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SPINE Table of Contents   
Year : 2005  |  Volume : 39  |  Issue : 4  |  Page : 232-236
Management of unstable spinal fractures with segmental spinal instrumentation (VSP System) : Results at 5 year follow up


Department of Orthopaedics. Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India

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   Abstract 

Background: Pedicle screw instrumentation has been widely used for spinal stabilisation following spinal injury with variable results. The controversial points associated with spinal injury are effects of canal compromise and decompression on neurological status.
Methods: Thirty four patients of unstable thoraco-lumbar fracture with or without neuro-deficit were treated by decompression and stabilisation with VSP system and followed up for 22 - 39 months (mean 29 months). The results were evaluated by neurological recovery (ASIA score), pain relief, loss of surgical correction and functional rehabilitation (FIM score).
Results: We achieved a mean post-operative correction of the kyphotic deformity by 14 degrees and an average gain of 30.2% in the canal diameter by decompression. However no correlation was established between degree of canal compromise before or after the surgery with the final neurological outcome.
Conclusion: Although the infrastructure for spinal injury management in developing countries is inadequate in many aspects, we find that it is still possible to achieve results, which are comparable with standard literature by adequate decompression and stabilisation followed by appropriate rehabilitation according to the social and cultural demands of the patients.

Keywords: Unstable spinal fracture; Decompression and stabilisation; Fusion; Rehabilitation; Social and cultural demands.

How to cite this article:
Sen D, Patro D K. Management of unstable spinal fractures with segmental spinal instrumentation (VSP System) : Results at 5 year follow up. Indian J Orthop 2005;39:232-6

How to cite this URL:
Sen D, Patro D K. Management of unstable spinal fractures with segmental spinal instrumentation (VSP System) : Results at 5 year follow up. Indian J Orthop [serial online] 2005 [cited 2019 Sep 23];39:232-6. Available from: http://www.ijoonline.com/text.asp?2005/39/4/232/36576

   Introduction Top


No other condition causes such an awful morbidity for a patient than an unstable spine. Not only it significantly restricts his/her normal daily activities due to pain, but may also produce significant neurological compression symptoms, which may convert a young active healthy individual into a completely bedridden and dependent person in a matter of hours. Along with this is added the psychological component within a few days. Then it is a menacing problem for the doctor who treats or the nurse who looks after. Hence there is importance of aggressive management [1],[2],[3] for these patients by quick stabilisation and mobilisation. However in a developing country like India the situation becomes more difficult because of inadequate facilities and infrastructures to provide a comprehensive management for these patients. The objective of our present study was to overcome these problems with locally available resources and evaluate our results in comparison with similar other studies in the literature. We have treated 34 patients of traumatic unstable spine with locally available implants [4],[5] - Variable Screw Placement system of pedicular screw and segmental spinal plate [6],[7] and subsequently rehabilitated them according to their social and cultural demand. We find that even within limits of funds and resources it is possible to treat these patients and send them home with reasonable degree of independence for normal daily living activities.


   Materials and methods Top


From August 1996 to May 1999, 41 patients were operated for unstable spinal fractures and were followed up for 28 to 67 months (mean 54 months) but a minimum of 24 months follow up data was available in only 34 patients and results were based on those patients only. The criterion for inclusion was unstable thoraco-lumbar spinal fractures with or without neurological deficit. A minimum of 24 months follow up was necessary after the surgery for assessment of outcome.

Initial assessment: Immediately after admission the patient was placed in a safe and comfortable position to prevent[8] any further neurological deterioration. ASIA (American Spinal Injury Association) neurological assessment was used to record/follow up the neurology (ASIA score = ASIA motor score + ASIA sensory score, [Table - 1] and FIM (Functional Independence Measure) scoring [Table 2] was used for functional assessment before and after treatment. For proper identification [9] of the fracture details and classification purpose we did CT scan for the affected segments and the fracture was classified according to the Dennis classification [10] . The stability pattern was established by the White and Punjabi scoring system[11].

Surgical technique: Surgery was done as soon as possible after admission. The spine was approached in the midline posterior approach, fracture site was identified and decompression done posterolaterally. The pedicle entry points were identified (by intersection method [11] and confirmed by image intensifier guidance) and opened, probed all around and the pedicular screw was introduced. The segmental spinal plate was contoured to maintain the lumbar lordosis and used for fixation along with bone graft.

