Fractures of the thoracolumbar segment of the spine (T10-L2) are the most common type of trauma in spine surgery, where the spine moves from the less mobile thoracic segment to the more mobile lumbar segment and is prone to stress concentrations that can lead to fractures.
Approximately 160,000 spinal fractures of the thoracolumbar segment are reported to occur in North America each year. Complications of thoracolumbar fractures include paraplegia, pain, deformity, and functional impairment. Usually thoracolumbar spine fractures are caused by massive violence, mostly from car accident injuries, and the fractures are often unstable, as the violence of the injury is high, and this type of fracture is often combined with multiple other organ injuries.
Although the devices and strategies used to treat spinal fractures have been improving to date, the ultimate goal of their treatment has not changed, which is to protect or promote the recovery of spinal nerve function based on stabilization of the fracture, prevent the occurrence of spinal deformities, and maximize the clinical functional prognosis.
Spinal injury classification system
Over the past 75 years spine surgeons have proposed various types of classification systems for spinal fractures, each with certain limitations.
Denis et al. further proposed a three-column fracture classification scheme based on the two-column classification system for spinal fractures by Hodldsworth et al. This classification method places special emphasis on the role of the middle column on the mechanical stability of the spine. Recent developments in imaging systems such as CT and MRI have allowed for a more comprehensive assessment of spinal fractures, thus challenging the Denis three-column approach based on radiographic classification.
In 1993, Magerl et al. proposed a complex classification system based on pathomorphological criteria of fractures, classifying spinal fractures according to injury type and stability into A (vertebral compression fractures, the most common, 66%), B (distraction separation), and C (fracture dislocation with rotation), as well as subgrouping under each classification according to fracture morphology. Although the above fracture typing scheme improves the accuracy of clinician follow-up, its clinical typing is more complex, making the application of this classification system less efficient in daily practice. Some studies have reported that the clinical reliability and reproducibility of AO spine staging is poor.
In recent years, a different perspective has been proposed, namely, that in addition to the bony structures of the spine itself, other spinal accessory structures, such as intervertebral discs and intervertebral ligaments of the spine, have a significant impact on spinal stability, and the inclusion of these structures in the spine typing system is beneficial in guiding clinical treatment decisions and accurately predicting clinical functional prognosis.
Vacarro et al. proposed a new fracture classification system, TLISS. TLISS staging is based on 3 variables: mechanism of vertebral fracture injury, patient’s neurological functional status, and integrity of the posterior ligamentous complex on CT or MRI (Table 4). A score greater than 4 recommended surgery; a score less than 4 recommended conservative treatment; and a score equal to 4, with treatment options depending on the clinician’s experience.
Table 4: TLISS scores
The TLISS classification system is a great advancement in spinal fracture staging. The classification system is simpler to apply in the clinic, has better compliance and reproducibility, and allows clinical treatment decisions to be known while assessing the presence of instability in the patient’s spine.Lenarz et al. retrospectively analyzed 97 patients with thoracolumbar fractures treated using the TLISS staging evaluation and found that 83% of patients had their treatment measures implemented and recommended in the early stages of the spine fracture in general agreement.
Later, Vacarro et al. improved the TLISS classification system (TLICS) by simplifying the vertebral fracture injury mechanism score to a more objective vertebral fracture pattern and making special provisions for certain special cases to make it more clinically useful.
Table 5: TLICS scores
Type of fracture
Compression fracture
Compression fractures (AO type A fractures) are the most common type of spinal fracture (Figure 1). This type of fracture is a stable fracture with structural integrity of the posterior spine, but these patients require further follow-up for persistent collapse later in life. A complete assessment of the patient’s spine is needed in patients with traumatic spinal fractures.
Figure 1 87-year-old female with osteoporotic fracture and multisegmental vertebral compression
Burst fracture
The majority of burst fractures (A3) occur at the thoracolumbar linkage site, with the T12 and L1 segments most frequently involved (Figure 2), and are the second most frequent fracture after compression fractures, with approximately 25,000 spinal burst fractures diagnosed in the United States each year. The mechanism of injury for a burst fracture is similar to that of a compression fracture, but it is subjected to greater violence. This type of fracture can usually involve either the anterior or posterior columns, but usually does not necessarily rupture resulting in spinal instability.
