Surgical timing of burst fractures in lumbar vertebrae: early surgery or late surgery?

Abstract

AimLumbar vertebral burst fractures may cause neurological damage due to displacement of bony fragments into the spinal canal. The main purpose of treatment is to remove mechanical compression, correct deformity, provide reduction, thus obtain a stable and functional spine. The goal of this study is to show the effects of early surgery on patients’ neurological outcomes.MethodsThis retrospective study included 80 cases of lumbar burst fractures requiring surgery. Posterior decompression and stabilization with fusion were performed at the fractured vertebrae and one level above and one level below the fracture level. Preoperatively and postoperatively the following radiological and clinical findings were evaluated: TLICS and ASIA scores.ResultsEighty patients with burst fractures were operated within 16 hours of referral. Fifty-seven patients were neurologically intact (ASIA E), the remaining 23 patients had various neurological deficits. Improvement was observed after early surgery in 17 patients. Meanwhile, 5 of ASIA E patients showed deterioration during preparations for elective operation, but they fully recovered after urgent surgery. No difference was found after surgery in ASIA A and B patients.ConclusionEarly surgery is important in patients with lumbar burst fractures and incomplete cord injury to prevent additional neurological deficits. However, early surgery had no effect on neurological outcomes in patients with complete cord injury.

Keywords

Introduction

Vertebral burst fractures constitute approximately 10 - 20% of all lumbar vertebra fractures.^1-2 The etiology is broad, including high-energy traumas like falls from height, traffic accidents, sport injuries, and simple traumas in the elderly population. Spinal vertebral burst fractures are usually results of compressive force on the vertebral body, which comprise the anterior and the middle columns, in some cases, the posterior column involvement of Denis 3-column theory.³ The fractured bony fragments may displace into the spinal canal and cause neurological compromise. Spinal cord or nerve injury may lead to sensory loss and motor weakness.⁴
There is still controversy on the treatment strategies for this type of injury, whether conservative or surgical. There is also no consensus on timing of surgery or the surgical approach. The main purpose of early surgical decompression and posterior stabilization is to remove mechanical compression, provide adequate canal decompression and reduction, correct deformity, obtain a stable and functional spine, therefore improve neurological deficit.^5-6-7
However, several studies showed no effect of early surgical decompression on neurological examination in patients with total spinal cord injury. Another important point is that during elective surgery preparation, patients who are neurologically intact may develop motor or sensory deficits, while waiting for the operation. It must be kept in mind that, especially in patients with considerable amount of canal invasion, spinal cord injury may develop in the later hours.^8-9
The aim of this study is to reveal the advantages of early decompressive surgery with posterior stabilization with fusion on neurological outcomes.

Materials and Methods

Study DesignA retrospective evaluation of 80 patients (49 males and 31 females) who were operated for lumbar vertebral burst fractures in our institution between 2014 - 2020 was performed. For each patient, age, gender, fractured vertebral levels and the preoperative and postoperative neurological status (motor and sensory) as assessed by American Spine Injury Association (ASIA) impairment scale were recorded (Table 1). The inclusion criteria for this study were single level burst lumbar fracture and early operation (within 16 hours after trauma).¹⁰ Study approval was obtained from the Research Ethics Board (2020.12.01.12).
For all patients, radiological assessment was performed by computed tomography (CT) scan and magnetic resonance imaging (MRI), as routine practice. After neurological and radiological evaluation, Thoracolumbar Injury Classification and Severity Score (TLICS) for each patient were noted. Patients with TLICS scores between 5 - 10 were considered suitable for surgery.^11-12
Patients with ASIA scores A, B, C and D, therefore with motor and/or sensory loss underwent urgent surgery, which was accepted as within 6 hours after preoperative preparations, whereas neurologically intact patients with ASIA score E underwent elective early surgery, which was accepted as within 16 hours after preoperative preparations.
Spinal canal encroachment rates of the patients who underwent surgery were examined. It was determined as the ratio of the mean midsagittal canal diameters of suprajacent and infrajacent vertebrae of the fractured vertebra to the midsagittal canal diameter at the level of fractured vertebra.Surgical ProcedureAll surgical procedures were performed under general anesthesia. Patients were placed in a prone position on a radiolucent operating table. The fracture level was confirmed by fluoroscopy and by using standard posterior midline approach, posterior wall decompression with laminectomy was performed, pedicle screws of appropriate diameter were inserted into the pedicles of the nonfractured suprajacent and infrajacent vertebrae. Indirect reduction via ligamentotaxis was achieved by adequate longitudinal rod contouring and distraction was applied along the entire instrumentation.

