Ostéosynthèse percutanée des fractures lombaires et thoracolombaires non neurologiques : technique chirurgicale et résultats préliminaires

Assessment of the outcome of percutaneous pedicle screws in management of degenerative and traumatic dorsal and lumbar pathologies

Background

Percutaneous pedicle screw technique is relatively a recent technique that evolved the concept of posterior spinal instrumentation, utilizing familiar fluoroscopic landmarks to guide the procedure of screws insertion, which despite being technically demanding, it avoids the Musculo-ligamentous damage associated with the conventional posterior technique.

Aim of the work

This study aims to report our experience in managing traumatic and degenerative spine pathologies by the minimally invasive percutaneous technique and assessing its radiological and functional outcome.

Materials and methods

A prospective observational study that included the analysis of the functional, operative, biochemical, and radiological outcomes of 20 patients who underwent uniplanar fluoroscopic-guided dorsal and/or lumbar percutaneous pedicle screw fixation procedures with or without fusion using the sextant, longitude, and Spineart system and any reported complications between January 2018 and December 2019.

Results

The clinical and radiological analysis of 100 percutaneous pedicle screws in degenerative (n:11) and traumatic (n:9) dorsal and/or lumbar cases revealed that the biomechanical stabilizing characteristics are comparable to the conventional posterior approach with the added benefits of the paraspinal muscle-sparing. Satisfactory functional outcome represented in the improvement of the postoperative back pain visual analog score and Oswestry Disability Index Score with acceptable morbidity and complications rate was noticed.

Conclusions

Percutanous pedicle screw fixation is a landmark in the evolution of the minimally invasive spine surgery which can be a safe alternative to the conventional posterior muscle stripping technique with a comparable functional and radiological outcome and good biomechanical profile and an acceptable morbidity rate.

Minimally invasive reduction of thoracolumbar burst fracture using monoaxial percutaneous pedicle screws: Surgical technique and report of radiological outcome

PURPOSE

To describe the reduction technique of thoracolumbar burst fracture using percutaneous monoaxial screws and its radiological outcomes compared to polyaxial screws.

METHODS

All surgeries were performed by minimally invasive technique with either percutaneous monoaxial or percutaneous polyaxial screws inserted at adjacent fracture levels perpendicular to both superior end plates. Fracture reduction is achieved with adequate rod contouring and distraction maneuver. Radiological parameters were measured during preoperation, postoperation, and follow-up.

RESULTS

A total of 21 patients were included. Eleven patients were performed with monoaxial pedicle screws and 10 patients performed with polyaxial pedicle screws. Based on AO thoracolumbar classification system, 10 patients in the monoaxial group had A3 fracture type and 1 had A4. In the polyaxial group, six patients had A3 and four patients had A4. Total correction of anterior vertebral height (AVH) ratio was 0.30 ± 0.10 and 0.08 ± 0.07 in monoaxial and polyaxial groups, respectively (p < 0.001). Total correction of posterior vertebral height (PVH) ratio was 0.11 ± 0.05 and 0.02 ± 0.02 in monoaxial and polyaxial groups, respectively (p < 0.001). Monoaxial group achieved more correction of 13° (62.6%) in local kyphotic angle compared to 8.2° (48.0%) in polyaxial group. Similarly, in regional kyphotic angle, 16.5° (103.1%) in the monoaxial group and 8.1° (76.4%) in the polyaxial group were achieved.

CONCLUSIONS

Monoaxial percutaneous pedicle screws inserted at adjacent fracture levels provided significantly better fracture reduction compared to polyaxial screws in thoracolumbar fractures.

Candidates for Percutaneous Screw Fixation Without Fusion in Thoracolumbar Fractures: A Retrospective Matched Cohort Study

STUDY DESIGN

Retrospective matched cohort study.

OBJECTIVES

Identifying candidates for isolated percutaneous screw fixation (PSF) in thoracolumbar fractures based on Thoracolumbar Injury Classification and Severity (TLICS) score.

METHODS

Patients underwent PSF were split into 3 TLICS-score categories, then matched with groups having similar scores managed either non-operatively or via open screw fixation (OSF). Each category was assessed for corrective power and loss of correction by comparing initial and 1-year Cobb angles as well as Oswestry Disability Index and rates of fracture healing at 1 year.

