Effect of loss of correction on functional outcomes in thoracolumbar burst fractures treated with short segment posterior instrumentation

Öz

Aim: Burst fractures are defined as vertebra fractures involving the anterior and middle columns and are associated with kyphotic deformity and retropulsion of bone fragment into the spinal canal. Although their treatment is controversial in the literature, use of transpedicular screws and short segment posterior instrumentation are increasingly common practices. The aim of this study is to investigate the radiological and functional outcomes of thoracolumbar vertebra burst fractures treated with short segment posterior instrumentation and to examine the effects of postoperative correction loss on these results.

Methods: Patients who were surgically treated for thoracolumbar burst fractures and prospectively followed-up between 2000-2003 were scanned retrospectively for this cohort study. 48 patients were included in the study, of which 18 were females (37.5%) and 30 were males (62.5%). Denis Pain Scale (DPS) and Denis Work Scale (DWS) were used for functional analysis. Cobb angles that were measured preoperatively, on the first postoperative day, and at the last follow-up visit were used for evaluation of radiological outcomes. Spinal stenosis and remodelization rates were also calculated by computerized tomography obtained preoperatively and at the last follow-up. One-way ANOVA and Pearson correlation tests were used for statistical analysis.

Results: No patient had any chronic pain complaints, and none were unable to work. The mean Cobb angles in the preoperative, early post-operative and final controls were measured as 23.2, 4.9, and 12.3 degrees, respectively. While preoperative mean Cobb angle and mean correction were positively correlated (r=0.85, P<0.001), there was no correlation between preoperative mean Cobb angle and loss of correction (r=0.27, P=0.43). There was a correlation between correction and loss of correction (r=0.38, P=0.008). Spinal stenosis, which was 35.7% preoperatively, reduced to 17.1% in the last follow-up. The mean remodelization was 51.3%, which was significant (P<0.001). Loss of correction was found significant in patients with poor DWS (P=0.003), and no such relationship was found in DPS. No correlation was found between the Cobb angle at the last follow-up, DPS and DWS. 

Conclusion: In conclusion, the loss of correction after short segment posterior instrumentation and fusion surgery is significantly higher in thoracolumbar burst fractures, especially when intraoperative correction exceeds 15 degrees. Denis Work Scale was significantly worse in patients with loss of correction above 10 degrees. The degree of loss of correction at the last follow-up is directly related to clinical and functional outcomes.

Anahtar Kelimeler

• Cobb angle,Burst fractures,Kyphosis,Remodelization,Loss of correction,Short segment posterior instrumentation

Kısa segment posterior enstrümentasyon ile tedavi edilen torakolomber burst kırıklarında korreksiyon kaybının fonksiyonel sonuçlar üzerine etkisi

Öz

Amaç: Burst kırıkları, ön ve orta kolonu içeren, kifotik deformite ve kemik fragmanının spinal kanala retropülsiyonu ile ilişkili vertebra kırıkları olarak tanımlanır. Tedavileri literatürde tartışmalı olsa da transpediküler vida ve kısa segment posterior enstrümentasyon oldukça sık uygulanmaktadır. Bu çalışmanın amacı kısa segment posterior enstrümentasyon ile tedavi edilen torakolomber vertebra burst kırıklarının radyolojik ve fonksiyonel sonuçlarını ve postoperatif korreksiyon kaybının bu sonuçlar üzerine etkisini incelemektir.

Yöntemler: 2000-2003 yılları arasında torakolomber burst kırığı nedeniyle cerrahi olarak tedavi edilen ve prospektif olarak takip edilen hastalar, bu retrospektif kohort çalışması için retrospektif olarak tarandı. Çalışmaya 18'i kadın (%37,5), 30'u erkek (%62,5) olan 48 hasta alındı. Fonksiyonel analiz için Denis Ağrı Skoru (DPS) ve Denis İş Skoru (DWS) kullanıldı. Radyolojik analiz için preoperatif, postoperatif ilk gün ve son takipte ölçülen Cobb açıları kullanıldı. Ayrıca preoperatif ve son takipte çekilen bilgisayarlı tomografi aracılığı ile spinal stenoz ve remodelizasyon oranları hesaplandı. İstatistiksel analiz için tek yönlü ANOVA ve Pearson korelasyon testleri kullanıldı.

