Objective To review the latest progress in classification system of thoracolumbar fractures and its surgical treatment with posterior approaches. Methods Recent l iterature about classification system of thoracolumbar fractures and its surgical treatment was reviewed. Results For the treatment of thoracolumbar fracture, the surgeon first should decide whether the surgical treatment was necessary. Recently, a new classification system had been developed to help the surgeon make the right decision. The surgical methods included short segment internal fixation and long segment internalfixation with or without fusion, and minimally invasive internal fixation. Conclusion The progress in the surgical treatmentof thoracolumbar fracture will help spinal surgeon decide the necessary surgery beneficial for the patients. The most appropriate and effective surgical method with the minimum damage should be used to treat the fracture. The advantages of non-fusion surgical treatment still need a further study.
ObjectiveTo explore the effectiveness and safety of tranexamic acid (TXA) in anterior approach surgery for thoracolumbar fractures.MethodsFrom January 2017 to January 2020, a total of 68 thoracolumbar fracture patients undergoing anterior approach surgery were included and randomly divided into TXA group (n=33) and control group (n=35). Patients in the TXA group were given a dose of 15 mg/kg of TXA by intravenous infusion during 30 min before skin incision and an additional 15 mg/kg of TXA intravenously at 8 h after the first infusion, while the ones in the control group were given 15 mg/kg of normal saline at the same time. Basic data of the patients were collected. The hemoglobin concentration, hematocrit, coagulation and fibrinolysis indexes of the patients were monitored preoperatively, 24-hour postoperatively, and 72-hour postoperatively. The intraoperative blood loss and wound drainage of the patients were recorded. The incidence of blood transfusion and thrombotic events were collected. Statistical analysis was performed.ResultsThere was no significant difference in age, sex, body mass index, operation time, fracture location distribution, anesthesia classification of American Society of Anesthesiologists, neurologic grade of American Spinal Injury Association, injury time, or length of hospital stay between the two groups (P>0.05). Compared with those in the control group, the total blood loss [(1 398.49±312.24) vs. (1 642.30±357.78) mL, P=0.003], intraoperative blood loss [(432.83±74.76) vs. (486.31±86.51) mL, P=0.008], and wound drainage [(276.73±89.42) vs. (389.24±125.71) mL, P<0.001] in the TXA group reduced. No statistically significant difference was found between the two groups in the preoperative hemoglobin or hematocrit (P>0.05), but the 24-hour postoperative hemoglobin concentration [(112.67±20.59) vs. (102.64±19.41) g/L, P=0.042] and hematocrit [(32.25±4.12)% vs. (30.13±4.28)%, P=0.042] in the TXA group were higher than those in the control group. The incidence of allogeneic blood transfusion in the TXA group was lower than that in the control group (6.1% vs. 25.7%, P<0.05). There was no statistically significant difference in preoperative, 24-hour postoperative, or 72-hour postoperative prothrombin time, international standardized ratio, activated partial prothrombin time, platelet count, fibrinogen, d-dimer, or fibrinogen degradation products between the two groups (P>0.05), and no thrombotic complications were found.ConclusionTXA has good efficacy and safety in the anterior approach surgery for thoracolumbar fractures.
