Sat., 10/16/10 Pelvis & Spine, Paper #83, 4:16 pm OTA-2010
Minimally Invasive Surgery (MIS) Reduction and Stabilization with Percutaneous Pedicle Screw and Rod Fixation without Arthrodesis for Unstable Spinal Fractures: Early Experience and Results
Sean Owen, MD; Dirk Alander, MD;
St. Louis University Hospital, St. Louis, Missouri, USA
Background: The recent advent of MIS percutaneous pedicle screw fixation techniques and hardware have allowed the initial stabilization of thoracolumbar fractures in polytrauma patients, in an application similar to external fixation in so called “damage control orthopaedics.” These early successes of MIS pedicle screw fixation for polytrauma patients as well as the ability to minimize the loss of spinal motion, operative trauma, and operative time has prompted its use as definitive treatment for isolated spinal trauma in our institution.
Methods: After IRB approval, the trauma registry at our Level 1 trauma center was reviewed. The charts of patients who had incurred thoracolumbar or proximal thoracic fractures and were treated with MIS fixation from January 2008 to November 2009 were evaluated retrospectively for mechanism of injury, fracture location and type, age and gender of patient, timing of fixation, associated injuries, and occupation. Operative reports were reviewed for blood loss, operative time, and any complications. Initial and follow-up radiographs were reviewed for maintenance of fracture reduction. Outpatient questionnaires were reviewed for patient satisfaction and perception of spinal motion. All patients were scheduled for elective removal of hardware at 4 to 6 months after initial fixation. Patients who had undergone MIS fixation were included as long as they had at least 3 months’ follow-up after removal of their hardware.
Results: 20 patients underwent MIS pedicle screw fixation and met our follow-up criteria. Patient ages ranged from 18 to 79 years, with 16 males and 4 females. The majority of fractures were either thoracolumbar junction (T11-L2) or proximal thoracic (T6 and above). Most injuries were high-energy (motor vehicle accident, motorcycle collision, fall >10 ft). Eight patients had single-level injuries, while 12 had multilevel. Three Chance-type injuries were treated; the remainder were either compression or burst fractures (Denis criteria). Fractures were percutaneously reduced and stabilized. All but three patients were treated within 3 days of injury. Nine subjects were multitrauma patients, while 11 had solitary spinal injuries. All operative times ranged from 1 to 2 hours, and all operative blood losses were less than 50 cc. There were no operative complications in either the initial fixation or elective hardware removal. In follow-up, all patients had significant relief in back pain by their first follow-up visit after fixation. There were no hardware complications; all hardware was uneventfully removed on an outpatient basis. After removal, 18 of our subjects had no significant loss of reduction. The 2 patients had less than 10° of increased kyphosis through the adjacent discs spaces. There was no evidence of spinal instability after hardware removal. Pain relief was consistent, with minimal narcotic need by 3 months. Subjectively, patients consistently had a sense of significantly improved spinal motion after hardware removal.
Conclusion: Definitive MIS pedicle screw fixation presents an attractive alternative to traditional fusion with instrumentation for unstable spinal fractures. All fractures healed in this study. Clinical spinal motion was maintained and there was high patient satisfaction. Our early series demonstrates maintence of spinal stability, leading to excellent clinical results while minimizing complications in both polytrauma patients and those patients with isolated spinal injuries.
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• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant.