September18, Unitedkingdom  2021 

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Abstract Volume: 2 Issue: 2 ISSN:

Comparative Study of Instrumentation for Dl Junction Spine Fractures.

Dr Suresh Kumar N Parmar*, Dr Dixitkumar R Chaudhari1, Dr Sandip Solanki2

1. Dr Dixitkumar R Chaudhari  MBBS MS Ortho Resident, Govt Medical College ,Sir T hospital, Bhavnagar 

2. Dr Sandip Solanki, MBBS, MS, MCH, Neurosurgery, Assistant professor in Govt Medical College ,Sir T Hospital ,Bhavnagar


Corresponding Author: Dr Suresh Kumar N Parmar, MS Ortho Trauma and Spine Surgeon, BIMS Hospital, Bhavnagar. Assistant professor, Government Medical College, Sir T Hospital, Bhavnagar.


Copy Right: © 2021 Dr Suresh Kumar N Parmar. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Received Date: July 23, 2021

Published date: August 01, 2021

Comparative Study of Instrumentation for Dl Junction Spine Fractures.

INTRODUCTION AND OVERVIEW

Vertebral injuries of the thoracolumbar spine are a major cause of long-term morbidity in trauma patients. Care of vertebral injuries contributes to the major expenditure of health care resources. 

Thoracolumbar injuries in trauma are concentrated at the thoracolumbar junction,60% occurring between T11 and L2. Lumbar and thoracic injuries together represent 37-41% of traumatic spinal cord injuries. A neurologic deficit occurs in 26% of TL junction fractures.

Since the earliest attempts, the treatment of fractures and fracture-dislocations of the thoracic and lumbar spine has been controversial. Initially, all fractures of the DL junction were treated conservatively. Since the past 30 years, more and more surgeons are shifting towards open reduction and intCernal fixation of these fractures. 

In the early years, laminectomy was the mainstay of surgical treatment. Recently reports by Levine and Edwards, Bohlman, McAfee, Bohlman & Yuan, Luque, Cassis and Ramirez-weill, Cotrel – Dubosset and Guillamat have emphasized the advantages of open reduction and internal fixation with instrumentation. 


AIMS AND OBJECTIVES

1. Comparison of results of various types of instrumentations in fractures of the dorsolumbar junction.

2. Determination of the optimum type of instrumentation, type of decompression and type of reconstruction for different types of fractures of the dorsolumbar junction.


REVIEW OF LITERATURE

Since the 1960s, there have been regular periodic attempts at the improvement of fixation of fractures in the thoracolumbar spine.

The following is a summary of the origin and development of various methods of fixation of fractures in the thoracolumbar spine.

 

1970 – HARRINGTON INSTRUMENTATION. 

Invented by Paul Harrington in 1970. Originally meant for fixation and correction of scoliosis and other spinal deformities. Later on, modified for fixation of vertebral body fractures. Now rarely used for the same.


1986 – Modification of the Harrington system by Edwards and Levine, Distraction rods, Polyethylene sleeves & anatomical hook design provided simultaneous hyperextension and distraction forces that eliminated kyphotic deformity and restored vertebral body height.


1984 – LUQUE INSTRUMENTATION

Another modification of the Harrington system. It provided more resistance to rotational forces than the traditional system.


1984 – SUBLAMINAR WIRING WITH HARRINGTON DISTRACTION INSTRUMENTATION

Combines the advantages of the Harrington and Luque systems by sublaminar wiring of the Harrington distraction rods, is supposed to increase stability and resistance to pullout.


1986 – STEFFEE AD, BISCUPS RS, SITKOWSKI DJSegmental spine Plates with pedicle screw fixation. A new internal fixation device for disorders of the lumbar and thoracolumbar spine 1986 Clinical Orthopaedics. This system uses pedicle screws with notched plates as the longitudinal linking component.


1986 – ROY CAMILLE, R, SAILLANT.G, MALEL C.

Plating of thoracic, thoracolumbar and lumbar injuries with pedicle screws Orthopaedic Clinics of North America. 1986.


1988 – WISCONSIN (DRUMMOND) INTERSPINOUS INSTRUMENTATION

This eliminates the risk of nerve/cord injury as the instrumentation is completely outside the spinal cord.


1988 – COTREL – DUBOSSET INSTRUMENTATION

Cotrel. Y, Dubosset.J, Guillamat M proposed new universal instrumentation in spinal surgery in Clinical Orthopaedics – 1988. This system consists of rods that are attached to the hook/screw system. This provides segmental fixation at multiple vertebral sites. Compression, Distraction and translation may all be used in the same construct, making it a powerful tool for multisegmental injuries.


1988 – TEXAS SCOTTISH RITE HOSPITAL SYSTEM.

Segmental fixation at multiple levels by hooks and /or screws, smooth rods are used.

 

ANATOMY AND BIOMECHANICS OF THE DL JUNCTION

The spine is a mechanical structure. The vertebral articulate with each other in a controlled manner through a complex system of joints, ligaments and levers. The stability is exhibited by ligamentous stability and dynamic neuromuscular structure. 

 

FUNCTIONS OF THE SPINE

a) Transfers the weight and bending movements of head and trunk to the pelvis.

b) Allows physiologic motion between head, trunk and pelvis.

c) The spine possesses curvatures in saggital plane. It gives flexibility and shock-absorbing capacity at the same time maintaining stiffness and stability of intervertebral joints.


VERTEBRAL ANATOMY

A typical human vertebral consists of an anterior cylindrical body and posterior elements. The posterior elements are two pedicles, two laminae, two transverse processes, one spinous process and four articular processes. Vertebrae are connected by 

1) Intervertebral discs – This consists of a central gelatinous nucleus pulposus which is surrounded by the annulus fibrosus.

2) The synovial joints and their capsules – Each vertebra articulates with its adjacent vertebrae by forming synovial joints with its articular processes. 

3) Spinal ligaments – The spinal ligaments are the (a) anterior longitudinal ligaments (b) posterior longitudinal ligaments (c) Interspinous ligaments (d) Intertransverse ligaments (e) ligamentum flavum (f) Capsular ligaments and (g) supraspinous ligament.

 

FUNCTIONS OF LIGAMENTS

1. Uniaxial Structure is most efficient in carrying loads along the direction of fibers.

2. Resist tensile force, buckle to compressive force.

3. Allow adequate physiologic motion

4. Prevent / Reduce displacement in the injured spine to provide static stability.

5.Anterior and posterior longitudinal and supraspinous ligaments play a principal role in ligamentotaxis 


Pedicle Morphology:

The pedicle is a part of the vertebral body connecting the body anteriorly with the laminae, transverse processes and the superior and inferior articular processes posteriorly. It is a tubular bone with an intramedullary different from putting a Rush rod in radius.

The diameter of the pedicle is largest in the lower lumbar spine and decreases in the thoracic area. Not only does the diameter of the pedicle decrease as one goes cephalad, but the angle of inclination also decreases, starting at about 30* at the L5 level to approximately 10* at L1. The resultant triangular construct form by attaching plates to the divergent screws makes this system exceedingly secure in resisting deforming forces.

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