| Abstract|| |
Background : Post traumatic kyphotic deformity are managed by different methods. Posterior stabilization of dorso-lumbar fractures with transpedicular screws and rods using intermediate facets as fulcrum can restore body height.
Methods and material : In a retrospective clinical study 6 consecutive patients with complete or incomplete neurological deficits as a result of the dorso-lumbar fractures were included. Local kyphosis was measured as the angle between the upper and lower end plates of the collapsed vertebrae preoperatively, postoperatively and at the last follow-up visit. The neurological condition of the patients was recorded in the pre-op and follow up period according to Frankel grading systems. Stabilization with pedicle screw fixation and posterior fusion with autogenous bone chips were done after decompression in all 6 patients included in this study. The outcome of the study was evaluated with regard to the correction of kyphotic deformity and increase in vertebral body height after adequate neural canal decompression and fusion.
Results : Of the 6 patients 4 were Frankel A and 2 Frankel C pre-operatively. Three patients sustained wedge fracture and three sustained burst fracture. The most commonly affected vertebra was L 1 with 4 cases followed by L 2 . The preoperative mean kyphotic angle was 23.3° (17°-28°), and was corrected to 15.8 (12° - 22°) with a correction rate of 32.3% (21.4 - 43.5 %) in the post-operative period and this correction was improved at three months follow up and the final correction was measured to be 46.3% (22.7-59.0 %). Serial postoperative radiographic followup assessment showed maintenance of kyphotic correction. Minimum correction of body height was .05 cm (correction rate1.8%) and maximum correction was .65 cm (correction rate28.9%) in post-operative period with a mean of 0.29 cm (correction rate-13.1%).
Conclusions : Preserved the intermediate articular processes can be used as fulcrum to reduce the kyphosis that can be maintained as they provides continuous support and traction.
Keywords: Dorso-lumbar spine; Spinal injuries; Spinal fracture; Spinal fusion.
|How to cite this article:|
Agrawal A, Shetty M S, Shetty J P, Srikrishna U, Nagvenkar SS. Correction of post-traumatic kyphosis using intermediate facet joints as fulcrum in dorso-lumbar spine injuries. Indian J Orthop 2006;40:164-7
|How to cite this URL:|
Agrawal A, Shetty M S, Shetty J P, Srikrishna U, Nagvenkar SS. Correction of post-traumatic kyphosis using intermediate facet joints as fulcrum in dorso-lumbar spine injuries. Indian J Orthop [serial online] 2006 [cited 2019 Dec 7];40:164-7. Available from: http://www.ijoonline.com/text.asp?2006/40/3/164/34484
| Introduction|| |
Acute injury to dorso-lumbar segment is the second most frequent site after cervical spine in adults. The injury, although not associated with high mortality, causes severe morbidity (mortality 0.5% as compared to 20% in the cervical spine)  . In India, majority of patients have axial load injury with unstable burst fractures of the vertebral bodies  . It is estimated that approximately 75% of patients with dorso-lumbar injuries sustain some degree of neurological deficit  . Stabilization following decompression of the dorso-lumbar junction is recommended to prevent progressive kyphosis with pain and or neurological deficit , . The posterior approach, using an internal fixator, is a standard procedure for stabilizing the injured dorso-lumbar spine ,,, . It uses the simple principles of distraction or compression or cantilever bending construct  . In present study we analyze six cases of dorso-lumbar spine injuries treated with transpedicular screws and rods and intermediate articular processes were used to maintain the correction of kyphosis.
| Methods|| |
The purpose of this study is to demonstrate the possibility of kyphosis correction and stabilization through a transpedicular approach using intermediate articular processes and facets as fulcrum to achieve correction of kyphosis and maintenance of correction at follow up in management of dorso-lumbar spine injuries. Total 6 patients with dorso-lumbar fractures were operatively treated and kyphotic angle and vertebral body height were measured preoperatively, post-operatively and at three months follow up. Preoperatively, patients were evaluated in detail by clinical, radiological and laboratory examinations. Preoperatively, in addition to anteroposterior and lateral radiographs, MRI was performed in all cases [Figure - 1]. All patients included in the study gave their informed consent. All patients were operated upon within two weeks of injury. Antibiotic prophylaxis was administered in all patients preoperatively with 1 gm Ceftriaxone and maintained postoperatively for 3 days. Posterior approach was used in all cases and complete laminectomy was performed to increase spinal canal and to achieve decompression. Articular processes of facet joints of upper and lower body were trimmed to accommodate the screws; however articular processes of affected body were preserved [Figure - 2]. Semirigid fixations achieved by a combination of rod and pedicle screw. Rods were suspended on the intermediate articular processes and were tightened on either side to achieve reduction in kyphosis. Intertransverse autogenous cancellous bone strips were packed prior to wound closing. Postoperative coronal and sagittal plane alignment and hardware position were evaluated with anteroposterior and lateral spine radiographs. Postoperative dorso-lumbar brace was utilized in all cases and minimum 6 weeks of bed rest was advised in all cases. Cobb angle  for kyphosis was measured as the angle between the upper and lower end plates of the collapsed vertebrae preoperatively, postoperatively and at 3-month intervals and their correction percentages were calculated. Anterior and posterior vertebral body height was also measured at the injury level preoperatively, postoperatively, and at 3-month intervals.
