24 Advances in the Treatment of Thoracolumbar Injuries ARTHUR I. KOBRINE, M.D., and BERNARD STOPAK, M.D.
The management of thoracolumbar spine injuries has undergone continuous change in the modern surgical era. From conservative nonoperative care (1, 7-9) to aggressive surgical intervention by neurological surgeons, with side roads of enthusiasm by orthopedic surgeons recommending fusion with no decompression (18, 20), the waters have remained muddied, with no clear winner emerging. Often, the neurosurgical approach, stressing decompression of the neural elements, accomplished this at the expense of spinal stability, while the zest of the orthopedic surgeon for spinal stability, at times, overlooked the need for neural element decompression. Recently, with the apparent happy marriage of neurological surgeons and orthopedic surgeons, the management of thoracolumbar spine injuries has benefited, with perhaps the best from both worlds being consolidated into a unified plan which takes the needs of both systems (neural and skeletal) into account. BIOMECHANICS OF SPINE FRACTURES
Because the thoracic spine is splinted by the ribs, the majority of noncervical spine fractures occur at or near the thoracolumbar junction. Various forces can be exerted on the spine, with differing types of pathoanatomy. Vertical compression forces, when exerted on the straightened spine, generally cause a collapse of the vertebral body, most often LI, with a resultant "burst fracture." These fractures often occur in parachutists who land improperly, people jumping from high places and landing on their feet, etc. Flexion forces, often occurring in auto accidents, result in wedge compression fractures of the vertebral body. Oftentimes, the posterior ligaments remain intact, allowing these fractures to remain stable. Injuries due to. extension forces are far more common in the cervical spine than in the thoracolumbar spine. Fractures of the posterior elements, e.g., neural arches, and facets may occur, with resultant neurolog570
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CLINICAL EVALUATION AND SURGICAL TECHNIQUE
A comprehensive physical examination is always imperative and can be exceedingly helpful in determining the type of injury. A gap between the spinous processes may be palpable, indicating that the interspinous and supraspinous ligaments have been torn. A bruise or abrasion on the back or side of one shoulder might indicate a rotational type of injury, with the strong possibility of resultant instability of the spine. Injuries to the feet or legs (broken heels or femurs) in patients who have jumped from buildings might suggest compression fractures of Ll. Multiple detailed neurological examinations are mandatory in all suspected spine fractures. The initial examination, performed in the emergency room, must be metiulous and recorded. It is exceedingly important to document any preserved neurological function in the so-called "complete" lesion. Often, patchy areas of preserved sensation are present and signify that neural elements are partially conducting across the injured zone. This is important in assessing prognosis and possible return of function. We have found the modality of light touch to be most useful for these considerations. The examiner can cover the entire body by running his hands over both legs, trunk, etc., in literally seconds, and can save pinprick testing for those areas which the light touch exam demonstrated possible preserved sensation. In thoracolumbar spine injuries, examina-
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ical deficit secondary to indriven bone in the spinal canal. If the anterior longitudinal ligament is also avulsed, these fractures are unstable. Perhaps the worst injuries occur when rotation forces are applied to the spine. Generally, all the ligaments are ruptured. Often, rotational and flexion forces are combined, resulting in facet fractures as well as ligamentous ruptures, with sheared or extruded intervertebral discs. Distraction forces, described originally by Chance (2) but further elaborated upon by Rennie and Mitchell (22), are usually a combination of flexion and distraction and produce a horizontal splitting of the vertebral body and neural arches, generally through the pedicles. It has been suggested that this type of injury can occur during an automobile accident, when the pelvis is anchored by a seat belt and the trunk initially flexes upon impact, but inertial forces continue to move the trunk forward, creating distraction. These fractures are generally unstable and best stabilized by Harrington compression rods. Generally, thoracolumbar fractures produced by either pure flexion or extension forces will be stable, even though the vertebral body may be significantly fractured, since the ligaments usually remain intact. However, when rotational forces are added to either flexion or extension forces, the ligaments are ruptured and the vertebra is fractured, and under these circumstances instability usually results (14-16).
