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Transcript of BF L2-5 1996
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Copyright 1996 by
The Journal of Bone and Joint Surgery Incorporated
Burst Fractures of the Second through Fifth Lumbar Vertebrae
C L I N I C A L A N D R A D I O G R A P H I C R E S U L T S *
BY DAVID A. AND REYC HIK, M.D.F . DIRK H. ALAN DER, M.D.T KAROLYN M. SEN1CA, M.D. ,
AND E. SHANNON STAU FFER, M.D. , SPRINGFIE LD, ILLINOIS
nvestigation performed at the Southern llinois University School
of Medicine
Springfield
ABSTRACT: Fifty-five patie nts w ho had sustain ed
a burst fracture of the lumbar spine were followed for
a mean of seventy-nine months (range, twenty-four to
192 months) after the injury. Thirty patients had been
managed non-operatively with a short period of bed
rest followed by protected mobilization. The remaining
twenty-five patients had been managed operatively:
eight, with posterior arthrodesis with long-segment
hook-and-rod fixation; eight, with posterior arthrodesis
with short-segment transpedicular fixation; six, with
posterior arthrodesis and instrumentation followed by
anterior decompression and arthrodesis; and three,
with anterior decompression and arthrodesis.
Thirty-six patients had bee n neur ological } intact
at the time of presentation and had remained so
throughout the follow-up period. No neurological de
terioration or symptoms of late spinal stenosis were
seen .
Isolated partial single-nerve-root deficits re
solved regardless of the m ethod of treatment. Patients
who had had a complete single or a multiple-nerve-root
paralysis seemed to have benefited from anterior de
compression.
Although the anatomical results as seen on the
most recent radiographs were superior for the group
that had been managed operatively with long posterior
fixation or anterior and posterior arthrodesis, the most
recent pain scores and the functional outcomes were
similar for all treatment groups. At the latest follow-up
evaluation, some loss of spinal alignment was noted in
the patients who had been managed with short trans-
pedicular fixation; the alignment at the most recent
follow-up examination was comparable with that in
the patients who had been managed non-operatively.
For the patients who had had non-operative treat
ment, we were unable to predict the deformity at the
time of follow-up on the basis of the initial diagnos
tic radiographs. The clinical outcome was not related
*No benefits in any form have been received or will be received
from a commercial party related directly or indirectly to the subject
of this article. No funds were received in support of this study.
tGeisinger Clinic, 100 North Academy, Danville, Pennsylvania
17822.
^Dickson Diveley Midwest Orthopaedic Clinic, 4320 Wornall
Road, Suite
610,
Kansas City, Missouri64111.
Division of Orthopaedics and Rehabilitation, Southern Illinois
University School of Medicine, P.O. Box 19230, Springfield, Illinois
62794-9230.
to the deformity at the latest follow-up evaluation.
On the basis of the results of our study, we recom
mend non-operative treatment for patients who do not
have neurological dysfunction or who have an isolated
partial nerve-root deficit at the time of presentation.
For patients who have a multiple-nerve-root paralysis,
anterior decompression is indicated.
T h e r e h a s b e e n c o n s i d e r a b l e c o n t r o v e r s y r e g a r d
i n g w h a t c o n s t i t u t e s t h e b e s t t r e a t m e n t f o r l u m b a r b u r s t
f r a c t u re s . P r o p o n e n t s o f n o n - o p e r a t i v e t r e a t m e n t h a v e
c l a im ed th a t , ex cep t in p a t i e n t s wh o h av e a l a rg e r r es id
u a l k y p h o s i s , t h e c li n i ca l o u t co m e co m p are s f av o rab ly
w i t h t h a t of o p e r a t i v e t r e a t m e n t , w i t h o u t th e a t t e n d a n t
r isk of an operat ive procedure
91 1
'
5
-
2627
'
3438454652
. H o w e v e r ,
a d v o c a t e s o f s t a b i l i z a t i o n p r o c e d u r e s h a v e c i t e d b e t t e r
r e s t o r a t i o n o f a n a t o m i c a l a l i g n m e n t , m o r e r a p i d m o b i
l i z a ti o n , a n d i m p r o v e d n e u r o l o g i c a l o u t c o m e s w i t h o p
erative intervention
2
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4
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5
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7
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10121417
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23
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25
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28
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32
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33
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37
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39
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4748
. A fear
o f n e u r o l o g i c a l d e t e r i o r a t i o n , o r t h e b e l i e f t h a t o p e r a
t i v e r e a l i g n m e n t a n d a r t h r o d e s i s p r e v e n t l a t e s y m p
to m at i c j o in t d eg en e ra t i o n an d sp in a l s t en o s i s , h as l ed
s o m e a u t h o r s t o r e c o m m e n d o p e r a t i v e r a t h e r t h a n n o n -
operative treatment
3
'
5
'
8
'
10
-
12
-
14
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17
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23
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28
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33
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36
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39
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44
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47
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48
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50
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53
.
