MARSHALL R. URIST
`Edz't0r~in-Chief
`
`Withthe Assistance of
`
`THE ASSOCIATE EDITORS
`THE BOARD OF ADVISORY EDITORS
`
`THE BOARD OF CORRESPONDING EDITORS
`
`Number Two Hundred Twenty—SeVen
`
`
`
`J. B. LIPPINCOTT COMPANY
`
`Philadelphia
`
`Medtronic,
`
`Inc. MSD lOl5
`
`1
`
`

`
`CLINICAL ORTHOPAEDICS AND RELATED’ RESEARCH
`~
`GUIDELINES FOR AUTHORS
`
`CLINICAL ORTHOPAEDICS AND RELATED RESEARCH is designed for the publication of original articles offering
`significant contributions to the advancement of orthopedic knowledge. Articles are accepted only for exclusive
`publication in CLINICAL ORTHOPAEDICS AND RELATED RESEARCH; published articles and their illustrations become
`the property of CLINICAL ORTHOPAEDICS AND RELATED RESEARCH.
`
`0 T0 COVER COSTS of postage and other overhead ex-
`penses, contributors should send a check for $25.00 (U.S.)
`with each unsolicited manuscript to CLINICAL ORTHOPAE-
`DICS AND RELATED RESEARCH, UCLA Bone Research Labo-
`ratory, 1000 Veteran Avenue, Los Angeles, California 90024.
`- ORGANIZE YOUR MANUSCRIPT as follows: Ab-
`stract; Introduction; Materials and Methods; Results; Dis-
`cussion.
`0 THE ACCURACY OF THE INFORMATION and of
`the citations of literature is the sole responsibility of the
`author(s).
`0 AUTHORS ARE NOT ENCOURAGED to submit
`articles in series, e.g., “Part I: Fractures of the Hip; Part 11:
`Complications of Fractures of the Hip; Part 111: etc."
`6 THE ABSTRACT should consist of a one paragraph
`statement less than 200 words in length, stating the main con-
`clusions without reference to any other part of the manuscript.
`The abstract must be independently understood for reproduc-
`tion by libraries and other publications as a separate entity.
`- ALPHABETIZE AND NUMBER REFERENCES. A
`bibliography of numbered references in alphabetical order
`should be attached to the manuscript. Each reference must be
`cited in the text by number. Follow exact style of references
`published in this copy of CLINICAL ORTHOPAEDICS AND RE-
`LATED RESEARCH. Each reference must list all co-authors.
`0 ALL TABULAR MATERIAL OR STATISTICAL
`DATA must be in the form of clear tables, placed one to a
`page, at the end of the manuscript. Tables must be titled,
`numbered, and cited in the text in numerical order.
`0 INCLUDE A SHEET OF LEGENDS DESCRIBING
`ILLUSTRATIONS. A separate Sheet of typed legends
`(captions) describing each illustration should be attached to
`the manuscript.
`0 SEND FOUR SETS OF UNMOUNTED BLACK AND
`WHITE GLOSSY PRINTS approximately 5” X 7" for all fig-
`ures, for reviewers’ use. Original drawings and X-rays must be
`of professional quality and photographed as black and white
`glossy prints. Do not write on the face of illustrations; put as
`much information as possible in the legends. If arrows or letters
`are necessary, use a professional product such as Letraset or
`Paratype. Attach a label to the backs of illustrations indicating
`“top,” figure number, and author’s name, or enter this infor-
`mation lightly with a pencil. Each figure must be cited in the
`appropriate place in the text in numerical order. Submit the
`minimum number of figures and tables necessary to highlight
`the article. The publisher reserves the right to charge for illus-
`nations and tables in excess of one page of illustrations, in-
`cluding tabular material, per four pages of printed text.
`
`6 LETTERS OF PERMISSION from the publisher of any
`borrowed illustration or table should be enclosed with the
`manuscript. Acknowledgment of the sources must also be in.
`cluded at the end of the legend for borrowed illustrations and as
`a footnote to the table of any borrowed tabular material.
`
`4» SEND THE ORIGINAL TYPESCRIPT AND TWO
`DUPLICATES. Manuscripts must be in English,
`typed
`double-spaced on the one side of 8‘/2" X I 1" paper with wide
`margins and pages numbered. Authors should retain copies
`of manuscripts and illustrations. Page I of the r1’IE11'1I1SCl‘ip[
`Should be a cover (title) page listing the title of the article and
`authors’ names and degrees, with footnotes including com.
