Treatment Algorithm For Unstable Burst Fracture

Volume 1 | Issue 2 | Sep – Dec 2016 | Page 27-32 | Ketan Khurjekar, Himanshu Kulkarni, Mayur Kardile


Authors : Ketan Khurjekar [1], Himanshu Kulkarni [1], Mayur Kardile1 [1]

[1] Department of Spine Surgery, Sancheti Institute for Orthopaedics and Rehabilitation, Pune India

Address of Correspondence
Dr. Ketan Khurjekar
Department of Spine Surgery, Sancheti Institute for Orthopaedics and Rehabilitation, Pune India
Email : kkhurjekar@gmail.com


Introduction

Burst fractures comprise of approximately 17% of all thoracolumbar fractures. These type of fractures result from compression failure of both the anterior and middle columns under substantial axial loads [1]. Between the immobile, kyphotic thoracic spine above, and the relatively mobile, lordotic lumbar spine below, throracolumbar region makes a transition zone where all the stress forces are concentrated. This makes the thoraco lumbar zone more prone to injuries than any other part of the spinal column. According to Denis, a spinal fracture is described as burst if there is compression of the anterior column, fracture of the middle column, and retropulsion of bone fragments into the spinal canal [2]. As a result neurologic injury has been reported to occur in 30% of the patients with thoracolumbar fractures [3]. The management of thoracolumbar burst fractures remains challenging. An ideal treatment modality should induce neurological recovery, should correct the deformity efficiently and allow early mobilization, should enable minimization of loss of work hours and should have minimal treatment related complications. For years together, a lot has been written in literature about how these aims can be achieved, with strong proponents for both non-operative and operative treatments existing. This difference of opinion and polarising philosophies can be confusing for an inexperienced clinician. So we have tried to put forth step by step approach to decode the dilemma that is the unstable thoracolumbar burst fracture with the help of a case.

Case-
A 21 year old engineering student came to casualty with history of fall from height 4 hours back. Patient was unable to move both his lower limbs. Power in both Hips wad grade 2 for flexion, Grade 1 for Knee extension and Grade 0 for ankle and great toe movements. There was partial loss of sensations with diminished sensations present in L1-2-3 dermatomes and complete loss of sensations below that. There was loss of sensation for micturition, but it was associated with weak anal contraction. Patient was shifted to department of radiology and plane radiogram was done. Plain lateral radiogram showed fracture of L2 vertebral body with a retropulsed fragment crossing posterior vertebral line (Fig. 1).


After this, MRI scan of the thoracolumbar spine was done. The scan showed the retropulsed fragments causing severe compression of the cord (Fig. 2).
Once the imaging studies were done, following steps were followed.

Assesment of Neurology –
Assessment of neurology has to be the first thing to be considered in a methodical treatment approach. In most circumstances, the treatment protocol and prognosis depends upon early neurological state. Frankel categorised the spinal cord injuries in a comprehensive classification. The injury was divided into 5 types, from severe to less severe. Modification of Frankel grading was included in now widely accepted American Spine Injury Association grading (ASIA Grading) in 1997 which was revised in 2011 [4]. ASIA grading grades the injury into complete or incomplete, with extensive dermatomal and myotomal charting.
Power charting for upper and lower limb myotomes was done. According to Frankel grading, the injury was labelled as Frankel 3, since some voluntary motor function was preserved below level of lesion but too was weak to serve any useful purpose. Some sensations were preserved too.

Assessment of stability-
In 1949, Nicoll [7] first introduced the concept of posttraumatic spinal instability. He defined unstable spinal injuries based on the presence of subluxation or dislocation, disruption of interspinal ligaments, or laminar fractures at L4 or L5. This concept has been used as a base for all the treatment approaches for unstable injures. It was stated by White and Panjabi that a stable spine is able, under physiological load, to maintain its normal movement so that there is no initial or additional neurological deficit, no major deformity, and no incapacitating pain.8 They also made a check list for thoracic instability.
According to Denis [2], there are 3 types of instability in the thoracolumbar spine; the mechanical instability that refers to the potential of spinal collapse with subsequent deformity, the neurological instability that refers to the potential of further neurological injury, and the combined mechanical and neurologic instability. The 3-column model is useful for the assessment of spinal instability; any thoracolumbar burst fracture can be unstable, while middle 2, or 2-column failures are absolute criteria for instability.
Mcafee et al in 1984 described factors indicative of instability in compression burst fractures of thoracic lumbar junction. According this criteria, fracture in our case was considered unstable. The fracture had progressive neurological deficit, had >50% loss of vertebral height, local kyphosis > 20 degrees and retropulsion of a bony fragment in the canal was present (Fig. 3).

Classifying the fracture pattern –
Since Bohler first tried to classify thoracolumbar spine fractures combining both anatomic appearance and mechanisms of injury as early as in 1930, classification of spinal fractures to facilitate communication and encourage optimal treatment protocols has long been a focus of the spine community [9]. Numerous classification systems have been put forth till now. Discussion of all is beyond the scope of this topic but none has been proven to be a gold standard yet due to the complexity of spinal anatomy and mechanisms of injury, as well as widely differing philosophies in treatment[10].
Some classification systems have gained more acceptance than others though. In 1994, McCormack et al [11]. stated that in long bone fixation, load sharing between the bone and the implant is of paramount importance. It helps in uneventful healing of the fracture and prevents implant failure. They applied same concept in spinal fractures, and put forth a CT based Load sharing classification taking into account the amount of comminution, apposition and Kyphosis.
The fracture in this case was classified as a Grade 2, with moderate comminution (Fig. 4) apposition and Kyphosis. Fracture was also classified according to Thoracolumbar injury classification and severity score (TICS) which is useful guide to treatment options. The classification holds a scoring system categorising the injury into operative or non-operative category based on the score.
The score for our fracture was found to be 8, which indicated the management should be operative. Like other long bone fractures, AO classification was also introduced in as AO- Magerl classification [12]. The classification system failed to gain wide universal international adoption due to its complexity. SO, the system was revised in 2013 into 3 main injury patterns: type A (compression), type B (tension band disruption), and type C (displacement/translation) injuries[13].
Our facture was classified as L2-B2;N3;M1.

Management Options –
Ideally, the treatment Goal in burst fracture should be to
1. Effective correction the deformity
2. Induction neurological recovery
3. Should allow early mobilization
4. Should have minimal risk of complication
Because of different philosophical ideologies, and there has been considerable controversy on the efficacy of conservative treatment and the need for surgical intervention in burst fractures with intact neuro status.
Argument for proponents of Surgery has always been on points of additional stability, prevention of neurological deterioration, attainment of canal clearance, prevention of kyphosis and early relief of pain. Denis et al [2]. reported late neurological deterioration in 17% of conservatively treated patients. They stated that prophylactic stabilization and fusion of acute burst fractures without neurologic deficit have significant advantages over conservative treatment. Likewise, Bohlman et al too were biased towards operative intervention. They expressed that operative intervention enhances clinical outcome and facilitates early rehabilitation [14]. However, Many subsequent trials showed that deterioration of the neurological status in patents who had intact neurology initially was unlikely [15,16]. To comment about the concerns about the persistent canal compromise in neurologically intact patients, Shen et al [17]. noted a resorption of approximately 50% of the retroplused fragment within 12 months. Also, no statistical difference was found in the degree of spinal canal remodelling between patients treated conservatively and operatively [18]. Also, Some surgeons have chosen direct decompression and canal clearance when CT scan has showed more than 40 % canal compromise [19]. However paralysis occurs at the moment of injury and it is not related to position of bony fragment [26]. Also, High-speed video tests have shown that at higher levels of occlusion, the final position of the bone fragments was inadequately correlated with the maximum level of impingement [27].
So, even though the preferred treatment for these fractures with intact neurology is still an ongoing debate amongst clinician, data has shown no significant superiority of operative treatment over non operative treatment. TLICS is a useful tool to make the decision of preferred treatment modality easy.

In patients with progressive neurological deterioration, or ones with unstable fractures & complete neurological loss, there’s no debate about the choice of surgical intervention as a preferred treatment modality. It ensures decompression of the spinal canal and nerve roots, and gives the fractured spine sufficient stability and realignment with correction of kyphosis to start early mobilization and rehabilitation [14]. Timing of the surgery is also a debatable factor. It’s a common opinion that surgery at the earliest can be beneficial for ultimate outcome. Carlo Bellabarba et al in 2010 stated that stabilization within 72 hours was safe and decreased respiratory morbidity. But other than decreased ICU and overall hospital stay, no other significant benefit of early surgery was found. It was also stated that currently there is very low supporting evidence in literature for benefits early surgery [19]. Surgery for these fractures can be via Anterior, posterior or a combined approach. Fracture morphology, neurologic status, and surgeon preference play major roles in making the decision about preferred approach. Usually, the anterior approach surgery should be limitedly used for severe Denis type B fracture with direct reduction. The posterior approach is used in most Denis type A and B fractures with indirect reduction and has less complication [20]. Some authors also stated that anterior only showed statistically significant improvement in sagittal alignment in long term follow up than posterior only fixation [21]. Anterior and middle column injuries with partial neurology have been effectively treated by anterior approach; decompression under direct vision and sagittal alignment are the key factor.
In our experience, anterior decompression and reconstruction for burst fractures with anterior and median column injury is effective. Decompression and reconstruction can be performed under direct vision at one stage, and the sagittal alignment can be corrected at the same time. Since anterior approach has a more surgical morbidity than posterior approach, it should be reserved for patients with canal compromise >67%. Focal kyphosis > 30 degree [22].
But at the same time, The benefits of posterior approach cant be undermined. It is more than once described that creating a posterior tension band and stabilisation is biomechanicvally more stronger It helps in Indirect decompression by ligamentotaxis ( though, ligamentotaxis has been shown to be inefficient in greater than 50% canal compromise 22), direct access to spinal canal for decompression, relieve hematoma, repair dural tears and extricate trapped nerve roots. Direct canal decompression through a posterior approach can be obtained by laminectomy, pediculectomy, fragment reposition or fragment removal [23]. Also, adequate neural canal decompression can also be achieved by a new modified transpedicular approach less invasively to avoid anterior surgery [24]. Kaya et al extended the transpedicular decompression for spinal cord and nerves by posterior alone approach along with stabilisation and showed adequately good results for burst fracture (spine J 2004) In posterior approach, the extent of fixation should be decided according to the classification of the fracture. Short segment fixation could usually suffice in AO type A and B fractures. Long segment fixations should be carried out in AO type 3 fractures, severely comminuted fractures and osteoporotic bones [25]. We feel that incomplete neurological deficit with demonstrable radiological compression on MRI, should be subjected to canal clearance either by transpedicular approach or direct decompression, anteriorly or posteriorly. So patient underwent Posterior surgery on 3rd day after injury with laminectomy, transpedicular neural decompression with partial corpectomy, reduction, fixation of two levels above and below with pedicle screws and reconstruction of anterior column by transforaminal approach with partial bone graft and Titaneum cage.

Take Home message –
To conclude, unstable thoracolumbar junctional fracture are known to cause neurological deficit though that is not the rule. Neurological deficit and structural instability dictates Surgical Intervention Classifying the grade of Instability and establishing level of neurological deficit is paramount. Pendulum is shifting towards all posterior spine surgery. Every fracture is unique and management is tailor made. Depending on Fracture pattern, stability, neurology and disruption of ligament complex will dictate the treatment protocol. Anterior versus posterior, short versus long fixation, open decompression versus indirect decompression have been issues. In today’s era, every treatment protocol is evidence based and result oriented. Issues of anterior surgery are well described, morbidity of approach, risk to major vascular structures and organs, need definite consideration. We have given algorithm depending on the literature and their clinical experience over years of managing thoracolumbar fractures.


References

1. Rajasekaran S, Thoracolumbar burst fractures without neurological deficit: the role for conservative treatment, Eur Spine J. 2010 Mar;19 Suppl 1:S40-7.
2. Dennis F. The three column spine and its signifi cance in the classifi cation of acute thoracolumbar spinal injuries. Spine (Phila Pa 1976). 1983; 8(8):817-831.
3. Tator CH, Koyanagi I (1997) Vascular mechanisms in the pathophysiology
of human spinal cord injury. J Neurosurg 86:483– 492
4. Steven C. Kirshblum et al, International standards for neurological classification of spinal cord injury (Revised 2011) J Spinal Cord Med. 2011 Nov; 34(6): 535–546.
5. Frankel HL, Hancock DO, Hyslop G, et al. The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. Paraplegia 1969;7(3):179–192
6. American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2000; Atlanta, GA, Reprinted 2008.
7. Nicoll EA. Fractures of the dorso-lumbar spine. J Bone Joint Surg Br. 1949; 31(3):376-395.
8. Panjabi MM, Thibodieau LL, Crisco JJ, White AA. What constitutes spinal instability? Clin Neurosurg. 1988; (34):313-319
9. Bohler L. Die techniek de knochenbruchbehandlung imgrieden und im kriege. Verlag von Wilhelm Maudrich 1930 (in German).
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11. McCormack, Thomas MD; Karaikovic, Eldin MD; Gaines, Robert W. MD
Spine:The Load Sharing Classification of Spine Fractures, SPINE vol9, pp1741-1744, J.B Lippincott
12. Magerl F, Aebi M, Gertzbein SD, et al. A comprehensive classification of thoracic and lumbar injuries. Eur Spine 1994;3: 184-201.
13. Alexander R. Vaccaro et al, AOSpineThoracolumbar Spine Injury Classification System, SPINE Volume 38, Number 23, pp 2028-2037 Spine 2013, Lippincott Williams & Wilkins
14. Fan KF, Tu YK, Hsu RW et al (1997) The high fixation failure rate of short segment pedicle instrumentation for unstable thoracolumbar burst fractures. Orthop Trans 21:267
15.Celibi L, Muratli HH, Dogan O et al (2004) The efficacy of nonoperative treatment of burst fractures of the thoracolumbar vertebrae. Acta Orthop Traumatol Turc 38(1):16–22
16. Shen WJ, Liu TJ, Shen YS (2001) Nonoperative treatment versus posterior fixation for thoracolumbar junction burst fractures without neurologic deficit. Spine 26:1338–1345
17. Lu J, Ashwell KW, Waite P (2000) Advances in secondary spinal cord injury: role of apoptosis. Spine 25:1859–1866
18. Bohlman HH, Freehafer A, Dejak J. The results of treatment of acute injuries of the upper thoracic spine with paralysis. J Bone Joint Surg Am 1985;67A:360–369
19. Bellabarba C, Fisher C, Chapman JR, Dettori JR, Norvell DC. Does early fracture fixation of thoracolumbar spine fractures decrease morbidity or mortality? Spine (Phila Pa 1976). 2010 Apr 20;35(9 Suppl):S138-45.
20. Wu H, Fu C, Yu W, Wang J. The options of the three different surgical approaches for the treatment of Denis type A and B thoracolumbar burst fracture. Eur J Orthop Surg Traumatol. 2014 Jan;24(1):29-35.
21. Zahra B, Jodoin A, Maurais G, Parent S, Mac-Thiong JM. Treatment of thoracolumbar burst fractures by means of anterior fusion and cage. J Spinal Disord Tech. 2012 Feb;25(1):30-7.
22. Schnee CL, Ansell LV. Selection criteria and outcome of operative approaches for thoracolumbar burst fractures with and without neurological deficit. J Neurosurg. 1997 Jan;86(1):48-55
23. M. Payer. Unstable burst fractures of the thoraco-lumbar junction: treatment by posterior bisegmental correction/fixation and staged anterior corpectomy and titanium cage implantation Acta Neurochir (Wien) (2006) 148: 299
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25. Altay M, Ozkurt B, Aktekin CN, Ozturk AM, Dogan O, Tabak AY. Treatment of unstable thoracolumbar junction burst fractures with short- or long-segment posterior fixation in magerl type a fractures. Eur Spine J. 2007;16:1145–1155
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How to Cite this Article: Khurjekar K, Kulkarni H, Kardile M. Treatment Algorithm for Unstable Burst Fractures . International Journal of Spine Sep-Dec 2016;1(2):27-32.


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Thoracolumbar Fractures: Classification and Clinical Relevance

Volume 1 | Issue 2 | Sep – Dec 2016 | Page 14-21 | Ajoy Prasad Shetty, Srikanth Reddy Dumpa, S Rajasekaran


Authors : Ajoy Prasad Shetty [1], Srikanth Reddy Dumpa [1], S Rajasekaran [1]

[1] Department of Spine Surgery, Ganga Hospital, 313, Mettupalayam road, Coimbatore, India.

Address of Correspondence
Dr. Ajoy Prasad Shetty
Department of Spine Surgery, Ganga Hospital, Coimbatore, India.
Email : ajoyshetty@gmail.com


Abstract

Classification systems of throcolumbar fractures have undergone many changes. From being completely descriptive to predicting prognosis and helping in decision making. An ideal system should be simple, reliable, comprehensive, and reproducible, should facilitate communication between surgeons and also guide the treatment. This review provides an overview on the evolution of various classification system & discusses the merits of the current systems.
Keyowrd: Throcolumbar fractures, classifications.