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tion of rectal sphincter tone is extremely important and may help to differentiate conus lesions from cauda equina lesions. The importance of multiple neurological exams cannot be stressed too heavily. Each examination tells the examiner the status of the patient's nervous system at that point in time. Far more important is a feeling for any dynamic changes which are occurring. Is there progression of a neurological deficit? Is the initial paraplegia improving? These questions, which are exceedingly important in planning an effective treatment regimen, can only be answered after multiple neurological examinations, ideally by the same individual. Plain radiographs .of the spine in the anteroposterior, lateral, and oblique projection are taken. Obvious fractures and changes in alignment can usually be seen. Bone fragments in the spinal canal occasionally can be seen on plain radiographs but, often, tomograms are necessary and should be done if the information is not readily available from the plain radiographs. A gap between the spinous processes or pedicles is indicative of ligamentous rupture and suggests an unstable fracture. Fractures of the transverse processes may be indicative of a rotational type of injury, and may also suggest instability. Myelography need not be done on a regular basis. Roentgenographic confirmation of spine fracture and/or malalignment, coupled with neurological dysfunction, is generally an indication for surgery. However, if the neurological lesion is clinically complete, and gross malalignment does not exist, myelography may be helpful in deciding which patients will not benefit from surgery, i.e., the patient with a "complete" neurological deficit with no evidence of instability or malalignment from radiographic examination, whose myelogram does not demonstrate significant neural impingement, would not generally be considered for surgery. All patients suspected of having a thoracolumbar spine injury, with resultant neural injury, should have a Foley catheter inserted in the bladder in the emergency room and should be given systemic corticosteroids. Although clear-cut, undeniable experimental evidence for the beneficial effects of steroids in spinal cord injury is still lacking, nevertheless, the feeling among clinicians regarding its positive effects is strong enough to warrant its use at this time. We use dexamethasone, 10 mg, I.M., immediately and 4 mg, I.M., q.4 hours. Some physicians use "mega" doses, such as 2 g Solu-Medrol acutely (which is roughly the same as 500 mg dexamethasone). The primary goal of all treatment regimes ought to be to ultimately restore the patient to a maximum functional status. For thoracolumbar spine injuries with resultant neurological deficit, we feel this is best accomplished by combining 2 goals, decompression of the neural elements to allow maximum neurological recovery and stabilization of the spine,
TREATMENT OF THORACOLUMBAR INJURIES
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which will allow early mobilization and rehabilitation. Consequently, all patients with unstable thoracic and lumbar fractures are stabilized. All patients with incomplete neurological lesions of the spinal cord, conus medullaris, or cauda equina, in whom there is evidence of neural compression, either by plain radiography or myelography, are treated by decompression and stabilization. Patients with complete lesions, in whom radiographic neural compression can be demonstrated, also fall into this category. When the patient is felt to be clinically stable, operation is elected. General endotracheal anesthesia is used. The patient is placed prone on the operating table on lateral pads to prevent- abdominal compression. Occasional temporary hyperextension may be employed to help reduce a marked flexion malalignment (case 2). A midline incision is utilized and made long enough to insure the exposure of at least 5 vertebral levels. This length of exposure is necessary for Harrington rod placement. The paravertebral muscles are mobilized bilaterally, out laterally to expose the zygapophyseal joints. The posterior elements are carefully examined. Fractures not seen on the radiographs often become apparent. It is not uncommon to find torn dura, herniated cauda equina entangled in bone fragments, indriven bone fragments into the dural contents, and partially or completely extruded discs. A laminectomy is performed at the level of the observed pathology. If the dura is torn, the intradural contents are examined and bone fragments are removed. Herniated rooletes of the cauda equina are gently returned to the intradural compartment, and every attempt is made to close the dura over the cauda equina. Dural substitutes are grafted into place whenever primary closure of the dura will result in constriction of the dural sac. If a segment of an intervertebral disc is herniated into the spinal canal, it is removed. After exposure and decompression are completed, the orthopedic surgeon inserts Harrington distraction rods. In our opinion, Harrington distraction rods, rather than compression rods, are to be preferred in the overwhelming majority of cases. The Harrington rods are generally inserted 2 segments above and 2 segments below the fracture site, thereby spanning a total of 5 vertebral levels. Several authors have advocated employing somatosensory evoked response recording during Harrington rod insertion (19). Most thoracolumbar fractures have an element of posterior vertebral body displacement, which projects into the spinal canal. Decompressive laminectomy will not alter this pathoanatomy. However, proper Harrington rod distraction generally eliminates this displacement, restoring the normal contours of the vertebral canal. The rods enhance the decompression, and maintain it. By maintaining this decompression, and by stabilizing the spine, early mobilization and rehabilitation are possible. After insertion of the rods, the orthopedic surgeon prepares the zygapophyseal
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CASE REPORTS Case 1. A nineteen-year-old white male was riding his motorcycle, when he experienced a bad jump which lifted him off his motorcycle and then back into the seat. He immediately experienced excruciating mid-low back pain with loss of sensation and movement of his lower extremities. On physical examination in the emergency room, he was found to have flaccid paraplegia with minimal quadriceps function bilaterally. He had a complete sensory level at L5. Deep tendon reflexes were absent in the lower extremities. Rectal sphincter tone was absent. Radiographic examination revealed a compressive subluxed fracture of T12 on L1, angulated at about 25 degrees (Fig. 24.1). A myelogram demonstrated a complete block at T12-Ll. A Foley catheter was inserted, and the patient was given systemic corticosteroids. He was taken to the operating room where, under general endotracheal anesthesia, a decompressive laminectomy of T10-L1 was accomplished. Multiple bony fragments were visualized within the spinal canal and removed. Thoracolumbar spine fusion was carried out by the insertion of distraction Harrington rods and an additional lateral bony fusion. After surgery, a body cast was applied. At his last follow-up, approximately 14 months after surgery, the body cast had been removed. The patient was ambulating unassisted without a cane and with minimal unsteadiness. He demonstrated full range of motion of his lower extremities but had minimal diffuse weakness of the muscle groups of his lower extremities and extensors. He demonstrated minimal spasticity in both lower extremities. His sensory examination was essentially normal. Deep tendon reflex examination revealed 3 to 4+ symmetrical reflexes with several beats of ankle clonus bilaterally. Good rectal sphincter tone was present. The patient has complete voluntary control of bowel and bladder function, was able to maintain an erection, and experienced sensation with ejaculation. Follow-up radiographs demonstrated good alignment of the thoracolumbar spine with a good bony fusion (Fig. 24.2 A and B). Case 2. A seventeen-year-old white female inpatient was being treated at a local hospital for phencyclidine (PCP) toxic psychosis. She escaped from the psychiatric ward and jumped off a 50-foot high roof, landing on her feet on soft ground. Although the emergency room physician thought she was able to minimally move her feet immediately after the fall, she was observed to have a complete flaccid paraplegia one-half hour after injury. Sensory examination revealed marked hypesthesia in the lower extremities with a TIl level, and there was complete saddle anesthesia. Light touch was preserved. Deep tendon reflexes were absent in the lower extremities. Rectal sphincter tone was absent. Radiographic evaluation revealed a dislocated compressive spine fracture at the thoracolumbar junction, with 85-to-90 degree angulation. The inferior cartilaginous end plate of T12 slipped forward over the anterior aspect of the body on L1 (Fig. 24.3). Under anesthesia, an 80% closed reduction of the fracture was carried out by prone hyperextension positioning on the operating table. A decompressive lami-
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joints, and adds bony chips to promote true bony fusion. Within 1 to 2 weeks following surgery, a body cast is applied, and the patient can begin ambulation and rehabilitation. The length of time necessary for the patient to remain in the body cast is somewhat variable, but should be a minimum of 20 to 24 weeks.