RESULTS

A total of 102 patients (40 females) with age range 19 to 51 years, were admitted 1 to 25 hours following trauma. Each of TLISC categories consisted of matched treatment groups for comparison. In TLICS-3 fractures (2 treatment groups, n = 12 each), PSF showed similar outcomes but longer time to ambulation and length of stay (LOS) compared with nonoperative management. In TLICS-4 fractures (3 treatment groups, n = 18 each), PSF showed comparable corrective power and outcomes as OSF but was better in terms of operative time, blood loss, time to ambulation, LOS, and cosmesis. Despite higher LOS when compared with nonoperative cases, PSF showed superior radiologic and functional outcomes. In TLICS-5 fractures (2 treatment groups, n = 12 each), PSF showed shorter admissions and time to ambulation but lower corrective power, functional recovery, and tendency to lower healing rates.

CONCLUSIONS

Isolated PSF is a valid choice in managing TLICS-4 thoracolumbar fractures; however, it did not surpass conventional methods in TLICS-3 or TLICS-5 fracture types. Further studies are needed before the generalization of findings.

Less Invasive Surgery is Feasible in the Management of Traumatic Thoracolumbar Fractures in Isolated and Polytrauma Injury

Background

Less invasive stabilization systems (LISSs) have gained popularity. However, limited quality of life (QOL) and clinical outcome data exist for trauma patients treated with LISSs. The objective of this study is to describe QOL and outcome for posterior percutaneous pedicle screw fixation in the management of traumatic thoracolumbar fractures.

Methods

Between January 2006 and December 2011, data from all patients treated with a posterior percutaneous pedicle screw fixation technique for thoracolumbar fractures were collected and analyzed. Sixty-nine patients met the inclusion criteria. Additional vertebral reduction and cement augmentation was used in 25 patients, when there was more than 50% of vertebral body comminution.

Results

Mean follow up of 19 months (range = 6-49 months). Fifty-one percent of the study population consisted of polytrauma patients, with 22% having injury severity score ≥ 15. In 6 cases (8.7%) there were perioperative complications. Response rate for the follow-up health survey was 78%, with a satisfactory overall median EuroQuol score of 0.811 (Q1-Q3 95% confidence interval = 0.709-0.897).

Conclusions

Posterior percutaneous pedicle screw fixation proves to be effective in the management of traumatic thoracolumbar fractures, with a good overall functional outcome. Percutaneous techniques that reduce perioperative morbidity are an alternative approach well suited for damage control orthopaedics, as long as there are no neurological deficits. Especially in polytrauma patients with spine fractures, the spinal column can be stabilized in an emergency setting, while limiting the risks of "a second hit" at the patients' already frail condition.

Level of Evidence

3.

Accuracy of percutaneous pedicle screws for thoracic and lumbar spine fractures compared with open technique

BACKGROUND

This study aimed to compare the accuracy of screw placement between open pedicle screw fixation and percutaneous pedicle screw fixation (MIS) for the treatment of thoracolumbar spine fractures (TSF).

METHODS

forty-nine patients with acute TSF who were treated with transpedicular screw fixation from January 2013 to December 2016 were retrospectively reviewed. The patients were divided into Open and MIS groups. Laminectomy was performed in either group if needed. The accuracy of the screw placement, the evolution of the Cobb sagittal angle postoperatively and at 12-month follow-up and the neurological status were recorded. AO type of fracture and TLICS score were also recorded.

RESULTS

Mean age was 42 years old. Mean TLICS score was 6.29 and 5.96 for open and MIS groups respectively. Twenty-five MIS and 24 open surgeries were performed, and 350 (175 in each group) screws were inserted (7.14 per patient). Twenty-four and 13 screws were considered "out" in the open and MIS groups respectively (Odds ratio 1.98. 0.97-4,03 P=0.056). The Cobb sagittal angle went from 13.3º to 4.5º and from 14.9º to 8.2º in the Open and MIS groups respectively (both P<0.0001). Loss of correction at 12-month follow-up was 3.2º and 4.2º for the open and MIS groups, respectively. No neurological worsening was observed.

CONCLUSIONS

For the treatment of acute thoracolumbar fractures, the MIS technique seems to achieve similar results to the open technique in relation to neurological improvement and deformity correction, while placing the screws more accurately.

