Copyright 1997 by The Journal of Bone and Joint Surgery, Incorporated

Anterior Decompression and Stabilization with the

Kaneda Device for Thoracolumbar Burst Fractures
Associated with Neurological Deficits*1
BY KIYOSHI KANEDA, M.D.t, HIROSHI TANEICHI, M.D4, KUN1YOSH1 ABUM1, M.D4, TOMOYUK1 HASHIMOTO, M.D4.
SHIGENOBU SATOH, M.D4, AND MASANORI FUJIYA, M.D., SAPPORO, JAPAN

Investigation performed at the Department of Orthopaedic Surgery, Hokkaido University School of Medicine,
and Hokkaido Orthopaedic Memorial Hospital, Sapporo

ABSTRACT: One hundred and fifty consecutive patients who had a burst fracture of the thoracolumbar
spine and associated neurological deficits were managed with a single-stage anterior spinal decompression,
strut-grafting, and Kaneda spinal instrumentation. At
a mean of eight years (range, five years to twelve years
and eleven months) after the operation, radiographs
showed successful fusion of the injured spinal segment in 140 patients (93 per cent). Ten patients had a
pseudarthrosis, and all were managed successfully with
posterior spinal instrumentation and a posterolateral
arthrodesis. The percentage of the canal that was obstructed, as measured on computed tomography, improved from a preoperative mean of 47 per cent (range,
24 to 92 per cent) to a postoperative mean of 2 per
cent (range, 0 to 8 per cent). Despite breakage of the
Kaneda device in nine patients, removal of the implant
was not necessary in any patient.
None of the patients had iatrogenic neurological
deficits. After the anterior decompression, the neurological function of 142 (95 per cent) of the 150 patients
improved by at least one grade, as measured with a
modification of the grading scale of Frankel et al.
Fifty-six (72 per cent) of the seventy-eight patients who had preoperative paralysis or dysfunction of
the bladder recovered completely. One hundred and
twenty-five (96 per cent) of the 130 patients who were
employed before the injury returned to work after the
operation, and 112 (86 per cent) of them returned to
their previous job without restrictions.
We concluded that anterior decompression, strut*No benefits in any form have been received or will be received
from a commercial party related directly or indirectly to the subject
of this article. No funds were received in support of this study.
tRead in part at the Annual Meetings of the Scoliosis Research
Society, Amsterdam, The Netherlands, September 22, 1989, and
Portland, Oregon, September 22, 1994, and at the Annual Meetings
of The American Academy of Orthopaedic Surgeons, Anaheim, California, March 8,1991, and Orlando, Florida, February 20,1995.
^Department of Orthopaedic Surgery, Hokkaido University
School of Medicine, Kita-15, Nishi-7, Kita-ku, Sapporo 060, Japan.
E-mail address for Dr. Kaneda: kkaneda@ga2.so-net.or.jp.
Hokkaido Orthopaedic Memorial Hospital, Hiragishi 7-13-5,
Toyohira-ku, Sapporo 062, Japan.
VOL. 7 9 - A , NO. 1, JANUARY 1997

grafting, and fixation with the Kaneda device in patients who had a burst fracture of the thoracolumbar
spine and associated neurological deficits yielded good
radiographic and functional results.
Burst fractures are a common major injury of the
thoracolumbar spine and have been reported to be associated with neurological deficits in two of thirteen patients in one series13, twelve (30 per cent) of forty in
another14, and fourteen (56 per cent) of twenty-five in
another5. The indications for operative decompression
and the selection of an operative procedure for stabilization of a thoracolumbar burst fracture associated with
neurological deficits are controversial. Laminectomy
has been shown not only to be ineffective for restoration of neurological function but also to allow further
progression of deformity and neurological injury310. Accepted methods of operative decompression and stabilization of this type of spinal injury include posterior
reduction with distraction instrumentation and arthrodesis without decompression (ligamentotaxis)5143", posterolateral (transpedicular or costotransversectomy)
decompression and arthrodesis with posterior instrumentation272932, posterior or posterolateral arthrodesis
with instrumentation followed by anterior decompression and arthrodesis or anterior decompression and
arthrodesis followed by posterior instrumentation and
arthrodesis626, and anterior decompression and arthrodesis with anterior instrumentation1223 25.
Many investigators have reported favorable results from anterior decompression by direct removal
of the fragments of the vertebral body from the spinal canal62324. However, several questions remain with
regard to whether the retropulsed osseous fragments
in the spinal canal should be removed, whether instrumentation should be used for spinal realignment
and arthrodesis after decompression, and whether the
spinal instrumentation should be placed anteriorly or
posteriorly.
Since reporting on our early series23, we have managed all patients who had a thoracolumbar burst fracture
associated with neurological deficits with a one-stage
69

70

KIYOSHI KANEDA ET AL.

