|Year : 2020 | Volume
| Issue : 1 | Page : 74-78
Is the transpedicular bone grafting an effective technique for prevention of kyphosis in thoracolumbar fractures?
Daniel Rios1, Mario Cahueque2, Guillermo Moreno1, Javier Ardebol3, Enrique Azmitia4
1 Department of Traumatology and Orthopaedics, Mexican Social Security Institute, Guadalajara, Mexico
2 Department of Traumatology and Orthopaedics, Centro Médico Hospital, Guatemala
3 Medical Research, Francisco Marroquín University, Guatemala
4 Department of Neurosurgery, Herrera Llerandi Hospital, Guatemala
|Date of Submission||17-Feb-2020|
|Date of Acceptance||20-Apr-2020|
|Date of Web Publication||26-Jun-2020|
Dr. Mario Cahueque
Hopsital Centro Medico, Guatemala City
Source of Support: None, Conflict of Interest: None
Study Design: This was an interventional randomized trial. Summary of Background Data: Fractures of the thoracolumbar spine represent 90% of all spine fractures, and the thoracolumbar burst fractures (Type A fractures) are the most common in the spine and important cause of posttraumatic kyphotic deformity. The cause of this problem appears to be the structural and mechanical deficiency of the anterior column following indirect fracture reduction by posterior fixation. Objective: The objective of this study was to evaluate the effects of transpedicular intracorporeal grafting associated with short-segment transpedicular fixation on kyphosis progression in patients with thoracolumbar burst fracture Type A3/A4. Materials and Methods: Fifty-nine consecutive patients with thoracolumbar burst fracture were treated with short-segment transpedicular monoaxial screw fixation. Patients were simply randomized divided into transpedicular grafting (TPG) (n = 35; A3 = 20 and A4 = 15) and non-TPG (n = 24; A3 = 19 and A4 = 5). The average follow-up was 21.1 ± 4.2 (range: 16–26) months for the entire study group: 22.1 ± 4.5 months for the TPG group and 20.2 ± 4.8 months for the non-TPG group (P = 0.49). Results: The global mean kyphosis angle before surgery was 21.93° ±3.92°, with 22.06° ±3.55° in the TPG group and 20.75° ±4.68° for non-TPG; P = 0.93. The mean kyphosis angle at the end of follow-up for the entire study was 9.21° ±8.86°, with 8.70° ±2.11° for TPG and 14.08° ±4.73° for non-TPG, (TPG vs. non-TPG, P = 0.010). No obvious clinical complications in both the groups were documented. Conclusions: Our findings demonstrate that transpedicular bone grafting associated with short-segment fixation in thoracolumbar burst fractures has caused a significant effect on the prevention of kyphosis progression after surgery.
Keywords: Burst fracture, kyphosis, short-segment instrumentation, spinal injuries, transpedicular grafting
|How to cite this article:|
Rios D, Cahueque M, Moreno G, Ardebol J, Azmitia E. Is the transpedicular bone grafting an effective technique for prevention of kyphosis in thoracolumbar fractures?. J Orthop Traumatol Rehabil 2020;12:74-8
|How to cite this URL:|
Rios D, Cahueque M, Moreno G, Ardebol J, Azmitia E. Is the transpedicular bone grafting an effective technique for prevention of kyphosis in thoracolumbar fractures?. J Orthop Traumatol Rehabil [serial online] 2020 [cited 2020 Jul 6];12:74-8. Available from: http://www.jotr.in/text.asp?2020/12/1/74/287706
| Introduction|| |
Fractures of the thoracolumbar spine represent 90% of all spine fractures, followed by cervical and finally by lumbar spine fractures. This area is made up of T11–L2 vertebrae, and it is considered biomechanically the weakest point in the spine., The most widely used is the classification of Magerl-AO; vertebral fractures are divided into three groups according to Arbeitsgemeinschaft für Osteosynthesefrage (AO). Type A fractures are those caused by compression, and Type B fractures are those caused by flexion and distraction forces accompanied by lesions in the posterior ligament complex. Type C fractures are any type of fracture that is accompanied by displacement in the sagittal or coronal plane.,
Thoracolumbar burst fractures (Type A fractures) are the most common in the spine and cause of a variety of complications, such as kyphotic deformity, paralysis, or nervous damage. Treatment for these fractures comprehends from conservative treatment to a various amount of surgical procedures, each one with multiple indications and in some cases depending on the surgeon's choice due to its experience.,,,,,
Posterior transpedicular short-segment instrumentation systems have diminished the amount of segments to fuse in the treatment of these fractures, and indirect reduction due to ligamentotaxis has allowed to perform a greater kyphosis correction.,,,, Despite these advantages, there is a failure of these systems to withstand the anterior column load resulting sometimes in loss of kyphosis correction and a high index of instrumentation failure.,,,
The cause of this problem appears to be the structural and mechanical deficiency of the anterior column following indirect reduction of the fracture because of the anterior column defect that invariably emerges as an effect of indirect vertebral height and lordosis restoration. Transpedicular grafting (TPG) of the involved vertebral body fracture has been offered and performed successfully as an alternative although the authors of some recent studies were against this technique.,, The idea of this procedure is first to restore the load-bearing capacity of the anterior column and second improve stability and promote the posterolateral fusion. Consequently, the method should prevent the collapse of the intervertebral disc space in the injured segment, which would result in loss of correction (re-kyphosing).,, The objective of this study was to evaluate the effects of transpedicular intracorporeal grafting on kyphosis progression in thoracolumbar burst fractures.