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FIG. 24.1. Case 1. Lateral radiograph, demonstrating compressive, subluxed fracture of T12 on Ll, angulated at approximately 25 degrees.
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nectomy of TII-Ll was performed with further reduction of the fracture site. Exploration of conus medullaris and cauda equina did not reveal any intradural pathology. Compressive Harrington rods were then inserted and a bony fusion was performed (Fig. 24.4). Postoperatively the patient's motor function began to improve. However, radiographs performed 3 weeks following surgery demonstrated slippage of the Harrington compressive rods at the fracture site (Fig. 24.5 A and B). A second surgical procedure was performed, with replacement of the compressive Harrington rods with distraction rods. An intraoperative myelogram was performed which demonstrated free flow of contrast material at the fracture site. Postoperatively, a body case was applied. At follow-up, 8 months after the second surgical procedure, the patient demonstrated virtually total recovery of motor function of the lower extremities. She ambulated easily without a cane. There was some tendency toward a flexion deformity of the toes. Sensory examination demonstrated decreased sensation in the S2, 3, 4 dermatomes, more on the left than the right. Deep tendon reflexes were 1 to 2+ and symmetrical. Babinski sign was not present. Some return of rectal sphincter tone was demonstrated; however, the patient controlled bowel and
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FIG. 24.2. (A) Case 1. Lateral radiograph, after Harrington distraction rods were inserted, demonstrating good alignment and contour of the spinal canal. (B) Anteroposterior radiograph of same patient after Harrington rod insertion.
TREATMENT OF THORACOLUMBAR INJURIES
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bladder function more by timing than by actual sensation. Radiographs demonstrated good alignment of the thoracolumbar spine (Fig. 24.6, A and B).
DISCUSSION
Guttmann has long opposed surgical intervention in the management of fracture dislocations of the spine with concomitant neurological dys-
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FIG. 24.3. Case 2. Lateral radiograph demonstrating dislocated compressive fracture at the thoracolumbar junction, with 85-to-90-degrees angulation.
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function (7-9). Some of his objections to operative intervention were the worsening of stability and resultant deformities after neurosurgical decompression, often without significant return of neurological function. Many methods of internal fixation of the spine have been advocated.
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FIG. 24.4. Case 2. Lateral radiograph of patient after Harrington compressive rod insertion, demonstrating good alignment of the thoracolumbar spine.
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Wire loops (18, 21, 23), plates (10, 20, 27, 28), Weiss springs (25), and methylmethacrylate fixation (17, 24) have all been suggested. However, distraction Harrington rods appear to have a distinct advantage (3-6, 1113, 26). Their role as an internal splint is probably not significantly superior to the other methods. However, by distracting the vertebrae at the fracture site, they can significantly restore contour and alignment and can even relieve compression of the contents of the spinal canal from posteriorly displaced segments of vertebral bodies. The use of Harrington compressive rods appears to be rather limited to flexion distraction type fractures, where posterior compression is 'necessary for stability. The combination of neurosurgical decompression and Harrington rod distraction stabilization appears to provide the setting for maximum return of
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FIG. 24.5. (A) Case 2. Lateral radiograph of thoracolumbar spine 2 weeks after insertion of Harrington compressive rods. Note angulation of vertebral body at fracture site. (B) Anteroposterior radiograph of thoracolumbar spine of same patient 2 weeks after insertion of Harrington compressive rods. Note marked lateral displacement of Ll.
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neurological function as well as early ambulation and rehabilitation in the majority of cases. With this treatment regimen, we finally may have occasion to be mildly optimistic toward the final outcome of treated thoracolumbar spine fractures with neurological deficit. REFERENCES 1. Bedbrook, G. M. Use and disuse of surgery in lumbo-dorsal fractures. J. Western Pacific Orthop Assoc., 6: 5-26, 1969. 2. Chance, G. Q. Note on a type of flexion fracture of the spine. Br. J. Radiol., 21: 452-453, 1948.
