CASE SERIES |
https://doi.org/10.5005/jojs-10079-1119 |
Does Intermediate Pedicle Screw Fixation in Thoracolumbar Fractures Provide a Better Functional Outcome? A Prospective Study
1-3Department of Orthopaedics, Thoothukudi Medical College, Thoothukudi, Tamil Nadu, India
Corresponding Author: Marimuthu Subramanian, Department of Orthopaedics, Thoothukudi Medical College, Thoothukudi, Tamil Nadu, India, Phone: +91 9894447770, e-mail: drsmms74@gmail.com
Received on: 15 May 2023; Accepted on: 06 June 2023; Published on: 07 July 2023
ABSTRACT
Background: The preferred treatment of choice in patients with unstable spine injuries and neurological deficits is posterior stabilization. Instrumentation is usually done with pedicle screws and rods, additionally; pedicle screws can also be inserted in fractured vertebrae. This research comprised 30 patients involving fixation additionally in fractured vertebra- intermediate pedicle screw fixation. This study is to prove that patients operated on with additional intermediate pedicle screws have a better postoperative functional outcome.
Materials and methods: This is a study of 30 patients with thoracolumbar fractures, who were admitted to Thoothukudi Medical College, Thoothukudi, Tamil Nadu, India. Patients were resuscitated and operated on after radiological and clinical evaluation.
Results: Patients were analyzed based on demographic criteria preoperatively and postoperatively by visual analog scale (VAS), Oswestry Disability Index (ODI), and Denis pain score.
Conclusion: Patients operated on using intermediate pedicle screw fixation showed a good postoperative outcome.
How to cite this article: Louis P, Subramanian M, L D. Does Intermediate Pedicle Screw Fixation in Thoracolumbar Fractures Provide a Better Functional Outcome? A Prospective Study. J Orth Joint Surg 2023;5(2):92-95.
Source of support: Nil
Conflict of interest: None
Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.
Keywords: Postoperative pain, Surgery, Trauma.
INTRODUCTION
One of the most frequent issues in orthopedic practice is spinal trauma. In the adult population today, thoracolumbar spine fracture is the main contributor to disability. The most frequent causes of fractures are high-energy trauma, such as falls from great heights and auto accidents. It has a bimodal distribution with ages 40 and 50–70 years. Around 5–10% of thoracolumbar injuries and polytrauma cases have a spine fracture, whereas 65% of individuals sustain dislocation. T11 to L2 is the most often injured spinal level.1,2 The rib cage stabilizes the thoracic spine, increasing its rigidity. The lumbar spine is more mobile. This segment where a transition occurs experiences much more biomechanical stress during damage than the remainder of the spinal column. The thoracolumbar injury classification and severity score system (TLICS) score assessment after trauma determines whether nonsurgical treatment or surgical treatment is required. Early mobilization and subsequent neurological deficit prevention are made possible by posterior instrumentation. Studies have shown that surgical treatment achieved better fracture reduction and long-term results.3,4 However, many authors stated that short-segment pedicle screw instrumentation was not sufficient to maintain the reduction of fractures and was associated with high rates of failure.5-7
AIMS AND OBJECTIVES
Study to assess the functional outcome of thoracolumbar fracture treated by intermediate pedicle screw fixation.
MATERIALS AND METHODS
The study is conducted for a period of 24 months. This study included patients who were admitted in Department of Orthopaedics in Thoothukudi Medical College, Thoothukudi, Tamil Nadu, India with thoracolumbar fractures treated with Intermediate pedicle screw fixation. Patients are initially brought into the emergency room and resuscitated. After secondary survey injection methylprednisolone 30 mg/kg bolus was given to patients with neurological deficit. Patients who agreed to participate in the study were given information on their injuries and the type of surgery performed.
Inclusion Criteria
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Age 15–70 years.
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Thoracolumbar injury classification and severity score system TLICS >4.
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Wedge compression fractures, burst fractures, and chance fractures.
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Both single and multilevel fractures.
Exclusion Criteria
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Polytrauma.
-
Metabolic bone diseases.
-
Pathological fractures.
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Associated cervical spine injury.
OPERATING PROCEDURE
Under general anesthesia, the patient in prone position parts is painted and draped. Tumescent solution infiltration was done. Using the posterior approach skin superficial fascia, lumbodorsal fascia incised, and paraspinal muscles identified subperiosteal dissection was done. Fracture vertebra exposed and identified under C-arm guidance. Entry point made using a bone awl, pedicle sound inserted to confirm the position. Screw length determined. Posterior instrumentation was done using pedicle screw fixation inserted above and below the fractured vertebra and in the fractured vertebra and connected using contoured rods and distraction was done based on the fracture pattern and involvement of soft tissues. A wound wash was given. The wound was closed in layers. Dressing was done. Patients were mobilized at the earliest postoperatively (intraoperative images and post-op X-rays are shown in Figures 1 to 3)
Fig. 1: Intraoperative image showing posterior stabilization with additional intermediate pedicle screw
Fig. 2: X-ray anteroposterior view of the lumbosacral spine showing intermediate pedicle screw fixation
Fig. 3: X-ray lateral view of the lumbosacral spine showing intermediate pedicle screw fixation
OUTCOME ANALYSIS
Postoperatively all patients were followed up for 2 years (2nd, 6th, 12th, and 24th month follow-up). Clinical assessment of neurological status and functional outcome were followed up.
