Posterior monoaxial screw fixation combined with distraction-compression technology assisted endplate reduction for thoracolumbar burst fractures: a retrospective study

Effect of screw insertion depth into fractured vertebrae in the treatment of thoracolumbar fractures

PURPOSE

The study's objective was to assess the effect of the screw insertion depth into fractured vertebrae in treating thoracolumbar fractures.

MATERIALS AND METHODS

This was a retrospective analysis of 92 patients with thoracolumbar fractures from December 2018 to February 2020. Patients had AO type A2, A3 thoracolumbar fractures. The patients were divided into two groups according to the screw insertion depth. The vertebral wedge angle (VWA), Cobb angle (CA), anterior vertebral body height (AVBH), middle vertebral body height (MVBH), visual analog scale (VAS) score, and Oswestry Disability Index (ODI) were compared preoperatively and at one week and 12 months postoperatively. The correlation between Vertebral height loss and potential risk factors, such as sex, age, BMD and BMI was evaluated.

RESULTS

Compared with the preoperative data, the postoperative clinical and radiographic findings were significantly different in both groups, But no significant difference between the two groups at 1 week. At 1 year postoperatively, there was a significant difference in the CA (p < 0.0001), VWA (p = 0.047), AVBH (p < 0.0001), MVBH (p < 0.0001), VAS score (p < 0.0001), and ODI (p < 0.0001) between the two groups, Except for age, bone density and other influencing factors the long screw group had better treatment results than the short screw group.

CONCLUSION

A longer screw provides greater grip on the fractured vertebral body and stronger support to the vertebral plate. The optimal screw placement depth exceeds 60% of the vertebral body length on the lateral view.

A Prediction Nomogram for Fractured Vertebra Recollapse After Posterior Reduction and Pedicle Screw Fixation in Thoracolumbar Fractures

OBJECTIVE

This study aimed to establish a predictive nomogram model for recollapse of fractured vertebra after posterior pedicle screw fixation in thoracolumbar fractures (TLFs).

METHODS

Patients undergoing posterior pedicle screw fixation for TLFs at our hospital between January 2016 and December 2021 were retrospectively reviewed. Patients were divided into 2 groups according to the presence or absence of recollapse of the fractured vertebra at the final follow-up. The predictors for fractured vertebra recollapse were identified by univariate and multivariable logistic regression analysis, and a nomogram model was developed. The prediction performance and internal validation were established.

RESULTS

A total of 224 patients were included in this study. Of these, 46 (20.5%) patients developed recollapse of fractured vertebra. Age, thoracic and lumbar injury severity score, screw distribution in the fractured vertebra, and anterior vertebral height compression ratio were associated with vertebral recollapse. These predictors were used to construct a predictive nomogram. The area under the receiver operating characteristic curve of the nomogram model was 0.891. The concordance index was 0.891, and it was 0.877 with bootstrapping validation. The calibration curves and decision curve analysis also suggested that the nomogram model had excellent predictive performances for fractured vertebra recollapse.

CONCLUSIONS

A clinical nomogram incorporating 4 variables was constructed to predict fractured vertebra recollapse after posterior pedicle screw fixation for TLFs. The nomogram demonstrated good calibration and discriminative abilities, which may help clinicians to make better treatment decisions.

[Effectiveness of sagittal top compression reduction technique in treatment of thoracolumbar vertebral fractures]

Objective

To investigate the effectiveness of sagittal top compression reduction technique in the treatment of thoracolumbar vertebral fractures.