Objective To study the effectiveness of transpedicular intervertebral bone graft and pedicle screws fixation in injured vertebrae for the treatment of thoracolumbar fractures. Methods Between February 2007 and January 2009, 25 patients with thoracolumbar fractures were treated by posterior short-segment fixation combined with transpedicular intervertabral bone graft and pedicle screw fixation in injured vertebrae. There were 18 males and 7 females with a mean ageof 46 years (range, 28-63 years). The injured vertebrae were located at T10 in 1 case, T11 in 2 cases, T12 in 8 cases, L1 in 6 cases, L2 in 6 cases, L3 in 1 case, and L4 in 1 case. According to Denis classification, there were 14 cases of burst fractures and 11 cases of compression fractures. Based on Frankel classifications, 2 cases were rated as grade A, 4 cases as grade B, 8 cases as grade C, 7 cases as grade D, and 4 cases as grade E. The time between injury and operation was 6 hours to 7 days (mean, 4.6 days). The X-ray film was taken to measure the relative height of fractured vertebrae and Cobb angle, and Frankel classification was conducted to evaluate the function recovery of the spinal cord. Results The operations were performed successfully, and incisions healed primarily. All the patients were followed up 12-25 months (mean, 16 months). CT and X-ray films showed good bone graft heal ing and no loosening or breakage of screws and rods. The relative height of fractured vertebrae were 56.8% ± 15.6% at preoperation, 91.2% ± 10.7% immediately after operation, and 89.6% ± 10.3% at 1 year after operation, showing significant differences between preoperation and postoperation (P lt; 0.01), while no significant difference between immediately after operation and 1 year after operation. The Cobb angles were (18.2 ± 2.6), (7.5 ± 1.4), and (8.7 ± 1.1)°, respectively, showing significant differences between preoperation and postoperation (P lt; 0.01), while no significant difference between immediately and 1 year after operation. At 1 year after operation, the neural function in 16 cases was improved 1-3 grades. ConclusionTreatment of thoracolumbar fractures with transpedicular intervertebral bone graft and pedicle screw fixation in injuredvertebrae has satisfactory effectiveness, which can reconstruct vertebral body height, increase the stabil ity of anterior and middle
Objective To investigate the effectiveness of posterior non-decompression surgery in the treatment of thoracolumbar fractures without neurological symptoms by comparing with the conventional posterior decompression surgery. Methods Between October 2008 and October 2015, a total of 97 patients with thoracolumbar fractures with intraspinal occupying 1/3-1/2 and without neurological symptoms were divided into the decompression surgery group (51 cases) and the non-decompression surgery group (46 cases). There was no significant difference in gender, age, cause of injury, injury segment, the thoracolumbar injury severity score (TLICS), combined injury, disease duration, and preoperative relative anterior vertebral height, kyphosis Cobb angle, intraspinal occupying percentage, visual analogue scale (VAS), Oswestry disability index (ODI), and Japanese Orthopaedic Association (JOA) score between 2 groups (P>0.05). The operation time, intraoperative blood loss volume, postoperative drainage, bed rest time, hospitalization time, and relative anterior vertebral height, kyphosis Cobb angle, intraspinal occupying percentage, and VAS score, ODI, JOA score at preoperative and postoperative 3 days and 1 year were recorded and compared. Results The operation time, intraoperative blood loss volume, and postoperative drainage in non-decompression surgery group were significantly less than those in decompression surgery group (P<0.05). There was no significant difference in the postoperative bed rest time and hospitalization time between 2 groups (P>0.05). In decompression surgery group, 4 cases had cerebrospinal fluid leakage and healed after conservative treatment. All incisions healed by first intention, and no nerve injury or infection of incision occurred. All patients were followed up 10-18 months (mean, 11.7 months). The recovery of vertebral body height was satisfactory in 2 groups, without secondary kyphosis and secondary nerve symptoms. The imaging indexes and effectiveness scores of 2 groups at 3 days and 1 year after operation were significantly improved when compared with preoperative ones (P<0.05). The intraspinal occupying percentage, VAS score, and ODI at 1 year after operation were significantly lower than those at 3 days after operation in 2 groups (P<0.05), and JOA score at 1 year after operation was significantly higher than that at 3 days after operation (P<0.05). Relative anterior vertebral height at 1 year after operation was significantly higher than that at 3 days after operation in non-decompression surgery group (P<0.05); and there was no significant difference in decompression surgery group (P>0.05). At 3 days, the intraspinal occupying percentage and JOA score in non-decompression surgery group were higher than those in decompression surgery group (P<0.05), and VAS score and ODI at 3 days in non-decompression surgery group were lower than those in decompression surgery group (P<0.05). No significant difference was found in the other indexes between 2 groups at 3 days and 1 year after operation (P>0.05). Conclusion Compared with the posterior decompression surgery, posterior non-decompression surgery has the advantages of less bleeding, less trauma, less postoperative pain, and so on. It is an ideal choice for the treatment of thoracolumbar fractures with intraspinal occupying 1/3-1/2 and without neurological symptoms under the condition of strict indication of operation.