| Materials and Methods|| |
This was an interventional randomized trial of 59 consecutive patients with thoracolumbar burst fractures; institutional review board approval was obtained. Inclusion criteria were compression fractures between the Levels T11 and L2 and correspond to fractures Type A3 and A4 AO classification, of which 39 (66%) were Type A3 fractures and 20 (34%) Type A4. The Type A1 fractures are managed conservatively in our hospital, and the A2 Type for being split fracture does not require TPG. All cases were demonstrated by computed tomography; in cases where there was doubt posterior ligamentous injury, magnetic resonance was performed. The time from the injury to operation was 3–10 days, with an average time of 7 days. The mean age of the patients was 46.12 ± 3.47 years; 47 were male and 12 female. All patients in this study showed no neurological deficit [Table 1].
Patients were divided into two groups, each group consisting of a different short-segment instrumentation intervention: TPG (n = 35; A3 = 20 and A4 = 15) and non-TPG in the fractured vertebra (non-TPG) (n = 24; A3 = 19 and A4 = 5). The study consisted of a homogeneous sample of participants who were randomly assigned to each group as there were no allocation criteria. The average follow-up was 21.1 ± 4.5 (range: 16–26) months for the entire study group: 22.1 ± 4.5 months for the TPG group and 20.2 ± 4.8 months for the non-TPG group (P = 0.49). X-ray follow-up measurements were performed by the same researcher, blinded as to the group.
All patients were instrumented using monoaxial pedicle screws inserted bilaterally at the upper and lower adjacent levels, connected by bilateral rods contoured to achieve the normal sagittal alignment of the involved level. Reduction of the fracture and indirect decompression of the spinal canal were accomplished by the rod contouring only, without any further effort for decompression (no laminectomy). For patients in the TPG group, TPG of the involved level was performed as a variation of the technique described by Daniaux in 1986. The fractured vertebrae were corrected utilizing bilateral transpedicular canals. Autologous cancellous osseous tissue extracted from the iliac crest bone was pushed through the endplates with spoons and a small hammer to pack and refill the voids created within the vertebral bodies. Posterolateral fusion with allografts (demineralized bone matrix)
and autologous iliac crest bone graft was performed in all patients. Preoperative, postoperative, and follow-up images through the levels of the pedicles of the involved vertebrae as well as the adjacent levels were obtained. After surgery in both the groups used brace for 3 months, as well rehabilitation, follow-up was performed by outpatients with regular appointments. Kyphosis angle measurements were analyzed to determine and compare the severity of the deformity in both the groups [Figure 1] and [Figure 2]. Student's t-test for independent samples was performed for statistical analysis, with a confidence interval of 95%.
