Surgical Treatment of Thoracolumbar Fractures:Anterior Versus Posterior Approach

Abstract

Background Data: Treatment of thoracolumbar vertebral fractures is highly controversial. The most important factor determining treatment strategy is whether the patient has a neurological injury. Purpose: This work studied the results of the surgical treatment of thoracolumbar fractures admitted at the Neurosurgery Department of Benha University Hospital between January 2006 and June 2014 and tried to outline the indications of either the anterior or the posterior approach based on this experience. Study Design: Descriptive retrospective clinical case study. Patients and Methods: This is a retrospective study of the medical records of 72 patients who were hospitalized with the diagnosis of traumatic thoracolumbar spinal fracture and operated upon at the neurosurgical department of Banha University between January 2006 and June 2014. Sixty patients operated through the anterior approach, where 12 operated through the anterior approach. Results: Clinical outcome: Posterior group: no patient experienced neurological deterioration postoperatively. Preoperative low back/leg pain improved greatly in most patients (54 out of 60) and remained the same in 6 patients based on the VAS for pain. Anterior group: According to ASIA; patients grade A (N=6) and D (N=1), remained the same post-operatively, whereas, of the other patients with incomplete cord lesion (N=5), three improved one grade and two did not improve at the last follow-up. Radiological outcome: Posterior group: Preoperatively, most patients experienced loss of more than 40% of the vertebra body’s height and compromise of more than 40% in canal. Its overall mean values were 42.5±11.5% and 50.6±10.2%, respectively. No statistically significant correlation appeared between the canal compromise and loss of vertebral body height (P>0.05). However, the mean kyphotic deformities measured preoperatively and at within 12 months follow-up, were 19.2±5.5 degrees and 8.0±3.6 degrees. The mean mid-sagittal diameter improved from 9.2±3.1 mm before surgery to 15.1±0.8 mm at the 12 months follow-up visit, with a significant difference between preoperative and postoperative values (P<0.01). The mean vertebral body height before surgery was 42.5±11.5%. At the 12-month follow-up visit, this score showed a statistically significant increase, to 69.0±11.4% (P<0.01). Anterior group: The preoperative segmental kyphosis improved postoperatively (at the three month follow up visit) from a mean of 26.5o (range 16- 35o) to a mean of 11o (range 5- 17o). This correction was maintained in all but three patients who lost correction of a mean 3o (at the end of the follow up visits- at 12 months). None of the patients had implant failure. All patients had bone fusion on final follow up plain radiography. Conclusion: Posterior surgery is performed primarily in the treatment of burst fractures without neurological deficit. Anterior decompression is indicated in an incomplete neurologic deficit with marked canal compromise and intact posterior ligamentous complex. Both approaches are safe and efficient in retaining the stability of the spine. (2014ESJ071)

Keywords

• thoracolumbar fractures
• anterior approach
• posterior approach