Surgical Outcome of Transpedicular Fixation Using Short Segment in Patients with Thoraco Lumber Spine Injuries
Dr Naeem Ul Haq, Dr Muhammad Ishaq, Dr Adnan Ahmed, Dr Musawer Khan, Dr Amir Aziz, Dr Tauqeer, Dr Haroon Sarwar
1Assistant Professor And Chairman Neurosurgery, Bacha Khan Medical College Mardan Medical Complex.
2Assistant Professor Neurosurgery, Bacha Khan Medical College Mardan Medical Complex.
3Registrar Neurosurgery Ward, Bacha Khan Medical College Mardan Medical Complex.
4Registrar Neurosurgery Ward, Bacha Khan Medical College Mardan Medical Complex.
5Assistant Professor Neurosurgery Ward, Lahore General hospital
6Consultant Neurosurgeon Neurosurgery Unit, Lahore General hospital
7Neurosurgery Resident, Mayo Hospital Lahore.
ABSTRACT:
BACKGROUND: Pedicle instrument placed in small segments (a normal vertebra is fixed below and above an injured lesion) has been introduced into routine medical practice with the development of transpedicular screw fixation procedures and instrumentation systems.
OBJECTIVE: The goal of this investigation is to describe the surgical measures of fractures in thoracic and lumber vertebra treated with pedicle fixation with a short section.
Study Setting: Neurosurgery Unit Bacha Khan Medical College Mardan Medical Complex METHOD: We conducted a systematic review of all thoracic and lumbar fractures treated by surgery within a time period of a year. The short-segment approach was used to instrument 84 surgically treated individuals. Graphical presentations, operation details, radiographs performed before and after the surgery, computed tomography, and magnetic resonance imaging were all performed. Neurological measures according to the Frankel functional classification were reviewed, as well as follow-up visits for six months following fixation.
RESULT: The pedicular fixation was installed in 86 instances, 53 of which were men and 33 of which were women, resulting in a men to women ratio of 1.6 :1. The mean age was 40years ranging between (15-60) with an standard deviation 13.75. The severity of injuries varied according to age group. The outcome was graded using the Frankle system. There was no evidence of an increase in neurological impairment in any patient. The majority of patients
improved to the following grade. Eight cases involved screw breakage, sixteen had bed sores, and three included deep vein thrombosis. In five instances, a screw was misplaced. Eight patients developed wound infection.
CONCLUSION: While long-term follow-up is necessary, the short-term data show a favorable outcome for short-segment instrumentation.
INTRODUCTION:
Pedicle instrument placed in small segments (a normal vertebra is fixed below and above an injured lesion) has been introduced to routine medical practice with the development of transpedicular screw fixation procedures and instrumentation systems1. In 1944, King described pedicular screws fixed in vertebral body via the transfacet technique to the lumbar part of spine.
In 1958, Boucher described a method for screw placement into the vertebral body via the pedicle. Since the widespread use of pedicle screws began in 1963, as documented by RoyCamille4 with other authors, pedicle fixation is frequently utilized to treat lumbar spine disorders2. The appropriate therapy of thoracolumbar fractures remains debatable. The transpedicular instrumentation within the short segments aims to re-establish the frontal portion of vertebral body without anterior strut grafting or fixing plates, hence escaping substantial arthrodesis of the motile segments. The utilization of pedicle fixation, which can restrict the assortment of segments of spine, hence minimizing harm to muscles and tendons, increasing the rate of synostosis, extends the great functions of pedicle screws previously documented in investigations. This approach has yielded a variety of unfavorable results to date3, 4. Those who advocated for temporising treatments insisted that they could only get adequate effects through posture and long-term relaxation therapy.
However, according to some who advocate surgical therapy, patients can expect to regain mobility early, do rehabilitative exercises, conquer the fracture within anatomical region, and improve, in the majority of cases, neurological functions through the use of decompression and
fixation5,6. There were several reports of degraded neurological functioning, spinal stenosis worsened, enhanced force on the body of vertebra, rising kyphosis, and generating radiculopathy and pain following temporising treatments. This study assesses the surgical measures of 86 thoracolumbar spine fractures treated with transpedicular instrument in small segments7, 8.
MATERIAL AND METHOD:
A prospective review evaluation of all treated fractures in thoracic and lumber spine by surgery was conducted to determine several clinical factors such as age, gender distribution, and the source and extent of damage. Between April 2020 and April 2021, individuals with thoracic and lumbar fractures were admitted to the Hospital of Lahore, Pakistan. 86 patients underwent transpedicular fixation in small segmentation9. Charts, operating notes, radiography performed before and after the surgery, computed tomography scans, MRIs, and visit records for a period of up to six months were evaluated. Denis10 categorised fractures (3-column classification). The neurological state of the subjects was determined using the Frankel grading system for spinal cord damage. The following conditions necessitated surgical intervention such as decompression and fixation: thoracic and lumber fractures with neurology defect, kyphosis greater than 22 degrees, collapsing of vertebra greater than 48% of body height, and canal compromise greater than 50%. Radiographs were used to assess the patient's progress. A ordinary X-ray was taken to confirm the fractures. Each patient had CT scans and magnetic resonance imaging to achieve an accurate diagnosis of vertebral injury10, 11.