`plete addresses and professional affiliations.
`
`o SEND A LETTER OF TRANSMYITAL SIGNED BY
`ALL AUTHORS containing the following paragraph: “In con.
`sideration of CLINICAL ORTHOPAEDICS AND RELATED RE.
`SEARCH reviewing and editing my (our) Submission, the an.
`thor(s) undersigned hereby transfeits), assign(s), or otherwise
`convey(s) all Copyright ownership to CLINICAL ORTH0PAEDIcs
`AND RELATED RESEARCH, and represent(s) that he(they)
`own(s) all rights in the material submitted. This assignment is
`to take effect only in the event that such work is published in
`CLINICAL ORTHOPAEDICS AND RELATED RESEARCH."
`
`0 CLINICAL ORTHOPAEDICS AND RELATED RE.
`SEARCH will expedite publication of selected manuscripts.
`To qualify for accelerated publication, the work must be
`judged to be of exceptional Significance and immediate in-
`terest. Such manuscripts must be labelled “FOR EXPE-
`DITED PUBLICATION,” contain the elements of a regular
`manuscript, and satisfy the criteria governing the publica-
`tion of papers in CO&RR, but must not exceed 12 manu-
`script pages (excluding illustrations, tables, and references).
`The manuscript must be accompanied by a transmittal let-
`ter giving the reasons why the authors believe the work
`justifies expedited publication and the names of at least
`three knowledgeable surgeons who will immediately return
`the manuscript with an impartial, detailed review. Except
`for minor revisions, such manuscripts will be either ac-
`cepted or rejected within four weeks. The aim is to publish
`an expedited paper within three to six months after submis-
`sion. The number of expedited publications is limited to one
`per issue.
`
`0 REPRINTS. The publisher will provide each senior
`author, free of charge, with 50 repiints of his article. If addi-
`tional reprints are desired, they may be ordered on the ordet
`form furnished with page proofs.
`
`Following are the subjects of Symposia to be published in forthcoming numbers:
`
`Advances in 1988; Controversy in Scoliosis Treatment
`
`Copyright © 1988, BY J. B. LIPPINCOTT COMPANY
`
`Library of Congress Catalog Card Number 53-7647
`
`CLINICAL ORTHOPAEDICS AND RELATED RESEARCH (ISSN 0009-921 X) is published monthly by J. B. Lippincott Company, at 2350 Virginia Avenue, Hagerstowrt
`MD 2 l 740. Business offices are located at East Washington Square, Philadelphia, PA 19105. Printed in the U.S.A. © Copyright 1988 by J. B. Lippincott Company. Al
`rights reserved. Second class postage paid at Hagerstown, MD, and at additional mailing offices.
`Subscription information, orders or changes of address: (except Japan) 2350 Virginia Avenue, Hagerstown, MD 21740, or call 1-800-638-3030; in Maryland, cal
`collect 301-824-7300. In Japan, contact Wcuodbell Scope, Mansui Bldg, 9-I8, Kanda-Surugadai 24:home, Chiyoda-ku, Tokyo lOl, Japan.
`In India, Nepal
`Bangladesh, and Sri Lanka, contact Universal Subscription Agency Pvt. Ltd, l0l— I02 Community Centre (F.F.) Saket, New Delhi—l 10017, India.
`Annual subscription rates: U.S. $155.00 individual, $215.00 institution; all other countries except Japan, India, Nepal, Bangladesh, and Sri Lanka, $l85.0i
`individual, $245.00 institution. Resident rate, U.S.: $99.00, Canada: $129.00. Single copies $30.00. Rates for airmail delivery available upon request. Copies will bi
`replaced without charge if the publisher receives a request within 60 days of the mailing date in the US. or within 5 months in all other countries.
`POSTMASTER: Send address changes to CLINICAL ORTHOPAEDICS AND RELATED RESEARCH, 2350 Virginia Avenue, Hngerstown, MD 21740.
`
`2
`
`

`
`Transpedicular Fixation of Thoracolumbar
`
`Vertebral Fractures
`
`SVEN OLERUD, M.D.,* GORAN KARLSTROM, M.D.,** AND LENNART SJOSTROM, MD)“
`
`The most frequent surgical treatment of thorac_o—
`lumbar fractures is still the Harrington rod system
`despite some adverse effects, the most serious
`being the locking of five to seven segments. The
`new pedicular fixation modifications suggested by
`Magerl and Dick lock only two segments and give
`far better stability of the fractures. Used’inter-
`nally, the system is convenient for the patient,
`permitting early mobilization, often without any
`external support. The instrument, called the “pos-
`terior segmental fixator” (PSF), is used both as a
`reduction device and as a fixation device. The in-
`jured vertebra is grafted through the pedicle, giv-
`ing security against late collapse after device re-
`moval. Twenty patients treated with this method
`had an average follow-up period of ten months.
