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ORIGINAL ARTICLE
Year : 2014  |  Volume : 27  |  Issue : 2  |  Page : 413-418

Evaluation of the short-term outcome of anterior approach surgery of the dorsal and lumbar spine


1 Department of Neurosurgery, Faculty of Medicine, Menoufia, Egypt
2 Department of General Surgery Department, Faculty of Medicine, Menoufia, Egypt

Date of Submission10-Feb-2013
Date of Acceptance17-May-2013
Date of Web Publication26-Sep-2014

Correspondence Address:
Mohamed Nabil Hanafy
MSc, Neurosurgery Department, Menoufia Faculty of Medicine, Yaseen Abdelghaffar Street, Shebin El-Koum - 32511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.141717

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  Abstract 

Objective
The aim of this study is to evaluate the short-term outcome of anterior decompression and fusion surgery of the dorsal and lumbar spine, in cases of traumatic and pathologic vertebral fractures, in terms of stability and function.
Background
Surgical treatment of dorsal and lumbar spine fractures aims to achieve bony union and restore spinal anatomy. An anterior approach is recommended for repair of anterior bone loss and to release medullary compression.
Materials and methods
Selection criteria included traumatic and pathologic lesions causing vertebral body comminution, kyphotic angulation, or intractable pain. Exclusion criteria included patients with complete cord injury, osteoporosis, or less than 3 months life expectancy. Seven patients (group A) underwent the solo anterior approach surgery, whereas the other seven patients (group B) underwent initial posterior decompression and instrumented fusion, followed by anterior surgery. Operative and postoperative events were noted. Patients were followed up clinically and radiologically for 6 months.
Results
Seven patients showed improved ASIA grade postoperatively. The mean improvement in the ASIA grade was 0.6 in group A and 1.0 in group B. Seven patients regained bladder control, whereas two remained catheter dependent (one from each group). The pain visual analog scale range was 3-9 preoperatively and 0-5 postoperatively. The mean postoperative improvement in segmental kyphosis was 2.42° in group A and 1.85° in group B. After 6 months, 28.57% of patients in group A had grade-5 bone fusion, 42.86% had grade-4 fusion, 7.14% had grade-3, and 7.14% had grade-2 fusion, whereas 42.86% of patients in group B had grade-5 bone fusion and 57.14% had grade-4 fusion. No instability was detected in the dynamic radiographic films of all patients. Only one case had metallic device malposition because of trauma. Postoperative complications included chest infection (four cases), wound infection (two cases), urinary tract infection (one case), retroperitoneal hematoma (one case), and sympathetic dysfunction (one case).
Conclusion
The anterior approach for dorsal and lumbar fractures enables direct, under-vision satisfactory decompression of the neural tissue, facilitating improvement in the neurological functions of the patients. It also helps to correct the instability of the fractured vertebral column by both internal metallic fixation for temporary stability and bone grafting with a high percentage of bony fusion to achieve permanent stability.

Keywords: Anterior approach, corpectomy, spine fracture


How to cite this article:
Hanafy MN, Hanafy AM, Sheha AF, Gad SS. Evaluation of the short-term outcome of anterior approach surgery of the dorsal and lumbar spine. Menoufia Med J 2014;27:413-8

How to cite this URL:
Hanafy MN, Hanafy AM, Sheha AF, Gad SS. Evaluation of the short-term outcome of anterior approach surgery of the dorsal and lumbar spine. Menoufia Med J [serial online] 2014 [cited 2019 Nov 20];27:413-8. Available from: http://www.mmj.eg.net/text.asp?2014/27/2/413/141717


  Introduction Top


Surgical treatment of thoracolumbar spine fractures aims to achieve bony union and restore spinal anatomy. It may be associated, as needed, with decompression, reduction, graft, and/or internal fixation using a posterior, anterior, or combined approach. The main purpose of an anterior approach is to enable medullary decompression by corpectomy while allowing reconstruction of the anterior spine. An anterior approach is to be recommended on mechanical grounds, to repair anterior bone loss, and neurologically, to release medullary compression by removing intracanal bone fragments. Neurologic recovery rates are slightly better than in posterior surgery, with better spinal profile correction in addition to smaller numbers of instrumentally fixed levels [1]. The last decade has witnessed marked changes in the approach to tumors of the spine, caused by several factors including improvement in radiological diagnosis, surgical approaches, and instrumentation systems [2].