| Results|| |
Clinical details [Table - 1]
There were 5 male and 1 female in this study in their 3 rd and 4 th decade (mean age-30.5 year, range 22-45 year). In all cases cause of injury was fall from height. Of the 6 patients 4 were Frankel A and 2 Frankel C pre-operatively. Three patients sustained wedge fracture and three sustained burst fracture. The most commonly affected vertebra was L 1 with 4 cases followed by L 2 . Five patients had single vertebral body involvement and 1 patient two vertebral body (L 1 &L 2 ) involvement.
Kyphotic angle [Table - 2]
Pre-operatively minimum kyphotic angle was 17 degree and maximum was 28 degree with a mean of 23.3 degree. After surgery in post-operative period minimum kyphotic angle correction was 5 degree (21.4%) and maximum was 10 degree (43.5%) with a mean of 7 degree (32.3%). At three months follow up minimum kyphotic angle correction was 5 degree (21.4%) and maximum was 13 degree (59%) with a mean of 10.8 degree (46.3%) after three months. The preoperative mean kyphotic angle was 23.3° (17°-28°), and was corrected to 15.8 (12°- 22°) with a correction rate of 32.3 (21.4-43.5 %) in the post-op period and this correction was improved at three months follow up and the final correction was measured to be 46.3 degree (22.7-59.0 %). Also serial postoperative radiographic follow-up assessment showed maintenance of kyphotic correction [Figure - 1]e.
Vertebral body height [Table - 3]
Minimum correction of body height was .05 cm (1.8%) and maximum correction was .55 cm (28.9%) in post-operative period with a mean of 0.23 cm (11.4%). Minimum correction of body height was .05 cm (correction rate-1.8%) and maximum correction was .65 cm (correction rate-28.9%) in post-operative period with a mean of 0.29 cm (correction rate-13.1%).
Postoperatively both Frankel C patients improved to Frankel D with bowel and bladder control. However there was no improvement in neurological status of patients with Frankel A. Both patients with initial incomplete injury were ambulatory at three months (Frankel D).
In this study, one complication was observed; that patient had intestinal obstruction due to faecoliths and improved with conservative treatment.
| Discussion|| |
The management of injuries at dorso-lumbar junction has remained controversial ,,, . Both anterior and posterior approach surgical techniques are equally effective and there are no differences in the neurological, economic activity, or functional pain outcome ,,. Anterior surgery achieves more complete and reliable decompression with interbody strut graft fusion. Also it has better advantage of canal clearance than posterior pedicle screws and plates system  . However it needs more expensive and sophisticated instruments. With the availability of locally manufactured instruments and implants in India, a combined anterior and posterior approach with short segment stabilization is also recommended  . However posterior surgery is recommended in emergency neurodecompression and fixation of unstable dorso-lumbar fractures because of the shorter operation time and smaller blood loss. The posterior approach also had better esthetic outcome, lower hospital cost, lower complication rate, and no donor site pain.  The posterior approach is also extremely important in management of cases with dural laceration 2 . Pedicle screw devices are widely used to accomplish spinal reduction and provide stability to an injured spine  . The construct stability had a complex association to the device adjustment. The device adjustments affected the spinal construct stability differently in different directions. Combined distraction-extension adjustment is more suitable while considering the neural decompression  . In present series reduction of kyphosis was achieved by using intermediate articular processes as fulcrum. It was also providing continuous traction on the spine helping in maintenance of kyphotic correction. In one study pedicle screws and dynamic compression plates could significantly correct relative kyphotic deformity after surgery; however, there were no differences in kyphotic angle at the 3-month interval  . Though the long rod and short fusion construct are more effective for all fracture types than short rod and fusion construct, however it leads to wider immobilization of normal segments , . Two major disadvantages make the posterior approach surgery less popular. The first one is the usually insufficient indirect spinal canal clearance obtained by annulotaxis , . Partial or complete laminectomy can improve decompressions of the spinal canal but may destabilize the spine by increasing the spinal deformity  . The second disadvantage is a frequent failure of pedicle screw fixation techniques, which happens even in cases in which a laminectomy has not been performed .