TABLE I
RELATIONSHIP BETWEEN THE FRACTURED VERTEBRAL LEVEL AND THE TYPE OF NEUROLOGICAL LESION*

Tvoe of
Neurological Lesion
Spinal cord (cephalad
to the epiconus
spastic)
Spinal cord (at the
epiconus
flaccid)
Pure conus medullaris
syndrome
Conus medullaris and
cauda equina
Cauda equina or nerve
root, or both
Total

T12

LI

L2

L3

L4

Level of Fracture
T12 + LI
LI + L2

L2 + L3

L2 + L5

T6 + L3 + L5

It

It

15

14

11

32

18

18

32

11

75

34

11

*The values are given as the number of patients.

tDecompression at the fifth lumbar level was performed by means of a posterior procedure.

procedure of anterior decompression and arthrodesis

with use of the Kaneda device for fixation. The purpose
of the present study was to analyze the long-term results for 150 patients who had been managed with this
protocol.
Materials and Methods
From April 1981 to March 1989, 163 consecutive
patients who had neurological deficits because of a
burst fracture of the thoracolumbar spine were managed operatively at Hokkaido University Hospital and
Hokkaido Orthopaedic Memorial Hospital in Sapporo,
Japan. The indication for the operation was a persistent
neurological deficit from encroachment on the spinal
canal by the retropulsed osseous fragments. In most
instances, the operation was performed when the neurological status of the patient had plateaued with only
limited recovery.
Thirteen patients were excluded from this investigation. Two patients died. One, a seventeen-year-old
boy who had had uncontrolled diabetes mellitus and
a severe urinary-tract infection preoperatively, died of
pneumonia fourteen days after the operation. The other
patient, a fifty-seven-year-old man, died because of a
rupture of an esophageal varix two years and seven
months postoperatively. The other eleven patients were
lost to follow-up. All of these patients had been followed
for two to three years postoperatively, had returned to
their previous jobs, and were noted to have a fusion of
the injured spinal segments at the most recent follow-up
examination. Some degree of neurological recovery had
been documented in all thirteen patients, and none of
the thirteen had a complication during the follow-up
period. We reviewed the results for 150 patients who
had been followed for a minimum of five years.
There were 109 male and forty-one female patients.
They had a mean age of forty-one years (range, thirteen
to seventy-two years). The male patients had an average

height of 168 centimeters (range, 150 to 178 centimeters), and the female patients had an average height of
155 centimeters (range, 145 to 164 centimeters). The
body weight of the patients ranged from fifty-three to
eighty-six kilograms; the male patients weighed an average of sixty-seven kilograms and the female patients, an
average of fifty-six kilograms.
Most of the patients were transferred to our institutions from other hospitals and, therefore, the injuries
were not acute. The interval from the injury to the operation was less than forty-eight hours for seven patients, two to less than fourteen days for thirty-eight
patients, two weeks to less than one month for forty-five
patients, one to less than six months for forty-one patients, six to twelve months for eight patients, and more
than one year for eleven patients. The mechanism of
injury included a fall from a height (ninety-four patients), a motor-vehicle accident (thirty-seven patients),
a fall from a height during a suicide attempt (nine patients), and a direct impact from a falling heavy object
(ten patients). Associated trauma included facial or cranial injury (five patients), thoracic injury (nine patients),
urogenital injury (three patients), pelvic fracture (four
TABLE II
OBSTRUCTION OF THE SPINAL CANAL*

Level of
Fractured
Vertebra

No. of
Fractured
Vertebrae

T6
T12
LI
L2
L3
L4
L5
Total

1
20
79
38
13
5
2
158

Obstructiont (Per cent)

Preoperative
Postoperative
11
40 (26-54)
46 (33-80)
58 (38-92)
60 (47-67)
33 (24-48)
19(17-21)
47 (24-92)

0
2(0-7)
2(0-8)
2(0-5)
0 (0-0)
0 (0-0)
0 (0-0)
2(0-8)

*The ratio of the maximum area of the retropulsed osseous fragment to the area of the original spinal canal.
tThe values are given as the mean, with the range in parentheses.

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A N T E R I O R D E C O M P R E S S I O N AND STABILIZATION WITH T H E K A N E D A

TABLE III
GRADING SYSTEM OF FRANKEL ET AL., AS MODIFIED BY
BRADFORD AND MCBRIDE'', FOR NEUROLOGICAL ASSESSMENT

Grade
A
B
C
Dl
D2
D3
E

Motor
Function*
(Points)

Function of Bladder
and Bowel

0
0-1
2
3
4-5
4-5
4
5

Paralysis
Paralysis
Paralysis or dysfunction
Paralysis to normal
Paralysis!
Dysfunctionf
Normal
Normal

*Motor function was determined by manual muscle-testing.

tThe pure conus medullaris syndrome is included in D l or D2.

patients), injury of the upper extremities (twelve patients), and injury of the lower extremities (twenty-nine
patients).
All patients had anteroposterior and lateral radiographs of the spine, preoperative myelography with
myelographic tomography or myelographic computed
tomography, and preoperative and postoperative computed tomography. Myelographic tomography and myelographic computed tomography were used to evaluate
the relationship between the epiconus, conus medullaris,
or cauda equina and the retropulsed osseous fragments.
These radiographic examinations were performed either at the referring hospitals or at our hospitals.
The 150 patients had 158 burst fractures; 143 patients had a fracture at a single level, six patients had
two contiguous or non-contiguous vertebral fractures,
and one patient had three non-contiguous fractures (Table I). According to the classification system of Denis10,
thirty-eight (24 per cent) of the fractures were type A
(a fracture of both of the end plates); ninety-two (58 per
cent), type B (a fracture of the superior end plate); ten
(6 per cent), type C (a fracture of the inferior end plate);
eleven (7 per cent), type D (a burst rotation fracture);
and seven (4 per cent), type E (a burst lateral flexion