Open Versus Minimally Invasive Fixation Techniques for Thoracolumbar Trauma: A Meta-Analysis

Study Design Systematic literature review and meta-analysis of studies published in English. Objective This study evaluated differences in outcome variables between percutaneous and open pedicle screws for traumatic thoracolumbar fractures. Methods A systematic review of PubMed, Cochrane, and Embase was performed. The variables of interest included postoperative visual analog scale (VAS) pain score, kyphosis angle, and vertebral body height, as well as intraoperative blood loss and operative time. The results were pooled by calculating the effect size based on the standardized difference in means. The studies were weighted by the inverse of the variance, which included both within- and between-study error. Confidence intervals were reported at 95%. Heterogeneity was assessed using the Q statistic and I (2). Results After two-reviewer assessment, 38 studies were eliminated. Six studies were found to meet inclusion criteria and were included in the meta-analysis. The combined effect size was found to be in favor of percutaneous fixation for blood loss and operative time (p < 0.05); however, there were no differences in vertebral body height (VBH), kyphosis angle, or VAS scores between open and percutaneous fixation. All of the studies demonstrated relative homogeneity, with I (2) < 25. Conclusions Patients with thoracolumbar fractures can be effectively managed with percutaneous or open pedicle screw placement. There are no differences in VBH, kyphosis angle, or VAS between the two groups. Blood loss and operative time were decreased in the percutaneous group, which may represent a potential benefit, particularly in the polytraumatized patient. All variables in this study demonstrated near-perfect homogeneity, and the effect is likely close to the true effect.

[Minimal invasive circumferential fusion in the management of kyphotic thoracolumbar lesions: Technical note]

INTRODUCTION

Management of spinal kyphotic deformities remains challenging in order to achieve a complete correction of the deformity, stabilize the spine and restore a satisfactory sagittal alignment. The aim of this study was to report the results of a technique combining, during the same operative session: a percutaneous osteosynthesis (with or without decompression) and a minimal invasive corpectomy using an anterior approach.

METHODS

Twelve patients (mean age 54 years old) were included in this single center retrospective study. Kyphotic deformity was related to a trauma in 9 cases, to a tumor in 2 cases and was infectious in the last case. The level involved was L1 in 7 cases, T12 in 3 cases, T10 and L4 in 1 case each. First step of the surgical strategy was a routine posterior percutaneous osteosynthesis. In 5 cases, a complementary minimal invasive decompression was performed using tubular retractors. During the second step, an anterior corpectomy was performed and the vertebral reconstruction was done using telescopic vertebral body prosthesis. Once the last correction was achieved, final locking of the posterior instrumentation was performed.

RESULTS

In the entire series, a short construct was done in 2 cases and a long construct was decided for the 10 other cases depending on the lesion. Mean surgical time was 246 min [173-375] and postoperative blood transfusion was not necessary. Patients were discharged from the hospital on average at day 8 [4-25] according to associated lesions. Based on radiographic analyses, a significant restoration of the vertebral kyphosis (average 17°, P<0.001) and vertebral body height (27% on average, P<0.001) were obtained.

CONCLUSION

Combination of these two minimal invasive techniques allows a circumferential spinal fixation with a low rate of complications and a satisfactory restoration of local sagittal deformity. This strategy is, in our experience, a valuable alternative to conventional techniques. Further studies with a longer follow-up will therefore needed in order to confirm these results.

Non-operative vs. percutaneous stabilization in Magerl's A1 or A2 thoracolumbar spine fracture in adults: is it really advantageous for a good alignment of the spine? Preliminary data from a prospective study

PURPOSE

Percutaneous and non-operative stabilization are very controversial choices in the management of Magerl's A1 or A2 thoracolumbar spine fractures in adults. Our purpose is to figure out which of the two treatments is more suitable for the management and outcomes of these injuries.

METHODS

From 12/01/2011 to 06/30/2014 at the AO Orthopedics and Traumatology, Gaetano Rummo in Benevento, Italy, we treated 39 adult patients with thoracolumbar spinal fractures according to Magerl's A1 and A2. Twenty-four patients were treated with a 3-point orthopedic corset, and 15 patients were treated with percutaneous posterior stabilization without augmentation. The patients decided on treatment after extensive explanation of the pros and cons of the two treatments. The endpoint evaluation was set at the 6-month follow-up through the evaluation of the Visual Analogue Scale, Angle's Regional Kyphosis, Oswestry Low Back Pain Disability Questionnaire, and Denis work scale.