The scales used were the Oswestry Disability Index (ODI), Denis pain score, and visual analog scale (VAS) score.
OBSERVATION AND RESULTS
The following observations were made from our study.
Age Incidence
Patient’s ages ranged from 16 to 70 years (shown in Table 1).
| Age in years | No of patients |
|---|---|
| 16–25 | 13 |
| 26–35 | 09 |
| 36–45 | 02 |
| 46–55 | 05 |
| 56–70 | 01 |
Sex Difference
Male patients dominated the study (shown in Table 2).
| Sex | No of patients |
|---|---|
| Male | 19 |
| Female | 11 |
Mechanism of Injury
Fall from height was the most common mode of injury (shown in Table 3).
| Mode of injury | No of patients |
|---|---|
| Fall from height | 22 |
| Accidental fall | 08 |
Type of Fracture
Burst fracture is the most common fracture type (shown in Table 4).
| Fracture | No of patients |
|---|---|
| Wedge compression | 7 |
| Chance | 1 |
| Burst | 22 |
Neurological Injury
Most patients did not suffer from neurological deficits (shown in Table 5).
| Neurological deficit | No of patients |
|---|---|
| Present | 7 |
| Absent | 23 |
Denis Pain Score
Most patients had reduced postoperative pain during follow-up (shown in Table 6).
| Denis pain score | Intermediate (n = 30) |
|---|---|
| 1 | 17 |
| 2 | 5 |
| 3 | 5 |
| 4 | 1 |
| 5 | 2 |
Visual Analog Scale (VAS)
Most patients didn’t suffer pain in the postoperative follow-up (shown in Table 7).
| Scale | No of patients (n = 30) |
|---|---|
| No pain | 15 |
| Mild | 8 |
| Moderate | 5 |
| Severe | 2 |
| Very severe | – |
| Worst pain possible | – |
Oswestry Disability Index (ODI)
A total of 20 patients (predominant) had only minimal disability (shown in Table 8).
| Modified ODI | Intermediate (n = 30) |
|---|---|
| Minimal disability | 20 |
| Moderate disability | 4 |
| Severe disability | 3 |
| Crippled | 3 |
| Bed bound | 0 |
DISCUSSION
As a result of spinal injuries, impairment in people with neurological deficits is now recognized as a serious health concern. Due to its role as a transition zone, the thoracolumbar Junction sustains the majority of them. The anatomy and physiology of the spine are altered by fracture, which increases morbidity in the patient. By restoring the spine’s normal structure, internal fixation of the spine aids in reducing neurological compression. Only injuries with substantial collapse and neurological loss necessitate surgery; stable spine injuries do not require it. Decompression and posterior stabilization are indications for surgical intervention in burst fractures with neurological impairment. Following surgery, neurological impairments can significantly improve, allowing for early patient mobilization. The addition of an intermediate pedicle screw provides a stronger fixation and good reduction of the vertebra.8 Placement of intermediate pedicle screws provides improve kyphotic correction.9,10 Systemic review and meta-analysis conducted by Carolijn Kapoen et al., information on the VAS is provided in nine of the included studies describing 501 patients. The VAS in these studies was rated at follow-up at least 3 months after surgery. The pooled results showed that the 6-screw construct reduces the VAS significantly with a mean difference of 0.64 points (95% confidence interval (CI) −1.08 to −0.19, p < 0.01, I2 = 93%). Information about ODI was extracted from five studies including 273 patients. The ODI was determined at follow-up at >1 year postoperative. The pooled results showed no significant difference between the 4-screw and 6-screw construct groups (mean deviation −0.19, 95% CI, −1.52 to 1.14, p = 0.78, I = 41%). In our study, most patients around 70% had good VAS and Denis pain scores though being subjective. Modified ODI showed many patients falling into the minimal disability category (Tables 6–8). Thus most patients undergoing surgery with an additional intermediate pedicle screw in the fracture have a good postoperative outcome.
CONCLUSION
Our study showed that patients operated in the intermediate pedicle screw fixation group had good Denis pain scores, VAS scores, and modified ODI. Hence, our study has proved that patients operated with Intermediate pedicle screw fixation do have a better outcome.
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