71

DEVICE

fracture). One hundred and twenty-three (78 per cent)

of the 158 burst fractures were associated with a fracture
of the lamina at the same level. There was no evidence
of nerve tissue interposed or trapped within the laminar fractures on the preoperative myelographic or plain
computed tomography scans.
The original area of the spinal canal was calculated
by averaging the areas of the spinal canal cephalad and
caudad to the injured vertebra. The percentage of obstruction of the spinal canal (the ratio of the maximum
area of the retropulsed osseous fragment or fragments
to the area of the original spinal canal) was estimated
on the preoperative computed-tomography scan according to our previously reported method21 (Table II).
The nerve-root lesions in the five patients who had a
burst fracture of the fourth lumbar vertebra were associated with a smaller percentage of obstruction of the
spinal canal. These nerve-root lesions were attributed
to retropulsed bone that had narrowed the lateral recesses and resulted in compression of the nerve roots.
Fractures of the sixth thoracic and fifth lumbar vertebrae were not associated with neurological deficits.
Burst fractures of the fourth or fifth lumbar vertebra
associated with neurological deficits have not been
treated with anterior decompression and instrumentation at our institutions since June 1985.
The neurological deficits were divided into five
groups according to the level of the nerve injury: the
spinal cord cephalad to the epiconus (spastic) (three
patients), the epiconus (flaccid) (thirty-two patients),
the conus medullaris only (thirteen patients), both the
conus medullaris and the cauda equina (thirty-three patients), and the cauda equina or an isolated nerve-root
lesion (sixty-nine patients) (Table I). The pure conus
medullaris syndrome was defined as a disturbance in the
function of the anal and bladder sphincters with sensory
loss in the perineal area only (no loss of motor function
or sensation in the lower extremities). Neurological assessment was performed with use of the new grading
scale of Frankel et al., as modified by Bradford and

TABLE IV
RELATIONSHIP BETWEEN THE TYPE OF NEUROLOGICAL LESION AND THE NEUROLOGICAL G R A D E *

Type of Neurological Lesion

Spinal cord (cephalad to the

epiconus spastic)
Spinal cord (at the epiconus
flaccid)
Pure conus medullaris
syndrome
Conus medullaris and
cauda equina
Cauda equina or nerve root,
or both
Total

10

Total
3

1
2

*The values are given as the number of patients.

VOL. 79-A, NO. 1, JANUARY 1997

Preoperative Grade According to the Modified System of Frankel et al.6

Dl
D2
D3
B
C

12

32

13

27

33

21

43

69

12

41

45

43

150

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KIYOSHI KANEDA ET AL.

FIG. 1-A

Figs. 1-A through 1-G: Drawings showing the operative procedure.

Fig. 1-A: After excision of the intervertebral discs cephalad and caudad to the injured level, the fractured vertebral body is excised with use
of a chisel, leaving the anterior longitudinal ligament intact. The displaced fragments of the vertebral body are removed from the anterior
aspect of the posterior longitudinal ligament or thecal sac with use of long, sharp curets.

McBride6 (Table III). We also used the lower-extremity

motor-index scale17 for the evaluation of motor function, which is performed by manual, bilateral testing of
five muscles (the iliopsoas, quadriceps femoris, tibialis
anterior, extensor hallucis longus, and gastrocnemius).
A normal score is 50 points.
The neurological deficits occurred immediately after the injury in 136 patients, and in thirty-four of them
the deficits improved by at least one grade between the
time of the injury to the time of the operation. However,
all 136 patients demonstrated some neurological deficits
at the time of admission to our hospitals (Table IV). In
fourteen patients, the onset of the neurological deficits
was delayed from one to six months after the injury. The
delayed onset of neurological loss from the unstable
burst fractures was attributed to increased kyphosis
or late segmental instability, which caused neurological
compression by retropulsed osseous fragments in the
spinal canal.
The preoperative function of the bladder was urodynamically evaluated by means of cystometry with estimation of residual urine. The patients were also asked
about the sensation of a full bladder, episodes of incontinence, and the need for self-catheterization. Thirtythree patients (22 per cent) had paralysis of the bladder
and forty-five (30 per cent) had dysfunction of the bladder on admission to our hospitals.
Seven patients had been managed with a posterior
procedure before admission to our hospitals. Posterior
instrumentation for reduction and decompression by
ligamentotaxis had been performed in three patients;
laminectomy and posterolateral arthrodesis with instrumentation, in two; and posterolateral decompres-

sion and arthrodesis with instrumentation, in two. All of

these patients still demonstrated neurological deficits
(grade C in one, D l in two, D2 in three, and D3 in one,
according to the modified system of Frankel et al.6) at
the time of the anterior decompression at our hospitals.
The posterior instrumentation was removed before the
anterior procedure was performed.
Operative Procedure
An extrapleural and retroperitoneal approach with
removal of the left tenth or eleventh rib22 was used
to expose the thoracolumbar junction (the eleventh
and twelfth thoracic and first lumbar vertebrae). The
twelfth rib was not removed from most patients because
it is too small and weak for use as a strut graft. Three
vertebrae (the fractured vertebra as well as one cepha-

FIG. 1-B
Anterior decompression must be performed until the base of the
contralateral pedicle is well visualized.
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TABLE V
PREOPERATIVE AND POSTOPERATIVE EVALUATION OF NEUROLOGICAL FUNCTION,
ACCORDING TO THE MODIFIED SYSTEM OF FRANKEL ET AL. 6

Grade at Most Recent Follow-up Examination*

C
Dl
D2

Preoperative
Grade

D3

2t

A
B
C
Dl
D2
D3
E

5 (2t, 3t)
3(it,2$)
5t

2t
It

2t
2t

2
34
45
43

*The values are given as the number of patients.

