1
COMPARATIVE ANALYSIS OF FUNCTIONAL
OUTCOME IN THORACOLUMBAR FRACTURES AND
DISLOCATIONS FIXED WITH SHORT SEGMENT WITH
INDEX VERTEBRA FIXATION AND LONG SEGMENT
SPANNING FIXATION
Dissertation submitted in partial fulfillment of the regulation for the award of
M.S DEGREE IN ORTHOPAEDIC SURGERY BRANCH II MAY 2018
THE TAMIL NADU
DR. MGR MEDICAL UNIVERSITY CHENNAI, TAMIL NADU MADURAI MEDICAL COLLEGE
2
CERTIFICATE
This is to certify that the work “COMPARATIVE ANALYSIS OF FUNCTIONAL OUTCOME IN THORACOLUMBAR FRACTURES AND DISLOCATIONS FIXED WITH SHORT SEGMENT WITH INDEX VERTEBRA FIXATION AND LONG SEGMENT SPANNING FIXATION" which is being submitted for M.S. Orthopaedics, is a bonafide work of Dr.G.PRASANTH, Post Graduate Student at Department of Orthopaedics, Madurai Medical College,
Madurai.
The Dean ,
Madurai Medical college,
3
CERTIFICATE
This is to certify that the work “COMPARATIVE ANALYSIS OF FUNCTIONAL OUTCOME IN THORACOLUMBAR FRACTURES AND DISLOCATIONS FIXED WITH SHORT SEGMENT WITH INDEX VERTEBRA FIXATION AND LONG SEGMENT SPANNING FIXATION" which is being submitted for M.S. Orthopaedics, is a bonafide work of Dr.G.PRASANTH, Post Graduate Student at Department of Orthopaedics, Madurai Medical College,
Madurai.
Prof. Dr. P.V.Pugalenthi, M.S Ortho.D.Ortho
Professor and Head, Department of Orthopaedics & Traumatology
Madurai Medical College,
4
CERTIFICATE
This is to certify that this dissertation “COMPARATIVE ANALYSIS OF FUNCTIONAL OUTCOME IN THORACOLUMBAR FRACTURES AND DISLOCATIONS FIXED WITH SHORT SEGMENT WITH INDEX VERTEBRA FIXATION AND LONG SEGMENT SPANNING FIXATION" is the bonafide work done by Dr.G.PRASANTH under my direct guidance and supervision in the Department of Orthopaedic Surgery, Madurai Medical College, Madurai-20.
Prof. Dr. R.Sivakumar, M.S Ortho., D. Ortho
Professor and Chief Ortho unit-III
Department of Orthopaedics & Traumatology
Madurai Medical College,
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ACKNOWLEDGEMENT
I am grateful to Prof.Dr.P.V. Pugalenthi, M.S., Ortho, D.Ortho., Professor and Head, Department of Orthopaedic Surgery and Traumatology, Madurai Medical College in guiding me to prepare this dissertation.
I am greatly indebted and thankful to my beloved chief, my
guideProf.Dr.R.Sivakumar, M.S.,Ortho, D.Ortho., Ortho-III unit, Department of Orthopaedic Surgery and Traumatology, Madurai Medical College for his
invaluable help, encouragement and guidance rendered to me in preparing this
dissertation.
I am most indebted and take immense pleasure in expressing my
deep sense of gratitude to Prof.Dr.B.Sivakumar M.S. Ortho.,D.ortho, Prof.Dr.R.Arivasan M.S.Ortho., Prof .Dr.V.R.Ganesan M.S.Ortho.,D.Ortho,
and Prof.Dr.N.Thanappan M.S.Ortho for their easy accessibility and timely suggestion, which enabled me to bring out this dissertation.
6
I take immense pleasure to thank my co-guide Dr.K.Senthil Kumar M.S.Ortho.,for his timely help and encouragement.
I also take this opportunity to thank Dr.M.N.Karthi M.S.Ortho., Dr.J.MaheswaranM.S.Ortho.,Dr.T.SaravanaMuthuM.S.Ortho.,Dr.V.A.Prabu M.S.Ortho., Dr.R.Ashok Kumar MS Ortho., Dr.R.Karthik Raja M.S.Ortho., Dr.Gopi Manohar DNB Ortho,Assistant Professors, Department of Orthopaedics, Madurai Medical College, for their timely help and guidance given
to me during all stages of the study.
7
DECLARATION
I, Dr.G.PRASANTH , solemnly declare that the dissertation titled“COMPARATIVE ANALYSIS OF FUNCTIONAL OUTCOME IN THORACOLUMBAR FRACTURES AND DISLOCATIONS FIXED WITH SHORT SEGMENT WITH INDEX VERTEBRA FIXATION AND LONG SEGMENT SPANNING FIXATION", has been prepared by me. This is submitted to “The Tamil Nadu Dr. M.G.R. Medical University, Chennai, in partial fulfillment of
the regulations for the award of M S degree branch II Orthopaedics.
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PART A
• ACKNOWLEDGEMENT
CONTENTS
Page No.
Introduction 10
Aim and Objective 12
Review of Literature 13
Anatomy and classification 15
Radiographic evaluation 32
9
PART -B
CONTENTS
Page No.
Methodology 42
Observation & Results 49
Cases 62
Discussion 82
Conclusion 87
ANNEXURES :
a. BIBLIOGRAPHY
b. PATIENT PROFORMA
c. CONSENT FORM
d. MASTER CHART
e. MODIFIED MACNAB’S CRITERIA AND OSWESTRY DISABILITY
INDEX
10
INTRODUCTION
Fractures in the thoracic and lumbar spine accounts for 90% of all spinal
fractures. The dorsolumbar junction is unique because of its anatomy and
biomechanical environment . Dorsolumbar spine fractures are the commonest
cause of traumatic paraplegia . They are most commonly seen in younger patients.
It involves most commonly in the region between T11 and L1. Injuries are
mostly due to fall from height, motor vehicle accidents and injuries related to
occupation and recreational activities.
The treatment usually are either conservative or surgery. Surgery involves
either posterior reduction and instrumentation or anterior decompression and
instrumentation or combined.Most commonly done procedure is Posterior
instrumentation . Most important aim of the management is to mobilise the patient
early and rehabilitation. Conservative treatment was used Until 1970. Hippocrates
was the first to treat the spinal fractures in the form of bed rest, postural reduction
, mobilization, ambulatory bracing and combination of these. The main goal was to
mobilize the patient with or without brace early.