Postoperative period: Post operatively the patients were re -evaluated neurologically every 2 weeks till the inpatient stay. A CT scan was performed within 2-3 weeks of surgery for assessment of accuracy of screw placement[13],[14] , adequacy of decompression, the degree of correction achieved in sagittal plane etc. The patients were mobilised with appropriate brace and callipers depending upon the pain tolerance and general condition.

Rehabilitation and follow up: All the patients were put into a rehabilitation programme under the supervision of physiotherapist and occupational therapist and when achieved adequate degree of independence in daily living activities (assessed by FIM score) were discharged. The focal point of rehabilitation was training for activities according to their actual demands in relation to their home circumstances rather than following a protocol for all patients. Subsequently they were followed up as outpatient at periodic interval for a variable period of 28 to 67 months (average of 54 months). The actual evaluation of the patient in each visit included clinical examination, assessment of ASIA and FIM score and radiological evaluation for maintenance of correction.

We have graded the recovery into 4 grades depending upon a combined scoring[7] system involving ASIA and FIM score and loss of surgical correction if any.

Excellent: Improvement of ASIA by more than 66 points and/or improvement of FIM by more than 55 points plus no loss of surgical correction.

Good: Improvement of ASIA by 49-65 points and/or improvement of FIM by 44-55 points and/or loss of correction by less than 10 degree.

Fair: Improvement of ASIA by 24-48 points and/or improvement of FIM by 22-44 points and/or loss of correction by 10-20 degrees.

Poor: Improvement of ASIA by less than 24 points and/ or improvement of FIM by less than 22 points and/or loss of correction by more than 20 degrees or implant failure.


   Results Top


The spinal injury consists of 3% of total trauma admissions in our hospital per year. Eight patients were less than 25 years, 16 patients in the age group of 25-40 years and 10 patients were of more than 40 years of age. Twelve patients were brought to the hospital on the same day of injury while ten patients were brought within 48 hours of injury. The two common modes of injury were a) fall between two different heights (22 patients) and b) road traffic accident (12 patients).

The vertebral level of fractures in the study group was as follows. D12 - 6 patients, L 1 - 22patients, L 2 - 4 patients and L 4 - 2 patient. Eight patients had other associated injuries along with the fracture spine. The neurological status of the patients at the time of admission was as follows: complete paraplegia 8, incomplete paraplegia 23, and 3 patients had no neurological deficit. The fractures were classified according to Dennis 3 column classification system and the distribution was as follows: True wedge compression - - 2 patients, Burst-20 patients, Fracture dislocation - - 12 patients.

We measured the kyphotic angle in all the patients both pre and post operatively. Mean preoperative kyphotic angle was 16 O (range 6 O - 28 O ) and mean postoperative angle was 3.8 O (range - 4 O - 8 O ). We achieved a mean surgical correction of kyphotic deformity by 14 degrees, but there was a loss of correction by 2-4 degrees within 12 months post - - operatively. For all patients we measured the antero-posterior canal diameter both pre and post operatively [Table - 1] to measure the adequacy of decompression and no correlation was established between the percentage of canal compromise with neurological grade or final neurological outcome. The functional improvement (FIM Score) was more or less parallel to neurological improvement. Patients having neuro-deficit caudal to L3-L4 segment had distinct better outcome in terms of mobilisation with callipers. Wheel chair mobilisation as commonly practised in the western world was not acceptable to patients as well as not feasible considering our building design, road condition and social circumstances around the patients. Rather mobilisation with callipers was more acceptable.

When considering the overall results involving neurological recovery (ASIA Score) and functional outcome (FIM Score) we have 6 patients in the excellent category, 15 considered as good, 9 in the fair group and 4 had done poorly.


   Discussion Top


Thoracolumbar junction is the commonest area involved in spinal injury. Gertzbein [15] had reported 44 burst fractures, out of which 30 (68%) were around D12 and L 1 , Viale [16] reported 15 (55%) out of 27 fractures in his series around L 1 . The importance of noting this data is three fold. First this area represents the transition from thoracic kyphosis to lumbar lordosis and the axis of body weight passes in front of this junction when the patient is erect. So there is an anterior bending moment working at this junction resulting in maximum stress concentration in this area which may be responsible for implant failure at this junction [17] .Therefore, we tried to rigidly stabilize this area to enable the spine to withstand that stress. Secondly patients having injury at this level have poor neurological status [15] . This is due to the fact that spinal cord ends at lower border of L 1 . Any injury involving D12 , L 1 will directly affect the cord. Thirdly this area represents the transition between the relatively stiff thoracic segment and mobile lumbar segments. So, we used the segmental fixation with pedicle screw plates so as to keep as much motion segment intact as possible.

