|Year : 2023 | Volume
| Issue : 1 | Page : 11-17
Study on results of laminectomy with short-segment pedicle screw fixation in dorsolumbar fractures with respect to anatomical reduction, functional recovery and pain
Deepanshu Maheshwari, Gyaneshwar Tonk, Sumit Agarwal
Department of Orthopedics, Lala Lajpat Rai Memorial Medical College (LLRMMC), Meerut, Uttar Pradesh, India
|Date of Submission||28-Nov-2022|
|Date of Acceptance||02-Jan-2023|
|Date of Web Publication||20-Apr-2023|
Lala Lajpat Rai Memorial Medical College (LLRMMC), Meerut, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: The aim of this study was to report the results of laminectomy with short-segment pedicle screw fixation in thoracolumbar fracture. Materials and Methods: Forty-two patients were analyzed prospectively, followed up in the outpatient department for the period of 24 months. Results: Most of the patients in the study had reasonable to good neurological recovery in the postoperative period assessed in the form of American Spinal Cord Injury Association (ASIA) score. There was also an excellent improvement in the components of anatomical reduction such as vertebral height, Cobb’s angle, and anterior wedge angle, which was directly related to functional recovery of the patient. Patients postoperatively also got relieved in pain in the dorsolumbar region assessed based on Denis pain scale. Conclusion: Laminectomy with pedicle screw fixation is an excellent option for patients with thoracolumbar fracture; it not only decompresses the spine but also provides stability with minimal manageable complications.
Keywords: Dorsolumbar fracture, laminectomy, pedicle screw fixation
|How to cite this article:|
Maheshwari D, Tonk G, Agarwal S. Study on results of laminectomy with short-segment pedicle screw fixation in dorsolumbar fractures with respect to anatomical reduction, functional recovery and pain. J Bone Joint Dis 2023;38:11-7
|How to cite this URL:|
Maheshwari D, Tonk G, Agarwal S. Study on results of laminectomy with short-segment pedicle screw fixation in dorsolumbar fractures with respect to anatomical reduction, functional recovery and pain. J Bone Joint Dis [serial online] 2023 [cited 2023 Jun 7];38:11-7. Available from: http://www.jbjd.in/text.asp?2023/38/1/11/374430
| Introduction|| |
Fracture of the dorsolumbar spine is one of the major causes of disability in the current adult population. In the present era, high-energy trauma such as fall from height and road traffic accidents stay at top as the most common cause for spine fractures. One-year mortality rate of patients with paraplegia or other major spinal cord injuries is 7%, which makes these spinal injuries a serious problem; therefore, more than 270 research papers have already been published from addressing the concern. In a polytrauma patients, 5%–10% suffer spinal fractures or dislocations. Dorsolumbar junction comprises T 11 to L2 vertebra and is the most mobile segment which is more prone to injury. Nonsurgical treatments for dorsolumbar fractures were advised by most authors, but later reports pointed toward the advantage of open reduction and internal fixation. Pedicle screw fixation with laminectomy for decompressing the spine has become the gold standard in managing these spinal injuries and is also one of the most common procedures done in orthopedics and thus it has been extensively studied and outcome of pedicle screw fixation has gained considerable attention.
| Materials and Methods|| |
This was a prospective observational study to analyze the outcome of laminectomy with short-segment pedicle screws fixation in dorsolumbar spine fractures. In this, we registered the patients with age 20–60 years with traumatic one or two vertebral fractures having a Thoracolumbar Injury Classification and Severity Score System (TLICS) score of >4. After thorough evaluation of the patients, we performed the open procedure using posterior midline approach using both mono and polyaxial pedicle screw of appropriate size. Patients with pathological fractures and TLICS score <4 were excluded from the study. A total of 47 patients were included in the study, of which five patients were lost on follow-up; therefore, in the remaining 42 patients, 28 men and 14 women were studied for an average duration of 24 months in the postoperative period through regular follow-up visits in outpatient department (OPD). Careful attention was paid for the development of any minor or major complication in the postoperative period. Neurological recovery of the patient was assessed using ASIA scoring system in pre and postoperative patients, while the 6, 12 and 24 months postoperative functional recovery and dorsolumbar pain were correlated to components of anatomical reduction such as vertebral height, Cobb’s angle, and anterior wedge angle.