Introduction

Thoracolumbar (TL) region is defined as the region between T10- L2 vertebral bodies [1] .The fractures of the thoracolumbar region constitute a spectrum of injuries ranging from simple undisplaced stable fracture to an unstable fracture dislocation. Injuries in this region are more common as it is transition zone between kyphotic thoracic region and the lordotic lumbar region, also transits from stiff thoracic spine to a mobile lumbar spine along with the change of orientation of facet joints from coronal to sagittal .In addition, the location of the body’s center of gravity anterior to the body causes compression forces to be transmitted to the anterior vertebral bodies & distraction of the posterior elements [1,2].
Bohler first classified TL fractures eight decades ago, which was followed by multiple fracture classifications [3]. Though there are various classification systems there is no consensus on which is the most applicable. The various classification systems has been described based on the mechanism of injury , morphology of the fracture , two or three column injuries including posterior ligamentous complex and presence of neurological deficit . The complex vertebral anatomy and ligamentous structures are to be included into the fracture classification making it difficult to classify. Occurrence of new pattern of injuries and advanced investigations create a lacunae in previous classification.
Fracture pattern depends on the mechanism of injury and the forces acting at specific position of spine. Rationale of stability of TL fractures is the one which dictates the treatment. The concept of stability has varied from posterior ligamentous complex injury, two column concept, and three column concept and scoring systems with time.
Plain radiographs & computer tomography (CT) are the investigative modality of choice for evaluating TL fractures. Even though MRI might be able to image the posterior ligamentous complex, its role in TL fractures is still not well defined. MRI is definitely indicated when there is disparity between the neurological level of injury and skeletal injury, and in patients with worsening of neurological deficit after admission. MRI may also have a role in evaluating the posterior ligamentous complex to differentiate between a stable or unstable burst fractures. Rajasekaran et al concluded that the MRI did offer modest gain in sensitivity in Posterior ligament complex (PLC) injuries but did not support the need for routine MRI for classification in assessing instability or need for surgery [ 4,5]. The classification systems are based on static images of the spinal injuries. The available imaging techniques are taken in supine position which cannot identify reduced thoracolumbar subluxation as well as the extent of deformity.
An ideal system should be simple, reliable, comprehensive, and reproducible, should facilitate communication between surgeons and also guide the treatment. This review provides an overview on the evolution of various classification system & discusses the merits of the current systems.

Thoracolumbar Classification systems
Bohler Classification [3 ]
First description of Thoracolumbar fractures in 1930 which was mainly descriptive based on plain radiographs . Classified into five categories: compression, flexion- distraction injury, extension, shear fractures and rotational injuries.
Watson Jones classification [6 ]
First classification to highlight the importance of posterior ligamentous complex (PLC). Described seven fracture types of which three are essential : simple wedge , comminuted fracture and fracture- dislocation.
Holdsworth Classification [7 ]
Holdsworth mechanistic classification revolutionized the classification system by introducing the concept of two columns .Spine was divided into two columns :anterior (vertebral body and intervertebral disc)and posterior (neural arch and posterior ligamentous complex)[Figure 1]. Based on the injury pattern he divided spinal fractures into five types: pure flexion, flexion rotation, extension, vertical compression or direct shearing force. The involvement of both the columns rendered the spine unstable .

Clinical Relevance of Bohler, Watson – Jones and Holdsworth Classification :
Bohler was the first to give a descriptive classification of TL fractures. Later Watson Jones introduced the concept of instability and attributed it to PLC injury. Nicoll stated that integrity of interspinous ligament is important for spinal stability. Holdsworth introduced the concept of columns and stated that the involvement of the posterior column renders the spine unstable . All these classifications are simple and state fracture patterns but are not predictive of outcome [8].

Denis Classification [ 9] :
Three column concept of Denis redefined the fracture pattern and classification of TL injuries. Computer Tomography (CT) analysis was done which helped to look more clearly into the fracture anatomy and patterns. Denis divided spine into three columns : Anterior, middle and posterior.
Anterior column includes the anterior half of vertebral body and anterior half of vertebral disc ,Middle column consists of posterior half of vertebral body and posterior half of vertebral disc and posterior column is similar to the posterior column proposed by Holdsworth[Figure 2]. According to Denis injury to middle column implies spinal instability . Classification proposed by Denis includes four types which have further subtypes [Table 1]:


Compression fractures: Failure of the anterior column under compression.
Burst fractures : Failure of the anterior and middle columns with fracture of the vertebral body under axial load
Seat belt injuries : Failure of the posterior and middle column, under flexion-distraction forces
Fracture dislocations : Failure of all the three columns
Denis highlighted the importance of neurological status and described three forms of instability by degrees. The first degree corresponds to isolated mechanical instability, second-degree includes injuries with neurologic component but no mechanical instability and third degree refers to injuries with mechanical and neurologic instability.
Denis classification is simple and highlights the relationship between neurologic injury and stability ,but it did not distinguish between stable and unstable patterns. Middle column as described by Denis is not an anatomical part but is an arbitrary division in the vertebral body itself. It has moderate inter -observer reliability and also does not predict outcome[10].

Mc Afee Classification [ 11]
McAfee based on study of 100 consecutive patients categorized the failure of the middle column into one of the three modes : axial compression, axial distraction & translation.
McAfee classification reinforces the importance of middle column in spinal stability , redefines the burst fractures into stable and unstable fractures ,further divided the seat belt injury into bony chance and flexion distraction injury. He described six injury patterns:
• Wedge-compression fracture : Injury causing isolated failure of the anterior column
• Stable burst fracture : Anterior and middle columns fail in compression with no loss of integrity of the posterior elements.
• Unstable burst fracture: Anterior and middle columns fail in compression and the posterior column is disrupted
• Chance Fracture : Horizontal avulsion injury of vertebral body as result of flexion about an axis anterior to the longitudinal ligament.
• Flexion-distraction injury : Compressive failure of the anterior column while the middle and posterior columns fail in tension.
• Translational injuries : Complete disruption of neural canal which shear failure of all three columns.

Wedge compression and stable burst fractures are stable and can be treated conservatively. Vertebral body height loss more than 50 %, kyphosis > 30 , facet joint subluxation, progressive neurological deficits and spinal canal occlusion by bone fragments in a CT with existence of incomplete neurological deficits were defined as instability criteria. According to these criteria all translational injuries, fracture dislocations , posterior ligamentous injuries with kyphosis greater than 30 degrees are unstable injuries and will need surgery . This classification is one of the most popular and practical which is still in use in clinical practice .
McCormack Load Sharing Classification [12]
First point based classification system to guide the treatment patterns based on score. Based on communition ,apposition and kyphosis reduction point scoring system was used for quantification [Figure 3]. McCormack et al. introduced this classification to predict the risk of implant failure after posterior short segment fixation for thoracolumbar fractures and was mainly applicable to Burst fractures . They proposed score greater than 7 points has greater failure rates with short segment fixation and requires anterior fixation.
The scoring system, mainly focuses on vertebral body fractures rather than posterior ligamentous complex and is not related to mechanism of injury. Thus this classification system is an adjunctive tool especially in burst fractures but cannot replace other classification systems . Li- yang Dai et al have shown a high level of interobserver & intraobserver reliability of load sharing classification in assessment of tharacolumbar burst fractures [13]. This classification has lost its significance in the recent years due to the increased use of “intermediate screw concept (pedicle screw in the fractured vertebral body ) in the surgical management of Burst fractures [14].

MAGERL /AO (ARBEITSGEMEINSCHAFT FÜR OSTEOSYNTHESEFRAGEN) CLASSIFICATION [15]:
Magerl in 1994 after an extensive analysis on 1445 cases came with a comprehensive classification which defines all the fracture patterns of TL injuries. Two column concept has been highlighted and was used for description of TL fractures. This is a complete classification which not only incorporates the mechanism of injury but also defines the fracture pattern. The classification proposes three types of injury mechanism: compression (type A), distraction (type B) and torsion (type C) [Figure 4]. They defined the fractures based on severity starting from simple patterns to more complex ones. Stability was also addressed by this fracture classification stating simple fractures as stable and complex ones as unstable. Though it defines the fracture in a more extensive way with total of 53 subtypes, this makes it complex and difficult.
Despite widespread usage of the AO/Magerl classification, it has lower inter-observer reliability and is less useful in therapeutic decision making and prognostic purposes .Blauth et al. have reported that the inter-observer reliability of the AO classification was low (fair agreement, κ = 0.33), and when the injury was classified into subgroups, the inter-observer reliability decreased further[16]. Oner et al. and Wood et al. have also reported that the Denis classification system (κ= 0.60 and 0.606) showed higher inter-observer reliability than the AO classification system (κ = 0.35 and 0.475)[10,17]. Neurologic injury is not addressed, which is a drawback to this classification. This classification has recently been simplified by the AO Spine Knowledge forum and will be discussed later.

TLICS : Thoracolumbar Injury Classification And Severity Score [18]
Spine Trauma study group came with a new classification system in 2005 that was designed to depict the features important to predict spinal instability, future deformity & progressive neurologic compromise . To guide a treatment protocol, they designed a 10 point scoring system considering three principal parameters- Injury morphology, Posterior ligamentous complex (PLC) status and neurological injury [Table 2] .The PLC includes the supraspinous ligament ,interspinous ligament ,ligamentum flavum & the facet joint capsule .
A score less than 4 indicates non-surgical treatment, while a score greater than 4 indicates the need of surgical treatment because of significant instability. A total score of 4 may be treated either surgically or non-surgically.
They defined three categories of instability
a) Immediate mechanical instability (suggested by the morphology of injury)
b) Long term stability ( indicated by integrity of the PLC )
c) Neurologic stability ( indicated by the presence or absence of instability)
The TLICS guides not only the need for surgery but the surgical approach as well [Table 3]
Though this system predicts outcome, the validation studies are performed by the authors which questions the reliability. Moreover the major determinants taken into consideration are independent of each other which may sometimes misguide treatment. MRI is needed for knowing the integrity of PLC which is one of the limitation to this classification.
Comparing the reliability of Denis, AO, and TLICS systems Lenarz et al. and observed that in all the three systems variation in reliability was present [19]. They noted the highest reliability in the senior resident group and attending spine surgeon group and the lowest reliability in the non – spine attending orthopedists and junior residents. The highest inter observer and intraobserver reliability was noted for the neurologic status. They concluded that the TLICS is an acceptably reliable system when compared with the Denis and AO systems. Joaquim et al in a retrospective case series noted that the TLICS score treatment recommendation matched the surgical treatment in 47 of the 49 patients studied[20] .

AO Spine Thoracolumbar Spine Injury Classification [21]
The AO spine knowledge forum in 2013 has proposed a comprehensive Spine Injury Classification System which includes the
1. Morphology of the fracture
2. Neurological status and
3. Patient-specific clinical modifiers.

1 .Morphological Classification
This is based on Magerl classification which is modified by the AOSpine Knowledge forum.and is based on mode of failure of the spinal column [ Figure 5].

Type A
Involve anterior element fracture without PLC involvement. They are subdivided into five subtypes [Figure 6]. These subtypes are used in description of vertebral body fractures in B and C types.


A0 : Minor Nonstructural fractures( transverse process or spinous process fractures )
A1 : wedge compression fractures( fracture involving one end plate without involvement of the posterior wall of the vertebral body ) [Figure 7]


A2 : Split fractures( pincer type fractures involving both endplates but does not involve the posterior vertebral wall [Figure 8]


A3 : Incomplete burst fractures(Fractures with involvement of the posterior vertebral wall & spinal canal and involving one end plate ) [Figure 9]


A4: Complete burst fractures(Fractures with involvement of the posterior vertebral wall & spinal canal and involving both end plate ) [Figure 10]

TYPE B
These fracture are due to failure of posterior or anterior constraints such as PLC or anterior longitudinal ligament
B1 : Chance fracture or transosseous tension band disruption [Figure 11]
B2 : Posterior tension band disruption ( includes osteoligamentous chance ,flexion distraction injuries and burst fractures with involvement of PLC ) [Figure 12]


B3 : Hyperextension injury through disc or vertebral body with disruption of anterior longitudinal ligament ( classical seen in stiff spine eg. Ankylosing spondylitis ) [Figure 13]

TYPE C
These fractures are characterized by displacement of the cranial or the caudal vertebral fractures segments in any plane ( any translation injury ) [Figure 14]. No subtypes are classified due to possibility of various configurations. Any associated vertebral body fracture should be specified separately ( eg : A1, A2, A3 , A4). Any associated posterior tension band injuries should be specified separately (eg: B1,B2, B3).

2.Neurologic Injury
This takes into consideration of the neurologic status at the moment of admission
N0 : Neurologically intact
N1 : Transient neurologic deficit , which is no longer present
N2 : Radicular symptoms
N3 : Incomplete spinal cord injury or any degree of cauda equina injury
N4 : Complete spinal cord injury
NX : Neurologic status is unknown due to sedation or head injury.

3 .Clinical Modifiers
M1 : Indeterminate posterior complex injury
M2 : Patient specific comorbidity ( includes but not limited to ankylosing spondylitis , rheumatologic conditions , DISH, osteoporosis, or burns affecting the skin overlying the injured spine )

This system is designed to be comprehensive with high interobserver reliability and good predictor of outcome. Similar to the AO/Magerl system it delineates the stable and unstable fractures thus helping in treatment guidelines. This classification system is being subjected to rigorous scientific assessement. Kepler et al in a survey of 100 AO spine members confirmed the hierarchial structure of the AOSpine thoracolumbar Spine Injury Classification system and the possibility of the development of a globally applicable injury severity scoring system[22] . Kaul et al in a multicenter study compared the reliability of AO Spine thoracolumbar Spine injury classification and TLICS ,observed better reliability with the AO spine classification [23]
Overview of Thoracolumbar Fracture Classifications (Table 4)

Guide to treatment based on New AO Classification
We propose the following factors to be considered based on AO classification system for the management of TL fractures.
1. Clinical scenario
2. Severity of the injury
3. Neurologic status
4. Associated polytrauma

Plain radiographs and CT are absolutely essential to classify the factors. MRI may be usual to identify PLC injury & hence in diagnosis of B2 type injuries. Simple fractures like TYPE A0, A1, A2 can be treated conservatively. Type B and C are better treated by surgical method. Management of A3 & A4 fractures depend on the presence of neurological deficit , kyphosis , communition and patient modifiers.

Posterior ligamentous complex plays an important role in long term functional outcome. Clinical findings like severe tenderness and palpable posterior gap suggests PLC injury. Radiological signs such as widening of interspinous distance, facet disruption, Local Kyphosis > 20 and vertebral body comminution to be considered as indicators of associated PLC injury.Surgical management is advised in such situations. Patients with neurologic injury must be surgically treated with or without direct decompression. The choice of surgical approach & technique has not proved to have any impact on the clinical and radiological outcome, hence currently there is no definitive recommendation . It depends on the training , center, & the understanding & beliefs of the surgeon .


Conclusions

The classification of TL fractures has been evolving over the last 9 decades. There is no universally accepted classification so far to guide the treatment. Historically McAfee, AO/Magerl and Load sharing classification had been widely in use but none proved flawless. TLICS came with scoring system which guides treatment and predictor of outcome which is widely in use but had its own pitfalls.. The AO spine thoracolumbar classification system and its attempt at developing a injury severity scoring system is the most recent and the promising classification so far . The AO spine thoracolumbar classification system should be able to guide treatment and predict the outcome to overcome the pitfalls of other classifications. However clinical experience and clinical scenario should not be outweighed by these classification systems to guide the treatment.