We classified the fracture according to Dennis 3 column classification [10] depending upon the CT scan pictures [9], [18]. This is because some fractures although appeared to be simple wedge compression on initial X-ray evaluation later on evaluation by CT scan found to have significant disruption of posterior elements and reclassified as burst fractures. The type of fracture determination is important in the sense that it influences the urgency of treatment (fracture dislocation are highly unstable and needs to be treated early), the type of treatment (compression fracture may be managed conservatively, but burst and fracture dislocation need stabilization). Moreover, we have seen that burst fracture and fracture dislocation are associated with worse neurological outcome post operatively.

For the purpose of evaluation of correction of deformity we measured the kyphotic angle pre and postoperatively. We had a mean preoperative kyphotic angle of 16° and postoperative 3.8°. Similar study reports include that of Viale and Silvestro [16] with corresponding figures of 17° and -2.58° respectively, Esses[19] 18.7° and 3.5° respectively. Our study result is in agreement with both of these two. We achieved a mean correction of kyphotic angle by 14° with subsequent loss of correction by 2-4 degrees in 6 patients over 12 months, all of them were asymptomatic for this. The importance of this fact is that more the kyphotic angle after the corrective surgery, more is the anterior bending load on the implant and the fused segment resulting in increased incidence of implant failure. The degree of correction achieved was statistically significant up to a confidence limit of 99.5% (t = 9.55), which justifies attempt to surgically correct Cobb's angle. Would solid fusion maintain this correction over a long period of time? The answer to this question remains statistically unreliable due to low frequency or short length of monitoring time (average 28 months only) after surgery.

Decompression in spinal injury is one of the most controversial concepts. Though the initial injury may well be the major determinant of neurological outcome [20] , the role of decompression has always been debated. Both experimental and clinical findings of Benzel [21] (1986), Dolan [22] (1980), Maiman [23] (1984) clearly documented the role of neural decompression in improving the neurological outcome. The essential key to reduction of the intracanal fragments in burst fracture is distraction [20],[24] . So any device used posterior must have large distractive force. The pedicular screw system can provide large amount of distraction [16] and open up the collapsed anterior segment at specific level by appropriately contouring the plate according to the saggital curvature of the spine. Viale and Silverstro [16] also provided evidence that transpedicular decompression in experienced hands is usually able to restore an almost normal cross-sectional area at the affected level of spinal canal. In our study decompression was done in patients having >50% canal compromise [25] , posterolaterally by scooping out the retropulsed bony fragments from the canal as well as pushing some of the fragments anteriorly and we achieved adequate cross sectional clearance by this method.

We measured the anteroposterior canal diameter both pre and postoperatively to evaluate the adequacy of decompression and tried to correlate the canal encroachment with the neurological grades and outcome. We had a mean preoperative canal compromise of 62.5% and postoperative 27.35%. Similar figures have been obtained by Gertzbein [15] (62% and 26% respectively), Viale [16] (63.71% and 4.56%), and Esses [19] (44.5% and 16.5% respectively). We achieved an average gain in the canal diameter by 30.2% by the process of posterolateral decompression. Using a t - - statistic test we find that the degree of decompression achieved by surgery was sufficiently significant up to a confidence level of 99.5%. However there was no correlation with the progress or final neurological outcome with the degree of decompression achieved (as evident from post operative CT scan). There is evidence in literature both supporting 9, 18, 23, 26-28 as well as negating [15],[29] our findings.

One of the major purposes of our study was to ensure solid fusion between the instrumented levels. The importance of fusion should never be neglected as no implant will hold the reduction or stabilisation unless there is a solid fusion. The fusion was assessed postoperatively by detecting intersegment movement in dynamic radiograph, increase in Cobb's angle and clinical symptoms. But because of the presence of implants on the posterior surface, it was not always easy to assess the fusion radiologically [30],[31],[32] . So, we relied more on clinical criteria like chronic low-grade pain, change of neurology if any. We had only one case of proven pseudoarthrosis with implant failure. It was detected by 1 year when the patient discarded the brace and started working as before. There were breakage of 2 pedicle screws along with progressive increase in kyphotic angle, and 2.5 mm of relative movement between L 1 and L 2 vertebral level in flexion extension views. The implants were removed and the patient was treated in an anterior spinal hyperextension brace for 3 months with no further symptoms.