Dorsolumbar burst fractures are unstable mostly which requires surgical
11
promote early bony fusion and mobilisation. Now most of the dorsolumbar
fractures are treated surgically to allow early mobilisation and to avoid the
complications of prolonged bed rest.
For the past 20 years, spine surgery has seen a dramatic increase in the
operative management. Posterior short segment pedicle screw fixation is usually
done for burst fractures. Eventhough early clinical results of this surgery are
usually satisfactory, a high failure rate and progressive kyphosis remain a
concern.To overcome this in addition to short segment fixation ,pedicle screw is
inserted at the fracture site.Long segment fixation is usually reserved for fracture
dislocation.Inorder to compare the results of functional outcome of both this
study is undertaken.
To
compare analysis of functional outcome in thoracolumbar
fractures and dislocations fixed with long segment spanning fixation
and short segment with index vertebra fixation
, this study was12
AIM OF THE STUDY
• To
compare
the
results
of
functional
outcome
in
thoracolumbar fractures and dislocations fixed with long
segment spanning fixation and short segment with index
vertebra fixation
OBJECTIVES OF STUDY
• To
compare the results of functional outcome in thoracolumbar
fractures and dislocations fixed with long segment spanning
fixation and short segment with index vertebra fixation
• To facilitate early mobilisation of patients and thus helping easy nursing
13
REVIEW OF LITERATURE
In a study by Jong-Jie et al (2010),82 Patients were included and followed up for 2 years.All cases achieved fusion,without vertebral body height loss and
implant failure.Improvement of neurological function was observed in patients
with incomplete neurological deficit.It concluded that posterior short segment
pedicle screw fixation with pedicle screw at the fracture level is a safe and
effective therapeutic option to treat thoracolumbar vertebral fractures, which can
help to correct the kyphosis and maintain the reduction.
In a study by Tarek ahmed aly(2016),no significant difference was found between short segment and long segment pedicle screw fixation in terms of
radiological ,functional outcome,neurologic improvement and implant failure
rate.[58]
In a study by Jun li(2016), 455 cases were taken(239 short segment and 216 long segment )eventhough operating time for long segment fixation was
14
fixation was seen but there was no significant difference in clinical outcome
between short and long sement fixation.[57]
In a study by Yue zhou and Changing li(2014),four fixation models were used and it concleded that additional pedicle screws at the level of fracture may
result in a stiffer construct and less von misses stress for pedicle screws and rods.
In a study by Tezeren G kuru(2005),18 consecutive patient were included with 9 patients treated by short segment and 9 patients with long
segment.Measurements of local kyphosis,sagittal index and anterior vertebral body
height compression showed that long segment fixation had better outcome at final
followup.Also short segment group had 55%failure rate whereras the long segment
group had prolonged operative time and increased blood loss.However there was
no significant difference between the two groups according to low back outcome
score.[32]
In a study by S.Acharya,A.Garg and R.S.Chahal(2012),20 patients were included(10 with short segment and 10 with long segment).postoperative kyphotic
correction and restoration of height was measured and results of both the groups
15
segment provides added stability,better postoperative maintenance of corrected
kyphosis at reduced cost of implant and also reduces the duration of surgery and
16 ANATOMY
Most of spinal fractures occur between levels T11 and L2. This
thoracolumbar junction is unique since it has a transitional anatomy. Thoracic
spine is stabilized by rib cage and costotransverse ligaments which provide
resistance to axial rotation and bending moments in coronal and sagittal plane. This
provides protection and also relative stiffness for the dorsal spine. But lumbar
spine is relatively unprotected and more flexible. The coronal and frontal
orientation of the facet joints of thoracic spine restrict mobility both in the flexion
and extension plane. But the sagittally oriented lumbar facet joints has increased
motion in both flexion and extension plane. Thoracolumbar junction provides less
shock-absorbing capacity or potential since it is straighter whereas the kyphosis of
the thoracic spine and lordosis of the lumbar spine serves to absorb and dissipate
axial loads .[14]
Thoraco lumbar injury-Classification :
Any classification should give the injury identification and clinical
,radiographic characteristics. It also should give information about the severity of
17
In 1930 Bohler was the first one who classified spinal fractures.
In 1949 Nicoll published the concept given by Watson and Jones regarding
stability and ligamentous integrity. In 1963 Holdsworth proposed two column
theory.In 1977 Louis proposed the three column concept. In 1983 Dennis based on
CT proposed the three column theory.[5]
In the Denis anatomical three-column model ,
1.Anterior column - anterior longitudinal ligament and the anterior half of anulus fibrosus and vertebral body .
2.Middle column -posterior longitudinal ligament and posterior half of the anulus fibrosus and vertebral body.
18
In three-column model, thoracolumbar fractures are classified based on the
injury to the middle column. Injury to the middle column is considered as a
potentially unstable fracture pattern in this three column classification system.
There is no involvement of middle column in compression fractures in which
anterior column goes for failure, whereas burst fracture both the anterior and the
middle column goes for compression failure. Chance fractures and Chance
variantsfailure in distraction, whereas any translation or rotation through the
middle column is a characteristic of a fracture-dislocation.[5,6]
In 1994 two new classification were come. The load sharing classification
(LSC) coined by McCormack
et and Comprehensive
Classification[14].
McCORMACK
CLASSIFICATIONgiving points to
1.The amount of comminution
in the fractured vertebral body
19
correction needs to restore the sagittal alignment
3.The spread of comminuted fragments in the fractured vertebral body (apposition)
Magrel et al presented Comprehensive classification based on AO fracture
classification[8]. It consists of
1. Type A fracture –compression type of injury without posterior lesion
20
3. Type C fracture- rotational type of injury
Each of these subdivided into three subgroups. At present Denis and
21 Common pattern of fractures
The most common fracture patterns at the thoracolumbar junctioninclude
1.Anterior wedge compression fractures
2.Burst fractures ( stable ,unstable)
3.Flexion-distractioninjuries ( chance fractures)
4.Fracture- subluxation and dislocations.
Anterior wedge Compression Fractures :
It occurs when vertebral body fails under axial loading.
The anteriorspinal column goes failure in compression, while the middle columnis
not involved. The posterior column may remain intact or failin tension, depending
on the energy level of the injury. They are usually not associated with neurological
deficit .But it can occur when multiple adjacent level fractured .[6]
This type of fracture can be easily diagnosedon plain radiographs and with
CT scan. On lateral plain radiographs, it is seen as a wedge-shaped vertebra with
22
height of injured vertebral body should be measured and compared with those at
the more cephaladand caudal levels.
