J Korean Neurosurg Soc.  2014 Sep;56(3):230-236. 10.3340/jkns.2014.56.3.230.

Predictive Factors for a Kyphosis Recurrence Following Short-Segment Pedicle Screw Fixation Including Fractured Vertebral Body in Unstable Thoracolumbar Burst Fractures

• Kim GW
• Jang JW
• Hur H
• Lee JK
• Kim JH
• Kim SH

• KMID: 2339962
• DOI: http://doi.org/10.3340/jkns.2014.56.3.230

Abstract

OBJECTIVE
The technique of short segment pedicle screw fixation (SSPSF) has been widely used for stabilization in thoracolumbar burst fractures (TLBFs), but some studies reported high rate of kyphosis recurrence or hardware failure. This study was to evaluate the results of SSPSF including fractured level and to find the risk factors concerned with the kyphosis recurrence in TLBFs.
METHODS
This study included 42 patients, including 25 males and 17 females, who underwent SSPSF for stabilization of TLBFs between January 2003 and December 2010. For radiologic assessments, Cobb angle (CA), vertebral wedge angle (VWA), vertebral body compression ratio (VBCR), and difference between VWA and Cobb angle (DbVC) were measured. The relationships between kyphosis recurrence and radiologic parameters or demographic features were investigated. Frankel classification and low back outcome score (LBOS) were used for assessment of clinical outcomes.
RESULTS
The mean follow-up period was 38.6 months. CA, VWA, and VBCR were improved after SSPSF, and these parameters were well maintained at the final follow-up with minimal degree of correction loss. Kyphosis recurrence showed a significant increase in patients with Denis burst type A, load-sharing classification (LSC) score >6 or DbVC >6 (p<0.05). There were no patients who worsened to clinical outcome, and there was no significant correlation between kyphosis recurrence and clinical outcome in this series.
CONCLUSION
SSPSF including the fractured vertebra is an effective surgical method for restoration and maintenance of vertebral column stability in TLBFs. However, kyphosis recurrence was significantly associated with Denis burst type A fracture, LSC score >6, or DbVC >6.

Keyword

Kyphosis; Short-segment pedicel screw fixation; Thoracolumbar burst fractures; Instability

MeSH Terms

Classification
Female
Follow-Up Studies
Humans
Kyphosis*
Male
Recurrence*
Risk Factors
Spine

Figure

• 

  Fig. 1 Schematic diagram of radiological parameters measured on a lateral neutral radiograph. Vertebral body compression ration : [1-(2×body height 2)/(body height 1+3)]×100. CA : Cobb angle, VWA : vertebral wedge angle, DbVC : difference between VWA and CA, UADH : upper anterior disc height, LADH : lower anterior disc height, PDH : posterior disc height.

• 

  Fig. 2 Radiographs obtained in a 36-year-old man demonstrating an L2 burst fracture. A : Preoperatively, the Cobb angle measured 20.1 degrees and the vertebral wedge angle is 30.5 degrees. The difference between vertebral wedge angle and Cobb angle (DbVC) is 10.4. B : Postoperatively, the Cobb angle and the vertebral wedge angle are reduced to 6.6 degrees and 15.8 degrees. C : In the last follow-up radiograph, kyphosis recurrence is observed with a decline of the adjacent anterior disc height of fractured vertebra.

• 

  Fig. 3 Radiographs obtained in a 53-year-old man demonstrating an L1 burst fracture. A : Preoperatively, the Cobb angle measured 27.9 degrees and the vertebral wedge angle is 29.7 degrees. B : Preoperatively, computed tomography (CT) scan shows severe comminution of fractured vertebral body. C : Postoperatively, the Cobb angle and the vertebral wedge angle are reduced to 13.8 degrees and 15.5 degrees. Load-sharing classification score is 8 points. D : In the last follow-up radiograph, 9.4 degrees of correction loss is observed with an additional collapse of fractured vertebra.

Reference

1. Alanay A, Acaroglu E, Yazici M, Oznur A, Surat A. Short-segment pedicle instrumentation of thoracolumbar burst fractures : does transpedicular intracorporeal grafting prevent early failure? Spine (Phila Pa 1976). 2001; 26:213–217. PMID: 11154543.

2. 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. PMID: 17252216.

3. Alvine GF, Swain JM, Asher MA, Burton DC. Treatment of thoracolumbar burst fractures with variable screw placement or Isola instrumentation and arthrodesis : case series and literature review. J Spinal Disord Tech. 2004; 17:251–264. PMID: 15280752.

4. Carl AL, Tromanhauser SG, Roger DJ. Pedicle screw instrumentation for thoracolumbar burst fractures and fracture-dislocations. Spine (Phila Pa 1976). 1992; 17(8 Suppl):S317–S324. PMID: 1523519.

5. Celebi L, Doğan O, Muratli HH, Yağmurlu MF, Biçimoğlu A. [The effectiveness of short-segment posterior instrumentation of thoracolumbar burst fractures]. Acta Orthop Traumatol Turc. 2007; 41:183–189. PMID: 17876116.

6. Chen HH, Wang WK, Li KC, Chen TH. Biomechanical effects of the body augmenter for reconstruction of the vertebral body. Spine (Phila Pa 1976). 2004; 29:E382–E387. PMID: 15371717.

7. Cho DY, Lee WY, Sheu PC. Treatment of thoracolumbar burst fractures with polymethyl methacrylate vertebroplasty and short-segment pedicle screw fixation. Neurosurgery. 2003; 53:1354–1360. discussion 1360-1361. PMID: 14633301.