Methods

A retrospective analysis was conducted on the clinical data of 59 patients with thoracolumbar vertebral fractures who met the selection criteria and were admitted between November 2018 and January 2022. Among them, 34 patients were treated with sagittal top compression reduction technique (top pressure group), and 25 patients were treated with traditional reduction technique (traditional group). There was no significant difference in baseline data between the two groups ( P>0.05), including gender, age, fracture segment, cause of injury, AO classification of thoracolumbar vertebral fractures, thoracolumbar injury classification and severity (TLICS) score, American Spinal Injury Association (ASIA) grading, surgical approach, preoperative vertebral body index, height ratio of the anterior margin of injured vertebra, injured vertebra angle, segmental kyphosis angle, visual analogue scale (VAS) score, and Oswestry disability index (ODI). The operation time, intraoperative blood loss, and incidence of complications between the two groups were recorded and compared. After operation, VAS score and ODI were used to evaluate effectiveness, and X-ray and CT examinations were performed to measure imaging indicators such as vertebral body index, height ratio of the anterior margin of injured vertebra, injured vertebra angle, and segmental kyphosis angle.

Results

There was no significant difference in operation time and intraoperative blood loss between the two groups ( P>0.05). No complication such as dural sac, nerve root, or vascular injury was found during operation, and all incisions healed by first intention. Patients in both groups were followed up 6-48 months, with an average of 20.6 months. No loosening, breakage, or failure of internal fixation occurred during follow-up. The imaging indicators, VAS score, and ODI of the two groups significantly improved at 1 week and last follow-up when compared to preoperative ones ( P<0.05). At last follow-up, the VAS score and ODI further significantly improved when compared to 1 week after operation ( P<0.05). At 1 week after operation and last follow-up, the vertebral body index, segmental kyphosis angle, injured vertebra angle, and ODI in the top pressure group were significantly better than those in the traditional group ( P<0.05). There was no significant difference in VAS score and height ratio of the anterior margin of injured vertebra between the two groups at 1 week after operation ( P>0.05), but the two indicators in the top pressure group were significantly better than those in the traditional group at last follow-up ( P<0.05).

Conclusion

The treatment of thoracolumbar vertebral fractures with sagittal top compression reduction technique can significantly improve the quality of vertebral reduction, and is superior to traditional reduction techniques in relieving pain and improving spinal function.

Effectiveness of the Endplate Reduction Technique Combined With Bone Grafting for the Treatment of Thoracolumbar Fractures by Using Posterior Short-Segment Fixation

Objective: This study aimed to examine the effect of the endplate reduction (EPR) technique combined with bone grafting for treating thoracolumbar burst fractures using posterior short-segmental fixation.Methods: Patients with thoracolumbar fractures admitted between January 2018 and October 2021 were retrospectively analyzed, and those meeting the criteria were assigned to the EPR group and the intermediate screws (IS) group. The vertebral wedge angle (VWA), Cobb angle (CA), anterior vertebral body height (AVBH), middle vertebral body height (MVBH), upper endplate line (UEPL), upper intervertebral angle (UIVA), and upper intervertebral disc height (UIDH) indices were examined and compared preoperatively, first day postoperatively, as well as at 12 months postoperatively.Results: The result indicated that the EPR group achieved better MVBH reduction (p < 0.001), UEPL reduction (p < 0.001), vertebral body fracture healing (p = 0.006), as well as implant breakage (p = 0.04) than the IS group; VWA (p < 0.001), CA (p = 0.005), AVBH (p < 0.001), MVBH (p < 0.001), UEPL (p < 0.001), and UIDH (p < 0.001) were lost after reduction less than those in the IS group. There was no significant difference in operative time (p = 0.315) and intraoperative bleeding (p = 0.274) between the 2 groups.Conclusion: The EPR group achieved better results in repositioning and maintaining MVBH and endplate morphology, with less correction loss after the reduction of the VWA, CA, AVBH, and endplate morphology. The EPR group exhibited a better healing pattern after vertebral fracture and disc degeneration was better relieved.

In-Fracture Pedicular Screw Placement During Ligamentotaxis Following Traumatic Spine Injuries, a Randomized Clinical Trial on Outcomes

Objective

To investigate the efficacy and safety of two different techniques for spinal ligamentotaxis. Spine ligamentotaxis reduces the number of retropulsed bone fragments in the fractured vertebrae. Two different ligamentotaxis techniques require clinical evaluation.