tPatients who had no recovery of function of the bladder and bowel.
tPatients who had partial recovery of function of the bladder and bowel.

lad and one caudad to it) were exposed. The second,

third, and fourth lumbar vertebrae were exposed by the
retroperitoneal approach with removal of the eleventh
rib. The intervertebral discs cephalad and caudad to the
injured level were almost completely excised, leaving
the anterior longitudinal ligament intact (Fig. 1-A). The
vertebral resection for anterior decompression of the
spinal canal was done, leaving the anterior and contralateral cortices of the fractured vertebral body intact
(Fig. 1-B). The displaced fragments of the vertebral
body in the spinal canal were removed from the anterior aspect of the posterior longitudinal ligament with
use of long sharp curets. The posterior longitudinal ligament was often found to be disrupted or attenuated
as a result of the original injury, but it was not removed
in order to avoid bleeding from the epidural venous
plexus. The anterior decompression was not judged to
be complete until the base of the contralateral pedicle
was well visualized.
After complete decompression, the vertebral plates

of the Kaneda device were attached to the lateral aspect of the vertebral bodies cephalad and caudad to
the vertebrectomy with the use of a punch and screw
fixation (Fig. 1-C). In the fifty-four patients who had
the operation before June 1984, the Mark-I model of
the Kaneda device (without rod couplers) (Mizuho

FIG. 1-D
The relation of the direction of the screws and the vertebral plate
should be triangular, and the screws must penetrate the contralateral
cortex. V.C. = vena cava and Ao. = aorta.

FIG.

1-C

After complete decompression, the vertebral plates of the Kaneda

device are gently attached to the lateral aspect of the vertebral
bodies cephalad and caudad to the vertebrectomy. Then, two screws
are inserted into each vertebral body. A finger is passed across the
vertebral body in order to feel the tip of the penetrated screw and to
make sure that it does not protrude more than three or four millimeters beyond the vertebral body.
VOL. 79-A, NO. 1, JANUARY 1997

Ikakogyo, Tokyo, Japan) was used. The Mark-II model

of the Kaneda device (with rod couplers) was used in
the ninety-six patients who were managed since June
1984. The relationship of the direction of the screws and
the vertebral plate was triangular, and the screws had to
penetrate the contralateral cortex (Fig. 1-D). Kyphosis
was corrected by use of a spreader device applied to the
heads of the two anterior screws (Fig. 1-E). Correction
of the kyphosis was judged by checking the arrangement of the end plates of the vertebrae cephalad and
caudad to the vertebrectomy. In patients who had late
presentation of kyphosis, the anterior longitudinal ligament was often scarred and needed to be sectioned at
the level of the disc.
After the kyphosis was corrected, the length of the

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KIYOSHI K A N E D A E T AL.

FIG. 1-E

Kyphosis is corrected with use of a spreader device applied to the heads of the two anterior screws. The tricortical iliac-crest graft and two
or three pieces of rib are placed as a strut into the vertebrectomy gap.

gap was measured from vertebral end plate to vertebral

end plate and a tricortical iliac-crest graft was obtained.
The defect of the iliac crest was reconstructed with a
ceramic substitute (bioactive apatite-wollastonite glassceramic; Nippon Electric Glass, Ootsu, Japan)2. The tricortical iliac-crest graft and two or three struts of rib
were placed into the defect created by the distracted
vertebral resection. In the first 109 patients, the bone
grafts were placed with the tricortical portion adjacent
to the instrumentation. In the forty-one patients who
had the operation in 1987 or later, the tricortical portion
of the iliac-crest graft was inserted opposite the Kaneda
plate, near the contralateral pedicles (Fig. 1-F). Bone
chips from the resected vertebral body were packed into
the gap between the iliac-crest graft and the anterior
vertebral wall (Fig. 1-F).

FIG. 1-F

The tricortical portion of the iliac-crest graft is inserted in the

frontal plane beyond the contralateral pedicles. Bone chips from the
resected vertebral body are packed into the gap between the iliaccrest graft and the anterior vertebral wall.

FIG. 1-G

After bone-grafting, threaded rods and two sets of the rod couplers are applied.
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ANTERIOR DECOMPRESSION AND STABILIZATION WITH THE KANEDA DEVICE

TABLE VI
SCORES ACCORDING TO THE LOWER-EXTREMITY MOTOR INDEX 1 '

Scoref (Points)
Preoperative
Postoperative

No. of
Patients*
Involved neural
element
Spinal cord
Cauda equina
Time from injury
to operation
Within one month
More than one
month
Onset of neurological
deficit
Immediately after
injury
Delayed onset

35
102

33 (0-49)
45 (25-49)

40 (0-50)$
49 (40-50)t

81
56

41 (0-48)
42 (0-49)

48 (0-50)
48 (0-50)

124

43 (0-47)

47 (0-50)f

13

45 (35-49)

49 (43-50)1

"Thirteen patients who had pure conus medullaris syndrome were

excluded.
fThe values are given as the mean, with the range in parentheses.
^Significantly different (p < 0.01; Welch t test).
Not significantly different.
INot significantly different.