`The primary reduction attains 88% of the calcu-
`lated height of the injured vertebra, with only a
`few percent loss during follow—up time. Clearance
`of fragments in the spinal canal, diagnosed with
`computed tomography scan in eight patients, was
`successfully accomplished in all but one, with only
`distraction or reduction of the fragment through a
`limited laminotomy. The instrumentation in these
`cases was lateral to the dura. Nine patients with
`neurologic deficits improved and could walk with-
`out support or with crutches within a few months.
`One patient with complete paraplegia remained
`unchanged.
`
`The main goals of surgical treatment of
`thoracolumbar vertebral fractures are to
`
`From the Department of Orthopaedic Surgery, Upp-
`sala University, Uppsala Hospital.
`* Professor and Chairman, Orthopaedic Department,
`University of Uppsala.
`** Associate Professor.
`T Fellow.
`Reprint requests to Sven Olerud, M.D., Department
`of Orthopaedic Surgery, University Hospital, S-751 85
`Uppsala, Sweden.
`Received: April 13, 1987.
`
`achieve reduction, stability, and early, pain-.
`less mobilization. It is assumed, though not
`proven, that stable fracture fixation and de-
`compression of nerve structures facilitate the
`restoration of neurologic deficits.4*5"°"9>2*’-’2“~
`2537'” A further aim is to avoid late malposi-
`tions and to preserve lumbar mobility and
`pOSmre_i1,37,3a,42
`Harrington instrumentation and similar
`methods are currently the most commonly
`used fixations for thoracolumbar frac-
`
`tures.2>7*‘2’2”39=“°’45 However, fracture treat-
`ment with the Harrington device has certain
`limitations. The main disadvantage is that
`this device fixates five to seven vertebrae, re-
`sulting in negative effects on mobility. This
`negative effect is greater the farther down in
`the lumbar spine the fracture is located. Fur-
`thermore, in the postoperative period a brace
`is needed for mobilization of the patient dur-
`ing healing time to avoid instrument fail-
`ures.2"3° Moreover, the patient is not allowed
`to sit for six months.
`
`Instability, instrument failures, and cor-
`rection losses have been reported.‘*5*'5*
`23'32"““‘5 Some loss of correction may occur
`after removal of the distraction devices, so
`that the end result is often roughly similar to
`the original defonnation.“23‘36
`Roy—Camille and co—-workers’ transpedic-
`ular screw fixations of plates37*33 paved the
`way for Mager1’s external fixation of verte-
`bral fractures with the aid of transpedicular
`screws3°‘3‘ and for posterior segmental fixa-
`tion with an internal fixator.‘*'3 This instru-
`
`mentation, according to Dick, seems to have
`
`3
`
`

`
`Number 227
`February. 1988
`
`Thoracolumbar Vertebral Fractures
`
`45
`
`FIG. 1. The posterior segmental fixator (PSF). The device consists of two reversed units. Each unit is
`composed of one threaded rod (1). On this rod two bolt grips (2) are movable in relation to each other as
`well as to two screw grips (3) that surround the pedicular screws. The components are locked into each
`other by conical screws (4). With the special handles (5), the deformed vertebral body can be reduced to
`normal height and correct lordosis.
`
`several advantages.” One is that only three
`vertebrae are immobilized, resulting in better
`preserved mobility.
`Because transpedicular screws, used for re-
`duction, are placed close to the injured ver—
`tebra, the possibility for anatomic reduction
`should be better, especially in the lower lum-
`bar region. When this treatment is combined
`with a transpedicular bone grafts the risk for
`secondary deformities should be minimized.
