Comparison of combined posterior and anterior spondylodesis versus hybrid stabilization in unstable burst fractures at the thoracolumbar spine in patients between 60 and 70 years of age

Hybrid kyphoplasty with short-versus intermediate- and long-segment pedicle screw fixations for the management of thoracolumbar burst fractures

BACKGROUND

This study aimed to determine if the hybrid short-segment (HSS) technique is a good alternative to the intermediate-segment (IS) and long-segment (LS) techniques in pedicle screw fixations for acute thoracolumbar burst fractures (TLBFs).

METHODS

In this retrospective evaluation, we examined 43 patients who underwent surgical treatments, including one- or two-level suprajacent (U) and infrajacent (L) pedicle screw fixations, for acute single-level TLBFs with neurological deficits between the T11 and L2 levels from July 2013 to December 2019. Among these patients, 15 individuals underwent HSS (U1L1), 12 received IS (U2L1), and 16 underwent LS (U2L2) fixations. Supplemental kyphoplasty of the fractured vertebral bodies was performed exclusively in the HSS group. Our analysis focused on assessing blood loss and surgical duration. Additionally, we compared postoperative thoracolumbar kyphotic degeneration using the data on Cobb angles on lateral radiographic images acquired at three time points (preoperatively, postoperative day 1, and follow-up). The end of follow-up was defined as the most recent postoperative radiographic image or implant complication occurrence.

RESULTS

Blood loss and surgical duration were significantly lower in the HSS group than in the IS and LS groups. Additionally, the HSS group exhibited the lowest implant complication rate (2/15, 13.33%), followed by the LS (6/16, 37.5%) and IS (8/12, 66.7%) group. Implant complications occurred at a mean follow-up of 7.5 (range: 6-9), 9 (range: 5-23), and 7 (range: 1-21) months in the HSS, IS, and LS groups. Among these implant complications, revision surgeries were performed in two patients in the HSS group, two in the IS group, and one in the LS group. One patient treated by HSS with balloon kyphoplasty underwent reoperation because of symptomatic cement leakage.

CONCLUSIONS

The HSS technique reduced intraoperative blood loss, surgical duration, and postoperative implant complications, indicating it is a good alternative to the IS and LS techniques for treating acute single-level TLBFs. This technique facilitates immediate kyphosis correction and successful maintenance of the corrected alignment within 1 year. Supplemental kyphoplasty with SpineJack® devices and high-viscosity bone cements for anterior reconstruction can potentially decrease the risk of cement leakage and related issues.

Treatment and Outcome of Osteoporotic Thoracolumbar Vertebral Body Fractures With Deformation of Both Endplates With or Without Posterior Wall Involvement (OF 4): Short-Term Results from the Prospective EOFTT Multicenter Study

STUDY DESIGN

Multicenter prospective cohort study.

OBJECTIVE

To analyse therapeutical strategies applied to osteoporotic thoracolumbar OF 4 injuries, to assess related complications and clinical outcome.

METHODS

A multicenter prospective cohort study (EOFTT) including 518 consecutive patients who were treated for an Osteoporotic vertebral compression fracture (OVCF). For the present study, only patients with OF 4 fractures were analysed. Outcome parameters were complications, Visual Analogue Scale, Oswestry Disability Questionnaire, Timed Up & Go test, EQ-5D 5L, and Barthel Index after a minimum follow-up of 6 weeks.

RESULTS

A total of 152 (29%) patients presented with OF 4 fractures with a mean age of 76 years (range 41-97). The most common treatment was short-segment posterior stabilization (51%; hybrid stabilization in 36%). Mean follow up was 208 days (±131 days), mean ODI was 30 ± 21. Dorsoventral stabilized patients were younger compared to the other groups (P < .001) and had significant better TuG compared to hybrid stabilization (P = .049). The other clinical outcomes did not differ in the therapy strategies (VAS pain: P = 1.000, ODI: P > .602, Barthel: P > .252, EQ-5D 5L index value: P > .610, VAS-EQ-5D 5L: P = 1.000). The inpatient complication rate was 8% after conservative and 16% after surgical treatment. During follow-up period 14% of conservatively treated patients and 3% of surgical treated patients experienced neurological deficits.