| Results|| |
The fractured vertebrae were L1 in 35 cases (59%), L2 in 10 (17%), T12 in 9 (15%), and T11 in 5 (9%). The average follow-up was 21.1 ± 4.5 and 22.1 ± 4.5 months for the TPG group and 20.2 ± 4.8 months for the non-TPG group (P = 0.49), and a mean of kyphosis angle before surgery was 21.93° ± 3.92°, with 22.06° ± 3.55° in the TPG group and 20.75° ± 4.68° in the non-TPG group; P = 0.93. Immediately after surgery, no differences were found in the angle of correction of kyphosis (P > 0.05). The angle of kyphosis at the end of the follow-up was 8.70° for TGP and 14.08° for non-TPG, P < 0.05; the corrected angle for the TPG group was 13.36, and for the non-TPG group, it was 6.67 [Table 2] and [Figure 3]. No statistically significant change was found in the scores of the American Spinal Injury Association (ASIA) scale; all they continued in ASIA E. No clinical difference in reported pain was found at the end of the follow-up (Visual Pain Scale).
|Figure 3: X-ray measurement of kyphosis angle after transpedicular screw plus transpedicular bone graft|
Click here to view
No significant posttraumatic angulation in the frontal or coronal plane was documented, either initially or on follow-up. In the TGP group, there was no failure of internal fixation, whereas in the non-TPG group, the internal fixation technique failed in 3 of 24 patients (12.5%) with fracture Type A4 after 12 months of follow-up, and surgery was performed to retrieve the instrumentation in the patients that presented broken screws. In all cases, a solid interbody fusion was observed and the broken screws were considered as implant failure.
During follow-up, there were no distinct clinical complications in the tomographic evaluation of both the groups such as entry of morselized bone into the spinal canal, nerve injury, bone or spinal canal infection, screw entrance into the medulla, or apparent nonunion.
| Discussion|| |
Posterior stabilization is a widely accepted treatment for the instability of the thoracic and lumbar spine. However, isolated posterior fixation is often associated with loss of correction or implant failure. According to the spine three-column theory, the anterior and middle columns play an important role in supporting the upper body, and the correction loss occurs primarily through disc space collapse.,,,
Posterior short-segment instrumentation and fusion in the treatment of burst fractures offer the advantage of preserving more mobile spine segments when compared to longer constructs. In addition to distractive forces, restoration of the physiological sagittal contours performed by manipulations on the sagittal positioning of the transpedicular screws in the global reference system may also be effective to a lesser extent. The location and incidence of various fracture types were similar to those reported by other authors.,,,,,,
The transpedicular screw fixation only provides temporary stability, and the permanent stability lies in the bony fusion. The key to the prevention of correction loss of thoracolumbar vertebrae is the physical support to fractured segments and, eventually, healing of fracture. During the healing process fibrous tissue may infiltrate the fracture space in the vertebral body which decreases consolidation capacity and consequent loss of kyphosis correction. This correction loss will lead to fracture and failure of the internal fixation with possible vertebral body collapse.
Transpedicular augmentation techniques would help maintain the correction, and the most widely used techniques are placing cement (vertebroplasty or kyphoplasty), the fractured vertebra screw, and the graft hydroxyapatite, all with good results,, but in our view, we believe that the cost increases with these techniques. In this study, we elaborated a transpedicular graft utilizing iliac crest bone and applied it to the injured vertebrae. The iliac crest may provide a sufficient amount of bone graft for the anterior column to appropriately restore the height of the vertebral body and fill the void space. Therefore, in the TPG group, there was a greater kyphosis adjustment and no correction loss during follow-up. At the same time, to achieve the stability, the grafting of iliac crest bone to posterior-lateral fusion was performed.
The failure of internal fixation for the fracture of the thoracolumbar vertebrae was mainly caused by, apart from skill-related factors, inadequate fusion of local bone graft, and internal fixation cannot lead to bony fusion. Some authors suggest that the loss of correction of more than 10° is considered surgical failure and recommends the use of orthotics if necessary. Liao et al. reported that body height collapse contributed to postoperative progressive kyphosis. Filling the defect can effectively decrease or prevent this situation. Not all studies described positive results. Alanay et al. demonstrated that TPG of the injured vertebral body did not effectively prevent correction loss and implant failure, although in this study, it was treated only ten patients.
The most common fractured vertebrae are L1 and T12, representing 49% and 18% respectively. According to other studies, fractures considering other vertebrae had a minor role.,,,, Thus, proving the tendency of developing a burst fracture during an accident when stress is directed towards the thoracolumbar junction.