`This article reports the authors’ early expe-
`riences with posterior segmental fixation
`using the Dick internal fixator” and a simi-
`
`lar, modified instrument, the “posterior seg-
`mental fixator” (PSF).35
`
`MATERIAL AND METHODS
`
`The PSF (Fig. 1) consists of two identical but
`reversed units: a threaded rod against which two
`bolt grips can be moved in relation to each other
`and two screw grips that embrace the pedicle
`screws. The firm hold of the screws in the pedicles
`greatly facilitates reduction of the fractured verte-
`bra to a correct height and to the correct degree of
`lordosis. The device is sufficiently stable to main-
`tain the reduced position until healing is com-
`pleted, without the need for a brace. If additional
`
`4
`
`

`
`46
`
`Olerud et al. ‘
`
`Clinical Orthopaedics
`and Related Research
`
`FIG. 2. The PSF allows reduction by extension as well as distraction. After reduction, the configuration
`and height of the fractured vertebra are normalized.
`
`translatory stability is necessary, diagonal cerclage
`between the two halves of the instrument can also
`be used.
`
`SURGICAL TECHNIQUE
`
`The operation is performed with the patient in
`the prone position on two boards meeting at the
`level of the fracture site. An operating table suit-
`able for fluoroscopy should be used, because an
`image intensifier with a C-arm is necessary for a
`correctly performed operation. The skin incision
`is made in the midline and should correspond to
`five spinous processes. The vertebral arches are
`dissected free subperiosteally to expose the facet
`joints. The sites of insertion of the screws are
`identified as described by Louis” and Roy—Ca-
`mille et al.“ The respective joint space and the
`middle of the transverse process are the most im-
`portant reference points. A Kirschner wire is used
`at fluoroscopy to locate the correct place to insert
`the screw. An opening is then made in the pedicle
`
`with a drill or awl, and a self-threading screw is
`bored manually through the pedicle into the ver—
`tebral body. The screw is bored 3.5-4 cm, z'.e.,
`almost to the anterior wall of the vertebral body.
`The position of the screw is checked most reliably
`in the lateral projection with the C-arm.
`When all four screws have been inserted in the
`correct position, the threaded rod is attached to
`the screws by its clutches. With the aid of the
`image intensifier, the posterior wall of the verte-
`bral body is reduced somewhat, but not com-
`pletely; this will be done later, when the normal
`lordotic angulation is achieved. Lifting the head
`end and the foot end of the two boards on which
`the patient is lying also reduces the anterior wall
`of the vertebral body, with the fixator as a support;
`this is necessary if the vertebral arches and/or in-
`tervertebral joints do not provide stability.
`Further lordosis is now achieved, if needed, by
`squeezing together the reduction pins that are
`fixed in the screw grips at the upper and lower
`vertebrae (Fig. 2). This can often be accomplished
`
`5
`
`

`
`Number 227
`February. 1988
`
`Thoracolumbar Vertebral Fractures
`
`47
`
`relatively easily with a pair of tongs. The screw
`grips are then locked to the bolt grips by means of
`the conical screws. When the threaded rods are
`rotated, the fractured vertebra is distracted (Fig. 2)
`until the height of the vertebral body is restored to
`normal.
`Subsequently, the threaded rods are locked to
`the bolt grips. If the posterior articular system is
`undamaged, the two segments around the frac-
`tured vertebra will be adequately stabilized. If any
`intervertebral joints or vertebral arches are frac-
`tured, however, some instability will remain in
`bending and in rotation. With the use of two diag-
`onal cerclage wires between the two units of the
`instrument, adequate stability can be achieved.
`On reduction of a compressed vertebral body,
`defects will occur in the cancellous bone (as in
`compression fractures in tibial condyles). Simi-
`larly, with the insertion of transpedicular screws, a
`hole can be made with a 5—mm drill through one
`of the pedicles of the fractured vertebra into the
`vertebral body. A slightly curved punch is brought
`through the pedicle into the vertebral body (Fig.
`3); under fluoroscopic control with the image in-
`tensifier, the end plates and anterior wall of the
`vertebra are reduced, if possible. An aural specu-
`lum is inserted into the pedicular hole and a can-
`cellous bone graft—bone paste obtained from the
`posterior aspect of the iliac crest with an acetabu-
`lar reamer“‘——-is pressed into the vertebra.3
`Posterolateral fusions are only rarely per-
`formed, 1'.e., in cases of facet fractures and after a
`laminectomy. Preoperative myelography or com-
`puted tomography (CT) scans will reveal any
`fragments that have been displaced into the spinal
`canal. If there is a burst fracture, the fragment can
`often be reduced with only distraction. Otherwise,
`with a minor laminectomy such a fragment can be
`identified by fluoroscopy with an image intensi-
`fier and with the aid of an elevator inserted at the
`side of the dura. Using the PSF, the fragment can
`then be pressed back into the vertebral body. If
`this is not possible, a limited laminectomy can be
`performed after removal of the threaded rod on
`one side. Any fracture fragments can then be re-
`duced or any fragments present in the spinal canal
`extracted without any effect on the dura. The re-
`moved threaded rod is subsequently reinserted.
