Abstract
The second, internet-based multicenter study (MCSII) of the Spine Study Group of the German Association of Trauma Surgery (Deutsche Gesellschaft für Unfallchirurgie) is a representative patient collection of acute traumatic thoracolumbar (T1–L5) injuries. The MCSII results are an update of those obtained with the first multicenter study (MCSI) more than a decade ago. The aim of the study was to assess and bring into focus: the (1) epidemiologic data, (2) surgical and radiological outcome, and (3) 2-year follow-up (FU) results of these injuries. According to the Magerl/AO classification, there were 424 (57.8%) compression fractures (A type), 178 (24.3%) distractions injuries (B type), and 131 (17.9%) rotational injuries (C type). B and C type injuries carried a higher risk for neurological deficits, concomitant injuries, and multiple vertebral fractures. The level of injury was located at the thoracolumbar junction (T11–L2) in 67.0% of the case. 380 (51.8%) patients were operated on by posterior stabilization and instrumentation alone (POSTERIOR), 34 (4.6%) had an anterior procedure (ANTERIOR), and 319 (43.5%) patients were treated with combined posteroanterior surgery (COMBINED). 65% of patients with thoracic (T1–T10) and 57% with lumbar spinal (L3–L5) injuries were treated with a single posterior approach (POSTERIOR). 47% of the patients with thoracolumbar junction (T11–L2) injuries were either operated from posterior or with a combined posterior–anterior surgery (COMBINED) each. Short angular stable implant systems have replaced conventional non-angular stable instrumentation systems to a large extent. The posttraumatic deformity was restored best with COMBINED surgery. T-spine injuries were accompanied by a higher number and more severe neurologic deficits than TL junction or L-spine injuries. At the same time T-spine injuries showed less potential for neurologic recovery especially in paraplegic (Frankel/AISA A) patients. 5% of all patients required revision surgery for perioperative complications. Follow-up data of 558 (76.1%) patients were available and collected during a 30-month period from 1 January 2004 until 31 May 2006. On average, a posterior implant removal was carried out in a total of 382 COMBINED and POSTERIOR patients 12 months after the initial surgery. On average, the rehabilitation process required 3–4 weeks of inpatient treatment, followed by another 4 months of outpatient therapy and was significantly shorter when compared with MCSI in the mid-1990s. From the time of injury until FU, 80 (60.6%) of 132 patients with initial neurological deficits improved at least one grade on the Frankel/ASIA Scale; 8 (1.3%) patients deteriorated. A higher recovery rate was observed for incomplete neurological injuries (73%) than complete neurological injuries (44%). Different surgical approaches did not have a significant influence on the neurologic recovery until FU. Nevertheless, neurological deficits are the most important factors for the functional outcome and prognosis of TL spinal injuries. POSTERIOR patients had a better functional and subjective outcome at FU than COMBINED patients. However, the posttraumatic radiological deformity was best corrected in COMBINED patients and showed significantly less residual kyphotic deformity (biseg GDW −3.8° COMBINED vs. −6.1° POSTERIOR) at FU (p = 0.005). The sagittal spinal alignment was better maintained when using vertebral body replacement implants (cages) in comparison to iliac strut grafts. Additional anterior plate systems did not have a significant influence on the radiological FU results. In conclusion, comprehensive data of a large patient population with acute thoracolumbar spinal injuries has been obtained and analyzed with this prospective internet-based multicenter study. Thus, updated results and the clinical outcome of the current operative treatment strategies in participating German and Austrian trauma centers have been presented. Nevertheless, it was not possible to answer all remaining questions to contradictory findings of the subjective, clinical outcome and corresponding radiological findings between different surgical subgroups. Randomized-controlled long-term investigations seem mandatory and the next step in future clinical research of Spine Study Group of the German Trauma Society.
Similar content being viewed by others
Notes
Comorbidities were graded according to an anatomical injury scale (Abbreviate Injury Scale = AIS) [2] from 0, meaning “no injury” up to 5, meaning “critical injury, survival unlikely”.