P r e v i o u s r e p o r t s h a v e d o c u m e n t e d c o n f l i c t i n g r e
s u l ts of n o n - o p e r a t i v e t r e a t m e n t o f p a t i e n t s w h o d o
not have a neuro logical def ici t
1
-
11
-'
7
-
26
-
38
-
44
-
52
. De n i s e t a l .
r ep o r t ed h ig h r a t es o f f a i l u re i n t h e fo rm o f sev ere d e
fo rm i ty , an i n c reas in g n eu ro lo g i ca l d e f i c i t , an d i n ca
p a c i t a t i n g p a i n
17
. T h e y c o n c l u d e d t h a t p a t i e n t s w h o
h a d b e e n m a n a g e d o p e r a t i v e l y f a r e d m u c h b e t t e r i n
t e r m s o f p a i n , d e f o r m i t y , r e t u r n t o w o r k , a n d n e u r o
l o g ic a l f u n c t i o n . M c E v o y a n d B r a d f o r d r e p o r t e d o n
t w e n t y - t w o p a t i e n t s w h o h a d i n i t i a l l y b e e n m a n a g e d
n o n - o p e r a t i v e l y
4 4
. A l t h o u g h n o n e u r o l o g i c a l d e t e r i o r a
t i o n was o b serv ed i n n eu ro lo g i ca l l y n o rm al p a t i en t s ,
t h e re wer e si x f a i l u res d u e t o an i n c rea s in g n e u ro lo g i
ca l d e f i c it i n p a r t i a l l y p a r a ly ze d p a t i en t s , i n c rea s in g d e
fo rm i ty , an d p er s i s t en t p a in .
D e s p i t e t h e s e p e s s i m i s t i c r e p o r t s , t h e r e i s a g r o w i n g
b o d y o f ev id en ce t h a t a b u r s t f r ac tu re wi th o u t a n eu ro
lo g i ca l d e f i c it can b e t r ea t e d n o n -o p era t i v e ly , wi th o n ly
r a r e n e u r o l o g i c a l d e t e r i o r a t i o n a n d w i t h a g o o d l o n g -
t e rm c l i n i ca l r esu l t . Wein s t e in e t a l .
52
, Ch an e t a l . , an d
M u m f o r d e t al .
45
r e p o r t e d t h e re s u l t s o f n o n - o p e r a t i v e
t r e a t m e n t o f t h o r a c o l u m b a r a n d l u m b a r b u r s t f r a c t u r e s .
1156
T H E J O U R N A L O F B O N E A N D J O IN T S U R G E R Y
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BURST FRAC TURE S OF THE SECOND THR OUG H FIFTH LUMBAR VERTE BRA E
1157
T A B L E I
DI S TRI BUTI ON OF THE-F IFT Y-FIVE PAT IE NT S AMONG THE F I V E T R E A T M E N T G R O U P S , A C C O R D I N G TO THE L E V E L OF THE F R A C T U R E
Level
of Fracture
G r o u pI:
Non-Op .
T rea tmen t
G r o u pII:
Posterior
Arthrodesis
(Long)
G r o u p
III:
Posterior
Arthrodesis
(Short)
G r o u pIV:
Ante r io rand
Posterior
Arthrodesis
G r o u p
V:
Anterior
Arthrodesis
Only
L2
L3
L4
L5
12
8
5
5
Of the 101pat ients in those three series, only one had
neurological deteriorat ion. All t h ree groups of investi
gators reported acceptable cl inical outcomes and the
lack of a relat ionship between the final anatomicalre
sultand the clinical sym ptoms.
A neurological defici t adds another component to
the process
of
making decisions regarding treatment .
No previous study, to our knowledge, has specifically
addressed the results of neurological injuries of the
cauda equina. Although neurological recovery
has
been
demonstrated after non-operat ive t reatment
of
t horaco
lumbar fractures
69153436
46
, there is current ly a t rend to
treat these injuries more intensively. Several reports
have documented improved neurological funct ion after
decompressive operative procedures
722
-
3742
.
The purpose
of the
presen t retrospect ive study
was
to compare the long-term radiographic and functional
resultsof t r ea t m en t of lumbar burst fractures with and
without operat ive decompression
and
arthrodesis .
aterials and ethod s
Seventy-four consecutive pat ientsinwhom alumbar
burst fractureat thesecond, third, fourth,orfifth lu mb ar
level
had
been t reated
at
Southern Illinois University
School of Medicine between 1976 and 1992 were iden
tified by a review of the records of the Or thopaedic
Spine Service.To be eligible for inclusion in the study,
the fracture had to have been non-pathological and
the pat ient had to have been fol lowed for more than
two years.Of the seventy-four patients,two haddiedof
causes unrelated to the injury of the spine, six were
contacted but refused to part icipate in the study,and
eleven had been lost to follow -up. This left fifty-five
pat ientsfor thereview.
There were for ty-one male and fourteen female
pat ien t s . The m ean age was thirty-one years (range,
four teen
to
s eventy-one years ) .