8. Dai LY, Jiang LS, Jiang SD. Posterior short-segment fixation with or without fusion for thoracolumbar burst fractures. A five to seven-year prospective randomized study. J Bone Joint Surg Am. 2009; 91:1033–1041. PMID: 19411450.

9. Dai LY, Yao WF, Cui YM, Zhou Q. Thoracolumbar fractures in patients with multiple injuries : diagnosis and treatment-a review of 147 cases. J Trauma. 2004; 56:348–355. PMID: 14960979.

10. Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine (Phila Pa 1976). 1983; 8:817–831. PMID: 6670016.

11. Denis F, Armstrong GW, Searls K, Matta L. Acute thoracolumbar burst fractures in the absence of neurologic deficit. A comparison between operative and nonoperative treatment. Clin Orthop Relat Res. 1984; (189):142–149. PMID: 6478691.

12. Frankel HL, Hancock DO, Hyslop G, Melzak J, Michaelis LS, Ungar GH, et al. The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. I. Paraplegia. 1969; 7:179–192. PMID: 5360915.

13. Greenough CG, Fraser RD. Assessment of outcome in patients with low-back pain. Spine (Phila Pa 1976). 1992; 17:36–41. PMID: 1531553.

14. Gurr KR, McAfee PC. Cotrel-Dubousset instrumentation in adults. A preliminary report. Spine (Phila Pa 1976). 1988; 13:510–520. PMID: 3187697.

15. Jacobs RR, Asher MA, Snider RK. Thoracolumbar spinal injuries. A comparative study of recumbent and operative treatment in 100 patients. Spine (Phila Pa 1976). 1980; 5:463–477. PMID: 7455777.

16. Kaneda K, Taneichi H, Abumi K, Hashimoto T, Satoh S, Fujiya M. Anterior decompression and stabilization with the Kaneda device for thoracolumbar burst fractures associated with neurological deficits. J Bone Joint Surg Am. 1997; 79:69–83. PMID: 9010188.

17. Katonis PG, Kontakis GM, Loupasis GA, Aligizakis AC, Christoforakis JI, Velivassakis EG. Treatment of unstable thoracolumbar and lumbar spine injuries using Cotrel-Dubousset instrumentation. Spine (Phila Pa 1976). 1999; 24:2352–2357. PMID: 10586460.

18. Leferink VJ, Zimmerman KW, Veldhuis EF, ten Vergert EM, ten Duis HJ. Thoracolumbar spinal fractures : radiological results of transpedicular fixation combined with transpedicular cancellous bone graft and posterior fusion in 183 patients. Eur Spine J. 2001; 10:517–523. PMID: 11806393.

19. Mahar A, Kim C, Wedemeyer M, Mitsunaga L, Odell T, Johnson B, et al. Short-segment fixation of lumbar burst fractures using pedicle fixation at the level of the fracture. Spine (Phila Pa 1976). 2007; 32:1503–1507. PMID: 17572619.

20. McCormack T, Karaikovic E, Gaines RW. The load sharing classification of spine fractures. Spine (Phila Pa 1976). 1994; 19:1741–1744. PMID: 7973969.

21. McLain RF. Functional outcomes after surgery for spinal fractures : return to work and activity. Spine (Phila Pa 1976). 2004; 29:470–477. discussion Z6. PMID: 15094545.

22. McLain RF, Sparling E, Benson DR. Early failure of short-segment pedicle instrumentation for thoracolumbar fractures. A preliminary report. J Bone Joint Surg Am. 1993; 75:162–167. PMID: 8423176.

23. Parker JW, Lane JR, Karaikovic EE, Gaines RW. Successful short-segment instrumentation and fusion for thoracolumbar spine fractures : a consecutive 41/2-year series. Spine (Phila Pa 1976). 2000; 25:1157–1170. PMID: 10788862.

24. Patel AA, Dailey A, Brodke DS, Daubs M, Harrop J, Whang PG, et al. Thoracolumbar spine trauma classification : the Thoracolumbar Injury Classification and Severity Score system and case examples. J Neurosurg Spine. 2009; 10:201–206. PMID: 19320578.

25. Roy-Camille R, Saillant G, Mazel C. Plating of thoracic, thoracolumbar, and lumbar injuries with pedicle screw plates. Orthop Clin North Am. 1986; 17:147–159. PMID: 3945476.

26. Sasso RC, Best NM, Reilly TM, McGuire RA Jr. Anterior-only stabilization of three-column thoracolumbar injuries. J Spinal Disord Tech. 2005; (18 Suppl):S7–S14. PMID: 15699808.

27. Shin TS, Kim HW, Park KS, Kim JM, Jung CK. Short-segment pedicle instrumentation of thoracolumbar burst-compression fractures; short term follow-up results. J Korean Neurosurg Soc. 2007; 42:265–270. PMID: 19096554.

28. Tezeren G, Kuru I. Posterior fixation of thoracolumbar burst fracture : short-segment pedicle fixation versus long-segment instrumentation. J Spinal Disord Tech. 2005; 18:485–488. PMID: 16306834.

29. Vaccaro AR, Lehman RA Jr, Hurlbert RJ, Anderson PA, Harris M, Hedlund R, et al. A new classification of thoracolumbar injuries : the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status. Spine (Phila Pa 1976). 2005; 30:2325–2333. PMID: 16227897.

30. Wang XY, Dai LY, Xu HZ, Chi YL. Kyphosis recurrence after posterior short-segment fixation in thoracolumbar burst fractures. J Neurosurg Spine. 2008; 8:246–254. PMID: 18312076.