References
Agus H, Kayali C, Arslantas M (2005) Nonoperative treatment of burst-type thoracolumbar vertebra fractures: clinical and radiological results of 29 patients. Eur Spine J 14(6):536–540
American Association for Automotive Medicine (1980) Die abgekürzte Verletzungsskala (AIS). Revidierte Fassung ed. Morton Grove, IL 60053, USA
American Spinal Injury Association (1992) ASIA classification: Standards for Neurological and Functional Classification of Spinal Cord Injury. American Spinal Injuries Association, Chicago
Atlas SW, Regenbogen V, Rogers LF, Kim KS (1986) The radiographic characterization of burst fractures of the spine. AJR Am J Roentgenol 147(3):575–582
Baker SP, O’Neill B, Haddon WJ, Long WB (1974) The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 14:187–196
Been HD, Bouma GJ (1999) Comparison of two types of surgery for thoraco-lumbar burst fractures: combined anterior and posterior stabilisation vs. posterior instrumentation only. Acta Neurochir (Wien) 141(4):349–357
Beisse R, Muckley T, Schmidt MH, Hauschild M, Buhren V (2005) Surgical technique and results of endoscopic anterior spinal canal decompression. J Neurosurg Spine 2(2):128–136
Beisse R, Potulski M, Bühren V (1999) Thorakoskopisch gesteuerte ventrale Plattenspondylodese bei Frakturen der Brust- und Lendenwirbelsäule. Operat Orthop Traumatol 11(1):54–69
Bence T, Schreiber U, Grupp T, Steinhauser E, Mittelmeier W (2007) Two column lesions in the thoracolumbar junction: anterior, posterior or combined approach? A comparative biomechanical in vitro investigation. Eur Spine J 16(6):813–820
Bensch FV, Koivikko MP, Kiuru MJ, Koskinen SK (2006) The incidence and distribution of burst fractures. Emerg Radiol 12(3):124–129
Boerger TO, Limb D, Dickson RA (2000) Does ‘canal clearance’ affect neurological outcome after thoracolumbar burst fractures? J Bone Joint Surg Br 82(5):629–635
Bohlman HH, Kirkpatrick JS, Delamarter RB, Leventhal M (1994) Anterior decompression for late pain and paralysis after fractures of the thoracolumbar spine. Clin Orthop Relat Res (300):24–29
Bombardier C (2000) Outcome assessments in the evaluation of treatment of spinal disorders: summary and general recommendations. Spine 25(24):3100–3103
Bradford DS, McBride GG (1987) Surgical management of thoracolumbar spine fractures with incomplete neurologic deficits. Clin Orthop (218):201–216
Buhren V, Beisse R, Potulski M (1997) Minimally invasive ventral spondylodesis in injuries to the thoracic and lumbar spine. Chirurg 68(11):1076–1084
Burney RE, Maio RF, Maynard F, Karunas R (1993) Incidence, characteristics, and outcome of spinal cord injury at trauma centers in North America. Arch Surg 128(5):596–599
Carlson GD, Gorden CD, Oliff HS, Pillai JJ, LaManna JC (2003) Sustained spinal cord compression: part I: time-dependent effect on long-term pathophysiology. J Bone Joint Surg Am 85-A(1):86–94
Clohisy JC, Akbarnia BA, Bucholz RD, Burkus JK, Backer RJ (1992) Neurologic recovery associated with anterior decompression of spine fractures at the thoracolumbar junction (T12–L1). Spine 17(8 Suppl):S325–S330
Croce MA, Bee TK, Pritchard E, Miller PR, Fabian TC (2001) Does optimal timing for spine fracture fixation exist? Ann Surg 233(6):851–858
Dai LY, Wang XY, Jiang LS (2007) Neurologic recovery from thoracolumbar burst fractures: is it predicted by the amount of initial canal encroachment and kyphotic deformity? Surg Neurol 67(3):232–237
Danisa OA, Shaffrey CI, Jane JA, Whitehill R et al (1995) Surgical approaches for the correction of unstable thoracolumbar burst fractures: a retrospective analysis of treatment outcomes. J Neurosurg 83(6):977–983
Defino HL, Rodriguez-Fuentes AE (1998) Treatment of fractures of the thoracolumbar spine by combined anteroposterior fixation using the Harms method. Eur Spine J 7(3):187–194
Dickman CA, Yahiro MA, Lu HT, Melkerson MN (1994) Surgical treatment alternatives for fixation of unstable fractures of the thoracic and lumbar spine. A meta-analysis. Spine 19(20 Suppl):2266S–2273S