The
mechanisms
of
injury included a motor-vehicle accident (twenty-nine
pat ients),a fal l (seventeen pat ients),a motorcycle acci
dent (four pat ients),a crush injury (four patients), and
a small-aircraft a ccident (o ne patie nt) . Twenty-five frac
tures were at the second lumbar vertebra; seventeen,
at the third lumbar vertebra; eight ,at the fourth lum
bar ver tebra; and five, at the f if th lumba r v erteb ra
(Table I).Th ere w ere forty-five associated injuries in
twenty-three pat ients . Twenty-one pat ientshad a frac
tureof anextrem ity; six,apelvic fracture ; five,aclosed
head injury; four,a chest injury; four, another injury of
the spine; three, a blunt abdominal injury; and two, a
burn . Of the four patients who had an additional in
jury of the spine, three had a compression fracture at
the first, third, or fourth lumbar level and the fourth
had a burst fracture at the first lumbar level.Thephys
ical and neurological status at the t ime of the injury
was assessed for each pat ienton thebasisof thephysi
cal examinat ion reports ,the repor ted motor- t rauma in
dex
4
,
and the
grade according
to the
classification
of
Frankel eta l.
27
.
Thirty pat ients were managed non-operat ively
(Gro u p I).Twenty pat ients were mana ged with a body
cast and seven, with a custom-molded thorac olumb o-
sacral orthosis; these patients were allowed out of bed
te n to fourteen days after the injury. The remaining
three pat ients were managed w ith mor e than four w eeks
ofbed rest because of an associated pelvic fracture.
Twenty-five pat ients were manage d operat ively Ta
ble I). Sixteen had posterior instrumentat ion and ar
throdesis: eight of t hem had long-segment (mo re than
two motion segm ents) hook-and-rod fixat ion (G rou p II) ,
and eight
had
short-segment
two
motion segments)
transpedicular fixat ion (Group III). An addi t ional six
pat ien t s (Group IV) had an ter ior and pos ter ior ar
throdesis . Three pat ients one who had a fracture at
the second lumbar leveland two who had a fracture at
the fourth lumbar level had anterior decompression
and arthrodesis only (Group V). No anterior metallic
implants were used. Autogenous bone graft was used
for all arthrodeses.It isnotewo rthy that onlyone frac
ture caudad to the third lumbar levelwas treated with
instrumentat ion.
Both
the
initial
and the
follow-up radiographs were
reviewed.Of thefifty-five pa tien ts, forty-eight hadcom
plete radiographic da ta. Becauseof an institutional pol
icy
of
destroying
the
rad iographs
of
patients w hose files
are inactive,the ini t ial radiographs were not available
fortheremaining seven pat ients . The init ial radiograp hs
had been made with
the
pat ient supine because
of the
acuteness of the injury. Radiographs at the follow-up
evaluat ion were made with the pat ient s tanding.An
t eropos ter ior
and
lateral radiographs, with
a
d is tance
of forty-four inches (111.8 centimeters) from the x-ray
tube to the film cassette, were made for all patients.
VOL. 78-A, NO. 8, AUG US T 1996
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D.
A. ANDREYCHIK, D. H. ALANDER, K. M. SENICA, AND E. S. STAUFFER
No radiog raphs w ere ma de with the spine in flexion or
extension.
The fractures were classified according to the sys
tem of Denis
16
, and m easure men ts of kyphosis , com
pression, scoliosis, and the vertebral wedge index were
recorded. Kyphosis and scoliosis were measured with
the Cobb
13
method, with the superior end plate of the
vertebra cephalad to the fracture and the inferior end
plate of the vertebra caudad to the fracture used as
references. Vertebral body compression was calculated
with the method of Willen et al.
M
. Th e wedg e index w as
expressed as a ratio of the anterior height of the body
to the posterior height , as measured on the lateral ra
diograph. The ini t ial computerized tomography scans
that had been made before t reatment were avai lable
for review for thirty-seven of the fifty-five patients.
Compromise of the spinal canal was calculated with
the method of Mumford et al.
45
, with the intact verte
brae cephalad and caudad to the fracture used as refer
ences. The p ostoperat ive and fol low-up computerized
tomography scans were also reviewed when they were
avai lable. Magnetic resonance imaging was not rou
tinely used in this population of patients, largely be
cause of the time-period of the study. The success of
the arthrodesis and the subsequent fusion were not
specifical ly addressed for the groups that had been
managed operat ively because of the inherent inaccu
racy of plain radiographs in defining a solid fusion.
However, the instrumentat ion did not fai l in any pa
tient. Evidence of injury of a facet joint or another pos
terior element was also recorded. For consistency, all
rad iographic measurements were made by one or tho
paedic surgeon (D. A. A.) who had not been involved in
the ini tial t rea tmen t .
The most recent follow-up evaluation consisted of
an office visit, during which the patient responded to
a quest ionnaire regarding pain and funct ional s tatus
and on e of us (D . A. A., D. H. A., or K. M. S.) perfor med
a complete clinical and radiographic examination. This
assessment was performed at a mean of seventy-nine
mo nths (r ange , twenty-four to 192 mo nths ) after the
injury. Each patient was assigned a pain score on the
basis of the frequency of pain and the use of medica
tions. According to this scoring system, 0 indicates no
pain; 1 point, intermittent mild pain not necessitating
use of medication; 2 points, frequent mild pain necessi
tat ing occasional use of non-narcotic medicat ion; 3
points , mo dera te pain necessi tat ing frequent use of non
narcotic medication; 4 points, severe pain necessitating
occasional use of narcotic medication; and 5 points, pro
found pain necessitating regular use of narcotic medica
t ion. If a pat ient needed a reconstruct ive procedure
because of pain or instability, the score immediately
before that operation was used for analysis.