  Materials and methods Top


This prospective study was carried out on 14 patients with thoracic and lumbar spine fractures because of trauma and tumors. The patients underwent anterior approach surgery to decompress the spinal canal by corpectomy and restore the normal vertebral alignment by instrumented fusion. The study included patients from four different hospitals in Egypt: Menoufia University Hospital, Zagazig University Hospital, Tanta University Hospital, and Nasser Institute Hospital. The ethical committee of the Menoufia Faculty of Medicine was informed about the details of this study and an official approval was obtained. Detailed written consent was signed by each patient or his closest relative. The inclusion criteria were single-level instability caused by trauma or tumors, incomplete neurologic deficit, segmental kyphotic angulation, significant comminution of the vertebral body, and intractable pain. The exclusion criteria were a previous anterior approach surgery at the diseased level, systemic metabolic disorders known to affect bone healing, major organ failure, and abdominal or thoracic cavity pathology obscuring the surgical corridor. Group A included seven patients who underwent solo anterior approach surgery, whereas group B included seven patients who underwent initial posterior canal decompression and posterolateral instrumented fusion using transpedicular screws and rods/plates, followed by the anterior approach surgery 2 weeks later. During the anterior approach surgery, all patients were operated under general anesthesia and in the dead lateral position with the left side up. The fractured level was approached using the retroperitoneal approach for L3-L5 levels, the retropleural retroperitoneal approach for T10-L2 levels, and the transthoracic approach for T5-T9 levels. The intervertebral disks above and below the fractured segment were removed and corpectomy was performed with rongeurs and a high-speed pneumatic drill. The four reconstruction options used were autologous bone graft (rib or iliac crest), bone cement spacer, titanium mesh, and distractable titanium cage (the meshes and cages were filled with morselized autologous bone). For fixation, the Z-plate system was used in all cases of the solo anterior approach, whereas posterior fixation alone was used in cases of the combined anteroposterior approach. Before and after surgery, all cases were subjected to a thorough assessment of history, general and neurological examinations, and routine laboratory investigations. All trauma cases had first-aid management lines and all cases with pathologic fractures underwent metastatic workup and bone scan [Figure 1] and [Figure 2]. The ASIA impairment scale [Table 1] was used to evaluate the motor function [3]. The visual analog scale [Figure 3] was used to evaluate pain [4]. All cases underwent preoperative and postoperative radiography, computed tomography, and MRI for the affected spinal regions. Postoperative stability was assessed by dynamic radiographic films. Postoperative bone fusion on plain radiographic films was evaluated using the classification system described by Brantigan and Steffee [5] [Table 2] and [Table 3]. All patients were followed up for at least 6 months after surgery. The difference in outcome between the two groups was tested using Student's t-test to determine its degree of significance.
Figure 1:

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Figure 2:

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Figure 3:

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Table 1: ASIA impairment scale

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Table 2: Bone fusion classification system by Brantigan and Steffee

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Table 3: General data and fixation methods

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  Results Top


The mean operative blood loss was 1300 ml in group A and 2900 ml in group B. The mean operative time was 180 min in group A and 320 min in group B, taking into consideration that the patients in group B underwent two operative events with at least a 1-week interval. Seven patients showed improved ASIA grade postoperatively, five patients showed no change, and in two patients the preoperative deficit remained unchanged. The mean improvement in the ASIA grade was 0.6 in group A and 1.0 in group B (P = 0.39). The other neurological function parameters are shown in [Table 4]. The mean postoperative improvement in segmental kyphosis was 2.42° in group A and 1.85° in group B (P = 0.09). After 3 months, 85.71% of the patients in group A had grade-3 bone fusion and 14.29% had grade-2 fusion, whereas 71.43% of patients in group B had grade-3 bone fusion and 28.57% had grade-4 fusion. After 6 months, 28.57% of patients in group A had grade-5 bone fusion, 42.86% had grade-4 fusion, 7.14% had grade-3, and 7.14% had grade-2 fusion, whereas 42.86% of patients in group B had grade-5 bone fusion and 57.14% had grade-4 fusion (P = 0.36) [Table 5] shows the difference between pre and post operative pain assessed by VAS. The other stability parameters are shown in [Table 6]. Postoperative complications are shown in [Table 7].
Table 4: Preoperative and postoperative neurological function

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Table 5: Preoperative and postoperative pain measured by a visual analog scale

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Table 6: Postoperative stability indicators

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Table 7: Postoperative complications

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  Discussion Top


The anterior surgery on the spine provides excellent exposure of the dorsal and lumbar vertebrae. Through a single-stage approach, direct visualization for spine decompression and stabilization is possible. The anterior approach to deal with structured insufficiency of the anterior and middle column and to perform decompression of the neural structures is based on solid theoretical concepts with favorable clinical results [6]. As the spine is a motion system composed of vertebrae, instrumentation alone is not enough for long-term fixation of a fractured spine and loosening will occur. Postoperative stability consists of two stages: initial stability and long-term stability. The initial stability depends on the internal fixation and long-term stability is ensured by bony fusion [7]. Expandable cages are becoming more popular largely in part because of their versatility; however, subsidence and catastrophic failure remain a concern [8].