These type of compression fractures are considered stable, and can
therefore be treated non-operatively. In the setting of normal neurologic function,
vertebral body height loss and kyphosis have been used as radiologic parameters to
assess the degree of injury. Patients with fractures exhibiting minimal height loss
(less than 10%) can usually be safely mobilized without the use of a brace or an
external support. Most practitioners consider a compression or wedge fracture with
less than 30% or 40% of vertebral body height loss and < 20 degrees to 25 degrees
of kyphosis to be inherently stable. So they can be treated in brace. A Jewett
hyperextension brace is applied for 6 to 8 weeks. Standing x-rays in the brace
should be obtained both initially and at regular follow-up visits to monitor fracture
23
If the height loss is > 50% or more than 30 degrees of kyphosis in
non-osteoporotic bone strongly suggests the possibility of PLC disruption, which places
the patient at risk of increasing kyphotic deformity or neurologic deficit.
Inter-spinous widening on lateral x-rays may strengthen this suspicion, and give cause
for concern if non-operative management is used. In such cases, posterior
stabilization is usually recommended.[28]
Burst fractures :
Because of high energy axial load that results in compression failure of
anterior and middle spinal column. The sudden application of high energy axial
load will cause vertebral end plate failure and adjacent disc tissue will be driven
into the fractured vertebral body. Most of the time fragments will be retropulsed
into the spinal canal which will cause the neurological deficit. Like
compressionfractures, burst fractures are more common in thoracolumbar spinal
segments.[28]
Denis further classified burst fracture into, a type-A fracture involves failure
of both the superiorand the inferior end plate, type B involves failure of the
24
results in an axial loading and rotational injury,and type E results in an axial
loading and lateral flexion injury.Type B is the most frequent fracture pattern,
followed by typeA. The other types are relatively rare. [5,6]
Most of the burst fractures are having some degree of spinal canal
compromise due to retropulsionof any bony fragment.The initial radiographic
evaluation should include assessmentof vertebral body height loss and the kyphosis
angle on lateralradiographs as well as the interpedicular distanceon anteroposterior
radiographs . Computedtomography imaging is useful for measuring thecanal
diameter. Magnetic resonance imaging is recommendedfor patients with a
neurological deficit. It is very useful to identify spinal cord or cauda equina injury,
25
The patient should be immobilized in Thoracic Lumbar Sacral Orthosis
(TLSO). Patient should be followed up by taking X-rays and MRI at every 2
weeks. The TLSO brace should be worn for atleast 2–3 months. The patient should
undergo physical therapy to strengthen weakened muscles. Once the fracture and
any associated neurological injuries havebeen characterized, spinal stability must
be evaluated. [39,41]
Several different systems for determining clinicalspinal stability, including
complicated point systems and checklists, havebeen proposed. Determinantsof
burst fracture instability common to these systems includea progressive
neurological deficit,>50% loss of vertebral body height in association with
substantial kyphosis, radiographicevidence of substantial posterior column injury
andprogressive kyphosis. These fractures may be treated non operatively, but late
progression of kyphosisand spinal stenosis tend to develop.[5]
Flexion-Distraction Injury:
In this type of flexion distraction or Chance fractures the primary vector
force acting anterior to the middle column. Middle and posterior column will go
26
compression depends on the location of the axis of rotation either at or anterior to
the anterior column. They may be purely ligamentous, purely osseous or a
combination of both. This type of injuries are more common in motor vehicle
accident while using seatbelt. An extremely high rateof intra-abdominal injury
(45%) has been observed in associationwith this injury pattern. So the abdominal
examination is important for this patient. Overall, the riskof substantial
neurological injury in association with a flexion-distractioninjury is 10% to 15%.
Conversely, the presence of the hallmark transabdominal or anterior chest wall
band of ecchymosis in conjunction with an intra-abdominal injury should highlight
the strong possibility of an underlying spinal injury. Even with careful evaluation,
the diagnosis is often missed or delayed. Abdominal evaluation should include CT
scanning, ultrasound and/or deep peritoneal lavage. Laparotomy with intestinal
repair and/or staged diversion takes precedence over spinal injuries, as it is a
life-saving procedure. Strict spinal precautions should be maintained at all times,
however, to avoid further displacement and potentially neurologic decline when a
patient has a flexion-distraction injury and a neurologicalinjury. Magnetic
resonance imaging is useful for identifyingongoing neural element compression
and to rule out an epiduralhematoma. A computed tomography scan with sagittal
27
there is no comminution of the middle spinal column. Thisdistinction is important
when planning surgical treatment, asthe compression forces that would be
necessary to reduce a flexion-distraction injurymay be contraindicated if the
middle column is disrupted inorder to prevent middle column retropulsion. The
magnetic resonanceimages and computed tomography scans with sagittal
reconstructionare also valuable for identifying injury involved eitherbone or
ligamentous, as this determines the likelihood of theinjury healing in a brace. The
selection and timingof treatment depend in part on the presence of associated
intraabdominalinjuries as well as on the neurological profile.[28]
There are few indications for non-operative management of
flexion-distraction injuries of the thoracolumbar spine. Some injuries occur primarily
through bone. In this setting, provided that the fracture can be reduced and
28
treatment can be effective. Anderson et al recommended that nonsurgical treatment
should be attempted in neurologically intact patients with less 15 degrees of
kyphosis provided the injury is primarily bony. X-ray follow-up should be frequent
to ensure that the reduction is maintained. External immobilization is
recommended for a minimum of 3 months. But most of the flexion-distraction
injuries need surgical stabilization.[24]
Fracture –Dislocation:
Fracture-dislocations are high energy injuries due to complex shearing force.
These are extremely unstable and involve disruption of all the three spinal
columns. Usually it is associated with complete neurological deficit.
They are easily recognized on plain radiographs. Any horizontal translation
or rotation through the injury level should raise the suspicion that a
fracture-dislocation is present. Computed tomography is useful for planning surgical
treatment as it identifies incompetent osseous structures and aids in the selection of
the implant size. In the less common case of an incomplete neurologicalinjury,
magnetic resonance imaging should be performed to characterize ongoing neural
29 SPINAL CORD INJURIES
It varies from complete cord injury to incomplete one.
Incomplete Spinal Cord Injury:
An incomplete spinal cord injury means some amount of
neurology is intact below the injury site. It is important as (1) the greater the
sparing of motor and sensory functions distal to the injury, the greater the expected
recovery; (2) the more rapid the recovery, the greater the amount of recovery; and
(3) when new recovery ceases and a plateau is reached, no further recovery can be
expected . It is described below as
• Spinal contusions
Spinal contusion is the commonest type of cord injury. Cord is just
contused but not severed due to inflammation and bleeding near the injury.