Dimar JR, Glassman SD, Raque GH, Zhang YP, Shields CB (1999) The influence of spinal canal narrowing and timing of decompression on neurologic recovery after spinal cord contusion in a rat model. Spine 24(16):1623–1633
Dunn HK (1984) Anterior stabilization of thoracolumbar injuries. Clin Orthop (189):116–124
Esses SI, Botsford DJ, Kostuik JP (1990) Evaluation of surgical treatment for burst fractures. Spine 15(7):667–673
Fehlings MG, Perrin RG (2005) The role and timing of early decompression for cervical spinal cord injury: update with a review of recent clinical evidence. Injury 36(Suppl 2):B13–B26
Frankel HL, Hancock DO, Hyslop G, Melzak J et al (1969) The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia I. Paraplegia 7(3):179–192
Frymoyer JW, Howe J, Kuhlmann D (1978) The long-term effects of spinal fusion on the sacroiliac joints and ileum. Clin Orthop Relat Res (134):196–201
Gebhard F, Weidner A, Liener UC, Stockle U, Arand M (2004) Navigation at the spine. Injury 35(Suppl 1):S–S45
Gertzbein SD (1992) Scoliosis Research Society. Multicenter spine fracture study. Spine 17(5):528–540
Ghanayem AJ, Zdeblick TA (1997) Anterior instrumentation in the management of thoracolumbar burst fractures. Clin Orthop (335):89–100
Goldhahn J, Reinhold M, Stauber M, Knop C et al (2006) Improved anchorage in osteoporotic vertebrae with new implant designs. J Orthop Res 24(5):917–925
Haug RH, Street CC, Goltz M (2002) Does plate adaptation affect stability? A biomechanical comparison of locking and nonlocking plates. J Oral Maxillofac Surg 60(11):1319–1326
Hebert JS, Burnham RS (2000) The effect of polytrauma in persons with traumatic spine injury. A prospective database of spine fractures. Spine 25(1):55–60
Heyde CE, Ertel W, Kayser R (2005) Management of spine injuries in polytraumatized patients. Orthopade 34(9):889–905
Hu R, Mustard CA, Burns C (1996) Epidemiology of incident spinal fracture in a complete population. Spine 21(4):492–499
Huang TJ, Chen JY, Shih HN, Chen YJ, Hsu RW (1995) Surgical indications in low lumbar burst fractures: experiences with anterior locking plate system and the reduction-fixation system. J Trauma 39(5):910–914
Jackson AB, Dijkers M, Devivo MJ, Poczatek RB (2004) A demographic profile of new traumatic spinal cord injuries: change and stability over 30 years. Arch Phys Med Rehabil 85(11):1740–1748
Kaneda K, Abumi K, Fujiya M (1984) Burst fractures with neurologic deficits of the thoracolumbar–lumbar spine. Results of anterior decompression and stabilization with anterior instrumentation. Spine 9(8):788–795
Knop C, Blauth M, Bühren V, Hax PM et al (1999) Operative Behandlung von Verletzungen des thorakolumbalen Übergangs: Teil 1 “Epidemiologie”. Unfallchirurg 102(12):924–935
Knop C, Blauth M, Bühren V, Hax PM et al (2000) Operative Behandlung von Verletzungen des thorakolumbalen Übergangs: Teil 2 “Operation und Radiologie”. Unfallchirurg 103:1032–1047
Knop C, Blauth M, Buhren V, Arand M et al (2001) Operative Behandlung von Verletzungen des thorakolumbalen Überganges—Teil 3: Nachuntersuchung. Unfallchirurg 104(7):583–600
Knop C, Oeser M, Bastian L, Lange U, Zdichavsky M, Blauth M (2001) Entwicklung und Validierung des VAS-Wirbelsäulenscores [Development and validation of the Visual Analogue Scale (VAS) Spine Score]. Unfallchirurg 104(6):488–497
Knop C, Reinhold M, Roeder C, Staub L et al (2006) Internet based multicenter study for thoracolumbar injuries: a new concept and preliminary results. Eur Spine J 15(11):1687–1694
Korovessis P, Baikousis A, Zacharatos S, Petsinis G, Koureas G, Iliopoulos P (2006) Combined anterior plus posterior stabilization versus posterior short-segment instrumentation and fusion for mid-lumbar (L2–L4) burst fractures. Spine 31(8):859–868
Kostuik JP (1988) Anterior fixation for burst fractures of the thoracic and lumbar spine with or without neurological involvement. Spine 13(3):286–293
