Scoliosis requires three dimensional correction at a global level (curve correction) and at a local one (apical axial derotation) as well as sagittal balance management. Except for in situ contouring, previously reported surgical techniques for scoliosis correction hardly deal with all these issues. The aim of the current study was to evaluate long term clinical and radiological outcomes after in situ contouring in 85 patients with severe scoliosis (Cobb= 40 to 110°). Age influence (adults versus adolescents) and surgical approaches (anterior release and posterior correction and fusion versus posterior correction and fusion only) were also assessed. The results of the study show that the in situ contouring is comparable to other surgical techniques in terms of surgery duration and blood loss. Anterior release proved useful in severe scoliosis correction. No difference in peroperative complications was found between age groups nor between approach groups. However, adolescents recover faster than adults. No difference of revision rates in double approach versus posterior approach populations was found. No statistically significant differences were found between the adolescent and adult populations. The mean overall frontal correction reached 68%. The mean loss of correction amounted 5%. No significant evolution was found in sagittal curvatures, emphasizing the difficulties in restoring physiological curvatures in patients with severe scoliosis. Our results suggest the in situ contouring technique is fully appropriate for severe scoliosis correction, regardless of the patient’s age and approach. Besides it will not result in higher morbidity for one specific population and warrants similar outcome when properly applied.

Aims. No randomized comparative study has compared the extensile lateral approach (ELA) and sinus tarsi approach (STA) for Sanders type 2 calcaneal fractures. This randomized comparative study was conducted to confirm whether the STA was prone to fewer wound complications than the ELA. Methods. Between August 2013 and August 2018, 64 patients with Sanders type 2 calcaneus fractures were randomly assigned to receive surgical treatment by the ELA (32 patients) and STA (32 patients). The primary outcome was development of wound complications. The secondary outcomes were postoperative complications, pain scored of a visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, 36-item Short Form health survey, operative duration, subtalar joint range of motion (ROM), Böhler’s angle and calcaneal width, and posterior facet reduction. Results. Although four patients (12.5%) in the ELA groups and none in the STA group experienced complications, the difference was not statistically significant (p = 0.113). VAS and AOFAS score were significantly better in the STA group than in the ELA group at six months (p = 0.017 and p = 0.021), but not at 12 months (p = 0.096 and p = 0.200) after surgery. The operation time was significantly shorter in the STA group than in the ELA group (p < 0.001). The subtalar joint ROM was significantly better in the STA group (p = 0.015). Assessment of the amount of postoperative reduction compared with the uninjured limb showed significant restoration of calcaneal width in the ELA group compared with that in the STA group (p < 0.001). Conclusion. The ELA group showed higher frequency of wound complications than the STA group for Sanders type 2 calcaneal fractures even though this was not statistically significant. Cite this article: Bone Joint J 2021;103-B(2):286–293

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

Purpose of the study: Surgical strategies for high-grade spondylolisthesis are controversial. The main subject of debate concerns the indications for reduction or in situ fusion. We present mid-term results obtained in a series of patients with high-grade spondylolisthesis treated by posterior reduction and fusion. Material and methods: Sixteen patient who had undergone surgery for spondylolisthesis of the superior isthmus > 50% were reviewed. Mean age was 12 years (range 9–16 years). Preoperatively, all patients were symptomatic with lumbalgia, truncated radicular pain, and gait anomalies. Surgical treatment consisted in a single posterior approach, L5 laminectomy, curettage of the L5-S1 disc combined with excision of the S1 dome, L4-S1 instrumented reduction, anterior L5-S1 and posterolateral L4S1 arthrodesis. Postoperative immobilization was achieved with a resin lumbar cast with crural stabilization for three months then a lumbar orthesis for three months. Clinical and radiographic outcome was assessed at 44 months on average (range 10–260 months). Results: Clinically, 14 patients were pain free and had resumed their former activities. One patient complained of intermittent pain. No improvement was observed in one patient. Radiographic results were: displacement 78% (range 52–100%) preoperatively and 30% (8–95%) at last follow-up. The L5S1 displacement angle was 14° kyphosis (range 8–30°) preoperatively and 9° lordosis (range 3–12°) at last follow-up excepting one case with complications. The pelvic incidence was 85° (range 65–100°) preoperatively and 74° (range 50–90°) at last follow-up. Complications: There was one early infection treated by wash-out debridement and antibiotics without removing implants. Disassembly of the implanted material in one patient with a poor clinical result led to complete recurrence and lumbosacral kyphosis. Sacral screw fracture was diagnosed in six patients on average one year after surgery but without any progression or recurrence of the displacement. There were no neurological complications. Discussion and conclusion: Posterior reduction enables restoration of a good sagittal balance. More than the reduction, it is particularly important to restore the lumbosacral junction in a lordosis position to guarantee long-term stability. This technique is a difficult surgical challenge and raises the risk of recurrence and potential neurological complications