`The reduction usually is not jeopardized by short-
`term intraoperative dismantling of one of the de-
`vice units, because the patient is in hyperexten-
`sion. If desirable, intraoperative myelography can‘
`be performed as a check. After operation, the pa-
`tients can often be mobilized immediately with-
`out any external support or, in a few cases, with a
`simple three-point brace.”
`At follow-up examination, the reduction effect
`was measured by comparing the anterior height of
`
`
`
`FIG. 3. With a transpedicularly introduced
`punch, further reduction of fragments in the ver-
`tebral body can be reduced. The defect in the ver-
`tebra is then filled with a graft in the form of bone
`paste.""3
`
`the injured vertebra with the calculated height of
`the same vertebra (the mean value of the vertebra
`above and the one below the injured vertebra).
`The reduction effect was also estimated by com-
`paring the Cobb angle.
`
`PATIENTS
`
`This series consisted of 20 consecutive patients
`with thoracolumbar burst fractures (14 men and
`six women) aged 16-59 years (average, 35 years).
`All fractures had been caused by high-energy
`trauma, mainly traffic accidents (1 3 patients). Ten
`of the patients had neurologic symptoms on ad-
`mission but only one had complete paraplegia.
`The injured vertebrae were T12 in three, L1 in
`five, L2 in four, L3 in two, and L4 in five patients
`(Table 1).
`When classified according to Denis,“ three
`fractures were of Type A, 14 of Type B, two of
`Type D, and one of Type E.
`Two patients were treated at a relatively late
`stage (19 and 45 days, respectively) after injury,
`and the remaining 18 patients were treated within
`five days of injury. Of these, seven had surgery on
`the day of injury.
`All were treated with open reduction and fixa-
`tion with the PSF in the manner described above.
`
`6
`
`

`
`48
`
`Olerud et al.
`
`~
`
`TABLE 1. Kyphotic Deformities
`
`FraCtzu'ea'
`Vertebra
`
`N0. of
`Patients
`
`‘
`Preoperative
`
`Cobb Angle (“J
`
`Postoperative
`
`8
`7
`8 lordosis
`0
`ll lordosis
`
`T12
`L1
`L2
`L3
`L4
`
`3
`6
`4
`2
`5
`
`24
`18
`7
`9
`10 lordosis
`
`Fifteen patients had transpedicular bone grafting
`(Fig. 4); in -the other five patients the comrninu-
`tion of the vertebra was too severe for grafting to
`be worthwhile. For these and two other patients, a
`posterior fusion was done over the two immobi-
`lized segments. In 11 patients, minor 1aminoto-
`mies were carried out for inspection and/or addi-
`tional repositioning of the anterior wall of the spi-
`nal canal. Later in the series, perioperative
`myelography was routinely carried out after re-
`duction to check the repositioning of the anterior
`wall. This markedly decreased the need for lami-
`notomy.
`Eleven of the patients had other injuries, such
`as thoracic compression injuries or fractures of
`the lower extremities.
`
`RESULTS
`
`The average follow-up period was ten
`months (range, six to 17 months). The mean
`time for roentgenographic control is eight
`months.
`
`When wound pain subsided, the patients
`were freely mobilized. They were discharged
`after two to three weeks if they had no other
`injury.
`Two patients needed further operations.
`One had an anterior decompression and fu-
`sion because a postoperative CT scan showed
`that the neural decompression was not ac-
`ceptable. The second patient had continuing
`radicular pain and was therefore treated with
`root decompression.
`At follow-up examination, only the pa-
`tient with complete paraplegia remained un-
`changed. Three patients who were classified
`before operation as “motor useless,” i‘.e.,
`Frankel et al. Grade C,” were improved to
`Frankel Grade D. Six Frankel Grade D pa-
`
`Clinical Orthopaedics
`and Related Research
`
`tients were improved, although none was en-
`tirely free from neurologic symptoms. All
`except the paraplegic patient are walking
`without support or with crutches. Six pa-
`tients have returned to work, four are back at
`school, and two are being retrained. Eight are
`still on the sick list.