The functional rating was based on a comparison of
the pat ient s occupational and recreat ional s tatus before
the injury and th at after it . Ac cord ing to this rating
system, 0 indicates a retu rn to the patien t s pre-injury
occup ation w ith no limitation; 1 point, a retu rn to the
pre-injury occupation but minor occupational and rec
reational limitations; 2 points, a return to the pre-injury
occupation but major occupational and recreat ional
limitations; 3 points, a return to work but in a job that
is less strenuo us th an that before the injury; and 4 points,
an inability to perform productive work or to partici
pat e in recre ationa l activities. The patie nt s e mp loym ent
status before and after the injury was recorded with use
of a 0 to 5-point work-sta tus scale, deve loped by the
United States Department of Training and Employment
Service
51
, to deter min e the effect of previou s em ploy
ment status on the functional outcome. According to
this scale, 1 point ind icates heavy labor that involves
constant lifting of more than fifty pounds (22.7 kilo
grams); 2 points, moderately heavy labor that involves
constant lifting of more than twenty-five pounds (11.3
kilograms); 3 points, light labor that involves constant
lifting of less than ten pounds (4.5 kilograms); 4 points,
a sedentary job that involves sitting or standing without
lifting; and 5 points, unemployment.
Each patient was assigned to one of five treat
ment groups: Gro up I was managed with bed rest and
use of a cast; G rou p II, poste rior arthro desis w ith long-
segment instrumentat ion; Group III , posterior arthro
desis with short-segment instrumentat ion; Group IV,
anterior and p osterior arthrodesis; and G rou p V, an
terior dec om pressio n and arthro desis only. Th e initial
and most recently seen deformities of the lumbar spine
were compared among the t reatment groups, and any
relat ionships among the method of t reatment , the de
formity and pain at the time of follow-up, and the func
t ional outcome were analyzed. In the pat ients who had
been managed non-operat ively, the ini t ial and most re
cent radiographic pat terns were compared to determine
whether the ini t ial radiographic parameters had been
predictive of the radiographic deformity at the time of
follow-up. The effectiveness of the opera tive fixation in
obtaining and maintaining correction was also evalu
ated. The results for the operatively and non-operatively
treated groups were compared with regard to the most
rece nt radiogra phic, neurolog ical, pain, and functional
outcomes.
A one-way analysis of variance with five levels
was used to compare the means of the five t reatment
groups for each of the outcome measures. The Du ncan
multiple-range follow-up tests were used to make pair-
wise comparisons. A result was considered significant
if the p value was less than 0.05.
esults
eurological Outcome
Thirty-six patients had been neurologically intact at
the t ime of presentat ion; twenty-three had been man
aged non-operat ively and thirteen had had posterior
arthrodesis . No neurological deteriorat ion was observed
THE JOURN L OF BONE ND JOINT SURGERY
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BURST FRACTURES OF THE SECOND THROUGH FIFTH LUMBAR VERTEBRAE
.1159
T ABL E I I
D A TA O N TH E N I N ETEEN P A TI EN TS W H O H A D A N EU RO LO G I CA L D EF I CI T A T TH E TI M E O F P RES EN TA TIO N
Case
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
Level of
Fracture
L2
L3
L3
L4
L5
L5
L5
L3
L 2
L4
L2
L2
L2
L 2
L2
L 3
L3
L3
L4
Treatment
Non-op.
Non-op.
Non-op.
Non-op.
Non-op.
Non-op.
Non-op.
Post, arthrodesis, short
Ant. arthrodesis
Ant. arthrodesis
Post, arthrodesis, long
Post, arthrodesis, long
Ant. and post, arthrodesis
Ant. and post, arthrodesis
Ant. and post, arthrodesis
Ant. and post, arthrodesis
Ant. and post, arthrodesis
Ant. and post, arthrodesis
Ant. arthrodesis
Initial
D
D
D
B
D
D
D
D
D
D
D
B
D
D
D
A
A
A
C
Grade
27
A t
Follow-up
E
E
E
D
E
E
E
D
E
E
E
D
D
D
E
D
D
D
E
Motor-Trauma Index
41
Initial
99
98
99
95
96
96
99
96
95
97
78
50
90
88
71
58
63
51
64
A t
Follow-up
100
100
100
99
100
100
100
99
100
100
100
74
95
99
100
65
80
63
100
regardless of the method of t reatment , and there were
no symptoms of spinal stenosis at the latest follow-up
evaluat ion.