We present an illustrative case using a modification of the Gaines procedure for the surgical management of patients with spondyloptosis. It involves excision of the inferior half of the body of L5 anteriorly combined with posterior reduction and fusion

This study was undertaken to evaluate the efficacy and reliability of posterior intra-operative reduction and fusion by pedicle screw fixation in the treatment of children and adolescents for severe lumbosacral spondy-lolisthesis.Researchers identified 21 patients who underwent reduction of their high-grade spondylolisthesis at our Institution between 1993 and 2000. Recent clinical and radiograph data were available for all patients. Indications for surgery were severe back pain in 21 patients, leg pain in 17, cosmetic appearance in 16 and progression of slippage in 15. There were 11 females and 10 males, aged 16 years on average (range, 11–18 years). Seven patients had grade III slippage, nine grade IV and five grade V. The slippage was at L4-L5 level in one patient and at L5-S1 in the remaining cases. The instrumented levels were 2 (L4-S1) in 12 patients and 1 in nine (L5-S1). The patients underwent surgery using a single posterior surgical procedure. After removal of the loosened arch and complete discectomy, gradual distraction and posterior translation of the anteriorly displaced vertebral body were performed using a temporary device (Harrington rod) placed bilaterally between L1 and the sacral wings. Reduction was followed by a posterior interbody strut graft or placement of titanium cages and pedicle segmental fixation. At a mean follow-up of 5 years (range, 1–10 years) a complete remission of back pain was observed in 18 cases and incomplete in three; all presented solid fusion radiographically. The mean correction of the slippage was 33.1%.(from 78.3% to 41%) and that of the slippage angle 51% (from 35.2° to 17°). Complications included two skin protrusions of a sacral screw, two transitory neurological deficit (L5-S1). Two patients with screw pullout underwent instrumentation revision and reinsertion of screws; another two patients underwent anterior interbody fusion since slippage exceeded 50% after posterior reduction. Reduction of high-grade spondylolisthesis may be considered for patients with a high degree of lumbosacral kyphosis, an unacceptable clinical appearance, and/or neurological deficit. With the advent of pedicle screw fixation, posterior instrumentation and reduction appears feasible. We found that using the gradual reduction by temporary Harrington rod incurs less risk than other options for treating high-grade spondylolisthesis. This procedure provides a controlled method of reduction where continuous visualisation of nerve roots is possible and internal fixation is achieved

Purpose of study. Unstable pelvic ring injuries usually occur in polytrauma patients and are associated with high mortality and morbidity. Percutaneous screw fixation of sacro-iliac joint dislocations, fracture-dislocations and sacral fractures is a well-recognised technique first described by Routt and is increasingly gaining popularity. This method is biomechanically comparable to open reduction and internal fixation with plates and screws but offers the advantages of minimally invasive surgical techniques. It is however a technically demanding procedure with reported complications including hardware failure, misplacement of screws, nerve injury and poor posterior reduction. The purpose of the study is to report clinical results of patients treated with closed reduction and percutaneous ilio-sacral screw fixation for unstable pelvic ring fractures by a single surgeon. Methods. A review of prospectively collected data was performed on all patients who had percutaneous sacro-iliac fixation between 2009 and 2012. Thirty five percutaneus sacro-iliac screws were inserted in 30 patients with a mean age of 25.6 years (range 17–62). Fracture types included 10 AO type B, and 20 AO type C. The mean follow-up period was 11.6 months (range 3–38). The complications assessed were screw misplacement, neurovascular complications, hardware breakage and loss of reduction. Results. All patients had a satisfactory initial reduction. One patient (2.8%) had misplacement of a screw with resultant temporary neurological fallout. One patient (2.8%) had screw misplacement without neurological fallout. Both of these patients initially had two screws inserted and the misplaced screws were removed and not reinserted. One patient (2.8%) had screw cut-out with loss of reduction. This screw was removed, open reduction peformed and the screw was re-inserted. Conclusion. The use of percutaneous sacro-iliac screws provides a safe and effective technique for the management of unstable posterior pelvic ring injuries. Our combined complication rate is comparable to published literature. NO DISCLOSURES