`
`Two patients were regarded as technical
`failures. In one patient the lower grips of the
`fixator were insufficient, and he regained al-
`most his original kyphotic deformity; how-
`ever, he is pain-free and working again. This
`patient was the second in this series and the
`device was a prototype. Another patient had
`a translatory instability that was not recog-
`nized at the time of operation. This patient
`should have had diagonal cerclage wiring
`done to prevent a late lumbar scoliosis of
`minor degree.
`The preoperative and postoperative ky-
`photic deformities are listed in Table I. In
`most of the fractures located in the middle
`
`and the lower lumbar spine, a local lordotic
`curve has been achieved.
`
`The reduction effect, measured by com-
`paring the anterior height of the injured ver-
`tebra before and after operation, was satisfy-
`ing. The preoperative value showed a com-
`pression to 56% of the calculated height of
`the vertebra. At the first postoperative check,
`the height of the vertebra was raised to an
`average of 88% of the calculated value. After
`eight months, this value decreased to 83%.
`Roughly one-half of the total loss occurred in
`the two patients defined as technical failures.
`If these cases are excluded, the average post-
`operative height is 85% of normal.
`The reduction effect, measured by calcu-
`lating the Cobb angle, showed an average
`loss of 4° in the group of 20 patients. If the
`technical failures are excluded, the angula-
`tion loss during the eight-month period
`averaged only 2°.
`
`_ DISCUSSION
`
`With the PSF, the primary goals of the
`treatment are achieved: the patients are
`
`7
`
`

`
`Number 227
`February. 1988
`
`Thoracolumbar Vertebral Fractures
`
`49
`
`FIGS. 4A—4C. (A) Burst fracture of L2
`(arrows). (B) CT scan showing a large frag-
`ment
`located in the spinal canal.
`(C)
`Roentgenogram taken six months after re-
`duction and fixation with PSF. The trans-
`pedicular grafting gives a slightly higher
`density to the central part of the body of the
`vertebra. The height of the vertebral body is
`well restored.
`
`
`
`pain—free after a few days, mobilization is
`easier than after Harrington distraction
`operations since there are no sitting restric-
`tions, and the brace, when required, is of a
`simple type.”'35 The anatomic end results
`are comparable to or somewhat better than
`
`those achieved with the Harrington tech-
`nique.”
`Two principles of treatment are consid-
`ered to promote regression of partial neuro-
`logic deficits in cases of unstable vertebral
`fractures. One is decompression of the spinal
`
`8
`
`

`
`50
`
`Olerud et -al.
`
`Clinical Orthopaedics
`and Related Research
`
`cord and nerve roots; the other is elimination
`of instability.5='6’2“’35 The time factor is also
`important.”
`Decompression of the contents of the spi-
`nal canal can be achieved with distraction
`
`procedures, laminectomy, or an anterior
`surgical approach. Laminectomies alone are
`currently considered to be of little value, be-
`cause they increase instability6*9"6 such that
`the neurologic deficit may even be aggra-
`vated.“ Moreover, posterior decompression
`is usually an illogical choice of treatment
`since the pressure on the nerve structures is
`due, in most cases, to vertebral fragments or.
`disc tissue that is forced into the spinal canal
`from the anterior direction.” This has been
`
`demonstrated in recent years with CT inves-
`tigations.‘”:‘‘‘’ Because distraction operations
`alone also do not guarantee adequate de-
`compression,” especially in patients with a
`fracture more than three or four days old,
`anterior decompression operations com-
`bined with posterior or anterior fixation pro-
`cedures have been used increasingly in recent
`yeaI.S.3,4,l7,26,27.33
`Radical anterior decompression and stabi-
`lization, however, is in many cases a rather
`extensive procedure. Posterior reduction and
`internal fixation with the Dick device” or
`
`the PSF,” used in this series, are far less de-
`manding procedures and give results equiva-
`lent to those of anterior operations.
`The anatomic results in this series are
`
`comparable to or somewhat better than those
`achieved with the Harrington technique, the
`reduction having been close to anatomic
`(Fig. 4). The tolerance for flexion deformity
`should also be better than in Harrington-
`operated patients, since the possibility of
`compensating for such a deformity is better
`preserved when only two vertebral segments
`are immobilized. Several problems with
`Harrington—operated patients have been re-
`ported (e.g., restricted lumbar mobility and
`loss of lordosis), notably after scoliosis sur-
`gery. The same is apparently true for trau-
`matized patients treated the same way.”