No patients in the present study present neurological deficit before or after surgery; in other studies, it demonstrated neurological recovery in patients with ASIA C to D, if the stabilization and decompression are performed early. Pain is one of the most commonly seen symptoms in a patient with posttraumatic deformity. The development of pain is thought to be due to abnormal spine biomechanics at the level of the deformity which results in altered forces being placed on the soft tissues and surrounding structures. Pain typically occurs initially at the level of the deformity, but because the vertebral levels above and below the deformity degenerate prematurely because of the altered spine biomechanics, patients may also complain of pain adjacent to the level of the deformity.,,, In this study, the Visual Analog Scale was utilized to evaluate pain during follow-up. According to this scale, patients in the non-TGP group reported having greater pain possibly related to kyphosis correction loss.
Transpedicular grafting with minimally invasive surgical approach
Evidently, the minimally invasive technique is superior than the open surgery approach for the management of thoracolumbar spine burst fractures owing to the fact that it is associated with shorter surgery time, less bleeding, and in some studies presented an adequate adjustment of kyphosis without loss of correction. The primary surgical benefits of utilizing minimally invasive surgical (MIS) approaches are the dramatic improvements seen in perioperative factors such as blood loss, hospitalization time, and operative times, which translate to reduced chances of incurring surgical morbidity. Furthermore, MIS techniques not perform posterolateral fusion, which would, once removed the hardware, preserve mobility segment, but the problem with percutaneous fixation is that it is relatively fragile when the posterolateral fusion has not been performed and transverse traction devices (cross-link) they are not used, especially in cases of Type A3/A4 fracture with a risk of fixation failure. This fragility could be corrected by performing intracorporeal augmentation systems such as balloon kyphoplasty, or as it was shown in this study the use of TPG technique to promote early consolidation without loss of vertebral body height and avoid the fatigue of implants, transpedicular intracorporeal graft placement in MIS technique will be performed under vision through mini-open transmuscular approach.
The results suggest that transpedicular bone grafting has caused a significant effect on the prevention of kyphosis progression after thoracolumbar burst fracture. This can be due to two main reasons: The TPG plays an important role in achieving reduction during surgery, allowing a greater kyphosis angle correction.,,,,,,, Furthermore, the TPG occupies the intervertebral space caused by a burst fracture, augmenting the load-bearing capacity of the anterior column, therefore, preventing Kyphosis progression.,,,,,,,
| Conclusions|| |
This study evaluated the effects of TPG on kyphosis progression in a group of patients with thoracolumbar burst fractures treated with short-segment posterior instrumentation. Our findings demonstrate that transpedicular bone grafting has caused a significant effect on prevention of kyphosis progression after thoracolumbar burst fracture; no clinical difference in reported pain was found at the end of the follow-up, and studies with a longer follow-up may be needed to establish a relation between kyphosis and chronic back pain.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Holmes JF, Miller PQ, Panacek EA, Lin S, Horne NS, Mower WR. Epidemiology of thoracolumbar spine injury in blunt trauma. Acad Emerg Med 2001;8:866-72.
Azam MQ, Sadat-Ali M. The concept of evolution of thoracolumbar fracture classifications helps in surgical decisions. Asian Spine J 2015;9:984-94.
Kim BG, Dan JM, Shin DE. Treatment of thoracolumbar fracture. Asian Spine J 2015;9:133-46.
Kim YM, Kim DS, Choi ES, Shon HC, Park KJ, Cho BK, et al
. Nonfusion method in thoracolumbar and lumbar spinal fractures. Spine 2011;36:170-6.
Knop C, Fabian HF, Bastian L, Rosenthal H, Lange U, Zdichavsky M, et al
. Fate of the transpedicular intervertebral bone graft after posterior stabilisation of thoracolumbar fractures. Eur Spine J 2002;11:251-7.
Vaccaro AR, Lim MR, Hurlbert RJ, Lehman RA Jr., Harrop J, Fisher DC, et al
. Surgical decision making for unstable thoracolumbar spine injuries: Results of a consensus panel review by the Spine Trauma Study Group. J Spinal Disord Tech 2006;19:1-0.
Kim YM, Kim DS, Choi ES, Shon HC, Park KJ, Cho BK, et al
. Nonfusion method in thoracolumbar and lumbar spinal fractures. Spine (Phila Pa 1976) 2011;36:170-6.
Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine (Phila Pa 1976) 1983;8:817-31.