3. Dickson, J. H., Harrington, P. R., and Erwin, W. D. Harrington instrumentation in the fractured, unstable thoracic and lumbar spine. Tex. Med., 69: 91-98,1973. 4. Erickson, D. L., Leider, L. L., and Brown, W. E. One stage decompression-stabilization for thoracolumbar fractures. Spine, 2: 53-56, 1977. 5. Flesch, J. R., Leider, L. L., Erickson, D. L., et al. Harrington instrumentation and spine fusion for unstable fractures and fracture-dislocations of the thoracic and lumbar spine. J. Bone Joint Surg. (Am.) 59: 143-153, 1977.
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FIG. 24.6. (A) Case 2. Lateral radiograph of thoracolumbar spine 7 months after Harrington distraction rod insertion. Note good alignment of thoracolumbar spine and bony fusion. (B) Anteroposterior radiograph corresponding to Fig. 24.6A. Note good alignment of thoracolumbar spine.
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6. Grantham, S. A., Malberg, M. I., and Smith, D. M. Thoraco-Iumbar spine flexiondistraction injury. Spine, 1: 172-177, 1976. 7. Guttmann, L. Initial treatment of traumatic paraplegia. Proc. R. Soc. Med., 47: 11031109,1954. 8. Guttmann, L. Spinal deformities in traumatic paraplegics and tetraplegics following surgical procedures. Paraplegia, 7: 38-58, 1969. 9. Guttmann, L. Surgical aspects of the treatment of traumatic paraplegia. J. Bone Joint Surg. (Br.), 31-B: 399-403, 1949. 10. Hardy, A. G. The treatment of paraplegia due to fracture dislocations of the dorsolumbar spine. Paraplegia, 3: 112-123, 1965. 11. Harrington, P. R. Instrumentation in spine instability other than scoliosis. S. Afr. J. Surg.,5: 7-12, 1967. 12. Harrington, P. R. Technical details in relation to the successful use of instrumentation in scoliosis. Orthop. Clin. North Am., 3: 49-67,1972. 13. Harrington, P. R., and Dickson, J. H. The development and further prospects of internal fixation of the spine. Isr. J. Med. Sci., 9: 773-778, 1973. 14. Holdsworth, F. W. Fractures, dislocations, and fracture-dislocations of the spine. J. Bone Joint Surg. (Br.), 45-B: 6-20, 1963. 15. Holdsworth, F. W. Fractures, dislocations, and fracture-dislocations of the spine. J. Bone Joint Surg. (Am.), 52-A: 1534-1551, 1970. 16. Holdsworth, F. W., and Hardy, A. Early treatment of paraplegia from fractures of the thoraco-Iumbar spine. J. Bone Joint Surg. (Hr.), 35-B: 540-550, 1953. 17. Hoppenstein, R. Immediate spinal stabilization using an acrylic prosthesis (Preliminary report). Bull. Hosp. Joint Dis. 33: 66-75, 1972. 18. Kaufer, H., and Hayes, J. T. Lumbar fracture-dislocation. A study of twenty-one cases. J. Bone Joint Surg. (Am.), 48-A: 712-730, 1966. 19. Larson, S. J., Holst, R. A., Hemmy, D. C., et at. Lateral extracavitary approach to traumatic lesions of the thoracic and lumbar spine. J. Neurosurg., 45: 628-637, 1976. 20. Lewis, J., and McKibbin, B. The treatment of unstable fracture-dislocations of the thoraco-Iumbar spine accompanied by paraplegia. J. Bone Joint Surg. (Br.), 56-B: 603-612, 1974. 21. Munro, D. The role of fusion or wiring in the treatment of acute traumatic instability of the spine. Paraplegia, 3: 97-111, 1965. 22. Rennie W., and Mitchell, N. Flexion distraction fractures of the thoracolumbar spine. J. Bone Joint Surg. (Am.)., 55-A: 386-390, 1973. 23. Smith, W. S., and Kaufer, H. Patterns and mechanisms of lumbar injuries associated with lap seat belts. J. Bone Joint Surg. (Am.), 51-A: 239-254,1969. 24. Spence, W. T. Internal plastic splint and fusion for stabilization of the spine (Letter). Clin. Orthop., 92: 325-329, 1973. 25. Weiss, M., and Bentkowski, Z. Biomechanical study in dynamic spondylodesis of the spine. Clin. Orthop., 103: 199-203, 1974. 26. Whitesides, T. E., Jr., and Shah, S. G. On the management of unstable fractures of the thoracolumbar spine. Spine, 1: 99-107, 1976. 27. Williams, E. W. M. Traumatic paraplegia. In Recent Advances in the Surgery of Trauma, pp. 171-186, edited by D. N. Matthews. A. Churchill, London, 1963. 28. Wilson, P. D., and Straub, L. R. Lumbosacral Fusion with Metallic-Plate Fixation. In Instructional Course Lectures, The American Academy of Orthopaedic Surgeons, Vol. 9. pp. 53-57. J. W. Edwards, Ann Arbor, 1952.