After bone-grafting, threaded rods and two sets

of rod couplers were applied (Fig. 1-G). When there
was a potential for compression of the aorta by an
implant located at the eleventh thoracic level (three
patients), the implants were covered with a Teflon (polytetrafluoroethylene) sheet. The wound was then closed
and drained in the standard fashion. A chest tube was
not necessary for most of the patients who had been
managed with the extrapleural and retroperitoneal approach. The pleura was checked for air leaks by pouring
saline solution into the extrapleural retroperitoneal
space just before wound closure. A chest tube was
used in nine (10 per cent) of the ninety-three patients
who had a burst fracture of the twelfth thoracic or first
lumbar vertebra and in whom the pleura had been
injured. No chest tube was used in the patients who
had a burst fracture of the second, third, or fourth

lumbar vertebra. No postoperative pneumothorax occurred in any of the patients who did not have a chest
tube.
Postoperative Care
At four to seven days after the operation, the patients were encouraged to walk with a polypropylene
thoracolumbosacral orthosis, which was worn for twenty
to twenty-four weeks. Eleven patients who had a delayed union or a pseudarthrosis wore the brace for more
than six months. The patients were taught to continue
active isometric exercises of the trunk muscles while
wearing the thoracolumbosacral orthosis. After removal
of the brace, the patients who were not manual laborers were allowed to perform the normal activities of
daily living without any special restrictions. The manual
laborers returned to their jobs six to eight months postoperatively.
Follow-up
The mean duration of follow-up was eight years
(range, five years to twelve years and eleven months).
The latest clinical and radiographic evaluations were
conducted by two of us (H. T. and T. H.) who had not
participated in the original operation.
Statistical Analysis
Statistical analyses were performed with use of the
Welch t test or the Student t test. A p value of less than
0.05 was considered to be significant.
Results
Neurological Recovery
None of the patients had neurological deterioration
after the anterior decompression and stabilization. The
patients stayed at our hospitals and at our affiliated
rehabilitation hospitals for an average of twenty-four
days (range, eleven to fifty-six days) after the operation.

TABLE VII
RECOVERY OF FUNCTION OF THE BLADDER AND BOWEL AT THE LATEST FOLLOW-UP EXAMINATION*

Level of Recovery
Complete!
(n = 56)
Incompleted
(n = 9)
None
(n = 13)
Total
(n = 78)

Type of Neurological Lesion

Pure Conus
Medullaris
Syndrome

Conus
Medullaris and
Cauda Equina

Cauda
Equina

28

17

13

33

12

Cephalad to
Epiconus

Epiconus

10

*The values are given as the number of patients.

| T h e function of the bladder was normal.
t-The patient had occasional incontinence but no need for self-catheterization.
The patient needed catheterization.
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KIYOSHI K A N E D A E T AL.

Figs. 2-A through 2-F: A forty-eight-year-old man sustained a burst fracture of the first lumbar vertebra with compression of the conus
medullaris and the cauda equina. He had paralysis of the bladder and bowel, and neurological function was given a grade of C, according to a
modification of the system of Frankel et al/\
Fig. 2-A: Preoperative myelogram.
Fig. 2-B: Preoperative myelographic tomogram.

The patients who had residual motor dysfunction that

was severe (grade A in two patients and grade C in three
patients postoperatively) needed a longer period of hospitalization for rehabilitation. The neurological function
of 142 (95 per cent) of the 150 patients had improved at
least one grade (Table V). Eight patients (5 per cent)
had not recovered any neurological function at the time
of the latest follow-up evaluation. Preoperatively and
postoperatively, the neurological function of two of
these patients, who had a burst fracture of the twelfth
thoracic vertebra, was grade A; that of one patient, who
had fracture of the first lumbar vertebra, was grade C;
and that of five patients, who had a fracture of the first
lumbar vertebra, was grade D l (Table V). Two of these
eight patients had sustained the spinal cord lesion cephalad to the epiconus; one, in the epiconus; and five, in
the conus medullaris. Preoperatively, all eight patients
had had complete loss of function of the bladder and
the bowel with anesthesia of the perineal area.
All seven patients who had been managed with
a posterior procedure before the anterior procedure
was performed showed some neurological recovery at

the time of the follow-up evaluation. One patient had

improvement from grade C to grade D2; one, from
grade D l to D2; one, from grade D l to E; three, from

FIG. 2-C

Preoperative computed-tomography scan.

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77

FIG. 2-D
FIG. 2-E
Radiographs made seven years and ten months after anterior decompression and arthrodesis with the Mark-II Kaneda device, which was
performed in 1986. Although the patient had complete recovery of motor function, mild dysfunction of the bladder and bowel persisted (grade
D2, according to the modified system of Frankel et al.6), despite complete decompression.

grade D2 to E; and one, from grade D3 to E.

The difference between the preoperative and postoperative scores on the motor-index scale was larger for
the group that had a lesion of the spinal cord than for
the group that had a lesion of the cauda equina (p <
0.01), but the final score was higher for the group that
had a lesion of the cauda equina (Table VI). With the
numbers available, we could not detect a significant association between the interval from the injury to the
operation and the amount of postoperative neurological
recovery.
Thirteen patients who had no recovery of bladder
function had had no sensation to pinprick in the perineal area preoperatively (Table VII). The patients who
had had decreased sensation to pain in the perineal area
preoperatively had incomplete or complete recovery of
bladder function.

strenuous work, and thirty-six (24 per cent) were unemployed. The unemployed patients included eleven (7 per

Functional Results
At the most recent follow-up examination, 101 patients (67 per cent) had returned to their previous occupation, thirteen (9 per cent) had changed to less
VOL. 79-A, NO. 1, JANUARY 1997

FIG. 2-F
Computed tomography scan made seven months after the operation.

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KIYOSHI K A N E D A ET AL.

TABLE
CLINICAL RESULTS OF SHORT-

Authors

No. of
Patients
(No. with
Neurol.
Deficit)

Duration of
Follow-up*
(Mos.)