Nineteen patients had had neurological loss at the
time of pre sen tatio n Table II). Of these patients, ten
had had an isolated single-nerve-root deficit: eight had
a partial paralysis and two, a complete paralysis. Seven
of these pat ients s ix who had had a part ial and one wh o
had had a complete paralysis) had been managed non-
operatively. All six patients who had had a partial pa
ralysis t reated non-operat ively had complete motor
recovery, although minor sensory deficits persisted in
three. On e pat ient Case 4) who had been m anage d
non-operat ively had had a complete uni lateral paralysis
of the fourth lumbar nerve root; nearly complete re
covery was note d at the time of follow-up chang e in
motor-trauma index
41
, from 95 to 99). An othe r pat ient
Case 8) who had had a part ial paralysis had bee n m an
aged with posterior arthrodesis. At the time of the in
jury, the left quadriceps had been noted to be grade 1
of 5. The patie nt had inc om plete reco very at the latest
fol low-up examination change in motor-trau ma index,
from 96 to
99).
Two additional patien ts Cases 9 and 10),
one who had had a part ial paralysis and the other who
had had a complete s ingle-nerve-root lesion, had had
anterior decom pression and arthrode sis; both had com
plete recov ery at the latest follow-up visit change in
mo tor-traum a indices,from 95 to
1
and from
97
to 100).
Nine patients had had diffuse multiple-nerve-root
dysfunct ion. Two had been managed with posterior
arthrodesis and seven, with anterior and posterior ar
throdesis or anterior decompression and arthrodesis
alone. Of the two pat ients who had been managed pos
teriorly, one Case 11) had comp lete mo tor reco very
change in motor-trauma index, from 78 to 100). This
patient had diffuse weakness of both lower extremities,
although there was some motor function of all muscle
groups. Soon after placem ent of Har rington instrumen
tation, there was a rapid return of motor function, mak
ing an ant icipated anterior procedure unnecessary. The
second pat ient Case 12) had had a complete m otor
paralysis grad e B, as defined by Frankel et al.
27
) sec
ondary to a fracture of the second lumbar vertebra. She
was subsequently managed with Harrington instrumen
tat ion, but despi te a s trong recommendation for an an
terior procedure she refused to have.it. She had partial
recovery change in motor -traum a index, from 50 to 74)
but, at the latest follow-up evaluation, no motor or sen
sory function was observed distal to the quadriceps. At
the time of writing, she was able to walk about the
community with use of an ankle-foot orthosis.
The remaining seven pat ients who had had mult iple-
nerve-root dysfunction at the time of presentation had
had anterior and posterior arthrodesis or anterior de
compression and arthrodesis alone. Thre e of these pa
tients had had gra de-D status
27
; one Case 15) of the thr ee
had complete recovery change in motor-trau ma index,
from 71 to 100), and two Cases 13 and 14) had pa rtial
recove ry change in mo tor-tra um a indices, from 90 to 95
and from 88 to 99). Sensory deficits persisted in all thre e
pat ients . Four pat ients had had nearly complete motor
paralysis grade C in one and grade A in three ). The
patient who had had grade-C paralysis Case 19) had
complete motor recovery change in motor-trau ma in-
VOL. 78-A, NO. 8, AUGUST 1996
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A. ANDREYCHIK, D. H. ALANDER, K. M. SENICA, AND E. S. STAUFFER
T ABL E I I I
DA TA O N K Y P H O S I S A N D CO M P RES S I O N , A CCO RDI N G T O TH E TY P E O F TREA TM EN T*
L2 fracture
N o.
of patients
Kyphosis degrees)
Initial
At follow-up
Change
Compression per cent)
Initial
At follow-up
Change
L3 fracture
No .
of patients
Kyphosis degrees)
Initial
At follow-up
Change
Compression per cent)
Initial
At follow-up
Change
L4 fracture
N o.of patients
Kyphosis degrees)
Initial
At follow-up
Change
Compression per cent)
Initial
At follow-up
Change
L5 fracture
No .
of patients
Kyphosis
degrees)
Initial
At follow-up
Change
Compression per cent)
Initial
At follow-up
Change
Gro up 1:
Non-Op .
Treatment
12
3 -5 to +12)
12 5 to 26)
9 0 to 21)
29 10 to 52)
37 1.4 to 63)
8 0 to 27)
8
-2 -19 to +17)
8 -5 to +26)
10 2 to 17)
32 24 to 43)
39 24 to 66)
7 0 to 25)
5
-24 -42 to -9)
-12 -22 to +5)
12 5 to 22)
33 9 to 46)
47 36 to 63)
14 1 to 22)
5
-25 0 to -35)
-15 -26 to +10)
10 4 to 15)
47 34 to 58)
51 33 to 69)
4 0 to 11)
Group II :
Post . Arthrodesis
18
15
- 2
54
27
-27
Long)
8
6 to 40)
7 to 30)
-10 to +15)
33 to 90)
21 to 41)
-49 to +1)
0
0
0
Group III :
Post . Arthrodesis
Short) t
1
N A
30
N A
60
6
5 -15 to +13)
10 -6 to+21)
5 -16 to +22)
48 44 to 54)
43 32 to 59)
-5 -17 to +7)
1
5
5
0
52
33
-19
0
Group IV:
Ant. and Post.