RESULTS

The preliminary results of this prospective study show that there is a considerable advantage in functionality and pain in treating adults suffering from thoracolumbar fractures with Percutaneous technique at the expense of the bust with three points.

CONCLUSIONS

Although the data are preliminary and based on data available in the literature, we can say that the Percutaneous posterior stabilization of thoracolumbar fractures in Magerl's A1 and A2 in adults is the ideal method for a good and functional alignment of the spine.

Percutaneous short fixation vs conservative treatment: comparative analysis of clinical and radiological outcome for A.3 burst fractures of thoraco-lumbar junction and lumbar spine

PURPOSE

The aim of the study is to use an algorithm previously published to decide whether to perform open surgery or percutaneous surgery with short fixation in patients with thoraco-lumbar junction and lumbar spine fractures, and to compare retrospectively surgical and conservative options of treatment.

METHODS

Between 2005 and 2009, two groups of 25 patients were analyzed to compare retrospectively surgical and conservative option of treatment to assess perception of pain and to evaluate quality of life during treatment, to evaluate how quickly patients return to work and to their daily activities, to evaluate patients' satisfaction. X-ray controls were performed to evaluate the fusion rate at 3 and 6 months and CT scans at 6 months.

RESULTS

The surgical group had a better functional recovery, a better quality of life and returned to work earlier in comparison to the conservative group.

CONCLUSIONS

We can conclude that the percutaneous procedure seems to give better results in terms of satisfaction and return to normal activities, although both procedures guarantee excellent fusion rates.

Early percutaneous fixation of spinal thoracolumbar fractures in polytrauma patients

INTRODUCTION

Care of polytrauma patients is complex and requires that a particular treatment sequence be followed during what is typically a short period of time. Early, temporary stabilization of injuries (damage control orthopedics [DCO]) is a validated strategy for the care of polytrauma patients. Application of this concept to spinal fractures has also led to good outcomes for patients. The recent development of percutaneous thoracolumbar fixation could improve the initial care of these vulnerable patients even more. The purpose of this study was to evaluate preliminary results in a series of polytrauma patients presenting with thoracolumbar fractures without neurological deficits who were treated according to DCO principles using early percutaneous fixation.

MATERIALS AND METHODS

All severe polytrauma patients admitted with a thoracic and/or lumbar spine fracture without neurological deficit were included in this prospective study. The care was standardized according to the degree of urgency of the initial injuries, with percutaneous spinal fixation being performed as early as feasible. The outcomes were evaluated using clinical parameters (duration of stay in intensive care unit, surgical data, blood loss) and radiographic parameters measured during a systematic postoperative CT scan (traumatic deformity, placement of pedicle screws, fusion rate). If needed, an anterior intervertebral graft was performed during a secondary procedure.

RESULTS

In all, 10 patients (average age of 40 years) were included, corresponding to 18 vertebral fractures. During the initial assessment, at least one peripheral bone fracture was found in 90% of cases and at least one organ was injured in all patients (thoracic in 80% of cases, cerebral in 50%, facial area in 40% and abdominal-pelvis in 30%). The average time elapsed between admission and spine surgery was 4 days (80% of cases before day 7). There were no cases of deep infection in any of the patients. An additional anterior procedure was needed in three patients within 1 month of the initial surgery.

DISCUSSION

The strategy for treating thoracolumbar fractures in polytrauma patients is still not widely accepted. The presence of associated lesions could make it difficult to perform conventional spine surgery early on. Development of percutaneous techniques that reduce perioperative morbidity seems to be an alternative approach well-suited to DCO, as long as there are no neurological deficits. However, a secondary evaluation of the anterior spine is essential to determining if an anterior graft remains needed.

LEVEL OF EVIDENCE

Level IV.