CONCLUSIONS

Conservative therapy of OF 4 injuries seems to be viable option in patients with only moderate symptoms. Hybrid stabilization was the dominant treatment strategy leading to promising clinical short-term results. Stand-alone cement augmentation seems to be a valid alternative in selected cases.

Effect of subsequent vertebral body fractures on the outcome after posterior stabilization of unstable geriatric fractures of the thoracolumbar spine

PURPOSE

The purpose of this study was analyzing the effect of subsequent vertebral body fractures on the clinical outcome in geriatric patients with thoracolumbar fractures treated operatively.

METHODS

Retrospectively, all patients aged ≥ 60 with a fracture of the thoracolumbar spine included. Further inclusion parameters were acute and unstable fractures that were treated by posterior stabilization with a low to moderate loss of reduction of less than 10°. The minimal follow-up period was 18 months. Demographic data including the trauma mechanism, ASA score, and the treatment strategy were recorded. The following outcome parameters were analyzed: the ODI score, pain level, satisfaction level, SF 36 score as well as the radiologic outcome parameters.

RESULTS

Altogether, 73 patients were included (mean age: 72 years; 45 women). The majority of fractures consisted of incomplete or complete burst fractures (OF 3 + 4). The mean follow-up period was 46.6 months. Fourteen patients suffered from subsequent vertebral body fractures (19.2%). No trauma was recordable in 5 out of 6 patients; 42.8% of patients experienced a low-energy trauma (significant association: p < 0.01). There was a significant correlation between subsequent vertebral body fracture and female gender (p = 0.01) as well as the amount of loss of reduction (p = 0.02). Thereby, patients with subsequent vertebral fractures had significant worse clinical outcomes (ODI: 49.8 vs 16.6, p < 0.01; VAS pain: 5.0 vs 2.6, p < 0.01).

CONCLUSION

Patient with subsequent vertebral body fractures had significantly inferior clinical midterm outcome. The trauma mechanism correlated significantly with both the rate of subsequent vertebral body fractures and the outcome. Another risk factor is female gender.

Effectiveness and postoperative rehabilitation of one-stage combined anterior-posterior surgery for severe thoracolumbar fractures with spinal cord injury

BACKGROUND

Thoracolumbar fractures are generally combined with spinal cord injury to varying degrees, which may cause deterioration of the patients' condition and increase the difficulty of clinical treatment. At present, anterior or combined anterior-posterior surgery is preferred for severe thoracolumbar fractures.

AIM

To investigate the effectiveness and postoperative rehabilitation of one-stage combined anterior-posterior surgery for severe thoracolumbar fractures with spinal cord injury.

METHODS

One-hundred-and-twenty patients who received surgery for severe thoracolumbar fractures with spinal cord injury at our hospital from February 2018 to February 2020 were randomly enrolled. They were randomly divided into group 1 (one-stage combined anterior-posterior surgery, n = 60) and group 2 (one-stage anterior-approach surgery, n = 60). Treatment efficacy was compared between the two groups.

RESULTS

Blood loss was greater and the operation time was longer in group 1 than in group 2, and the differences were statistically significant (P < 0.05). Incision length, intraoperative X-rays, and length of hospital stay were not significantly different between the two groups (P > 0.05). Preoperative function of the affected vertebrae was not significantly different between the two groups (P > 0.05). In each group, the patients showed significant improvement after surgery. The anterior vertebral height ratio and the posterior vertebral height ratio in group 1 after surgery were significantly higher than those in group 2. The Cobb angle after surgery was significantly lower in group 1 than in group 2 (P < 0.05). The canal-occupying ratio of the affected vertebrae was not significantly different between the two groups (P > 0.05). Before surgery, there was no significant difference in the quality of life scores between the two groups (P > 0.05). The above indicators were significantly improved after surgery compared with before surgery in each group. In addition, these indicators were markedly better in group 1 than in group 2 after surgery (P < 0.05 for each).

CONCLUSION

One-stage combined anterior-posterior surgery effectively improves the function of the affected vertebrae and the life quality of patients with severe thoracolumbar fractures and spinal cord injury. This surgical approach is worthy of popularization in clinical use.

Comparison of clinical effectiveness of fenestrated and conventional pedicle screws in patients undergoing spinal surgery: a systematic review and meta-analysis

INTRODUCTION

Pedicle screws are commonly used for spinal procedures for fusion stability, which is particularly important in osteoporotic patients, who are at an increased risk of requiring revision procedures.

