Posterior Tension Band Wiring and Instrumentation for Thoracolumbar Flexion- Distraction Injuries

Journal of Orthopaedic Surgery 2014;22(1):88-91

Posterior tension band wiring and instrumentation for thoracolumbar flexion- distraction injuries

EG Hasankhani, F Omidi-Kashani Orthopedic Research Center, Orthopedic Department, Imam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran

anterior vertebral body height improved from 20.5 to 38.8 mm (p<0.001). The mean kyphosis improved ABSTRACT from 20.4º to 1.5º (p<0.001). Four patients had persistent neurologic deficit: ASIA scale C (n=2) and Purpose. To evaluate treatment outcome of tension D (n=2); their ASIA scales improved by one grade. All band wiring followed by posterior spinal fusion patients returned to their original work at 6 months. and instrumentation for thoracolumbar flexion- There were no intra-operative complications or distraction injury (FDI). implant failures. Methods. 36 men and 12 women aged 21 to 56 (mean, Conclusion. Posterior tension band wiring followed 36) years underwent tension band wiring followed by posterior spinal fusion and instrumentation for by posterior spinal fusion and instrumentation thoracolumbar FDIs achieved good outcome. using pedicular screws for FDI of the thoracolumbar spine. The injured vertebral levels were T11 (n=2), Key words: spinal fusion; spinal injuries T12 (n=12), T11-T12 (n=1), T12-L1 (n=1), L1 (n=28), and L2 (n=4). Anterior vertebral body height and kyphosis were measured before and after surgery. INTRODUCTION Neurologic status was assessed using the American Spinal Injury Association (ASIA) scale. The Oswestry 43% of spinal injuries are secondary to trauma.1,2 Disability Index questionnaire and visual analogue Neglected spinal instability may lead to severe scale for pain were also used. complications such as intractable pain, post-traumatic Results. The mean follow-up was 38 (range, 26–72) deformity, or neurologic deterioration. Flexion- months. At final follow-up, the mean visual analogue distraction injury (FDI) accounts for 5 to 15% of all scale for pain was 1.7, and the median Oswestry spinal injuries and most commonly occurs in the Disability Index was 4% (range, 0–32%). The mean thoracolumbar region. It is sometimes confused with