Posterior column fracture fragments can protrude into the spinal canal and may cause neurological deficits in some cases, but the literature reports no significant correlation between the degree of protrusion of the fracture fragment into the spinal canal and the prognosis for neurological function. In patients with thoracic spine fractures, patients with less than 40% spinal stenosis can be free of any neurological symptoms, while in patients with lumbar spine fractures this percentage can even reach 90%.
Figure 2 CT cross-sectional view of T7 burst fracture with protrusion of the fracture mass into the spinal canal
A careful reading of the patient’s X-rays or CT, for example, if the spinous process gap is widened, suggests a disruption of the integrity of the posterior ligaments and an unstable burst fracture of the spine. Minor spinal vertebral displacement suggests ruptured bicolumnar injury, and in these patients, MRI and CT examinations can show acute rupture of the interspinous ligament, ligamentum flavum, and articular eminence joint and edema of the soft tissues.
It has also been shown that spinal stenosis shown on CT axial films correlates with late neurological dysfunction.Maves et al. analyzed imaging X-rays of 184 vertebral burst fractures for correlation between spinal stenosis and neurological function and found a statistically significant correlation between the two, with patients with neurological dysfunction having a smaller mean spinal canal area in the fractured segment.In fact, the degree of neurological impairment The higher the grade, the higher the degree of stenosis in the spinal canal.
Flexion-distraction injury
Flexion distraction injuries, also known as seat belt injuries (AO B), have the structures of the anterior spinal column (anterior longitudinal ligament B1, bony structure B2) as the midpoint of rotation and the posterior structures are distracted. CT scans may reveal joint dislocation or associated dislocation, and MR may reveal injury or rupture of the posterior ligaments. This type of fracture often involves the anterior, middle, and posterior columns.
Because of the violent spine injury pattern, these patients can have a combination of intra-abdominal organ injuries, so these patients need to be evaluated for abdominal conditions along with spine injuries.
There is also a very rare subtype of fracture in which the patient suffers a violent distraction force with an anterior longitudinal ligament tear with disc rupture (AO B3 type, Figure 3). Because these fractures tend to involve the anterior and posterior columns, they are usually very unstable fractures.
Figure 3: T11-12 distraction separation fracture
Fracture dislocations (AO type C) usually originate from massive violence, resulting in separation of the entire spine, are usually unstable, and this type of fracture is usually combined with other soft tissue or neurological impairments (Figure 4).
In this type of patient, even if neurological function is intact, adequate protection during transport and evaluation is required, and spinal stability needs to be reestablished as early as possible; if reconstruction is not possible at a very early stage, external spinal stabilization devices need to be applied for temporary fixation.
Figure 4: a, Lateral radiograph suggesting T8 vertebral fracture dislocation, anteroposterior radiographs (a, b) showing a 37-year-old female with a stable burst fracture of L1 and 30 degrees of posterior convexity at an angle, CT (c) and MRI suggesting a 50% intradiscal occupancy without neurological symptoms.
Treatment
Non-surgical treatment
Most thoracolumbar spine fractures are mechanically stable, and a good clinical outcome can be achieved with conservative treatment alone. Good results can be obtained with plastic spinal supports or overdrawing casts, Figure 4A. Excessively prolonged bed rest is not currently recommended for this group of patients, and in some patients, early bed release can be considered after adequate spinal stability has been determined.
Patients with simple lumbar compression fractures or stable burst fractures (without rupture of posterior bone or ligamentous structures) without combined neurological impairment can be considered for early functional exercise under functional branching therapy, and some findings even suggest that patients with stable spinal burst fractures can get out of bed for functional exercise without brace protection with good results.
In patients with severe vertebral burst fractures, good results can be achieved with conservative treatment even if the degree of spinal stenosis exceeds 70%.
Patients treated conservatively are discharged with an upright spinal weight-bearing x-ray under brace wear. Late onset of kyphosis is inevitable in some conservatively treated patients, but there is no significant correlation between kyphosis and pain. Persistent increased kyphosis (more than 10 degrees), or persistent increased pain, is recommended for surgical treatment.