Kuklo TR, Potter BK, Ludwig SC, Anderson PA, Lindsey RW, Vaccaro AR (2006) Radiographic measurement techniques for sacral fractures consensus statement of the Spine Trauma Study Group. Spine 31(9):1047–1055
La Rosa G, Conti A, Cardali S, Cacciola F, Tomasello F (2004) Does early decompression improve neurological outcome of spinal cord injured patients? Appraisal of the literature using a meta-analytical approach. Spinal Cord 42(9):503–512
Landreneau RJ, Hazelrigg SR, Mack MJ, Dowling RD et al (1993) Postoperative pain-related morbidity: video-assisted thoracic surgery versus thoracotomy. Ann Thorac Surg 56(6):1285–1289
Lim TH, An HS, Hong JH, Ahn JY et al (1997) Biomechanical evaluation of anterior and posterior fixations in an unstable calf spine model. Spine 22(3):261–266
Linke B, Butscher A, Schneider R, Wahl D, Gasser B (2003) Holding strength of conventional and locking head screws. Folia Traumatol Lovaniensia 68–79
Lohmann R, Haid K, Stockle U, Raschke M (2007) Epidemiology and perspectives in traumatology of the elderly. Unfallchirurg 110(6):553–562
Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S (1994) A comprehensive classification of thoracic and lumbar injuries. Eur Spine J 3(4):184–201
McAfee PC, Bohlman HH, Yuan HA (1985) Anterior decompression of traumatic thoracolumbar fractures with incomplete neurological deficit using a retroperitoneal approach. J Bone Joint Surg Am 67(1):89–104
McDonough PW, Davis R, Tribus C, Zdeblick TA (2004) The management of acute thoracolumbar burst fractures with anterior corpectomy and Z-plate fixation. Spine 29(17):1901–1908
McEvoy RD, Bradford DS (1985) The management of burst fractures of the thoracic and lumbar spine. Experience in 53 patients. Spine 10(7):631–637
McLain RF (2004) Functional outcomes after surgery for spinal fractures: return to work and activity. Spine 29(4):470–477
McLain RF (2006) The biomechanics of long versus short fixation for thoracolumbar spine fractures. Spine 31(11 Suppl):S70–S79
McLain RF, Sparling E, Benson DR (1993) Early failure of short-segment pedicle instrumentation for thoracolumbar fractures A preliminary report. J Bone Joint Surg Am 75(2):162–167
Meves R, Avanzi O (2006) Correlation among canal compromise, neurologic deficit, and injury severity in thoracolumbar burst fractures. Spine 31(18):2137–2141
Mohanty SP, Venkatram N (2002) Does neurological recovery in thoracolumbar and lumbar burst fractures depend on the extent of canal compromise? Spinal Cord 40(6):295–299
Otte D, Sandor L, Zwipp H (1990) Bedeutung und Mechanismen von Brust- und Lendenwirbelsaulenverletzungen bei Verkehrsunfallen [Significance and mechanism of thoracic and lumbar spine injuries in traffic accidents] Bedeutung und Mechanismen von Brust- und Lendenwirbelsaulenverletzungen bei Verkehrsunfallen. Unfallchirurg 93(9):418–425
Pickett GE, Campos-Benitez M, Keller JL, Duggal N (2006) Epidemiology of traumatic spinal cord injury in Canada. Spine 31(7):799–805
Potulski M, Beisse R, Buhren V (1999) Thoracoscopy-guided management of the “anterior column”. Methods and results. Orthopade 28(8):723–730
Rahimi-Movaghar V, Vaccaro AR, Mohammadi M (2006) Efficacy of surgical decompression in regard to motor recovery in the setting of conus medullaris injury. J Spinal Cord Med 29(1):32–38
Rampersaud YR, Moro ER, Neary MA, White K et al (2006) Intraoperative adverse events and related postoperative complications in spine surgery: implications for enhancing patient safety founded on evidence-based protocols. Spine 31(13):1503–1510
Rath SA, Kahamba JF, Kretschmer T, Neff U, Richter HP, Antoniadis G (2005) Neurological recovery and its influencing factors in thoracic and lumbar spine fractures after surgical decompression and stabilization. Neurosurg Rev 28(1):44–52
Reinhold M, Knop C, Lange U, Rosenberger R, Schmid R, Blauth M (2006) Reposition von Verrenkungen und Verrenkungsbrüchen der unteren Halswirbelsäule [Reduction of traumatic dislocations and facet fracture-dislocations in the lower cervical spine]. Unfallchirurg 109(12):1064–1072
