[Delayed indications for additive ventral treatment of thoracolumbar burst fractures : What correction loss is to be expected]. / Zeitverzögerte Indikationsstellung zur additiv ventralen Versorgung thorakolumbaler Berstungsfrakturen : Welcher Korrekturverlust ist zu erwarten.

INTRODUCTION: There is a general consensus that unstable vertebral body fractures of the thoracolumbar junction with a B type fracture or a high load shear index need to be surgically stabilized, primarily by a dorsal approach. The authors believe that there are indications for an additional ventral spondylodesis in cases of reduction loss or a relevant intervertebral disc lesion in magnetic resonance imaging (MRI) 6 weeks after dorsal stabilization. However, in cases of unstable vertebral fractures it remains unclear if a delayed anterior spondylodesis will lead to unacceptable loss of initial reduction. MATERIAL AND METHODS: A total of 59 patients were included in this study during 2013 and 2014. All patients suffered from a traumatic vertebral fracture of the thoracolumbar junction and were initially treated with a dorsal short segment stabilization. All vertebral body fractures had a load shear index of at least 5 or were B type fractures. An x-ray control was carried out after 2 and 6 weeks and MRI was additionally performed after 6 weeks. An additional ventral spondylodesis was recommended in patients showing a reduction loss of at least 5° and in patients with relevant intervertebral disc lesions. The extent of the reduction loss was analyzed. Other parameters of interest were the fracture level, fracture classification, patient age and surgical technique (e.g. implant, index screw, laminectomy and cement augmentation). RESULTS: The patient collective consisted of 23 women and 36 men (average age 51 years ± 17 years). The mean reduction loss was 5.1° (± 5.2°) after a mean follow-up of 60 days (± 56 days). The reduction loss was significantly higher when polyaxial implants were used compared to monoaxial dorsal fixators (10.8° versus 4.0°, p < 0.001). There was a significantly higher reduction loss in those patients who received a laminectomy (11.3° versus 4.3°, p = 0.01) but there were no significant differences if an index screw was used (4.5° versus 5.3°). Additionally, there was a significantly lower reduction in the subgroup of patients 60 years or older who were stabilized using cement-augmented screws (3.9° versus 11.3°, p = 0.02). The mean reduction loss was 2.8° (± 2.5°) in patients treated with a monoaxial implant, cement-augmented if 60 years or older and without laminectomy (n = 39). There was no significant correlation between reduction loss and the other parameters of interest, such as fracture morphology with classification according to the working group on questions of osteosynthesis (AO) and McCormack or fracture level. CONCLUSION: Delayed indications for an additional ventral spondylodesis in patients with unstable thoracolumbar vertebral fractures and initial dorsal stabilization will cause no relevant reduction loss if monoaxial implants are used and laminectomy can be avoided. Additionally, cement augmentation of the pedicle screws seems to be beneficial in patients 60 years of age or older.

[Incomplete cranial burst fracture in the thoracolumbar junction. Results 6 years after thoracoscopic monosegmental spondylodesis]. / Kraniale inkomplette Berstungsfraktur im thorakolumbalen Übergang. 6-Jahres-Ergebnisse nach thorakoskopischer monosegmentaler Spondylodese.

INTRODUCTION: Ventral thoracoscopic spondylodesis of the thoracolumbar spine is an elegant treatment strategy. MATERIAL AND METHODS: In the years 2002 and 2003 a total of 16 patients with incomplete cranial burst fractures were treated by ventral thoracoscopic monosegmental spondylodesis and were included in this study prospectively. The data acquisition was done preoperatively, postoperatively and after 3, 6, 12 and 18 months. After 6 years a follow-up examination was performed in 13 of these patients (5 men and 8 women, average age 36.3 years, follow-up rate 81%) and 8 patients were treated ventrally only whereas 5 patients were treated dorsoventrally. RESULTS: The operative reduction of the kyphotic malalignment was superior in the dorsoventrally treated patients. The persistent gain of monosegmental correction after 6 years seemed to be higher in the patient group treated dorsoventrally. The average physical component summary (PSC) scores were comparable to a control group of the same age and revision surgery was performed in two patients both related to the iliac crest bone graft. CONCLUSIONS: The ventral and dorsoventral therapy strategies showed good and very good functional outcomes, respectively. The dorsoventral treatment concept secured a persistent gain of monosegmental correction which seemed to be superior compared to a ventral only therapy strategy.

[What is the effect of ventral thoracoscopic spondylodesis (VTS) on elderly patients and what is the medium-term outcome?]. / Die ventrale Spondylodese beim älteren Patienten--Overtreatment oder sinnvolle Therapieoption?

