脊椎ジャーナル

Anterior Approach for Thoracolumbar Fracture Dislocations: Surgical Management in Poor Resource Region, Record of 7 years Follow-up

Abstract

Aram Baram, Ali A Alwan Al-Tameemi and Warzer Fatah Shali

Introduction: Thoracolumbar fracture dislocation is a trauma of high energy which generally is treated with longsegment stabilization. Anterior spine exposure may be used alone or in combination with a posterior midline approach in a staged or sequential fashion. In this study, we report the 7-years’ experience of the anterior approach to the thoracolumbar spine fracture dislocations at a single institution.

Patients and methods: Over a 7-year period (2007–2014), 15 patients (9 males and 7 females) with a mean age of 41.1 years ranging between 25 and 61 years, were operated on using an anterior approach at our institution. All patients were submitted to standard anterior spine surgery, thoracotomy (in 9 patients), thoracophrenolumbotomy (in 3 patients) and lumbotomy (in 2 patients), one patient required left thoracotomy alone. In all cases, we used heavy duty plate fixation and autologous bone (rib or vertebral bone) inside the cylinder. The criteria for surgical intervention were: partial or progressive neurologic deficit, kyphotic angulation ≥25º at one segment, progressive kyphosis, lesion with a loss of 50% of vertebral height with angulation and a residual canal diameter 50% of normal. All patients had a failure of the anterior and middle columns as viewed on a CT scan or MRI if available.

Results: The average duration of follow-up was 24 months. One patient died during the follow-up period. Concerning ethiology, there were two types of vertebral body lesions, which were traumatic and infectious. There were also 12 patients with traumatic lesions. The mean age was 41.1 years (range 25-61). There were 10 males and 5 female patients. Six patients had a burst fracture (type A3), with compression failure of the anterior and middle columns of the spine (level T12 in 3, level T11 in 1, level L1 in 2,). All patients with traumatic lesions underwent singlestage anterior fixation by heavy duty conventional plate and screw and the gap filled with autograft (rib and morselized vertebral bone). Three patients were operated because of the thoracic and lumbar tuberculous spondylitis and Hydatid cyst (one patient T9, one at T10, one T5).

Discussion: Initial reports of the anterior thororacotomic approach to the thoracic spine were related to Pott’s disease, spine surgery innovations and aging with a more active population resulting in a progressive increase in spine instrumentation. The main indication for anterior decompression is an incomplete neurological injury with radiographically demonstrated neural compression by bone or disk fragments. The anterior surgical treatment allows direct decompression of the neural elements and correction of the deformity.

Conclusion: The anterior approaches provide excellent exposure of the relevant bony anatomy and can be used to secure anterior column support with bony fusion. Anterior spinal fusion surgery is a safe procedure and can be used with confidence when the nature of a patient’s spinal disorder dictates its use.