Reinhold M, Schmid R, Knop C, Blauth M (2004) Komplikationsspektrum operativ versorgter Wirbelsäulenverletzungen Eine Analyse der Multicenterstudien I und II der AG Wirbelsäule. Trauma Berufskrankh 7(Supp 2):281–291
Reinhold M, Schmolz W, Canto F, Krappinger D, Blauth M, Knop C (2007) An improved vertebral body replacement for the thoracolumbar spine A biomechanical in vitro test on human lumbar vertebral bodies. Unfallchirurg 110(4):327–333
Reinhold M, Schwieger K, Goldhahn J, Linke B, Knop C, Blauth M (2006) Influence of screw positioning in a new anterior spine fixator on implant loosening in osteoporotic vertebrae. Spine 31(4):406–413
Sasso RC, Renkens K, Hanson D, Reilly T, McGuire RA Jr, Best NM (2006) Unstable thoracolumbar burst fractures: anterior-only versus short-segment posterior fixation. J Spinal Disord Tech 19(4):242–248
Schnee CL, Ansell LV (1997) Selection criteria and outcome of operative approaches for thoracolumbar burst fractures with and without neurological deficit. J Neurosurg 86(1):48–55
Seller K, Wahl D, Wild A, Krauspe R, Schneider E, Linke B (2007) Pullout strength of anterior spinal instrumentation: a product comparison of seven screws in calf vertebral bodies. Eur Spine J 16(7):1047–1054
Seybold EA, Sweeney CA, Fredrickson BE, Warhold LG, Bernini PM (1999) Functional outcome of low lumbar burst fractures A multicenter review of operative and nonoperative treatment of L3–L5. Spine 24(20):2154–2161
Shields CB, Zhang YP, Shields LB, Han Y, Burke DA, Mayer NW (2005) The therapeutic window for spinal cord decompression in a rat spinal cord injury model. J Neurosurg Spine 3(4):302–307
Siebenga J, Leferink VJ, Segers MJ, Elzinga MJ et al (2006) Treatment of traumatic thoracolumbar spine fractures: a multicenter prospective randomized study of operative versus nonsurgical treatment. Spine 31(25):2881–2890
Speth MJ, Oner FC, Kadic MA, de-Klerk LW, Verbout AJ (1995) Recurrent kyphosis after posterior stabilization of thoracolumbar fractures 24 cases treated with a Dick internal fixator followed for 15–4 years. Acta Orthop Scand 66(5):406–410
Spinalcord Injury Information Network (2007) The National SCI Database. http://www.spinalcord.uab.edu
Trafton PG, Boyd CA Jr (1984) Computed tomography of thoracic and lumbar spine injuries. J Trauma 24(6):506–515
Vaccaro AR, Lim MR, Hurlbert RJ, Lehman RA Jr et al (2006) Surgical decision making for unstable thoracolumbar spine injuries: results of a consensus panel review by the Spine Trauma Study Group. J Spinal Disord Tech 19(1):1–10
Verlaan JJ, Diekerhof CH, Buskens E, van der Tweel I et al (2004) Surgical treatment of traumatic fractures of the thoracic and lumbar spine: a systematic review of the literature on techniques, complications, and outcome. Spine 29(7):803–814
Wang ST, Ma HL, Liu CL, Yu WK, Chang MC, Chen TH (2006) Is fusion necessary for surgically treated burst fractures of the thoracolumbar and lumbar spine?: a prospective, randomized study. Spine 31(23):2646–2652
Acknowledgments
The authors like to thank all clinical collaborators of the Spine Study Group of the German Association of Trauma Surgery Spine for their exceptional commitment to this project throughout the past years. Special thanks go to PD. Dr. L. Audigé for his expert advice and Mark Kanodi, MSc for help with the manuscript preparation.
Conflict of interest statement
This study was supported by the German Association of Trauma Surgery.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Reinhold, M., Knop, C., Beisse, R. et al. Operative treatment of 733 patients with acute thoracolumbar spinal injuries: comprehensive results from the second, prospective, internet-based multicenter study of the Spine Study Group of the German Association of Trauma Surgery. Eur Spine J 19, 1657–1676 (2010). https://doi.org/10.1007/s00586-010-1451-5
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00586-010-1451-5