Arthrodesis
3
13 6 to 19)
13 6 to 21)
0 -5 to +19)
56 52 to 58)
40 31 to 61)
-16 -25 to+ 9)
3
7 5 to 8)
9 5 to 14)
2 0 to 6)
40 30 to 56)
44 30 to 63)
4 -11 to +20)
0
0
*The values are given as the mean, with the range in parentheses.
tNA = not available.
dex, from 64 to 100), and the rem aining th ree Case s 16,
17,and 18) all had incomplete recovery moto r-trauma
indices at the time of follow-up, 65, 80, and 63). One of
these patients used an ankle-foot orthosis bilaterally for
walking about the community. The other two used a
wheelchair al though both had enough strength in the
lower extremities for transfers. Of the nine patients who
had had mult iple-nerve-root involvement , four had had
bowel and bladder dysfunction at the time of presenta
tion. Th ree of the four attained no rma l function after
anterior decompression and arthrodesis .
Radiographic Evaluation
The initial kyphosis and initial compression associ
ated with fractures at the second and third lumbar lev
els were compared between the group that had been
managed non-operat ively and the groups that had been
managed with posterior arthrodesis , to determine if
there had been a bias toward performing an operat ion
for fractures associated with a larger initial deformity
Table III). Only fractures at these two levels were in
cluded, as only one fracture caudad to the third lumbar
level had been stabilized with instrumentation.
The mean initial kyphosis was 2 degre es range , -1 9
to +17 degrees) for the pat ients who had been mana ged
non-operat ively Gro up I), com pared with 10 degrees
range, -15 to +40 degrees) for the pat ients who had had
posterior s tabi lizat ion Gro ups II and III) . The m ean
initial compre ssion was 29 per cen t range , 10 to 52 per
cent) for G rou p I, com pared with 50 per cent range, 33
to 90 per cent) for Groups II and III. Both of these
differenc es w ere significant p = 0.05 and 0.0006).
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BURST FRACTURES OF THE SECOND THROUGH FIFTH LUMBAR VERT EBRAE
1161
T A B L E
IV
D A T A W IT H R E G A R D TO C O R R E C T I O N OF THE K Y P H O S I S , A C C O R D I N G TO THE T Y P E OF INST RUME NT ION*
Initial kyphosis
Correction obtained
Correction lost with
instrumentation
in
place
Correction lost after
removal
of
instrumentation
Total lossof correction
Total change
in
kyphosis
G r o u pII:
Post. Arthrodesis
Long)
N =8)
18 6 to 40)
9
0 to 20)
9 3 to 14)
- 2 -10 to +15)
G r o u pIII:
Post. Arthrodesis Short)
Steffee Plates
N =3)
1 -15 to +10)
19
15 to 27)
23 11to 38)
4 -16 to +22)
Fixateur Internet
N = 5)
5 5 to 13)
13 11
to 16)
13 7 to 18)
6 5 to 7)
19 12 to 26)
6 -1 to +14)
G r o u pIV:
Ant .andPost.
Arthrodesis
N =
6)
12 5 to 19)
17
8 to 25)
18 9 to 25)
1 -5 to +19)
*The values
are
given
as the
mean ,
in
degrees, with
the
range
in
parentheses.
The
mean duration
of
follow-up
for all
patients
was
eighty-six
months.
t F o u r
of
the five patients who were managed with
the
fixateur inter ne
had the
device removed
at a
mean
of
eleven months postoperatively.
The degree of kyphosis immediately after the in
jury
and
preoperat ively
was
com pared with that
at the
latest follow-up evaluation. The mean increase in ky
phosis during treatment
was 10
degrees range,
0 to 21
degrees)
for the
pat ients
who had
been managed
non-
operat ively Group
I)
compared with
-2
degrees range,
-1 0to +15degrees) for thosewho hadbeen managed
withalong hook -and-ro d system Gro up II) ,5degrees
range,
-16 to +22
degrees)
for
those
who had
been
treated with a short t ranspedicular construct Gro up
I I I ) ,and 0
degrees range,
-5 to +19
degrees)
for
those
who had been managed wi th an ter ior and posterior
ar throdes i s Group
IV). The
increase
in
kyphosis
for
the pat ients who had been manag ed non-operat ively
and for thosewho had been treated with short t rans-
pedicular fixation
was
similar. Both values w ere signifi
cant ly greater than thosefor thepat ientswho had been
managed with ei ther long posterior arthrodesis
or
an te
rior and posterior arthrodesis p =0.005).
The change
in
vertebra l body compression averaged
8per cent range,0 to 27 per cent) for the group that
had been managed non-operat ively, -27
per
cent range ,
- 4 9to +1 percent )for the group thathad been treated
with long posterior arthrodesis ,
-5 per
cent range,
-17
to +7 per cent) for the group thathad had short pos
terior arthrodesis ,and -10 per cent range,-25 to +20
per cent)
for the
group that
had had
anterior
and
pos
terior arthrodesis . The difference betw een the group
that
had
been managed non-operat ively
and the
groups
that had been treated operat ively wassignificant p =
0.0004).
The
change
in
kyphosis
did not
correspond
to
the change in compression in the group that had been
managed with short fixation.
The ini t ial radiographic measurements, including
the type of fracture according to the classification of
Denis
16
,
the
location
of the
fracture,
the
initial kyphosis,
the initial compression, the ini t ial vertebral wedge in
dex,
and the
presence
of
radiogra phically identifiable
injury of the posterior elements, were analyzed with
regard
to
progressive deformity
in the
form
of
increased
kyphosis. Sixteen fracture s we re classified asDenis type
Aandfourteen,astype
B.
