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THE CLASSIC: Current Concepts Review

2006; Lippincott Williams & Wilkins; Volume: 443; Linguagem: Inglês

10.1097/01.blo.0000200229.68942.93

1528-1132

Edouard Stauffer,

Bone fractures and treatments

In the accompanying article Dr. Stauffer considered how an aggressive surgical approach to the treatment of thoracolumbar spine fracture would compare with nonsurgical treatment of the same injury. He pointed out that surgical decompressions and instrumented fusions have the potential for exposing a patient to major complications and he drew on his lifetime of experience to counsel more conservative methods whenever possible. Recognizing that treatment had the goals of preserving neurologic function and stabilizing the spine in good alignment, he made the point that the nonsurgical treatment often can provide satisfactory end results without subjecting patients to surgery. His classic paper embodies the issues raised in this symposium.Fig 1: E. Shannon Stauffer is shown.E. Shannon Stauffer died almost 3 years ago. He came from the Pennsylvania Dutch Country (around Lancaster, PA) and attended Pennsylvania state universities: Temple Medical School and the University of Pittsburgh for an orthopaedic residency. He practiced medicine in Los Angeles, CA for about 10 years and mostly worked thereafter at the Rancho Los Amigos Hospital in Downey, CA. He left the West Coast in 1975, however, and became the first Chairman of Orthopaedics at the University of Illinois Medical School in Springfield; he worked there until he retired in 1998. He had an outstanding career in orthopaedic education and research and was recognized internationally as a leader in the specialty of spine surgery. Henry H. Sherk, MD During the past ten years, the field of orthopaedics has seen a dramatic increase in interest in the operative management of patients with fractures. Recent trends toward rigid internal fixation of fractures to allow rapid mobilization of patients and decrease the complications of prolonged immobilization of joints and muscles, along with the development of biomechanically sound instrumentation to provide internal fixation, have rapidly changed concepts of patient management and stimulated controversies regarding various techniques. Several factors have combined to cause a similar change in the management of fractures of the spine. The major step in the improvement of the care of patients with paralysis caused by spine fractures was the development of antibiotics during the 1940's. This prevented the rapid death of the paralyzed patient from sepsis secondary to urinary tract infection and pressure sores. During the late 1940's, spinal cord-injury centers were established in England under the National Health Service to care for war veterans and civilians alike. Postural reduction, cast immobilization, or prolonged bed rest, as advocated by Watson-Jones and by Guttmann, have been the standard of care with which newer operative methods must be compared. Orthopaedic surgeons such as Holdsworth pioneered early orthopaedic interest in the management of the unstable thoracolumbar fracture. His classification of the stability of fractures remains a classic in the orthopaedic literature. He deviated from the traditional approach of postural reduction by advocating open reduction and internal fixation with plates attached to the spinous processes of the fractured vertebrae. The purpose was to restore the alignment of the spine and prevent further injury to the neural elements as the patient was being turned in bed. These patients, however, still required three months of bed rest. During the 1950's, centers were developed in the United States by the Veterans Administration for the care of paralyzed veterans. These centers were mainly directed by urologists. The prevention of genito-urinary complications greatly improved the outlook for survival and functional rehabilitation of these patients. During the 1960's, comprehensive research-and-demonstration civilian spinal cord-injury centers were designated in the United States, and this fostered cooperation between neurosurgeons, orthopaedic surgeons, internists, physiatrists, and urologists to demonstrate the realistic functional goals obtainable by paralyzed patients with a comprehensive rehabilitation program. The problems of late instability, with increasing kyphosis, gibbus formation, pain, pelvic obliquity, increased spasticity, or progressive neural loss, which interfered with maximum rehabilitation, attracted the orthopaedic surgeon's interest. Posterior Instrumentation The development of reliable, biomechanically sound internal fixation by Harrington provided the technical method of stabilizing the spine in a straight position during healing. Other methods of internal fixation, including interspinous-process wiring, serrated spinous-process plates, short compression rods, springs, circumlaminar wiring, and transpedicular screws, have been advocated to improve fixation. However, at this time modifications of the Harrington double-distraction-rod system provide the most reliable documented method of re-establishing normal alignment of the spine and allowing it to heal in the most anatomically correct position. During the 1970's, many authors2,5,8 published their results of treatment of thoracolumbar fractures by internal fixation. As the decade of the 1970's passed, the duration of bed rest after surgery was reduced and more stable methods of internal fixation decreased the necessity of postoperative external immobilization. These authors documented shorter hospitalization times, more complete rehabilitation, and few complications in patients who were treated with internal fixation and early mobilization, as compared with patients who were treated non-operatively with bed rest followed by a cast or brace for varying lengths of time. Even though it appeared that some of these patients had improved neural recovery (presumably secondary to re-establishment of the anatomy of the spinal canal and decompression of the bone fragments impinging on the cauda equina), this has not been statistically documented in carefully controlled series. In 1982, Luque et al. described segmental spinal instrumentation using sublaminar wires. The addition of sub-laminar wires to the Harrington distraction-rod system greatly enhanced the inherent rigidity and allowed open reduction with an internal fixation system of sufficient immediate stability to eliminate the need for postoperative immobilization. The added surgical risk of passing the sublaminar wires and the long-term consequences of the possibility of breakage of the sublaminar wires in the spinal canal have not been assessed as yet. A method of providing segmental stabilization by passing wires through the base of the spinous process instead of in sublaminar fashion has been recently advocated by Drummond et al. This appeared, in the laboratory, to provide sufficient rigidity without the complications of sub-laminar wiring. The techniques that have been described and documented were based on the use of instrumentation developed for correcting scoliosis and not specifically for fractures. New devices, which are currently being investigated and evaluated, have been developed specifically for the internal fixation of fractures. Laminar hooks that grasp the laminae from the posterior aspect and are attached to threaded rods have undergone laboratory testing and are currently under clinical investigation. Decompression During the 1950's, routine posterior laminectomy to “decompress” the spinal cord and cauda equina was practiced as the standard of care. After careful review of this procedure, it became evident that posterior laminectomy not only did not decompress the spinal canal, since most of the compression was anterior, but that in fact it made many patients worse by destabilizing the spine, causing increased kyphosis, and placing more pressure on the anterior part of the spinal cord and nerve roots. So-called laminectomy decompression alone has been shown to be of no value and has been rightly abandoned for the routine management of closed, non-progressive spinal-cord injuries.10 With the increasingly widespread use of the computer-assisted axial tomographic scanner, it has become readily apparent that distraction rods or compression rods do not routinely decompress the bone fragments from residual impingement on the neural elements in the spinal canal. This has resulted in a new controversy regarding the necessity of anterior decompression and possibly the efficacy of anterior instrumentation. Several authors currently advocate a primary anterior approach to the fractured vertebra, débridement of the fracture fragments from the anterior aspect of the spinal canal, and the use of bone grafts or anterior trans-vertebral-body internal-fixation devices to provide stability.4 These approaches have not as yet stood the test of time to be documented as the standard of care. Many factors must be considered when recommending the most appropriate treatment of a specific patient with a fracture of the thoracolumbar spine. These factors include the magnitude and displacement of the fracture, the vertebral level involved, the presence of injury to the spinal cord or nerve root, the stability of the fracture in the displaced position, the stability after reduction of the fracture, the age of the patient, and the severity of coexisting injuries. Many patients will not benefit from open reduction and internal fixation and are best treated with best rest, postural reduction, or external immobilization with a body jacket or brace. Many fractures are inherently stable and are not improved by open reduction and internal fixation.1 Patients with a grossly unstable fracture that disrupts both the anterior and the posterior column may have no neural injury. These fractures will usually heal with non-operative methods and no neural sequelae. Patients with an incomplete