Kyphopasty and vertebroplasty

Vertebroplasty and balloon kyphoplasty are percutaneous techniques performed under radioscopic control. They were initially developed for tumoral and osteoporotic lesions; indications were later extended to traumatology for the treatment of pure compression fracture. They are an interesting alternative to conventional procedures, which are often very demanding. The benefit of these minimally invasive techniques has been demonstrated in terms of alleviation of pain, functional improvement and reduction in both morbidity and costs for society. The principle of kyphoplasty is to restore vertebral body anatomy gently and progressively by inflating balloons and then reinforcing the anterior column of the vertebra with cement. In vertebroplasty, cement is introduced directly under pressure, without prior balloon inflation. Both techniques can be associated to minimally invasive osteosynthesis in certain indications. In our own practice, we preferably use acrylic cement, for its biomechanical properties and resistance to compression stress. We use calcium phosphate cement in young patients, but only associated to percutaneous osteosynthesis due to the risk of secondary correction loss. The evolution of these techniques depends on improving personnel radioprotection and developing new systems of vertebral expansion.

Comparison between percutaneous and traditional fixation of lumbar spine fracture: intraoperative radiation exposure levels and outcomes

OBJECTIVE

To compare radiation exposure doses and clinical and radiological outcomes between percutaneous pedicular screwing (closed reduction internal fixation [CRIF]) and classical open reduction internal fixation (ORIF) in lumbar spine fracture without neurologic deficit.

MATERIALS AND METHODS

Sixty patients (mean age, 42.5 years) were divided into two treatment groups: (Percutaneous) CRIF versus (traditional) ORIF. Screw position and anatomic vertebral reconstruction were checked on routine control X-ray and postoperative CT scan. Study parameters comprised: surgery time, radiation exposure time, radiation dose level for X-ray (DAP) and for CT (DLP),blood loss, length of hospital stay and postoperative pain (VAS).

RESULTS

At a mean 25.5 months' follow-up,there were no significant inter-group differences on the epidemiological parameters: age, gender, fracture level, fracture type on the Magerl classification, preoperative local vertebral kyphosis angle, or fracture-to-surgery interval. Effective radiation dose was 3-fold higher in CRIF than in ORIF, but 6-fold lower than for the postoperative CT scan. Postoperative pain on VAS was significantly lower after CRIF, allowing earlier gait resumption and return to work and daily activity. There were no significant differences in length of hospital stay, patient satisfaction, screw malpositioning or postoperative or end-of-follow-up kyphosis angle.

CONCLUSION

Percutaneous surgery provided clinical and radiological outcomes strictly comparable to those of open surgery, but with a higher effective radiation exposure dose, including for the medical team and especially for the surgeon. This higher exposure dose, however, is to be relativized by comparison to that of the postoperative CT scan, which involved a much higher exposure dose for the patient.

LEVEL OF EVIDENCE

Level IV. Retrospective study.

Thoracolumbar fracture reduction by percutaneous in situ contouring

PURPOSE

Percutaneous in situ contouring is based on bilateral bending of rods on the spine, thus increasing lordosis at the fracture. It was analyzed if this technique would provide a better reduction than prone positioning and how sagittal alignment would behave.

METHODS

Twenty-nine patients were operated using in situ contouring and selective anterior fusion for non-neurologic A2, A3 or B2 fractures. Clinical results were assessed prospectively using visual analog scale (VAS) and Oswestry Disability Index (ODI). The radiographic deformity correction was measured by sagittal index and regional kyphosis. Sagittal balance was assessed using kyphosis, lordosis, T9 tilt, pelvic incidence, pelvic tilt and sacral slope. Posterior wall fragment reduction was evaluated by computed tomography.

RESULTS

After 2 years, VAS and ODI were comparable to the status prior to the accident. The sagittal index was 19.7° preoperatively, 5.3° after prone positioning and -1.1° after in situ contouring (p < 0.001). The loss of correction was 2.4°, mainly during the first 3 months. Similar observations were made for regional kyphosis. The sagittal spino-pelvic alignment was stable postoperatively. A preoperative canal obstruction ≥50 % was observed in 16 patients, and the fragments migrated anteriorly in all patients.

CONCLUSIONS

Percutaneous instrumentation and anterior fusion provides good clinical results. In situ contouring increases lordosis obtained by prone positioning. Anterior column lengthening and ligamentotaxis reduce posterior wall fragments, which decompress the canal without laminectomy. The fusion of anterior defects prevents the loss of correction and provides a stable sagittal profile. The instrumentation may be removed without damaging the paravertebral muscles and loss of correction.

