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ORIGINAL ARTICLE
Year : 2017  |  Volume : 17  |  Issue : 2  |  Page : 87-92

Unstable thoracolumbar spinal injuries treated by pedicle screw fixation: A short-term evaluation


Department of Orthopaedics, Burdwan Medical College, Burdwan, West Bengal, India

Date of Web Publication6-Jun-2017

Correspondence Address:
Abhilash Sarkar
5A, Sushil Sen Road, Kolkata - 700 025, West Bengal
India
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DOI: 10.4103/1319-6308.207578

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  Abstract 

Context: The incidence of spinal cord injury, especially in thoraco-lumbar junction has increased substantially owing to increase in high energy blunt trauma. Since it tends to affect younger population, they become a huge emotional, social and financial problem to the patient and their families. This study evaluates the use of pedicle screw fixation for preservation of remaining spinal cord function, restoration of spinal alignment, and achievement of pain-free fracture site, early mobilization and maximization of neurological recovery.
Aims: Assess functional and radiological outcome after pedicle screw fixation and analysing the complications.
Settings and Design: Institution based prospective, longitudinal study.
Materials and Methods: Pedicle screw fixation of 10 adult patients with unstable thoraco-lumbar spinal trauma and their follow-up.
Statistical Analysis Used: Patients evaluated pre and post operatively, both clinically (ASIA scale) and radiologically at regular intervals.
Results: Out of 10 patients, according to the ASIA impairment scale, during pre-operative period, 50% were graded as grade A, 20% as grade B, and 30% as C. During last follow up, grade A was 50%, grade B was 10%, C was 20%, D was 20%. 80% of the patients had shown no complications, only pressure sore (20%) and wound dehiscence (10%) were observed in the study group.
Conclusions: Pedicle screw fixation is a better option for early ambulation and recovery. It achieves reduction and stability in both anterior and posterior column injuries. Earlier the intervention better the prognosis. Large scale trials are needed to assess the true magnitude of the problem and their management in the developing world.

Keywords: Pedicle screw, spinal cord injury, thoracolumbar


How to cite this article:
Mondal S, Dasgupta S, Naiya S, Ghosh A, Sarkar A. Unstable thoracolumbar spinal injuries treated by pedicle screw fixation: A short-term evaluation. Saudi J Sports Med 2017;17:87-92

How to cite this URL:
Mondal S, Dasgupta S, Naiya S, Ghosh A, Sarkar A. Unstable thoracolumbar spinal injuries treated by pedicle screw fixation: A short-term evaluation. Saudi J Sports Med [serial online] 2017 [cited 2019 Jul 19];17:87-92. Available from: http://www.sjosm.org/text.asp?2017/17/2/87/207578


  Introduction Top


With the introduction of motorized vehicles and greater exposure to high-energy blunt trauma, the occurrence of thoracolumbar fractures and dislocations has increased substantially. The global estimate of spinal cord injury (SCI) incidence as estimated is in between 15 and 40/million/year.[1] In India, the prevalence of SCI is approximately 1.5 million and annual incidence of new cases is about 10,000.[2] Most of the patients are males of 16–30 years. In India, the common causes of injuries include fall from height (48%) and road traffic accidents (43%).[3] Although the incidence of spinal injury is not so high, the prognosis is not very satisfactory.

Approximately 90% of all spinal fractures occur in the thoracic and lumbar spines.[4] In fact, the majority of thoracic and lumbar injuries occur within the region between T11 and L2, commonly referred to as the thoracolumbar junction. Neurologic deficit occurs in approximately 15%–20% of thoracolumbar fractures and dislocations. Although blunt trauma remains responsible for the majority of thoracolumbar fractures, other mechanisms such as gunshot wounds and osteoporosis have become increasingly more common.

Despite vast improvements in conventional therapies and increased public safety awareness programs, SCI remains a significant cause of disability worldwide. This tragedy is compounded with the fact that SCI frequently afflicts the younger segment of the population – individuals who still have most of their lives to live and the greatest capacity for productivity in society. The emotional, social, and financial costs to these patients and their families are enormous.

The aim of this study was to evaluate the use of pedicle screw fixation for preservation of remaining spinal cord function, restoration of spinal alignment, and achievement of pain-free fracture site, early mobilization and maximization of neurological recovery in spinal injury patients.

Aims and objectives

Patients undergoing stabilization for fractured thoracolumbar spine by pedicular screw fixation with indirect decompression of spinal cord are assessed pre- and post-operatively.