If there is persistent separation of bony structures in flexion-distraction fractures, they can be treated with cast fixation in the overdistraction position. Conservative bracing may not be appropriate in older patients or in patients with persistent fracture displacement and soft tissue impaction in the fracture gap. In addition, patients with combined injuries at other sites are not suitable for conservative treatment. Surgical treatment is more effective for fractures in which the fracture line extends into the posterior longitudinal ligament and the intervertebral disc.
Spines with flexion-distraction fractures with concomitant injury to the secondary supporting ligaments are usually extremely unstable and require surgical treatment to obtain adequate spinal stability. Some clinicians believe that early spinal stability reconstruction can be beneficial even in patients with complete loss of spinal cord function, but these conclusions are not supported by the literature.
Surgical treatment
Surgical treatment of thoracolumbar spinal fractures has advantages over non-surgical treatment, especially in patients who are unable to tolerate bracing and bed rest for long periods of time. Timely surgical reestablishment of spinal stability allows for earlier motion and rehabilitative exercise, and maintains later sagittal alignment of the spine.
Surgical decompression is reliable in patients with spinal stenosis and is more beneficial to the patient in terms of late neurological recovery. However, surgeons need to be aware of the balance of risks and benefits when evaluating patients for surgical indications. In acute trauma patients, emergency surgery often means a higher risk of complications, and Rechtine et al. reported a 10% incidence of infection in trauma patients after emergency surgery.
Compression fractures
Most compression fractures involve only the anterior column and can be treated with bracing or bed rest; osteoporotic vertebral compression fractures in the elderly are a more specific classification and are discussed separately in subsequent sections.
Coronal separation compression fractures (A2, Figure 5) are usually not easy to heal and often present with pain later in life due to nonunion of the fracture; surgical treatment is usually recommended for this type of fracture, especially if it occurs in the lower lumbar region.
Figure 5:45-year-old female with a separated compression fracture in the L3 coronal position
Burst fracture
Burst fractures are mechanically stable because the posterior ligamentous complex structure and synovial joint are not disrupted. However, when a burst fracture has more than 50% compression, the latter at an angle greater than 25 degrees, care needs to be taken to assess the posterior ligamentous complex for damage; in addition, the patient may be evaluated for spinal stability if any neurological deficits are present.
Clinicians making surgical decisions need to consider the patient’s fracture site, the degree of vertebral destruction, whether neurologic function is involved, the angle of kyphosis, and the stability of the posterior column structures. The degree of protrusion of the vertebral fracture mass into the spinal canal is not an absolute basis for surgical treatment, and some studies have reported that fracture masses occupying less than 50% of the spinal canal can be resorbed and reconstructed during conservative treatment.
Patients with simple burst fractures can achieve a good functional prognosis with conservative treatment. Some authors believe that the angle of kyphosis depends on the patient’s condition at the onset of the fracture at the beginning of the injury, and there is no clinically proven significant correlation between kyphotic deformity and clinical functional prognosis.
In patients with thoracolumbar spinal burst fractures, posterior pedicle screw fixation is definitive, reliable, and safe (Figure 6). To this day, this technique is still the most popular technique for treating spinal fractures. However, there are some complications associated with this surgical technique, such as failure of internal fixation, pseudoarthrosis, infection, and the need to remove the internal fixation at a later stage.
Posterior pedicle screws are usually placed above or below the fractured vertebral body in the adjacent vertebral body to obtain support and reposition the fracture. It has been suggested that in burst fractures, anterior spinal column fixation is also necessary to prevent loosening of the posterior internal fixation or loss of fracture angle while obtaining posterior fixation.
McCormack et al. analyzed all patients after posterior short-segment fixation of spinal burst fractures and found that the degree of compression damage of the fractured vertebral body, the degree of separation of the fracture mass, and the angle of correction of the posterior convexity deformity were factors that predicted the failure rate of posterior short-segment fixation, and the need for anterior-posterior combination was recommended for patients who met certain criteria for all three of these indicators.
