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Table of Contents    
ORIGINAL ARTICLE
Year : 2022  |  Volume : 70  |  Issue : 8  |  Page : 189-194

Efficacy of Non-Fusion Surgeries in the Management of AO Type C Injuries of the Thoracic and Thoracolumbar Spine: A Retrospective Study


Department of Spine Surgery, Ganga Medical Centre and Hospitals Pvt. Ltd., Mettupalayam Road, Coimbatore, Tamil Nadu, India

Date of Submission11-Dec-2021
Date of Decision25-Jun-2022
Date of Acceptance01-Aug-2022
Date of Web Publication11-Nov-2022

Correspondence Address:
Ajoy P Shetty
Senior Spine Consultant, Department of Spine Surgery, Ganga Medical Centre and Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore - 641 043, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.360910

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 » Abstract 


Background: The initial descriptions of successful management of non-fusion surgeries in the management of unstable burst injuries of the thoracic and thoracolumbar spine (TTLS) were published by Osti in 1987 and Sanderson in 1999. These were further supported by prospective studies and meta-analyses establishing comparable results between fusion and non-fusion surgeries. However, there is a paucity of literature regarding the efficacy of non-fusion surgeries in the management of AO type C injuries.
Objective, Materials and Methods: The study aims to determine the efficacy of open posterior instrumented stabilization without fusion in AO type C injuries of the TTLS. Patients with AO type C injuries of the TTLS (T4-L2 levels) with normal neurology who underwent open, posterior, long segment instrumented stabilization without fusion between January 2015 and June 2018 were included. The regional kyphotic angle, local kyphotic angle, AP (anterior and posterior wall) ratio, and cumulative loss of disc space angle were assessed on radiographs. Functional outcome was assessed using Oswestry Disability Index (ODI) and the AO Spine patient-reported outcome spine trauma (PROST) instrument.
Results and Conclusion: The study included 35 patients with AO type C injury of the TTLS and a normal neurology who underwent open posterior instrumented stabilization and had a mean follow-up of 43.2 months (range 24–60 months). The mean preoperative regional kyphotic angle decreased from 19.8 ± 13.7° to 6.6 ± 11.3° after surgery but showed an increase to 9.21 ± 10.5° at final follow-up (P = 0.003). The cumulative loss of disc space angle was significant at final follow-up (2.4 ± 5° [P = 0.002]). Twenty-eight out of 35 patients had minimal while seven had moderate disability on the ODI score. The AO Spine PROST revealed that patients regained 95.7 ± 4.2% of their pre-injury functional status at final follow-up. Posterior instrumented stabilization without fusion in the management of AO type C injuries of the TTLS gives satisfactory results with acceptable functional and radiological outcomes.


Keywords: AO spine PROST, AO type C, cumulative loss of disc space angle, non-fusion, Oswestry disability index, regional angle, sagittal index, thoracolumbar injury, wedge angle
Key Message:> There is paucity on literature concerning non-fusion surgeries for AO type C injuries of the TTLS, which is safe and gives satisfactory functional and radiological long-term results.


How to cite this article:
Murugan C, Shetty AP, Kavishwar R, Krishnan V, Kanna RM, Rajasekaran S. Efficacy of Non-Fusion Surgeries in the Management of AO Type C Injuries of the Thoracic and Thoracolumbar Spine: A Retrospective Study. Neurol India 2022;70, Suppl S2:189-94

How to cite this URL:
Murugan C, Shetty AP, Kavishwar R, Krishnan V, Kanna RM, Rajasekaran S. Efficacy of Non-Fusion Surgeries in the Management of AO Type C Injuries of the Thoracic and Thoracolumbar Spine: A Retrospective Study. Neurol India [serial online] 2022 [cited 2022 Dec 3];70, Suppl S2:189-94. Available from: https://www.neurologyindia.com/text.asp?2022/70/8/189/360910




Fusion has been considered the gold standard in the management of unstable thoracic and thoracolumbar spine (TTLS) injuries as it provides long-term stability and protects the fixation from fatigue failure.[1],[2] However, surgical management of unstable burst injuries (AO A3, A4 and AO type B) of the TTLS have gradually transitioned from fusion to non-fusion techniques over the last decade due to many shortcomings of fusion. Successful management of unstable burst injuries of the thoracolumbar spine by posterior instrumentation without fusion was first reported by Osti in 1987, followed by Sanderson in 1999.[3],[4] Emphasis is laid on healing of the fracture and ligaments to maintain stability rather than fusion. Their results were encouraged by meta-analyses and prospective, randomized studies with level 1 evidence, reporting similar functional and radiological outcomes between fusion and non-fusion surgeries. Non-fusion surgery has added advantages of shorter duration of surgery, lesser blood loss and comorbidities of surgery as it does not involve decortication and preparation of fusion beds as well as obtaining bone grafts required for fusion.[5],[6],[7],[17],[18] Successful management of burst fractures by percutaneous techniques has further encouraged the use and acceptance of surgical stabilization alone to manage such injuries.[8],[19],[20]