Objective To study the feasibil ity and rel iabil ity of the multi-plannar reformation (MPR) of multispiral CT (MSCT) in measuring the kyphosis angle (KA) after thoracolumbar fracture. Methods From December 2007 to December 2009, 45 thoracolumbar fracture patients who underwent computed radiology (CR) and MSCT were recruited. There were 32 males and 13 females with a mean age of 48 years (range, 24-63 years), including 36 simple compression fractures and 9 burst fractures. The fracture locations were T11 in 6 cases , T12 in 11 cases, L1 in 20 cases, and L2 in 8 cases. Fracture was caused by trafffic accident in 25 cases, by fall ing from height in 12 cases, and by others in 8 cases. The imaging examination was performed after 2 hours to 7 days of injury in 22 cases and after more than 7 days in 23 cases. The KA was measured on the lateral X-ray films of CR and MPR by two observers, then the measurements were done again after three weeks. The data were statistically analyzed. Results The average KA values on CR by two observers were (20.75 ± 8.31)° and (22.49 ± 9.07)°, respectively; showing significant difference (P lt; 0.05), and the correlation was good (r=0.882, P lt; 0.05). The average KA values on MPR by two observers were (16.65 ± 8.62)° and (17.08 ± 7.88)°, respectively, showing no significant difference (P gt; 0.05), the correlation was excellent (r=0.976, P lt; 0.05). The average KA values on CR and MPR were (21.61 ± 8.43)° and (16.87 ± 8.20)°, respectively; showing significant difference (P lt; 0.05), the correlation was good (r=0.852, P lt; 0.05). Conclusion It is more feasible and rel iable in measuring the KA on MRP of MSCT than CR, but the value is larger on CR.
Objective To develop a deep learning system for CT images to assist in the diagnosis of thoracolumbar fractures and analyze the feasibility of its clinical application. Methods Collected from West China Hospital of Sichuan University from January 2019 to March 2020, a total of 1256 CT images of thoracolumbar fractures were annotated with a unified standard through the Imaging LabelImg system. All CT images were classified according to the AO Spine thoracolumbar spine injury classification. The deep learning system in diagnosing ABC fracture types was optimized using 1039 CT images for training and validation, of which 1004 were used as the training set and 35 as the validation set; the rest 217 CT images were used as the test set to compare the deep learning system with the clinician’s diagnosis. The deep learning system in subtyping A was optimized using 581 CT images for training and validation, of which 556 were used as the training set and 25 as the validation set; the rest 104 CT images were used as the test set to compare the deep learning system with the clinician’s diagnosis. Results The accuracy and Kappa coefficient of the deep learning system in diagnosing ABC fracture types were 89.4% and 0.849 (P<0.001), respectively. The accuracy and Kappa coefficient of subtyping A were 87.5% and 0.817 (P<0.001), respectively. Conclusions The classification accuracy of the deep learning system for thoracolumbar fractures is high. This approach can be used to assist in the intelligent diagnosis of CT images of thoracolumbar fractures and improve the current manual and complex diagnostic process.
ObjectiveTo explore the application of different digestive system management strategies in the perioperative period of thoracolumbar fracture.MethodsThe clinical data of the patients with thoracolumbar fractures and pedicle screw fixation in Affiliated Hospital of Southwest Medical University from January 2016 to January 2018 were retrospectively analyzed. According to different perioperative management strategies of the digestive system, they were divided into two groups. Patients with careful management strategy were included in the observation group, and patients with routine management were included in the control group. The baseline conditions, the abnormalities of digestive tract function at admission and before and after surgery, the postoperative first feeding time, exhaust time, defecation time, the incidence of other postoperative complications except digestive tract complication, length of stay and patient satisfaction were compared between the two groups. At 6 months after surgery, the fracture healing, loosening or fracture of internal plants were compared between the two groups.ResultA total of 121 patients were included in the study, including 67 cases in the observation group and 54 cases in the control group. There was no significant differences in the baseline conditions between the two groups (P>0.05). There were no significant differences between the two groups in the incidences of digestive system dysfunction at admission (P>0.05). The incidences of digestive system dysfunction in the observation group before and after surgery were lower than those in the control group (29.9% vs. 53.7%, P<0.05; 35.8% vs. 61.1%, P<0.05). The first eating time [(3.7±1.1) vs. (6.7±2.6) h], exhaust time [(7.8±2.3) vs. (13.6±4.2) h], defecation time [(26.7±8.1) vs. (40.9±11.2) h] and length of stay [(6.5±2.4) vs. (9.0±2.7) d] in the observation group were shorter than those in the control group (P<0.005), and the patients’ satisfaction was better than that of the control group (8.3±1.1 vs. 7.6±1.3; t=−3.208, P=0.002). There was no statistically significant difference in the incidence of postoperative complications except digestive tract complication, and the fracture healing rate, the incidence of nail-rod breakage at6 months after surgery between the two groups (P>0.05). No internal plant loosening was found in the two groups of patients within 6 months after surgery.ConclusionThe application of the careful digestive system management strategy in patients with thoracolumbar fractures can help reduce the incidence of perioperative gastrointestinal dysfunction, promote the recovery of perioperative gastrointestinal function, shorten the length of hospital stay, and improve patient satisfaction.