Bulgular: Hiçbir hastada kronik ağrı ya da işe geri dönememe şikâyeti görülmedi. Hastaların ameliyat öncesi, sonrası ve son kontrollerde ortalama Cobb açıları sırası ile 23,2, 4,9 ve 12,3 derece olarak ölçüldü. Ameliyat öncesi ortalama Cobb açısı ile ortalama korreksiyon arasında anlamlı bir korelasyon saptanırken (r=0,85, P<0,001); korreksiyon kaybı ile arasında anlamlı ilişki bulunmadı (r=0,27, P=0,43). Korreksiyon ve korreksiyon kaybı arasında bir korelasyon tespit edildi (r=0,38, P=0,008). Ameliyat öncesi %35,7 olarak hesaplanan spinal darlığın, son takipte %17,1’e gerilediği görüldü. Ortalama remodelizasyon %51,3 olarak hesaplandı. Spinal kanal remodelizasyonu anlamlı bulundu (P<0,001). 10 dereceden fazla korreksiyon kaybı olan hastalar ile DWS arasında anlamlı ilişki bulundu (P=0,003). DPS'de böyle bir ilişki bulunamadı. Son takipte ölçülen Cobb açısı ile DPS ve DWS arasında ilişki saptanmadı.

Sonuç: Sonuç olarak, kısa segment posterior enstrümentasyon ve füzyon cerrahisi sonrası korreksiyon kaybı, torakolomber burst kırıklarında, özellikle intraoperatif korreksiyon 15 dereceyi aştığında, belirgin olarak daha yüksektir. DWS, 10 derecenin üzerinde korreksiyon kaybı olan hastalarda anlamlı olarak daha kötüdür. Son takipteki korreksiyon kaybının derecesi doğrudan klinik ve fonksiyonel sonuçlarla ilgilidir.

Anahtar Kelimeler

• Burst kırıkları,Kifoz,Cobb açısı,Remodelizasyon,Korreksiyon kaybı,Kısa segment posterior enstrümentasyon

Kaynakça

1. 1. Shamhoot EA, Elkholy AR. The Role of Combined Posterior and Anterolateral Retroperitoneal Approach in the Treatment of Posttraumatic Burst Lumbar Fractures. Asian J Neurosurg. 2019 Apr-Jun;14(2):467-72. doi: 10.4103/ajns.AJNS_262_18.
2. 2. Gajjar SH, Menon HJ, Chaudhari N, Chaudhari V. Outcomes of short segment posterior instrumentation in unstable thoracolumbar fractures. J Clin Diagn Res. 2016 Nov;10(11):RC04-RC08. doi: 10.7860/JCDR/2016/23133.8825.
3. 3. Vu TT, Morishita Y, Yugue I, Hayashi T, Maeda T, Shiba K.. Radiological Outcome of Short Segment Posterior Instrumentation and Fusiın for Thoracolumbar Burst Fractures. Asian Spine J. 2015 Jun;9(3):427-32. doi: 10.4184/asj.2015.9.3.427.
4. 4. Gündoğdu, E. Rare and overlooked two diagnoses in low back pain: Osteitis consensans ilii and lumbosacral transitional vertebrae. J Surg Med. 2018;2(3):320-3. Doi: 10.28982/josam.429889.
5. 5. Scheer JK, Bakhsheshian J, Fakurnejad S, Oh T, Dahdaleh NS, Smith ZA. Evidence-Based Medicine of Traumatic Thoracolumbar Burst Fractures: A Systematic Review of Operative Management across 20 Years. GSJ. 2015 Feb;5(1):73-82. doi: 10.1055/s-0034-1396047.
6. 6. Denis F, Armstrong GWD, Searls K, Matta L. Acute Thoracolumbar Burst Fractures in the Absence of Neurologic Deficit. Clin Orthop. 1984;189:142-9.
7. 7. Leventhal MR. Fractures, Dislocation, and Fracture-Dislocations of Spine. In: Crenshaw AH, ed. Campbell’s Operative Orthopaedics. Eight Edition, Vol. 5, 3517-3582, 1992.
8. 8. Chapman JR, Anderson PA. Thoracolumbar Spine Fractures with Neurologic Deficit. Orthop Clin North Am. 1994;25:595-612.