Figure 6:39-year-old female with L1 burst fracture and no neurological symptoms. 70% of the fracture mass occupancy in the spinal canal is seen in A, B. C, D show follow-up X-rays of posterior short-segment fixation.
Anterior fixation for burst fractures is a surgical procedure that emerged after the invention of CT in the 1980s. CT examination of patients with combined neurological impairment usually reveals a burst fracture mass protruding into the spinal canal, so it is considered necessary to perform anterior decompression to relieve intracanal compression.
This type of surgery is usually performed via a transthoracic or combined transthoracic-abdominal approach, during which the operator can remove the fracture mass under direct vision, and the vertebral space presented after removal of the fracture mass can be reconstructed by large bone graft blocks or metallic or synthetic materials (Figure 7).
The literature reports that surgical reconstruction of spinal burst fractures by a surgical volume clinician can achieve the same surgical results as posterior surgery, and even better results in reconstructing the sagittal balance of the spine.
Anterior surgical treatment has been recommended for patients with spinal fracture sites in the L2-5 segment, where the spinal mechanical integrity and sagittal notch balance are important and posterior surgery may disrupt the aforementioned stable structures.
Figure 7:A 49-year-old female with an unstable L1 vertebral fracture, sagittal CT (a) suggesting protrusion of the L1 fracture mass into the spinal canal, axial CT (b) suggesting arthrodesis, sagittal MRI (c) suggesting fracture through the posterior bony structures, and imaging follow-up X-rays 3 years postoperatively before and after (d) and laterally (e).
Unstable burst fractures with rupture of the posterior ligamentous complex usually require surgical treatment because of poor healing function of the posteriorly torn ligaments. Anterior reconstruction combined with posterior short-segment fixation is also more effective in treating vertebral burst fractures when the patient’s kyphosis angle and the degree of anterior vertebral fracture comminution are taken into account.
Flexion-distraction injury
Because this type of fracture is primarily posterior, posterior fixation + fusion is the most effective treatment (Figure 8).
However, care should be taken not to overdo posterior compression in these patients, as some patients have been reported in the literature to have late neurological deficits due to protrusion of the injured disc or endplate structures into the spinal canal during posterior compression and fixation.
Therefore, it has been suggested that such patients can be repositioned by postural repositioning prior to surgery and maintained with mild compression and anterior convexity during internal fixation, and the disc position can be detected by adjunctive methods such as intraoperative ultrasound.
Figure 8:A 19-year-old female with a flexion-distraction fracture of T11-12 with a lateral position suggesting a misalignment of T11-12, and sagittal angle correction was obtained after short-segment fixation
Modern anterior internal spinal fixation systems are sufficiently stable in terms of material, and it has been reported that even in patients with damage to the posterior spinal structures, good results can be obtained with short-segment reconstruction by applying an anterior internal fixation system alone (Figure 9).
Sasso et al. reported the results of 40 patients with AO type B and C fractures who were treated with anterior fixation alone compared to those treated with posterior fixation and found that less angular loss (1.8 degrees) was achieved with anterior fixation.
Figure 9: 42-year-old painter with anteroposterior (a) and lateral (b) X-rays, rotational burst fracture dislocation of L1 vertebrae, axial CT (c, d) suggesting spinal stenosis and articular synovial misalignment, and 2 years follow-up X-rays after posterior decompression and fixation (e, f)
Fracture dislocation
As mentioned previously, fracture dislocations are usually high-energy injuries, usually associated with neurological function and damage to the rest of the skeletal system. Rupture of bony and ligamentous structures occurs in response to shear-rotational and flexion-distraction stresses. In patients with incomplete spinal cord injury, the prognosis for patients with early surgery to reestablish spinal stability is better than for patients treated conservatively. According to the characteristics of this type of injury, posterior repositioning with multisegmental fixation and fusion is recommended (Figure 9).
Most fracture dislocations do not require anterior surgical treatment, but in some cases, if the patient remains functionally unstable in the anterior spine after posterior fixation, a second-stage procedure is required to fix the anterior spine.