In our institute, unstable injuries including AO type C injuries of TTLS have been managed by reduction and stabilization using transpedicular instrumentation without arthrodesis over the last two decades. Previous studies have reported reasonably good outcomes following non-fusion surgeries for AO type C injuries.[9],[10] The current study assessed the radiological and functional outcomes and whether the principles of ligament and fracture healing rather than fusion apply to AO type C injuries of TTLS.


 » Materials and Methods Top


This retrospective study was conducted in our center after approval from the Institutional Review Board (IRB).

Patients with AO type C injuries of TTLS (T4-L2) with normal neurology and managed by long segment, open, posterior reduction and stabilization without fusion between January 2015 and June 2018 were enrolled in the study. Patients with pathological fractures, osteoporotic fractures, and those with a neurological deficit were excluded from the study. Patients with a neurological deficit were excluded so that a clear and objective assessment of the functional outcome was possible and to avoid errors due to difference in neurology and recovery. Injuries proximal to T4 and distal to L2 were excluded considering the difference in biomechanics, fracture patterns, and management of injuries at these levels. The approval from the ethics committee was obtained on 13.03.2020.

The demographic details, detailed history, and examination findings were obtained from hospital records and HIS (Hospital Information System). All the patients had undergone preoperative imaging in accordance with our protocol, which included antero-posterior (AP) and lateral radiographs of the thoracolumbar spine, computed tomography (CT) and magnetic resonance imaging (MRI) at the time of diagnosis followed by AP and lateral radiographs immediately following surgery, at six weeks, three months, six months, one year, two years, and latest follow-up. All the radiological images were retrieved from the hospital picture archiving and communication system (PACS). Four parameters were assessed from each x-ray, including the regional angle, local kyphotic angle, AP ratio, and cumulative loss of disc space angle. Regional angle is a measure of the Cobb angle formed by the superior endplate of the proximal vertebra and the inferior endplate of the distal vertebra to the injured level. The local kyphotic angle is measured using the wedge angle between the superior and inferior endplates of the index vertebra to determine the amount of vertebral body collapse contributing to postoperative kyphosis. The AP ratio is the ratio of the anterior to the posterior vertebral body height. The AO type A subtypes of the fractures were also recorded and analyzed to determine the role of vertebral body injury in the overall progression of kyphosis following non-fusion surgery. The cumulative loss of disc space angle is measured by subtracting the sum of disc spaces within the instrumented segments at follow-up from the sum of the disc spaces in the immediate postoperative period [Figure 1]. The objective functional assessment was done at the last follow-up using the Oswestry Disability Index (ODI) scoring system while the AO Spine patient-reported outcome spine trauma (PROST) questionnaire was used to determine the patients' health quality compared to their pre-injury status.
Figure 1: (Original) Radiographic parameters. (a) Regional angle; (b) local kyphotic angle; (c) AP ratio; (d) cumulative loss of disc space angle

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All of the patients underwent open posterior transpedicular instrumentation two levels above and below the level of translation, including pedicle screw instrumentation at the index fracture level. Reduction maneuver was based on the pattern of translation as described by Kanna.[10] None of the patients underwent any form of fusion procedure. All clinical and radiological adverse events including implant failures, implant related complications, and neurological worsening during the immediate postoperative period or any follow-ups were recorded.

The statistical analysis was done using the Wilcoxon test for paired samples performed with the Statistical Package for the Social Sciences (SPSS) version 15 software, and a P value of <0.05 was considered significant. Pearson correlation and analysis of variance (ANOVA) test were performed for the unpaired samples.


 » Results Top


The study included 35 patients (25 males [71.4%]) with AO type C injury of the TTLS with normal neurology. The power of the study was satisfied at 90% with a sample size of 35. The age group ranged from 18 to 50 years with a mean age of 30.7 ± 12.8 years. The two most common mechanisms of injury were falls from height (51.4%) and road traffic accidents (45.7%). The most common injured level was T12-L1 (37%) followed by L1-L2 (17%). T11-L2 constituted 63% of the injuries whereas T4-T10 levels accounted for 37% of injuries. The mean preoperative regional kyphotic angle decreased from 19.8 ± 13.7° to 6.6 ± 11.3° immediately following surgery. There was a loss of correction and the mean regional kyphotic angle increased to 8.7 ± 10.4° at six months (P = 0.005) and to 9.21 ± 10.5° at final follow-up (p = 0.003) [Figure 2]. The cumulative loss of disc space angle (2.4 ± 5°) was significant at the last (P = 0.002) follow-up starting six months (1.8 ± 4°, P = 0.010) following surgery measured using estimated marginal means and pairwise comparisons [Table 1]. The mean AP ratio increased from 0.58 ± 0.2 preoperatively to 0.77 ± 0.17 following surgery without a significant change and to 0.75 ± 0.2 at the last follow-up (P = 0.443). The local kyphotic angle was corrected from a mean value of 21.21 ± 10.5 to 12.25 ± 7.8 after surgery without a significant change and to 12.41 ± 8.1 (P = 0.690) [Table 2]. The functional outcome was measured using the ODI and the AO Spine PROST tool. The ODI showed 80% of the patients with a score of <20% (minimal disability), whereas 20% had a score between 20%–40% (moderate disability) [Table 3]. The Pearson correlation (−0.023) ruled out a significant relationship between ODI and loss of correction (P = 0.898). The Pearson correlation also ruled out any significant relationship between age and ODI (P = 0.170). The AO Spine PROST tool showed that the patients could regain 95.7 ± 4.2% of their pre-injury functional status at final follow-up, and it was corresponding to the functional outcome according to the ODI. Patients with a minimal disability had a mean AO Spine PROST of 97 ± 2.9, whereas the patients with a moderate disability had a mean AO Spine PROST of 90 ± 7.8. The most frequently encountered AO type A subtype was A3 (34%), followed by A4 (31%), A1 (20%), A2 (8.5%) and A0 (6%). The analysis of variance (ANOVA) test did not reveal a relationship between the AO type A subtypes and the ODI when compared between groups (P = 0.370). None of the patients in the study developed an implant failure, implant related complications, or neurological deficit at any point following surgery.
Figure 2: (Original) Graph representing the loss of kyphosis correction with time. The x-axis represents the duration of follow-up and the y-axis represents the kyphotic angle

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Table 1: Cumulative loss of disc space angle

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Table 2: Radiological parameters

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Table 3: Oswestry disability index

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 » Discussion Top


Fusion surgery is the gold standard in the management of AO type C injuries of the thoracolumbar spine. Theoretically, it protects the metal fixation systems and prevents fatigue of the material subjected to movement cycles throughout the patient's life.[1],[2] Fusion is, however, associated with a longer operating time, greater blood loss, adjacent segment degeneration, and graft donor site morbidities.[5],[6],[7]

Non-fusion surgeries have largely replaced fusion surgeries in the management of burst fractures of the TTLS. Osti in 1987 and Sanderson in 1999 reported successful outcomes in the management of unstable burst fractures of the thoracolumbar spine with non-fusion surgeries.[3],[4],[21] Sanderson conducted a retrospective review of 28 patients managed by short-segment pedicle screw fixation of thoracolumbar burst fractures without fusion with a mean follow up of 3.1 years.[3] Fifty percent of the patients achieved an excellent result, 12% good, 20% fair, and only 16% had a poor result as per the Low Back Outcome Scale. Once satisfactory reduction was achieved, it was considered that sufficient bone and soft tissue healing would occur and obviate the need for bone grafting. Several randomized controlled trials have validated this by comparing fusion and non-fusion surgeries for such injuries.[5],[6],[7] The current study addressed whether the same principles apply to AO type C injuries of the thoracolumbar spine and whether non-fusion surgeries are successful in managing these injuries.