We have evaluated the overall results in our patients considering the actual demands and needs of their life. The parameters considered were neurological recovery (ASIA score), functional recovery (FIM score) and occupational rehabilitation, pain relief and loss of radiological correction. The average increase in ASIA and FIM scores were 50.29 and 43.61 respectively (statistically significant; Paired t-test; p<0.05). 6 patients in the excellent category recovered neurologically completely, went back to previous job and had no complaints till last visit into the follow up clinic. We had 15 patients with good result. They had minimal loss of correction, signification pain relief and returned to previous job with restriction of heavy weight lifting. Nine patients were graded fair, as they had minimal neurological recovery or had complications, needed calipers and other aids for mobilisation, could not go back to previous job (all of them were involved in heavy activities in their occupation). Four patients were poor in terms of recovery. They had no neurological recovery, developed pressure sore, could not be rehabilitated. The intellectual level of these patients was also poor affecting the progress in rehabilitation training.

Therefore overall 30 patients (88%) were somewhat benefited by the surgery and rehabilitation protocol which by any standard may be considered good enough given our infrastructure, patient profile and socio-economic atmosphere in a developing world.

Management of spinal injury is usually considered an extremely difficult and demanding job when considered in respect of inadequate infrastructural support in the hospitals of developing countries. However we find that the results of this study is comparable with similar other studies in most aspects although we have used locally manufactured implants which is much cheaper than the standard latest implants and this is particularly significant when considering the socio­economic structure of our country. We have rehabilitated our patients keeping in mind about their actual demands and needs in life which is entirely different from that in a Western country, and that has made our job easier. Therefore we believe that with little extra effort and dedication it is possible even within limits of resources to deliver some benefit both medical and social to the patient to make their daily life reasonably comfortable.

Acknowledgements

We express our sincere gratitude to The Director JIPMER Hospital, Pondicherry, India for providing us the opportunity to carry out the study for a prolonged period in the department. We are also grateful to Dr. S Elangovan, Professor and Head of the Department of Radiology, JIPMER Hospital, Pondicherry, India for providing the radiological backup during the study. Dr. John K Liakos has done the statistical work for the study. This study could not have been carried out without the extensive support provided by our colleagues in the Physiotherapy and Occupational therapy department.

