Successful short-segment instrumentation and fusion for thoracolumbar spine fractures - A consecutive 4(1)/(2)-year series

Study Design. A retrospective review of all the surgically managed spinal f ractures at the University of Missouri Medical Center during the 41/2-year period from January 1989 to July 1993 was performed. Of the 51 surgically m anaged patients, 46 were instrumented by short-segment technique (attachmen t of one level above the fracture to one level below the fracture). The oth er 5 patients in this consecutive series had multiple trauma. These patient s were included in the review because this was a consecutive series. Howeve r, they were grouped separately because they were instrumented by long-segm ent technique because of their multiple organ system injuries. Objectives. The choice of the anterior or posterior approach for short-segm ent instrumentation was based on the Load-Sharing Classification published in a 1994 issue of Spine. The purpose of this review was to demonstrate tha t grading comminution by use of the Load-Sharing Classification for approac h selection and the choice of patients with isolated fractures who are coop erative with spinal bracing for 4 months provide the keys to successful sho rt-segment treatment of isolated spinal fractures. Summary of Background Data, The current literature implies that the use of pedicle screws for short-segment instrumentation of spinal fracture is dang erous and inappropriate because of the high screw fracture rate. Methods. Charts, operative notes, preoperative and;postoperative radiograph s, computed tomography scans, and follow-up records of all patients were re viewed carefully from the time of surgery until final follow-up assessment. The Load-Sharing Classification had been used prospectively for all patien ts before their surgery to determine the approach for short-segment instrum entation. Denis' Pain Scale and Work Scales were obtained during follow-up evaluation for all patients. Results. All patients were observed over 40 months except for 1 patient who died of unrelated causes after 35 months. The mean follow-up period was 66 months (51/2 years). No patient was lost to follow-up evaluation. Prospect ive application of the Load-Sharing Classification to the patients' injury and restriction of the short-segment approach to cooperative patients with isolated spinal fractures (excluding multisystem trauma patients) allowed 4 5 of 46 patients instrumented by the short-segment technique to proceed to successful healing in virtual anatomic alignment. Conclusions. The Load-Sharing Classification is a straightforward way to de scribe the amount of bony comminution in a spinal fracture. When applied to patients with isolated spine fractures who are cooperative with 3 to 4 mon ths of spinal bracing, it can help the surgeon select short-segment pedicle -screw-based fixation using the posterior approach for less comminuted inju ries and the anterior approach for those more comminuted. The choice of whi ch fracture-dislocations should be strut grafted anteriorly and which need only posterior short-segmented pedicle-screw-based instrumentation also can be made using the Load-Sharing Classification.