| Operative Procedure|| |
In this study, we used a standard posterior approach centering the involved spinal unit, and the incision was extended one vertebral level above and below the fractured vertebrae. Deep dissection was carried out, cutting the spinous process and erasing the paraspinal muscle till the facets and mammillary process were exposed. The intersection method was used for the entry point, which is the point at the junction of lines joining the lateral aspect of the facet and line in the middle of the transverse process. An entry was made with k-wire before inserting the screw under C-arm guidance and probing was done on all four sides to make sure that all the four walls are intact. Tapping of the hole was done only till the pedicle body junction to obtain a good purchase at the body. Depth gauge was used for measuring the length of the screw, which was inserted under image guidance. The appropriate size rods were taken and contoured. The lock nut was applied after placing the rod over the pedicle screw and was tightened once the reduction was obtained by distraction [Figure 1]. After the appropriate distraction, vertebral height of fractured vertebrae was confirmed under C arm. After the indirect decompression, direct decompression was done by laminectomy of fractured vertebrae using rongeurs of appropriate size until ligamentum flavum was visualized. The wound was closed in layers after achieving hemostasis and a thorough wash. Sterile dressing was applied at the end.
| Method of Assessment|| |
Preoperatively neurological status of the patient was assessed using ASIA scoring system. X-ray DL spine AP and lateral were done which helped in calculating the anatomical parameters such as vertebral height, Cobb’s angle, and anterior wedge angle [Figure 2]. After the patient was operated, postoperative X-ray was evaluated for the same anatomical parameters [Figure 3]. The difference in vertebral height and angles in pre- and postoperated X-rays was documented. Postoperative ASIA scoring was done on day 3, repeated every third day, on discharge and on every follow-up of patients in OPD, last final documentation for comparing the result from preop ASIA scoring was done on 24-month follow-up.
Functional recovery of the patient was assessed using functional independence measure scale and pain in dorsolumbar region postoperatively was assessed using Denis pain scale at 6-, 12- and 24-month follow-up (final assessment at 24 month) in order to establish their correlation with vertebral height, Cobb’s angle, and anterior wedge angle.
| Results|| |
There were a total of 42 patients (28 men and 14 women) in the study, majority (50%) young adults in the age group of 20–30 years [Figure 4] with mean age of 35.8 years. A total of 30 of 42 patients in our study sustained injury following fall from height, while 12 patients had road traffic accidents [Figure 5]. L1 vertebrae (54.17%) was the most common vertebral level to be fractured followed by T12 (25%), L2 (12.5%), and T11 (8.33%) [Figure 6]. Maximum patients (62.5%) in our study had isolated spine fracture but the most common associated injury was calcaneus fracture accounting for 16.7% of total patients [Figure 7].
The mean preoperative ASIA sensory and motor subscore in this study was 147.25 ± 7.12 and 52.91 ± 3.83 respectively, while the 24-month postoperative sensory subscore was 160.83 ± 10.08 and motor subscore 64.0 ± 7.73. The mean vertebral height preoperatively in this study was 14.8 ± 2.77 mm, whereas the postoperative was 21.0 ± 2.41 mm, the height improved by 30%. In our study, the mean Cobb’s angle preoperatively was 20.96 ± 2.94 which improved to 11.92 ± 1.95 on 24-month follow-up postoperatively; on the contrary, the mean preoperative anterior wedge angle was 19.7 ± 4.03, the postoperative angle at 24-month follow-up was 11.9 ± 1.95, the improvement seen was 39.5%.
| Discussion|| |
Laminectomy with short-segment pedicle screw fixation is the ideal treatment for dorsolumbar spine fracture, it not only decompresses the spine at the level of injury but also provides stability for early mobilization of the patient. Recently, the percutaneous method of pedicle screw insertion has taken over the conventional open method of fracture reduction and stabilization, but in our center, we have practiced the conventional method of fixation for the study . Our study included 42 patients in total with vertebral fracture, and the most commonly fractured vertebral level in our study was L1 vertebrae which favors the theoretical literature as it is the zone of transition from flexible to rigid spine. Huang’s study also concluded L1 vertebrae as the most common vertebrae to be fractured including 48% of the patients, while Ye et al.’s study included 21 patients out of 44 patients who underwent L1 vertebrae fracture.