The most common type of spinal cord injury. It will result in temporary block
30 • Anterior cord syndrome
It is due to damage to the anterior areas of spinal cord which results in
compete motor loss and loss of temperature and pain. It occurs mostly in hyper
flexion injuries which leads to bony or disc fragments compressing the anterior
spinal artery. Deep touch, position sense, and vibratory sensation is preserved.
Prognosis for recovery is bad.
• Posterior cord syndrome
It commonly occurs in extension type of injuries. It affects the posterior
column of the cord. So it results in loss of deep touch and vibration sense and
position sense. This syndrome is rare.
• Brown-Sequard syndrome-
Sensation and movement are lost on same side but pain and temperature
will be lost on opposite side of the bodybelow the level of injury . It occurs
31 • Mixed syndrome
Usually it is a combination of several syndromes. It describes the
small percentage of incomplete spinal cord injuries that do not fit one of the
previously described syndromes
• Conus medullaris syndrome
This type of syndrome occurs when injury happened between T11 and L2
because cord ends at L1. So Injury to the sacral cord or conus and lumbar
nerve roots occur. It results in bladder and bowel areflexia, and motor loss of
lower extremities. Bulbocavernous reflex and perianal wink will be absent.
Motor function may be spared some times between L1 and L4 if nerve roots
are escaped from the injury.
• Cauda equina syndrome,
It is a lower motor neuron type of injury and incomplete one. It
occurs when injury occurs beyond L1 vertebra and injury between the
conus and the lumbosacral nerve roots. It will lead to areflexic bladder,
bowel, and asymmetry motor and sensory loss of lower limbs and absence of
bulbocavernosus reflex, anal wink and all modalities of reflex activity in the
32
Pre hospital care and Assessment in Emergency department:
Prehospital care
First aid is very important for any spine fractures. The short and long-term
outcomes for patients with a dorsolumbarspine fracture depends upon pre hospital
care. Extrication and transportation of trauma patientson a backboard and
adherence to Advanced Trauma Life Support(ATLS) protocols for resuscitation
have been credited for much of this improvement. Breathing and circulation should
be focused.
In hospital resuscitation
Hypotension and bradycardia indicates patient in spinal shock. So it should
be differentiated from hypovolemic shock. Fluid and oxygen therapy is important
in intial stage.
Examination of the patient
Examination should be done thoroughly and other injuries should be ruled
out. Examination of a patient with a possible spine fracture should begin with
visual inspection of the back. The presence and location of lacerations,
33
Palpation of the spine for localized tenderness,spinous process gaps, step-offs,and
34
The neurological examination is important for knowing the severity of injury
as well as deciding the treatment option. It should include assessment of
spinalcord function as well as assessment of nerve root and peripheralnerve
integrity. The spinal cord terminates as conus medullaris atL1 vertebral body in
adults sometimes it may extend upto L2 vertebra. So it varies from damage to the
terminal spinal cord, conus medullaris, cauda equina, and thoracolumbar nerve
roots. Radiculopathy is identified by a dermatomal patternof paresthesias or
sensory alterations with or without myotomal weakness and hyporeflexia. A more
diffuse distribution of lower-extremity paresthesias, weakness, and reflex loss may
signify acute injuryto the cauda equina, conus medullaris, or spinal cord. The
bulbocavernosusreflex should be evaluated to assess for spinal shock. In
theabsence of this reflex, loss of sensorimotor function may be temporarily due to
spinal shock and may not necessarily reflect a complete neurological injury. The
presence of rectal tone and perineal pinprick sensation is very important for
diagnosing incomplete involvement the cord as well as for prognostic purposes
too. [36]
Role of steroids
All patients with a confirmed spinal cord injury should receive a high dose
35
hour and continued at an infusionat a rate of 5.4 mg/kg/hr according to NASCIS
protocol. [28]
Spinal cord injury grading
Frankel system and the American Spinal Injury Association (ASIA) are
commonly used for grading spinal cord injury.It plays a major role in determining
treatment and ultimate prognosis for manypatients following thoracolumbar spinal
36 RADIOGRAPHIC-EVALUATION:
PLAIN XRAYS
Atleast two views should be taken. Anteroposterior and lateral radiographs
of the cervical, thoracic,and lumbar spine should be taken. Because of the high
prevalence of contiguous and noncontiguous associated spinal fractures,
comprehensive radiographic evaluation,including the entire cervical, thoracic,
37
high-energyinjury and in whom a spinal injury is suspected. In AP view we have to
look interpedicular distance and inter spinous distance. Coronal translational
deformity should be looked. In lateral view posterior vertebral line and sagittal
malalignment and vertebral body height and Cobbs angle should be seen.
COMPUTED TOMOGRAPHY
Computed tomography will give fine details about bony injuries. CT
scanning is the next step afterplain radiographic evaluation. Axial fine cuts and
sagittalsections are useful for identifying fracture patterns and the degree of
compromise of the spinal canal. The canal diameter of the fractured vertebra
should be measured. It will give details about vertebral body comminution.
MAGNETIC RESONANCE IMAGING
MRI is very important for identifying cord involvement and ligamentous
complex involvement. It will give fine details about canal compromise and cord
changes and epidural hematomas. And it will give details about PLC integrity. It is
flexion-38
distractioninjury. When a patient has a neurologicaldeficit, however, magnetic
resonance imaging is recommendedto identify any ongoing spinal cord
compression, evaluate cordanatomy.[18]
TREATMENT :
The treatment goal in spinal fractures is to mobilise the patient early and to
obtain stable vertebral column with maximum spine mobility and good
neurological function. The most important factors to consider the treatmentfor
patients are general condition , neurologicalstatus, spinal stability, degree of
deformity, and associatedinjuries. Recently Vaccaro score is very useful to decide
39
Thoracolumbar Injury Classifcation and severity Score (TLICS score, Vaccaro score):
• FRACTURE MECHANISM
Compression fracture 1
Burst 2
Translation 3
Distraction 4
• NEUROLOGICAL INVOLEMENT
Intact 0
Nerve root 2
Cord,conus medullaris,incomplete 3
Cord,conus medllaris,complete 2
Cauda equine 3
40
Intact 0
Injury suspected/indeterminate 2
Injured 3
1.Score less than 3 –it is a stable fracture so it can be treated conservatively
2.Score 5 or more –it is a unstable one. So it should be treated surgically.