Onlyonetype-B fra cturewas
caudad
to the
third lumbar level, indicating
a
predi lec
tion of type-A fractures for the more caudad lumbar
segments. With
the
numbers avai lable,
the
level
of the
fracture
p =
0.47),
the
initial kyphosis
p =
0.27),
the
initial compression p =0.07),anddisruptionofthe pos
terior elements p = 0.10)demons t ra tednorelat ionship
to increased kyphosis.
The
only significant relationship
was between Denis type-A fractures and progressive
kyphosis mean increase,12degrees [range,2 to 22 de
grees] ,
comp ared w ith
7
degrees [range, 0
to 15
degrees]
for the type-B fractures;p =0.02).The initial compres
sion associated with the type-A fractures was greater
than that associated with
the
type-B fractures
38
com
pared with28 per cent). This wedge compression re
mained constantand did notaccountfor theincreasein
kyphosis seen
at the
t ime
of
follow-up.
The effectiveness
of the
various types
of
operat ive
t reatment
in
achieving
and
maintaining correct ion
of
the deformity wasassessed Table IV). With the n u m
bers available,
the
mean values
for the
initial kyphosis
and
the
initial compression were
not
significantly
dif
ferent p = 0.10 and 0.94)amongthe t reatment groups.
For
the
pat ients
who had had
long posterior arthro
desis Group
II),
short posterior arthrodesis Gr oup
I I I ) ,andanteriorandposterior arthrodesis Gro upIV),
the mean initial kyphosis
was 18
degrees range,
6 to
40 degrees),
5
degrees range,
-15 to +13
degrees) ,
and
12 degrees range, 5 to 19 degrees), respectively.The
mean ini t ial compression
was 54 per
cent range,
33 to
90
per
cent),
48 per
cent range,
44 to 54 per
cent ) ,
and
50per cent range,30 to 58 per cent). With the num
bers available,
no
significant differences w ere obse rved
among
the
groups with respect
to
correct ion obtained
and correct ion lost throughout the follow-up perio d
p
= 0.15 and
0.09).
For the
pat ients
who had had
long
posterior arthrodesis Gro up
II), the
me an correct ion
was 9 degrees range,0 to 20 degrees) and the mean
correction lost
was 9
degrees range,
3 to 14
degrees).
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1162
D.
A. ANDREYCHIK, D. H. ALANDER, K. M. SENICA, AND E. S. STAUFFER
For the pat ients who had had short posterior arthro
desis (Group III) , the mean correct ion was 15 degrees
(range, 11 to 27 degrees) and the mean correct ion lost
was 19 degrees (range, 7 to 38 degrees). For the pa
t ients who had had anterior and posterior arthrodesis
(G roup IV), the mean correct ion was 17 degrees (range,
8 to 25 degrees) and the mean correct ion lost was 18
degrees (range, 9 to 25 degrees). Although transpedicu-
lar fixation and anterior and posterior arthrodesis dis
played the greatest capacity for correction, all constructs
tended to col lapse toward the preoperat ive deformity.
The radiographs of the three pat ients who had had an
terior arthrodesis only were excluded from the analysis,
as only one of these pat ients had comp lete radiographic
data.
The ini t ial comp uterized tom ography scans were an
alyzed for twenty-one of the thirty patients in Group I,
none of the eight in Group II, all eight in Group III, all
six in Gro up IV, and two of the thre e in Gro up V. The
mean reduction in the cross-sectional size of the canal
was 43 per cent (range, 10 to 90 per cent) for Group I,
68 per cent (range, 50 to 90 per cent) for Group III, and
87 per cent (range, 75 to 90 per cent) for Group IV. In
Gr ou p V, both pat ients for whom c omputerized tomog
raphy scans were available had a 90 per cent reduction
in the cross-sectional size of the canal.
Follow-up computerized tomography scans were in
terpreted for two pat ients (one fracture at the second
lumbar level and one at the third lumbar level) who had
been managed non-operat ively. Both pat ients had par
tial resorption of the fragments in the canal. The patient
who had had a fracture at the second lumbar level had
an initial reduction of 44 per cent in the cross-sectional
size of the canal; forty-four mo nths after the injury, the
canal had increased to 90 per cent of its expected size.
The pat ient who had had a fracture at the third lumbar
level had an initial reduction of 40 per cent in the cross-
sectional size of the canal; fifty months after the injury,
the can al had increa sed to 80 pe r cent of its expected
size.
Immediate postoperat ive scans were avai lable and
were reviewed for four of the eight patients who had
been managed with a short t ranspedicular construct
(Group III); all four had had a fracture at the third
lumbar level. The increase in the cross-sectional size of
the canal at the level of the injury was unpredictable;
the mean initial decrease was 78 per cent (range, 60 to
90 per cent), and the mea n postop erat ive size was 62 per
cent (range, 50 to 90 per cent).