Address correspondence and reprint requests to: F Omidi-Kashani, Orthopedic Research Center, Orthopedic Department, Imam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. Email: [email protected] Vol. 22 No. 1, April 2014 Posterior tension band wiring for thoracolumbar flexion-distraction injuries 89 a compression or burst fracture and inappropriately transverse rolls under the chest and pelvis to create treated with an orthosis; the posterior column thoracolumbar hyperlordosis. Most reductions were disruption eventually leads to complications.1,3,4 achieved with this positioning and also with gentle, Radiography is the initial investigative tool for manual hyperextension force. The posterior surface the injured spine.5–7 In patients with FDI, posterior of the spine was cautiously exposed, and pedicular column disruption usually occurs through the screws were inserted into intact vertebrae above and ligaments (rather than bone), and spinal stability below the injured vertebra. The tension band wire should be achieved by open reduction and internal was then added and tightened on the upper and lower fixation.8,9 There is usually an associated compression intact spinous processes (Fig.). Two longitudinal fracture in the anterior part of the vertebral body, and rods with appropriate lordosis posture (about 5º simple distraction force through the pedicular screws more than normal regional lordosis) were inserted, can aggravate posterior injured elements (although it and then about 5 mm distraction of the screws was can also reduce the anterior fracture). To prevent this, applied to reduce the compressed vertebral bodies, posterior tension band wiring is added to the usual while the injured spine was tightly maintained, posterior instrumentation to oppose the dissociation using rigid, more posteriorly oriented wires. The of the posterior element while reducing the anterior rest of the procedure (facetectomy, decortication, and vertebra. This study evaluated treatment outcome spondylodesis) was conducted routinely. of tension band wiring followed by posterior spinal Postoperatively, a thoracolumbosacral orthosis fusion and instrumentation for thoracolumbar FDI. was used for about 3 months. Patients were followed up at months 1, 3, 6, and 12 and yearly thereafter. The Oswestry Disability Index questionnaire and visual MATERIALS AND METHODS analogue scale for pain were used.12–14 The percentage of correction of kyphosis was calculated relative to Between July 2007 and April 2011, 36 men and 12 normal, straight thoracolumbar sagittal alignment. women aged 21 to 56 (mean, 36) years underwent Loss of correction was determined at the final follow- tension band wiring followed by posterior spinal up. Pre- and post-operative outcome was compared fusion and instrumentation using pedicular screws using the Student’s paired t-test. A p value of <0.05 for FDI of the thoracolumbar spine. Patients who was considered statistically significant. underwent direct anterior decompression (for severe neurologic deficit) or direct anterior vertebral reconstruction10 (for McCormack classification of >6) RESULTS were excluded, as were those who were followed up for <24 months. The mechanisms of injury included The mean follow-up was 38 (range, 26–72) months. road accident (n=26), falling (n=14), crush injury At final follow-up, the mean visual analogue scale (n=6), and equestrian accident (n=2). 16 of the patients for pain was 1.7 (standard deviation [SD], 0.5; range, had other associated fractures of the spinal column 0–4), and the median Oswestry Disability Index was or extremities. The injured vertebral levels were T11 4% (range, 0–32%). The mean anterior vertebral body (n=2), T12 (n=12), T11-T12 (n=1), T12-L1 (n=1), L1 height improved from 20.5 (SD, 4.2) to 38.8 (SD, 4.1) (n=28), and L2 (n=4). The mean time interval from injury to surgery was 8 (range, 2–12) days. Radiography and computed tomography of the thoracolumbar spine were obtained, and anterior vertebral body height and kyphosis were measured. The latter was done by drawing lines parallel with the superior and inferior end plates of the intact adjacent upper and lower vertebrae, respectively. For those with an associated neurologic deficit or suspected posterior ligamentous injury, magnetic resonance imaging (MRI) was also performed. Neurologic status was assessed using the American Spinal Injury Association (ASIA) scale.11 In 2 patients, definitive diagnosis (disruption of the posterior ligamentous complex) could only be made during surgery. Figure Posterior tension band wiring and pedicular screw Patients were placed in a prone position, with 2 fixation for thoracolumbar flexion-distraction injury. 