Summary and ConclusionsThe work was conducted on 102 patients who sustained traumatic thoracic and lumbar spine injuries during the period from July 1999 to March 2004 at neurosurgery division of Al-Zagazig University Hospital.The cases were divided into two main groups:1. Conservative group:Thirty patients who admitted lately, had major, severe and multiple associated systemic injuries or had a major medical contraindication for spinal surgery.2. Surgical group:Seventy-two patients were admitted early after injury, had spinal surgical intervention within 30 days of the injury.Evaluation of the extent of neurological function was done by using the numerical Yale Scale Scoring system.All patients had plain X-rays, CT scans and MRI images for initial evaluation and in the follow up period.We have achieved the following results: The age range was 13-60 years with a mean of 38 years. There were 68 men (66.6%) and 34 women (33.4%) with male to female ratio was 2:1. Traffic accidents were the causative trauma in 53 patients (52%) and fall from height were the cause in 49 patients (48%). Early presentation after injury in the first 24 hours was found in 62 patients (86.1%) in surgical group while late presentation more than 5 weeks after injury was found in 12 patients (40%) of conservative group. Clinical data:a. Back pain:Was noted in all cases, radicular pain in 32 patients (31.4%). The pain was severe in 97 patients (95.1%).b. Initial neurological status:1. Surgical group: 72 patientsNo neurological deficits (score 10) 13 patients (18%)Incomplete neurological deficits (scores 9-1) 52 patients (72.2%).Complete neurological deficits (score 0) 7 patients (9.7%)2. Conservative group: 30 patientsNo neurological deficits 8 patients (26.7%)Incomplete neurological deficits 17 patients (56.6%).Complete neurological deficits 5 patients (16.7%)c. Bladder function1. Surgical group:Normal bladder 29 patients (40.3%)Bladder dysfunction 43 patients (59.7%).2. Conservative group:Normal bladder 12 patients (40%)Bladder dysfunction 18 patients (60%).d. Associated systemic injuries:* Other associated injuries were found in 32 patients (31.4%).* Head injuries in 22 patients (21.6%).* Single associated injury was noted in 23 patients (22.5%) and multiple injuries in 9 patients (8.8%).* Patients in conservative group had more frequent, severe, and multiple associated injuries than in surgical group. Radiological data:a. Level of spinal injury:* Thoracolumbar was the most common involved region in 77 patients (75.5%).* L1 vertebra was the most common vertebra involved by the injury in 41 patients (40.2%).b. Number of vertebrae involved by the injury:* Single vertebral injury was found in 83 patients (81.4%).* Multiple vertebral injuries in 19 patients (18.6%) which was contiguous in 15 patients (14.7%) and non-contiguous in 4 patients (3.9%).c. Types of spinal injuries:* Wedge compression fractures were found in 16 patients (16.7%).* Burst fractures were found in 78 patients (70.5%) where superior end plate fracture type was the commonest, found in 50 patients (64.1%).* Fracture dislocations, found in 8 patients (7.8%).d. Involvement of the posterior vertebral elements by the injury was found in 19 patients (18.6%).e. Reduced vertebral height:* The range was 16-72%.* The mean was 58.6%.* More than 50% loss of vertebral height was noted in 43 patients with burst fractures (55.2%).f. Canal compromise:* The range was 17-76%.* The mean was 48.6%.* More than 50% canal compromise was noted in 49 patients (62.8%).g. Spinal kyphosis:1. Surgical group:* The range was 13-39 degrees.* The mean was 25.3 degree.* More than 25 degrees angulation was found in 31 patients (43.1%).2. Conservative group:* The range was 8-24 degrees.* The mean was 16.7 degree. Management:a. Conservative group:* Complete bed rest until pain was tolerable.* Use of analgesics to control pain.* Use external orthoses.* Program of physiotherapy.b. Surgical group:* Timing of surgery: the range of interval between injury and operation was 5-27 days. The mean was 11.7 days.* Type of surgery:a. Decompressive procedures: In 59 patients who had incomplete or comlete neurological deficits:1. Laminectomy in 20 patients (33.8%).2. Transpedicular in 23 patients (38.9%).3. Lateral extracavitary in 13 patients (22%).4. Anterior transthoracic in 3 patients (5%).b. Spinal fixation (instrumentation): In 72 patients.1. Luque rectangle and sublaminar wiring in 37 patients (51.4%).2. Transpedicular rods-screw system in 30 patients.3. Body implant systems in 5 patients (6.9%).* Kaneda system in 3 patients (60%).* Z-plate system in 2 patients (40%).* Autologus bone grafting was applied in all surgically treated patients.* All patients wore external supportive orthoses on ambulation for 6 months.* Operative complications:- It was noted in 12/72 patients (16.7%).- Two patients (2.7%) developed deep back wound infection responded to antibiotics and debridement.- One patient (0.9%) developed C.S.F leak, required reoperation.- Three patients (2.9%) developed deep venous thrombosis.- Neither neurological deterioration nor mortality were recorded. Follow-up:Clinical follow-up ranged from 12-36 months with the mean was 21.6 months.a. Conservative group:1. Neurological recovery:- No neurological deficits in 12 patients (40%).- Incomplete neurological deficits in 13 patients (43.3%).