References

1. Stagnara P, De Mauroy JC, Dran G, Gonon GP, Costanzo G, Dimnet J, Pasquet A. Reciprocal angulation of vertebral bodies in a sagittal plane: approach to references for the evaluation of kyphosis and lordosis. Spine. 1982 Jul 1;7(4):335-42.
2. Smith HE, Anderson DG, Vaccaro AR, Albert TJ, Hilibrand AS, Harrop JS, Ratliff JK. Anatomy, biomechanics, and classification of thoracolumbar injuries. InSeminars in Spine Surgery 2010 Mar 31 (Vol. 22, No. 1, pp. 2-7). WB Saunders.
3. Boehler L. Die techniek der knochenbruchbehand¬lung im grieden und im kriege. Vienna: Verlag von Wilheim Maudrich; 1930.
4. Rajasekaran S, Vaccaro AR, Kanna RM, Schroeder GD, Oner FC, Vialle L, Chapman J, Dvorak M, Fehlings M, Shetty AP, Schnake K. The value of CT and MRI in the classification and surgical decision-making among spine surgeons in thoracolumbar spinal injuries. European Spine Journal. 2016 Jun 1:1-7.
5. Rajasekaran S, Maheswaran A, Aiyer SN, Kanna R, Dumpa SR, Shetty AP. Prediction of posterior ligamentous complex injury in thoracolumbar fractures using non-MRI imaging techniques. International orthopaedics. 2016 Mar 17:1-7.
6. Watson-Jones R. The results of postural reduction of fractures of the spine. J Bone Joint Surg Am. 1938 Jul 1;20(3):567-86.
7. Holdsworth F. Review article fractures, dislocations, and fracture-dislocations of the spine. J bone joint surg Am. 1970 Dec 1;52(8):1534-51.
8. Verlaan JJ, Diekerhof CH, Buskens E, Van der Tweel I, Verbout AJ, Dhert WJ, Oner FC. Surgical treatment of traumatic fractures of the thoracic and lumbar spine: a systematic review of the literature on techniques, complications, and outcome. Spine. 2004 Apr 1;29(7):803-14.
9. Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. spine. 1983 Nov 1;8(8):817-31.
10. Oner F, Ramos L, Simmermacher R, Kingma P, Diekerhof C, Dhert W, Verbout A. Classification of thoracic and lumbar spine fractures: problems of reproducibility. European Spine Journal. 2002 Jun 1;11(3):235-45.
11. McAfee PC, Yuan HA, Fredrickson BE, Lubicky JP. The value of computed tomography in thoracolumbar fractures. An analysis of one hundred consecutive cases and a new classification. J Bone Joint Surg Am. 1983 Apr 1;65(4):461-73.
12. McCormack T, Karaikovic E, Gaines RW. The load sharing classification of spine fractures. Spine. 1994 Aug 1;19(15):1741-4.
13. Dai LY, Jiang LS, Jiang SD. Conservative treatment of thoracolumbar burst fractures: a long-term follow-up results with special reference to the load sharing classification. Spine. 2008 Nov 1;33(23):2536-44.
14. Shen WJ, Liu TJ, Shen YS. Nonoperative treatment versus posterior fixation for thoracolumbar junction burst fractures without neurologic deficit. Spine. 2001 May 1;26(9):1038-45.
15. Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S. A comprehensive classification of thoracic and lumbar injuries. European Spine Journal. 1994 Aug 1;3(4):184-201.
16. Blauth M, Bastian L, Knop C, Lange U, Tusch G. [Inter-observer reliability in the classification of thoraco-lumbar spinal injuries]. Der Orthopade. 1999 Aug;28(8):662-81.
17. Wood KB, Khanna G, Vaccaro AR, Arnold PM, Harris MB, Mehbod AA. Assessment of two thoracolumbar fracture classification systems as used by multiple surgeons. J Bone Joint Surg Am. 2005 Jul 1;87(7):1423-9.
18. Vaccaro AR, Lehman Jr RA, Hurlbert RJ, Anderson PA, Harris M, Hedlund R, Harrop J, Dvorak M, Wood K, Fehlings MG, Fisher C. A new classification of thoracolumbar injuries: the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status. Spine. 2005 Oct 15;30(20):2325-33.
19. Lenarz CJ, Place HM, Lenke LG, Alander DH, Oliver D. Comparative reliability of 3 thoracolumbar fracture classification systems. Clinical Spine Surgery. 2009 Aug 1;22(6):422-7.
20. Joaquim AF, Fernandes YB, Cavalcante RA, Fragoso RM, Honorato DC, Patel AA. Evaluation of the thoracolumbar injury classification system in thoracic and lumbar spinal trauma. Spine. 2011 Jan 1;36(1):33-6.
21. Vaccaro AR, Oner C, Kepler CK, Dvorak M, Schnake K, Bellabarba C, Reinhold M, Aarabi B, Kandziora F, Chapman J, Shanmuganathan R. AOSpine thoracolumbar spine injury classification system: fracture description, neurological status, and key modifiers. Spine. 2013 Nov 1;38(23):2028-37.
22. Kepler CK, Vaccaro AR, Schroeder GD, Koerner JD, Vialle LR, Aarabi B, Rajasekaran S, Bellabarba C, Chapman JR, Kandziora F, Schnake KJ. The Thoracolumbar AOSpine Injury Score. Global spine journal. 2016 Jun;6(04):329-34.
23. Kaul R, Chhabra HS, Vaccaro AR, Abel R, Tuli S, Shetty AP, Das KD, Mohapatra B, Nanda A, Sangondimath GM, Bansal ML. Reliability assessment of AOSpine thoracolumbar spine injury classification system and Thoracolumbar Injury Classification and Severity Score (TLICS) for thoracolumbar spine injuries: results of a multicentre study. European Spine Journal. 2016:1-7.


How to Cite this Article: Shetty AP, Dumpa SR, Rajasekaran S. Thoracolumbar Fractures: Classification and Clinical Relevance.. International Journal of Spine Sep-Dec 2016;1(2):14-21.


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Thoracolumbar Fractures – “Changing Perspectives”.

Volume 1 | Issue 2 | Sep – Dec 2016 | Page 9-13 | Raghava D Mulukutla


Authors : Raghava D Mulukutla [1]

[1] Director & Chief of Spine Surgery
Udai Omni & Apollo Health city
Hyderabad

Address of Correspondence
Dr. Raghava D.Mulukutla
Director & Chief of Spine Surgery
Udai Omni & Apollo Health city
Hyderabad.
Email: rdmuluk@gmail.com


Abstract

Road traffic accidents are commonest cause of Thoracolumbar fractures which may or may not be associated with neurological injuries. Most of the classification are purely descriptive, but recently focus has shifted in developing more prognostic classifications. Diffirent management approaches are defined depending on the fracture type and the scenario is still remains a dynamic and evolving one. The current review aims to provide an overview of changing perspectives in this field
Keywords: Thorocolumbar fractures, management options.


Introduction

The thoracic spine which is fixed and the lumbar spine which is mobile predisposes this area for fractures and it is not surprising that this area which is a transitional zone accounts for nearly 58% of spinal injuries [1]. Pre existing Osteopenia or osteoporosis and other metabolic disorders can precipitate fractures in this area. However severe injuries with or without neurological deficit are mostly due to road traffic accidents, fall from heights or industrial injuries. Since the early part of 20th century various classifications have emerged and till date there is no thoracolumbar fracture classification system that is perfect and classification systems are still evolving. Various treatment options including non operative treatments, short segment fusions, and more recently minimally invasive surgical techniques are used by surgeons in managing these injuries. It is important not to overlook other serious associated injuries and if present should be addressed first before undertaking surgery of thoracolumbar spinal injuries. Neurological deficits are not uncommon with more serious thoracolumbar trauma and it is important to protect the spine during transport and emergency stabilization of the patient up until final treatment [2].

The Ever Evolving Classifications
Classification of thoracolumbar fractures is important to identify stable and unstable injuries and help strategize treatment and to study the results of such treatments across various centres. Ideally, classifications should be easily understandable in clinical settings, reproducible, simple and direct the treating surgeon to appropriate management protocols. Newer classifications systems continue to emerge and is it is true to mention that there is no universally acceptable classification of thoracolumbar fractures.

The initial classification systems started with descriptive terms3 and later biomechanical factors such as anatomical regions and mechanical forces acting on the spinal column were introduced. Boehler [4] was the first to classify thoracolumbar fractures and he described five categories.
1. Compression fractures
2. Flexion –distraction injuries
3. Extension fractures with injury to anterior and posterior long. Ligament.
4. Shear fractures and
5. Rotational injuries

Watson Jones [5] introduced the concept of instability and was one of the first few to recognize the importance of posterior longitudinal ligament in maintaining spinal stability. There were seven types in his classification of Thoraco lumbar injuries with three major patterns: viz. a. simple wedge fractures b. comminuted fractures and c. Fracture dislocations

Nicoll [6] described anatomical classification and felt that the major determinant of stability was the interspinous ligament.3 Holdsworth7 was the first to coin the term “Burst Fracture” and introduced the “column concept” dividing the spine into two major columns : anterior column comprising the vertebral body and disc and the posterior column comprising the facet joints and posterior ligamentous complex. He felt that if both columns are disrupted the fracture would then be unstable. Kelly and Whitesides8 working on the Holdsworth concept felt that all burst fractures are inherently unstable.
With the advent of CT scans and after a review of 412 patients Denis presented his 3 column concept which is widely accepted [9]. He postulated that ALL (anterior longitudinal ligament), anterior half of the vertebral body and disc form the anterior column; PLL (Posterior longitudinal ligament) posterior half of vertebral body and disc constitute the middle column and the remaining posterior elements comprising the posterior column. The middle column according to Denis is the key for the stability of thoracolumbar fractures. Anterior column transmits 30% body weight and posterior column about 20%. However Anterior and Middle columns both resist 70-80% of body weight in flexion and the middle and posterior column resist 60% of body weight in extension. In Compression Fractures there is an anterior column failure and Burst fractures are secondary to Anterior and Middle column failure .Seat belt injuries are due to flexion distraction forces with failure of middle and posterior columns . In fracture dislocation all the three columns fail. Many surgeons do not agree that all Burst fractures are unstable; which is contrary to Denis classification where if two columns are involved in a fracture, then that fracture must be unstable [3,10].
The Holdsworth and Denis classification systems are anatomical classifications systems and they do not take into account the mechanisms of injuries of thoracolumbar fractures. McAfee [11] described a classification system where both the mechanism of injury and morphology of the fracture were included and he made the important contribution of describing the failure of the middle column due to a. axial compression b. axial distraction and c. translation.

Ferguson and Allen [12] proposed a mechanistic classification system and the mechanisms described are a. flexion compression, b. axial compression c. flexion distraction d. hyperextension –compression e. hyperextension distraction f. rotation –shear.

The AO – Magerl [13] classification and subsequent modifications of this classification system is very comprehensive and divides these injuries into Type A: compression; Type B : distraction and Type C : rotation and /or shear. Type A injuries are mostly simple and stable and Type C being very unstable injuries.
McCormack and Gains[14] described a Load sharing classification to predict implant failure and the need for additional Anterior surgery.
The Spine Trauma study group described the Thoracolumbar Injury Severity Score (TLISS) and The Thoracolumbar Injury classification and severity system (TLICS). This study based their severity scores on the a. mechanism of injury, b. integrity of Posterior ligament complex and c. the Neurologic status [15,16]. They recommended non operative treatment for scores less than 3 and surgery for scores more than 5 with a score of 4 to be treated with our without surgery [17].

Investigations:
AP and Lateral Radiographs, CT scans, MRI are all routinely used in the work up for thoracolumbar injuries. Standing lateral Radiographs and dynamic X-rays have little role in the acute setting but when safe to do and not uncomfortable to the patient are useful to monitor vertebral collapse, progression of deformity if any and overall sagittal alignment of the spine.18 Whilst CT scans are useful in accurate classification of the thoracolumbar fractures, they are especially useful to rule out a chance fracture.18 MRI is invaluable to identify epidural haematoma, SCIWORA, injury to the disc and most importantly the posterior ligamentous injury. With increasing availability of scanning machines, and with improvements in image quality, acquisition time, and image reformatting there has been a dramatic change in the commonly used algorithms [19].

Management Strategies
The steroid controversy : In the 1990s use of Methylprednisolone in the treatment of acute spinal cord injury became a routine following publication of NASCIS II trials [20,21]. However, Hurlbert et al [22] from an evidence based approach reported that methylprednisolone cannot be recommended for routine use in SCI. They also concluded that prolonged administration for up to 48 hours may be harmful to the patient and suggested that methylprednisolone should be considered to have investigational (unproven) status only. Most surgeons today have abandoned the use of methylprednisolone in the management of acute spinal cord injury following thoracolumbar trauma.

Compression Fractures
These injuries mostly involve the anterior column without involvement of the middle and posterior columns and are usually managed conservatively with analgesics, and restricted activity and strict bed rest may not be necessary. Most surgeons use front back support or TLSO or modifications of various hyper extension braces. However Giele et al [23] found no evidence to support that these braces are effective in Thoraco lumbar fractures. Vertebroplasty, Balloon Kyphoplasty are some of the procedures employed for pain relief. In those who present late with significant symptomatic kyphotic deformity or with late onset paraparesis, it is important to restore the sagittal balance with Pedicle subtraction osteotomy.
In spite of a large volume of literature on Burst fractures and their management, there is still no consensus on their management. The classification systems that are available are many and not universally acceptable leading further to the confusion about management of these injuries [24]. The problem is compounded when there is a neurological injury associated with these injuries. With fall from heights being the commonest cause of these injuries in India, the incidence of Neurological events is much higher at 60% compared to 40 % reported by various US studies [17].
Burst fractures are also classified as Stable and Unstable . Stable burst fractures are two column injuries. In the absence of neurological deficits and when not associated with other systemic injuries there is a trend amongst some surgeons to manage these injuries conservatively [25]. Those who manage these injuries conservatively believe that there is spontaneous remodeling of the spinal canal. However this view is not shared by many and conservative management demands regular radiological and clinical follow up to document late collapse and progression of kyphotic deformity.
Surgery: Neurological deficit and instability are definite indications for surgery in burst Thoraco lumbar fractures. In the presence of neurological deficit it is important to decompress the spinal cord. There is controversy regarding timing of surgery in those patients with neurological deficit. A few authors have advocated early surgery in patients with Neurological deficit [26], but there is no evidence that emergency surgical decompression has better outcomes. In the presence of progressive neurological deficit it is unwise to delay surgery and should be performed as early as possible. Controversy also exists as to the choice of approach in these fractures. McCormack based on their load sharing classification proposed that those with a score of 6 or less can be managed by posterior approach and those with a score of 7 or more should be managed by anterior approach. The anterior approach is indicated in those patients with extensive comminution of the vertebral body with severe retropulsion of fragments into the spinal canal. However there has been a recent trend to manage these burst fractures through a posterior only approach. Biomechanically placing short pedicle screws in the fractured vertebral body prevents implant failure. Short pedicle screws help in correcting the kyphotic deformity and in increasing the stiffness of the construct [2,27]. There is also controversy in literature about fusion following stabilization with some surgeons advocating fusion in predominantly ligamentous injuries [17].

Flexion –Distraction Injuries
Chance fractures or sea belt injuries are flexion distraction injuries with failure of all three columns in tension and the disruption of posterior elements may be osseous, ligamentous or both [28]. It is prudent to look for Intra abdominal injuries as they are sometimes associated with these injuries [29]. Some of these fractures without neurological deficit and in the absence of visceral injuries can be managed with a hyperextension brace. The trends in management of these fractures appears to be posterior approach when there is no neurological deficit or when there is a nerve root injury and in the presence of spinal cord or cauda equina injury a combined approach may be more appropriate [30].

Fracture Dislocations
According to TLICS classification these are inherently unstable injuries and need stabilization. They are typically 3 column injuries and it is commonly believed that pure hyperflexion or hyperextension alone may not produce thoracolumbar fracture dislocations and that there is always an additional rotational force that produces these injuries [31]. Fracture dislocations are associated with severe neurological deficits, except in those rare instances where a concomitant neural arch fracture may be associated with intact neurological function [32]

Biomechanics of Instrumentation
That Posterior pedicular instrumentation provides a slightly greater stiffness than anterior plate systems is proven by biomechanical studies. However these systems do not provide enough stiffness in axial rotation. Bence et al [33] believe that a combined approach is biomechanically superior to either an anterior or posterior approach alone in management of Thoraco lumbar trauma.

Long or Short constructs?
Opinion amongst surgeons is divided as to the number of levels to be instrumented in fractures of thoracolumbar spine. Short segment instrumentation has greater chance of instrumentation failure compared to longer constructs. However extending fusion to the lower lumbar vertebrae is not advisable and last instrumented vertebra should be L3 or above to minimise the risk of degeneration of lower lumbar discs [34].
The advantages of long segment constructs being that they resist bending forces much better than short segment instrumentation and help prevent kyphosis. There is also less pull out failure and a satisfactory spinal alignment can be achieved with long constructs [30]. According to Joseph et al [35]Short segment instrumentation is ideal for flexion distraction injuries.

Minimally Invasive Surgery In Thoraco Lubar Trauma(MIS)

MIS technologies are evolving and there is no long term studies to give definite guidelines. The posterior instrumentation by MIS technique works like an internal tension band while the fracture is healing. Some times anterior approaches are supplemented by MIS posterior instrumentation techniques.


Conclusions

Thoracolumbar trauma can range from simple fractures to more serious and complex fracture dislocations sometimes associated with life threatening injuries with or without neurological deficits. There is no universally acceptable classification system so far and some of these may not have much use in clinical settings. There are no randomized controlled trials comparing various treatment modalities and it is therefore not surprising that there is hardly any evidence based guidelines in the management of these injuries [30].

With better understanding of the morphology and mechanism of injury, a variety of treatment options are advocated for these injuries. There is a trend to manage stable burst fractures without neurological injury conservatively. However, more studies are needed to validate conservative treatment vs surgery, and in those with neurological deficits early vs. elective decompression of spinal cord and role of fusion in management of thoracolumbar fractures. It is important for the treating surgeon to understand the morphology of these fractures and the mechanisms responsible and plan and execute appropriate treatment strategies.