Talking about the associated injury, 26 patients in our study had isolated spine fracture. There was an associated calcaneal fracture in 16.7% of patients, whereas five patients had fracture other than fracture calcaneus (fracture distal end radius in three and fracture clavicle in two patients), and three patients had associated head injury following trauma. Erturer et al.’s prospective study on Evaluation of vertebral fractures and associated injuries in adults including 372 patients for duration of 5 years also concluded calcaneal fracture as the most common associated injury accounting for 9.4% of total patients under study. Only pitfall in our study is, it has low sample size and duration of our study is also short.
As per the neurological recovery of the patients, the mean preoperative ASIA sensory subscore in this study was 147.25 ± 7.12, whereas the postoperative score was 160.83 ± 10.08. There was a significant improvement in postoperative ASIA sensory subscore when compared with preoperative score, the same significant improvement was seen in postoperative motor subscore (64.0 ± 7.73) when compared with preoperative ASIA motor subscore (52.91±3.83). Mustafa et al. reported improvement of ASIA grade by 1 grade in six of the eight patients who had neurological affection, which is comparable and significant to the study of Mustafa et al.
The mean vertebral height preoperatively in this study was 14.8 ± 2.77 mm, whereas the postoperative was 21.0 ± 2.41 mm and the height was improved by 30% which is a significant improvement. In Ye et al.’s study, preoperative Cobb’s angle was 16.7 ± 5.2, after fixation the postoperative angle was 9.6 ± 4.5, while in our study, the mean Cobb’s angle preoperatively was 20.96 ± 2.94, which improved to 11.92 ± 1.95 on 24-month follow-up postoperatively. On the contrary, the mean preoperative anterior wedge angle in our study was 19.7 ± 4.03, the postoperative angle at 24-month follow-up was 11.9 ± 1.95. The improvement seen was 39.5%, Mustafa et al. reported an increase by 48% in anterior wedge angle postoperatively. The difference in AWA can be explained on the basis of an intermediate screw in fractured vertebrae which led to added stability to the spine which was deficient in our study.
In our study, there was a strong correlation between the functional recovery score and anatomical reduction based on anterior wedge angle, vertebral height, and Cobb’s angle [Table 1]. With an increase in vertebral height, the functional recovery score improved, while increase in Cobb’s angle and anterior wedge angle led to decrease in functional recovery score. Mustafa et al. evaluated the functional recovery of the patient based on ASIA grading on spinal impairment and also concluded the improvement in ASIA grade with decrease in Cobb’s angle at6-month follow-up.
|Table 1: Correlation between anatomical reduction (vertebral height, anterior wedge angle, Cobb’s angle) and functional recovery score|
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There was a strong inverse correlation between the vertebral height and pain perception (P = 0.02). Patients with vertebral height restored in postop had less pain in dorsolumbar region on 24-month follow-up but no correlation was found between pain and anterior wedge angle or Cobb’s angle [Table 2]. Avanzi et al. study on thoracolumbar burst fracture and correlation between kyphosis with function postoperative in 36 patients concluded weak positive correlation between anterior wedge angle and pain in dorsolumbar region based on Denis pain scale.
|Table 2: Correlation between anatomical reduction (vertebral height, anterior wedge angle, Cobb’s angle) and pain perception|
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In our study, none of the patients had any infection at the surgical site till the last to follow-up. Lastly, three patients developed grade 2 bed sore at 6-month follow-up for which they were treated conservatively by local debridement and dressing while two patients developed urinary tract infection, of which one patient developed it in immediate postop and second patient on 6-month follow-up for which patients were treated accordingly with appropriate antibiotics.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2]