- Complete neurological deficits in 5 patients (16.7%)2. Recovery index (mean % recovery rate) was 46.6%.3. Mean number of Yale Scale Score improvement was 0.6 score.4. Normal bladder recovery was found in 5 patients.5. Duration of maximum neurological improvement:- The range was 7-12 months.- The mean was 10.6 months.6. Mean recovery rate per month was 8.6%.7. Back pain:Four patients (13.3%) had severe back pain that required frequent use of orthoses. 8/30 patients (26.7%) had moderate back pain that required part time use of orthoses.b. Surgical group:1. Neurological recovery:- No neurological deficits in 36 patients (50%).- Incomplete neurological deficits in 29 patients (40.3%).- Complete neurological deficits in 7 patients (9.7%)2. Recovery index (mean % recovery rate) was 74.4%.3. Mean number of Yale scale score improvement was 1.5 score.4. Normal bladder recovery was found in 29 patients (67.4%).5. Duration of maximum neurological improvement:- The range was 2-8 months.- The mean was 4.9 months.6. Mean recovery rate per month was 14.2%.7. Back pain:Two patients (5.4%) had severe back pain that required use of orthoses most of time. Radiological data:a. Conservative group:1. Kyphotic angle:It increased as the mean initial angle was 16.7 degrees and at final follow-up it was 22.6 degrees with 35.3% increase.2. Vertebral collapse:Progressive vertebral collapse was noted in 14/22 patients (63.6%) with burst fracture. The mean duration for reaching the maximum collapse was 4.6 months.3. Canal compromise:Slow reduction of canal compromise as result of bone remodeling was noted in 14/22 patients with burst fracture. The range was 5-40% and the mean was 20.2%.b. Surgical group:1. Kyphotic angle:Spinal stabilization provided its correction from 25.3 degrees (mean initial) to 12.6 degrees (mean final) with 50.2% mean reduction.2. Vertebral collapse:No further vertebral collapse was noted as result of the supportive stabilization implants.Sagittal translation (Dynamic flexion/extension):No motion at the injured spinal level was noted at final follow up in both conservative and surgical groups.Hard ware complications:Screw break was noted in 7/30 patients (23.3%) with 3 or 4 screws break that required reoperation was noted in 3/30 patients (10%). 3 or 4 wire loop break of Luque rectangle was found in 4/37 patients (10.8%) and required reoperation.Outcome: Employment scale:Excellent outcome with return to pre-injury employment occurred in 44/72 patients (61.1%) in surgical group and in 50% in conservative group.B. Statistical correlations (level of significance P < 0.05): Wedge compression fractures had more tendency towards less neurological deficits. The difference was significant. No significant difference as regard burst fractures and extent of neurological deficits. Fracture dislocation had more tendency towards worst neurological deficits. The difference was significant. Significant difference has existed between the extent of neurological function and the reduced vertebral body with > 50% loss of vertebral height is the break point. Significant difference has existed between canal compromise and neurological function with 50% canal compromise is the break point. No significant difference has existed between kyphotic angle and the neurological function. Significant difference has existed between the initial Yale scale score and the percentage of recovery rate, the higher the Yale score the higher was the percentage recovery rate. Significant difference has existed between the initial Yale score and the duration of achieving maximum improvement. The higher the Yale score the shorter was the duration of improvement. Significant difference has existed between the initial kyphotic angle and its progression in conservative group. The greater the initial angle, the more was the progression. Significant difference has existed between initial percentage of reduced vertebral height and further vertebral collapse in conservative group with > 50% reduced vertebral height is the break point.The choice of the treatment modality:A. Surgical versus Conservative treatment: In patients without neurological deficits (Yale score 10), no significant difference has existed between surgical and conservative groups. In patients with mild neurological deficits (Yale scores 9,8), no significant difference has existed between surgical and conservative groups. In patients with moderate neurological deficits (Yale scores 7,6), significant difference has existed with better results in surgical than conservative group. In patients with severe neurological deficit (Yale scores 5-1), high significant difference has existed with better results in surgical than conservative groups. In patients with complete neurological deficits (Yale score 0), no significant difference has existed between surgical and conservative groups. Patients who had kyphotic angle up to 20 degrees, no significant difference has existed between surgical and conservative groups. Patients who had kyphotic angle more than 20 degrees, significant difference has existed with better results (back pain) in surgical than conservative groups.B. Selection of the surgical procedures: Neural decompressive procedures:Lateral extracavitary and anterior transthoracic decompressive approaches gave better results than laminectomy and transpedicular approaches. The difference was significant. Spinal stabilization techniques:Transpedicular and lateral vertebral body fixation had better results than Luque rectangle and sublaminar wiring with significant difference.