Purpose: Minimally invasive video-assisted thoracotomy can be proposed for potentially unstable fractures of the thoracolumbar junction with rupture of the anterior column after satisfactory posterior reduction and osteo-synthesis. Long-term results are improved in terms of graft quality and stability of the postoperative angular gain.
Material and methods: Ninety-one patients, mean age 36 years, with spinal fractures involving T12 to L2 underwent video-assisted mini-thoracotomy for arthrodesis as a complementary procedure after posterior reduction and osteosynthesis without bone graft. The left approach was preferred over the right due to the lower risk of bleeding. A massive tricortical anterolateral iliac graft was inserted in the intersomatic space. Perfect stability was achieved with the MIASPAS system which provides an exact measure of the intersomatic space and the bone graft.
Results: Follow-up was five years for the first patients and ten months for those operated on after January 2003. At last follow-up, functional outcome (Stauffer-Coventry score) was excellent or good in 52% and 41% of the patients respectively. Outcome was poor in 7%. Postoperative radiograms demonstrated 100% graft fusion which was confirmed by tomography. There was no loss of angular gain.
Discussion: This novel approach provides a means of preserving the posterior instrumentation and achieving anterior fusion in the zone of maximal stress. Because of the relative facility of the technique together with the operative time and the relatively low risk of postoperative complications, surgical indications for complementary intersomatic arthrodesis can be revisited. Anterior fusion is, in our opinion, the only sure means of maintaining long-term correction. The ability to access the disc, generally without metameric hemostasis, eliminates the risk of vascular cord lesions.
Conclusion: This thoracoscopic technique for anterior fusion after a short posterior osteosyntheis without graft will greatly modify indications for complementary anterior fusion for the treatment of unstable thoracolumbar fractures.