Level of
Injury

T9-L3
T12-L4
L3-L5
T12-L5
L1-L4
L1-L4
T10-L5
T12-L4
L1-L4

Posterior instrumentation
(pedicular screw system)
Esses et al.M
Ebelkeetal. 1 3
Sasso et al.-10

22(3)
13 (2)
7(5)

20.1 (12-34)
17.0(4-32)
20.0(5-31)

Carl et al.7
Stephens et al.32
McNamara et al.29
Benson et al.5
McLain et al.28
Viale et al.33

38(9)
16(3)
13(6)
25 (12)
14 (?)
27 (27)

22.7 (12-39)
18.9(11-35)
22.5 (8-42)
22.0 (12-38)
15.0 (4-28)
18.7

Anterior instrumentation
Dunn 12
Kostuik24

48 (40)
63 (?)

Haas et al.1"

18 (?)

Been4
Present study

29 (10)
150(150)

T4-L5
T4-L5

37.0(21-61)
100.0 (60-155)

T6-L4

Type of
Implant

AO intern, fix.
Steffee VSP
Dyn. compres.
plate
Cotrel-Dubousset
Cotrel-Dubousset
Steffee VSP
AO intern, fix.
Cotrel-Dubousset
Post. seg. device
and Steffee VSP
Dunn
KostuikHarrington
Dyn. compres.
device and
specially
contoured
spinal plale
Slot-Zielke
Kaneda

No. of
Segments in
Arthrodesis*

Interval
from Injury
to Op.
(Days)

2.0 (2-2)
2.0 (2-2)
3.3 (2-6)

3.0

2.2 (2-4)
2.7 (2-4)
2.2 (2-4)
2.0 (2-3)
2.7 (2-4)

5.5

0-4

0-21
0-3

8.6

1.9(1-4)

2.0
2.0 (1-3)

0-30
0-7 yrs.

*The values are given as the mean, with the range in parentheses.
fPatients who had a neurological improvement of one grade 6 or more. Those who had a preoperative grade of A were excluded.
tThe value is the mean improvement.
The values represent the findings for the fractures of the twelfth thoracic and first lumbar vertebrae followed by those for the second, third,
and fourth lumbar vertebrae.

cent) who had reached retirement age after returning to

their previous occupation, seven (5 per cent) who had
retired before the operation, five (3 per cent) who had
paraplegia or paraparesis (incontinence), ten (7 per
cent) who were managed for schizophrenia before and
after the operation, and three (2 per cent) who had
alcoholism. Twenty patients (13 per cent) had not been
working preoperatively. Therefore, 125 (96 per cent) of
the 130 patients who had been employed before the
injury returned to work after the operation; 112 (86 per
cent) of those 130 patients returned to their previous
jobs at full capacity. Patients who had performed light
labor returned to work with the aid of a brace a mean
of three months (range, one to five months) after the
operation. Patients who had performed heavy labor returned to work with or without the aid of a brace a mean
of seven months (range, six to nine months) after the
operation.
Pain in the back was assessed at the most recent
follow-up examination with use of the pain scale of
Denis". One hundred and fifteen patients (77 per cent)
were given a rating of PI (no pain); twenty-one (14 per
cent), a rating of P2 (occasional slight pain with no need

for medication); ten (7 per cent), a rating of P3 (moderate pain with a need for occasional medication but no
interruption of work or major change in activities of
daily living); four (3 per cent), a rating of P4 (moderateto-severe pain with a need for frequent medication and
occasional absence from work or a major change in
activities of daily living); and none were given a rating
of P5 (constant or severe incapacitating pain and a
chronic need for medication). The four patients who had
a rating of P4 were receiving workers' compensation
and demonstrated a complete neurological recovery.
Radiographic Results
The percentage of the spinal canal that was obstructed was evaluated before and after the operation
(Table II).
The fusion at the site of the three-level arthrodesis
was evaluated on lateral flexion-extension radiographs
and tomograms. A pseudarthrosis developed in six (11
per cent) of the fifty-four patients who had fixation with
the Kaneda Mark-I device (without rod couplers); two
of these patients had had a fracture of the second lumbar vertebra, two had had a fracture of the third lumbar
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79

A N T E R I O R D E C O M P R E S S I O N AND STABILIZATION WITH T H E KANEDA D E V I C E

VIII
SEGMENT ARTHRODESIS

Neurol.
Improve.t
(Per cent)

100

Obstruction of
Canal (Per cent)
Preop.
Postop.

45

17

80
100
100
83
92

43
71
72
42

28

100

Preop.

Kyphosis (Degrees)
Latest
FollowPostop.
up

18.2
15.0
-11.8

3.5
0
-21.7

6.2
4.9
16.0

-0.6
4.0
-4.0

14.2

-8.5

100
1.6
grades^
50

90
96

6.7
8.0
-1.1.1

11.2
12.7
5.0
8.3

Failure
Loss of
Correct.

f. ' NonUnion
(Per cent) (Per cent)
o

" " '

Implant

2.7
8.0
10.6

.9
5*
14

0
15
0

6.5
11.9

24
50
46
25
53
1.9

0
0
0
0

8.7
9.7
7.4

Pain
Relief
(Per cent)

Return to
Work
(Per cent)

