Does ‘Canal Clearance’ Affect Neurological Outcome After Thoracolumbar Burst Fractures?

Abstract

Surgical decompression of the spinal canal is presently accepted worldwide as the method of treatment for thoracolumbar burst fractures with neurological deficit in the belief that neurological recovery may be produced or enhanced. Our clinical and laboratory experience, however, indicates that the paralysis occurs at the moment of injury and is not related to the position of the fragments of the fracture on subsequent imaging. Since the preoperative geometry of the fracture may be of no relevance, our hypothesis, backed by more than two decades of operative experience, is that alteration of the canal by 'surgical clearance' does not affect the neurological outcome.We have reviewed the existing world literature in an attempt to find evidence-based justification for the variety of surgical procedures used in the management of these fractures. We retrieved 275 publications on the management of burst fractures of which 60 met minimal inclusion criteria and were analysed more closely. Only three papers were prospective studies; the remainder were retrospective descriptive analyses. None of the 60 articles included control groups. The design of nine studies was sufficiently similar to allow pooling of their results, which failed to establish a significant advantage of surgical over non-surgical treatment as regards neurological improvement. Significant complications were reported in 75% of papers, including neurological deterioration. Surgical treatment for burst fracture in the belief that neurological improvement can be achieved is not justified, although surgery may still occasionally be indicated for structural reasons. This information should not be withheld from the patients. There are many different classifications of thoracolumbar spinal injuries but the most popular is that of Denis 1 which is based on the three-column theory as considered in the sagittal plane. The three columns are the anterior, which comprises the front half of the bodies and the anterior longitudinal ligament, the middle, namely the back half of the bodies and the posterior longitudinal ligament, and the posterior, which includes the laminae, facet joints and spinous processes plus the ligaments and muscles attached to them. The more columns which are damaged the more unstable is the injury. Four fundamental types of fracture can be distinguished: 1) a simple, stable anterior wedge compression fracture with compression of the anterior column; 2) distraction injuries, referred to as seat-belt injuries; 3) burst fractures with compression of both the anterior and middle columns; and, finally, 4) fracture-dislocations of the spine which are unstable and involve all three columns.Burst fractures are produced by vertical compressive loads, usually with some degree of flexion, since the anterior column is squashed down more than the middle column. Although bone bursts in all directions, one of the compelling images of a burst fracture can be seen on transverse CT which shows bone retropulsed into the spinal canal. Such scans may show a range o...

Does early decompression improve neurological outcome of spinal cord injured patients? Appraisal of the literature using a meta-analytical approach

“…Another interesting finding was that the outcome of overall decompressed patients, combining together data of early and late treatment, namely overlooking the time factor, was similar to that of conservatively managed patients. This agree with the observations of other authors, 32,[50][51][52][53] and suggest that timing may play a role in surgical decompression.…”

“…Their results demonstrated that surgery does not offer a significant advantage compared with conservative treatment with respect to neurological outcome. 53 In that study, however, again the timing of surgery was not considered as a factor affecting outcome.…”

“…Early treatment ranged between 6 h and more than a week in the reviewed literature. 39,51,53,55,56 Even when performed within 24 h, which we selected as time window for early surgery, the operation might be too late to reverse some of the secondary injury mechanisms that follow acute SCI. The only therapeutic window established in humans, actually, is the 8-h trauma-to-treatment window reported in the NASCIS-2 in which methyl-prednisolone was used.…”

Traumatic Spinal Cord Injuries: An Evidence-based Practice Approach

“…The same conclusions were made by reviewing the outcome of conservative treatment of 50 consecutive patients with between 10% to 90% canal encroachment in Frankel C, D and E groups; patients in Frankel C and D group recovered ambulation and none of the patients deteriorated neurologically or otherwise [13] Other groups have since published similar findings [14][15][16].…”

Treatment of severe double spinal cord injuries

“…Boerger et al in July 2000 9 reviewed the literature and came to a similar conclusion stating that clearance of the spinal canal is not necessary for neurological recovery. Unfortunately, I cannot ®nd any convincing evidence in the literature to suggest that either the speed of recovery or the ®nal neurological outcome are improved by surgery (decompression+stabilisation) in patients with complete or incomplete cord injuries.…”