Pain and unctional Results
At the latest follow-up evaluation, the pain scores
were a mean of 1.50 points for Group I, 1.13 points
for Group II, 1.38 points for Group III, 1.17 points
for G rou p IV, and 1.33 points for Gr ou p V; with the
num ber s available, these differences w ere not signifi
cant (p = 0.78). No relat ionship was demon strated be
tween the pain score and the level of the fracture, the
kyphosis at the time of follow-up, the compression at
the time of follow-up, the change in the kyphosis, or the
change in the compression (p = 0.27,0.15,0.23,0.09, and
0.09, respectively). The only variable that had a signifi
cant relationship (p = 0.03) to the pain score was the
type
16
of fracture. The pain score was a mean of 1.76
points for type-A fractures, 1.33 points for type-B, and
1.00 for type-D. Although we could not determine a
significant difference with the numbers available, there
was a trend for higher pain scores in association with
the fractures at the more caudad lumbar segments (a
mean of 1.33, 1.18, 1.50, and 2.20 points in association
with fractures at the seco nd, third, fourth, and fifth lum
bar levels, respec tively).
Most of the thirty pat ients who had been managed
non-operat ively had mild or moderate pain. Only three
of these pat ients were pain-free (a pain score of 0
points). Seventeen pat ients had intermit tent mild pain
(a pain score of 1 poin t); three , freque nt mild pain (a
score of 2 points); five, moderate pain (a score of 3
points); one, severe pain (a score of 4 points); and one,
profound pain (a score of points). The pat ient who h ad
a score of 4 points was a nineteen-year-old w oman who
had sustained a burst fracture at the fourth lumbar level
as a result of a motor-vehicle accident. She did well (a
pain score of 1 point) for two and one-half years, until
she was involved in another motor-vehicle accident. Af
ter the second accident, she had persistent back pain
al though she remained employed. She eventual ly had
anterior and posterior arthrodesis for rel ief of pain
associated with instability at a level cephalad to the
fracture. Eight months postoperatively, she had only
interm ittent mild discomfort (a pain score of 1 poin t).
The patient who had a pain score of 5 points was a
twenty-nine-year-old man who had sustained a fracture
at the second lumbar level secondary to a work-related
injury. He reported profound pain and eventually, at
twelve months, had anterior and po sterior arthrodesis
for the pain as well as disc degeneration and instability
(13 degrees on flexion and extension). Seven years after
the operat ion, the pat tern of pain remained unchanged
and the patient was totally disabled.
In the ope rat ive groups, three pa t ients had no pain;
fifteen, inter mitte nt mild pain; five, frequen t mild pain;
and two, mo dera te pain.
For the pat ients who did not have neurological
dysfunction, the functional outcome at the time of the
most recent follow-up was analyzed with respect to the
pa tien t s age , the level of the fra cture, the kypho sis
and compression at the time of follow-up, and the pa
tient s pre-injury oc cupa tion. With the nu mb ers avail
able, no significant relationships were found. Of the
thirty pat ients who had been managed non-operat ively,
ten had performed heavy labor before the injury, six
had performed moderately heavy labor, three had per
formed light labor, nine had been sedentary, and two
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BURST FRACTURES OF THE SECOND THROU GH FIFTH LUMBAR VERTEBRAE 11 63
had bee n unemp loyed. Of the twenty-eight pat ients who
had been employed at the time of the injury, twenty-five
(89 per cent) returned to their pre-injury occupational
status,
al though ten had minor and two had major l imi
tations (a functional score of 1 and 2 points, respec
tively). One patient, who had a functional score of 3
points , need ed to change to a less s trenuous occupa
tion. Two patients were disabled as a result of pain: the
twenty-nine-year-old man described previously as well
as a forty-eight-year-old man who had sustained a frac
ture at the fifth lumbar level and was unable to return
to work because of moderate pain; these pat ients had a
pain score of 5 and 3 points, respectively.
Of the twenty-five pat ients who had been managed
operat ively, seven had performed heavy labor before
the injury, six had performed moderately heavy labor,
three had engaged in light labor, five had been seden
tary, and four had bee n une mploye d. Of the tw enty-one
patients who had been employed at the t ime of the
injury, three were disabled secondary to neurological
dysfunct ion. O f the e ighteen re maining pa t ients , s ixteen
return ed to their pre-injury work status, one was em
ployed in a less s trenuous job, and one was unem ployed
secondary to moderate act ivi ty-related back pain. Of
the en tire grou p of twenty-five patients, fifteen ha d no
functional impairment and four had minor functional
limitations.
iscussion
Burst fractures of the lumbar spine have unique
biomechanical and neurological features as compared
with burst fractures in other regions of the spine. Deci
sions with regard to stability and treatment are different
than those made when there is a more cephalad frac
ture of the vertebral column. In the lumbar spine, the
body's center of gravity falls at or posterior to the ver
tebral axis
1
. Slight flexion decre ases the lordosis and
places the axial load force-of-injury vector throu gh th e
vertebral body. This dictates the specific pattern of in
jury as well as the tendency for progressive deformity.
Pure axial load injuries are more common in this spinal
region
16
-
24
. Bec ause of the rela tive stability provid ed by
the posterior elements, the risk of neurological d eterio
rat ion is iow
1
'
1U5
'
263
'
38
'
45