  1. To assess functional outcome (neurological outcome, overall quality of life) after pedicular screw fixation
  2. To assess radiological outcome after pedicular screw fixation
  3. To identify complications associated with the procedure.



  Materials and Methods Top


This prospective longitudinal interventional study was done at a tertiary care institute of a developing country with ten patients after taking institutional ethical clearance and consent of the patients in a period of 1-year.

Study population

Patients attending orthopedics emergency and outpatients department (OPD) of our hospital were selected for the study.

Inclusion criteria

  • Age 18–60 years
  • Unstable thoracolumbar spinal injury caused by trauma
  • No additional comorbidities.


Exclusion criteria

  • Stable fracture of thoracolumbar spine
  • Associated head or chest trauma.


Sample size

Ten patients (n = 10).

Study design

Institution-based prospective, longitudinal study of patients treated by pedicular screw fixation for fracture of unstable thoracolumbar spine.

Parameters to be studied

  • Motor status
  • Sensory status
  • Kyphotic deformity (Cobb's angle) before surgery, immediately after surgery, and at follow-up
  • Bowel bladder control
  • Pain
  • Complication rate after surgery, namely, implant failure, persistent neurological deterioration, wound infection, pulmonary embolism.


Study tools

  • General spinal instruments
  • Pedicular screw
  • Trocar with stopper
  • Pedicle centralizers
  • Pedicle probe
  • Tap (5.5 and 6.25 mm)
  • Pedicle sound
  • Rod contouring template
  • Rod cutter
  • Rod holder
  • Rod pusher
  • Combined insertion device for inner screw and outer nut
  • Rod stabilizer
  • Distractor
  • Hex screwdriver
  • Socket wrench for outer nut
  • T-handle
  • Image intensifier
  • General instrument set, etc.


Study technique

Patients are treated by pedicular screw fixation. The outcome of the treatment is evaluated both clinically according to American Spinal Injury Association (ASIA) impairment scale and radiologically.

Plan for data analysis

Patients are evaluated in details pre- and post-operatively, both clinically and radiologically at a regular interval. The results are analyzed.

Preoperative investigations

  • For preoperative planning: X-ray of dorsolumbar (DL) spine, computed tomography scan, and magnetic resonance imaging of DL spine
  • Preanesthetic workup.


Postoperative treatment

All the patients were given postoperative intravenous antibiotics for 5 days. They were switched over to oral antibiotics till stitch removal. Stitches were removed on 14th day. On the 2nd day, patients were allowed to roll from side to side. They were allowed to sit up and were mobilized on a wheelchair after application of Long Taylor's brace on 4th postoperative day. Patients with complete neurological deficits were given physiotherapy and ambulated on wheelchair. Routine postoperative X-rays were taken before discharge.

Follow-up

All the patients were followed up in OPD every 6th week after surgery for 6 months, and at each follow-up, clinical, radiological, and neurological examination were done. At the end of 6 months of follow-up, the patients were evaluated clinically. Evaluation of neurological status with ASIA grading and radiological assessment of deformity was done at the time of admission, 12th week, 24th week, and 1 year.


  Results and Analysis Top


This prospective interventional study was undertaken in the Department of Orthopedics of a tertiary care hospital. Ten adult patients with unstable thoracolumbar spinal injuries who gave the consent for surgery during the study period were included as study sample [Table 1],[Table 2],[Table 3],[Table 4],[Table 5] and [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5].
Table 1: Injury operation interval

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Table 2: Denis pain scale

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Table 3: American Spinal Injury Association impairment scale for neurological status

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Table 4: Complications

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Table 5: Outcome at 1-year follow-up

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Figure 1: Age distribution of patients

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Figure 2: Sex distribution of patients

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Figure 3: Mode of injury

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Figure 4: Distribution of fracture pattern

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Figure 5: Cobb's angle

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  Discussion Top


Traumatic spine injuries are major contributors to death and disability in the population. The individuals are at risk of high-energy trauma in the modern era.[5],[6] Thoracolumbar spine fractures are serious injuries of concern if left untreated may result in marked morbidity and disability to the patient. In trauma patients, spinal fractures are reported to be around 6%, of which around 2.6% of the patients sustain spinal cord or nerve root level neurological injury. Such fractures are commonly associated with motor and sensory disturbances, bladder and bowel disturbances, erectile dysfunction, deformities such as kyphosis and scoliosis as result of neurological injury. The patients are also prone to bed sores and pulmonary infections.