Preserving the intermediate articular processes can be used as fulcrum to reduce the kyphosis that can be maintained as provides continuous support and traction. The limitations of present study are the relatively small study size. It needs a more number of patients and long term follow up for further confirmation.
| References|| |
|1.||Ramani PS, Patkar SV. Classification and principles of management of injuries to the dorso lumbar junction. In: Textbook of spinal surgery. Ramani PS (ed.). Mumbai. 1996; 27: 221-225. |
|2.||Ramani PS, Singhania BK, Murthy G. Combined Anterior and Posterior Decompression and Short Segment Fixation for Unstable Burst Fractures in the Dorso Lumbar Region. Neurol India. 2002; 50 : 272-278 |
|3.||Rengachary SS, Sanan A. Thoraco lumbar fractures. In: Textbook of spinal surgery. Ramani PS (ed.). Mumbai. 1996; 26: 216-220. |
|4.||Sasso RC, Cotler HB, Reuben JD. Posterior fixation of thoracic and lumbar spine fractures using DC plates and pedicle screws. Spine. 1991;16(3):S134-9. |
|5.||Knop C, Fabian HF, Bastian L, Blauth M. Late results of thoracolumbar fractures after posterior instrumentation and transpedicular bone grafting. Spine. 2001; 26(1):88-99. |
|6.||Danisa OA, Shaffrey CI, Jane JA, Whitehill R, Wang GJ, Szabo TA, et al. Surgical approaches for the correction of unstable thoracolumbar burst fractures: a retrospective analysis of treatment outcome. J Neurosurg. 1995; 83:977-83. |
|7.||Kaneda K, Abumi K, Fujiya M. Burst fractures with neurologic deficit of the thoracolumbar-lumbar spine. Results of anterior decompression and stabilization with anterior instrumentation. Spine. 1984; 9:788-95. |
|8.||Kim M, Nolan P, Finkelstein JA. Evaluation of 11th rib extrapleuralretroperitoneal approach to the thoracolumbar junction. Technical note. J Neurosurg. 2000; 93(1):168-74. |
|9.||Benzel EC. Short segment fixation of the thoracic and lumbar spine. Spinal instrumentation AANS publication. 1994; 7: 111-124. |
|10.||Cobb JR. Outline for the study of scoliosis. Instructional Course Lectures. Am Acad Orthop Surg. 1948; 5:261-75. |
|11.||Haas N, Blauth M, Tscherne H. Anterior plating in thoracolumbar spine injuries. Indication, technique, and results. Spine. 1991; 16(3 Suppl):S100-11. |
|12.||Schnee CL, Ansell LV. Selection criteria and outcome of operative approaches for thoracolumbar burst fractures with and without neurological deficit. J Neurosurg. 1997; 86:48-55. |
|13.||Staneix MF, et al. Anterior Decompression and Fixation versus Posterior Reposition and Semirigid Fixation in the Treatment of Unstable Burst Thoracolumbar Fracture: Prospective. Croatian Med J. 2001;42(1):49-53 |
|14.||Staneix MF, Mixovix V, Sto"six A, Potoenjak M, Kolix Z. Posterior approach to circumferential fixation of unstable burst thoracolumbar fractures. Proceedings of the 4th International Neurotrauma Symposium; 1997Aug 23-26, Seoul, South Korea. J Neurotrauma. 1998; 15:38. |
|15.||Staneix MF, Mixovix V, Potoenjak M. Hook-rod with pedicle screw fixation for unstable spinal fracture. Technical note. J Neurosurg. 2000; 92(1 Suppl):117-21. |
|16.||Oda T, Panjabi MM. Pedicle screw adjustments affect stability of thoracolumbar burst fracture. Spine. 2001 Nov 1; 26(21):2328-33. |
|17.||Moon MS, Choi WT, Moon YW, Kim YS, Moon JL. Stabilisation of fractured thoracic and lumbar spine with Cotrel-Dubousset Instrument. J Orthop Surg.11(1):59-66 |
|18.||Gertzbein SD, Crowe PJ, Fazl M, Schwartz M, Rowed D. Canal clearance in burst fractures using the AO internal fixator. Spine. 1992; 17:558-60. |
|19.||Crutcher JP Jr, Anderson PA, King HA, Montesano PX. Indirect spinal canal decompression in patients with thoracolumbar burst fractures treated by posterior distraction rods. J Spinal Disord. 1991; 4:39-48. |
|20.||Malcolm BW, Bradford DS, Winter RB, Chou SN. Post-traumatic kyphosis. A review of forty-eight surgically treated patients. J Bone Joint Surg (Am). 1981; 63:891-9. |
|21.||McLain RF, Sparling E, Benson DR. Early failure of short-segment pedicle instrumentation for thoracolumbar fractures. A preliminary report. J Bone Joint Surg (Am). 1993; 75:162-7. |
Department of Neurosurgery, K.S.Hegde Medical Academy, Deralakatte-575018, Mangalore
Source of Support: None, Conflict of Interest: None
[Figure - 1], [Figure - 2]
[Table - 1], [Table - 2], [Table - 3]