76
69
85
67
58

69
94
69

90

94

91

96

7.0

48, 60S

2, 1

19

vertebra, and two had had a fracture of the fourth lumbar vertebra. A pseudarthrosis developed in four (4 per
cent) of the ninety-six patients who had fixation with
the Kaneda Mark-II device (with rod couplers); one of
these patients had had a fracture of the first lumbar
vertebra, two had had a fracture of the fourth lumbar
vertebra, and one had had a two-level fracture at the
second and third lumbar vertebrae. Over-all, fusion was
achieved in 140 (93 per cent) of the patients. A pseudarthrosis developed in four of five patients who had
had a burst fracture of the fourth lumbar vertebra. The
mean height, body weight, and duration of hospitalization after the operation of the patients who had a
pseudarthrosis were 165 centimeters, sixty-eight kilograms, and twenty-two days, respectively. These values
were not significantly different from those for the patients who did not have a pseudarthrosis (p = 0.70, Student t test). All ten patients who had a pseudarthrosis
had a successful repair with a posterolateral arthrodesis
and posterior instrumentation, and all had a solid fusion
at the most recent follow-up examination.
Kyphosis was measured by the angle between the
superior end plate of the vertebral body cephalad to the
injury and the inferior end plate of the vertebral body
caudad to the injury. This measurement was not performed for eighteen patients who had a burst fracture
VOL. 79-A, NO. 1, JANUARY 1997

5.0
1.0

24
6

of the third or fourth lumbar vertebra because of the

lack of a preoperative kyphotic deformity. The average
kyphosis for the remaining 132 patients was 19 degrees
preoperatively, 7 degrees at the time of discharge from
the hospital, and 8 degrees at the most recent follow-up
examination.
Complications
Seven of the ten patients who had a pseudarthrosis
reported back pain and three did not; none of them
showed neurological deterioration. Complications other
than pseudarthrosis included failure of the device in
nine patients who had a pseudarthrosis (breakage of a
screw or screws in eight patients and breakage of the
screws and the rod in one) intraoperative laceration of
the inferior vena cava in one patient who had an old
burst fracture of the second lumbar vertebra with severe
kyphosis, a deep wound infection in one, a superficial
wound infection in three, postoperative urinary-tract infection in three, postoperative atelectasis in ten, transient dysesthesia in the distribution of the genitofemoral
nerve in five, and sympathectomy effect on the ipsilateral lower extremity in fifteen patients who had had
exposure of the fourth or fifth lumbar vertebra, or both.
All four postoperative infections were treated successfully with intravenous administration of antibiotics

80

KIYOSHl KANEDA ET AL.

FIG. 3-A
Figs. 3-A through 3-D: A twenty-three-year-old man sustained a
burst fracture of the fourth lumbar vertebra associated with injury of
the cauda equina.
Fig. 3-A: Preoperative tomogram.

direct6232426 or indirect"415. Indirect decompression is accomplished with use of posterior instrumentation, with
reliance on distraction, correction of any kyphosis, and
ligamentotaxis to clear the canal of the displaced anterior bone and soft tissues. Ligamentotaxis is not always
successful, and it has been reported that, at best, this
method produces incomplete decompression of the spinal canal8. With use of ligamentotaxis, Bradford and
McBride found that the mean percentage of stenosis of
the spinal canal, as determined with computed tomography scanning, was 26 per cent (range, 0 to 50 per cent)
postoperatively6. If ligamentotaxis is to be successful,
the technique should be performed within forty-eight to
ninety-six hours after the injury8. Crutcher et al.' reported that type-B fractures, according to the classification system of Denis10, were often resistant to indirect
reduction by ligamentotaxis, resulting in an incomplete
decompression of the spinal canal.
Many investigators have found that better results
can be obtained with direct removal of the retropulsed
fragments and soft-tissue debris from the spinal canal6122324. One of the two methods of direct decompression is a transpedicular decompression through
pedicular resection. It is difficult to decompress the far
side of the canal with unilateral posterior transpedicular
decompression, and there is a risk of iatrogenic neurological injury or incomplete decompression32028. Bilateral transpedicular decompression provides increased
exposure of the canal, but it also increases vertebral
instability3. A few of the reported series in which transpedicular decompression and cancellous bone-grafting
to the fractured body by means of the transpedicular
approach were used have shown good results with slight
loss of correction of the kyphosis, low rates of implant
failure, and no increase in neurological complications13.
However, it is difficult to conceive how a cancellous

(cephalosporin) for two to four weeks. The sympathectomy effects, which subsided spontaneously without any
treatment within six to twelve months postoperatively,
were hotness (twelve patients) and dryness (three patients) of the lower extremity, including the foot, on the
side of the operation. None of the patients had an iatrogenic neurological injury, retrograde ejaculations, late
vascular injury, or loosening of the hardware other than
the nine patients who had pseudarthrosis and failure of
the device. None of the implants needed to be removed.
Discussion
The indication for decompression of the spinal canal
in patients who have a thoracolumbar burst fracture is
a neurological deficit with radiographic evidence of obstruction of the spinal canal (Figs. 2-A through 2-F). The
compressive tissues after a thoracolumbar burst fracture are invariably located in the anterior portion of the
spinal canal. Decompression of the spinal canal can be

FIG.

3-B

Preoperative computed-tomography scan.

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A N T E R I O R DECOMPRESSION AND STABILIZATION WITH T H E K A N E D A D E V I C E

81

FIG. 3-C
FIG. 3-D
Computed tomography scans made twelve months after anterior decompression and arthrodesis with the Mark-II Kaneda device.
Neurological recovery was complete, but a pseudarthrosis developed because of insufficient resection of the crushed vertebral body. The
iliac-crest strut graft had been improperly positioned as it had not been placed beyond the contralateral pedicle (arrows), and it caused
asymmetrical axial loading and breakage of the screw. Posterior arthrodesis with instrumentation was subsequently performed, and there was
a solid fusion anteriorly and posteriorly six months after that operation.

non-structural graft through the pedicle provides any

additional support to the anterior column, which might
collapse with early loading before incorporation of the
graft. With a longer duration of follow-up and a larger
series, it is possible that the expected failure of instrumentation and loss of correction of the kyphosis due to
an unstable anterior column would become evident.
Newer instrumentation systems that include pedicle
screws have allowed a decrease in the number of fused
segments and greater correction of kyphosis. Despite
these advantages, failure to support the anterior spinal
column after posterior correction and instrumentation
has led to the failure of the posterior spinal instrumentation in many patients'3283032.
The second method of direct decompression is an
anterior approach with partial or complete resection of
the vertebral body232426. This anterior decompression has
to be combined either with anterior stabilization and
instrumentation (a one-stage anterior procedure)122324
or with posterior instrumentation and arthrodesis (a
VOL. 79-A, NO. 1, JANUARY 1997

combined anterior and posterior procedure)26.

We reviewed the clinical results that have been reported for short-segment pedicle-screw fixation (with
the screws placed one level cephalad and one level caudad to the fracture) and for other anterior decompression procedures in the treatment of thoracolumbar
burst fractures (Table VIII). The loss of correction of
kyphosis and the rate of failure of instrumentation were
greater in the series that had fixation with pedicular
5,7.13.14.28-30,32.33 than in our series. The mean loss of
screws
correction of kyphosis ranged from 3 to 12 degrees in
the reported series that we reviewed, whereas the mean
loss of correction in our series was only 1 degree. The
rate of failure of posterior instrumentation ranged from
9 to 54 per cent in the other series, whereas the rate was
6 per cent in the present report. Failure of pedicle screw
fixation included breakage, bending, or loosening of the
screw because of inadequate support of the anterior
column13282932. Despite the high rates of failure of the
instrumentation in the series that had pedicle screw fix-

82

KIYOSHI KANEDA ET AL.

ation, the rate of non-union was surprisingly low (0 per

cent) except for that reported by Ebelke et al. (15 per
cent)13.
The rate of failure of the Kaneda device depends on
proper positioning of the anterior strut graft consisting
of tricortical iliac-crest bone and two or three sections
of rib. Biomechanical studies of the Kaneda device
have shown adequate stability for most loading situations11831,34. With respect to height, body weight, and
duration of hospitalization after the operation, we detected no significant difference (with the numbers available) between the group that had a solid fusion and the
group that had a pseudarthrosis. All pseudarthroses occurred in patients who had had poor placement of the
anterior strut graft. The graft had not provided stable
and symmetrical anterior load-sharing in the spinal column because of placement of the cortical portion of the
iliac-crest strut graft on the same side as the Kaneda
device. Consequently, we think that one of the most
important factors that cause pseudarthrosis is the use of
poor technique for the placement of the anterior strut
bone graft (Figs. 3-A through 3-D). The Kaneda device
relies directly on load transmission through a stout,
strong tricortical iliac-crest graft for secure fixation.
Since 1987, we have used our present technique of
placement of the anterior strut graft with the tricortical
portion beyond the contralateral pedicle (Fig. 1-F) in
fifty-one patients; pseudarthrosis developed in only one
patient. Failure of the Kaneda device may be more of a
problem for heavier, non-Japanese populations if anterior strut-grafting does not provide adequate supplemental support. We also noted that a larger percentage
of pseudarthroses occurred with burst fractures of the
fourth lumbar vertebra (four of five patients). The increased rate of pseudarthrosis at this level is most likely
related to the difficulty in providing a sufficient amount
of bone graft as well as to the large strut graft that is
needed to bridge the third, fourth, and fifth lumbar ver-

tebrae. The location of the fourth lumbar vertebral body

and the shape of the fifth lumbar vertebral body make
instrumentation technically more demanding. Because
of the high rate of non-union of burst fractures of the
fourth lumbar vertebra, we have not treated this fracture with anterior fixation since 1985.
In our series, the most important predictive factor
with regard to neurological recovery was an injury
involving the epiconus or conus medullaris. For patients who had such an injury, a complete lack of bladder function with loss of sensation to pinprick in the
perineal area preoperatively was indicative of a poor
prognosis for recovery of bladder function. Complete
paralysis of the bladder associated with incomplete sensation of pain in the perineal area was associated with
a better prognosis for recovery of bladder function after
decompression.
It is important to note that, although the operation
was performed more than forty-eight hours after the
injury in 143 (95 per cent) of our patients, the neurological recovery was acceptable. Thus, we believe that when
anterior decompression of the spinal canal is performed
in patients who have a thoracolumbar burst fracture
with neurological deficits, recovery of neurological function is not always dependent on the timing of the operative intervention.
The goals of an operation for a thoracolumbar burst
fracture with associated neurological deficits should be
decompression of the spinal canal, restoration of spinal
alignment, and successful arthrodesis of the injured spinal segments. These goals were accomplished in more
than 90 per cent of our patients, who had low perioperative and postoperative rates of complications. We
attribute our excellent results to the use of the anterior approach, the design of the Kaneda device, and our
close attention to operative details.
N o m The authors wish to acknowledge Paul C. McAfee, M.D., of the Spine and Scoliosis
Center in Baltimore. Maryland, for his help in reviewing and editing this manuscript.

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