Methods

This was a randomized clinical trial. The case group was defined as one pedicular screw insertion into a fractured vertebra, and the control group as a no-pedicular screw in the index vertebra. Spine biomechanical values were defined as primary outcomes and complications as secondary outcomes.

Results

A total of 105 patients were enrolled; 23 were excluded for multiple reasons, and the remaining were randomly allocated into the case (n=40) and control (n=42) groups. The patients were followed up and analyzed (n=56). The postoperative mid-sagittal diameter of the vertebral canal (MSD), kyphotic deformity correction, and restoration of the anterior height of the fractured vertebrae showed equal results in both groups. Postoperative retropulsion percentage and pain were significantly lower in the case group than in the control group (p=0.003 and p=0.004, respectively). There were no group preferences for early or long-term postoperative complications.

Conclusions

Regarding clinical and imaging properties, inserting one extra pedicular screw in a fractured vertebra during ligamentotaxis results in better retropulsion reduction and lower postoperative pain.

Minimally invasive technique of monoaxial percutaneous screws and instrumentational maneuvers in thoracolumbar and lumbar fractures

OBJECTIVES

Percutaneous pedicle screw fixation (PPSF) has been a common surgery for treating thoracolumbar and lumbar fractures. Many studies have reported PPSF is associated with poor reduction. We present a reliable method by using short-segment monoaxial percutaneous screws and instrumentational maneuvers to reduce the spine. This study aimed to evaluate radiological and clinical results of this method of reduction compared to traditional polyaxial screws method in treating thoracolumbar and lumbar fractures.

METHODS

From February 2015 to February 2021, 64 patients with thoracolumbar and lumbar fractures in our department were retrospectively reviewed and divided into experimental group and control group according to different treatment methods. The experimental group was treated with short-segment monoaxial percutaneous screws (which were inserted at the adjacent vertebrae one level above, one level below the fracture, and the fractured vertebra) and instrumentational maneuvers method, while the control group was treated with traditional polyaxial screws method. The operation time was recorded. Visual analogue scale (VAS) and Oswestry disability index (ODI) were assessed as the clinical outcomes. The anterior height of the injured vertebra (AVH), the kyphosis cobb angle and the vertebral wedge angle were used to evaluate the fracture radiological reduction.

RESULTS

A total of 64 patients were enrolled including 31 in the experimental group and 33 in the control group. There were no significant difference in operation time, AVH, the kyphosis cobb angle,the wedge angle of injured vertebra,VAS and ODI score between the two groups in preoperation. In each group, there were significant differences in the AVH, the kyphosis cobb angle and wedge angle of injured vertebra between preoperation and immediate postoperation. In each group, there were significant differences in VAS and ODI score between the preoperation and last follow-up. The total correction rates of AVH,the kyphosis cobb angle and the wedge angle of injured vertebra were significantly higher in the experimental group than those in the control group, while the loss of correction was significantly lower than the control.

CONCLUSIONS

The reduction technique using monoaxial percutaneous screws and instrumentational maneuvers for thoracolumbar and lumbar fractures exhibited better radiological results and satisfying functional outcomes when compared to traditional polyaxial screws.

Risk Factors for Postoperative Loss of Correction in Thoracolumbar Injuries Caused by High-Energy Trauma Treated via Percutaneous Posterior Stabilization without Bone Fusion

