Modified transpedicular approach for the surgical treatment of severe thoracolumbar or lumbar burst fractures.
BACKGROUND
Conventional transpedicular decompression of the neural canal requires a considerable amount of lamina, facet joint and pedicle resection. The authors assumed that it would be possible to remove the retropulsed bone fragment by carving the pedicle with a high-speed drill without destroying the vertebral elements contributing to spinal stabilization. In this way, surgical treatment of unstable burst fractures can be performed less invasively.


OBJECTIVE
The purpose of this study is to demonstrate both the possibility of neural canal decompression through a transpedicular approach without removing the posterior vertebral elements, which contribute to spinal stabilization, and the adequacy of posterior stabilization of severe vertebral deformities after burst fractures.


METHODS
Twenty-eight consecutive patients with complete or incomplete neurological deficits as a result of the thoracolumbar burst fractures were included in this study. All patients had severe spinal canal compromise (mean, 59.53%+/-14.92) and loss of vertebral body height (mean, 45.14%+/-7.19). Each patient was investigated for neural canal compromise, degree of kyphosis at fracture level and fusion after operation by computed tomography and direct roentgenograms taken preoperatively, early postoperatively and late postoperatively. The neurological condition of the patients was recorded in the early and late postoperative period according to Benzel-Larson grading systems. The outcome of the study was evaluated with regard to the adequate neural canal decompression, fusion and reoperation percents and neurological improvement.


METHODS
Modified transpedicular approach includes drilling the pedicle for removal of retropulsed bone fragment under surgical microscope without damaging the anatomic continuity of posterior column. Stabilization with pedicle screw fixation and posterior fusion with otogenous bone chips were done after this decompression procedure at all 28 patients included in this study.


RESULTS
Twenty-three of 28 patients showed neurological improvement. The percent of ambulatory patients was 71.4% 6 months after the operation. The major complications included pseudarthrosis in five patients (17.8%), epidural hematoma in one (3.5%) and inadequate decompression in one (3.5%). These patients were reoperated on by means of an anterior approach. Of the five pseudarthrosis cases, two were the result of infection.


CONCLUSIONS
Although anterior vertebrectomy and fusion is generally recommended for burst fractures causing canal compromise, in these patients adequate neural canal decompression can also be achieved by a modified transpedicular approach less invasively.
Kaya
Ramazan Alper
RA
Department of Neurosurgery, Sişli Etfal State Hospital, Istanbul, Turkey. alpkaya67@hotmail.com
Aydin
Yunus
Y
D000293:Adolescent; D000328:Adult; D019299:Decompression, Surgical / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015601:Injury Severity Score; D008159:Lumbar Vertebrae / Q000293:injuries*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D016059:Range of Motion, Articular / Q000502:physiology; D020127:Recovery of Function; D018570:Risk Assessment; D012494:Sampling Studies; D013119:Spinal Cord Injuries / Q000517:prevention & control*; D016103:Spinal Fractures / Q000000981:diagnostic imaging / Q000534:rehabilitation / Q000601:surgery*; D013123:Spinal Fusion / Q000009:adverse effects / Q000379:methods*; D013904:Thoracic Vertebrae / Q000293:injuries*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome