The study protocol was approved by the Institutional Review Boards and the Ethics Committees of Luohe Medical College. Before operation, informed consents were signed by all the patients after detailed explanation of the therapeutic procedure to the patients。
This study is a multi-center case series which was conducted in 3 hospitals specialized in the management of spinal cord diseases. The study is conducted according to the guideline for case series.
The data of patients with thoracolumbar fracture treated in 3 affiliated hospitals from January 2008 to January 2015 were retrospectively analyzed. A total of 161 cases were included. The patients were divided into two groups according to whether to use intraoperative CT scanning or not. 79 patients who used intraoperative CT scanning and decided to decompression according to the CT scanning results were in the treatment group.82 patients who received vertebroplasty and decompression without intraoperative CT scanning were in the observation group.
Inclusion criteria:①single segment fresh fracture of thoracolumbar vertebral body of the herniated thoracolumbar vertebra, A3 fracture in AO classification, complete or partial crushing of vertebral body, backward protrusion of vertebral posterior wall fracture plate into vertebral canal; ②The involvement of the spinal canal was greater than or equal to 40%, with or without nerve damage;③The height of the anterior edge of the vertebral body was lost or greater than 40%. ④The posterior ligament of the vertebral column is intact.
Exclusion criteria: ①anterior posterior thoracolumbar ligament or bone structure injury; ②Patients with type B and C fractures with dislocation in the adiao classification.③Patients with previous neurological diseases; ④To be associated with spinal infection, tumor, metabolic bone disease and other diseases of bone damage; ⑤loss of visitors.
During the research period all patients were assessed for suitability according to the inclusion and exclusion criteria. The study protocol was approved by the local ethnic board, and informed consent was obtained from all the patients in the study.
There were 43 males and 36 females in the treatment group. The average age was 45.2 + 13.8 years. Among them, there were 3 cases of T10, 8 cases of T11, 18 cases of T12, 21 cases of L1, 20 cases of L2 and 9 cases of L3, all of which were single segment fresh vertebral fractures (course < 2 weeks). Causes of injury: 37 cases of high fall injuries, 23 cases of traffic accident injuries, 19 cases of heavy object injuries. According to the American Spinal Injury Association (ASIA), neurological function is graded  : 0 cases of grade A, 9 cases of grade B, 18 cases of grade C, 16 cases of grade D and 36 cases of grade E. There were 45 males and 37 females in the observation group. Age 19 ~ 69, average 44.9 + / − 12.9 years. There were 2 cases of T10, T119, T12, L1, 22 cases of L2 and 8 cases of L3, all of which were single segment fresh vertebral fractures. Causes of injury: 39 cases of high fall injuries, 21 cases of traffic accident injuries, 22 cases of heavy object injuries. Neuro-functional ASIA was classified into 0 cases of grade A, 10 cases of grade B, 18 cases of grade C, 19 cases of grade D and 35 cases of grade E. The comparison of general data was shown in table 1. There were no statistically significant differences between the two groups in gender, age, fracture segments, high compression ratio of the anterior margin of the injured vertebra, Cobb Angle of the injured vertebra, and neurological function ASIA grading (P > 0.05).
After admission to the hospital, To illustrate the extent of the fracture and to determine the adequate surgical procedure, all the patients received both anteroposterior and lateral X-rays as well as a computed tomography (CT) and magnetic resonance imaging (MRI) according to standard protocol.
After evaluation, ensure that eligible patients undergo surgery in accordance with established guidelines and regulations to reconstruct spinal sequence and stability.
1 Treatment group: With general anesthesia in the prone position, the part of the spine fracture is placed at the folding line of the foldable surgical bed. The posterior median approach was adopted. Peeling off the paravertebral muscles, revealing the lower edge of the superior articular process of the upper and lower vertebral bodies of the injured vertebrae, placing pedicle screws with the method of articular process and transverse process positioning, placing the pre-bent connecting rod, folding the operating table to make the spine hyperextension.The pedicle screw was pricked and tightened under the extremely overstretched position to restore the height of the injured vertebra and restore the fracture block . After the vertebral height was restored by fluoroscopy, the intraoperative bedside CT (German Siemens 3d imaging c-arm machine) was performed for rapid examination to understand the reduction of the fracture block at the posterior margin of the injured vertebra.If the fragment has been repositioned or basically repositioned, the spinal canal will not be decompressed; if the fragment still occupies the spinal canal and compresses the dura mater, according to the intraoperative three-dimensional CT information, the position and size of the fragment protruding into the spinal canal will be positioned. Unilateral lamina fenestration will be performed according to the position of the corresponding lamina and ligamentum flavum intervertebralis applied. A proton dissector or L-knife (Fig. 1a) is used to explore the posterior wall of the spinal canal (Fig. 1b) around the lateral dura mater, and to hold the fragment against it. The hammer is tapped gently until the fragment is reduced and the posterior edge of the vertebral body is smooth (Fig. 1c ~ d). Rinse the incision, place negative pressure drainage, close the incision. After 12 ~ 18 months, internal fixation was taken out.
2. Observation group: Posture, anesthesia, exposure, pedicle screw placement were the same as above, without rapid intraoperative CT scan, total laminectomy and spinal canal decompression were performed directly, and then posterolateral bone fixation, drainage tube placement, closure of the incision.
All statistical analyses were performed with the use of SPSS software, version 12(SPSS Inc, Chicago, IL). The results were expressed as average ± SD. Dunnett method was used to compare different time in groups. The counting data is indicated by percentage and chi-square test is adopted. Check level was set at both sides = 0.05.
Evaluation criteria of clinical efficacy
Neurological function was assessed by the American Spinal Cord Injury Association (ASIA) scoring standard .
Evaluation standard of orthopedic effect
- The height compression ratio of the injured anterior vertebra  was measured on the standard lateral radiographs of the spine. The height of the injured anterior vertebra was measured on the lateral radiographs before operation, the third day after operation and 24 months after operation. The normal height of the anterior edge of the injured vertebrae was divided by the sum of the height of the anterior edge of the upper and lower vertebrae divided by 2.The measured value of the anterior edge of the injured vertebra was divided by the proposed normal height and multiplied by 100% to obtain the compression ratio of the anterior edge of the injured vertebra.
- Cobb angle kyphosis: The Cobb angle on the lateral radiographs of the spine was measured preoperatively, 3 days postoperatively and 24 months postoperatively.