In our study, the mean age was 35.9 years. The mean age from various literatures is 30 years.[7] Majority of the patients were male. Alvine et al. in their study found that the average age was 31 years, with a male predominance. Sasso et al. in their study had 77% males and 23% females with a mean age of 34 years. Razak et al. in their study found that average was 30 years with a male predominance. Our result is almost comparable to the study by Sasso et al. However, the mean age in this study group was higher compare to these studies.

In our study group, 60% of the patients had injury due to fall from height. Alvine et al. noted it as 52% and Razak et al. noted 69% of the injuries due to fall from height.

Regarding fracture pattern, about 60% of the patients had Type A fractures, 30% had Type B fractures, and 10% had Type C fracture. Alvine et al.,[8] Sasso et al., and Nasser et al. have also noted similar findings.

All of the vertebrae involved in this series were between T11 and L2 (in the transition zone). While Alvine noted to the extent of 70%, Sasso et al. noted to the extent up to 80%, and Razak et al.[9] noted up to 92% of the fractures were at the level of T11–L2.

In our study, the mean duration of injury to admission to our hospital was 3 days. Mean duration of injury to surgery was 17.7 days and mean duration of stay in hospital was 35.5 days. Sasso et al. noted that the average time interval between injuries and surgery was 4 days and mean hospital stay was 16 days. While Razak et al. noted the average time duration to surgery was 5.6 days and average hospital stay was 24 days. In this study, about 25% of the patients were operated within 4 days of the injury and about 75% were operated after 4 days of injury.

From our study, we observed that the mean preoperative Cobb's angle was 16.6°. In the final follow-up, it is improved to 4.4°. Nasser et al. noted the kyphotic angle was 23.6° on admission, 7° postoperatively, and 11.5° at latest follow-up. Alvine et al. noted that sagittal plane angulation was 12° preoperatively, 1° postoperatively, and 6° at follow-up. Sasso et al. noted that the kyphotic angle was 17.6° preoperatively, 3.5° postoperatively, and 11.6° at latest follow-up. Razak et al. noted that the average kyphotic angle was 20° preoperatively, 7° postoperatively, and 9° at latest follow-up.

According to the ASIA grading for neurological state during preoperative period, 50% were graded as Grade A, 20% as Grade B, and 30% as Grade C. During last follow-up, Grade A was 50%, Grade B was 10%, Grade C was 20%, and Grade D was 20%.

Nasser et al. noted that patients who had neurological deficits showed at least one-grade improvement at latest follow-up. Alvine et al. noted that neurological improvement was seen in 50% of cases with 40% improving with one grade and 20% with two grades and none had a decrease in neurological level. Sasso et al. in their study noted that all patients with incomplete neurological deterioration improved at least by one grade.

Razak et al. noted that 64.4% of those with incomplete lesions showed an improvement of at least 1 grade. In a study conducted on forty complete paraplegic patients with lower thorasic or lumbar fracture, Prabhakar et al.[10] reported that improvement by more than one grade of Asia impairment scale had been observed in almost 90% of the patients.

Eighty percent of the study group had shown no complications; pressure sore (20%) and wound dehiscence (10%) were observed in the study group. Razak et al. noted two instances of hardware loosening and three misplaced pedicle screws.

About 50% of the patients had no pain, 30% had occasional minimal pain with no need for medication, 10% had moderate pain with occasional need for medication, and 10% had moderate to severe pain.

Fifty percent of patients in our study group are confined to wheelchair and rest of the patients (50%) can walk with support.

In a limited infrastructural backup, the outcome of our study regarding regaining bony stability and neurological outcome is comparable to the published results in various journals.


  Summary Top


Ten patients of unstable thoracolumbar spinal injuries having different level of vertebral fractures treated by pedicular screw fixation have been studied. Fall from height was the most common (60%) mode of trauma responsible for such dorsolumbar vertebral injuries followed by road traffic accident (30%). Males (mean age 35.9 years) are more commonly injured than females because of their much involvement of outdoor activities and occupational mishap. Among the study group, 80% of male and 20% of females were affected. L1 vertebra was more vulnerable for fracture comprising 40%, followed by D12 and L2 vertebra (comprising 30% and 20%, respectively). Most of the fractures were compression fractures. Cobb's angle and vertebral body height reduction were taken as radiological parameter during follow-up. Mean Cobb's angle was decreased 16.6°–4.4° and regain of vertebral body height was 18% at final follow-up. Neurological outcome was assessed by ASIA impairment scale. According to this scale, during preoperative period, 50% were graded as Grade A, 20% as Grade B, and 30% as Grade C. During last follow-up, Grade A was 50%, Grade B was 10%, Grade C was 20%, and Grade D was 20%. Eighty percent of the patients had shown no complications, only pressure sore (20%) and wound dehiscence (10%) were observed in the study group. In the final follow-up, 50% of patients were confined to wheelchair whereas rest of the 50% can walk with support.