Evaluation of percutaneous surgery in the treatment of thoracolumbar fractures. Preliminary results of a prospective study on 65 patients

INTRODUCTION

We conducted a prospective, single-center, continuous study of patients operated for fractures urelated to osteoporosis at the thoracolumbar junction level using percutaneous techniques. The aim of this study was to investigate the clinical and radiological outcomes of percutaneous techniques for these indications.

PATIENTS AND METHODS

This study included patients who underwent standalone balloon kyphoplasty surgery or combined with percutaneous posterior osteosynthesis in cases of associated distraction. The fractures were classified according to the Magerl classification. The patients were evaluated clinically (visual analog scale [VAS], the Oswestry Disability Index, and autonomy) and radiologically (vertebral kyphosis and height variations of the vertebral body) for 12 months.

RESULTS

Sixty-five patients were included. The mean age at the time of the surgery was 45.4 years (range, 19-72 years). The main indications were A.1 fractures of L1. We noted 22% cement leakages, none having a clinical impact. In the overall series, the VAS at the lesional level improved from 5.5 (range, 3-8) preoperatively to 0.6 (range, 1-3) at 12 months. In all, 95% of the workers resumed their occupation. Traumatic kyphosis improved from 13.3° (range, 5-23°) before the surgery to 8.3° (range, 1-20°).

DISCUSSION

The complication rate was low. The radiological results are comparable to those reported in the literature for other series with percutaneous surgery. Only the loss of the correction observed in the group undergoing standalone kyphoplasty with calcium phosphate cement led us to propose another type of treatment for these indications. This study must be continued over the long term to detect the appearance of discopathy related to cement leakage and to answer questions as to how cement evolves.

LEVEL OF EVIDENCE

III, prospective study with low statistical power.

Percutaneous management of thoracolumbar burst fractures: Evolution of techniques and strategy

INTRODUCTION

A number of techniques have been described in the management of thoracolumbar spinal fractures, testimony to the absence of consensus on their treatment. For the past few years, minimally invasive techniques have been developed to limit surgery-related iatrogenic injury. The objective of this study was to report the results of percutaneous management of these lesions and the technical progress made based on our experience.

PATIENTS AND METHODS

Twenty-nine patients presenting an A3 fracture, with a mean age of 51 years, were included in this study. All had a balloon kyphoplasty and percutaneous osteosynthesis. Of the first 22 cases, kyphoplasty was the initial procedure performed associated with reduction maneuvers using distraction. Assessment was clinical (neurological status and pain intensity) and radiological (implant positioning, cement leakage, restoration of local kyphosis and any loss of correction).

RESULTS

In the overall series, the mean local kyphosis correction was 11° with a 2° angle loss at the last follow-up. Pain assessment showed significant improvement, decreasing from 6/10 to 1/10 on discharge. The mean hospital stay lasted 4 days. On the follow-up radiological exams, no cases of extrapedicular screw migration were noted; in two cases, lateral cement leakage was found. The results were equivalent in terms of correction no matter which procedure was performed first, although for the second part of the series the technology was available to bend the spinal fixation rod to the desired curve.

DISCUSSION

The results of this study support the growing interest in minimally invasive techniques in the management of spinal injuries with no neurological deficit. In addition, the evolving material makes it possible to come close to conventional techniques, including reduction maneuvers, while limiting muscle injury by using a purely percutaneous approach. Rigorous patient selection is necessary and the time to learn the procedure must be taken into account. Studies with a longer follow-up are required to confirm the stability of the correction over time.

LEVEL OF EVIDENCE

Level IV. Retrospective observational study.

Systems for long-segment percutaneous spinal fixation: technical feasibility for various indications

SUMMARY OF BACKGROUND DATA

New methods of spinal percutaneous fixation are developing very rapidly. However, few studies to date have focused on long-segment methods of instrumentation.

OBJECTIVE

To report the technical feasibility of long-segment percutaneous stabilization for various indications.

METHODS

The study included 24 patients with a mean age of 58 years (range 38-79). The etiologies included trauma, infection, tumors, or pathology secondary to degenerative lumbar scoliosis. The damaged vertebrae ranged from T5 to L4. All of the patients underwent posterior percutaneous long-segment fixation. When necessary, the anterior spinal column was stabilized by balloon kyphoplasty or via anterior approach. The results obtained were analyzed on the basis of clinical and radiological criteria.