The progressive kyphosis and pain in patients with acute thoracolumbar burst fractures treated conservatively so as the recurrent kyphosis after posterior reduction and fixation were associated to disc collapse rather than vertebral body compression. It depends on redistribution of the disc tissue in the changed morphology of the space after fractures of the endplate. The aim of this study is to evaluate the safety and the efficacy of balloon kyphoplasty with calcium phosphate, alone or associated to short posterior instrumentation, in the treatment of acute thoracolumbar burst fractures. Eleven fractures in ten consecutive patients with an average age of 48 years who sustained acute thoracolumbar traumatic burst fractures without neurological deficits were included in this study. The fractures were A1.2 (3), A3.1 (4) and A3.2 (4), according to AO classification. In 7 fractures (A1.2 and A3.1) the kyphopasty was performed alone in order to make the most of efficacy in fracture reduction, anterior and medium column stabilization and, as much as possible, segmental kyphosis correction. In the A3.2 fractures (4), that are unstable, the kyphoplasty was associated to a short posterior instrumentation. To avoid the PMMA long run complications in younger patients, we used a calcium phosphate cement. VAS, SF-36, Roland-Morris questionnaire (RMQ) and Oswestry low back pain disability questionnaire (ODQ) were used to evaluate pain, state of health, functional outcomes and spine disability. To the average follow-up time of 15.5 months (range 8–31) we did not observe statistically significant differences in 7 of 8 SF-36 domains in comparison to general healthy population of same sex and age. At the same follow-up, the spine disability questionnaire showed a functional restriction of 18% (ODQ) and 29,6% (RMQ) being 100% the maximum of disability. No bone cement leakage, no implant failure and no height correction loss were observed in any case. Our data confirm the safety and the efficacy of ballon kyphoplasty with calcium phosphate in the treatment of acute thoracolumbar burst fractures. In this way we can reduce the possible complications resulted from discal space collapse and obtain an early functional restoration. When performed alone, this mini invasive surgical technique offer the advantage of almost immediate return to daily activities. When associated to posterior instrumentation, it decreases the long run complications and allows to reduce the number of stabilized levels, maintaining, in part, the thoracolumbar junction movement

We have studied the intervertebral discs adjacent to fractured vertebral bodies using MRI in 63 patients at a minimum of 18 months after injury. There were 75 thoracolumbar fractures of which 26 were treated conservatively and 37 by posterior reduction and fusion with an AO internal fixator. We identified six different types of disc using criteria based on the morphology and the intensity of the MRI signal. The inter- and intraobserver variability of this system was good. Most of the discs showed predominantly morphological changes with no variation in signal intensity. Some disc types were associated with progressive kyphosis in patients treated conservatively. In those managed by operation, recurrent kyphosis appeared to result from creeping of the disc in the central depression of the bony endplate rather than from disc degeneration. Changes in the disc space after posterior fixation should not be seen as a form of chronic instability but as a redistribution of the disc tissue in the changed morphology of the space after fractures of the endplate

The cervical spine is the most vulnerable segment in high velocity injuries. Bifacet dislocations are associated with significant soft tissue damage and neurological deficit. Management of delayed presentation of cervical facet dislocations, which are not uncommon, is varied. The aims of this study are to create awareness and to develop a management strategy. We retrospectively reviewed 14 patients (10 men and four women) with chronic dislocations treated over 4 years. The mean age was 42.5 years (23 to 62). The delay in presentation ranged from 15 to 135 days. Seven patients had neurological deficit. All patients underwent CT scan and MRI. Common areas of involvement were C6/7 (five patients) and C5/6 (four patients). Associated fracture of posterior elements was identified in 40% of patients. In two patients sequestrated disc ruptured into the canal. All patients underwent surgical reduction and stabilisation, with eight having one-stage and six two-stage surgery. The sequence of one-stage surgery was posterior release, reduction (facet reduction/facetectomy), anterior discectomy and anterior fusion. In three patients with sequestrated discs, anterior decompression preceded posterior release and finally anterior fusion. The six patients who had staged surgery had a prolonged delay (over 3 months) in presentation. Posterior release was followed by an anterior decompression, then a 7 to 10-day period of traction reduction and finally anterior fusion. None of our patients developed neurological deficit. Three patients improved from Frankel-C to Frankel-D. We recommend that the sequence of surgery should be posterior release/reduction and then anterior decompression and anterior fusion. However, in chronic cases, staged reduction and fusion is a viable option

Fractures and fracture dislocations involving the lower lumbar spine and lumbosacral junction are uncommon. These high velocity injuries are often associated with neurological deficit, incontinence and dural tears. The accepted treatment has been posterior stabilisation with fusion, but loss of reduction has often been reported. We reviewed our experience over the past four years in the management of eight male patients, two of whom sustained injuries in motor vehicle accidents and two in falls from a height. Two patients had L5/S1 traumatic spondylo-listhesis with no neurological deficit. Of the six patients with fracture dislocations of L3/4, four had translation in the sagittal and coronal planes and incomplete neurological deficit. Associated injuries in four patients included an ankle fracture, multiple rib fractures, dislocation of knee and hip, and a fracture dislocation of the midfoot. Following satisfactory reduction, seven patients were treated by posterior spinal fusion (PSF) with instrumentation. One patient had anterior decompression, strut-grafting and posterior instrumentation. Three patients had dural tears. In three patients treated by single segment PSF, reduction was not maintained. The maintenance of alignment was attributed to stable facet joints in one patient, two-segment instrumentation in three, and anterior strut grafting in one. One patient developed postoperative wound sepsis, which settled after repeated debridement and antibiotic treatment. Symptoms of nerve root compression improved in two of the four patients with neurological deficit. Posterior reduction and instrumentation alone did not maintain reduction in these severe injuries. Anterior column support and multisegmental instrumentation may be required where there is marked vertebral body compression and neurological deficit

Post Traumatic Fixed Thoraco-Lumbar Spinal Deformity may result in pain, regional and or global spinal deformity and neural compromise. Treatment is demanding as osteotomy is required in either anterior alone or both anterior and posterior spinal columns with concomitant reconstruction. This paper reviews 15 years experience with these cases. A retrospective review of 21 patients operated on over 15 years was conducted. Patients were grouped based on original thoraco-lumbar injury pattern – Type A, B and C. Osteotomies and reconstruction were performed from both anterior and posterior approaches dependent upon the pathology. Clinical and radiological follow up for all patients was a minimum of one year. Analysis of outcomes was performed in relation to the clinical and radiological success. Complications were recorded. Sixteen patients had two-column involvement and five had only the anterior column affected. Initial injury patterns were – Type A–9, Type B–4, and Type C–8. Approaches were anterior in six (five in Type A injuries), posterior and anterior in 11 (five two-stage and six three-stage operations), and posterior only in four (one pedicle subtraction osteotomy, one vertebral column resection, one posterior reduction of a dislocation, and one case abandoned after the posterior procedure). Anterior reconstruction was performed with structural iliac crest (two), titanium mesh cages (14) and expanding corpectomy cages (three). All 14 cases requiring posterior stabilisation were treated with pedicle screw based systems. The global assessment of outcome was individualised to the original indication – mechanical pain, deformity, and or symptomatic spinal stenosis. Success (good or excellent outcome) was achieved in 16 cases. Failure (fair or poor outcome) occur red in three completed cases. These three cases had chronic pain (two major, one minor). Two patients had incomplete assessment – one dying of MI in recovery after a technically successful procedure – and one developing deep infection with abandonment of the later stages (see above). There was one non-union. There were no neurological complications. Delayed treatment of late posttraumatic deformity is challenging however good results are achievable with attention to the specific clinical and biomechanical requirements of each case. Technical failure occurred with inadequately radical intervention on one occasion. Major chronic thoracotomy pain occurred in one otherwise technically successful reconstruction