  Conclusion Top


Thoracolumbar injury is a common neurosurgical problem in road traffic accidents and fall from height. Surgical treatment is a better option for early ambulation and faster recovery.

Pedicle screw fixation is a useful choice, which achieves reduction and stability in both anterior and posterior column injuries. Complications related directly to pedicle screw rod instrumentation such as pedicle screw breakage, pressure sore, and misplacement of screws are comparable with other studies. Early the intervention betters the prognosis. This study is also not without limitations. Sample size is too small. There was limited infrastructural support also. Thoracolumbar spinal injury is a significant cause of morbidity and mortality in developing countries. The demographics, epidemiological pattern of spine injury in the developing world is different from the developed world and this should be considered while formulating policies for the SCI in future. Large-scale trials are needed to assess the true magnitude of the problem and their management in the developing world.


  Case Report Top


A 20-year-old male patient with a history of fall from height and presenting with paraplegia of both lower limbs (MRC Grade 0) and loss of bladder sensation. Skiagram of DL spine revealed a compression fracture of L1 vertebra. Pedicle screw fixation was done after taking proper consent and preanesthetic evaluation. The pre and post-operative radio-imaging findings are shown in [Figure 6],[Figure 7],[Figure 8],[Figure 9].
Figure 6: Preoperative skiagram

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Figure 7: Preoperative magnetic resonance imaging

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Figure 8: Preoperative magnetic resonance imaging sagittal sections

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Figure 9: Postoperative skiagram

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Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Sekhon LH, Fehlings MG. Epidemiology, demographics, and pathophysiology of acute spinal cord injury. Spine (Phila Pa 1976) 2001;26 24 Suppl: S2-12.  Back to cited text no. 1
    
2.
Pawar UM, Sengupta DK. Pathophysiology of spinal cord injuries. In: Rajasekaran S, editor. Spinal infections and trauma, 1st ed. New Delhi: Jaypee Brothers Medical Publishers; 2011. P. 389.  Back to cited text no. 2
    
3.
Pandey V, Nigam V, Goyal TD, Chhabra H. Care of post-traumatic spinal cord injury patients in India: An analysis. Indian J Orthop 2007;41:295-9.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
DeWald RL. Burst fractures of the thoracic and lumbar spine. Clin Orthop Relat Res 1984;184:150-61.  Back to cited text no. 4
    
5.
Chapman JR, Mirza SK. Rockwood, Green Fractures in Adults. 5th ed., Vol. 2. Philadelphia, USA: Lippincott Williams and Wilkins; 2001. p. 1295-466.  Back to cited text no. 5
    
6.
Alpantaki K, Bano A, Pasku D, Mavrogenis AF, Papagelopoulos PJ, Sapkas GS, et al. Thoracolumbar burst fractures: A systematic review of management. Orthopedics 2010;33:422-9.  Back to cited text no. 6
[PUBMED]    
7.
Burney RE, Maio RF, Maynard F, Karunas R. Incidence, characteristics, and outcome of spinal cord injury at trauma centers in North America. Arch Surg 1993;128:596-9.  Back to cited text no. 7
[PUBMED]    
8.
Alvine GF, Swain JM, Asher MA, Burton DC. Treatment of thoracolumbar burst fractures with variable screw placement or Isola instrumentation and arthrodesis: Case series and literature review. J Spinal Disord Tech 2004;17:251-64.  Back to cited text no. 8
[PUBMED]    
9.
Razak M, Mahmud MM, Hyzan MY, Omar A. Short segment posterior instrumentation, reduction and fusion of unstable thoracolumbar burst fractures – A review of 26 cases. Med J Malaysia 2000;55 Suppl C: 9-13.  Back to cited text no. 9
    
10.
Prabhakar MM, Rao BS, Patel L. Thoracolumbar burst fracture with complete paraplegia: Rationale for second-stage anterior decompression and fusion regarding functional outcome. J Orthop Traumatol 2009;10:83-90.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
    Tables

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



 

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Abstract
Introduction
Materials and Me...
Results and Analysis
Discussion
Summary
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Case Report
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