| Abstract |
Τhe management of fractures of the thoracolumbar spine remains a challenge to the spinal surgeon. The goal in the treatment of fractures is to achieve permanent pain-free stability. Although clinical evidence supports operative management, conservative treatment is also useful. Many classifications have been proposed for the classification of injury severity, and prognosis of the patients. All classifications accept the fact that imaging techniques provide only a static view of spinal injuries. The purpose of these prospective studies has been algorithmic approach for the management of thoracolumbar burst spine fractures. These studies assessed the efficacy of the Gertzbein classification and the Load Sharing scoring on selection, conservative or operative treatment and prognosis of the patients included in these studies. Fifty patients with incomplete burst fractures, burst split fractures, and complete burst fractures (Gertzbein A3) in the thoracolumbar zone, with a Load Sharing score of 6 points or less, were treated in a closed manner with a custom molded thoracolumbosacral brace. The mean loss of SI in our study group was 22%, and the average AVC loss was 5,5% (statistically non-significant). The functional outcome of our study group was satisfactory in 28 of 30 patients (93%) and a mean correction of 50% + 13% in SCO was achieved (statistically significant). The initial severity of injury on x-ray imaging or residual deformity following conservative treatment, did not correlate with functional outcome. Also one hundrend patients with a thoracolumbar burst spinal fracture and with a Load Sharing score of 6 points or less, were treated in a closed manner with a custom molded thoracolumbosacral brace. The mean loss of kyphosis in our study group was 20 and the average AVC loss was 9,5% (statistically non-significant), more than at the time of the initial injury. The SCO was reduced to 10 %, which was statistically significant. Indeed, it has been clearly shown that over a period course of between six months and two years the burst fracture remodels itself with a return to nearly normal dimensions of the canal. The functional outcome of our study group was satisfactory in 55 of 60 patients (91%) with a Load Sharing scoring of 3 and 4. Patients with 5 and 6 points had poor functional outcome. Finally, thirty patients were treated operatively with Load Sharing and Gertzbein classifications. Patients with Load Sharing scoring < 6 and Gertzbein Α were treated with a short segment posterior instrumentation and fusion, patients with Load Sharing scoring 7,8,9 and Gertzbein Α had an anterior short segment instrumentation and in patients with Load Sharing scoring 7,8,9 and Gertzbein B and C a short segment posterior instrumentation with fusion and an anterior strut graft was applied. Fewer motion segments were incorporated in the fusion, which was thus faster, less invasive, and less technically demanding. Radiological measurements from SI and CP showed a slight loss, but the clinical outcome for the patients was not affected. This slight loss of sagittal index, and compression percentage correction was probably caused because the initial x-rays had been taken with the patient supine because of the acuteness of the injury, and x-rays at the follow-up evaluation were taken with the patient upright. Hospitalization time was diminished, and the functional outcome of the study group was also satisfactory in 73,33% of the patients. Neurological improvement of one or two Frankel grades was also observed in 55,55 % of the neurological injured patients. In conclusion, the Load Sharing scoring can be combined with the Gertzbein classification for better fracture treatment and prognosis. The Gertzbein classification correlates the type of fracture with the degree of mechanical instability and neurological lesion. The Load Sharing classification correlates fracture comminution and displacement with mechanical stability. This classification does not grade ligament damage, and has nothing to do with mechanism of injury, and so it is a helpful adjunctive tool that can complete, but not replace, other classification. Patient selection, and careful evaluation of X-rays, C/T scan and MRI are fundamental components in the clinical success of these classifications. In using these classifications for operative decision making, no implant failures or pseudoarthrosis were recorded. The best candidates for short segment instrumentation and fusion are younger patients who would utilise spinal mobility, patients who are able to tolerate a two-stage reconstruction and patients in good general health. Also the Load Sharing scoring can be combined with the Gertzbein classification for the conservative treatment and prognosis of thoracolumbar spinal fractures. Because of the three charateristics of the fracture site the Load Sharing scoring can also predict the structural effects of the spinal injury, such as post-traumatic kyphosis, and thereby the functional outcome in conservatively treated patients.
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Αλγοριθμική προσέγγιση στο χειρισμό των θωρακοοσφυικών καταγμάτων