3.Score 4- conservative or operative
Non operative treatment:
Until 1970 non-operative treatment was used for spine fractures. Patients
were treated by distraction, and reduction and rest on scamnum (low bench).Non
operative treatment usually consists of bed rest, postural reduction, direct
mobilization , ambulatory bracing and combination of these.
Most of the compression fractures are stable injuries treated nonoperatively
in a thoracolumbar orthosis for approximately twelve weeks. Burst fractures are
more unstable with some degree of canal compromise. The amount of collapse of
41
factors to decide the treatment whether surgical or non-surgical .Neurological
worsening with substantial canal compromise often needs surgical decompression
and stabilization. [45]
The treatment of flexion-distraction injuries largely depends on the
predominant type of tissue injury.Pure Chance fractures with only bony
involvement often will heal reliably if immobilized in a hyperextension orthosis,
especially in an immature patient. But ligamentous involvement needs surgical
stabilization. Fracture –Dislocation injuries are highly unstable. It needs surgical
stabilization.
Nonoperative treatment - advantages:
The principal advantage are the avoidance of operative morbidity, including
postoperative infection, iatrogenic neurological injury, failure of instrumentation,
and complications related to anesthesia. Secondary issues include deformity
correction, minimizing motion loss,and facilitating rapid rehabilitation.
Conservative methods can be used in stable injuries with intact neurology.
The patient should be followed up regularly to identify any instability or worsening
of neurology. In cases of neurological deficit and unstable fractures surgical
42 Surgical management:
Treatment is based on considering several factors . The patient's age,
general health, occupation, lifestyle and body habitus are integral to obtain a
satisfactory outcome. Most of the young patients needs aggressive surgical
treatment due to high energy trauma.
There are three surgical approaches for dorsolumbar spine fractures.
Anterior and posterior as well as combined surgical approaches.
Anterior instrumentation can be done for most compression and burst
fractures limited to the anterior and middle columns without involvement of the
posterior column. But surgical related complications are high. Morbidity and
mortality is high.
A posterior approach with instrumentation fromtwo or three levels cephalad
to the injury to two levels caudad to (long segment fixation) it is an acceptable
alternative procedure, but it involves fusing a more extensive portion of the spine.
A posterior short-segment fusion with instrumentation and utilization of pedicle
screw fixation from one level cephalad to the injury to one level caudal to it is the
recent concept for treating spine fractures. In the presence of three column
43
of iatrogenic spinalstability. Because of the nature of instability
,fracture-dislocations and flexion-distraction injuries are best approached from the back
initially, with posterior stabilization, followed by an anterior decompression and
reconstruction if needed.[28]
If there is complete neurological injury, surgery is recommended to provide
immediate spinal stability, and facilitating more rapid rehabilitation. In this case,
posterior approach is the ideal one with the goal of restoring sagittal and coronal
alignment and stability.
Neural Decompression:
There are several types of decompression.
1.Direct anterior decompression
2. Posterior decompression
A) Indirect posterior decompression by ligamentotaxis
B) Postero lateral decompression ( transpedicular, costotransversectomy)
44
Spinal canal decompression needed whenthere is neural compression and
neurological deficit with spine fractures. Although the extent of canal compromise
at the time of the initial evaluation has been associated in some studies with the
severity of theneurological deficit, the timing of surgical decompression hasnot
been well correlated with the degree of neurological recovery. [36]
However, most investigators agreethat progressive neurological
deterioration is an indication for surgical intervention.Many surgeons also
recommend surgical decompression for a patientwith a stable incomplete
neurological deficit when there isevidence of ongoing compression of the neural
elements. In most of the patients, the site of the neural compressionis located
anteriorly, so anterior approach is the ideal one. Laminectomy alone further
disrupts theposterior supporting spinal elements, which leads to
additionalinstability at the fracture site so failure rate is high.
Sometimes posterolateral or transpedicular approach may be employed to
gain access to compressing anterior bonefragments through the posterior approach.
A posterior surgical approach may be used in certain cases to indirectly
decompress the spinal canal through distraction instrumentation and
45
based on the integrity of Sharpey fibers or annular ligament attachments to the
displaced fracture fragments. By means of posterior instrumentation, the
distraction force will reduce the fragment from the canal into the vertebral body.
sometimes posterior distraction also tends to aggravate any preexisting
kyphosis.The efficacy of indirect decompression is greater when surgeryis
performed within 72 hours after the traumatic event. This technique may be less
effective in the setting of canal compromiseof >70%, which is associated with a
higher prevalence ofannular ligament disruption. By transpedicular decompression,
anterior vertebral body can be addressed very well.[28,24]
Stabilization :
Most of the unstable thoracolumbar fractures needs surgical stabilization. The
goal is to get a stable spine for early mobilization and early rehabilitation. It
consists of either
1. long segment spanning fixation
2. short segment with index vertebra fixation
The advantages of early surgical stabilization of unstable fractures will give
improved fracture reduction, preservation of neurological function, early
46
Early fusion techniques with Harrington hook and rod constructs were
suboptimal because of length of fusion from five or six motion segments and they
are also less reliable in the middle and lower lumbar regions.the long with short
fusion techniques were developed to reduce number of motion segments requiring
fusion.it involves fusing the two level which are adjacent to fractured vertebra
while spanning cephalad and caudad levels with pedicle screws.but the results
were poor due to arthritic changes of unfused segments and progressive kyphosis
following rod removal and reappearance of pain.hence this technique has fallen out
of favour and fixation without fusion is recommended as a routine.[13,15]
The modern pedicle screw-basedsystems allow more reliable rigid fixation
.Long segment spanning fixation(by fixing two levels above and two levels below
the fracture site) can be done which provides good stability .As
previouslymentioned, short-segment fixation with pedicle screw
instrumentation(from a level cephalad to the fracture site to a level caudad to it) is
a recent concept to preserve the motion.Short segment with index vertebra fixation
is inclusion of fracture vertebra which helps in achieving better intra-operative
reduction of deformity,does not interfere with fracture healing,maintains the
reduction and associated with low failure rates.
47
METHODOLOGY
AIM:
• To compare the results of functional outcome in thoracolumbar fractures and
dislocations fixed with short segment with index vertebra fixation and long
segment spanning fixation.
OBJECTIVE:
• To analyse and compare the results of functional outcome in thoracolumbar
fractures and dislocations fixed with long segment spanning fixation and
short segment with index vertebra fixation
• To facilitate early mobilisation of patients and thus helping easy nursing
care of patients in order to provide a stable and pain free spinal column.