`The fractured and grafted vertebraesi” are
`expected to heal after six months, although
`
`the device is not removed before at least one
`
`year. The loss of anterior vertebral height
`and increasing flexion deformity can to some
`extent be explained by the two technical fail-
`ures in this series. For the rest of the patients,
`the loss of vertebral height is less than that
`described after Harrington fixation without
`technical failures.“ The reason for the loss of
`
`correction in patients who do not show any
`signs of PSF failure is probably that the grip
`of the screws decreased somewhat in the
`cancellous bone of the vertebrae.
`
`It is interesting that there is relatively more
`loss of flexion than of vertebral height. This
`is probably due to fact that an injured disc
`will collapse when the screw grip in the ver-
`tebra decreases somewhat.
`
`The major advantage of this method seems
`to be that further deformation after device
`
`removal can be avoided, but this still has to
`be evaluated and confirmed.
`
`REFERENCES
`
`1. Aebi, M., Mohler, J., Zach, G., and Morscher E.:
`Analysis of 75 operated thoracolumbar fractures
`and fracture dislocations with and without neuro-
`logical deficit. Arch. Orthop. Trauma. Surg.
`1051100, 1986.
`2. Armstrong, G. W. D., and Johnston, D. H.: Stabili-
`zation of spinal injuries using Harrington instru-
`mentation. J. Bone Joint Surg. 56B:590, 1974.
`3. Bohlman, H. H.: Traumatic fractures of the upper
`thoracic spine with paralysis. J. Bone Joint Surg.
`56A:1299, 1974.
`4. Bohlman, H. H., and Eismont, F. J.: Surgical tech-
`niques of anterior decompression and fusion for spi-
`nal cord injuries. Clin. Orthop. 154:57, 1981.
`5. Bradford, D. S., Akbarnia, B. A., Winter, R. B., and
`Seljeskog, E. L‘.: Surgical stabilization of fracture
`dislocation ofthe thoracic spine. Spine 2: 185, 1977.
`6. Clark, W. K.: Spinal cord decompression in spinal
`cord injury. Clin. Orthop. 154:9, 1981.
`7. Convery, F. R., Minteer, M. A., Smith, R. W., and
`Emerson, S. M.: Fracture dislocation of the dorso-
`lumbar spine. Acute operative stabilization by Har-
`rington instrumentation. Spine 3:160, 1978.
`8. Daniaux, H.: Teknik und erste Ergebnisse der tran-
`spedikularen Sponglosaplastik bei Kompres-
`sionsbriichen im Lendenwirbelséiulenbereich. Acta
`Chir. Austriaca (Suppl.) 43:79, 1982.
`9. Davies, W. E., Morris, J. H., and Hill, V.: An analy-
`sis of conservative (non-surgical) management of
`thoracolurnbar fractures and fracture dislocations
`with neural damage. J . Bone Joint Surg. 62A:1324,
`1980.
`10. De la Torre, J. C.: Spinal cord injury: Review of
`basic and applied research. Spine 6:315, 1983.
`
`9
`
`

`
`10
`
`Number 227
`February, 1988
`
`ll.
`
`13.
`
`14.
`
`15.
`
`16.
`
`17.
`
`18.
`
`19.
`
`20.
`
`21.
`
`22.
`
`23.
`
`24.
`
`25.
`
`26.
`
`27.
`
`28.
`
`Denis, F.: Spinal instability as defined by three-col-
`umn spine concept in acute spinal trauma. Clin.
`Orthop. 189265, 1984.
`-
`Denis, F., Armstrong, G. W. D., Searls, K., and
`Matta, L.: Acute thoracolumbar burst fractures in
`the absence of neurologic deficit. Clin. Orthop.
`189:142, 1984.
`Dick, W.: lnnere Fixation von Brust— und Lenden-
`wirbelfrakturen. Bern, Verlag Hans Huber, 1984.
`Dick, W.: Use of the acetabular reamer to harvest
`autogenic bone graft material: A simple method for
`producing bone paste. Arch. Orthop. Trauma. Surg.
`105:235, 1986.
`Dickson, J. H., Harrington, P. R., and Erwin, W. D.:
`Results of reduction and stabilization ofthe severely
`fractured thoracic and lumbar spine. J. Bone Joint
`Surg. 60_A:799, 1978.
`-
`Donovan, W. H., and Dwyer, A. P.: An update on
`the early management of traumatic paraplegia (non-
`operative and operative management). Clin.
