abumi K, Hashimoto T, Satoh S, Fujiya M. Anterior decompression and stabilization with the Kaneda device for thoracolumbar burst fractures associated with neurological deficits. J Bone Joint Surg Am. 1997; 79:69–83.

15. Kostuik JP. Anterior fixation for fractures of the thoracic and lumbar spine with or without neurologic involvement. Clin Orthop Relat Res. 1984; (189):103–115.

16. Magerl F, Aebi M, Gertzbein S, Harms J, Nazarian S. A comprehensive classification of thoracic and lumbar injuries. Eur Spine J. 1994; 3:184–201.

17. Markel DC, Graziano GP. A comparison study of treatment of thoracolumbar fractures using the ACE Posterior Segmental Fixator and Cotrel-Dubousset instrumentation. Orthopedics. 1995; 18:679–686.

18. McDonough PW, Davis R, Tribus C, Zdeblick TA. The management of acute thoracolumbar burst fractures with anterior corpectomy and Z-plate fixation. Spine (Phila Pa 1976). 2004; 29:1901–1908. discussion 1909.

19. McNamara MJ, Stephens GC, Spengler DM. Transpedicular short-segment fusions for treatment of lumbar burst fractures. J Spinal Disord. 1992; 5:183–187.

20. Mumford J, Weinstein JN, Spratt KF, Goel VK. Thoracolumbar burst fractures. The clinical efficacy and outcome of nonoperative management. Spine (Phila Pa 1976). 1993; 18:955–970.

21. Narotam PK, Pauley SM, McGinn GJ. Titanium mesh cages for cervical spine stabilization after corpectomy: a clinical and radiological study. J Neurosurg. 2003; 99:2 Suppl. 172–180.

22. Okuyama K, Abe E, Chiba M, Ishikawa N, Sato K. Outcome of anterior decompression and stabilization for thoracolumbar unstable burst fractures in the absence of neurologic deficits. Spine (Phila Pa 1976). 1996; 21:620–625.

23. Parker JW, Lane JR, Karaikovic EE, Gaines RW. Successful short-segment instrumentation and fusion for thoracolumbar spine fractures: a consecutive 41/2-year series. Spine (Phila Pa 1976). 2000; 25:1157–1170.

24. Rechtine GR 2nd, Cahill D, Chrin AM. Treatment of thoracolumbar trauma: comparison of complications of operative versus nonoperative treatment. J Spinal Disord. 1999; 12:406–409.

25. Shono Y, McAfee PC, Cunningham BW. Experimental study of thoracolumbar burst fractures. A radiographic and biomechanical analysis of anterior and posterior instrumentation systems. Spine (Phila Pa 1976). 1994; 19:1711–1722.

26. Verlaan JJ, Diekerhof CH, Buskens E, van der Tweel I, Verbout AJ, Dhert WJ, et al. Surgical treatment of traumatic fractures of the thoracic and lumbar spine: a systematic review of the literature on techniques, complications, and outcome. Spine (Phila Pa 1976). 2004; 29:803–814.

27. Zdeblick TA, Shirado O, McAfee PC, deGroot H, Warden KE. Anterior spinal fixation after lumbar corpectomy. A study in dogs. J Bone Joint Surg Am. 1991; 73:527–534.