The adequate reduction of vertebral burst fractures is dependent on successful application of distractive forces in combination with the restoration of normal spinal lordosis. However, the optimal sequence of distraction in comparison to distraction plus lordosis in the anatomic restoration of the fractured thoracolumbar spine has not been described. Burst fractures of the L1 vertebra were first created and the reduced in vitro using three differing reduction techniques. In six fresh human cadaver spine speciemens, the mean fracture severity based on the degree of canal compromise was 31% (SD +/- 20%) after fracture. Reductions were performed using the AO fixator intern, the Reduction Fixation (RF) Device, and the Steffee plate systems following standard clinical techniques. The AC Fixator Intern provided independent but variable control of distraction and lordosis, the RF device provided variable distraction with independent, but preset, correction of lordosis and the Steffee system provided set distraction and stabilization. Both the AO and RF devices restored the lordosis (7.60 +/- 5.20 and 9.70 +/- 4.50, respectively) better than the Steffee plate system (00 +/- 1.60). However, the AO device provided poorest restoration of the posterior vertebral body height (92% vs 95% for the RF device and 99% for the Steffee plate). The RF device, which restored both lordosis and posterior vertebral body height to the near anatomic prefracture level, provided significantly better canal clearance (9% +/- 8%) than the other techniques, P<0.05. The study demonstrates that instrumentation systems that provide independent correction of distraction and lordosis can best restore anatomic alignment, with indirect neurodecompression of the compromised spinal canal. Training and experience with devices offering variable correction of distraction and lordosis is needed to realize the capability of each system in the treatment of thoracolumbar burst fractures.
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