9. 9. Denis F. Spinal Instability as Defined by the Three Column Spine Concept in Acute Spinal Trauma. Clin Orthop. 1984;189:65-76.
10. 10. Alanay A, Acaroğlu E, Yazıcı M, Öznur A, Surat A. Short-Segment Pedicle Instrumentation of Thoracolumbar Burst Fractures: Does Transpedicular Intracorporeal Grafting Prevent Early Failure? Spine. 2001;26:213-7.
11. 11. Knop C, Fabian HF, Bastian L, Blauth M. Late Results of Thoracolumbar Fractures after Posterior Instrumentation and Transpedicular Bone Grafting. Spine. 2001;26:88-99.
12. 12. Shen WJ, Shen YS. Nonoperative Treatment versus Posterior Fixation for Thoracolumbar Junction Burst Fractures without Neurologic Deficit. Spine. 2001;26:1038-45.
13. 13. De Peretti F, Hovorka I, Cambas PM, Nars JM, Argenson C. Short Device Fixation and Early Mobilization for Burst Fractures of the Thoracolumbar Junction. Eur Spine J. 1996;5:112-20.
14. 14. Kaneda K, Taneichi H, Abumi K, Hashimoto T, Satoh S, Fijiya M. Anterior Decompression and Stabilization with the Kaneda Device for Thoracolumbar Burst Fractures Associated with Neurological Deficits. J Bone Joint Surg. 1997;79(Am):69-83.
15. 15. Denis F. The Three Column Spine and Its Significance in the Classification of Acute Thoracolumbar Spinal Injuries. Spine. 1983;8:817-31.
16. 16. Çelebi L, Muratlı HH, Doğan Ö, Yağmurlu MF, Akterkin CN, Biçimoğlu A. The Efficacy of Non-Operative Treatment of Burst Fractures of the Thoracolumbar Vertebra. Acta Orthop Traumatol Turc. 2004;38(1):16-22.
17. 17. Willen J, Anderson J, Toomoka K, Singer K. The Natural History of Burst Fractures at the Thoracolumbar Junction. J Spinal Disorders. 1990;3:39-46.
18. 18. Willen J, Uttam HG, Kakulas BA. Burst Fractures in the Thoracic and Lumbar Spine. A Clinic-Neuropathological Analysis. Spine. 1989;14:1316-23.
19. 19. Esses SI, Batsford DJ, Kostuik JP. Evaluation of Surgical Treatment for Burst Fractures. Spine. 1990;15:667-73.
20. 20. Sasso RC, Cotler HB. Posterior Instrumentation and Fusion for Unstable Fractures and Fracture Dislocations of the Thoracic and Lumbar Spine. Spine. 1993;18:45-60.
21. 21. Kerttula LI, Serlo WS, Tervonen OA, Paakko EL, Vanharanta HV. Post-traumatic findings of the spine after earlier vertebral fracture in young patients: clinical and MRI study. Spine. 2000;25:1104-8.
22. 22. Tschoeke SK, Hellmuth M, Hostmann A, Robinson Y, Ertel W, Oberholzer A, et al. Apoptosis of human intervertebral discs after trauma compares to degenerated discs involving both receptors mediated and mitochondrial-dependent pathways. J Orthop Res. 2008;26:999-1006.
23. 23. Carl AL, Tromanhauser SG, Roger DJ. Pedicle Screw Instrumentation for Thoracolumbar Burst Fractures and Fracture-Dislocations. Spine. 1992;17:317-24.
24. 24. Öner FC, Van Gils AP, Faber JA, Dhert WJ, Verbout AJ. Same Complication of Common Treatment Schemens of Thoracolumbar Spine Fractures can be Predicted with Magnetic resonance Imaging: Prospective Study of 53 Patient with 71 Fractures. Spine. 2002;27:629-36.
25. 25. Esses SI. The Placement and Treatment of Thoracolumbar Spine Fractures: An Algorithmic Approach. Orthop Review. 1998;17:571-83.
26. 26. Yazıcı M, Atilla B, Tepe S, Çalışır A. Spinal Canal Remodeling in Burst Fractures of the Thoracolumbar Spine: A Computerized Tomographic Comparison Between Operative and Non-Operative Treatment. J Spinal Disord. 1996;9:409-13.
27. 27. Bohlman HH, Kırkpatrick JS, Delamarter RB, Leverthal M. Anterior Decompression for Late Pain and Paralysis after Fractures of the Thoracolumbar Spine. Clin Orthop. 1994;300:24-9.
28. 28. Dai Ly. Remodeling of the Spinal Canal after Thoracolumbar Burst Fractures. Clin Orthop. 2001;382:119-23.