AREAS COVERED

A systematic review and meta-analysis were conducted to compare clinical effectiveness of conventional pedicle screws (CPS) vs fenestrated pedicle screws (FPS) in patients undergoing spinal surgery. Primary outcomes included screw loosening, revision surgeries (involving an implant) and reoperations (not involving intervention on an implant) in patients treated with CPS vs FPS, sub-stratified by with and without osteoporosis. Secondary outcomes included changes in pain scores. Forty-eight studies with 8,302 patients were included, with 1,565 (19.18%) treated with FPS and 6,710 (80.82%) treated with CPS. FPS was associated with a lower risk of screw loosening (p = 0.001) vs CPS. In the general population, there was a non-significant trend of lower revision rate, but no difference in reoperation rate, between patients treated with FPS vs CPS. In osteoporotic patients, revision rates were significantly lower for FPS vs CPS (p = 0.009).

EXPERT OPINION

This review suggests that FPS are effective for surgical fixation and reduce rates of screw loosening, and in osteoporotic patients, revision surgeries, compared to CPS.

Multicenter evaluation of therapeutic strategies of inpatients with osteoporotic vertebral fractures in Germany

PURPOSE

The aim of this study was to assess therapeutic strategies of inpatients with osteoporotic thoracolumbar fractures (OTF) in Germany.

METHODS

Prospective multi-center study including 16 German-speaking trauma centers over a period of 7 months. All inpatients with OTF were included. Radiological and clinical data on admission and treatment modalities were assessed.

RESULTS

Seven hundred and seven (99.3%) out of 712 included patients (73.3% female) could be evaluated. Mean age was 75 years (30-103). 51.3% could not remember any traumatic incident. Fracture distribution was from T2 to L5 with L1 (19%) most commonly affected. According to the Magerl classification type A1 (52.1%) and A3 (42.7%) were most common. B and C type injuries (2.6%) and neurological deficits (3.1%) were rare. Previous progression of vertebral deformation was evident in 34.4% of patients and related to t score below - 3 (Odds ratio 1.9661). Patients presented with anticoagulation medication (15.4%), dementia (13%), and ASA score > 3 (12.4%) frequently. 82.3% of patients complained of pain > 4 on VAS, 37% could not be mobilized despite pain medication according to grade II WHO pain ladder. 81.6% received operative treatment. Kyphoplasty (63.8%) and hybrid stabilization including kyphoplasty with (14.4%) or without screw augmentation (7.6%) were the techniques most frequently used. Invasiveness of treatment increased with degree of instability.

CONCLUSIONS

OTF are mostly type A compression fractures. Patients suffer from severe pain and immobilization frequently. Progression of deformity is correlated to t score below - 3. Treatment of inpatients is mainly surgical, with kyphoplasty followed by hybrid stabilization as commonly used techniques.

Treating Lumbar Fracture Using the Mixed Reality Technique

The mixed reality (MR) technique has recently been widely used in the orthopedic surgery with satisfactory results reported. However, few studies have focused on the application of MR in the Lumbar fracture (LF). In this retrospective study, our aim is to analyze some findings by investigating the feasibility of MR applied to lumbar fracture treatment. Posterior vertebrectomy has been operated on 7 patients. The MR–based intraoperative three-dimensional image-guided navigation system (MITINS) was used to assist implantation of pedicle screws. The feasibility and safety of pedicle screw implantation were assessed by postsurgery radiography. The visual analog scale (VAS) and Oswestry Disability Index (ODI) were used to assess the pain level and recovery situation before and after surgery. 57 pedicle screws were safely and precisely placed into three-dimensional lumbar models by using MITINS. No screw was found outside the pedicle of the models, and it was not necessary for the X-ray to provide extra locative information during the operation with the use of MITINS. In summary, the application of MITINS is feasible, safe, and accurate while the lumbar fracture surgery is processing, providing satisfactory assistance for spine surgeons.

[Minimally invasive stabilization of thoracolumbar osteoporotic fractures]

BACKGROUND

Minimally invasive stabilization of thoracolumbar osteoporotic fractures (OF) in neurologically intact patients is well established. Various posterior and anterior surgical techniques are available. The OF classification and OF score are helpful for defining the indications and choice of operative technique.

OBJECTIVE

This article gives an overview of the minimally invasive stabilization techniques, typical complications and outcome.

