The Feasibility And Efficacy Of Anterolateral Precise Incision Approach In The Treatment Of Type A3 And A4 Thoracolumbar Fractures Complicated With Neurological Deficits

Introduction: The majority of spine vertebral fractures occur at the thoracolumbar junction(T11-L2),for the thoracolumbar is relatively fixed,the kyphotic thoracic and relative movement,the lumbar lordosis junction.This area is biomechanically considered the weakest point in the spine.The etiology for this injury varies according to patient age.In young patients,falls from a great height are the most common cause of vertebral body fractures,road,traffic accidents and sporting trauma are the other common causes.In an aged population,thoracolumbar fractures suffer from slight violence,such as simple falls.Thoracolumbar burst fractures,frequently associated with kyphotic deformity and neurological deficit,are very common in younger patients and could have a great impact on their daily physical activities.However,there is still controversy regarding the ideal management for these injuries.Treatment goals for thoracolumbar burst fractures include restoration of spinal stability and alignment,correction of kyphotic deformity and decompression of the spinal canal.For achievement of these desired results,most authors believe that burst fractures require surgical intervention;however,controversy with regard to treatment continues.According to the latest classification of thoracolumbar fractures,thoracolumbartype A3 fractures are incomplete burst fractures,with any involvement of the posterior wall of the vertebral body but without disruption of the posterior ligament complex.Only a single endplate fractured.Vertical fracture of the lamina is usually present and does not indicate a tension band failure.Type A4 fractures,complete burst fractures,are vertebral body fractures involving both endplates as well as the posterior wall.Similar to A3 injuries,these may be associated with vertical fracture lines of the lamina but without disruption of the posterior tension band.There is still some controversy over the need for surgical treatment of thoracolumbar type A3 and A4 fractures without nerve injury.However,the thoracolumbar A3 and A4 fractures with nerve injury have definite indications for surgery.The anterolateral precise incision approach of depression and fusion can be used to treat this type of fractures.Direct decompression and fusion are indeed effective in avoiding posterior approach surgical destruction of the original complete posterior ligament complex,long-term loss of intervertebral height,failure of internal fixation,but also to avoid the traditional anterior approach incision,bleeding and more drawbacks.Objective: Aimed at the thoracolumbar fractures A3 and A4 with nerve injury,the feasibility and efficacy of the anterolateral precise incision approach in the treatment of this type of fracture were investigated through clinical case studies.Methods: From June 2013 to September 2016,we selected 15 patients in our hospital used the anterolateral precise incision approach of depression and fusion in the treatment of type A3 and A4,single-level thoracolumbar fractures complicated with neurological deficits.All patients were evaluated using X-ray prior to surgery,1week,3 month,6 month and 1 year postoperatively.For radiologic parameters,the sagittal plane Cobb angle and the height of fractured vertebrae were measured.For patient's functional assessment,the visual analogue scale(VAS),the AISA classification of spinal cord injury before and after operation were measured.Operation time,and the amount of intraoperative estimated bleeding loss were also recorded.Results: All patients successfully completed the operation,during which noimportant organs and vascular injury occurred.The operation time was 140-210 minutes,with an average time of about 163 minutes.The estimated intraoperative blood loss range from 270 ml to 420 ml,and the average value of about 348 ml.All patients were followed up after surgery for 14 to 40 months with an average of 21 months.The preoperative average Cobb angle was 19.2 °,the Cobb angle was 8.8 ° at1 year follow-up;the preoperative average vertebral body height was 32.4 mm;the vertebral body height at the 1 year follow-up was 40.1 mm;the preoperative average VAS score was 8.0 points,after 1 year follow-up the VAS score was 2.6 points.At 1year after operation,the ASIA classification increased by at least one grade.All of the15 patients,9 patients were classified as ASIA grade C,6 patients were recovered to grade D at one year after follow-up and 3 patients returned to grade E.6 patients were classified as ASIA grade D,and all of them were recovered to grade E at one year follow-up after the operation.Conclusions: The anterolateral precise incision approach is a reliable surgical method for the treatment of type A3 and A4 thoracolumbar fractures complicated with neurological deficits has the advantages of less trauma,less pain and better intervertebral height.