Background and Objectives: Percutaneous pedicle screws were first introduced in 2001, soon becoming the cornerstone of minimally invasive spinal stabilization. Use of the procedure allowed adequate reduction and stabilization of spinal injuries, even in severely injured patients. This decreased bleeding and shortened surgical time, thereby optimizing outcomes; however, postoperative correction loss and kyphosis still occurred in some cases. Thus, we investigated cases of percutaneous posterior fixation for thoracolumbar injury and examined the factors affecting the loss of correction. Materials and Methods: Sixty-seven patients who had undergone percutaneous posterior fixation for thoracolumbar injury (AO classifications A3, A4, B, and C) between 2009 and 2016 were included. Patients with a local kyphosis angle difference ≥10° on computed tomography at the postoperative follow-up (over 12 months after surgery) or those requiring additional surgery for interbody fusion were included in the correction loss group (n = 23); the no-loss group (n = 44) served as the control. The degree of injury (injury level, AO classification, load-sharing score, local kyphosis angle, cuneiform deformity angle, and cranial and caudal disc injury) and surgical content (number of fixed intervertebral vertebrae, type of screw used, presence/absence of screw insertion into the injured vertebrae, and presence/absence of vertebral formation) were evaluated as factors of correctional loss and compared between the two groups. Results: Comparison between each group revealed that differences in the wedge-shaped deformation angle, load-sharing score, degree of cranial disc damage, AO classification at the time of injury, and use of polyaxial screws were statistically significant. Logistic regression analysis showed that the differences in wedge-shaped deformation angle, AO classification, and cranial disc injury were statistically significant; no other factors with statistically significant differences were found. Conclusion: Correction loss was seen in cases with damage to the cranial intervertebral disc as well as the vertebral body.

Efficacy and Radiographic Analysis of Minimally Invasive Posterior Mono-Axial Pedicle Screw Fixation in Treating Thoracolumbar Burst Fractures

Background: The purpose of this study was to evaluate the effectiveness of minimally invasive posterior mono-axial pedicle screws fixation in the treatment of thoracolumbar burst fractures. Methods: In the present study, we analyzed 98 patients retrospectively who had thoracolumbar burst fractures without a neurological deficit. Patients were divided into two groups: mono-axial pedicle screw fixation group (n = 52) and poly-axial pedicle screw fixation group (n = 46). We collected clinical data (visual analog scale (VAS) score for back pain) and included radiographic measurements. Results: Sagittal index was significantly improved at postop and last follow-up in the mono group and the poly group. The mono group was better for reducing and maintaining anterior vertebral height. For the mono group, the mean postoperative regional kyphosis correction rate was 62.31%, and correction loss was 14.18% in late follow-up. For the poly group, the mean postoperative regional kyphosis correction rate was 52.17%, and correction loss was 33.42% in late follow-up. The mono-axial pedicle screw group had a good correction rate and reduced the risks of correction loss. The mean VAS scores for back pain improved by 2.4/2.5 and 3.8/4.2 for the mono and poly groups, respectively. There was no significant difference between groups. Conclusions: The mono-axial pedicle screw fixation was better for reducing and maintaining anterior vertebral height and regional kyphosis. Therefore, the mono-axial pedicle screw is a better optional instrumentation to treat thoracolumbar vertebral fractures.

Surgical Techniques for Thoracolumbar Spine Fractures: WFNS Spine Committee Recommendations

To formulate the specific guidelines for the recommendation of thoracolumbar fracture regarding surgical techniques and nonfusion surgery. WFNS (World Federation of Neurosurgical Societies) Spine Committee organized 2 consensus meeting. For nonfusion surgery and thoracolumbar fracture, a systematic literature search in PubMed and Google Scholar database was done from 2010 to 2020. The search was further refined by excluding the articles which were duplicate, not in English or were based on animal or cadaveric subjects. After thorough shortlisting, only 50 articles were selected for full review in this consensus meeting. To generate a consensus, the levels of agreement or disagreement on each item were voted independently in a blind fashion through a Likert-type scale from 1 to 5. The consensus was achieved when the sum for disagreement or agreement was ≥ 66%. Each consensus point was clearly defined with evidence strength, recommendation grade, and consensus level provided. A magnitude of prospective papers were analyzed to formulate consensus on various surgical techniques that can be employed to address different types of thoracolumbar fractures. Surgical treatment of thoracolumbar fractures can be a better option over the nonoperative approach, especially for those who cannot tolerate months in an orthosis or cast, such as those with multiple extremity injuries, skin lesions, obesity, and so forth. It generally allows early mobilization, less hospital stay, reduced pulmonary complications, and better correction of sagittal balance. Current available literature fails to demonstrate any statistically significant benefit of fusion surgery over nonfusion in thoracolumbar fractures.