Video-assisted treatment of thoracolumbar junction fractures using a specific distractor for reduction: prospective study of 50 cases

Abstract

Posterior instrumentation allows good osteosynthesis for thoracolumbar junction fractures. However, in approximately 20% of cases, anterior bone defects may persist, leading to pseudoarthrosis and loss of reduction. Anterior approaches can circumvent this drawback, but they are considered aggressive with a high rate of complications. The advent of the endoscopic mini-invasive techniques has led to a reduction in the number of complications while maintaining the same consolidation rate. Nevertheless, poor restitution of anatomic curves is a reproach for this technique. This prospective study reports clinical and radiological result of 50 patients (19 women and 31 men) operated between April 2000 and March 2006 with a video-assisted anterior approach using an endodistractor for reduction and consequent insertion of the implant. There were A3 (n = 44), A2 (n = 2), A1 (n = 3) and C1 (n = 1) fractures (Magerl classification). The specific system for fracture reduction was used in the last 39 cases of this series. A Pyramesh cage (Medtronic, Memphis, USA) was used in 15 patients, a peek cage (Creaspine, Bordeaux, France) in 30 patients and a tricortical graft in 5 patients. Standard X-rays and CT scan were performed pre-operatively. Kyphosis, and angulations were measured pre-, per- and post-operatively. Mean immediate postoperative gain in localized kyphosis was 12.18 degrees and mean gain at last follow-up was 11.71 degrees. Mean immediate postoperative gain in RA was 13.24 degrees and remained identical at last follow-up. Five patients had a transient pulmonary atelectasia and there was one pulmonary infection. No neurological complication occurred. Fracture reduction is comparable to the best thoracotomy series while limiting approach-related complications.

Implications of the center of rotation concept for the reconstruction of anterior column lordosis and axial preloads in spinal deformity surgery

“…This was not the case with the LZ+TLS in which the tactile feedback of increasing recoil forces indicated stopping the lordosizing maneuver. With all endplate-based techniques, correction was stopped when cracks or very small injuries occurred, in anticipation of endplate failure, which might explain why we did not observe significant correlations between correction and BMD or age of specimens as we 1,37,38,49,86,87 In our experience standard spreaders are successful at opening the 1-level discectomy defect, but the current study stressed that with a lamina spreader and its edges cutting into the endplates, only little and pure distractive correction can be applied. Application of external forces at the apex of a kyphosis is a successful measure to open a corpectomy defect and insert a VBR press-fit.…”

“…Within 17 studies, correction averaged only 9.5°. 6,14,15,18,30,38,39,46,49,55,62,70,75,83,87 The amount of correction with anterior-only restoration of lordosis largely depends on the aggressiveness of the release and on the extent of posterior element rigidity. Despite the possibility of correction by an anterior-only approach with aggressive release, correction is less predictable, and powerful instruments that enable controlled application of reduction forces without causing significant damage to the vertebrae or osteoporotic bone are desirable.…”

“…Yet clinically this is of minor disadvantage as the majority of surgeries for correction of angular plane deformities are performed around the thoracolumbar junction. 1,5,6,14,17,34,[37][38][39]49,55,66,83,86,87 …”

“…34,55 Other methods consist of the use of lamina and arthrodesis spreaders to open the intervertebral space, 1,37,38,86,87 distractors placed on bolt screws, 6 manufactured distractors (such as Kaneda instruments), 66,83 an anterior rigid plate with in situ expandability and reduction features, 17 or customized distractive forceps. 49 A concern is that current techniques apply mainly distractive forces to the vertebra adjacent to a corpectomy, which can cause functional unlocking of the facets and compromise the fulcrum of the COR that is otherwise provided by the posterior facets. In turn, segmental stability is reduced.…”

The Michel Benoist and Robert Mulholland yearly European Spine Journal Review: a survey of the “surgical and research” articles in the European Spine Journal, 2010

“…It was useful to read together the papers by Le Huec [22] who presented the results of operating on 50 patients, and Rajasekaran [39] who reviewed the literature on conservative treatment of such fractures. In the Le Huec series of 50, 49 were all A fractures, presumably stable (the only one other was C1) and none had neurological injury.…”