Easier patient positioning and less extensive soft tissue dissection have spurred a trend for anterior instrumentation and fusion for C-spine fracture/ dislocations. We present group of forty-six patients treated over an eighteen month period with an anterior approach. There were no permanent approach related complications, infections, hardware failures or graft displacements. One patient had worsened post-operative neurological findings. One patient required additional posterior stabilization for a missed injury. Two patients were not reducible from the front and required posterior reduction and stabilization followed by anterior instrumentation and fusion. All grafts healed within four months of the operation. The purpose of this study was to assess the efficacy of anterior instrumentation and fusion for Cervical Spine fracture/ dislocations. Over an eighteen month period, forty-six out of fifty-two patients with C-spine injuries requiring surgical treatment were followed prospectively. All patients underwent anterior approaches to stabilize and fuse the unstable segments using tricortical bone grafting and application of an anterior plate (CSLP, Synthes). Thirty-eight patients had single level injuries treated with discectomy and fusion. Two patients had two level discecomies. Six patients underwent corpectomy and fusions for fractures of the vertebral bodies. There were no approach related complications such as recurrent laryngeal nerve injuries, oesophageal perforations, vascular injuries or strokes. One patient deteriorated neurologically. All other patients either improved neurologically or remained with their original findings. Two patients required oral antibiotics for superficial infections at the donor site. There were no spine infections, hardware loosening or graft extrusions. All bone grafts healed within four months both clinically and radiologically. Forty-one patients complained of minor or no pain after four months. Five patients continued to have moderate discomfort. One of these patients had a missed injury above his two-level fusion with gradual progression into kyphosis requiring posterior stabilization. Halo vest immobilization and posterior stabilization for C-spine fracture /dislocations have been the treatment of choice for many surgeons. The low complication and failure rate has spurred on a gradual change towards anterior instrumentation and fusion. Our study very strongly supports this trend. We see little indication for the more invasive posterior approach given our present results

Purpose: The purpose of this study was to analyse the results and morbidity of video-assisted minimally invasive thoracoctomy for anterior arthrodesis of thoracolumbar fractures treated with a two-stage procedure and to evaluate mid-term outcome. Material and methods: This retrospective series included 6 patients with an unstable thoracolumbar fracture who underwent surgery between November 1997 and June 2002. A two-stage procedure was used: posterior reduction osteosynthesis and anterior arthrodesis with a tricortico-cancellous graft via video-assisted minimally invasive thoracotomy. The cohort included six women and eighteen men, mean age 34.5 years. Fractures were located at: L1 (n=4), T12 (n=10), T11 (n=2). At initial assessment the Franckel classification was: A (n=3), B (n=1), C (n=1), D (n=3), 3 (n=18). Time between the posterior procedure and the anterior thoracotomy was 30.2 days (range 6–86). Postoperative results as well as the time to fusion were recorded. Mean follow-up was 21 months (range 6–45) for functional and radiological assessment. No patient was lost to follow-up. Results: Mean operative time was 188 min (range 80–240). Mean blood loss was 235 ml (range150–1000) with no intraoperative event requiring conversion to open thoracotomy. Mean duration of morphine administered postoperatively was 2.2 days, the same as for thoracic drainage. Residual pleural effusion was observed in one patient and residual pneumothorax in two; all resolved spontaneously. Mean hospital stay was 12 days (range 6–27). Twenty-five patients had achieved fusion at four months. One patient developed a radiological non-union which was asymptomatic at one year. At last follow-up, the Oswestry function score was 22.6% for the entire series, 18% for Franckel D or E patients (n=21) and 42% for Franckel A, B and C patients (n=5). Loss of angular correction of the spinal kyphosis and regional traumatic angulation between the postoperative films and the last follow-up films was 2 (mean). Discussion: This series of complementary anterior arthrodesis by video-assisted minimally invasive thoracotomy confirmed the minimally invasive nature of this approach in comparison with thoracophrenolaparotomy and its complications. At mid term, this technique has provided satisfactory functional and radiographic results. Applied for thoracolumbar fractures, this combined surgical option can limit intraoperative morbidity and assure good mid-term results

