Transpedicular Approach To Dorso-Lumbar Spine Injuries

Arjun Shetty*,  Sandeep S, Ireshanavar**

*Consultant Neurosurgeon
**Registrar In Orthopaedics, Tejasvini Hospital, Mangalore, India.

Address for Correspondence
Dr Arjun Shetty
Consultant Neurosurgeon,
Tejasvini Hospital And SSIOT, Kadri,  Mangalore , Karnataka
Fax : 0824 2225998
drsandeepsi25@Yahoo.com

Abstract

Over a period of 2 years thirty-seven patients with dorso-lumbar spine injuries were operated using the transpedicular approach. This approach provides adequate cord decompression which was confirmed using an endoscope. Fusion using iliac crest graft and stabilisation with transpedicular screws and plates were done through the same approach. Of the cases treated there was no mortality. One patient had implant failure while two cases had infection of the graft donor site.
Key words: Thoraco-lumbar spine; transpedicular approach; endoscope. 

J.Orthopaedics 2007;4(2)e8

Introduction:

Thoraco-lumbar spine injuries can be operated through a number of approaches. The posterior decompressive laminectomy has fallen out of favour with reports now suggesting that neurological deterioration could result following the procedure1,2,3. The anterior approach allows for excellent exposure of the vertebral body. However the procedure is associated with significant post-operative morbidity and a second procedure may be needed for posterior stabilization of the spine4. The transpedicular approach allows for a single stage vertebral body decompression, graft placement and fixation. The procedure is cost effective and allows early mobilisation of patients.

Material and Methods :

Thirty-seven patients with thoraco-lumbar spine injuries involving D11 vertebrae and below were operated via the transpedicular route over a period of two years. Of these four were female and thirty-three were male. The patient’s age ranged from 17 to 62 years (average age 39 years).[FIGURE I]

Nine patients had no neurological deficit. Of the remaining, twelve presented with paraplegia and sixteen with paraparesis. Bladder and bowel involvement was noted in twenty-three patients and twenty-six patients had diminished sensory perception. Seventeen patients had associated orthopaedic injuries while three had chest injuries and two patients had abdominal injuries which necessitated surgical exploration.

All patients were investigated with radiographs and CT scans. Eight patients with no neurological deficit and three patients with neurological deficit were noted to have no evidence of cord compression. In the three who had neurological deficit the absence of cord compression was confirmed with an MRI.

All eleven patients who had no evidence of cord compression were stabilised using transpedicular screws and plates5. All twenty-six patients who had evidence of cord compression were subjected to transpedicular decompression. A fibre optic nasal endoscope was used to confirm adequate decompression on table6. In twenty-three cases iliac crest grafts were used for fusion. All twenty-six patients were stabilised using transpedicular screws and plates.

Results :

All nine patients who presented without neurological deficits remained neurologically intact after surgery and could be mobilised on a thoraco-lumbar brace.

Of the twelve patients who presented with complete paraplegia, four patients improved enough to achieve mobilisation with callipers and a single crutch. Six patients were mobilised on callipers and two crutches using a swing through gait. Two patients could not be mobilised on callipers and remained wheel-chair bound on discharge.

Seven out of the sixteen patients who presented with paraparesis improved sufficiently to allow mobilisation on a thoraco-lumbar brace. Six patients could be mobilised on callipers and a single crutch. Two patients were mobilised on two crutches using swing through gait. One patient could not be mobilised on callipers and was wheel-chair bound on discharge.

The duration of hospital stay varied form fifteen to sixty-three days (average twenty-eight days). There was no mortality in this series of patients. One patient had an implant failure which necesstated the removal of the implant. Two patients developed infection at the donor graft site which responded to antibiotics. Sixteen patients developed bedsores, all of which could be managed conservatively.

Discussion :

Decompressive laminectomy has fallen out of favour as a treatment option in thoraco-lumbar spine injuries as it does not relieve the primary compression and also further increases instability. The damage to the already oedematous cord may be worsened during the procedure1,3,7,8.

The anterior approach provides excellent visualisation of thoraco-lumbar vertebral body. However the exposure is associated with some morbidity and entails venturing into areas not routinely accessed by neurosurgeons. Stabilisation through the anterior approach requires the use of stabilisation devices which are expensive and not manufactured locally at present4,9,10.

The transpedicular approach allows for vertebral body decompression, fusion and fixation through a single area of access with minimal morbidity. The functional recovery seen with this procedure are comparable with other procedures2,7,11.

The transpedicular approach however does have certain drawbacks. Decompression is a tedious process and there is a possibility of a compressive fragment being left behind. We have tried to overcome this by using a flexible fibre optic nasal endoscope to directly visualise the fragments6. We have had some success with this technique. However bleeding from the bone may limit visibility in some cases.

We have found the transpedicular decompression and fixation to be technically difficult in injuries above the tenth thoracic vertebrae. In lesions above this level we have used the anterior approach for decompression and fixation.

The thoraco-lumbar transpedicular approach allows good decompression, fusion and fixation to be done as a single procedure. It is associated with minimal morbidity and allows rapid cost effective mobilisation of these patients.

Reference :

1. Erickson D.L., Hancook D.O.  Brown W.E. et al.: One stage decompression, stabilisation for thoraco-lumbar fractures. Spine 1977 2: 53-56.

2. Frankel H.L., Hancock D.O., Hyslop G. et al: The value of postural reduction in the initial management of closed spine injuries with paraplegia and tetraplegia. Paraplegia 1969: 7: 179-192.

3. Jelsma R.K., Rice J.F., Jelsma L.F. et al: The demonstration and significance of neural compression after spinal surgery. Surg. Neurology 1982: 18: 79-92.

4. Cook W.A. Jr., Hardaker W.T. Jr.: Injuries to the thoracic and lumbar spine. In Wilkins R.H., Rengachary S.S. (eds), Neurosurgery Vol II McGraw Hill, 1996. pp 2987-2995.

5. Steffe A.D., Biscup R.S., Sitteroski D.J.: Segmental spine plates with pedicle screw fixation: a new internal fixation device for disorders of the lumbar and thoraco-lumbar spine. Clin. Orthop. 1986: 203: 45-53.

6. Le Roux P.D., Haglund M.M., Harris A.B.: Thoracic disc disease experience with transpedicular approach in twenty consecutive patients. Neurosurgery 1993 33(1): 58-66.

7. Benzel E.C., Larsen S.J.:  Functional recovery after decompressive  operation for thoracic and lumber spine fractures. Neurosurgery 1986 19: 772-778.

8. Guttman L.: The conservative management of closed injuries of the vertebral column resulting in damage to the spinal cord and spinal roots. In Vinken P.J., Bruyn G.W. (eds): Handbook of clinical neurology, Vol 26. New York: American Elsevier, 1976 pp 285-306.

9. Kaneda K: Anterior spinal instrumentation for the thoracic and lumbar spine. In An. H.S. Cotter J.M. (eds): Spinal instrumentation. Baltimore: Williams and Wilkins, 1992 pp 413-433.

10. Yuan H.A., Mann K.A. Found E.M. et al: Early clinical experience with the Syracuse I plate an anterior spinal fixation device. Spine 1988 13: 278-285.

11. Jelsma R.K., Kirsh P.T., Jelsma L.F. et al: Surgical treatment of thoracolumbar fractures. Surg. Neurology 1982 18:156-166.

This is a peer reviewed paper 

Please cite as :Arjun Shetty: Transpedicular Approach To Dorso-Lumbar Spine Injuries

J.Orthopaedics 2007;4(2)e8

URL: http://www.jortho.org/2007/4/2/e8

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