The management of thoracolumbar spine injuries has undergone continuous change in the modern surgical era. From conservative nonoperative care (1, 7-9) to aggressive surgical intervention by neurological surgeons, with side roads of enthusiasm by orthopedic surgeons recommending fusion with no decompression (18, 20), the waters have remained muddied, with no clear winner emerging. Often, the neurosurgical approach, stressing decompression of the neural elements, accomplished this at the expense of spinal stability, while the zest of the orthopedic surgeon for spinal stability, at times, overlooked the need for neural element decompression. Recently, with the apparent happy marriage of neurological surgeons and orthopedic surgeons, the management of thoracolumbar spine injuries has benefited, with perhaps the best from both worlds being consolidated into a unified plan which takes the needs of both systems (neural and skeletal) into account. BIOMECHANICS OF SPINE FRACTURES
Because the thoracic spine is splinted by the ribs, the majority of noncervical spine fractures occur at or near the thoracolumbar junction. Various forces can be exerted on the spine, with differing types of pathoanatomy. Vertical compression forces, when exerted on the straightened spine, generally cause a collapse of the vertebral body, most often LI, with a resultant "burst fracture." These fractures often occur in parachutists who land improperly, people jumping from high places and landing on their feet, etc. Flexion forces, often occurring in auto accidents, result in wedge compression fractures of the vertebral body. Oftentimes, the posterior ligaments remain intact, allowing these fractures to remain stable. Injuries due to. extension forces are far more common in the cervical spine than in the thoracolumbar spine. Fractures of the posterior elements, e.g., neural arches, and facets may occur, with resultant neurolog570
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CHAPTER
TREATMENT OF THORACOLUMBAR INJURIES
571
CLINICAL EVALUATION AND SURGICAL TECHNIQUE
A comprehensive physical examination is always imperative and can be exceedingly helpful in determining the type of injury. A gap between the spinous processes may be palpable, indicating that the interspinous and supraspinous ligaments have been torn. A bruise or abrasion on the back or side of one shoulder might indicate a rotational type of injury, with the strong possibility of resultant instability of the spine. Injuries to the feet or legs (broken heels or femurs) in patients who have jumped from buildings might suggest compression fractures of Ll. Multiple detailed neurological examinations are mandatory in all suspected spine fractures. The initial examination, performed in the emergency room, must be metiulous and recorded. It is exceedingly important to document any preserved neurological function in the so-called "complete" lesion. Often, patchy areas of preserved sensation are present and signify that neural elements are partially conducting across the injured zone. This is important in assessing prognosis and possible return of function. We have found the modality of light touch to be most useful for these considerations. The examiner can cover the entire body by running his hands over both legs, trunk, etc., in literally seconds, and can save pinprick testing for those areas which the light touch exam demonstrated possible preserved sensation. In thoracolumbar spine injuries, examina-
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ical deficit secondary to indriven bone in the spinal canal. If the anterior longitudinal ligament is also avulsed, these fractures are unstable. Perhaps the worst injuries occur when rotation forces are applied to the spine. Generally, all the ligaments are ruptured. Often, rotational and flexion forces are combined, resulting in facet fractures as well as ligamentous ruptures, with sheared or extruded intervertebral discs. Distraction forces, described originally by Chance (2) but further elaborated upon by Rennie and Mitchell (22), are usually a combination of flexion and distraction and produce a horizontal splitting of the vertebral body and neural arches, generally through the pedicles. It has been suggested that this type of injury can occur during an automobile accident, when the pelvis is anchored by a seat belt and the trunk initially flexes upon impact, but inertial forces continue to move the trunk forward, creating distraction. These fractures are generally unstable and best stabilized by Harrington compression rods. Generally, thoracolumbar fractures produced by either pure flexion or extension forces will be stable, even though the vertebral body may be significantly fractured, since the ligaments usually remain intact. However, when rotational forces are added to either flexion or extension forces, the ligaments are ruptured and the vertebra is fractured, and under these circumstances instability usually results (14-16).