48 INCLUSION CRITERIA:
• Patients with age 20 – 60 yrs
• Patients with TLICS(thoracolumbar injury classification and severity score) score>4
• Patients with AO classification type A4 and C2
EXCLUSION CRITERIA:
•
Patients with age <20 and >60 yrs
•
Patients with co-morbid conditions not permitting for surgery
•
Patients with associated injuries like pelvic injury, head injury.
MATERIALS & METHODS
The prospective study was done in patients with Post Traumatic
dorsolumbar fractures and dislocations in the Department of Orthopaedics,
Madurai Medical College & Govt. Rajaji Hospital, TamilNadu. Twenty five
49
followed for a period of 12 months.Of these four patients were lost followup and
hence twenty one cases were included in the study and followed for a period of 1
year.
First assessment of a patient included the history of injury, the mode of
injury, a thorough clinical and neurological examination, and status of the stability.
Then, priorities included resuscitation of patient, and treatment of life-threatening
injuries before stabilization of the spinal injuries.
The skeletal system was examined to rule out associated injuries. The
patient's spine was examined for any swelling, contusion, tenderness, haematoma,
gibbus or step off. Full neurological examination (sensation, motor, anal tone)was
done and documented. Protection of the spinal column was given immediately.
Daily neurological examination was done. Pattern & level of neurological injury
were identified and noted.
Antero posterior and lateral plain X rays, CT scans, and MRI were taken to
50
and pedicle were identified in CT scan. Soft tissue injuries and cord changes were
identified in MRI. The level and type of fractures were classified according to AO
Magrel classification and ThoracoLumabar Injury Classification Score (TLICS)
was calculated.The indications for surgical intervention were TLICS score more
than four.
The patient and his/her relatives were explained in detail about the nature of
injury, severity of injury, the possible outcomes of non-surgical/surgical
management and the importance of rehabilitation.
The patients under the effect of general anesthesia were positioned on the
prone position and antero-posterior & lateral c-arm views were taken to determine
the direction of the pedicles, end plates and disc spaces. All patient underwent
either short segment posterior stabilization with index vertebra fixation or long
51
52
SURGICAL TECHNIQUE
All patients were placed in prone position over radiolucent table. A standard posterior midline approach was used for exposure. For short segment with index
vertebra fixation,Pedicle screws were inserted into the vertebra one level above and below the fractured vertebra and pedicle screw inserted at the fracture site under fluoroscopic control at the intersection point of transverse process and facet
joint.
For long segment spanning fixation, Pedicle screws were inserted into the
vertebra two levels above and two levels below the fractured vertebra under fluoroscopic control at the intersection point of transverse process and facet joint.
End on view is obtained under image intensifier to verify that the screw is
53
After long segment spanning posterior instrumentation with transpedicular screws and rod
After skin closure
54 POST OPERATIVE PROTOCOL
• On the second postoperative day, Patients were encouraged to sit upright
with brace support
• 3rd POD – 1st EOT , 6th POD-2nd EOT, 9th POD – 3rd EOT
• 11th POD- suture removal done
• In neurological deficit patients ,Bladder , bowel and back care done.
• Initial 3months – Mobilisation with brace , increasing the activities
gradually
• After 3 months – patient can resume his routine activities
For functional assessment , Modified macnab’s criteria and Oswestry
disability index used in all patients pre operatively , immediate post op , 3rd month
55
Modified macnab’s criteria
Excellent:
no pain,no restriction of mobility,return to normal work and
level of activity
Good:
occasional non radicular pain ,relief of presenting symptoms,able
to return to modified work
Fair:
some improved functional capacity,still handicapped and/or
unemployed
Poor:
continued objective symptoms of root involvement,additional
operative intervention needed at index level irrespective of length of
postoperative followup
Oswetry disability index
Section 1 – Pain intensity
I have no pain at the moment
The pain is very mild at the moment
The pain is moderate at the moment
The pain is fairly severe at the moment
The pain is very severe at the moment
The pain is the worst imaginable at the moment
56
I can look after myself normally without causing extra pain
I can look after myself normally but it causes extra pain
It is painful to look after myself and I am slow and careful
I need some help but manage most of my personal care
I need help every day in most aspects of self-care
I do not get dressed, I wash with difficulty and stay in bed
Section 3 – Lifting
I can lift heavy weights without extra pain
I can lift heavy weights but it gives extra pain
Pain prevents me from lifting heavy weights off the floor, but I
can manage if they are conveniently placed eg. on a table
Pain prevents me from lifting heavy weights, but I can manage
light to medium weights if they are conveniently positioned
I can lift very light weights
I cannot lift or carry anything at all
Section 4 – Walking*
Pain does not prevent me walking any distance
Pain prevents me from walking more than 1 mile
Pain prevents me from walking more than ½ mile
Pain prevents me from walking more than 100 yards
I can only walk using a stick or crutches
I am in bed most of the time
Section 5 – Sitting
57
I can only sit in my favourite chair as long as I like
Pain prevents me sitting more than one hour
Pain prevents me from sitting more than 30 minutes
Pain prevents me from sitting more than 10 minutes
Pain prevents me from sitting at all
Section 6 – Standing
I can stand as long as I want without extra pain
I can stand as long as I want but it gives me extra pain
Pain prevents me from standing for more than 1 hour
Pain prevents me from standing for more than 30 minutes
Pain prevents me from standing for more than 10 minutes
Pain prevents me from standing at all
Section 7 – Sleeping
My sleep is never disturbed by pain
My sleep is occasionally disturbed by pain
Because of pain I have less than 6 hours sleep
Because of pain I have less than 4 hours sleep
Because of pain I have less than 2 hours sleep
Pain prevents me from sleeping at all
Section 8 – Sex life (if applicable)
My sex life is normal and causes no extra pain
My sex life is normal but causes some extra pain
58
My sex life is severely restricted by pain
My sex life is nearly absent because of pain
Pain prevents any sex life at all
Section 9 – Social life
My social life is normal and gives me no extra pain
My social life is normal but increases the degree of pain
Pain has no significant effect on my social life apart from limiting my more energetic interests eg, sport
Pain has restricted my social life and I do not go out as often
Pain has restricted my social life to my home
I have no social life because of pain
Section 10 – Travelling
I can travel anywhere without pain
I can travel anywhere but it gives me extra pain
Pain is bad but I manage journeys over two hours
Pain restricts me to journeys of less than one hour
Pain restricts me to short necessary journeys under 30 minutes
59
INTERPRETATION OF RESULTS:
0% to 20%: minimal disability: The patient can cope with most living activities. Usually no treatment is indicated apart from advice
on lifting sitting and exercise.