Minimally invasive approach
Over the past few decades, spine surgeons have worked to minimize the impact of surgery on normal spine function. In some cases, the thoracoscopic approach to thoracolumbar fractures offers significant advantages, such as reduced postoperative pain, smaller postoperative scars, lower perioperative mortality, early functional exercise, and fewer doses of anesthetics.
Indications for anterior reconstruction or decompression surgery are neurological deficits caused by protrusion of the fracture mass into the spinal canal, or anterior comminuted vertebral fractures with loss of anterior loading function, requiring anterior reconstruction.
Traditional anterior surgery has a high mortality rate and may not be tolerated by certain patients with poor general condition; when doing thoracolumbar spinal exposure, it requires separation of the diaphragm attachment point and is more prone to postoperative complications such as diaphragmatic hernia and intercostal neuralgia. In contrast, the posterior standard or paraspinal surgical approach to treatment has damage to the muscle, reducing the strength and tolerance of the paraspinal muscle after surgery.
The minimally invasive endoscopic surgical approach reduces the diameter of the surgical incision and the incidence of complications associated with the thorax and abdomen. The thoracoscopic approach allows direct visualization of the entire thoracic spine structure and has been specifically designed to allow simultaneous visualization of the subtransverse thoracolumbar spinal structures.
During the thoracoscopic approach, the patient is placed in the right lateral position, and the pelvis, upper extremities, and lower extremities are immobilized to maintain intraoperative position stability (Figure 10).
The left-sided approach was adopted during the operation, because the right side was obscured by the liver and the diaphragm would be elevated compared to the left side, which was not conducive to intraoperative exposure. A thoracoscopic approach was established through the rib cage to complete the exposure of the spinal segments and perform surgical operations such as vertebral body resection, discectomy, and decompression of the spinal canal.
Studies in the literature have found that thoracoscopic resection of intravertebral fracture blocks is similar to open resection in terms of completeness. After decompression is complete, an intervertebral fusion device can be placed and fixed with the addition of a lateral fixation device (Figure 11).
Figure 10: Thoracoscopic spine surgery position and access
Figure 11: Endoscopically treated L1 vertebral burst fracture, preoperative and 2-year postoperative radiographs
Kim et al. reported surgical results of 212 patients with thoracoscopic reconstruction of thoracolumbar segment fractures, and fusion of the fractured segments was obtained in approximately 90% of patients, but the postoperative complication rate was not significantly different from that of open surgery in other investigators.
Khoo et al. reported the results of a study of 371 thoracoscopically assisted treatment of thoracolumbar segment vertebral fractures and found a low surgical complication rate of approximately 1.3%. However, Beisse et al. reported a higher complication rate of about 20% for thoracoscopic treatment.
Thoracoscopic surgery should be applied with caution in patients with restrictive ventilatory dysfunction, acute traumatic pulmonary failure, thoracic exudate, and severe medical complications. It is important to note that there is no literature reporting that patients with thoracolumbar segment fractures treated thoracoscopically have a better functional prognosis than those treated with open surgery.
The open posterior approach to thoracolumbar spine fractures has been studied in recent years for the treatment of vertebral fractures by percutaneous placement of pedicle screws and nail rods because of intraoperative muscle stripping, injury, and possible postoperative pain and dysfunction at the surgical site.
In patients with spinal fractures of the thoracolumbar segment, especially AO subtype A, without neurological involvement and for whom conservative treatment is not recommended, percutaneous placement of pedicle screws without fusion can establish and maintain spinal stability and promote fracture healing.
Wang et al. prospectively compared the postoperative functional prognosis of patients with posterior fixation and posterior fixation + fusion of spinal fractures and found no significant differences between them; Wild et al. retrospectively analyzed the relevant indicators in patients with percutaneous screw fixation without fusion at 5 years postoperatively and found no significant differences compared with those with open surgery.
In recent years, a combination of both percutaneous pedicle screw internal fixation technique and vertebroplasty has been used to treat spinal fractures, allowing anterior support to be obtained along with posterior fixation. Reports in the literature have shown that even in burst fractures, good results can be obtained in patients with posterior rupture of the posterior edge of the vertebral body with transpedicular vertebroplasty + posterior percutaneous pedicle screw internal fixation, with good early clinical functional prognosis, pain relief, and no significant loss of vertebral body repositioning angle reported in the literature in approximately 95% of patients.