In our study, the analysis of the clinical and imaging data of 14 patients with dorsal and lumbar traumatic and pathological fractures operated upon by the anterior approach showed the following: the mean improvement in the ASIA grade was 0.6 in group A and 1.0 in group B. The difference in outcome - although statistically insignificant - may be because of better neural canal decompression and the time factor in favor of group B, in which the patients with neurologic deficits underwent an early initial (familiar) posterior approach. Neurogenic improvement in group B was in agreement with the result of McAfee et al. [9], who reported at least 1 grade neurological improvement, Marin et al. [10], who reported an average neurogenic 1.5 grade improvement in their study, Dini et al. [6], who reported, in their study, an average 1.3 grade neurogenic improvement, Wang et al. [7], who reported an average 1.3 grade neurogenic improvement in their study, and Xiaolan et al. [11], who reported an average 1 grade neurogenic improvement in their study. Seven patients regained their bladder control whereas 2 remained catheter dependent (one from each group). In our study, we found that there was no deterioration in the bladder function in any patient who had a normal bladder function preoperatively and this indicates the safety of the anterior approach. The results of our study are in agreement with those of Wang et al. [7], who, in their study, found that 15 of 22 cases with a neurogenic bladder preoperatively showed recovery postoperatively, and Xiaolan et al. [11], who, in their study, found that 45 of 56 cases with a neurogenic bladder preoperatively showed recovery postoperatively. In group A, preoperatively, the mean kyphotic angle was 13.42° and the range was 0-30°. Postoperatively, the mean kyphotic angle was 11° and the range was -20 to 15°. Thus, we had a mean correction angle of the kyphosis equal to 2.42° postoperatively. In group B, preoperatively, the mean kyphotic angle was 19.42° and the range was 16-27°. Postoperatively, the mean kyphotic angle was 17.57° and the range was 8-25°. Thus, we had a mean correction angle of kyphosis equal to 1.85° postoperatively. In our study, we found that group A had better overall degree of kyphosis correction and this could have been because of removal of almost all the body of the fractured vertebra and exchange it by an expandable cage which give an enough chance for correction of the kyphosis and prevent the loss of the obtained correction. Many other studies have proven the advantage of the anterior approach in correction of the kyphotic angle such as Dini et al. [6], who achieved a mean correction of the preoperative kyphotic angle equal to 12° ranging from 6 to 18°, Xiaolan et al. [11], who reported a mean correction angle of the kyphosis of 18.1°, and Yong-Dong et al. [12], who reported a mean correction of the kyphotic angle of 15°. In terms of metallic system malposition, we encountered a problem with a cage in one case in group A, who showed slight cage migration after exposure to trauma; the slight cage displacement did not compromise the canal or cause any neurologic deterioration. This did not happen in group B perhaps because of the rigid fixation conferred by the circumferential approach. For postoperative bone fusion, in group A, we had one case with grade-2 and six cases with grade-3 in the 3-month postoperative follow-up. In the 6-month follow-up in the same group, we had one case with grade-2, one case with grade-3, three cases with grade-4, and two cases with grade-5. The overall improvement in bone fusion between the two follow-ups was 7 grades, with an average of 1 grade. In group B, we had two cases with grade-4 and five cases with grade-3 in the 3-month postoperative follow-up. In the 6-month follow-up in the same group, we had three cases with grade-5 and four cases with grade-4. The overall improvement in bone fusion between the two follow-ups was 8 grades, with an average of 1.14 grades. Only one case in the study (7.14% of cases) showed pseudoarthrosis (grade-2) and this was higher than the results obtained by McAfee [13], who reported a 6% failure rate, and Kaneda et al. [14], who reported a 7% failure rate. This case was from group A. In terms of the complications in our study, wound infection developed in two cases (14.28%) that was superficial and showed good response with administration of antibiotics and repeated dressing; there was no deep extension of the infection and no need for wound exploration or system removal. Chest infection developed in four cases (28.57%) and all of them were treated conservatively, without any further complications. Also, a urinary tract infection developed in only one case, retroperitoneal hematoma in only one case, and postoperative sympathetic dysfunction in only one case. In the study of John et al. [15], in one case (3.2%), the aorta was punctured while performing the corpectomy, two cases (6.4%) developed a superficial wound infection, four cases (12.9%) developed postoperative atelectasis, and one case (3.2%) developed an ileus. In the study of Marin et al. [10], one case (7.7%) developed a superficial wound infection and one case (7.7%) had hematothorax on the operated side. In the study of Rod and Johnson [16], direct vascular injuries occurred in seven cases (3.4%) and deep venous thrombosis occurred in five cases (2.4%). In the study of Xiaolan et al. [11], five cases (14.3%) developed an ileus, three cases (8.6%) developed pulmonary atelectasis, and one case (2.9%) showed wound infection.