Introduction: Reversed oblique subtrochanteric fractures are unstable and pose a surgical challenge. Fixation with Dynamic Hip Screw is prone to collapse with medial displacement and high rate of non or mal union. The use of Proximal Femoral Nails may result in non anatomical reduction which delays union and impedes rehabilitation. PCCP is a percutaneous plate originally designed for fixation of intertrochanteric fractures. However, the plate supports the greater trochanter and can prevent collapse of subtrochanteric fractures and rigidly secure the femoral neck. This study summarized our experience in fixating reversed oblique subtrochanteric fracture with the PCCP technique. Patients and Methods: Between January 2005 and March 2006 26 patients who sustained reversed oblique subtrochanteric fractures (AO-31A3) were consecutively treated with PCCP. Two patients died and were excluded from this study. Patients’ age ranged between 58 and 93 (average 86, median 80). Follow-up was between 6 to 20 months (average 12). All patients were operated on a standard fracture table with the use of posterior reduction device. An attempt to reduce the fracture was done in each case prior to the surgical incision. In the majority of cases the shaft was displaced medially to the greater trochanter. The PCCP plate was introduced percutaneously and the medially displaced shaft was pulled to the plate using the reduction clamp. The rest of the procedure was done according to the regular technique of the PCCP. All patients were instructed to refrain from weight bearing for six weeks after the surgery and then resume full weigh bearing. Follow-up was in the out patient clinic 6 weeks, 3 months and one year after the surgery. Results: Time of surgery varied between 35 to 75 minutes. There were no patients who were planned to undergo this procedure and were diverted to a different modality of fixation. All the procedures were done percutaneously. Anatomic or near anatomic reduction was achieved in all cases. All patients resumed full weigh bearing six weeks after the surgery. All but one fracture united. The patient whose fracture did not unite was blind and fell a few times during rehabilitation and eventually suffered from pull-out of the plate from the femur with breakage of the shaft screws. She underwent revision surgery with bone graft and the fracture united. Follow-up radiograms showed that the reduction was maintained in all but three patients. Medial displacement of 8–15 mm occurred in 3 patients. There were no infections. Conclusions: While there is an ongoing debate among “nailers” vs. “platers” for the fixation of femoral neck fractures, PCCP combines the theoretical advantages of both percutaneous technique and absolute stability. In this study this biological system was found to be a reliable solution for the challenging fixation of reversed oblique (AO-31A3) subtrochanteric fractures, with high union rate, fast recovery and low complication rate

In order to predict more detailed outcomes of paralysis in patients with acute cervical cord injury, we have compared degree of paralysis at the time of admission and the time after more than 6 months by using our modification of Frankel’s criteria. Material and Method: The modified Frankel’s criteria comprises following items. Frankel B is divided into B1, B2, B3, C into C1, C2, D into D0, D1, D2, D3. B1; toutch sensation is preserved only in sacral segment, B2; it is preserved in more area, B3; pain sensation preserved. C1; MMT of the L/E has 1~2, C2; MMT of L/E 3. D1; ambulant but wheel chair is practically used. D2; crutch gait or central cord injury type, being liberated from wheel-chair. D3; completely independent. 2) 298 patients were included in this study, 259 males and 39 females, aged 48.1 yrs. in av. The time of admission from injury was within 7 days(average 1.7 days) and follow-up period was 28.6 months in av. Number of cases with bony injuries accounted for 154, those with no bony injury for 144. Patients with bony injury were treated operatively in acute stage; posterior reduction/fusion with wiring +or− anterior fusion . Patients with no bony injury were treated conservatively. Result: Out of 151 pts with Frankel A, only 5 pts(3.3%) were restored to D, also B to D in 37%, C to D in 79%. Itemizing group B pts, B1 recovered to D in 20%, B2 to D in 32%, B3 to D in 80%. Itemizing group C pts, C1 improved to D in 61%, C2 to D in 97%. There were statistically differences between them. At the goal stage there were 111 Frankel D pts and they divited to D1(30%), D2(40%), D3(30%). D2 and D3 showed better abilities in whole ADLs than D1. Conclusion: Comparing to the result reported by Frankel et al in 1969 we found that there were few neurologic improvement despite new technology. Using our modified Frankel’s classification we can estimate pts neurology more precisely and predict outcomes practically more in detail which have benefits to set the goal of treatment