RESULT:
Transpedicular instrumentation was accomplished in 86 cases, with a men to women ratio of 1.6:
1, as illustrated in Figure-1. The mean standard deviation of age was 40 years (range: 15–60), 13.75 SD12.
D11 fractures occurred in four instances, D12 fractures occurred in eight cases, L1 fractures occurred in 37 cases, L2 fractures occurred in 18 instances, D12 and L1 fractures occurred in 14 instances, and L3 fractures occurred in just three instances13.
Frankle grading determined the following outcomes: grade A with 29 cases; grade B with 19 cases; grade C with 16 instances; grade D with 19 instances; and grade E with only 2 cases.
Fixation with decompression of neural components was the surgical method. All patients were observed and followed for a period of six months. Following surgery, patients were evaluated according to the Frankle grade as displayed. Fixation screws broken in five cases,while bed sores occurred in sixteen. Deep vein thrombosis in two instances, misplaced screw in eight instances, and wound infection in eight instances15.
Gender Ratio
Males 52%
females 32%
0 0.5 1 1.5 2 2.5 3 3.5 4
D11 D12 L1 L2 D12 & L1 L3
Level of Fractures
Series 1
Frankle Grading Before Surgery Grade
A 15 19%
B 17 21.3%
C 24 29.6%
D 16 20.4%
E 9 9.3%
Frankle Grade After Surgery Grade
A 29 35.6%
B 19 21.3%
C 16 17.7%
D 19 23.9%
E 2 2%
DISCUSSION:
The significance of treating vertebral breakage are to accomplish early neurological rebuilding, conquer damage spinal segments anatomically and achieve firm and stable obsession for early rehabilitation. Pedicle screw instrumentation of spinal cracks is proceeded as a fundamental treatment for thoracic and lumbar vertebral breaks and posterior and lateral synostosis in numerous emergency clinics. Sasso et al did clinical correlations and examinations among Harrington hook and rods, Luque bars, sublaminar wires and pedicle fixation with 70 patients and found that pedicle screw instrumentation was posterior fix which could be applied to more small segments than could other tools of posterior fixation. Hereby, pedicle screw instrument is a tremendous posterior fix strategy reasonable for this instance12, 13. The principle benefits of the dorsal methodology in short sections of fixation are that it safeguards the movement portion, and is straightforward and practicable to spine specialists yet perceived detriment is the trouble in reestablishing the front segment. Inability to reestablish the foremost section, it can prompt
advanced kyphosis, pain, instability and late beginning of neurologic defect contingent essentially upon leftover burden move limit of the broke vertebral body. A few reports have demonstrated that sagittal plane kyphosis was hopeless utilizing pedicle screw instrumentation in thoracic and lumbar cracks because of bone breakage by the subsequent assessment of patients in 6 months. Nonetheless, this examination showed acceptable outcomes with no neurological defect after transpedicular fixation14.
Pedicle tightens can be utilized in both the lumbar and thoracic vertebrae and are valuable in extreme cracks, for example, dislocation of bones. Recorded reports showed the infection rate as roughly 6% after posterior fixation and synostosis, nonetheless, no disease was found in this investigation. Humford et al revealed that stalling strategies showed great outcomes for patients with thoracic and lumbar body breakage without nerve damage. In any case, Denis et al.
discovered that patients with thoracic and lumbar vertebrae cracks without nerve harm that leads all the way return to their living style when they went through spinal fixation, however these discoveries were not identified with the radiographic discoveries. Huge bending of screws or equipment breakage were not experienced. Beginning reformist rigid breakdown was noted in a paraplegic patient, yet without expanding pain15.
Significant benefits of careful internal fixation over brief medicines that early transpedicular instrumentation make the patients mobile early, forestalling nerve harm by settling the spine. It shields harmed structures from external factors while expanding the chance of reclamation of neurological issues and to supplant the harmed constructions' with fitting internal fixation apparatuses. Frankel et al announced that medicines utilizing stances would be sufficient and that it is feasible to make patients mobile in the wake of reestablishing their stability by long term restoration16.
Jacobs et al. performed near investigations between careful strategies and delaying techniques, and tracked down that careful techniques were better compared to stalling ones at repairing cracks, reestablishing neurological defect, moving patients and diminishing complications. Burst fractures regularly include infringement of the mediocre or potentially unrivaled endplates, and hence the distortion may advance by slow settling of the circles into the cracked endplates and vertebral body. Farcy et al recommended that if the sagittal record surpasses 15 degrees, the biomechanical climate favors the movement of kyphosis) There was one instance of loss of kyphotic remedy in an older osteoporotic patient. In this way, in osteoporotic patients, certain standards ought to be thought of, like different segment fixation, tolerating lesser levels of deformation remedy, and staying away from the instrumentation length inside the kyphotic portion. Singular patient trademark may influence the event of contiguous fragment degeneration. Age was likely identified with the diminished capacity of the matured spine to oblige the biomechanical modifications forced by a combination. Aota et al saw that the occurrence of adjacent segments degeneration was higher in patients with 55 years and above17.
CONCLUSION:
Transpedicular instrumentation is protected, simple and successful procedure. Patients showed synostosis and fruitful recuperating in virtual anatomic arrangement with no complications. Yet, this examination is restricted by its short subsequent period18.
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