The results of our study demonstrated a significant correction of kyphosis following surgery (from 19.8 ± 13.7° to 6.6 ± 11.3°). With the alignment, local kyphotic angle, and AP ratio remaining constant, there was a statistically significant loss of kyphosis correction as demonstrated by the regional angle. The loss of correction was first observed at six months follow-up (8.7 ± 10.4°, P = 0.005), which was constant after that and reached a mean value of 9.2 ± 10.5° at final follow-up [Figure 3] and [Figure 4]. The loss of kyphosis correction occurred at the disc spaces rather than by vertebral collapse, as evidenced by the significant loss of cumulative disc space angle with a preserved local kyphotic angle and AP ratio. The cumulative loss of disc space corresponded to the increase in kyphosis at six months (1.8 ± 4°, P = 0.010) following surgery without a significant change after that (2.3 ± 5°, P = 0.002). The study by Kushal showed a statistically significant correction of kyphosis following surgery (16 ± 5.1° to 3.9 ± 4°) with the maintenance of correction at the last follow-up (47 ± 4.2 at 24-week follow-up).[11],[22] However, a follow-up of 24 weeks was too short to determine the long-term radiological and functional outcome following the intervention. Since most of the available literature on AO type C injuries focuses on the maintenance of reduction alone without assessment of local and regional kyphosis and the subsequent functional outcome, we have further compared our results with studies where non-fusion surgeries were employed in the management of unstable burst fractures of the thoracolumbar spine. Kocanli[12],[23] reported a mean loss of 11.6° of kyphosis correction in their retrospective study of 45 patients managed by non-fusion surgery. Sanderson[3] had a loss of 8° of correction, with the loss occurring at disc spaces within the instrumented levels. This is similar to our study concerning both the magnitude of progression of kyphosis and the involved segments.
Figure 3: (Original) Serial radiographs with regional angles of a 37-year-old lady with AO L1-L2 type C, L2 A4 injury and normal neurology. (a) Preoperative radiograph - 20° kyphosis. (b) 6 weeks - 5° lordosis. (c) 3 months - 5° lordosis. (d) 6 months - 2° kyphosis, 1 year - 2.7° kyphosis, 2 years - 3° kyphosis

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Figure 4: (Original) Serial radiographs with regional angles of a 28-year-old lady with AO L1-L2 type C, L2 A4 injury and normal neurology. (a) Preoperative radiograph - 13° kyphosis. (b) 6 weeks - 13° lordosis. (c) 3 months - 12° lordosis. (d) 6 months - 7° lordosis, 1 year - 5.6° lordosis, 2 years - 5° lordosis

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In their prospective, randomized study, Chou[13],[24] reported a mean loss of correction of 12.3° and 10.7° in their non-fusion and fusion groups, respectively. The final kyphosis was more in the non-fusion group but was not significant and did not influence the functional outcome. Similarly, in a meta-analysis by Juliete, the loss of kyphosis correction was less in the fusion group, but the difference was not statistically significant, and its magnitude suggests that this effect was clinically irrelevant.[1]

A loss of initial correction was also reported by authors who routinely fused the spine; some reported a more marked loss than that in our series. Further loss of soft tissue support resulting from the increased exposure and tissue destruction required to perform a fusion was the likely explanation for any additional loss of correction when fusion was employed.[5],[6],[14],[25] Serial assessment of the AP ratio in our study demonstrated that the loss of kyphosis correction occurred between three and six months following surgery without a significant difference after that. The loss of kyphosis correction has no statistically significant relation to the age, sex, or associated AO type A component.

Anterior fusion and stabilization of unstable injuries of the thoracolumbar spine were reported to produce a lesser but reliable kyphosis correction with good radiological and functional outcomes. They require shorter fusion segments and preserve the posterior soft tissue. A study by Graillon[15],[26] showed mean corrections of vertebral regional kyphosis angle and vertebral kyphosis at −1.8° and −3.5°, respectively. In thoracic fractures with intact posterior vertebral segment, a single anterior approach provided a significant correction of 10° of regional kyphosis and 20° of vertebral kyphosis. Anterior fusion may be used as a standalone procedure, but it has selected indications and needs to be frequently combined with posterior stabilization.

The clinical outcome measured by the ODI demonstrated minimal disability in 80% and moderate disability in 20% of the patients. None of our patients had a severe disability and there was no relation between the loss of kyphosis correction and the ODI at final follow-up which compares favorably with previously reported series.[3],[16] Studies comparing fusion and non-fusion groups have established similar clinical outcomes in both groups, with most patients who underwent fusion complaining of postsurgical pain at the graft harvest site that would compromise their mobility.[1] The AO Spine PROST shows that patients could regain 95.7 ± 4.2% of their pre-injury functional status at final follow-up.

The loss of kyphosis correction occurred at disc spaces while the vertebral height and angle were preserved. This loss occurred three to six months following surgery after which it stabilized. The increase in kyphosis was not related to the age or sex of the patient, to the morphology of vertebral body fracture, nor did it correlate with the functional outcome. Future prospective studies with comparative fusion control groups would be necessary to provide more conclusive evidence for its use in AO type C injuries.


 » Conclusions Top


Posterior instrumented stabilization without fusion is a reasonable management strategy for AO type C injuries of the TTLS which gives satisfactory results with acceptable functional and radiological outcomes.

Acknowledgements

There are no disclosures of technical, financial or material support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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