Introduction: Flexion distraction injuries (FDI)of the thoracic and lumbar spine can be stabilized with a short construct spanning one motion-segment. This fracture is functionally defined by failure of the posterior and middle columns in tension and the anterior column in compression or tension. Treatment of a predominantly bony injury with minimal deformity (Chance type) is usually non-operative. Intra-abdominal pathology, and ligamentous spinal instability are relative indications for surgery. Deformity of greater than 17 degrees of kyphosis has a poor prognosis when treated conservatively, and represents true instability in vitro. Surgical treatment is mainly through a posterior approach with instrumentation. Which construct to use and the number of motion segments to include is controversial. Multi-level instrumentation techniques both in distraction and compression have been used as well as shorter constructs, particularly in the lumbar spine. We addressed the efficacy of single motion-segment fixation by evaluating the radiographic and functional results of this treatment technique. Methods: All patients diagnosed with a FDI were prospectively identified over a 48 month period. Non-operatively treated fractures were excluded. Other spine fractures were excluded. Demographics, comorbidity, neurological status, operative details and complications were recorded. Radiographic reviewers were blinded to the functional outcome of the patient and the time of follow-up. The Oswestry Functional Assessment Questionnaire was administered by mail. Results: Twenty-one eligible patients were identified. A significant (p< 0.0001) correction of deformity was achieved, from a mean preoperative kyphosis of 10.1 degrees to a mean postoperative lordosis of 0.9 degrees. No loss of correction occurred. The mean Oswestry score was 11.5, with 88% of patients having minimal disability. One patient died from unrelated morbidity. Conclusions: Hoshikawa etal showed in vitro how compression forces alone can create FDI. Compression without flexion causes burst fractures. With moderate flexion there is FDI with anterior body compression. With increasing flexion FDI becomes entirely distractive. As the forces are concentrated at a single point, reconstruction only requires that this location be addressed. As all FDI are created by the same mechanism, regardless of structures injured only short segment fixation is required. We have demonstrated in FDI, single level fixation is biomechanically sound. Multilevel instrumentation creates loss of adjacent level motion segments. This is not necessary. The absence of a control group precludes absolute conclusions. Nonetheless most patients reported minimal disability related to their back and had excellent radiological outcomes. This study demonstrates that posterior reduction and stabilization of a single motion-segment for FDI can adequately stabilize the spine and lead to excellent functional outcomes

INTRODUCTION: Flexion distraction injuries (FDI) of the thoracic and lumbar spine can be stabilised with a short construct spanning one motion-segment. This fracture is functionally defined by failure of the posterior and middle columns in tension and the anterior column in compression or tension. Treatment of a predominantly bony injury with minimal deformity (Chance type) is usually non-operative. Intra-abdominal pathology, and ligamentous spinal instability are relative indications for surgery. Deformity of greater than 17 degrees of kyphosis has a poor prognosis when treated conservatively, and represents true instability in vitro. Surgical treatment is mainly through a posterior approach with instrumentation. Which construct to use and the number of motion segments to include is controversial. Multi-level instrumentation techniques both in distraction and compression have been used as well as shorter constructs, particularly in the lumbar spine. We addressed the efficacy of single motion-segment fixation by evaluating the radiographic and functional results of this treatment technique. METHODS: All patients diagnosed with a FDI were prospectively identified over a 48 months period. Non-operatively treated fractures were excluded. Other spine fractures were excluded. Demographics, co-morbidity, neurological status, operative details and complications were recorded. Radiographic reviewers were blinded to the functional outcome of the patient and the time of follow-up. The Oswestry Functional Assessment Questionnaire was administered by mail. RESULTS: Twenty-one eligible patients were identified. A significant (p< 0.0001) correction of deformity was achieved, from a mean pre-operative kyphosis of 10.1 degrees to a mean post-operative lordosis of 0.9 degrees. No loss of correction occurred. The mean Oswestry score was 11.5, with 88% of patients having minimal disability. One patient died from unrelated morbidity. CONCLUSIONS: Hoshikawa et al showed in vitro how compression forces alone can create FDI. Compression without flexion causes burst fractures. With moderate flexion there is FDI with anterior body compression. With increasing flexion FDI becomes entirely distractive. As the forces are concentrated at a single point, reconstruction only requires that this location be addressed. As all FDI are created by the same mechanism, regardless of structures injured only short segment fixation is required. We have demonstrated in FDI, single level fixation is biomechanically sound. Multilevel instrumentation creates loss of adjacent level motion segments. This is not necessary. The absence of a control group precludes absolute conclusions. Nonetheless most patients reported minimal disability related to their back and had excellent radiological outcomes. This study demonstrates that posterior reduction and stabilisation of a single motion-segment for FDI can adequately stabilise the spine and lead to excellent functional outcomes

Aims

To determine the effectiveness of prone traction radiographs in predicting postoperative slip distance, slip angle, changes in disc height, and lordosis after surgery for degenerative spondylolisthesis of the lumbar spine.