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tion of rectal sphincter tone is extremely important and may help to differentiate conus lesions from cauda equina lesions. The importance of multiple neurological exams cannot be stressed too heavily. Each examination tells the examiner the status of the patient's nervous system at that point in time. Far more important is a feeling for any dynamic changes which are occurring. Is there progression of a neurological deficit? Is the initial paraplegia improving? These questions, which are exceedingly important in planning an effective treatment regimen, can only be answered after multiple neurological examinations, ideally by the same individual. Plain radiographs .of the spine in the anteroposterior, lateral, and oblique projection are taken. Obvious fractures and changes in alignment can usually be seen. Bone fragments in the spinal canal occasionally can be seen on plain radiographs but, often, tomograms are necessary and should be done if the information is not readily available from the plain radiographs. A gap between the spinous processes or pedicles is indicative of ligamentous rupture and suggests an unstable fracture. Fractures of the transverse processes may be indicative of a rotational type of injury, and may also suggest instability. Myelography need not be done on a regular basis. Roentgenographic confirmation of spine fracture and/or malalignment, coupled with neurological dysfunction, is generally an indication for surgery. However, if the neurological lesion is clinically complete, and gross malalignment does not exist, myelography may be helpful in deciding which patients will not benefit from surgery, i.e., the patient with a "complete" neurological deficit with no evidence of instability or malalignment from radiographic examination, whose myelogram does not demonstrate significant neural impingement, would not generally be considered for surgery. All patients suspected of having a thoracolumbar spine injury, with resultant neural injury, should have a Foley catheter inserted in the bladder in the emergency room and should be given systemic corticosteroids. Although clear-cut, undeniable experimental evidence for the beneficial effects of steroids in spinal cord injury is still lacking, nevertheless, the feeling among clinicians regarding its positive effects is strong enough to warrant its use at this time. We use dexamethasone, 10 mg, I.M., immediately and 4 mg, I.M., q.4 hours. Some physicians use "mega" doses, such as 2 g Solu-Medrol acutely (which is roughly the same as 500 mg dexamethasone). The primary goal of all treatment regimes ought to be to ultimately restore the patient to a maximum functional status. For thoracolumbar spine injuries with resultant neurological deficit, we feel this is best accomplished by combining 2 goals, decompression of the neural elements to allow maximum neurological recovery and stabilization of the spine,
TREATMENT OF THORACOLUMBAR INJURIES
573
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which will allow early mobilization and rehabilitation. Consequently, all patients with unstable thoracic and lumbar fractures are stabilized. All patients with incomplete neurological lesions of the spinal cord, conus medullaris, or cauda equina, in whom there is evidence of neural compression, either by plain radiography or myelography, are treated by decompression and stabilization. Patients with complete lesions, in whom radiographic neural compression can be demonstrated, also fall into this category. When the patient is felt to be clinically stable, operation is elected. General endotracheal anesthesia is used. The patient is placed prone on the operating table on lateral pads to prevent- abdominal compression. Occasional temporary hyperextension may be employed to help reduce a marked flexion malalignment (case 2). A midline incision is utilized and made long enough to insure the exposure of at least 5 vertebral levels. This length of exposure is necessary for Harrington rod placement. The paravertebral muscles are mobilized bilaterally, out laterally to expose the zygapophyseal joints. The posterior elements are carefully examined. Fractures not seen on the radiographs often become apparent. It is not uncommon to find torn dura, herniated cauda equina entangled in bone fragments, indriven bone fragments into the dural contents, and partially or completely extruded discs. A laminectomy is performed at the level of the observed pathology. If the dura is torn, the intradural contents are examined and bone fragments are removed. Herniated rooletes of the cauda equina are gently returned to the intradural compartment, and every attempt is made to close the dura over the cauda equina. Dural substitutes are grafted into place whenever primary closure of the dura will result in constriction of the dural sac. If a segment of an intervertebral disc is herniated into the spinal canal, it is removed. After exposure and decompression are completed, the orthopedic surgeon inserts Harrington distraction rods. In our opinion, Harrington distraction rods, rather than compression rods, are to be preferred in the overwhelming majority of cases. The Harrington rods are generally inserted 2 segments above and 2 segments below the fracture site, thereby spanning a total of 5 vertebral levels. Several authors have advocated employing somatosensory evoked response recording during Harrington rod insertion (19). Most thoracolumbar fractures have an element of posterior vertebral body displacement, which projects into the spinal canal. Decompressive laminectomy will not alter this pathoanatomy. However, proper Harrington rod distraction generally eliminates this displacement, restoring the normal contours of the vertebral canal. The rods enhance the decompression, and maintain it. By maintaining this decompression, and by stabilizing the spine, early mobilization and rehabilitation are possible. After insertion of the rods, the orthopedic surgeon prepares the zygapophyseal
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CASE REPORTS Case 1. A nineteen-year-old white male was riding his motorcycle, when he experienced a bad jump which lifted him off his motorcycle and then back into the seat. He immediately experienced excruciating mid-low back pain with loss of sensation and movement of his lower extremities. On physical examination in the emergency room, he was found to have flaccid paraplegia with minimal quadriceps function bilaterally. He had a complete sensory level at L5. Deep tendon reflexes were absent in the lower extremities. Rectal sphincter tone was absent. Radiographic examination revealed a compressive subluxed fracture of T12 on L1, angulated at about 25 degrees (Fig. 24.1). A myelogram demonstrated a complete block at T12-Ll. A Foley catheter was inserted, and the patient was given systemic corticosteroids. He was taken to the operating room where, under general endotracheal anesthesia, a decompressive laminectomy of T10-L1 was accomplished. Multiple bony fragments were visualized within the spinal canal and removed. Thoracolumbar spine fusion was carried out by the insertion of distraction Harrington rods and an additional lateral bony fusion. After surgery, a body cast was applied. At his last follow-up, approximately 14 months after surgery, the body cast had been removed. The patient was ambulating unassisted without a cane and with minimal unsteadiness. He demonstrated full range of motion of his lower extremities but had minimal diffuse weakness of the muscle groups of his lower extremities and extensors. He demonstrated minimal spasticity in both lower extremities. His sensory examination was essentially normal. Deep tendon reflex examination revealed 3 to 4+ symmetrical reflexes with several beats of ankle clonus bilaterally. Good rectal sphincter tone was present. The patient has complete voluntary control of bowel and bladder function, was able to maintain an erection, and experienced sensation with ejaculation. Follow-up radiographs demonstrated good alignment of the thoracolumbar spine with a good bony fusion (Fig. 24.2 A and B). Case 2. A seventeen-year-old white female inpatient was being treated at a local hospital for phencyclidine (PCP) toxic psychosis. She escaped from the psychiatric ward and jumped off a 50-foot high roof, landing on her feet on soft ground. Although the emergency room physician thought she was able to minimally move her feet immediately after the fall, she was observed to have a complete flaccid paraplegia one-half hour after injury. Sensory examination revealed marked hypesthesia in the lower extremities with a TIl level, and there was complete saddle anesthesia. Light touch was preserved. Deep tendon reflexes were absent in the lower extremities. Rectal sphincter tone was absent. Radiographic evaluation revealed a dislocated compressive spine fracture at the thoracolumbar junction, with 85-to-90 degree angulation. The inferior cartilaginous end plate of T12 slipped forward over the anterior aspect of the body on L1 (Fig. 24.3). Under anesthesia, an 80% closed reduction of the fracture was carried out by prone hyperextension positioning on the operating table. A decompressive lami-
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joints, and adds bony chips to promote true bony fusion. Within 1 to 2 weeks following surgery, a body cast is applied, and the patient can begin ambulation and rehabilitation. The length of time necessary for the patient to remain in the body cast is somewhat variable, but should be a minimum of 20 to 24 weeks.