`Orthop. 189212, 1984.
`Dunn, H. K.: Anterior stabilization of thoracolum-
`bar injuries. Clin. Orthop. 189:116, 1984.
`Edwards, C. C., Simmons, S., Levine, A. M., Bands,
`R. E., and Campbell, S. E.: Primary rigid fixation of
`135 thoracolumbar injuries: Analysis of results.
`Orthop. Trans. 9:479, 1985.
`Erikson, D. L., Leider, L. L., and Brown, W. E.:
`One-stage decompression-stabilization for thoraco-
`lumbar fractures. Spine 2:53, 1977.
`Frankel, H. L., Hancock, D. 0., Hyslop, G., Mel-
`zak, J., Michaelis, L. S., Ungar, G. H., Vernon,
`J. D. S., and Walsh, J. J.: The value of postural
`reduction in the initial management of closed inju-
`ries of the spine with paraplegia and tetraplegia.
`Paraplegia 7:179, 1969.
`Harrington, P. R.: Instrumentation in spine insta-
`bility other than scoliosis. S. Afr. J. Surg. 5:7, 1967.
`Jacobs, R. R., and Casey, M. P.: Surgical manage-
`ment of thoracolumbar spinal injuries: General
`principles and controversial considerations. Clin.
`Orthop. 189222, 1984.
`Jacobs, R. R., Nordwall, A., and Nachemson, A.:
`Reduction, stability, and strength provided by in-
`ternal fixation systems for thoracolumbar spinal in-
`juries. Clin. Orthop. 171:300, 1982.
`Jelsma, R. K., Kirsch, P. T., Jelsma, L. F., Ramsey,
`W. C., and Rice, J . F.: Surgical treatment of thora-
`columbar fractures. Surg. Neurol. 182156, 1982.
`Jelsma, R. K., Rice, J. F., Jelsma, L. F., and Kirsch,
`P. T.: The demonstration and significance of neural
`compression after spinal injury. Surg. Neurol.
`18:79, 1982.
`Johnson, J. R., Leatherman, K. D.,’ and Holt, R. T.:
`Anterior decompression of the spinal cord for neu-
`rological deficit. Spine 8:396, 1983.
`Kostuik, J. P.: Anterior fixation for fractures of the
`thoracic and lumbar spine with or without neuro-
`logical involvement. Clin. Orthop. 1891103, 1984.
`Lindahl, S., Willén, J., and Irstam, L.: Unstable
`thoracolumbar fractures: A comparative radiologic
`study of conservative treatment and Harrington in-
`strumentation. Acta Radiol. [Diagn.] 26:67, 1985.
`
`29.
`
`30.
`
`31.
`
`32.
`
`33.
`
`7 34.
`
`35.
`
`36.
`
`37.
`
`38.
`
`39.
`
`40.
`
`41.
`
`42.
`
`43.
`
`44.
`
`45.
`
`Thoracolumbar Vertebral Fractures
`
`51
`
`Louis, R.: Surgery of the Spine. Berlin, Springer
`Verlag, 1983.
`Magerl, 17.: External skeletal fixation of the lower
`thoracic and the lumbar spine. In Uhthoff, H. K.
`(ed.): Current Concepts of External Fixation of
`Fractures. Berlin. Springer Verlag. 1982, pp.
`353-366.
`Magerl, F. P.: Stabilization ofthe lower thoracic and
`lumbar spine with external skeletal fixation. Clin.
`Orthop. 1892125, 1984.
`McAfee, P. C., and Bohlman, H. H.: Complications
`following Harrington instrumentation for fractures
`of the thoraco-lumbar spine. J. Bone Joint Surg.
`67A:672, 1985.
`McAfee, P. C., Bohlman, H. H., and Yuan, H. A.:
`Anterior decompression of traumatic thoraco-lum-
`bar fractures with incomplete neurologic deficit
`using a retroperitoneal approach. J. Bone Joint
`Surg. 67A:89, 1985.
`Morgan, T. H., Wharton, G. W., and Austin, G. N.:
`The results oflaminectomy in patients with incom-
`plete spinal cord injuries. Paraplegia 9:14, 1971.
`Olerud, S., Karlstrbm, G., and Sjostrom, L.: A new
`principle in the treatment of fractures of the thora-
`columbar spine: Transpedicular segmental fixation.
`Orthopedics (in press).
`Osebold, W. R., Weinstein, S