BACKGROUND: Only limited data are available concerning the effect of ventral thoracoscopic spondylodesis (VTS) on elderly patients and the medium-term outcome. MATERIAL AND METHOD: In a retrospective study, 23 patients were included from 2003 to 2008. An age over 60, a traumatic burst fracture in the thoracolumbar region and a VTS procedure were inclusion criteria. A preoperative neurological deficit, ASA scores greater than 3 and a malignant disease were exclusion criteria. The mean age was 65 (62-70) years, 17 male and 6 female patients were included. In 87 % (n = 18) of the patients a compression fracture type A was found. Bone density values were obtained in 5 patients, mean value was -1,7. 21 patients were treated with a dorsoventral, bisegmental procedure. Two patients with limited kyphosis and no relevant stenosis of the spinal canal were treated with a ventral only procedure. In two cases with measured low bone quality, pedicle screws were placed with bone cement. Patients were monitored on ICU for 24 hours after operation until the thoracic drainage was removed. At an average follow-up of 3.9 years, patients were evaluated with SF 36 (short form 36) and an Oswestry disability index score (ODI score). The postoperative radiographic control was performed with a CT scan, X-ray controls were taken 3, 6, 12 and 18 months after the operation. Cobb angle and scoliosis angle were measured. Statistical analysis was carried out with SPSS-Software 17.0 (SPSS®, Inc., Chicago, USA) and a Mann-Whitney U test and a level of significance of p < 0,05. RESULTS: In five patients pulmonary complications occurred, in one case a revision operation had to be performed due to pleural effusion. One patient suffered from a delayed pneumonia. The mean loss of correction in all patients was 3,3° (-20°-1°). In four patients with a distinct loss of correction at an average of 13,6° ± 4,5°, iatrogenic damage of the lower or upper cover plate of the adjacent vertebral bodies was found. The risk of loss of correction was found to be significantly higher in case of damage to the lower or upper cover plate (p < 0.001). Test results from the SF 36 score (sum scale 40.8) showed no significant difference in life quality to a similar aged comparison group. The ODI score revealed a mean vertebral column associated impairment of 10.8 %, 20 patients showed only minimal limitations. CONCLUSION: Also in older patients VTS seems to be an adequate treatment of traumatic burst fractures of the thoracolumbar spine. Perioperative pulmonary complications were easy to handle and had no effect on the clinical outcome. Postoperative radiographs showed only little loss of correction, in four cases iatrogenic damage of the cover-plate led to a distinct loss of correction. Careful and accurate preparation of the cover plates is therefore decisive.

[Long-term results of kyphoplasty with additive dorsal instrumentation of incomplete burst fractures of the thoracolumbar spine in the elderly]. / Langzeitergebnisse nach Hybridstabilisierung inkompletter Berstungsfrakturen der thorakolumbalen Wirbelsäule des älteren Patienten.

BACKGROUND: To offer a correct treatment strategy for osteoporotic vertebral body fractures remains a huge challenge in modern spine surgery. PATIENTS AND METHODS: In the years 2002 and 2003 5 patients with incomplete burst fractures (AO type A3.1) of the thoracolumbar spine were included in this study (4 men, 1 woman, average age: 62.6 years, follow-up rate: 100 %). All 5 were treated by kyphoplasty and additional dorsal bisegmental instrumentation. Unlike today, dorsal instrumentation was done without cement augmentation. Inclusion criteria were age above 60 years, an adequate trauma, and a fracture between thoracic body 11 and lumbar body 3. Data acquisition was performed prospectively before and after the operation, after 3, 6, 12, 18 months, and after 5 years, including visual analogue scale (VAS) spine score, spinal function score, X-ray examination or in cases of complaints or limited assessability a CT examination, and SF 36 score after 5 years. As comparison group, we used 4 patients, suffering the same fracture type with a similar fracture location (1 man, 3 women, average age: 67.3 years), who were treated with kyphoplasty alone during the same time period. RESULTS: No clinically relevant intra- and postoperative complications were registered in our study group. The operative bisegmental kyphotic reduction was slightly higher in our study group. Afterwards the correction loss was 9.8° in our study group, exceeding the reduction by 3.6°, whereas the comparison group suffered from a correction loss of 11.8°, exceeding the operative reduction by 8.5°, respectively. These differences were not statistically significant. Similarly, no statistically significant differences were registered with respect of physical component summary (PSC), mental component summary (MSC) score and VAS spine score. Both groups had comparable PSC and MSC scores to a norm group of the same age. CONCLUSION: After 5 years the therapy concept seems to be of low risk and not being associated with major complications. The PCS and MCS scores are comparable to a norm group of the same age. The correction loss exceeded the operative reduction marginally but turned out to be slightly lower compared to that of an isolated kyphoplasty.