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FIG. 24.1. Case 1. Lateral radiograph, demonstrating compressive, subluxed fracture of T12 on Ll, angulated at approximately 25 degrees.
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nectomy of TII-Ll was performed with further reduction of the fracture site. Exploration of conus medullaris and cauda equina did not reveal any intradural pathology. Compressive Harrington rods were then inserted and a bony fusion was performed (Fig. 24.4). Postoperatively the patient's motor function began to improve. However, radiographs performed 3 weeks following surgery demonstrated slippage of the Harrington compressive rods at the fracture site (Fig. 24.5 A and B). A second surgical procedure was performed, with replacement of the compressive Harrington rods with distraction rods. An intraoperative myelogram was performed which demonstrated free flow of contrast material at the fracture site. Postoperatively, a body case was applied. At follow-up, 8 months after the second surgical procedure, the patient demonstrated virtually total recovery of motor function of the lower extremities. She ambulated easily without a cane. There was some tendency toward a flexion deformity of the toes. Sensory examination demonstrated decreased sensation in the S2, 3, 4 dermatomes, more on the left than the right. Deep tendon reflexes were 1 to 2+ and symmetrical. Babinski sign was not present. Some return of rectal sphincter tone was demonstrated; however, the patient controlled bowel and
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FIG. 24.2. (A) Case 1. Lateral radiograph, after Harrington distraction rods were inserted, demonstrating good alignment and contour of the spinal canal. (B) Anteroposterior radiograph of same patient after Harrington rod insertion.
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bladder function more by timing than by actual sensation. Radiographs demonstrated good alignment of the thoracolumbar spine (Fig. 24.6, A and B).
DISCUSSION
Guttmann has long opposed surgical intervention in the management of fracture dislocations of the spine with concomitant neurological dys-
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FIG. 24.3. Case 2. Lateral radiograph demonstrating dislocated compressive fracture at the thoracolumbar junction, with 85-to-90-degrees angulation.
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function (7-9). Some of his objections to operative intervention were the worsening of stability and resultant deformities after neurosurgical decompression, often without significant return of neurological function. Many methods of internal fixation of the spine have been advocated.
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FIG. 24.4. Case 2. Lateral radiograph of patient after Harrington compressive rod insertion, demonstrating good alignment of the thoracolumbar spine.
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Wire loops (18, 21, 23), plates (10, 20, 27, 28), Weiss springs (25), and methylmethacrylate fixation (17, 24) have all been suggested. However, distraction Harrington rods appear to have a distinct advantage (3-6, 1113, 26). Their role as an internal splint is probably not significantly superior to the other methods. However, by distracting the vertebrae at the fracture site, they can significantly restore contour and alignment and can even relieve compression of the contents of the spinal canal from posteriorly displaced segments of vertebral bodies. The use of Harrington compressive rods appears to be rather limited to flexion distraction type fractures, where posterior compression is 'necessary for stability. The combination of neurosurgical decompression and Harrington rod distraction stabilization appears to provide the setting for maximum return of
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FIG. 24.5. (A) Case 2. Lateral radiograph of thoracolumbar spine 2 weeks after insertion of Harrington compressive rods. Note angulation of vertebral body at fracture site. (B) Anteroposterior radiograph of thoracolumbar spine of same patient 2 weeks after insertion of Harrington compressive rods. Note marked lateral displacement of Ll.
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neurological function as well as early ambulation and rehabilitation in the majority of cases. With this treatment regimen, we finally may have occasion to be mildly optimistic toward the final outcome of treated thoracolumbar spine fractures with neurological deficit. REFERENCES 1. Bedbrook, G. M. Use and disuse of surgery in lumbo-dorsal fractures. J. Western Pacific Orthop Assoc., 6: 5-26, 1969. 2. Chance, G. Q. Note on a type of flexion fracture of the spine. Br. J. Radiol., 21: 452-453, 1948.