  Conclusion Top


The anterior approach for dorsal and lumbar fractures enables direct, under-vision satisfactory decompression of the neural tissue, facilitating improvement in the neurological functions of the patients. It also helps to correct the instability of the fractured vertebral column by both internal metallic fixation for temporary stability and bone grafting with a high percentage of bony fusion to achieve permanent stability.


  Acknowledgements Top


Conflicts of interest

None declared.

 
  References Top

1.Allain J. Anterior spine surgery in recent thoracolumbar fractures: an update. Orthop Traumatol Surg Res 2011; 97 :541-554.  Back to cited text no. 1
    
2. Sundaresan N, Boriani S, Rothman A, et al. Tumors of the osseous spine. J Neurooncol 2004; 69 :273-290.  Back to cited text no. 2
    
3. American Spinal Injury Association. Standards for neurological classification of SCI worksheet, 2006. Available at: http://asia-spinalinjury.org/elearning/ISNCSCI.php  Back to cited text no. 3
    
4. Wewers ME, Lowe NK. A critical review of visual analogue scales in the measurement of clinical phenomena. Res Nurs Health 1990; 13 :227-236.  Back to cited text no. 4
    
5. Brantigan JW, Steffee AD. A carbon fiber implant to aid interbody lumbar fusion. Two-year clinical results in the first 26 patients. Spine (Phila Pa 1976) 1993; 18 :2106-2117.  Back to cited text no. 5
    
6. Dini LI, Saraiva GA, Isolan G, et al. Anterior thoracic and lumbar spine arthrodesis: a series of 23 consecutive cases and review of operative technique. Coluna/Columna 2006; 5 :90-98.  Back to cited text no. 6
    
7. Wang YS, Yin L, Bao H, et al. Titanium mesh fusion device in the treatment of thoracolumbar burst fracture. Chin Med J 2007; 120 :246-247.  Back to cited text no. 7
    
8. Pekmezci M, Tang JA, Cheng L, et al. Comparison of expandable and fixed interbody cages in a human cadaver corpectomy model: fatigue characteristics. J Spine Disord Tech 2012, Aug 23:[Epub ahead of print].  Back to cited text no. 8
    
9. McAfee PC, Bohlman HH, Yawn HA. Anterior decompression of thoracolumbar fractures with incomplete neurological deficit using retroperitoneal approach. J Bone Joint Surg 1985; 67A :89-104.  Back to cited text no. 9
    
10.Marin FS, Egidio G, Etica N, et al. Anterior decompression and fixation versus posterior reposition and semirigid fixation in the treatment of unstable burst thoracolumbar fracture: prospective clinical trial. Clin Sci 2001; 42 :49-53.  Back to cited text no. 10
    
11.Xiaolan L, Yunhua L, Sheting L, et al. The traditional anterior surgery versus thoracoscope-assisted minimal incision surgery for thoracolumbar burst fracture. Chin J Spine Spinal Cord 2010; 11 :1-7.  Back to cited text no. 11
    
12.QIAO Yong-Dong, Jian-Wei SI, Jian-Bo LIU, et al. Effects of anterior-only decompression and stabilization for thoracolumbar fracture. Ningxia Med J 2010; 3 :2-5.  Back to cited text no. 12
    
13.McAfee PC. Complications of anterior approaches to the thoracolumbar spine. Emphasis on Kaneda instrumentation. Clin Orthop Relat Res 1994; 306 :110-119.  Back to cited text no. 13
    
14.Kaneda K, Taneichi H, Abumi K, et al. Anterior decompression and stabilization with the Kaneda device for thoracolumbar burst fractures associated with neurological deficits. J Bone Joint Surg Am 1997; 79 :69-83.  Back to cited text no. 14
    
15.John AW, Bowen S, Branch CL, et al. Review of 31 cases of anterior thoracolumbar fixation with the anterior thoracolumbar locking plate system. Neurosurg Focus 1999; 7 :1.  Back to cited text no. 15
    
16.Rod JO, Johnson JP. Vascular complications in anterior thoracolumbar spinal reconstruction. J Neurosurg 2002; :1-5.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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