Leferink VJ, Nijboer JM, Zimmerman KW, Veldhuis EF, ten Vergert EM, ten Duis HJ. Burst fractures of the thoracolumbar spine: Changes of the spinal canal during operative treatment and follow-up. Eur Spine J 2003;12:255-60.
Dai LY, Jiang LS, Jiang SD. Conservative treatment of thoracolumbar burst fractures: A long-term follow-up results with special reference to the load sharing classication. Spine (Phila Pa 1976) 2008;33:2536-44.
Knight RQ, Stornelli DP, Chan DP, Devanny JR, Jackson KV. Comparison of operative versus nonoperative treatment of lumbar burst fractures. Clin Orthop Relat Res 1993;293:112-21.
Pneumaticos SG, Triantafyllopoulos GK, Giannoudis PV. Advances made in the treatment of thoracolumbar fractures: Current trends and future directions. Injury 2013;44:703-12.
Toyone T, Tanaka T, Kato D, Kaneyama R, Otsuka M. The treatment of acute thoracolumbar burst fractures with transpedicular intracorporeal hydroxyapatite grafting following indirect reduction and pedicle screw fixation: A prospective study. Spine (Phila Pa 1976) 2006;31:E208-14.
Winkler H. Failure of posterior cancellous bone grafting at the anterior column. Trauma Berufskrankh 2005;7 Suppl: S307-10.
Daniaux H. Transpedicular repositioning and spongioplasty in fractures of the vertebral bodies of the lower thoracic and lumbar spine. Unfallchirurg 1986;89:197-213.
Kanna RM, Shetty AP, Rajasekaran S. Posterior fixation including the fractured vertebra for severe unstable thoracolumbar fractures. Spine J 2015;15:256-64.
Xu G, Fu X, Du C, Ma J, Li Z, Ma X. Biomechanical effects of vertebroplasty on thoracolumbar burst fracture with transpedicular fixation: A finite element model analysis. Orthop Traumatol Surg Res 2014;100:379-83.
Liao JC, Fan KF, Keorochana G, Chen WJ, Chen LH. Transpedicular grafting after short-segment pedicle instrumentation for thoracolumbar burst fracture: Calcium sulfate cement versus autogenous iliac bone graft. Spine (Phila Pa 1976) 2010;35:1482-8.
Alanay A, Acaroglu E, Yazici M, Oznur A, Surat A. Short-segment pedicle instrumentation of thoracolumbar burst fractures: Does transpedicular intracorporeal grafting prevent early failure? Spine (Phila Pa 1976) 2001;26:213-7.
Rath SA, Kahamba JF, Kretschmer T, Neff U, Richter HP, Antoniadis G. Neurological recovery and its influencing factors in thoracic and lumbar spine fractures after surgical decompression and stabilization. Neurosurg Rev 2005;28:44-52.
Leferink VJ, Keizer HJ, Oosterhuis JK, van der Sluis CK, ten Duis HJ. Functional outcome in patients with thoracolumbar burst fractures treated with dorsal instrumentation and transpedicular cancellous bone grafting. Eur Spine J 2003;12:261-7.
Vaccaro AR, Silber JS. Post-traumatic spinal deformity. Spine 2001;26:S111-8.
Barbagallo GM, Yoder E, Dettori JR, Albanese V. Percutaneous minimally invasive versus open spine surgery in the treatment of fractures of the thoracolumbar junction: A comparative effectiveness review. Evid Based Spine Care J 2012;3:43-9.
Leferink VJ, Zimmerman KW, Veldhuis EF, ten Vergert EM, ten Duis HJ. Thoracolumbar spinal fractures: Radiological results of transpedicular fixation combined with transpedicular cancellous bone graft and posterior fusion in 183 patients. Eur Spine J 2001;10:517-23.
Chen LH, Lai PL, Niu CC, Chen CH, Chen WJ, Fu TS. Intracorporeal bone grafting for vertebral compression fractures with intraosseus vacuum phenomenon. Int Orthop 2004;28:52-5.
Liao JC, Fan KF, Chen WJ, Chen LH. Posterior instrumentation with transpedicular calcium sulphate graft for thoracolumbar burst fracture. Int Orthop 2009;33:1669-75.
Knop C, Fabian HF, Bastian L, Blauth M. Late results of thoracolumbar fractures after posterior instrumentation and transpedicular bone grafting. Spine (Phila Pa 1976) 2001;26:88-99.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]