References 

1.Leucht P, Fischer K, Muhr G et al. epidemiology of traumatic spine fractures. Injury 2009;40:166-72
2. Ajoy Shetty :Review Article,Thoraco lumbar Trauma :Journal of OASIS; 2011 p. 7-12
3.Uday M Pawar, Swapnil Keny, R.Chadda : Biomechanics and classification of Thoracolumbar Spinal Injuries:Ch. 44. ASSI Textbook of Spinal injuries and Trauma 2011;P.449-456
4.Boehler L. Die Techniek der Knochenbruchbehandlung im Grieden und im Kriegeed. Vienna , Austria: Verlag von Wilheim, Maudrich; 1930
5.Watson Jones R. The results of postural reduction of fractures of the spine. J Bone Joint surg Am. 1970;52:1534-51
6. Nicoll EA (1949) Fractures of the dorso-lumbar spine. J Bone Joint Surg Br 31:376–94
7. Holdsworth F (1970) Fractures, dislocations, and fracture-dislocations of the spine. J Bone Joint Surg Am 52:1534–51 56
8. Kelly RP, Whitesides TE (1968) Treatment of lumbodorsal fracture-dislocations. Ann Surg 167:705–17
9. Denis F (1983) The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine 8:817–31 31.
10. Agus H, Kayali C,Arslantas M. Non operative treatment of burst –type thoracolumbar vertebral fractures. Clinical and radiological results of 29 patients. Eur Spine J.2005;14:536-40
11. McAfee PC,Yuan HA,Friedrickson BE, et al. The value of computed Tomography in thoraco lumbar fractures. An analysis of one hundred consecutive cases and new classification. J Bone Joint Surg Am.1983;65: 461-73
12. Ferguson RL, Allen BL. A mechanistic classifiction of thoraco lumbar spine fractures. Clin Ortho Relat Res. 1984;(189):77-88
13. . Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S (1994) A comprehensive classification of thoracic and lumbar injuries. Eur Spine J 3:184–201 81
14. McCormack T, Karaikovic E , Gains RW. The laod sharing classification of spine fractures .Spine (Phila Pa 1976)1994;19:1741-4
15. Sethi MK, Schoeffeld AJ, Bono CM et al. The evolution of thoraco lumbar injury classification systems. Spine J. 2009,9:780-8
16.Vaccaro AR,Zeiller SC,Hulbert RJ,et al : The thoraco lumbar injury severity score: a proposed tratment algorithm. J Spinal Disord Tech 2005;18:209
17.KV Menon, R Dalwai : Burst Fractures of Thoraco lumbar Spine : ASSI Text book of Spinal infections and Trauma :2011: Ch. 46; p462-470
18.A.Kulkarni, SM Shah :Vertebral compression Fractures, Ch. 45. ASSI Textbook of Spinal infections and Trauma 2011.P.457-461
19.Bagley LJ (2006) Imaging of spinal trauma. Radiol Clin North Am 44:1–12, vii
20.Bracken MB, Shepard MJ, Collins WF, et al: Methylprednisolone or naloxone treatment after acute spinal cord injury: 1-year follow-up data. Results of the second National Acute Spinal Cord Injury Study. J Neurosurg 76:23–31, 1992 5.
21.Bracken MB, Shepard MJ, Holford TR, et al: Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury. Results of the third National Acute Spinal Cord Injury Randomized Controlled Trial. National Acute Spinal Cord Injury Study. JAMA 277:1597–1604, 1997
22.Hurlbert, R. John, The Role of Methylprednisolone in Acute Spinal Cord Injury
Spine: 2001 Issue 24S:- Vol 26 – pp S39-S46
23.Giele BM, Wiertsema SH, Beelen A et al. No evidence for effectiveness of bracing in patients wioth thoraco lumbar fractures. Acta Orthop. 2009;80:226-32
24Mirza SK, Mirza AJ, Chapman JR et al.Classification of thoraco lumbar fractures and their effect on treatment. J Am Acad Orthop Surg. 2002;10: 364-77
25.S.Rajasekharan. Thoraco lumbar fractures without neurological deficit: the role for conservative treatment. Eur Spine J.2010; 19(suppl 1):S40-S47
26.Krengel WF, Anderson PA, Henley MB. Early stabilisation and decompression for incomplete paraplegia due to thoracic level spinal cord injury. Spine. 1993; 18:2080-7
27.Mahar A,Kim C, Wedemeyer M, Mitsunaga L, Odell T, Johnson B, Graffin S. Short segment fixation of lumbar burst fractures using pedicle fixation at the level of fracture. Spine 2007Jun 15;32(14):1503-7
28.Groves CJ, Cassar-Pullicino VN,Tins BJ et al. Chance type flexion –distraction injuries in the throaco lumbar spine: MR imaging characteristics.Radiology.2005;236: 601 -8.
29.Chapman JR, Agel J, Jurkowich GJ,et al. Thoraco lumbar felxion –distraction injuries: associated morbidity and neurological outcomes.Spine (Phila Pa1976)2008;33:68-57
30.Harsh Priyadarshi,Thomas J kishen, Greg Etherington,Ashish D Diwan : Flexion –Distraction injuries and Fracture dislocations of the Thoracic and Lumbar spine. ASSI Text book of Spinal infections and Trauma :2011: Ch. 47; p 471-480
31.Roaf R. A study of the Mechanics of spinal injuries. J Bone Joint Surgery (Br). 1960;42-B (4):810-23
32.Gitelman A, Most MJ Stephen M. Traumatic thoracic spondyloptosis without neurological deficit and treatment with in situ fusion. Am J Orthop (Belle Mead NJ).2009;38:E 162-5
33.Bence T, Schreiber U Grupp T et al. Two column lesions in the Thoraco lumbar junction. Anterior, posterior or combined approach? A comparative biomechanical in vitro investigation. Eur J spine 2007;16:813-20
34.Mc Lain RF. The biomechanics of long versus short fixation for Thoraco lumbar spine fractures. Spine (Phila Pa 1976)2006;31:S 70-79ldiscussion s 104
35.Joseph Sa, Stephen M , Meinhard BP. The successful short term treatment of flexion distraction injuries of thoracic spine using posterior-only pedicle screw instrumentation. J spinal diso Tech. 2008;21:192-8.


How to Cite this Article: Mulukutla RD. Thoracolumbar fractures – “Changing Perspectives”. International Journal of Spine Sep-Dec 2016;1(2):9-13.


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Primary disseminated Hydatid disease of the vertebral body and paraspinal region

Volume 1 | Issue 2 | Sep – Dec 2016 | Page 52-54 | Tyagi S K, Mediratta Sunit


Authors : Tyagi S K [1], Mediratta Sunit [1]

[1] Department of Neurosurgery, Indraprastha Apollo Hospital, Sarita Vihar, Mathura Road, New Delhi.

Address of Correspondence
Dr Sunit Mediratta
Department of Neurosurgery, Indraprastha Apollo Hospital,
Sarita Vihar, New Delhi-110076.
Email: sunit_medi@yahoo.com


Abstract

Introduction: Hydatid disease is caused by parasitic infestation by tapeworm of the genus echinococcus. Although any organ can be involved, hydatid disease involving vertebral body and paraspinal soft tissue is a rare occurrence even in endemic areas. Liver is the most commonly involved organ followed by the lungs and together they constitute about 90% of all hydatid disease involvement. Primary spinal hydatid cysts are rare and account for only 1% of all hydatid disease cases. We present a rare case of disseminated primary hydatid disease involving the vertebral body and extensive extradural paravertebral soft tissue causing cord compression .The patient was treated with surgical decompression of the spine and spinal stabilization was achieved using implants followed by antihelminthic therapy using oral albendazole.
Keywords: Hydatid disease, vertebral body, albendazole, spinal stabilization.


Introduction

Hydatid disease or human echinococcosis is a zoonotic infection caused by the larval forms of the genus Echinococcus [1]. It is endemic in areas where dogs and livestock coexist[2] and is prevalent worldwide .Humans are intermediate or accidental hosts and contract the disease by means of contamination through direct contact with the definitive host or its feces or by ingesting infected food[2].Primary spinal involvement occurs in only 1% of all cases [2,3,4,5]. Extensive spinal involvement proposes a challenge for the treating surgeon and makes it nearly impossible to remove entire cysts in-Toto [6].Intra operative rupture of cyst can lead to anaphylaxis, local recurrence and dissemination of hydatid disease, increasing morbidity. In this report we present a case of primary hydatid disease involving vertebral bodies with extensive extradural paravertebral soft tissue involvement causing cord compression .Patient was treated with surgical decompression and spinal stabilization along with medical therapy.

Case Report

A 40 year old male presented with complaints of low back ache and progressive bilateral lower limb weakness and decreased sensations below the inguinal region of two months duration. One month after onset of the initial symptoms he was unable to walk without support and developed urinary frequency and constipation. On examination, he had spastic paraparesis with power 4-/5 bilaterally. The deep tendon reflexes were brisk in both the lower limbs with extensor Babinski reflex. He had hypoesthesia for all sensations below Dorsal (D)-10 dermatome bilaterally .Local examination of spine did not reveal any deformity, swelling or tenderness. Magnetic resonance imaging (MRI) of the dorsolumbar spine revealed multiple small round to oval well defined lesions in the D11-12 vertebral bodies, disc space, epidural and paraspinal soft tissue. The lesions were hypointense on T1 weighted images and brightly hyperintense on T2 weighted images with bright peripheral contrast enhancement. The involved vertebral bodies were collapsed and along with the epidural lesions caused cord compression [Fig 1].

All his hematological investigations were normal except an erythrocyte sedimentation rate (ESR) of 28 mm/hour and ELISA (Enzyme linked immunosorbant assay) was strongly positive for Echinococcal antigen. Chest x-ray and ultrasound abdomen was normal. He underwent a laminectomy at D11-12 with wide excision of epidural cysts and partial corpectomy of diseased D11-12 vertebral body. Cysts were thin walled pearly white containing clear fluid [Fig 2]. Paraspinal soft tissue lesions were also excised. There was intra operative rupture of the cyst. 3% hypertonic saline was used as scolicidal agent for irrigation of the operative field. Thereafter spinal fusion and stabilization was done using a titanium cage with autologous bone graft placed between D10 and L1 vertebral bodies and D10-L1 fused using titanium pedicle screws and laminar hook [Fig 3]. Post operatively the patient was started on oral Albendazole 10 mg/kg /day for 3 months. Power in both the lower limbs had improved to 4+/5 with complete relief from back pain and subjective improvement in sensations by 50%.

Discussion

Cystic hydatid disease is caused by infection with larval form of the tapeworm Echinococcus granulosus and mostly seen in areas where sheep and cattle are raised. Adult worms mature in the intestine of dog, wolf, and other carnivorous animals (definitive host), and eggs are released in feces [2]. Intermediate hosts such as sheep and cattle ingest the eggs. Human are accidental intermediate hosts and contract the disease by means of contamination through direct contact with the definitive host or its feces or by ingesting food infected with parasite eggs [2]. Oncospheres hatch in duodenum, which penetrate intestine and enter portal circulation [2,5,7].Liver and lungs trap oncospheres that migrate from intestine to the portal circulation which then develop into hydatid cysts. Although liver (75%) and lungs (15%) are the most commonly involved organs, the disease can be seen anywhere in the body [4,8]. Bone is involved in 0.5 to 4% of the cases of hydatid disease [4,9].Primary spinal hydatid cysts account for 1% of all cases of hydatid disease [2,5,10]. The disease usually spreads to the spine by direct extension from pulmonary, abdominal, or pelvic infestation[1].After ingestion the parasite can also reach vertebrae directly through Porto-vertebral shunt by paradoxical flow during transient increase in intraabdominal pressure[9,11,12].Spinal hydatid cysts are located most commonly at the thoracic (52%), followed by the lumbar (37%) and then the cervical and sacral levels (1,3).The parasite cyst generally consist of an inner layer(endocyst) and outer layer(ectocyst).The host defense reaction forms vascularised fibrous capsule(pericyst) which provides nutrition to the parasite. The host defense in bony tissue is marginal and thus outer capsule is usually thin or absent [9].On plain x-rays the cyst is seen as osteolytic lesions with well defined rounded margins without any periosteal reaction. Rarely the cyst can be seen as a calcified rounded mass, however most cysts do not calcify and gradually enlarge over time[9].Computed tomography(CT) scan show well defined hypodense rounded lesion within the marrow, osteolytic lesions, cortical thinning and destruction, bone expansion and extension into adjacent soft tissue.[9,11,13 ].
On MRI imaging the cysts appear as hypointense on T1 weighted images and brightly hyperintense on T2 weighted images, rounded or oval in shape, thin walled with no septations[1,2] and conglomeration of the cysts appear as bunch of grapes. Fluid within the cysts has intensity of cerebrospinal fluid (CSF) with no debris in the lumen [2,6].The lesion shows poor contrast enhancement [1,9] however our case showed bright contrast enhancement around the periphery of the lesion .The MRI appears to be the best pre-operative diagnostic modality which also provides comprehensive information about anatomical relationship to neural and surrounding structures. Diagnosis is difficult to miss when there is a conglomeration of cysts or multiple compartment involvement; however diagnosis is difficult to make in cases with few cysts and single compartment involvement. Differential diagnosis may include Aneurysmal bone cyst, cystic component of giant cell tumor and epidermoid cyst [9].
Definitive diagnosis can be achieved by histopathological examination of the resected tissue. Fine needle aspiration biopsy is an invasive procedure and puncture of a cyst may lead to dissemination and anaphylaxis. [6, 14]
The surgical treatment of spinal hydatid disease should be reserved for symptomatic lesions[9,15].Radical resection of the cyst must be followed by albendazole therapy, however controversy remains regarding the dose and duration of albendazole therapy [6] the mean duration in literature is 3 to 4 months[2,5].
Radical resection in extensive spinal hydatid disease is generally impossible and decompression is the more realistic achievable goal [9].Cyst rupture is very common while resecting from within the vertebral body and can induce anaphylactic reaction along with increase chances of recurrence and dissemination[5,9]. These hazards can be minimized by using steroids during procedure and dissemination can be prevented by injecting the cyst or irrigating the wound in case of spillage with scolicidal agents like hypertonic saline, 0.5% silver nitrate, dilute betadine, glycerin or ethanol [2,3, 9].Chemical sterilization however does not kill all microscopic daughter cysts [9].Some authors also recommend poly-methyl methacrylate reconstruction of the vertebral body defect for its antihelminthic effect [1,9].
The prognosis of patients with spinal hydatid disease has been varied, ranging from complete eradication of disease to multiple recurrences, systemic dissemination and death. Recurrence rates from 30 to 100% have been reported [2,3,5] and investigators in one study suggest that the mean life expectancy after spinal involvement is 5 years [3].


Conclusions

Conglomeration of round to oval lesions with CSF intensity on MRI is nearly definitive of vertebral hydatid disease. Contrary to the reported literature, in our patients, bright peripheral rim enhancement of the cyst wall was seen on MRI. Patients do become pain free and show neurological recovery when treated with resection of the cysts from extensively involved vertebra and paravertebral soft tissue followed by spinal stabilization. We believe that aggressive surgery followed by albendazole therapy offers a chance for a prolonged symptom free survival with this illness, even in cases of extensive spinal hydatid disease.


References 

1. Jain A, Prasad G, Rustagi T, Bhojraj SY. Hydatid disease of spine: Multiple meticulous surgeries and a longterm followup. Indian J Orthop 2014; 48:529-32.
2. Kalkan E, Cengiz SL, Ciçek O, Erdi F, Baysefer A.Primary Spinal Intradural Extramedullary Hydatid Cyst in a Child. J Spinal Cord Med. 2007; 30(3): 297–300.
3. Lath R, Ratnam B.G, Ranjan A. Diagnosis and treatment of multiple hydatid cysts at the craniovertebral junction. J Neurosurg spine. 2007; 6:174–177.
4. Suslu HT, Cecen A, Karaaslan A,et al:Primary Spinal Hydatid Disease.Turkish Neurosurgery 2009,vol: 19,No:2,186-188.
5.Hakan Somay, Erdogan Ayan, Cezmi Cagri Turk, Selin Tural Emon, Mehmet Zafer Berkman. Long-Term Disseminated Recurrence in Spinal Hydatid Cyst. Turkish Neurosurgery 2014; Vol: 24, No: 1, 78-81.
6. Moharamzad Y, Kharazi HH, Shobeiri E, Farzanegan G, Hashemi F, et al:Disseminated intraspinal hydatid disease J Neurosurg Spine8:490-493,2008.
7. Pamir MN, Akalan N, Özgen T, et al: Spinal hydatid cyst. Surg neurol 1984; 21: 53–57.
8. Iliac AT, Kocaoglu M, Zeybek N et al: Extrahepatic abdominal hydatid disease caused by echinococcus granulosus: imaging findings. AJR 2007; 189:337–343.
9. Bron JE,Kemenade FJ,Verhoof OJ, Wuisman PIJ.Long term follow-up of a patient with disseminated spinal hydatidosis. Acta orthop, Belgica 2007; 73: 674-677.
10. Benzagmout M,Kamouni I,Chakour K,Chouni ME: Primary spinal epidural hydatid cyst with intrathoracic extension. Neurosciences 2009; vol.14 (1):81-83.
11. Brian JF,Richez P ,Belliol E etal.Osteoarticular involvement in parasitic diseases; bone echinococcosis. J Radiol 1998; 79:1351-1357.
12. Sener RN,Calli C,Kitis O,Yalman O.Multiple primary spinal- paraspinal hydatid cysts. Eur Radiology 2001; 11:2314-2316.
13. Tuzun M,Hekimoglu B.CT findings in skeletal cystic echinococcosis.Acta Radiol 2002 ;43:533-538.
14. HerreraA,Martinez AA,Rodriguez J:spinal hydatidosis.Spine 2005;30:2439-2444.
15. McManus DP, ZhangW,Li J,BartleyPB.Echinococcosis.Lancet 2003;362:1295-1304.


How to Cite this Article: Tyagi S K, Mediratta S. Primary disseminated Hydatid disease of the vertebral body and paraspinal region. International Journal of Spine Sep-Dec 2016;1(2):51-54.


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Thoracolumbar Spinal Injuries – Evolution of Understanding of fracture Mechanics and Management Options

Volume 1 | Issue 2 | Sep – Dec 2016 | Page 7-8 | Shailesh Hadgaonkar, Ketan Khurjekar


Authors : Shailesh Hadgaonkar [1], Ketan Khurjekar [1]

[1] Sancheti Institute for Orthopaedics &Rehabilitation, Pune, India.

Address of Correspondence
Dr Shailesh Hadgaonkar
Sancheti Institute for Orthopaedics &Rehabilitation, Pune, India
Email: editor.ijspine@gmail.com


Introduction

This symposia on thoracolumbar fractures is aimed at providing an overview to the reader with respect to evolving trends in fracture diagnosis and management.
There has always been controversies in treating thoracolumbar spine injuries with neurological deficit, but as we know the goal of managing these T-L junction injuries is to maintain the sagittal alignment for mechanical stability and to give additional support for rehab and physiotherapy for neurological recovery. The main aim of thoracolumbar fracture surgery is to give structural support to the spinal column for wheelchair mobilization in cases with complete injury and paraplegia. We have found significant improvement in quality of life in patients who were operated for these severe thoraco lumbar spinal injuries. As we all know the most common level of these injuries is T 12 and L1, sustaining from the high velocity trauma. The flexibility at thoraco lumbar junction, the thoracic rib cage ending at the junctional level, coronal alignment of facet joint in thoracic spine and the changes in the lower thoracic facets to less coronal alignment is likely to cause fracture dislocations. Various transitional zone injuries- between T 11- L2 are approximately 50 – 60 % of all injuries. Most common reason for these injuries – are fall from height and high velocity RTA. There is a significant association of other injuries such as chest, abdominal, vascular injuries and also head injuries with these fracture dislocations.
It is paramount to evaluate these patients in detail, thorough clinical and neurological assessment is mandatory. The standard American Spinal Injury Association (ASIA) guidelines should be followed in neurological assessment. Associated relevant investigations as the X-rays and MRI scans will guide for non-operative Vs operative management. Additional modalities such as CT scans and 3D reconstruction is important clinically unstable and high grade T-L injuries. Primary assessment and medical management is important to stabilize the patient before planning the surgery.