90 EG Hasankhani and F Omidi-Kashani Journal of Orthopaedic Surgery mm (p<0.001), with a mean percentage correction of anterior reconstruction. 95.1% (SD, 2.2%) and loss of correction of 2.1 (SD, Surgical instrumentation enables immediate 1.8) mm. The mean kyphosis improved from 20.4º stabilisation, more rapid mobilisation, and more (SD, 3.6º) to 1.5º (SD, 2.2º) [p<0.001], with a mean reliable neurologic recovery.17–19 In most patients percentage correction of 90.3% (SD, 3.1%) and loss with FDI (except for those with associated severe of correction of 3.1º (SD, 1.4º). Four patients had burst fractures), canal compromise is not significant persistent neurologic deficit: ASIA scale C (n=2) and and therefore direct decompression is not needed. D (n=2); their ASIA scales improved by one grade. All Surgical procedures for unstable injuries usually patients returned to their original work at 6 months. involve indirect deformity correction, posterior There were no intra-operative complications or fusion and instrumentation with pedicular screws implant failures. One patient developed symptomatic and rods.22–24 deep vein thrombosis, which resolved with medical Surgical procedures for FDIs secondary to treatment. Anti-thrombotic drugs were not used to interruption of the posterior ligamentous complex avoid the risk of an epidural haematoma; ambulation differ from those for other spinal injuries such as burst was encouraged as early as possible after surgery. fractures, and simple distraction is not indicated. In Another patient had a superficial wound infection, our study, the posterior spine was first reconstructed which healed with oral antibiotic therapy and local with tension band wiring, followed by open reduction wound care. with gentle distraction. In a study of 19 young adults who underwent posterior hybrid instrumentation (thoracic hooks and lumbar pedicular screws) DISCUSSION without any posterior tension band wiring, the About 50 to 60% of spine injuries occur at the surgical outcome was good, but neurologic deficit in thoracolumbar area,15 and the most commonly 9 of the patients (2 with ASIA scale B and 7 with ASIA injured vertebrae are L1 (50%), T12 (25%), and L2 scale A) persisted without any improvement.25 The (21%).16 This is consistent with the findings of our mean kyphosis improved from 13° (range, 4º–35°) study. 10 to 15% of these injuries are FDIs (type B of preoperatively to 4° (range, 0º–11°) at the final follow- the AO classification),17 and include 3 subtypes: B1 up.25 In our study, neurologic deficit persisted in 4 (posterior disruption predominantly ligamentous), patients (2 with ASIA scale C and 2 with ASIA scale B2 (posterior disruption predominantly osseous D), but their neurological scales improved one grade. [true Chance fracture]), and B3 (a hyperextension The mean kyphosis correction was higher (from 20.4º shear injury with anterior disruption through the to 1.5º); this may be due to the use of pedicular screws disc). The severity of injury depends on posture and only, compared to the use of hooks and screws. instantaneous axis of rotation at the time of the injury. A study reported a high rate of implant failure Depending on the axis of flexion, the vertebral body after posterior short-segment pedicular screw and disc may fail in compression or tension in FDIs.18 fixation for FDIs.26 There were 18 hardware failures MRI is useful in evaluation of posterior involving 20 pedicular screws (8 loose, 7 bent, and ligamentous injury.19–21 Comparing MRI with intra- 5 broken). This was likely due to improper use of a operative findings, MRI has a high diagnostic short-segment construct for these highly unstable accuracy and inter-observer reliability.19 In our study, thoracolumbar injuries. In our study, short-segment only 2 patients with a normal MRI had a posterior pedicular screws were not used. ligamentous injury subsequently identified intra- operatively. A high rate (40%) of associated abdominal CONCLUSION injury is reported in Chance-type fractures.21 The most common viscerae involved are the bowel and Posterior tension band wiring followed by posterior mesentery. Comprehensive abdominal studies are spinal fusion and instrumentation for thoracolumbar thus advocated. In our study, no patient had an FDIs achieved good outcome. abdominal injury, but there were 8 rib fractures, 4 transverse process fractures, 2 leg fractures, and 2 femoral shaft fractures. The absence of abdominal DISCLOSURE injury in our patients may be due to exclusion of the more severely injured patients who underwent No conflicts of interest were declared by the authors. Vol. 22 No. 1, April 2014 Posterior tension band wiring for thoracolumbar flexion-distraction injuries 91