Marco et al. recently reported 28 patients with unstable thoracic burst fractures who underwent percutaneous pedicle balloon-assisted vertebral body repositioning with artificial bone filling reconstruction + posterior short-segment fixation to obtain good treatment results.
Osteoporotic fracture
Osteoporosis is the most common bone metabolic disease in clinical practice today, and vertebral compression fractures are one of its more common complications. The literature reports that approximately 800,000 osteoporotic vertebral compression fractures occur each year in the United States. Because elderly vertebral compression fractures are prone to chronic back pain, pulmonary dysfunction, and severe limitations in daily activities without management, early diagnosis and management of this disease is very important.
Once a patient develops a vertebral compression fracture, the probability of a later recurrent fracture increases dramatically. The literature reports a 20% probability of re-fracture within 1 year of untreated fracture in patients with earlier fractures. The incidence of complications was also found to be significantly correlated with the number of vertebral segments involved in the fracture, with the greater the number of vertebral segments fractured, the higher the probability of complications.
The traditional treatment of osteoporotic vertebral compression fractures has been reduced activity and bed rest, and spinal bracing is often indicated in these patients, but many patients cannot tolerate prolonged wear of these braces. Today, there is no evidence that wearing a spinal support in conservatively treated patients improves functional prognosis.
The recent development of cement-filled enhancement of the vertebral body offers a new strategy for the treatment of this condition. The advantage of this approach is that cement is injected into the diseased segment through the pedicle, which strengthens the vertebral body and allows the patient to get out of bed early while reducing the incidence of complications associated with braking.
It has been suggested that pain relief is related to several factors: reconstruction of spinal stability, thermal and chemical damage effects of the cement.
Although the complication rate of vertebroplasty is low, there are complications associated with it that are worth discussing
Bone Cement Leakage
There is a risk of forward or backward spillage of the bone cement when filling the vertebral body, with backward spillage being into the spinal canal. Not all cement spills are symptomatic, and for most patients, there is no significant correlation between cement spillage and the degree of low back pain in patients. The probability of a cement spill being symptomatic is related to the site of the spill, and if the cement spill enters the spinal canal or intervertebral foramen, it may cause severe neurological deficits.
Due to anatomical features, the amount of cement spillage into the foramen causing symptoms is much less than that of the spinal canal, and it has been reported in the literature that patients with severe neurological symptoms due to cement leakage into the foramen require emergency surgical decompression and removal of the cement. Leakage of cement into other areas such as the anterior intervertebral space is often related to the operator’s practice.
It is also not uncommon for bone cement to leak into the vasculature, usually within the venous system, such as the pelvic plexus, the odd vein, etc. Very rarely, bone cement can enter the lung along the venous system, leading to pulmonary embolism with serious consequences, and one retrospective report found that vertebral bone cement may enter the lung in up to 5% of cases.
Another concern with cement filling is the incidence of re-fracture of the adjacent vertebral body. In a follow-up study of 94 patients with 109 vertebroplasty, Lavell et al. found a 10% probability of re-fracture of the patient’s adjacent vertebral segment within 90 days after surgery, with patients treated for multiple segments most likely to have vertebral re-fractures.
Newly developed bone-reinforcing materials in recent years may better match the biomechanical properties of the human bone structure and reduce the concentration of vertebral stress in the adjacent segments, thereby reducing the incidence of fracture reoccurrence in the adjacent vertebral segments.
Contraindications to vertebroplasty include severe cardiopulmonary dysfunction, infection or coagulation disorders, severe vertebral compression, or severe protrusion of the vertebral fracture mass into the spinal canal.
Balloon-expandable vertebroplasty is a modified version of vertebroplasty with a basic procedure similar to vertebroplasty, except that the vertebral body is expanded by a balloon to restore the height of the vertebral body prior to cement injection.
Kasperk et al. reported no loss of spinal repositioning at 1 year postoperatively for acute painful vertebral compression fractures using a combination of balloon distension vertebroplasty + spinal brace, and Majd et al. reported similar results.