Evolution of classification systems :
Various different classification system have evolved from the World War I and II days, as Bohler in 1930 classified T-L fractures into five categories :-
1- Compression fractures
2- Flexion /distraction injuries
3- Extension fractures
4- Rotational injuries
5- Shear fractures
Watson Jones in 1938 classified T-L injuries adding instability to Bohler’s classification. The most important factor in Watson Jones classification was description of Posterior ligamentous complex (PLC) in spine stability, as they felt the integrity of interspinous ligament is most important stability factor.
Nicole in 1949, further classified using anatomical classification with emphasis on interspinous ligament integrity. He described the stability structures as the vertebral body, disc, intervertebral joint, and interspinous ligament. This classification serves as a foundation for subsequent classifications.
Holdsworth in 1963, described Two column theory and he emphasized the spinal stability on posterior ligamentous complex (PLC) stability. Kelly and Whitesides attempted to modify Holdsworth classification, as they specifically mentioned anterior column as solid vertebral body whereas posterior column as posterior elements and neural arch. Also they emphasized the treatment of neurological deficit.
Dennis in 1983, came up with a new concept – Three column theory using the radiological parameters. He provided a new insight in detailing the classification into anterior, middle and posterior column. They described the middle column – osteo-ligamentous complex injury is the primary determinant of mechanical spinal stability.
Mcafee et al described the classification based on CT scans of 100 consecutive patients and divided into 6 groups. This was the most detailed classification system in the 1980’s. They described the height loss of vertebral body, facetal joint subluxation, fragments in the spinal canal, progressive neurological deficit, kyphosis angle because of instability was assessed with the CT scan. As per their criteria translational and flexion/rotational fracture dislocation and posterior ligamentous complex (PLC) injury with kyphosis more than 30 degrees angle should undergo surgery.
In 1994 Mc Cormack classified on load sharing concept, which focuses more on location of the fracture in the vertebral body.
Then in 1994, Magrel et al came up with classification based on evaluation of 1445 cases and classified into 3 types and 53 injury models.
In 2005, Vaccero et al came up with Spine trauma study group – Thoraco Lumbar Injury Classification System (TLICS) which takes a detail note on fracture mechanism, the intact PLC status and the neurological status of the patient.
TLICS points:
Fracture Mechanism
Compression fracture 1
Burst fracture 1
Rotational fracture 3
Splitting 4
Neurological involvement
None 0
Nerve root 2
Medulla spinalis, conus medularis-
– Incomplete 3
– Complete 2
Cauda equina 3
Posterior ligamentous complex
Intact 0
Possibly injured 2
Injured 3

Surgical indication is for cases with 5 points or more, cases with 4 points are between surgical vs non surgical, and cases with 3 or less points are non surgical. It is quite a comprehensive and popular classification in clinical practice and many centers prefer to use this classification worldwide.
Recently AO Spine knowledge forum has proposed a comprehensive modified AO classification based on morphology of fracture, neurology status and description of relevant patient specific modifiers
These classifications signify the growth in our understanding of pahtomechanics of the spine fracture as well as takes into account our growing expertise in the offering better surgical options to the patients.

Management Options:
Various management options are discussed in the current symposia and most of the options are individualised depending on the etiology and extent of fracture. Few general rules are noted below –
– Cases where there is retropulsion up to 40- 50 degrees without neurological deficit with intact PLC we can attempt indirect decompression and distraction in first 5 -6 days after the injury.
– Cases with less angulation and wedging with minimal kyphosis can be dealt with short segment fixation.
– Interlink in long construct always adds-up to the stability. Reduction of the dislocation with various maneuvers always beneficial for sagittal profile.
– Role of steroid is controversial post T-L injury with neurological deficit and is rarely used worldwide.
– Role of minimally invasive spine (MIS) surgery is evolving and needs a longer follow up. MIS surgery helps in reducing the bleeding, morbidity in selective cases.
– There is a significant role of rehabilitation post-surgery, in cases of T-L fractures with neurological deficit. Stem cells are promising in animal and Fish models in research labs and we are very hopeful about the same in humans.
Most of the above options are discussed in details in the symposia and we would encourage the readers to go through the articles. Ultimately the clinical evaluation summed with the radiological parameters will decide the management plan as cases with instability, neurological deficit and progressive neurological worsening cases will need surgical intervention. A lot of cases can be conserved with careful monitoring.
We thank all the authors and contributors for participating in the symposia and invite interested readers to participate as symposium editors or authors. Please write to us by email and provide your suggestions and comments.


How to Cite this Article: Hadgaonkar S, Khurjekar K. Thoracolumbar Spinal Injuries Evolution of Understanding Fracture Mechanics and Management Options . International Journal of Spine Sep-Dec 2016;1(2):7-8.


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Interview with Dr Rajasekaran: Part I

Volume 1 | Issue 2 | Sep – Dec 2016 | Page 3-6 | Prof. S. Rajasekaran


Authors : Prof. S. Rajasekaran 

M.S., DNB., F.R.C.S.(Ed)., M.Ch(Liv)., FACS., F.R.C.S.(Eng)., Ph.D
Chairman, Dept of Orthopaedics, Trauma & Spine Surgery.
Ganga Hospital, Coimbatore.


Prof. S Rajasekaran

One of the most Revered Academicians and most decorated Spine surgeon in India, Dr Rajasekaran has inspired an entire generation of Orthopaedic Surgeons across the country. This interview is an attempt to gain an insight into Dr Rajasekaran as a human being as an academician and as an Orthopaedic Surgeon


This interview with Dr S Rajasekaran (SR) was conducted at Kochi at the venue of IOACON 2016. The interview was conducted by Dr Ketan Khurjekar (KK) and Dr Ashok Shyam (AKS). The purpose of this interview was to know more about the journey of Dr Rajasekaran and also to catch a glimpse of his life and personality. A broader objective is to attract people to excellence in orthopaedics and to have pride in our own people who have done exceptionally well in reaching international acclaim in respective fields. This is part I of the interview and part II will be published in the forthcoming issue.

KK: Today you are at cross roads or rather in middle of world orthopaedic landscape and have experienced so many things. You were the IOA president and know about the national scenario and you are now involved in many international association including SICOT, SRS and AO spine. You are exposed to working in India as well as the western world. What are the differences that you perceive between the two worlds and how can we can attain the next level especially in terms of western world?
SR: Successful persons worldwide share the common trait of being focussed and hardworking. Indians as a rule, we work hard (may be even harder than the west) but the western world works with more focus and planning. We work hard and grow but they plan ahead and work towards the goals. Our growth is a more like an organic growth. We all are better than what we were 10 years ago but most of our growth is unplanned. When you don’t have a planned and targeted growth, you often don’t achieve or reach your greatest potential. For example, say a department did 1000 surgeries a year and 1100 the following year. This represents a growth of 10% and one can be happy about it. But the other way of looking at it is if the growth could have been up to 2000 surgeries? To achieve this type of growth, planning in advance is essential. Once a realistic goals have been set, timely audit, at least every every 3 months and a critical appraisal of performance will help to achieve the targets. Otherwise, performance deficit is common.
We have to realise that time waits for no body and keeps on moving. All of us have only a certain amount of time and certain of amount energy and this has to be channelised and not wasted. So we have to have concentrate our time and energy towards our targets. When you are doing things that you don’t need to do, then there is very little time to do what you really want to do. Every activity that is undertaken that is not in line with the long or short term plan, actually amounts to distraction. So we have to learn to say ‘No’ to things that waste our time.
Goals also have to be very specific rather than vague. Every new year, probably most of us aim to be better surgeons and to do more surgeries. But these will be the goals of every orthopaedic surgeon and is very nonspecific, without concrete plans or strategies. Plans need to be specific, time bound, realistic and tangible. And this makes a very huge difference.
Growth is either organic or planned. Orthopaedic speciality in India is growing by 15 to 18% every year. If one is growing at rate of 15%, you can’t take pride in that as you are riding the general growth of the speciality. So unless the growth is by more than 10% of the general growth we cannot take credit for it. If you are growing less than the national average, then someone else is growing much faster than you. So to be aware of one’s growth and performance in relation to other people around you is important.
It is also important not to assess just the performance but also the ‘performance gap’. Not appreciate ourselves on the performance that we have achieved but look at the highest possible that we could have performed and note if we have achieved it. Most of us our very happy in patting ourselves too easily and very early. This can be a big problem. I think achievers are more tuned toward looking at the performance gap and improving themselves continuously.

AKS: Does that mean we should be a bit discontent?
SR: We should have clarity on this subject. Contentment of mind is something that is spiritual and is needed for your happiness, peace of mind and healthy living. But contentment is a poisonous word when it comes to your work and professional life. People often confuse contentment in life and contentment in professional work. When the elders advocate contentment, they simply mean not to be greedy in life. They didn’t advocate to perform less or be happy with poor performance. Contentment is a good word for your spirit but not so good for your work. We should be contended only in worldly possessions but as far as the excellence in academics and profession is concerned, ‘passion for more’ is necessary. I would say you should have fire in your belly every day in your profession. At any time there is a reduction in passion for excellence, there is going to be stagnation.

KK: How then do we achieve our fullest ability?
SR: I often quote the famous words of Dr APJ Kalam, “Small aim is a crime”. One has to aim to achieve to his fullest capacity, whatever that may be. For this to happen, people with whom you spend time and interact become very important. I am often asked the advantage of being closely involved in international societies and also playing leadership roles in them. The most important benefit, and which I really enjoy is the ability and opportunity to move shoulder to shoulder with other giants in the field. I think this is really true – ‘you are the sum average of the five people you constantly move with’. This is very very important. If you are always interacting with people who are high thinking and who are professionally oriented and who are high achievers, you will be motivated towards higher performance than before. In contrast if one spends time with people who are distracted or poor achievers there is every chance that your performance will come down too. So one’s concept of hard work, happiness, contentment, definition of good life is all defined by people with whom you move with, people whom you look up to and people who look up to you.
There is a saying ‘If you are the best person in the room, then you are in the wrong room’. You have to move to a room where there are better persons than you. If you work with better people than you, then it becomes an incentive to improve your life. So it is vital to choose colleagues and friends who are better than you. It will keep you humble and help you to raise your bar from time to time. This is very important.

KK: We have seen that you are not easily attracted to material positions like luxury cars. I always wonder about this?
SR: At different periods of time in your life, different things impress you and it’s probably a sign of growing up. I was really impressed with jaguar cars when I was in England, specially the olive green car XJ8 model. I have taken many pictures of them with me standing in front of the car. My wife was really tired with this and told me to buy one and get over my obsession with it. I could not afford it at that time and I think that the attraction was increased by my inability to buy the car. That really made the car more attractive. At this stage of life where I can buy any car easily, the attraction has just simply vanished. So one gets over your attractions as you grow up . Your focus in life changes.
Please don’t get me wrong. I am not against worldly pleasures or luxury cars etc. I do love a ‘good life’ and I think that we should indulge ourselves from time to time. Life should not be just a bed of nails and should be sprinkled with worldly pleasures also. But not to a point of distraction. We need to keep the proportion and balance. Sometimes we have to get a luxury car to know that it is the most important thing in life. Sometimes they look more important than what they are until they are acquired. Happiness is basically a personal issue. Does not depend on your worldly possessions. If you are sad, having a BMW does not change things in any way. If you have had a successful day, it doesn’t make any difference whether you are travelling in an ambassador or BMW, you will still feel happy.
Materialistic indulgences from time to time is also important. Don’t need to be a ‘sanysi’ to be an achiever. It is the enthusiasm, inquisitiveness and the energy to do things that is very important.

KK : What is your opinion about hard work and professional stress?
SR: This is another area where there is a lot of confusion amongst the younger generation.
Hard work is completely different and has nothing to do with stress. Hard work is important as it allows you to achieve your dreams and give you professional satisfaction which are very important for happiness. Hard work is necessary for success and you can never be happy if you are unsuccessful in your profession. Productive hard work has never harmed anybody. In fact if we look back in our lives, we always remember fondly the times that we have worked hard and achieved a lot. Every surgeon feels happy when he has more work than less. All of us have to accept that.
But stress is something completely different and has to be avoided. It comes from a variety of factors like poor performance and failures in day to day work. Very frequently the cause of stress is lack of hard work, poor preparation and under performance. Stress also comes from doing a work which you are not passionate about. Stress is not working 15 hours at a job you like. Stress is working even 15 minutes at a job you dislike. a. If you are not passionate about your profession and you are feeling stressed you must look seriously at alternatives. Stress can also come from work place problems, incompatibility with working colleagues and family members, uncontrolled anger, jealousy etc. These issues are more relevant and are cause for poor health than hard work. The reason why worry kills more people than work is that nowadays more people worry than work.

 

In my experience, the most happiest people are the people who are fortunate enough to love what they do and be able to do what they love. They don’t need any further incentive for performing well.
Lastly, it is important to have a ‘wholesome life’. We need some buffers in life and best one is a loving and happy family. If you are struggling in family life, you would be pretty stressed in every area of life. A happy family is probably the most important factor and one needs a good ‘work – life balance’.
– To be continued in Next Issue of IJS


Dr S Rajasekaran
M.S., D.N.B, F.R.C.S(Ed)., F.R.C.S.(Lond))., M.Ch. , FACS, Ph.D.
Dr Rajasekaran is the Chairman of the Department of Orthopaedics & Spine Surgery, Ganga Hospital, Coimbatore, India and Adjunct Professor of Orthopaedic Surgery, The Tamilnadu Medical University.

Dr Rajasekaran holds several administrative and academic positions in Spine Surgery. He is the Current President of the Association of Spine Surgeons of India, President Elect of Indian Orthopaedic Association, President of the World Orthopaedic Concern, UK, President of Computer Assisted Orthopaedic Surgery Society, India, and Founder Chairman of Trauma Section of Asia Pacific Orthopaedic Association. He has also been elected as the Hunterian Professor 2011-12 by the Royal College of Surgeons of England.

Dr Rajasekaran heads one of the largest clinical and research units in Spine Surgery in South Asia. His research interests relate to disc biology and nutrition, Diffusion Tensor Imaging of the Spinal Cord, Genetic basis of disc degeneration and kyphotic deformities in spinal tuberculosis on which he has 151 publications in international journals. He has authored many chapters in Textbooks and is the Chief Editor of a Video Atlas in Spine Surgery and Chief Editor of ASSI Textbook of Spinal Infections & Trauma.

Dr Rajasekaran is the Deputy Editor, SPINE, USA and serves as a Editorial Board Member of European Spine Journal, Journal of Craniovertebral Surgery and Journal of Orthopaedic Science, Japan. He is the recipient of many awards in spine research which include the ISSLS Award for 2004 & 2010, EuroSpine Open Paper Award in 2008, APOA Award in 2007 and Sofamer Danek Award of ISSLS for the years 1996, 2002 and 2006.


How to Cite this Article: Rajasekaran S. Interview with Dr Rajasekaran: Part I. International Journal of Spine Sep-Dec 2016;1(2):3-6.


Prof. S. Rajasekaran
M.S., DNB., F.R.C.S.(Ed)., M.Ch(Liv)., FACS., F.R.C.S.(Eng)., Ph.D
Chairman, Dept of Orthopaedics, Trauma & Spine Surgery.
Ganga Hospital, Coimbatore.


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Management of Pathological vertebral collapse in elderly

Volume 1 | Issue 2 | Sep – Dec 2016 | Page 22-26 | Rajesh Parasnis, Alpesh Thumbadiya, Sachin Pathak, Shantanu Patil


Authors : Rajesh Parasnis [1], Alpesh Thumbadiya [1], Sachin Pathak [1], Shantanu Patil [1]

[1] Oyster and pearl hospital, Pune
[2] Jehangir Hospital, Pune
[3] SRM Medical College, SRM University, Kattankulathur, Tamil Nadu 603203

Address of Correspondence
Dr. Rajesh Parasnis
Department of Spine Surgery, Oyster and pearl hospital, India.
Email : rajeshparasnis@rediffmail.com


Abstract

Pathological vertebral fractures can be due to various reasons and management plans will differ as per the diagnosis. We present our series of patient with pathological fractures along with a management algorithm
Material and Methods: All patients aged more than 60 years presenting with intractable back pain with or without neurological deficit were screened. Of the 532 patients, 274 osteoporotic insufficiency fractures were identified by DEXA scan and excluded from the analysis. 258 patients with vertebral collapse caused by infection or neoplastic conditions were included in study.
Results: 212 patients (82.2%) had a single vertebral lesion followed by 34 (13.2%) at 2 levels and 12 (4.7%) with multiple vertebral levels involved. 161 cases (62.9%) had an infective pathology while the remaining 97 (37.9%) had a neoplastic cause. Needle biopsy was positive in 218 (84.49% ) cases. Repeat biopsy was required in 39 cases where Fine Needle Aspiration Cytology (FNAC) was inconclusive. There were 130 tubercular lesion, 7 atypical tuberculosis, 5 MDR tuberculosis, 13 pyogenic, 2 fungal, 4 hydatid cyst, 24 malignant lesions and 73 metastasis. 60 patients (58 TB spine and 2 pyogenic infection) were managed without surgery and the remainder 197 patients underwent surgical intervention
Conclusion: Pathological fractures can be due to varied etiology and although tuberculosis formed major cohort in our series, neoplastic lesion had to be suspected and tissue biopsy is essential to reach correct diagnosis and management plan
Keywords: Thoracolumbar fractures, pathological fractures, biopsy.