spinal-cord or cauda-equina injury have the most to gain from early stabilization, internal fixation, and mobilization out of bed.8 A stable, reduced fracture may prevent further injury to the tissue and provide a better atmosphere for recovery of the partial neural deficit.5 For patients with a complete spinal-cord lesion and permanent paraplegia, open reduction and internal fixation allows early mobilization for more rapid rehabilitation and prevention of the complications of prolonged bed rest, such as muscle atrophy, joint contracture, pressure sores, urinary tract stasis, negative calcium balance, osteopenia, and psychological depression.11 Length of Fusion There are several controversial areas in the open management of spine fractures. The first is the length of the fusion. Harrington and Dickson recommended instrumenting two levels above and two levels below the fractured level and fusing the entire instrumented area. Armstrong recommended so-called long rodding of three levels above the fracture and three levels below the fracture, without fusion. This provides a better reduction and allows the fracture to heal in a more anatomical position; however, it does require removal of the Harrington rods in a second procedure, twelve to twenty-four months postoperatively. This controversy has not been satisfactorily resolved. Several authors have documented a progressive kyphosis at the fracture site after removal of the Harrington rods, due either to inadequate healing or to inadequate strength of the cancellous bone formed under the circumstance of distraction. The compromise position of “rod long - fuse short” consists of inserting the rod three levels above the fracture and at least two below it, and fusing only the area of the fracture and its adjacent vertebrae. This technique also requires the subsequent removal from the fusion mass of the rods and any sublaminar wires or wires across the spinous processes. Only the long-fusion technique has adequate follow-up at present to document long-term results. Currently techniques are available to provide reduction and stabilization of most displaced unstable fractures. Firm fixation for healing in the anatomical position while allowing mobilization of the patient provides the best environment for functional rehabilitation and may provide improved neural recovery while decreasing medical complications. For patients with partial or improving paralysis, the risks and complications of the surgical stabilization procedure should be carefully weighed against the benefits gained by early mobilization. Patients with a stable or undisplaced fracture and no neural loss have the least to gain from open surgical reduction. The fracture will usually heal without surgical intervention, obviating the surgical risks and the possibility of neural deterioration. Current practice most frequently consists of bed rest followed by cast or brace immobilization for patients with no neural loss. Posterior open reduction and internal fixation with dual Harrington rods, using square-ended rods and bifid upper hooks around the upper pedicles, is recommended for the completely paraplegic patient with an unstable fracture, to provide a straight spine for sitting, rapid rehabilitation, and shorter hospitalization. Sublaminar wires or wires across the spinous processes may be used for additional stability in order to eliminate the need for a postoperative brace. The patient with incomplete paraplegia who is improving is observed at bed rest until he or she reaches a plateau. Then posterior open reduction with Harrington rods is performed, to provide reduction and stability. If a patient with incomplete paralysis fails to demonstrate continued neural improvement, a computed tomography scan is made and anterior decompression of compressing bone fragments is recommended - particularly for partial lumbar cauda equina injuries, since these have a better prognosis for recovery than thoracic cord injuries. The use of internal fixation devices to reduce and stabilize unstable fractures is technically demanding and requires experience and specialized training. Many complications - both intraoperative and postoperative - are possible, and they can be quite harmful to the patient. These complications include dislodgment of hooks and rods, redisplacement of the fracture, breakage of rods and wires, and increased neural deficits due to manipulation of the spine and instrumentation. It has also been demonstrated that the distraction-reduction does not always decompress the fracture fragments from the neural canal. The mere technical mastery of a new surgical procedure will not ensure optimum care for our patients. As Sir Robert Jones taught newly emerging orthopaedists in 1921: function is the orthopaedist's goal; his specialty is to know and be able to practice the best way of obtaining it. The operation is only the beginning of the treatment, and the most brilliant operative exploit can only be measured by its functional success.