Elsevier

World Neurosurgery

Volume 108, December 2017, Pages 798-806
World Neurosurgery

Original Article
A Retrospective Study of Thoracolumbar Fractures Treated with Fixation and Nonfusion Surgery of Intravertebral Bone Graft Assisted with Balloon Kyphoplasty

https://doi.org/10.1016/j.wneu.2017.08.093Get rights and content

Background

Posterior fixation and fusion is the primary treatment for thoracolumbar fractures, although this treatment may sacrifice range of motion (ROM) to achieve stability, rather than treating the fracture itself. Two issues addressed when treating thoracolumbar fractures are 1) replacing the fractured vertebrae, especially the upper end plate of the injured vertebrae and 2) providing strong fixation with biomechanical stability and flexibility.

Methods

This retrospective study included 61 consecutive patients with thoracic or lumbar fractures treated from October 2010 to May 2014. Patients were divided into 1 of 2 groups: group A, intravertebral bone graft with balloon kyphoplasty (nonfusion surgery), and group B, traditional posterior fixation and fusion surgery. The visual analog scale was used preoperatively and at 3 months, 1 year, and 2 years. Radiography, computed tomography, and magnetic resonance imaging were performed preoperatively. Radiography was performed postoperatively at 3 months and 2 years. At 3 months after surgery, computed tomography was used to confirm healing of the vertebral fracture.

Results

All fractures in both groups were reduced successfully, and deformities were improved. After the removal of hardware in group A, ROM at the injury level recovered, and at 2 years, there was no loss of vertebral height or recurrence of deformity. There was no hardware failure in group A, but there was evidence of screw loosening in 3 screws in group B.

Conclusions

Nonfusion treatment of intravertebral bone graft assisted with balloon kyphoplasty showed good fracture reduction, deformity correction, fracture healing, and ROM maintenance. There were no complications associated with the implant.

Introduction

Thoracolumbar fractures are common spinal injuries, and approximately 15% of these fractures are unstable.1, 2 Posterior fixation and fusion is the primary treatment, with good stability and arthrodesis being obtained if the fracture is treated relatively early.3, 4, 5 However, this surgery results in a loss of spinal range of motion (ROM), which could influence patients' quality of life and ability to work. There is also a risk of hardware failure or neurologic injury after the placement of pedicle screws.

The nonoperated levels compensate for the fractured vertebra after fusion, resulting in ROM loss and increased stress and interbody pressure. These conditions may consequently accelerate the degenerative process, leading to disc and facet joint degeneration with clinical symptoms occurring at adjacent levels.6, 7, 8 In addition, fusion surgery may cause complications such as deformity, hardware failure, pseudarthrosis, and chronic low back pain because of delayed fusion or nonfusion.4, 9 The primary reasons for these complications are the principles and techniques of fusion surgery itself, which are fusion of the joint and the sacrifice of ROM to achieve stability, rather than treating the fracture itself. Nonoperative treatment for stable thoracolumbar fractures cannot perfectly restore the fractured vertebral height or lordosis, which may result in kyphosis and chronic low back pain.4, 5, 10

The question regarding the treatment of thoracolumbar fractures is how best to treat the fracture and maintain as much ROM as possible, which is the guiding principle of treating extremity fractures. Therefore, there are 2 issues to address when treating both stable and unstable thoracolumbar fractures: 1) the restoration of height to the fractured vertebrae, especially the upper end plate of the injured vertebrae; and 2) strong fixation with biomechanical stability and flexibility.

The current traditional fixation and fusion surgical technique does not meet both of these conditions perfectly, but it can preserve the fracture level and spinal ROM as much as possible. Recently, balloon vertebroplasty and transpedicle vertebral bone graft have met the first requirement of replacing the fractured vertebrae.11 Pedicle screws have met the second requirement of providing strong fixation with biomechanical stability and flexibility.

In this study, we describe a surgical technique of kyphoplasty and temporary pedicle fixation, which allows restoration of height, healing of the fractured vertebral body, and motion preservation of the injured segment.

Section snippets

Methods

This retrospective study included 75 consecutive patients with thoracic or lumbar fractures treated from October 2010 to May 2014. A total of 61 patients met the inclusion and exclusion criteria. To evaluate the clinical outcomes of the new nonfusion surgical technique, we used patients undergoing traditional fixation and fusion as the control group.

The inclusion criteria were age 18–60 years; fracture from T11 to L5 caused by trauma; no neurologic deficit; fracture classification of A1, A2,

Results

A total of 61 patients met the inclusion and exclusion criteria and all the patients signed the consent form before surgery. Fourteen patients were excluded, including 7 patients with multilevel spine fractures, 5 patients without 2 years of follow-up, and 2 patients with intact internal fixations after the intravertebral bone graft with balloon kyphoplasty nonfusion surgery. There were 31 patients in group A (balloon kyphoplasty) and 30 patients in group B (posterior fixation and fusion).

Mean

Discussion

Restoring and maintaining spinal stability is the primary principle of spinal fracture treatment. The thoracolumbar region has unique stress transfer properties, multiple segments, and a multicenter motion pattern, all of which make it difficult to reduce a fracture and maintain the new position while the fracture heals.

Traditional spinal fracture treatment principles and techniques have recently been revisited as a result of various developments in spine surgery, including an increased

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  • Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

    Chengmin Zhang and Bin Ouyang are co-first authors and contributed equally to the article.

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