Introduction

Atraumatic vertebral collapse is a common clinical problem, especially in elderly population (1). It includes fractures because of osteoporosis or any other pathological cause. Pathological vertebral fracture in elderly occurs due to infective or neoplastic condition. Spinal column affection by neoplastic lesions include primary (benign or malignant ) or secondary metastasis. 50 to 85% of patients with cancer experience skeletal metastasis, most commonly in the spine (2). Infection of spine occurs due to tuberculosis, atypical tuberculosis, pyogenic, fungal and parasitic infestation (e.g.hydatid cyst). Tuberculosis is most common among them and a major health problem in developing countries. In elderly population because of comorbidity and lower immunity, spinal affection by tuberculosis is high.
The spine has a load-bearing and a neuro-protective function, Any failure of its structural integrity as a result of metastatic or infective vertebral involvement often brings about severe pain and/or paralysis. These symptoms impair the ambulatory ability of the patients and worsen their quality of life. One of the main causes of severe pain or paralysis is pathologic vertebral body collapse caused by an osteolytic lesion. Therefore, prevention and treatment of collapse is a key factor in maintaining the patients’ ambulatory ability especially in morbid elderly population (3,4,5,6). Early diagnosis of such conditions is very important to start with proper treatment.
Diagnosis of pathological vertebral collapse in aged population is usually missed or delayed. Elderly patients presenting with backache and vertebral collapse are a challenge for diagnosis as well as for management. Correct diagnosis may require all blood invastigations and imaging modalities including plain X-rays, ultrasonography (USG), computed tomography (CT), radionuclide bone scan, magnetic resonance imaging (MRI) and PET scan. For conclusive diagnosis one needs to identify the causative organism and know histopathology of the lesion by biopsy. One may need to repeat the biopsy if required before starting any treatment. It is mandatory to do a culture and test the sensitivity to rule out drug resistance in case of spinal tuberculosis. Management depends on multiple factors and requires multidisciplinary approach.
While many studies have investigated osteoporotic vertebral collapse in the elderly, not many have reported on other pathological fractures. We present our series of such patients and propose a treatment and management algorithm.

Methods and Materials

All patients aged more than 60 years presenting with intractable back pain with or without neurological deficit were identified from a data base spanning seven and half years (May 2008 to Nov 2015 ) at a tertiary care hospital. Of the 532 patients, 274 osteoporotic insufficiency fractures were identified by DEXA scan and excluded from the analysis. 258 patients with vertebral collapse caused by infection or neoplastic conditions were included in study. The patients were classified according to age, gender, pathology, levels affected, region involved, neurological deficit, type of biopsy and management protocol. Base line haematological tests included haemogram, liver function test (LFT), renal function test (RFT), CRP, ESR and serum electrophoresis studies. Radiological studies included Xrays of the affected region ( anteroposterior & lateral views ) and MRI were done in all cases. CT scan, Bone scan, PET scan and Bone marrow examination were done in indicated cases. Tissue diagnosis was done by biopsy in all cases for histopathology and/or culture sensitivity. Management protocol was decided according to the pathology and severity of the lesions. All patients were followed up at regular intervals 3 months, 6 months, 12 months and yearly follow up after that.

Results

The cohort included 258 patients (Male 156: Female 102) aged between 60 and 82 years age (mean age 63.4 years). 212 patients (82.2%) had a single vertebral lesion followed by 34 (13.2%) at 2 levels and 12 (4.7%) with multiple vertebral levels involved. 161 cases (62.9%) had an infective pathology while the remaining 97 (37.9%) had a neoplastic cause. Out of 258 patients mean aged 63.4 years ( 60-82 years ), we found 156 male and 102 female patients. Level of involvement was found to be single, double and multiple in 212 (82.17%), 34 (13.17%) and 12 (4.65%) cases respectively. Infective pathology was found in 161(62.89%) and neoplastic cause was found in 97(37.89%) cases. Distribution of pathology and level affected are detailed in Table 1.
Out of 258, 234 patients presented with intractable pain[predominant back pain in 198 (76.74%) and predominant extremity pain in 62 (24.03%) patients ] of mean duration8.2 weeks ( 1- 32weeks). 68 (26.35%) patients presented with neuro deficit( Frankel grade B in 3, C in 14 and D in 51 ). Constitutional symptoms were present in 38 (14.72) patients. Spinal deformity was present in 21 cases.
Biopsy: Diagnosis of pathological vertebral fracture in elderly age group is usually delayed but sometimes it may be wrongly diagnosed or even missed. Tissue diagnosis is mandatory in all cases. Needle biopsy using Jamshidi needle was done in all suspicious vertebral pathology. Biopsy material was sent for gram stain, Ziehl-Nielson stain, Pus culture and sensitivity, and histopathological examination. Acid fast bacteria culture was advised in relevant cases ( not responding to treatment and MDR Tb ). Gene expert study ( PCR ) for tuberculosis was done in last 2 years only. Needle biopsy was positive in 218 ( 84.49% ) cases. Repeat biopsy was required in 39 cases where Fine Needle Aspiration Cytology (FNAC) was inconclusive. Core biopsy was done in all these 39 cases using large bore Jamshidi needle and it showed malignancy in 19 cases and tuberculosis in 20 cases. In 11patients who had an unbiopsied vertebral lesion initially as primary lesion was confirmed, and not responding to chemotherapy or radiotherapy, a subsequent vertebral biopsy was done. 5 of these patients were diagnosed to have a tuberculous lesion. 27 vertebral collapse initially thought to be osteoporotic on radiological imaging ( MRI and DEXA ) but not responding to osteoporotic treatment were reevaluated by biopsy and turned out to be Koch’s spine in 21 cases and neoplastic in 6 cases. 17 patients who were put on AKT for Koch’s spine but not responding were reevaluated by biopsy and report turned out to be malignant lesion.

Management

60 patients (58 TB spine and 2 pyogenic infection) were managed without surgery and the remainder 197 patients underwent surgical intervention. Non surgical management comprised of bed rest, analgesics, bracing, anti microbial regimen according to pathogen in case of infective lesions.
The 58 patients of tubercular spondylitis were treated by ATT, 4 drug regimen ( Rifampicin, Isoniazide, Ethambutol, Pyrazinamide ) for 3 months, 3 drugs for 3 months, 2 drugs for 3 months. In 2 cases of pyogenic osteomyelitis culture sensitivity specific antibiotics were given intravenously for 2-3 weeks followed by orally for 6 weeks. CBC, CRP, ESR, LFT and RFT were done at regular interval to modify the dosage in all these old age patients.
In MDR cases second line drug therapy was administered and monitored by the Infectious disease specialist.
101 infective lesions were managed surgically ( 92 primary and 9 revision ).
53 patients of spinal tuberculosis were operated by posterior decompression and fixation. 28 patients underwent surgery by posterolateral extrapleural approach and anteroposterior reconstruction. 13 patients were operated by anterior approach for decompression and reconstruction. 7 patients required a combined surgery and reconstruction by anterior and posterior approaches.
All 97 neoplastic vertebral lesions required surgical intervention. Out of 24 primary malignant lesions 3 (out of 7) solitary plasmacytoma were removed enblock, rest all 21 cases were managed by intralesional removal of tumor mass. Pre operative embolisation was done in all vascular tumors ( Solitar plasmacytoma and spindle cell sarcoma ). 1 multiple myeloma and 2 implant related complications required revision surgery.
Out of 73 metastatic vertebral lesions, Vertebroplasty was done in 29 patients, kyphoplasty was done in 6 cases and surgery was done in 38 cases. En block removal was done in 4 patients while in rest 34 cases intralesional removal of tumor was done. Pre operative embolisation was done in all 38 operated cases. 7 cervical and 9 thoracolumbar lesions were operated by anterior approach, 13 thoracolumbar and lumbar lesions were operated by posterior approach, while 9 cases of thoracolumbar and lumbar lesions were dealt by combination of both anterior as well as posterior approach. All 38 operated cases of vertebral metastases were stabilized by at least 2 levels above and 2 levels below with cementation of involved vertebra in posterior approach and anterior reconstruction using cage with autograft.
Chemotherapy and/or radiotherapy was administered according to neoplastic pathology. Post operatively all malignant cases were put on bisphosphonate therapy.
Complications: 4 out of 197 surgically operated elderly morbid patients died in the perioperative period.
Neurological and / or functional improvement was seen in 185 operated cases. Frankel grade B 3 patients improved to grade C in 1 and grade d in 2 cases. Frankel grade c 14 cases showed no improvement in 3 cases, 9 improved to grade D and 2 improved to grade E. Out of 51 Frankel grade D, 4 patients didn’t show much improvement but 37 fully recovered. Operated Koch’s spine all patients showed neurological improvement.
Mean survival time in primary malignancy cases was 36.2 months, while in metastatic cases it was 14.3 months. 7 patients developed recurrence at same level after mean time of 9 months, out of those 2 patients developed paraplegia.

Discussion

Atraumatic vertebral collapse is a common clinical problem, especially in elderly population (1). Osteoporotic vertebral fracture is the major cause in such elderly population. The prevalence of osteoporotic vertebral fractures varied from about 3% in the age group below 60 to about 19% in the 70+ group in women, and from 7.5% to about 20% in men, with an overall prevalence of 11.8% in women and 13.8% in men (7). Among other causes of pathological collapse in the elderly, infective lesions are also common with neoplastic lesions being on the higher side. A fairly high index of suspicion is necessary when dealing with vertebral collapses in the elderly population.
Infection of spine is still a mojor health issue in developing countries. Poor hygiene, poverty, unawareness, poor ventilation along with that other co-morbidities make elderly individual more prone for the infection especially tubercular in developing countries.

With ageing bony trabeculae becomes weak and osteoporotic vertebral collapse become more prevalent. Because the spine has a load-bearing and a nerve-protecting function, failure of its structural integrity as a result of pathological vertebral involvement often brings about severe pain and/or paralysis. These symptoms impair the ambulatory ability of the patients and worsen their quality of life. One of the main causes of severe pain or paralysis is pathologic vertebral body collapse caused by an osteolytic lesion. Therefore, prevention and treatment of collapse is a key factor in maintaining the patients’ ambulatory ability especially in morbid elderly population (3,4,5,6). So early diagnosis of such conditions is very important to start with proper treatment.
Tan DY et al., studied 58 vertebral collapse out of which he found 36 benign vertebral collapses (20 osteoporotic, 7 post-traumatic, 9 infective) and 22 malignant ones (20 metastatic carcinoma, 2 multiple myeloma). In our study we found Infective pathology in 161 (62.89%) [ 13 pyogenic, 130 tubercular, 7 atypical tubercular, 5 MDR tubercular, 2 fungal, 4 hydatid cyst ] and neoplastic lesions in 97 (37.89%) [ 24 primary malignant ( 13 multiple myeloma, 7 solitary plasmacyetoma, 3 lymphoma, 1 spindle cell sarcoma ) and 73 metastases ].The most frequent spinal metastases (60%) are from breast, lung, or prostate cancer (15).

Any elderly patient presenting with intractable back pain especially at night, weight loss and other constitutional symptoms without any history of trivial injury then think of pathological vertebral lesion. Any vertebral collapse detected on a radiograph must initially undergo MRI and routine blood investigations, followed by a DEXA scan to rule out osteoporosis. Even though DEXA scan is indicating osteoporosis it doesn’t always rule out infection or malignancy. In our study we found 27 patients with osteoporotic vertebral collapse, who didn’t respond to osteoporotic treatment and later on confirmed by biopsy as malignancy in 6 cases and infection in 21 cases.
Typical spinal tuberculosis affects the continuous vertebral levels and causes narrowing of the adjacent disc space and bone destruction (8). However, Atypical tuberculous spondylitis shows spondylitis without discitis, isolated central lesion in single vertebral body, non-contiguous skip vertebral body lesions, isolated posterior vertebral elements involvement and isolated intraspinal canal lesions. Atypical form of spinal tuberculosis is difficult to distinguish from malignancy, leading to misdiagnosis and inadequate treatment. Pyogenic and fungal spondylitis, sarcoidosis, metastasis and lymphoma are the close differential diagnosis for tuberculous spondylitis (10, 11).
Differentiating tuberculous spondylitis from these conditions is very important since the line of management completely differs and also early intervention helps in minimizing the residual spinal deformity and permanent neurological deficits (12). Tan DY et al. stated that features which pointed to malignant cause were hypointense marrow on T1-weighted images, marrow enhancement after intravenous contrast, greater than 50% marrow involvement and involvement of posterior elements. Of the vertebral collapses due to infection, 78% showed end-plate disruption(14). Image guided biopsy is very helpful for early diagnosis and prompt intervention if the clinical and imaging findings are not very helpful arriving diagnosis, especially with the atypical presentations (13).
Biopsy: Diagnosis of pathological vertebral fracture in elderly age group is usually delayed but sometimes it may be wrongly diagnosed or even missed. Tissue diagnosis is mandatory in all cases. Needle biopsy is the procedure of choice in definitive diagnosis of pathologic lesions of the spine (17). Needle biopsy is positive in 65% for lytic lesions, incisional biopsy is useful in 85% of blastic lesion while excisional biopsy is positive in >85% for posterior lesions and benign tumors. The percentage of positive results of biopsy are higher in metastases than primary tumors. The cystic and sclerotic vertebral tumors have less positive results. Transpedicular biopsy with Jamshidi needle has better success rate than FNAB in such lesions.
Once tissue diagnosis is done by biopsy then one should go ahead with other investigations such as CRP, ESR, Procalcitonin for infective pathology. For Neoplastic lesions one should do specific tumor markers and screening of whole body to rule out metastases elsewhere.
All Patients with spinal tuberculosis are started on antituberculosis treatment as Tuberculous spondylodiscitis is primary medical problem. Surgery reserved only for the patients with complications or potential complications (9). Only the patients who had lost neurological power to Frankel grade A,B,C,D or with sphincter involvement were advised surgery. 11 patients who did not show good response to ATT after 3 months were also operated. 17 patients who had progressive kyphosis and instability due to more than 2 vertebral level involvement were also advised surgery. Operative management gives satisfactory results in elderly patients with tuberculous spondylodiscitis (21). Single level involvement of spinal tuberculosis can be very well dealt by posterior approach only ( Transpedicular decompression, 2 level above and 2 level below fixation and shortening). The posterior approach provides adequate exposure for decompression and rigid fixation, providing satisfactory clinical and radiological outcomes (21).
2 level involvement requires pasterolateral extraplueral approach for decompression and reconstruction ( 3 or 4 level above and below ). In case of more than 2 levels are involved one should think of anterior or anterior and posterior approach for thorough decompression and stabilization of segment involved.
The pathological fractures due to neoplastic inlvolvement require a thorough check up to determine the general condition of the patient, staging and grading of the tumor, life expectancy , anticipated hospital and ICU stay etc. The indications for surgery for primary lesions are neurological deficit, instability, intratctable pain, radioresistant tumor and not sensitive to chemotherapy. The metastatic lesion may need surgery for severe pain, progressive neurogical deficit, instability affecting ambulatory ability or solitary metastases where in complete excision may be advocated.
The decision of surgery in malignant or metastatic lesion is taken only if the general condition allows the patient to recover without significant postoperative morbidity or ICU stay.
Vertebroplasty or kyphoplasty is the modality used in such inoperable painful collapse. Transpedicle body augmenter Vertebroplasty proved to be safe and effective in reducing pain andimproving functional status of patients with spinal tumor (18). Percutaneous Vertebroplasty (PVP) can be an effective treatment for metastatic spinal tumors in patients even with posterior wall deficiency (16).
Takayuki Yamashita stated that palliative surgery benefited half of the patients with metastatic spinal tumor, with a greater probability of benefit found in persons with a higher total revised Tokuhashi score (score 9–15) and/or primary cancers with longer survival times (19).
The modified Tokuhashi scoring system is used to decide the operability of the tumor.
The type of surgery and approach is decided depending upon primary or metastasis, extent of involvement of vertebra (Tomita classification) and expected morbidity of the surgery. The response of the tumor to radiotherapy and chemotherapy is also an important factor in management. David W. Polly et al concluded that there is a strong recommendation for posterior or posterolateral approach from T2 through T5. For the T6–L5 regions of the spine we recommend either anterior, posterior, or combined anterior and posterior surgery depending on the clinical presentation, surgeon and patient preference (20).

Hormonal treatment and immunotherapy may play an important role in certain tumors like Ca breast, ovary. In some inoperable tumors management to control pain is very important.
The pathological fractures in elderly can be managed by the following algorithms.