3. Dickson, J. H., Harrington, P. R., and Erwin, W. D. Harrington instrumentation in the fractured, unstable thoracic and lumbar spine. Tex. Med., 69: 91-98,1973. 4. Erickson, D. L., Leider, L. L., and Brown, W. E. One stage decompression-stabilization for thoracolumbar fractures. Spine, 2: 53-56, 1977. 5. Flesch, J. R., Leider, L. L., Erickson, D. L., et al. Harrington instrumentation and spine fusion for unstable fractures and fracture-dislocations of the thoracic and lumbar spine. J. Bone Joint Surg. (Am.) 59: 143-153, 1977.
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FIG. 24.6. (A) Case 2. Lateral radiograph of thoracolumbar spine 7 months after Harrington distraction rod insertion. Note good alignment of thoracolumbar spine and bony fusion. (B) Anteroposterior radiograph corresponding to Fig. 24.6A. Note good alignment of thoracolumbar spine.
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6. Grantham, S. A., Malberg, M. I., and Smith, D. M. Thoraco-Iumbar spine flexiondistraction injury. Spine, 1: 172-177, 1976. 7. Guttmann, L. Initial treatment of traumatic paraplegia. Proc. R. Soc. Med., 47: 11031109,1954. 8. Guttmann, L. Spinal deformities in traumatic paraplegics and tetraplegics following surgical procedures. Paraplegia, 7: 38-58, 1969. 9. Guttmann, L. Surgical aspects of the treatment of traumatic paraplegia. J. Bone Joint Surg. (Br.), 31-B: 399-403, 1949. 10. Hardy, A. G. The treatment of paraplegia due to fracture dislocations of the dorsolumbar spine. Paraplegia, 3: 112-123, 1965. 11. Harrington, P. R. Instrumentation in spine instability other than scoliosis. S. Afr. J. Surg.,5: 7-12, 1967. 12. Harrington, P. R. Technical details in relation to the successful use of instrumentation in scoliosis. Orthop. Clin. North Am., 3: 49-67,1972. 13. Harrington, P. R., and Dickson, J. H. The development and further prospects of internal fixation of the spine. Isr. J. Med. Sci., 9: 773-778, 1973. 14. Holdsworth, F. W. Fractures, dislocations, and fracture-dislocations of the spine. J. Bone Joint Surg. (Br.), 45-B: 6-20, 1963. 15. Holdsworth, F. W. Fractures, dislocations, and fracture-dislocations of the spine. J. Bone Joint Surg. (Am.), 52-A: 1534-1551, 1970. 16. Holdsworth, F. W., and Hardy, A. Early treatment of paraplegia from fractures of the thoraco-Iumbar spine. J. Bone Joint Surg. (Hr.), 35-B: 540-550, 1953. 17. Hoppenstein, R. Immediate spinal stabilization using an acrylic prosthesis (Preliminary report). Bull. Hosp. Joint Dis. 33: 66-75, 1972. 18. Kaufer, H., and Hayes, J. T. Lumbar fracture-dislocation. A study of twenty-one cases. J. Bone Joint Surg. (Am.), 48-A: 712-730, 1966. 19. Larson, S. J., Holst, R. A., Hemmy, D. C., et at. Lateral extracavitary approach to traumatic lesions of the thoracic and lumbar spine. J. Neurosurg., 45: 628-637, 1976. 20. Lewis, J., and McKibbin, B. The treatment of unstable fracture-dislocations of the thoraco-Iumbar spine accompanied by paraplegia. J. Bone Joint Surg. (Br.), 56-B: 603-612, 1974. 21. Munro, D. The role of fusion or wiring in the treatment of acute traumatic instability of the spine. Paraplegia, 3: 97-111, 1965. 22. Rennie W., and Mitchell, N. Flexion distraction fractures of the thoracolumbar spine. J. Bone Joint Surg. (Am.)., 55-A: 386-390, 1973. 23. Smith, W. S., and Kaufer, H. Patterns and mechanisms of lumbar injuries associated with lap seat belts. J. Bone Joint Surg. (Am.), 51-A: 239-254,1969. 24. Spence, W. T. Internal plastic splint and fusion for stabilization of the spine (Letter). Clin. Orthop., 92: 325-329, 1973. 25. Weiss, M., and Bentkowski, Z. Biomechanical study in dynamic spondylodesis of the spine. Clin. Orthop., 103: 199-203, 1974. 26. Whitesides, T. E., Jr., and Shah, S. G. On the management of unstable fractures of the thoracolumbar spine. Spine, 1: 99-107, 1976. 27. Williams, E. W. M. Traumatic paraplegia. In Recent Advances in the Surgery of Trauma, pp. 171-186, edited by D. N. Matthews. A. Churchill, London, 1963. 28. Wilson, P. D., and Straub, L. R. Lumbosacral Fusion with Metallic-Plate Fixation. In Instructional Course Lectures, The American Academy of Orthopaedic Surgeons, Vol. 9. pp. 53-57. J. W. Edwards, Ann Arbor, 1952.