The reason why balloon distension vertebroplasty is safer than vertebroplasty alone may be. In vertebroplasty, the cement is injected with less viscosity and high pressure, whereas in balloon kyphoplasty, a cavity has been created before the cement is injected, and the cement can be injected with more viscosity and less pressure. Although balloon kyphoplasty is safer than vertebroplasty, it is not completely risk-free.
Two meta-analyses showed that the complication rate for balloon kyphoplasty was 2% compared with 3.9% for the corresponding vertebroplasty; the probability of cement leakage for balloon kyphoplasty ranged from 0-0.3% compared with 1.6%-3.0% for vertebroplasty.
In a recent study by Lee et al. of 83 postoperative CT examinations of 473 patients treated with both treatment options, a very high probability of cement leakage was found for both procedures (87.5% for vertebroplasty vs. 49.2% for balloon kyphoplasty), although most patients had no clinically significant symptoms.
A multicenter study completed by Patel et al. found complete loss of neurological function after cementing in 14 patients, 4 with vertebroplasty and 10 with balloon kyphoplasty: 6 patients had acute spinal cord compression due to cement leakage into the spinal canal (4 with balloon kyphoplasty); 8 patients had a delayed decrease in ASIA scores 3-112 days postoperatively. delayed decrease in ASIA score occurred.
Burst fractures in elderly patients
In some elderly patients, untreated compression fractures progress to burst fractures late in life, with the fracture fragments projecting into the spinal canal and causing severe neurological deficits. Although these cases are rare, clinicians need to be especially alert when conservatively treated patients present with worsening neurologic function or pain at the time of presentation, or when there is no significant progression with treatment; Morie et al. reported paraplegia 5.7 months after the initial fracture, and CT can help determine this.
These patients usually require surgical treatment. The surgical approach can be anterior, such as transthoracic, or transabdominal or retroperitoneal, with decompression, fusion and internal fixation. However, these patients are prone to problems such as settling of the bone graft and unsound internal fixation during the anterior approach. Therefore, after anterior decompression and bone graft fusion, long segment fixation with posterior pedicle screws is required for these patients.
In recent years, a combination of minimally invasive percutaneous pedicle screw fixation + vertebroplasty has been proposed for the treatment of vertebral burst fractures in elderly patients, with good results.
Prognosis
The debate on the indications for surgery for thoracolumbar spine fractures has not ceased during the past 30 years; most of the research evidence reported in the literature is currently derived from retrospective studies, and few prospective studies with a high level of evidence are available.
A summary of the available research evidence leads to the following conclusions: in most patients with thoracolumbar fractures, especially those who are mechanically unstable, spinal stabilization leads to a better clinical functional prognosis, although the concept of spinal stabilization is still controversial.
Mclain et al. performed spinal fusion fixation in 62 patients with unstable thoracolumbar spine fractures and found that approximately 70% of them were able to work full-time after 5 years, with 54% of them returning to their previous level of work and 16% being able to work full-time at a slightly easier level than before.
Non-operative treatment has been shown to be effective in most but not all cases of mechanically stable spinal fractures; moreover, non-operative treatment has some complications due to longer braking cycles, such as blood clots, pulmonary infections, and muscle atrophy, and non-operative treatment does not restore the patient’s spinal height and is prone to spinal deformity later in life.
Surgical treatment also has some problems, such as complications and some may be fatal; in clinical practice, some patients may have too much surgery, such as fusion treatment for patients who do not need fusion. In a retrospective study, risk factors for the probability of postoperative complications in patients with acute trauma were found to include ASIA score, CHarlson comorbidity index, and hormone use.
Most reports examining stable thoracolumbar spinal burst fractures with neurological integrity concluded that there was a significant difference in return to work, mobility, pain, and quality of life between patients treated surgically and those treated nonoperatively at 5 years.
Percutaneous or minimally invasive pedicle screw fixation can reduce trauma while achieving spinal stability, and early findings reported in the literature support the use of these techniques. Whether this technique becomes mainstream in the future still needs to be confirmed by more clinical trials.