References

1. Cicala D, Briganti F, Casale L, et al. Atraumatic vertebral compression fractures: differential diagnosis between benignosteoporotic and malignant fractures by MRI. MusculoskeletSurg 2013;97(Suppl. 2):169–79.
2. Asdourian PL. Metastatic disease of the spine. In: Bridwell KH, DeWald RL, eds. The Textbook of Spinal Surgery. Philadelphia, JB Lippincott, 1991:1187-242. [Context Link]
3. Cybulski GR. Method of surgical stabilization for metastatic disease of the spine. Neurosurgery 1989;25:240-52. Buy Now Bibliographic Links [Context Link]
4. Hammerberg KW. Surgical treatment of metastatic spine disease. Spine 1992;17:1148-53. [Context Link]
5. Sundaresan N, Galicich JH, Lane JM. Harrington rod stabilization for pathological fractures of the spine. J Neurosurg 1984;60:282-6.Bibliographic Links [Context Link]
6. Matsubayashi T, Koga H, Nishiyama Y, et al. The reparative process of metastatic bone lesions after radiotherapy. Japan J ClinOncol 1981;11(Suppl):253. [Context Link]
7. Svanhild Waterloo, Luai A Ahmed et al. Prevalence of vertebral fractures in women and men in the population-based Tromsø Study. BMC Musculoskeletal Disorders 2012, 13:3
8. Naim-Ur-Rahman, El-Bakry A, Jamjoom A, et al. Atypical forms of spinal tuberculosis: case report and review of the literature. Surg Neurol. 1999;51(6):602- 07.
9. Rasouli MR, Mirkoohi M, Vaccaro AR, Yarandi KK, Rahimi-Movaghar V. Spinal Tuberculosis: Diagnosis and Management. Asian Spine J. 2012;6(4):294–308.
10. Jung NY, Jee WH, Ha KY, Park CK, Byun JY. Discrimination of tuberculous spondylitis from pyogenic spondylitis on MRI. AJR Am J Roentgenol. 2004;182(6):1405-10.
11. Khattry N, Thulkar S, Das A, Alan Khan S, Bakhshi S. Spinal tuberculosis mimicking malignancy: Atypical imaging features. Indian J Paediatr. 2007;74(3):297-8. PMID: 17401273.
12. Moore SL, Rafii M. Imaging of musculoskeletal and spinal tuberculosis. RadiolClin North Am. 2001;39(2):329-42.
13. Momjian R, George M. Atypical Imaging Features of Tuberculous Spondylitis: Case Report with Literature Review. J Radiol Case Rep. 2014;8(11):1–14.
14. Tan DY , Tsou IY , Chee TS. Differentiation of malignant vertebral collapse from osteoporotic and other benign causes using magnetic resonance imaging. Annals of the Academy of Medicine, Singapore [2002, 31(1):8-14]
15. Max Aebi. Spinal metastasis in the elderly .Eur Spine J (2003) 12 (Suppl. 2) : S202–S213
16. Hongpu Sun et al Safety of percutaneous vertebroplasty for the treatment of metastatic spinal tumors in patients with posterior wall defects. Eur Spine J (2015) 24:1768–1777
17. J. Tehranzadeh, C. Tao & C. A. Browning (2007) Percutaneous Needle Biopsy of the Spine, Acta Radiologica, 48:8, 860-868.
18. Anna F-Y. Li, Kung-Chia Li, Fang-Yuan Chang and Ching-Hsiang Hsieh. Preliminary Report of Transpedicle Body Augmenter Vertebroplasty in Painful Vertebral Tumors. SPINE Volume 31, Number 21, pp E805–E812 ©2006.
19. Takayuki Yamashita, Yoichi Aota et al Changes in Physical Function After Palliative Surgery for Metastatic Spinal Tumor Association of the Revised Tokuhashi Score With Neurologic Recovery. SPINE Volume 33, Number 21, pp 2341–2346 ©2008
20. David W. Polly, Jr, Dean Chou et al. An Analysis of Decision Making and Treatment in Thoracolumbar Metastases. SPINE Volume 34, Number 22S, pp S118–S127 ©2009.
21. Manish Kothari, Kunal Shah, Agnivesh Tikoo, Abhay Nene. Short to Mid-Term Term Surgical Outcome Study with Posterior Only Approach on Tuberculous Spondylodiscitis in an Elderly Population. Asian Spine J 2016;10(2):258-266.


How to Cite this Article: Parasnis R, Thumbadiya A, Pathak S, Patil S. Management of Pathological vertebral collapse in elderly. International Journal of Spine Sep-Dec 2016;1(2):22-26.


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Taking IJS Ahead

Volume 1 | Issue 2 | Sep – Dec 2016 | Page 1-2 | Ketan Khurjekar [1], Shailesh Hadgaonkar [1], Ashok Shyam [1,2]


Authors : Ketan Khurjekar [1], Shailesh Hadgaonkar [1], Ashok Shyam [1],[2]

[1] Sancheti Institute for Orthopaedics &Rehabilitation, Pune, India
[2] Indian Orthopaedic Research Group, Thane, India

Address of Correspondence
IJS Editorial Officie
A-203, Manthan Apts, Shreesh CHS, Hajuri Road, Thane [W]
Maharashtra, India.
Email: editor.ijspine@gmail.com


International Journal of Spine has made its mark from the release of first issue and in the second issue we have tried to make it better. As mentioned in the first editorial IJS has two main focus points, Research as well as Education. Currently most of the journals are focussed on research based articles and almost 90% of their publication is original articles. IJs is planned to take a different route where we wish to include equal amount of educational material in the journal.
Every issue of IJS is planned to contain a symposia on a specific topic. These symposia are solicited from leading spine surgeons in the field and are formatted in form of a review article which is easy to read. We encourage authors to include case based scenarios in the review which become much easier to relate to a clinician unlike articles full of statistics. The symposium are created in such a way that even small topics related to the scope of symposia are given adequate space and not become part of foot note. This approach will help general orthopaedic surgeons also who wish to refresh their knowledge and update themselves in the field of spine surgery. This will be especially useful to students who can get collection of articles on single topic written by best authors at one place. We will continue this trend of symposia in all future issue of IJS and invite suggestions from our readers for the topic of symposia. We also invite interested surgeons who wish to be symposium editors to contact the editorial office.
Short narrative reviews and literature updates also form the education element in IJS. One narrative review is published in this issue and from next issue the literature updates will start. It will include summary of most important articles and research that are published in other spine journals and are of practical importance to our readers. Original research articles and case reports will continue to be published in the journal but with strict review guidelines and will follow all ethical standards
From this issue we have started a new feature called ‘Interview’. IJS intends to interview the role models in field of spine surgery, especially people who inspire us to achieve excellence. The aim is to know them better and to understand their though process. We can learn many things from them even outside orthopaedics and this aspect comes out beautifully in the current interview of Dr S Rajasekaran. He was gracious enough to give us his precious time and share with us his knowledge and principles that he follows in his life. We believe this interview will inspire many and everyone will learn something valuable from it. The interview was almost two hours long and in this issue we could include only the part of the interview. The second part will be published in the forthcoming issue. We wish to continue this feature and will be interviewing many more stalwarts in the field of Spine surgery.
IJS is receiving more and more submissions each day and we wish to continue publishing good quality articles. We will appreciate any suggestions of comments, please write to us by email to editor.ijspine@gmail.com.

Dr. Ketan Khurjekar | Dr. Shailesh Hadgaonkar | Dr. Ashok Shyam


How to Cite this Article: Khurjekar K, Hadgaonkar S, Shyam A. Taking IJS Ahead. International Journal of Spine Sep – Dec 2016;1(2):1-2.

1


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Positive Sagittal Balance and Management Strategies in Adult Spinal Deformities

Volume 1 | Issue 1 | Apr – June 2016 | Page 33-38|Charanjit Singh Dhillon1


Authors :Charanjit Singh Dhillon[1]

[1] MIOT Center for Spine Surgery, MIOT International, Chennai

Address of Correspondence
Dr Charanjit Singh Dhillon. MS, DNB, FNB Spine, D-Ortho,
Director MIOT Center for Spine Surgery, MIOT International, Chennai. India
Email: drdhillonc@hotmail.com


Abstract

Human Spine has adapted a curved morphology to compensate for the upright posture. Normally these curves are sagittally balanced and a vertical line drawn from the center of the C7 vertebral body (the C7 plumb line) passes within a few millimeters of the posterior-superior corner of S1. A positive sagittal balance occurs when the C7 plumb line falls anterior to the posterior-superior corner of the S1 endplate. The extent of imbalance is measured as centimeters of deviation of the C7 plumb line (also known as Sagittal vertical axis- SVA) from the posterior-superior corner of the S1 endplate[4](Figure 2). Negative sagittal balance is much less common in clinical practice and rarely warrants surgical attention. In this article we shall deal with only positive sagittal balance which is encountered more often. The article covers the diagnosis and also details of surgical management. In absence of effective conservative measures, the patient seeking surgical remedies are on rise. Selecting the appropriate surgical technique to achieve spinal balance is crucial to success.
Keywords: Positive Sagittal Balance, Smith-Petersen Osteotomy, Pedicle Subtraction Osteotomy, Vertebral Column Resection


Introduction
Ever since man has assumed an erect posture and bipedal gait, a series of morphological changes have taken place in the homosapien vertebral column to adapt to this new challenge of upright posture. One of the most distinctive adaptive changes seen in human spinal column has been the assumption of a gentle ‘S’ curve in sagittal plane with thoracic kyphosis [TK] interposed between cervical and lumbar lordosis [LL]. These curves work like a coiled spring to absorb shock, maintain an upright balance and allow the spine to withstand great amounts of stress than what a straight column would otherwise absorb. At the same time it still allows for a wide range of movements in the cervical and the lumbar region to optimize the use of extremities while still maintaining an upright stance with the head centered over the pelvis and finally over both feet. In most individuals with a disease free and deformity free sagittally balanced spine, a vertical line drawn from the center of the C7 vertebral body (the C7 plumb line) passes within a few millimeters of the posterior-superior corner of S1[1] (Fig. 1).

Figure 1 and 2

This is the most ergonomically favorable position for the spine to maintain an erect posture in the most energy-efficient manner. However, with progressively larger deviations from this ideal position, the endeavor to remain upright increases exponentially, thereby warranting greater muscular effort and energy to maintain standing balance[2]. By convention, positive sagittal balance occurs when the C7 plumb line falls anterior to the posterior-superior corner of the S1 endplate. Conversely, negative sagittal balance occurs when the C7 plumb line falls posterior to this point[3]. The extent of imbalance is measured as centimeters of deviation of the C7 plumb line (also known as Sagittal vertical axis- SVA) from the posterior-superior corner of the S1 endplate[4](Fig. 2). Negative sagittal balance is much less common in clinical practice and rarely warrants surgical attention. In this article we shall deal with only positive sagittal balance which is encountered more often.

Causes
Positive sagittal imbalance can occur due to destruction of the vertebral body by trauma, tumor or infection. It may also result from loss of LL as a consequence of multilevel degenerative disc disease, ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis or osteoporosis[5]. Secondary causes include iatrogenic flat back syndrome resulting from failure of restoration of the appropriate LL according to the patient’s Pelvic incidence[PI]. Rarely, sagittal imbalance may be seen following spinal fusion surgery through an area of pseudarthrosis or through a degenerated segment adjacent to a previous fusion. In the past the use of distraction instrumentations such as the Harrington rods was the frequent cause of iatrogenic flat back syndrome[6]. Positive sagittal imbalance due to congenital deformities is outside the preview of this symposium on adult deformities.

Compensation
Barrey et al. [7] described three stages of compensatory mechanisms corresponding to the severity of the sagittal imbalance: balanced, balanced with compensatory mechanisms and imbalanced spine. In the initial stages when positive sagittal imbalance begins, the pelvis retroversion takes place in an attempt to push the C7 plumb line backwards behind the femoral heads resulting in extension of the hips[7-9]. At this stage the PI determines the global capacity of pelvis retroversion and consequent compensatory capability. In patients with higher PI the pelvis can tilt more and compensate better than patients with a low PI[10]. The full body is now balanced but it is a compensated balance, which is less efficient[11]. At the same time the posterior spinal muscles act as a posterior tension band (trying to restore some LL) pulling the adjacent segments of the lower dorsal spine into hyperextension. In young patients with flexible spines this hyperextension leads to reduction of TK. Spine hyperextension is an energy consuming process that generates increase of stresses on posterior structures resulting in risk of retrolisthesis, facet joints overstress and even sometimes isthmic lysis (Fig. 3) [11]. When pelvis retroversion and spine hyperextension are not enough to keep the C7 plumb line behind the femoral heads, the only solution to keep the gravity line between the two feet is to bend the knees. This process needs good psoas and quadriceps muscles activity, which is again energy consuming and not an efficient situation. When the knee flexion also fails to keep the C7 plumb line behind the femoral heads, a stage of decompensation (imbalance) is reached and an external aid (e.g., crutches, walker) is often required to maintain upright posture[11].

Figure 3

Imaging Studies
Standard full-length anteroposterior and lateral radiographs should be performed in all patients with suspected sagittal imbalance. Horton et al[12] reported the ‘clavicle position’ in which the patient stands with both hips and knees fully extended, the elbows fully flexed, the wrists flexed with the hands in a relaxed fist placed into the supraclavicular fossa without any external support as the best patient position for the study of sagittal deformity. Sagittal imbalance is basically determined by the C7 plumb line offset from the posterior-superior corner of S1 (Fig. 2). An offset >2.5 cm anteriorly or posteriorly is considered to be abnormal[13]. Different components such as TK, LL and PI are also measured to define the overall sagittal balance[14]. Dynamic lateral radiographs with the spine in full flexion and full extension helps to assess the mobility of discs in the kyphotic segment and hence plan appropriate surgical management. Alternately, some surgeons use traction views to assess spine mobility.

Management
Nonsurgical Management
Symptomatic patients with sagittal imbalance are often unresponsive to nonsurgical treatment. Physical therapy programs, bracing, facet joint injections, selective nerve root blocks and epidural steroid injections[15] are often ineffective in decompensated patients.

Surgical Management
Surgery is the mainstay of treatment for patients with sagittal deformity[15]. Indications include failure of nonsurgical treatment, kyphosis progression, significant back pain, radicular symptoms and exhaustion due to effort to maintain upright stance. The goals of surgery are to achieve a solid fusion with a balanced spine in both sagittal and coronal planes, relieve pain, and prevent progression of imbalance. Several studies have shown that adequate restoration of sagittal plane alignment is necessary to significantly improve clinical outcome and avoid pseudarthrosis[16,17]. Prior to surgery, the patient should be evaluated for risk factors such as pulmonary and cardiac disease, osteoporosis, smoking, and malnutrition. Careful consideration should be given to especially elderly patients due to higher incidence of pseudarthrosis and complications[17,18]. Relative contraindications to major spinal reconstructive surgery include psychiatric disease, uncontrolled diabetes, osteoporosis, substantial cardiopulmonary disease, and poor family or social support[19]. Flexibility of the spine should be assessed radiologically using long-cassette standing and supine AP and lateral radiographs and lateral dynamic flexion and extension radiographs. Patients’ standing sagittal imbalance may decrease in supine or prone position due to mobile segments. Bridwell[20] classified spinal deformities into three categories based on curve flexibility: totally flexible, partially flexible through mobile segments, and fixed deformity with no correction in the recumbent position. Flexible deformities can be addressed with anterior-posterior or posterior only surgery not requiring any osteotomy[6]. Sagittal balance is improved by lengthening the anterior column, either through an anterior or a posterior approach, using cages, structural allograft or autograft. The posterior column is then shortened with laminectomies (when there is evidence of stenosis), facetectomies and fusion with compression instrumentation to correct kyphosis. Fixed deformities can be managed by anterior-only, combined anterior and posterior or posterior-only approaches. Spinal osteotomies like the Smith-Petersen osteotomy[SPO], pedicle subtraction osteotomy [PSO], and vertebral column resection[VCR] are often employed to correct the stiff apical kyphotic segment. The amount of correction needed determines the type of osteotomy warranted (Fig. 4). With recent advances in instrumentation and techniques, posterior-only approaches have become more popular. Numerous studies support the safety and efficacy of a posterior-only approach for the treatment of most spinal deformities[21,22]. Fusion across the L5-S1 junction is mandatory in the presence of lumbosacral pathology, such as postlaminectomy defects, lumbar spinal stenosis, oblique take-off of L5, and L5-S1 disc degeneration to reduce the risk of pseudoathrosis and loss of fixation[22].

Figure 4

Smith-Petersen Osteotomy [SPO]
In 1945, Smith-Petersen and associates[23] were the first to describe a posterior osteotomy for correction of fixed sagittal deformity in patients with rheumatoid arthritis. In 1946, La Chapelle[24] described a modification of Smith-Petersen’s technique by adding an anterior release in a case of ankylosing spondylitis. The use of this osteotomy for the treatment of flat back deformity was first reported by Moe and Denis in 1977[25]. In 1984 Ponte[26] described multiple chevron osteotomies with spinal instrumentation in a patient with Scheuermann’s disease.

The surgical technique involves removal of all the posterior ligaments (supraspinous, interspinous, and ligamentum flavum) and facets to produce a posterior release. Dissection is then performed laterally to decompress the nerve roots. The lamina is beveled to allow sufficient room for the dura and nerve roots after closure of the osteotomy. The osteotomy hinges at the posterior border of the vertebral body and creates hyperextension by closing the posterior elements and opening the anterior elements providing sagittal plane realignment. Posterior segmental pedicle screw instrumentation is used to maintain closure of the osteotomy (Fig. 5). It should be emphasized that either a mobile disc or an anterior release is required to allow lengthening of the anterior column.