ObjectiveTo investigate the short-term effectiveness of percutaneous pedicle fixation combined with intravertebral allograft by different methods for thoracolumbar fractures. MethodsThe clinical data of 94 patients with single segment thoracolumbar fracture who underwent percutaneous pedicle fixation combined with intravertebral allograft by different methods between October 2018 and October 2019 were retrospectively analyzed. According to the different methods of intravertebral allograft, they were divided into group A (bone grafting by Jack dilator, 40 cases) and group B (bone grafting by funnel, 54 cases). There was no significant difference between the two groups (P>0.05) in the gender, age, body mass index, cause of injury, injured segment, Wolter index, time from injury to operation, and preoperative visual analogue scale (VAS) score, injured vertebral height ratio, and Cobb angle. The operation time, fluoroscopy frequency, allograft volume, and complications were recorded and compared between the two groups. VAS score of low back pain was used to evaluate the remission of clinical symptoms before operation, at 3 days, 3 months, 12 months after operation, and at last follow-up. The injured vertebral height ratio and Cobb angle were measured before operation, at 3 days, 3 months, and 12 months after operation. ResultsThe operation time, fluoroscopy frequency, and allograft volume in group A were significantly higher than those in group B (P<0.05). No complication occurred after operation, such as loosening or fracture of internal fixation. And bone grafting in the injured vertebrae healed at last follow-up. The VAS score, injured vertebral height ratio, and Cobb angle at each postoperative time point significantly improved when compared with preoperative ones (P<0.05); compared with 3 days postoperatively, the VAS score improved further after 3 months, but the injured vertebral height ratio decreased and the Cobb angle increased, and the differences were significant (P<0.05). There was no significant difference in the VAS scores of low back pain between the two groups at each time point after operation (P>0.05); the injured vertebrae height ratio in group A was significantly higher than that in group B, and the Cobb angle was significantly lower than that in group B, all showing significant differences (P<0.05). ConclusionThe intravertebral allograft via Jack dilator can restore the height and decrease the Cobb angle of the injured vertebrae, but accompanied with higher fluoroscopy frequency and longer operation time when compared with funnel bone grafting. For patients with single level thoracolumbar fractures, intravertebral allograft via Jack dilator is recommended.
A new method of anterior decompression for thoracolumbar fractures with paralysi s in six cases was reported. In a follw-up of one to five months, was shown that the neurological functions in all six cases has improved ⅡⅢ rank in Frankl classification. The author believe that the method has the following advantages, such as: less trauma from operation; the level and the limit of decompression could be made without Xray during the operation; usually only 1/5 to 1/4 of the vertebral body was excised so that the stability of the spine was not disturbed, and the obvious favourable results.
Objective To analyze the imaging characteristics of vertebral " shell” phenomenon of thoracolumbar fractures after posterior reduction and to explore the relationship between vertebral " shell” and fracture healing. Methods Between January 2013 and December 2015, the clinical data of 116 patients with thoracolumbar fractures treated with posterior pedicle screw-rod system reduction and internal fixation were analyzed retrospectively. There were 72 males and 44 females, aged 22-66 years (mean, 43 years). Injury causes were traffic accident in 24 cases, falling from height in 54 cases, bruise in 38 cases. Fracture segment located at T11 in 5 cases, T12 in 38 cases, L1 in 52 cases, L2 in 21 cases. There were 51 cases of compressive fracture and 65 cases of burst fracture. The sagittal Cobb angle ranged from 8 to 27°, with an average of 15°. Degree of preoperative spinal compression ranged from 20% to 75%, with an average of 44%. Bone density measurement showed that normal bone mass in 30 cases, bone loss in 40 cases, osteoporosis in 41 cases, and severe osteoporosis in 5 cases. The number, pathological characteristics, and imaging regularity of the vertebral " shell” phenomenon were observed and analyzed by logistic regression. Results All patients were followed up 11-18 months with an average of 13 months. A total of 72 cases of vertebral " shell” phenomenon mainly located in the vertebral anterior column and the end plate near the weak area (54/72, 75.0%). Most of them were in the irregular shape (50/72, 69.5%). The vertebral fracture line was related to the shape of the vertebral body and the displacement of the vertebral body after reduction. The outcome of the " shell” can be divided into disappeared type, reduced type, and collapse type, the volume of vertebral " shell” and its outcome were the risk factors for vertebral fracture healing. Conclusion The incidence of vertebral " shell” and nonuion of thoracolumbar fractures after posterior reduction are high. The main influencing factors are vertebral " shell” outcome and size.