Results

Lumbar burst fractures were detected as follows: 25 cases at lumbar 1 level, 22 at lumbar 2, 18 at lumbar 3, 11 at lumbar 4, and 4 at lumbar 5.
The mean time from referral to surgery for patients with neurological deficits (ASIA A, B, C, D) was determined as within 6 hours following the preoperative preparations. Patients without motor or sensory deficits (ASIA E) were operated under elective conditions and the average duration until surgery was determined to be within 16 hours of referral.
Preoperative ASIA scores of patients were found as follows: ASIA A: 3 persons (3.75%), ASIA B: 3 persons (3.75%), ASIA C: 8 persons (10%), ASIA D: 9 persons (11.25%), ASIA E: 57 persons (71.25%). After surgery 9 patients with ASIA D score showed improvement to ASIA E, while 8 patients showed improvement from ASIA C score to ASIA D. However, no recovery was observed at the neurological examination of 6 patients with ASIA A and ASIA B scores (Table 2).
During elective preoperative preparations neurological deterioration was detected in 5 patients with ASIA E score; 4 of them regressed to ASIA D, while 1 patient became ASIA C. Hence, urgent surgical intervention was performed for these 5 patients, and postoperatively their neurological deficits recovered back to ASIA E (Table 2).
When the relationship between ASIA scores and spinal canal encroachment rates were evaluated; it was found that spinal canal encroachment rates of patients with ASIA E scores were between 25 - 55%, they were 50 - 60% at patients with ASIA D score, 55 - 70% at patients with ASIA C score, and 65 - 75% at patients with ASIA B score, whereas they were 65 - 80% at patients with ASIA A score (Table 3). The measurements performed for ASIA E scored 5 patients that showed deterioration, while waiting for elective surgery revealed 50 - 55% spinal canal encroachment rates.

Discussion

Treatment goals for vertebral burst fractures are to stabilize the spine, preserve and ameliorate neurological condition, restore sagittal alignment and allow rapid mobilization. However, there is still debate on the adequate treatment strategies, surgical or conservative, and if surgical, on timing of surgical decompression and posterior stabilization in patients with spinal cord injury.⁸
Studies suggest that surgery should be performed as soon as possible, however in cases with complete cord injury it should be delayed until 24 - 48 hours from the trauma to reduce intraoperative bleeding. Urgent surgery is required in cases with incomplete cord injury, because it has been found that in cases with cord compression only, early decompression increases the chance of neurological recovery.⁹
In a review by Aviles et al., they reported that 2.4% of patients with intact neurological examination and conservative follow-up developed a neurological deficit.¹³ In another study, in patients with neurological deficits, early surgical decompression was shown to improve ASIA scores.¹⁴ These two studies results are parallel to our study. In their study, Vaccaro et al. stated that there is no difference between early and late surgery in terms of neurological function, hospitalization and rehabilitation in patients with complete cord injury.¹⁵ This result is not correlated with our study.
Our study revealed that early decompression surgery has a positive effect on prognosis in patients with incomplete cord injury. Therefore, the timing of operation after trauma is important. However, even with early decompression, in patients with complete cord injury no improvement was observed, and the prognosis was poor.
Another significant point in lumbar vertebral burst fractures is that, in neurologically intact patients, motor strength weakness and/or sensory deficits may develop while waiting for the operation. In our current study, we wanted to emphasize the importance of early surgery for those patients with no motor or sensory loss planned to have elective surgery, that have to wait until optimum conditions like preoperative necessary clinical consultations and preparations are complete. We found that neurological deterioration may occur during the elective operation process, especially in the patient group with ASIA E score and with spinal canal encroachment rates of more than 50%.
As a result, we believe that early surgery is of vital importance in patients with lumbar burst fractures and incomplete cord injury to prevent additional neurological deficits. However, we found no efficacy of urgent surgery on neurological examination in patients with complete cord injury.

Conclusion

In this study, we compared the results of our patients who were operated for burst fractures. We have seen that early surgical intervention without delay in incomplete injuries is very important in order to prevent neurological deficits. Unfortunately, we have seen that early and late surgical intervention does not affect complete injuries. Our study has a short case series and more studies are needed.

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