REFERENCES

1. Aebi M. Classification of thoracolumbar fractures and dislocations. Eur Spine J 2010;19(Suppl 1):S2–7. 2. Inamasu J, Guiot BH. Thoracolumbar junction injuries after rollover crashes: difference between belted and unbelted front seat occupants. Eur Spine J 2009;18:1464–8. 3. Chapman JR, Agel J, Jurkovich GJ, Bellabarba C. Thoracolumbar flexion-distraction injuries: associated morbidity and neurological outcomes. Spine (Phila Pa 1976) 2008;33:648–57. 4. Hoshikawa T, Tanaka Y, Kokubun S, Lu WW, Luk KD, Leong JC. Flexion-distraction injuries in the thoracolumbar spine: an in vitro study of the relation between flexion angle and the motion axis of fracture. J Spinal Disord Tech 2002;15:139–43. 5. Angtuaco EJ, Binet EF. Radiology of thoracic and lumbar fractures. Clin Orthop Relat Res 1984;189:43–57. 6. Ballock RT, Mackersie R, Abitbol JJ, Cervilla V, Resnick D, Garfin SR. Can burst fractures be predicted from plain radiographs? J Bone Joint Surg Br 1992;74:147–50. 7. Keynan O, Fisher CG, Vaccaro A, Fehlings MG, Oner FC, Dietz J, et al. Radiographic measurement parameters in thoracolumbar fractures: a systematic review and consensus statement of the spine trauma study group. Spine (Phila Pa 1976) 2006;31:E156–65. 8. Jacobs RR, Asher MA, Snider RK. Thoracolumbar spinal injuries. A comparative study of recumbent and operative treatment in 100 patients. Spine (Phila Pa 1976) 1980;5:463–77. 9. Fabris D, Costantini S, Nena U, Gentilucci G, Ricciardi A. Cotrel-dubousset instrumentation in thoracolumbar seat belt- type and flexion-distraction injuries. J Spinal Disord 1994;7:146–52. 10. McCormack T, Karaikovic E, Gaines RW. The load sharing classification of spine fractures. Spine (Phila Pa 1976) 1994;19:1741–4. 11. Maynard FM Jr, Bracken MB, Creasey G, Ditunno JF Jr, Donovan WH, Ducker TB, et al. International Standards for Neurological and Functional Classification of Spinal Cord Injury. American Spinal Injury Association. Spinal Cord 1997;35:266–74. 12. Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine (Phila Pa 1976) 2000;25:2940–52. 13. Mousavi SJ, Parnianpour M, Mehdian H, Montazeri A, Mobini B. The Oswestry Disability Index, the Roland-Morris Disability Questionnaire, and the Quebec Back Pain Disability Scale: translation and validation studies of the Iranian versions. Spine (Phila Pa 1976) 2006;31:E454–9. 14. Wewers ME, Lowe NK. A critical review of visual analogue scales in the measurement of clinical phenomena. Res Nurs Health 1990;13:227–36. 15. Hu R, Mustard CA, Burns C. Epidemiology of incident spinal fracture in a complete population. Spine (Phila Pa 1976) 1996;21:492–9. 16. Knop C, Blauth M, Bühren V, Hax PM, Kinzl L, Mutschler W, et al. Surgical treatment of injuries of the thoracolumbar transition. 1: Epidemiology [in German]. Unfallchirurg 1999;102:924–35. 17. Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S. A comprehensive classification of thoracic and lumbar injuries. Eur Spine J 1994;3:184–201. 18. Heinzelmann M, Wanner GA. Thoracolumbar spine injuries. In: Boos N, Aebi M, editors. Spinal disorders. Fundamentals of diagnosis and treatment. Berlin: Springer-Verlag; 2008:883–924. 19. Haba H, Taneichi H, Kotani Y, Terae S, Abe S, Yoshikawa H, et al. Diagnostic accuracy of magnetic resonance imaging for detecting posterior ligamentous complex injury associated with thoracic and lumbar fractures. J Neurosurg 2003;99(1 Suppl):20–6. 20. Groves CJ, Cassar-Pullicino VN, Tins BJ, Tyrrell PN, McCall IW. Chance-type flexion-distraction injuries in the thoracolumbar spine: MR imaging characteristics. Radiology 2005;236:601–8. 21. Bernstein MP, Mirvis SE, Shanmuganathan K. Chance-type fractures of the thoracolumbar spine: imaging analysis in 53 patients. AJR Am J Roentgenol 2006;187:859–68. 22. Benzel EC. Biomechanics of spine stabilization: principles and clinical practice. New York: McGraw-Hill; 1995: 197–203. 23. Sar C, Bilen FE. Thoracolumbar flexion-distraction injuries combined with vertebral body fractures. Am J Orthop (Belle Mead NJ) 2002;31:147–51. 24. Abe E, Sato K, Shimada Y, Mizutani Y, Chiba M, Okuyama K. Thoracolumbar burst fracture with horizontal fracture of the posterior column. Spine (Phila Pa 1976) 1997;22:83–7. 25. Ramieri A, Domenicucci M, Cellocco P, Raco A, Costanzo G. Effectiveness of posterior tension band fixation in the thoracolumbar seat-belt type injuries of the young population. Eur Spine J 2009;18(Suppl 1):89–94. 26. Butt MF, Farooq M, Mir B, Dhar AS, Hussain A, Mumtaz M. Management of unstable thoracolumbar spinal injuries by posterior short segment spinal fixation. Int Orthop 2007;31:259–64.