RESULTS

The constructs involved four levels on average per patient, located between T3 and S1. No extra-pedicular misplacements were observed. Two technical difficulties were noticed without clinical consequences. A significant improvement in the pain levels was obtained in all the patients in this series.

CONCLUSIONS

Long-segment percutaneous fixation was found to be technically feasible and to considerably improve the patients' spinal deformations. When associated with balloon kyphoplasty, this intervention seems to provide less loss of correction than previous methods, and posterior fusion was therefore not required. As with all new methods, there is a learning curve, and the indications have to be strictly observed. Further studies need to be performed, however, with a longer follow-up to confirm the absence of long-term complications.

[Minimally invasive osteosynthesis in septic conditions]

BACKGROUND AND PURPOSE

Management of pyogenic spondylodiscitis in adults remains controversial. The aim of this study was to evaluate the results of a minimally invasive method for deformity correction and stabilization of these lesions with percutaneous osteosynthesis.

METHODS

Ten patients were included in this study and treated with a two-step procedure: posterior percutaneous osteosynthesis completed by complementary intervertebral grafting via an anterior access. Postoperative evaluation was clinical and radiological with measurement of local sagittal deformity and restitution of vertebral body height.

RESULTS

In this series, bacteriologic identification was possible and pain was controlled in every case. On postoperative evaluation, the implants were always properly positioned. The mean local sagittal deformation was +2.1° preoperatively and -8.4° postoperatively. The mean increase in vertebral body height was measured at 8mm postoperatively. At the last follow-up, a moderate loss of correction was noted (mean: 2° and 3mm) and all patients but one showed solid bony fusion.

CONCLUSION

Percutaneous osteosynthesis in septic conditions in association with an anterior graft provides satisfactory clinical and radiographic results. It provides a valuable alternative for deformity correction and spinal stabilization with a minimally invasive access in patients with comorbidities.

[Minimally invasive spine arthrodesis in degenerative spinal disorders]

BACKGROUND AND PURPOSE

As in many other surgical fields, new minimally invasive techniques have been developed over the past 20 years, with reducing the muscular trauma associated with the traditional surgical approach and reducing related morbidity as the main goals. Initially limited to the laparoscopic or video-assisted approaches of the anterior spine, these techniques have been extended to the posterior transmuscular access of the lumbar spine. This article reviews the value of these approaches in the treatment of degenerative lumbar spine disorders.

METHODS

We describe the main techniques used in minimally invasive lumbar spine surgery, including posterior pedicle screwing as well as anterior (ALIF), posterior (PLIF), transforaminal (TLIF), extreme lateral (XLIf), and presacral (AxiaLIF) interbody fusion. The results of recently published series are reported.

RESULTS

Percutaneous pedicle screwing is reported to be an effective technique of lumbar spine arthrodesis associated with a low rate of screw misplacement. Minimally invasive PLIF, TLIF, and ALIF have been associated with shorter mean operative time, less postoperative pain, reduction of the estimated blood loss, a shorter hospital stay, and quicker functional recovery. Despite these encouraging early clinical results, no prospective, randomized published scientific study has proved that minimally invasive techniques are better than standard techniques. Larger clinical series with a longer follow-up could fill this gap.

[Minimally invasive surgery for Chance fractures: Three case studies]

BACKGROUND AND PURPOSE

Chance fractures are quite rare injuries that require surgical treatment in cases of spinal instability. Development of percutaneous and minimally invasive procedures can alter the management of such lesions, resulting in fewer related soft tissue lesions and morbidities.

METHODS

We present our experience with three patients who underwent percutaneous posterior osteosynthesis associated with a minimally invasive anterior graft for discal lesion. The first two cases presented fracture through the disc and osteosynthesis was done on a single mobile level. In the third case with a bony Chance fracture, we performed a short-segment fixation one level above and below the fractured vertebra.

RESULTS

In all three cases, operative blood loss was minimal and clinical outcomes were favorable, with tolerable postoperative pain. Fusion and consolidation were visible for all the patients without loss of correction or implant failure.

CONCLUSION

Percutaneous osteosynthesis and minimally invasive surgery can be an advantageous alternative for the management of Chance fractures. They allow early mobilization of the patient with less soft tissue trauma and morbidities associated with open procedures.