21%-40%: moderate disability: The patient experiences more pain and difficulty with sitting, lifting and standing. Travel and social
life are more difficult and they may be disabled from
work. Personal care, sexual activity and sleeping
are not grossly affected and the patient can usually
be managed by conservative means.
41%-60%: severe disability: Pain remains the main problem in this group but activities of daily living are affected. These patients
require a detailed investigation.
61%-80%: crippled: Back pain impinges on all aspects of the patient's life. Positive intervention is required.
60
OBSERVATION AND RESULTS:
I.AGE DISTRIBUTION
In our study among 25 patients,highest number is seen in the
age between 36-45 years(40%) ,followed by 28% in the age <25
years and 24% between 26-35 years.
7
6
10
2
0
2
4
6
8
10
12
< 25
26 - 35
36 - 50
> 50
AGE DISTRIBUTION
61
Age in years Long Percentage Short Percentage
< 25 2 15.3% 5 41.6%
26 - 35 5 38.4% 1 8.3%
36 - 50 4 30.7% 6 50%
> 50 2 15.3% 0 0%
Total 13 100 12 100
0 1 2 3 4 5 6
< 25 26 - 35 36 - 50 > 50 2
5
4
2 5
1
6
0 AGE VS PROCEDURE
62
II.SEX DISTRIBUTION
In our study,almost 88% of the cases(22 patients) were
males and only 3patients(12%)were females.
Sex No.of cases
Percentage
Male 22 88%
Female 3 12%
Total 25 100
22
3
SEX DISTRIBUTION
63
0
2
4
6
8
10
12
Male
Female
12
1
10
2
GENDER VS PROCEDURE
Long
Short
Sex Long Percentage Short Percentage
Male 12 92.3% 10 83.33%
Female 1 7.6% 2 16.66%
64
III.MODE OF INJURY
In our study,most common mechanism of injury is fall
from height which constitutes almost 92%(22 patients)of
the patients followed by RTA in 8% of cases.
Mode of Injury No.of cases Percentage Fall from Height 23 92%
RTA 2 8%
Total 25 100
23
2
MODE OF INJURY
65
IV.DIAGNOSIS
In our study,most commonly seen fracture pattern is
burst fractures which is een in 52% (13 patients)of the
cases and followed by fracture dislocation in 12 cases(48%).
10
11
12
13
14
15
16
Dislocation
Burst
12
13
DIAGNOSIS
No.of cases
Diagnosis No.of cases Percentage
Dislocation 12 48%
Burst 13 52%
66
V.VERTEBRAL LEVEL
In our study,D12 and L1 level was the most common
vertebral level involved comprising almost 64% of cases.
Diagnosis No.of cases Percentage
D10 - D 11 3 12%
D 11 1 4%
D11 - 12 3 12%
D 12 6 24%
D12 - L1 5 20%
L1 5 20%
L2 1 4%
L2 - L3 1 4%
Total 25 100
0 1 2 3 4 5 6 D10 -D 11
D 11 D11 -12
D 12 D12 -L1
L1 L2 L2 - L3
67
VI.AO TYPE
In our study,according to AO classification A4(complete
burst)was the most common type which accounted for 52%
of cases.
10 11 12 13 14 15
A4 C2
13
12 AO TYPE
No.of cases
AO Type No.of cases Percentage
A4 13 52%
C2 12 48%
68
VII.TLICS SCORE
In our study, thoracolumbar injury severity score of 7
and 8 constituted 80% of the cases.
0
5
10
T5 &
6
7
8
T9
4
10
10
1
TLICS
No.of cases
TLICS No.of cases Percentage
5 2 8%
6 2 8%
7 10 40%
8 10 40%
T9 1 4%
69
VIII.PROCEDURE
In our study,long segment was done in 13 cases and
short segment was done in 12 cases.
10 11 12 13 14 15
Long Short 13
12 PROCEDURE DONE
No.of cases
Procedure Done No.of cases Percentage
Long 13 52%
Short 12 48%
70
IX.MODIFIED MACNAB CRITERIA
In our study,in long segment 72.7% of the patients were
good(8 cases) and in short segment 70% of the cases were good(7
cases).In long segment,27.7% of the patients were fair(3 cases) and
in short segment 30% of the cases were fair(3 cases).
MODIFIED MACNAB CRITERIA AT
FINAL FOLLOWUP Good
Percentage
Fair
Percentage Lost followup
Long 8 72.7% 3 27.27% 2
Short 7 70% 3 30% 2
Total 15 100 6 100 4
71
8
3
2 7
3
2
0 1 2 3 4 5 6 7 8 9
Good Fair Lost followup MODIFIED MACNAB CRITERIA AT FINAL
FOLLOWUP
72
X.OSWESTRY DISABILITY INDEX
In our study,the mean of oswestry disability index in
long segment is 32.31 and mean in short segment is 31.99.P
VALUE is 0.956 which is not significant
OSWESTRY DISABILITY INDEX AT FINAL
FOLLOWUP Mean SD p value
Long 32.31 12.04
Short 31.99 13.78 0.956
Not significant
28 29 30 31 32 33 34 35
Long Short 32.31 31.99
OSWESTRY DISABILITY INDEX AT FINAL FOLLOWUP
73 XI.COMPLICATIONS
In our study, among the 25 patients , one patient had rod
breakage but the patient had no pain and no neurological deficit
and functional outcome is good. Patient resumed his activities.
One patient had superficial wound infection which was treated
with antibiotics and dressing. Among the patients with
neurological deficit, no patient had bed sore. Remaining 23
patients had no complications.