 
   References Top

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2. Hardcastle P, Bedbook G, Curtis C. Long term results of conserva­tive and operative management in complete paraplegics with spinal cord injuries between T10 and L2 with respect to function. Clin Orthop. 224: 88-96; 1987.  Back to cited text no. 2    
3. Weynes F, Rommens PM, Calenbergh VF, Goffin J, Broos P, Plets C. Neurological outcome after surgery for thoracolumbar fractures. Euro Spine J. 3(5): 276-281; 1994.  Back to cited text no. 3    
4. Anand N, Tanna DD. Unconventional pedicle spinal instrumentation - The Bombay experience. Spine. 19(19): 2150-2158; 1994.  Back to cited text no. 4    
5. Bhojraj S, Archik SG. Early results of unconventional pedicular screw plate fixation. Spine. 16(10): 1190-1195; 1991  Back to cited text no. 5    
6. Steffee AD, Biscup R, Sitkowski DJ. Segmental spine plates with pedicle screw fixation: A new internal fixation device for disorders of the lumbar and thoracolumbar spine. Clin Orthop. 203:45-53; 1986.  Back to cited text no. 6    
7. Steffee AD, Brantigan JW. The variable screw placement spinal fixa­tion system. Spine. 18(9): 1160-1172; 1993.  Back to cited text no. 7    
8. Gertzbein SD. Neurological deterioration in patients with thoracic and lumbar fractures after admission to the hospital. Spine. 19(15): 1723­1725; 1994.  Back to cited text no. 8    
9. Mcafee PC, Yuan H, Fredrickson BE, Lubicky JP. The value of computed tomography in thoracolumbar fractures. J Bone Joint Surg (Am). 65(4): 461-473; 1983.  Back to cited text no. 9    
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11. White AA, Panjabi M. Clinical Biomechanics of the Spine. 2nd ed. Philadelphia : JB Lippincott, 1990.  Back to cited text no. 11    
12. Weinstein JN, Spratt KF, Spengler D, Brick C, Reid S. Spinal pedicle fixation reliability and validity of roentgenogram based assess­ment and surgical factors on successful screw placement. Spine. 13(9): 1012-1018; 1988.  Back to cited text no. 12    
13. Farber GL, Place HM, Mazur RA, Jones DE, Damiano TR. Accuracy of pedicle screw placement in lumbar fusion by plain radiographs and computed tomography. Spine. 20(13): 1494-1499. 1995.  Back to cited text no. 13    
14. Gertzbein SD, Robbins SE. Accuracy of pedicular screw placement in vivo. Spine. 15(1): 11-14; 1990.  Back to cited text no. 14    
15. Gertzbein SD, Brown CMC, Marks P, Martin C, Fazl M, Schwartz M, Jacobs RR. The neurological outcome following surgery for spinal fractures. Spine. 13:641-644; 1988.  Back to cited text no. 15    
16. Viale GL, Silvestro C, Francaviglia N, Carta F, Bragazzi R, Bernucci C, Maiello M. Transpedicular decompression and stabilisation of burst fractures of the lumbar spine. Surg Neurol. 40: 104-111, 1993.  Back to cited text no. 16    
17. Carl AA, Tromanhauser SG, Douglas JR. Pedicle screw instrumen­tation for thoracolumbar burst fractures and fracture dislocation. Spine. 17 (Suppl): S317-S324, 1992.  Back to cited text no. 17    
18. Trafton PG, Boyd CA. Computed tomography of thoracic and lumbar spine injuries. J Trauma. 24: 506 - 515, 1984.  Back to cited text no. 18    
19. Esses Sl, Botsford DJ, Kostuik JP. Evaluation of surgical treatment for burst fractures. Spine. 15(7): 667-673; 1990.  Back to cited text no. 19    
20. Crutcher JP, Anderson PA, King HA. Indirect spinal canal decom­pression in patients with thoraco-lumbar burst fractures treated by pos­terior distraction rods. J Spinal Disorder. 1991; 4: 39-48.  Back to cited text no. 20    
21. Benzel EC, Larson SJ. Functional recovery after decompressive op­eration for thoracic and lumbar spine fractures. Neurosurg. 19(5): 772­778; 1986.  Back to cited text no. 21    
22. Dolan EJ, Tator CH, Endrenyi L. The value of decompression for acute experimental spinal cord compression injury. J Neurosurg. 53(6):749­755; 1980. Spine 16(8): S428-S432; 1991  Back to cited text no. 22    
23. Maiman D, Larson S, Benzel E. Neurological improvement associated with late decompression of the thoracolumbar spinal cord. Neurosurg. 1984; 14: 302- 307.  Back to cited text no. 23    
24. Fredrickson EB, Mann KA, Yuan HA, Lubicky JP. Reduction of the intracanal fragment in experimental burst fractures. Spine. 13: 267 - 271, 1988.  Back to cited text no. 24    
25. Mcnamara MJ, Stephens GC, Spengler DM. Transpedicular short segment fusions for treatment of lumbar burst fracture. J Spinal Disor­der. 5(2): 183-187; 1992  Back to cited text no. 25    
26. Mick CA, Carl A, Sachs B, Hresko T, Pfeifer B. Burst fracture of the fifth lumbar vertebrae. Spine. 18(13): 1878-1884:1993.  Back to cited text no. 26    
27. Guha A, Tator CH, Endrenyi L, Piper I. Decompression of the spinal cord improves recovery after acute experimental spinal cord compres­sion injury. Paraplegia. 1987 Aug; 25(4): 324-339.  Back to cited text no. 27    
28. Knop C, Blauth M, Buhren V, Hax PM, Mutschler W, Pommer A, Ulrich C,Wagner S, Weekbach A, Worsdorfer O. Surgical treatment of injuries of the thoracolumbar transition.2: Operation and roentgeno­logic findings: Unfallchirurg. December ;103(12):1032-1047.  Back to cited text no. 28    
29. Dall BE, Stauffer ES. Neurologic injury and recovery patterns on burst fractures at the T 12 or L 1 motion segment. Clin Orthop. 233:171-176; 1988.  Back to cited text no. 29    
30. Kant AP, Daum WJ, Dean SM, Uchida T. Evaluation of lumbar spine fusion: Plain radiograph versus direct surgical exploration and observa­tion: Spine. 20(21): 2313-2317; 1995.  Back to cited text no. 30    
31. Blumenthal SL, Gill K. Can lumbar spine radiographs accurately de­termine fusion in postoperative patients? Spine. 18(9): 1186-1189; 1993  Back to cited text no. 31    
32. Lang P, Genant HK, Chafetz N, Steiger P, Morris J. Three dimen­sional computed tomography and multiplanar reformation in the assess­ment of pseudoarthrosis in posterior lumbar fusion patients. Spine. 13(1): 69-75; 1989  Back to cited text no. 32    

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Correspondence Address:
Dipankar Sen
Department of Orthopaedics. Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5413.36576

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