MATERIAL AND METHODS

Selective literature search and description of surgical techniques and outcome.

RESULTS

Vertebral body augmentation alone can be indicated in painful but stable fractures of types OF 1 and OF 2 and to some extent for type OF 3. Kyphoplasty has proven to be an effective and safe procedure with a favorable clinical outcome. Unstable fractures and kyphotic deformities (types OF 3-5) should be percutaneously stabilized from posterior. The length of the pedicle screw construct depends on the extent of instability and deformity. Bone cement augmentation of the pedicle screws is indicated in severe osteoporosis but increases the complication rate. Restoration of stability of the anterior column can be achieved through additional vertebral body augmentation or rarely by anterior stabilization. Clinical and radiological short and mid-term results of the stabilization techniques are promising; however, the more invasive the surgery, the more complications occur.

CONCLUSION

Minimally invasive stabilization techniques are safe and effective. The specific indications for the individual procedures are guided by the OF classification and the individual clinical situation of the patient.

[Hybrid stabilization and geriatric complex treatment of type A spinal fractures]

Approximately 200,000 spinal fractures occur each year in Germany. The decimated stability of the vertebra often leads to type A fractures with a substantial influence by osteoporosis. A mobility preserving and gentle treatment has clear advantages compared to conservative treatment. The hybrid stabilization as a combination of minimally invasive dorsal stabilization and vertebral augmentation has become an established method. In the period from July 2014 to June 2015 a total of 205 spinal operations were documented. In the group of very old patients more than 80% were treated for a geriatric type A vertebral fracture, 24 with hybrid stabilization, 5 by percutaneous bisegmental, 22 by kyphoplasty stabilization and 13 by percutaneous polysegmental procedures. Furthermore, these 4 groups were also considered with respect to the treatment in geriatric trauma centers (GTC). The 4 forms of treatment achieved a mean remuneration of 11,238.77 €. For the individual treatment form of kyphoplasty there was an increase in the remuneration of 4276.54 €, when patients undergo geriatric complex treatment and the remuneration is according to the diagnosis-related groups (DRG) classification I34Z. In the field of operative treatment of geriatric vertebral fractures, the augmentative procedures of kyphoplasty and vertebroplasty are well-established but an injury-related involvement of adjacent spinal segments and continuity fractures are frequent occurrences so that a bisegmental hybrid stabilization is advantageous. In addition, the perioperative stress in hybrid stabilization is only negligibly longer so that hybrid stabilization and geriatric complex treatment can be recommended as the new standard in spinal surgery for the treatment of type A fractures in aged patients.

Posterior Vertebrectomy via the Unilateral Pedicle or Bilateral Pedicle Approach in the Treatment of Lumber Burst Fracture with Neurological Deficits: A Comparative Retrospective Cohort Study

BACKGROUND Posterior vertebrectomy with bilateral pedicle approach (BPA) is widely applied in lumber burst fracture (LBF). However, some disadvantages exist, such as a prolonged operation time, extensive soft tissue injury, and excessive blood loss. Posterior vertebrectomy with unilateral pedicle approach (UPA) is a novel technique for decompression of spinal canal. Thus, we explored the potential of UPA to achieve better outcomes than BPA. MATERIAL AND METHODS Of 47 patients who underwent posterior vertebrectomy for LBF, 23 patients were treated with UPA and 24 patients were treated with BPA. Clinical and radiographical outcomes were assessed with a follow-up of more than 24 months. Patients were evaluated before and after surgery according to the following parameter: duration of operation (DO), blood loss volume (BLV), the kyphotic angle (KA), the ratio of the height of anterior vertebral edge, the ratio of the sagittal injury, visual analog scale (VAS), Oswestry Disability Index (ODI), and Frankel scores. RESULTS The follow-up time ranged from 24 to 37 months (average 26.4 months). The UPA group had significantly decreased DO and BLV (P<0.05). The 2 cohorts showed similar performance at 6 months (P>0.05), 12 months (P>0.05), and 24 months (P>0.05) post-surgery, in terms of parameters including KA, the ratio of the vertebral anterior, the ratio of sagittal damage, Frankel scores, ODI, and VAS. CONCLUSIONS UPA and BPA had a similar clinical performance for LBF. However, the shorter DO and lower BLV achieved in the UPA cohort suggested UPA is a better alternative for LBF.