Fracture reduction by postoperative mobilisation for the treatment of hyperextension injuries of the thoracolumbar spine in patients with ankylosing spinal disorders

Abstract

IntroductionThe aim of this study was to evaluate results of surgical stabilisation of hyperextension injuries of the thoracolumbar spine in patients with ankylosing spinal disorders using two different treatment strategies: the conventional open rigid posterior instrumentation and percutaneous less rigid posterior instrumentation. Surgical and non-surgical complications, the postoperative radiological course, and clinical outcome at final follow-up were comparatively assessed. Moreover, we sought to discuss important biomechanical and surgical aspects specific to posterior instrumentation of the ankylosed thoracolumbar spine as well as to elaborate on the advantages and limitations of the proposed new treatment strategy involving percutaneous less rigid stabilisation and fracture reduction by postoperative mobilisation.Materials and methodsBetween January 2006 and June 2012, a consecutive series of 20 patients were included in the study. Posterior instrumentation was performed either using an open approach with rigid 6.0 mm bars (open rigid (OR) group) or via a percutaneous approach using softer 5.5 mm bars (percutaneous less rigid (PLR) group). Complications as well as the radiological course were retrospectively assessed, and patient outcome was evaluated at final follow-up using validated outcome scores (VAS Spine Score, ODI, RMDQ, Parker Mobility Score, Barthel Score and WHOQOL-BREF).ResultsSurgical complications occurred more frequently in the OR group requiring revision surgery in two patients, while there was no revision surgery in the PLR group. The rate of postoperative complications was lower in the PLR group as well (0.7 vs. 1.3 complications per patient, respectively). Fracture reduction and restoration of pre-injury sagittal alignment by postoperative mobilisation occurred within the first 3 weeks in the PLR group, and within 6 months in the OR group. The clinical outcome at final follow-up was very good in both groups with no relevant loss in VAS Spine Score (pain and function), Parker Mobility Score (mobility), and Barthel Index (social independency) compared to pre-operative values.ConclusionsThis study indicates that the proposed treatment concept involving percutaneous less rigid posterior instrumentation and fracture reduction by postoperative mobilisation is feasible, seems to facilitate adequate reduction and restoration of pre-injury sagittal alignment, and might have the potential to reduce the rate of complications in the management of hyperextension injuries of the ankylosed thoracolumbar spine.

Minimally Invasive versus Conventional Open Surgery for Fixation of Spinal Fracture in Ankylosed Spine

“…The advent of MISt using PPS in the treatment of vertebral fractures in ankylosing disorders has reduced the morbidity associated with open surgery such as increased blood loss, higher infection rate, longer operative time, higher pain score, longer hospital stay and recovery time 13 , 14 , 25 - 28 . Kruger et al 13 reviewed 10 patients with AS or DISH treated with MISt and reported good mid-term functional outcome with shorter operative time of 60.2 minutes (range, 32-135 min).…”

“…Moussallem et al 14 compared 25 patients treated with MISt and 16 patients with open surgery and documented shorter operative time (254.8 vs. 334.7 min, p=0.04), lower blood loss (166.8 vs. 1240.4ml, p<0.001), decreased transfusion rate (36.0% vs. 87.5%, p=0.001), lower complication rate (56.0% vs. 87.0%, p=0.045) and shorter hospital stay (9.6 vs. 16.7 days, p=0.008) in the MISt group. Lindtner et al 28 compared six patients in MISt group and 14 patients in open group and found that the open group had higher post-operative complication rate (1.3 vs. 0.7 complications per patient). Okada et al 29 , in a retrospective review comparing 16 DISH patients undergoing MISt and 25 DISH patients undergoing conventional open surgery for spinal fractures, reported shorter operation duration and lower blood loss in the MISt group.…”

Surgical Outcomes of Minimally Invasive Stabilization for Spinal Fractures in Patients with Ankylosing Spinal Disorders

“…However, improving reduction of hyperextension spine injuries in ASD patients may be difficult, as the disruption of the anterior column is worsened when the patients are in the prone position. Lindtner et al [ 20 ] described a new treatment concept for the surgical management of hyperextension injuries of the thoracolumbar spine in patients with ASD, involving percutaneous less rigid posterior instrumentation. Fracture reduction by postoperative mobilization is feasible, and seems to facilitate adequate reduction and restoration of the preinjury sagittal alignment [ 20 ].…”

“…Lindtner et al [ 20 ] described a new treatment concept for the surgical management of hyperextension injuries of the thoracolumbar spine in patients with ASD, involving percutaneous less rigid posterior instrumentation. Fracture reduction by postoperative mobilization is feasible, and seems to facilitate adequate reduction and restoration of the preinjury sagittal alignment [ 20 ]. In our study, there were no cases of obvious malalignment, although the disruption of the anterior column did worsen in some cases.…”

Management of Andersson Lesion in Ankylosing Spondylitis Using the Posterior-Only Approach: A Case Series of 18 Patients

“…Van Royen et al [24,25] have described cases where pseudoarthrosis fixation and fusion was performed along with deformity correction at same level with success; they also described a mathematical formula for such osteotomies. Recently, a series has been published describing postoperative fracture reduction by controlled kyphosis through early mobilization following semi rigid posterior fixation with percutaneous screws [26].…”