0
1
2
Long
Short
2
0
COMPLICATIONS
No.of cases
Complications No.of cases
Long 2(18.1%)
Short 0
p value 2 / 13 vs 0/12
74 AGE/SEX:50/M
DIAGNOSIS:D12 BURST# PROCEDURE:LONG SEGMENT TLICS:7 FUNCTIONAL OUTCOME:GOOD
D
Case 1(S.NO 7)
PREOP XRAY
CT
IMMEDIATE POSTOP XRAY
MRI
75
FUNCTIONAL OUTCOME AT FOLLOWUP FINAL FOLLOWUP
76 PREOP XRAY
CT
MRI
IMMEDIATE POSTOP AGE/SEX:65/M
DIAGNOSIS:D10-D11 #DISLOCATION PROCEDURE:LONG SEGMENT TLICS:8 FUNCTIONAL OUTCOME:GOOD
77
AT FINAL FOLLOWUP
78
Case 3(S.NO 1)
AGE/SEX:28/M
79
PREOP XRAY CT MRI
AT FINAL FOLLOWUP
80
Case 4(S.NO 24)
FUNCTIONAL OUTCOME AT FINAL FOLLOWUP
AGE/SEX:25/M
DIAGNOSIS:D12 BURST# PROCEDURE:SHORT SEGMENT
TLICS:7 FUNCTIONAL OUTCOME:GOOD
81 CT
IMMEDIATE POSTOP
82
Case 5(S.NO.19)
FUNCTIONAL OUTCOME AT FINAL FOLLOWUP
AGE/SEX:45/M
DIAGNOSIS:L1 BURST# PROCEDURE:SHORT SEGMENT
83 PREOP XRAY
CT
MRI
84
AGE/SEX:45/M
DIAGNOSIS:D12 BURST # PROCEDURE:SHORT SEGMENT AT FINAL FOLLOWUP
FUNCTIONAL OUTCOME AT FINAL FOLLOWUP
85
TLICS: 5 FUNCTIONAL OUTCOME: GOOD
MRI
IMMEDIATE POSTOP
86 AGE/SEX:43/M
DIAGNOSIS:D10-D11#DISLOCATION PROCEDURE:LONG SEGMENT FUNCTIONAL OUTCOME AT FINAL FOLLOWUP
87
TLICS: 8 FUNCTIONAL OUTCOME:FAIR
CT
MRI
IMMEDIATE POSTOP
88 AGE/SEX:30/M
DIAGNOSIS:L2-L3 #DISLOCATION PROCEDURE:LONG SEGMENT TLICS: 9 FUNCTIONAL OUTCOME: FAIR
FUNCTIONAL OUTCOME AT FINAL FOLLOWUP
89
CT
90 AGE/SEX:20/M
FUNCTIONAL OUTCOME AT FINAL FOLLOWUP
91
DIAGNOSIS:D12 BURST # PROCEDURE:SHORT SEGMENT TLICS: 6 FUNCTIONAL OUTCOME:GOOD
CT MRI
92 Case 10(S.NO 12)
AT FIN AL FOLLOWUP
93 AGE/SEX:32/M
DIAGNOSIS:D12 BURST# PROCEDURE:SHORT SEGMENT TLICS: 7 FUNCTIONAL OUTCOME: FAIR
PREOP
XRAY
CT
94
AT FINAL FOLLOWUP
95
DISCUSSION
The dorsolumbar injuries of the spine are the most common in whole of
spinal trauma.The anatomy of the Dorsolumbar spine makes it highly vulnerable to
high-energy trauma associated with motor-vehicle accidents and falls .Main
objectives of initial evaluation and diagnosis include injury characterization and
identifying any neurological deficit. The goal of treatment is to obtain pain free
stable spine and maximum restoration of function.
Thoracolumbar junction is the commonest site of the spinal injuries with
52% occurring between T11 & L1 (Burgoss et al 1988;krauss et al 1975).
Spinal injuries are more common in younger individuals. They are most
commonly caused by fall from height and motor vehicle accidents (Carpenter et al
1991). More common in sports activities in adolescents (Hubard et al 1974). Four
fold increased risk is seen in males than females in many of the studies.
Depending on the type of spinal injury, associated spinal and non spinal
96
thoracic injuries in 20% of patients while intra abdominal injuries in 10% patients
and associated skeletal injuries in upto 20% of the patients. In our study,calcaneal
fractures were most commonly seen.
Transpedicular screws and rod system is currently the standard in fixation
of thoracolumbar spine. Long segment spanning fixation with two levels above and
below the fracture is a method which provides good stability but motion between
adjacent segments cannot be preserved.Posterior surgery with a short segment
stabilization allows early mobilization. Posterior surgery corrects deformity but
post operative vertebral collapse common , which leads to post surgical kyphosis.
To prevent this, inclusion of fractured vertebra in short segment fixation is done. In our series,patients underwent either posterior short segment fixation with inclusion of fractured vertebra or long segment spanning fixation with two level
above and below the fracture. Ligamentotaxis was done in all fractures and
dislocations with intact neurology utilizing the partially intact posterior
ligamentous complex(PLC). Posterior decompression was done in patients with
neurological deficit. In our study ,we have not encountered loss of kyphotic
97
Post-operative ASIA grade improved in patients with incomplete paraplegia
at three months after surgery which were comparable with most of the
studies.There was no new onset or deterioration of neurological deficit .
Radiologically,mean kyphotic angle in long segment group preoperatively
was 26.8 degrees which was reduced to 5.84 degrees postoperatively and mean
kyphotic angle in short segment group preoperatively was 21.4 degrees which was
reduced to 4.75 degrees.But there was loss of kyphotic correction in long segment
group during followup.
Posterior transpedicular screw fixation initially was reported by Boucher in
1959. Since then, modern instrumentation systems have been developed. These
systems control segmental motions in three dimensions, preserve motion segments,
avoid long fusions, and provide a more stable construct .Short-segment posterior
fixation is the most common and simple treatment, offering the advantage of
incorporating fewer motion segments in the fusion . A review of the literature
showed that Short-segment posterior fixation alone led upto 54% incidence of
implant failure and re-kyphosis in the long-term follow-up, and 50% of the patients
with implant failure had moderate-to-severe pain. To prevent this, several
techniques have been developed like short segment with inclusion of fracture
98
Altay et al.(2007) reported that use of four pairs of screws (two above and two below) to lengthen the level arm of the construct would probably not only
enhance the stability but also allow effective reduction of kyphotic deformity.[61].
Tezeren and Kuru(2005) , in their study comparing short segment versus long segment fixation in thoracolumbar burst fractures, demonstrated that long segment
instrumentation is an effective way to manage thoracolumbar burst fractures.
However, long segment instrumentation prolonged the operative time and
increased the amount of blood loss significantl[32]. In our study,Operative time
and amount of blood loss is increased in long segment fixation well comparable to
the above study.
Carl et al.(1992) also reported that segmental transpedicular fixation two levels above the kyphosis should be used at the thoracolumbar junction where
compressive forces act more anteriorly. Therefore, they prefered to put the pedicle
screw two levels above the fracture site in order to prevent progressive kyphosis as
well as hard ware failure. On the other hand preferring one level fixation distal to
fracture site was to preserve the motion segment as much as possible in the lumbar
99
Butt et al.(2007) , reported success of short segm