Figure 5 and 6
The SPO should be considered for patients with C7 plumb line that is less than 7 cm positive[27]. Amount of correction provided by a single SPO is in the range of 4-10° depending on the disc height and the mobility of the disc. One degree of correction is usually achieved per millimeter of bone resected posteriorly[27]. The SPO is technically easier and safer than other osteotomies offering a reduction in operative time, blood loss and risk of neurological complications, although rupture of the great vessels has been reported following anterior-column lengthening in an unfortunate case[23].For the patient requiring 10° to 20° of lordosis or 6-8 cm of correction of the C7 plumb line, it is more appropriate to perform multiple SPOs than one PSO, unless the fixed deformity is fused anteriorly[27].

Pedicle-Subtraction osteotomy [PSO]
In 1963, Scudese and Calabro[28] were the first to describe a monosegmental intravertebral closing wedge posterior osteotomy of the lumbar spine. Later, Thomasen[29] reported on 11 patients with ankylosing spondylitis treated with posterior closing wedge osteotomies. In the same year, Heining et al[30] described an eggshell osteotomy as a variant of the PSO. The PSO is performed by removing the posterior elements and both pedicles, performing a transpedicular V shaped wedge osteotomy of the vertebral body, and closing the osteotomy by hinging on the anterior cortex (Fig. 6) achieving bone-on-bone contact in the posterior, middle, and anterior columns[31]. Central canal enlargement is critical to avoid neurologic injury during closure of the osteotomy. Posterior segmental pedicle screw instrumentation is used to maintain the correction. Instrumentation of at least three vertebral levels above and below the osteotomy is recommended[32]. The PSO has the advantage of obtaining correction through all the three spinal columns, while the posterior and middle columns shorten, this osteotomy does not lengthen the anterior column avoiding stretch on the major vessels and viscera anterior to the spine[33]. An average of 30º to 40º correction can be achieved with one level PSO[34]. The ideal candidates for a PSO are patients with a fixed sagittal imbalance of more than 10 cm and those patients who have circumferential fusion along multiple segments, which would contradict multiple SPOs(Fig. 7)[27].

Figure 7

Although PSOs are more technically demanding and more prone to complications than SPOs, PSOs provide satisfactory clinical and radiologic outcomes in long-term follow-up. Kim et al[34] in a series of 35 PSOs reported their good results with 87% patient satisfaction and 69% restoration of function after more than 5 years of follow-up. Cho et al[35] compared one level of PSO with three levels of SPOs in their study and reported that an average total kyphosis correction was 31.7º for PSO group and the improvement in the sagittal imbalance (11.2 ± 7.2 cm) was much better than multiple SPOs. Blood loss was significantly higher in PSO group but there was no statistical difference between one level PSO and three levels of SPO groups with respect to operating times. Regarding neurological complications, Buchowski et al[36] reported a postoperative immediate neurological deficit rate of 11.1% which subsequently reduced to 2.8% during follow up. Deficits were mostly unilateral and never proximal to osteotomy site, often did not correspond to the level of osteotomy, and surprisingly were not detected by neuromonitoring[36].

Figure 8

Vertebral Column Resection [VCR]
VCR was first described in 1922 by MacLennan[37] as a combined anterior and posterior procedure and was popularized by Bradford and Tribus[38] as a method of correcting severe coronal deformity and combined coronal and sagittal deformity. It is indicated in rigid severe deformities of the spine such as congenital kyphosis, rigid multiplanar deformities, sharp angulated deformities, posttraumatic deformities and spondyloptosis. The VCR technique is a challenging procedure involving the complete resection of the posterior elements and the vertebral body including adjacent discs of one or more levels (Fig. 8) providing controlled manipulation of both the anterior and posterior columns simultaneously. It can be performed using either combined anterior and posterior approaches or a posterior-only approach[39]. Of all the spinal osteotomies, VCR provides the greatest amount of correction. Suk et al[40] reported a correction of 61.9o in the coronal plane and 45.2o in the sagittal plane in their series of 70 patients after VCR. In their series of 35 patients, Lenke[41] reported major curve improvements of 55o in global kyphosis cases, 58o in angular kyphosis cases and 54o in kyphoscoliosis cases after VCR. Vertebral column resection through a posterior-only [PVCR] approach has become popular in the recent years. Suk[40] and Lenke[41] popularized the use of PVCR for severe deformities of the spinal column. PVCR enables simultaneous manipulation and control of both anterior and posterior spinal columns and thus provides better correction than other types of osteotomies. It is a single procedure compared to combined anterior and posterior VCR, reducing the total operating time and the amount of blood loss and also avoiding opening of the thoracic cage and pleura. Avoiding anterior surgery may be very beneficial for patients with severe pulmonary function compromise because of severe thoracic deformity[27]. Inspite of all advantages, PVCR is a technically demanding procedure. One major concern with PVCR is the potential for neurologic complications, which may result from direct neurologic injury during bone resection or deformity correction. Neurologic complications may also result from subluxation of the spinal column, dural buckling and compression of the spinal cord by residual bone or soft tissues in the canal after correction[27]. Suk[40] reported a 34.3% overall rate of complications and a 17.1% rate of neurological complications. Lenke[41] reported a similar 40% overall rate of complications and an 11.4% rate for neurological complications. Hamzaoglu[39] reported neurological complications of 7.84%.

Figure 9


Conclusions

With rising life expectancy the number of patients seeking consultation for pain due to sagittal imbalance is increasing. In the absence of effective conservative measures, the patient seeking surgical remedies are on rise. Selecting the appropriate surgical technique to achieve spinal balance is crucial to success. SPO, PSO and VCR all play an important role in the armamentarium of the spine deformity surgeon. However, each of these procedures are technically demanding and carries a certain amount of risks. Appropriate preoperative optimization of the patient as well as preoperative surgical planning are critical in order to avoid potential complications. Surgical achievement of the ideal spinopelvic alignment parameters is the desired goal. Nevertheless, even a partial improvement in these parameters is very likely to translate into substantial clinical benefits.


References 

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4 Gelb DE, Lenke LG, Bridwell KH, et al. An analysis of sagittal spinal alignment in 10° asymptomatic middle and older aged volunteers. Spine 1995; 20: 1351-1358.
5 Kim KT, Lee SH, Suk KS, Lee JH, Im YJ. Spinal pseudarthrosis in advanced ankylosing spondylitis with sagittal plane deformity: Clinical characteristics and outcome analysis. Spine 2007; 32: 1641-1647
6 Bridwell KH, Lenke LG, Lewis SJ. Treatment of spinal stenosis and fixed sagittal imbalance. Clin Orthop Relat Res 2001; 384: 35-44
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8 Barrey C, Jund J, Perrin G, Roussouly P. Spinopelvic alignment of patients with degenerative spondylolisthesis. Neurosurg 2007; 61: 981-986
9 Berthonnaud E, Dimnet J, Roussouly P, Labelle H. Analysis of the sagittal spine and pelvis using shape and orientation parameters. J Spinal Disord Tech 2005; 18: 40-47
10 Barrey C, Roussouly P, Perrin G, Le Huec JC. Sagittal balance disorders in severe degenerative spine. Can we identify the com-pensatory mechanisms? Eur Spine J 2011 Sep; 20 Suppl 5: 626-633
11 Le Huec JC, Charosky S, Barrey C, Rigal J, Aunoble S. Sagittal imbalance cascade for simple degenerative spine and consequenc¬es: algorithm of decision for appropriate treatment. Eur Spine J 2011 Sep; 20 Suppl 5: 699-703
12 Horton WC, Brown CW, Bridwell KH,Glassman SD, Suk SI, Cha CW. Is there an optimal patient stance for obtaining a lateral 36” radiograph? A critical comparison of three techniques. Spine 2005; 30: 427-433
13 Jackson RP, McManus AC. Radiographic analysis of sagittal plane alignment and balance in standing volunteers and patients with low back pain matched for age, sex, and size: A prospective con¬trolled clinical study. Spine 1994; 19: 1611-1618
14 Hammerberg EM, Wood KB. Sagittal profile of the elderly. J Spi¬nal Disord Tech 2003; 16: 44-50
15 Bradford DS, Tay BK, Hu SS. Adult scoliosis. Surgical indications, operative management, complications, and outcomes. Spine 1999; 24: 2617-2629
16 Bridwell KH, Lewis SJ, Lenke LG, Baldus C, Blanke K. Pedicle subtraction osteotomy for the treatment of fixed sagittal imbal¬ance. J Bone Joint Surg Am 2003; 85: 454-463
17 Kim YJ, Bridwell KH, Lenke LG, Rhim S, Cheh G. Pseudarthro¬sis in long adult spinal deformity instrumentation and fusion to the sacrum: Prevalence and risk factor analysis of 144 cases. Spine 2006; 31: 2329-2336
18 Booth KC, Bridwell KH, Lenke LG, Baldus CR, Blanke KM. Complications and predictive factors for the successful treatment of flatback deformity (fixed sagittal imbalance). Spine 1999; 24: 1712-1720
19 Hu SS, Berven SH. Preparing the adult deformity patient for spi¬nal surgery. Spine 2006; 31(19 suppl): S126-S131
20 Bridwell KH. Decision making regarding Smith-Petersen vs. pedicle subtraction osteotomy vs. verterbral column resection for spinal deformity. Spine 2006; 31(19 suppl): S171-S178
21 Pateder DB, Kebaish KM, Cascio BM, Neubaeur P, Matusz DM, Kostuik JP. Posterior only versus combined anterior and posterior approaches to lumbar scoliosis in adults: A radiographic analysis. Spine 2007; 32: 1551-1554
22 Tsuchiya K, Bridwell KH, Kuklo TR, Lenke LG, Baldus C. Mini¬mum 5-year analysis of L5-S1 fusion using sacropelvic fixation (bilateral S1 and iliac screws) for spinal deformity. Spine 2006; 31: 303-308
23 Smith-Petersen MN, Larson CB, Aufranc OE. Osteotomy of the spine for correction of flexion deformity in rheumatoid arthritis. Clin Orthop Relat Res 1969; 66: 6-9
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How to Cite this Article: Dhillon CS. Positive sagittal balance and management strategies in adult Spinal deformities. International Journal of Spine Apr – June 2016;2(1):33-38 .

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Shoulder Balance and Scoliosis

Volume 1 | Issue 1 | Apr – June 2016 | Page 31-32|Ketan Khurjekar[1].


Authors :Ketan Khurjekar[1]

Sancheti Institute for Orthopaedics &Rehabilitation, Pune, India

Address of Correspondence

Dr Ketan Khurjekar
Sancheti Institute for Orthopaedics &Rehabilitation, Pune, India

Email: kkhurjekar@googlemail.com


Abstract

Abstract: Shoulder imbalance is a fairly new outcome variable that is been associated with complex spinal deformities. The presentation of should imbalance is variable and depends on the extent, severity of primary curve, compensatory curves and overall balance of the spine both in sagittal and coronal planes (rotatory planes). It is definitely an important outcome measure in terms of satisfactory patient outcome, however factors that affect it are still unclear and more studies are required. Current article focusses on the basics of shoulder imbalance and currently available methods of measuring it.
Key Words: Adult spinal deformity, shoulder imbalance, cosmoses.


Introduction
Shoulder Balance and Scoliosis
Scoliosis though termed as a coronal deviation in normal architecture of spine, it is often found that there is sagittal imbalance associated with the rotation of the spinal column. Scoliosis is a 3-D deformity and its rotation element was not taken into consideration till recent times. Sagittal imbalance or coronal deviation along with rotational mal-alignment gives obnoxious spinal deformity and severity is perceived more because of shoulder imbalance. Shoulder imbalance is reported as difference in shoulder asymmetry. Residual shoulder asymmetry ruins the result of good anatomical Cobb to Cobb correction. Patient undergoing spinal fusion surgery did not do well unless the sagittal Balance is corrected. It plays important role in cosmesis achieved after surgery. It is unclear, that which factors of scoliosis complex determines the shoulder balance. How does preoperative severity of shoulder imbalance affect the post operative outcome still remains speculative. Why only proximal thoracic and main thoracic curve are given significance when we talk about shoulder balance is topic of discussion? Just as a corollary, for years abnormal abdominal reflex was considered to be indicator of intraspinal problem. Yngve demonstrated that abnormality of abdominal refelex was seen in 27 % of normal individuals[1]. Shoulder imbalance associated with proximal curve, dictates the long fusion surgery till T2 which balances out the shoulder and helps achieve good cosmetic correction. If left shoulder is higher > 5 mm in right proximal thoracic curve, then including proximal thoracic curve in instrumentation is mandatory. As per Lenke et al, if left shoulder is higher in a right proximal thoracic curve, upper instrumented vertebra (UIV) would be T2. If right shoulder is higher, then UIV would be T4. If both shoulders are equal, then fusion would be restricted to T3 [2]. Pelvic girdle is base of spine foundation. Any deviation or malalignment of spine is noted as abnormal pelvic tilt. But pectoral girdle has no direct attachment. So it has been postulated that correction of chest wall deformities can correct shoulder level and Scapulae to give desired shoulder balance [3].
Few of the Current practices of measuring shoulder Imbalance [4]
· Curve pattern on standing AP and Lateral (whole Spine Scannograms) are mandatory to measure shoulder asymmetry
· T1 tilt- Positive T1 tilt is defined as the angulation of upper end plate of T1 to the horizontal with the proximal vertebral body up and right lower vertebral body down
· Clavicle Angle- Intersection of horizontal line and tangential line connecting the higher two points of each clavicle. Positive clavicle angle means left clavicle is up and right clavicle is down
· T1-ICL correlation- T1 vertebral tilt and intercoracoid line (ICL) tilt have simplified measurement of shoulder balance. T1-ICL relationship is concordant or discordant. Relationship is concordant if T1 is tilted to the same side as that of ICL. Similarly it is discordant if T1 has tilted in opposite direction of ICL [3].
· Coracoid Height Difference- Difference between two horizontal lines drawn from each coracoid will tell us about Coracoid Height difference.
· Trapezius length- Showed weak correlation with post-operative shoulder balance
· First rib- Clavicle height- Vertical distance of first rib apex to superior clavicle
· RSH- radiographic Shoulder height- Graded height difference of Soft tissue shadow directly superior to acromio-clavicular joint in AP view. When imbalance is more than 3 cm, it is called as Significant Shoulder Imbalance. Moderate imbalance would be 2 to 3 cm and less than 1 cm would be minimal shoulder imbalance.
In a series of 112 cases, Kuklo et al4 concluded that the clavicle angle and not the T1 tilt is the best predictor of preoperative and post operative shoulder balance. Standing Proximal Cobb and side bending Cobb is considered as essential part of survey.
Determination of UIV would have bearing on post-op shoulder balance. Whether to stop at T2 or T3 or T4 is unclear. Suk et al has suggested that neutral vertebra of the proximal thoracic curve should be selected as UIV irrespective of shoulder level particularly when all pedicle screw construct is used [5]. However above findings are true if the curve T1-ICL concordant. Means if the T1 is tilted along with the proximal curve then depressing the neutral vertebra or T1 will get the shoulder balanced. As against that, if the proximal thoracic curve is T1-ICl discordant, then depressing T1 will further enhance the shoulder imbalance [3]. Only radiological shoulder balance doesn’t correlate with the clinical appearance. Correcting T1 tilt radiologically will correct Shoulder balance has proven to be myth beyond doubt. Researchers from Turkey evaluated shoulder balance radiologically and clinically in healthy adults and proved that shoulder balance in healthy adults doesn’t exist [6].
Healthy adolescent patients almost 19 % had asymmetric shoulders and almost 72 % had side to side difference of < 1 cm. None of the individuals ever complained of shoulder imbalance. The radiological shoulder balance parameters reliably reflect the clinical appearance. Coracoid height difference is taken into consideration when shoulders are included in radiographs and clavicular tilt angle is considered when shoulders are obviated. Researchers from Japan have classified shoulder balance broadly into medial and lateral shoulder height asymmetry. Medial differences reflected in trapezial prominence created by upward tilted proximal ribs and tilted T1. Lateral shoulder height asymmetry correlates weakly with clavicular angle. Correlation of trapezial prominence is more predictable to compare after scoliosis surgery [7]. Shoulder balance is considered as paramount indicator in cosmesis correction. It has significant impact of patient’s self-perception [8]. Generally anterior shoulder balance is perceived by patient and posterior shoulder balance is perceived by clinician. From patient’s perspective, achieving anterior shoulder balance is vital. Both, anterior and posterior shoulder balance were thought to be correlating equally. Unlike, it is showing weak correlation and it is recommended for clinicians and surgeons to evaluate both sided in planning deformity correction, particularly Lenke type 2 curves [8]. Chinese workers have affirmed that radiologic parameters alone will not guide post-operative shoulder balance. We should pay more attention to clinical cosmetic correction than only radiological angle restoration to get proper shoulder balance. We should not only include shoulder height but should also include the shoulder angle, axilla angle and areal balance between left and right shoulder. Qiu et al has suggested that estimate of shoulder height, which is intersection of clavicle and rib cage is the most reliable landmark. It will guide in assessing shoulder balance to better extent [9]. To Summarise, the shoulder balance is an area of complexity with many researchers with their experienced thought process. The common mandate is to get satisfactory cosmetic correction of scoliosis for patient as well as clinician.


References 

1. Yngve D. Abdominal reflexes J Pediatric orthop. 1997: 17(1): 105-108
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9. Qiu XS, Ma WW, Li WG, Wang B, Yu Y, Zhu ZZ, Qian BP, Zhu F, Sun X, Ng BK, Cheng JC, Qiu Y. Discrepancy between radiographic shoulder balance and cosmetic shoulder balance in adolescent idiopathic scoliosis patients with double thoracic curve. Eur Spine J. 2009 Jan;18(1):45-51.


How to Cite this Article: Khurjekar K. Shoulder Balance and Scoliosis. International Journal of Spine Apr – June 2016;2(1):31-32 .

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