Comparison of Anterior Versus Posterior Approach in the Treatment of Thoracolumbar Fractures: A Systematic Review

Comparative Analysis of Three Vertebral Screw Placement Directions in Anterior Thoracolumbar Fracture Surgery: A Finite Element Study

BACKGROUND

Thoracolumbar fractures, especially burst fractures, are common severe spinal injuries requiring surgery. The main goals are to restore spinal stability and normal curvature, relieve nerve compression, and prevent further neurological damage. Minimally invasive techniques are increasingly used in spinal surgery. This study aims to use finite element analysis to compare two new thoracolumbar anterior fixation systems: Hybrid cross-thoracolumbar fixation system and new hybrid cross-thoracolumbar fixation system (HXTL and NHXTL) with Medtronic's ANTERIOR system, providing a theoretical reference for surgeries.

METHOD

A finite element model of the T12-L2 vertebrae of a 27-year-old healthy male was built based on CT images. The model was processed, optimized, meshed, and analyzed using software. In vitro biomechanical tests were compared with the finite element model results to verify the model's validity. A 500 N compressive load and a 10 N m bending moment were applied to the upper surface of T12. The stress and displacement of the vertebral body and the stress state of the support body of the two models under various conditions like forward flexion and backward extension were observed and analyzed.

RESULTS

The study compared the biomechanical performance of the HXTL, NHXTL, and ANTERIOR systems under six physiological conditions. The vertebral body displacement of the three systems was maximum under forward flexion. During right flexion, the HXTL displacement was significantly greater than that of the ANTERIOR and NHXTL systems, while during extension, the HXTL and NHXTL displacements were significantly less than those of the ANTERIOR system. Under other motion conditions, the displacements were relatively small. In terms of vertebral body stress, the ANTERIOR model had the maximum stress during left flexion, significantly greater than that of the other two. In terms of titanium mesh stress, the HXTL system had significantly higher stress during extension and left rotation compared to the other two systems. In terms of nail-rod stress, the ANTERIOR system had higher stress in all directions than the HXTL and NHXTL systems.

CONCLUSION

Compared with the ANTERIOR system, the HXTL system reduces the surgical incision through oblique nail placement, can reduce the risk of nail-rod failure, and increase the stability of the titanium mesh between vertebral bodies, but it also brings a higher risk of subsidence. The NHXTL model not only reduces the surgical incision and the risk of accidental injury to contralateral blood vessels but also reduces the risk of nail-rod failure and does not increase the risk of titanium mesh subsidence. It is a more optimized choice.

Surgical Decision-Making in Thoracolumbar Fractures: A Systematic Review of Anterior and Posterior Approach

Introduction

Fractures in the thoracolumbar region of the vertebral column are very common and often require surgical intervention. Surgery is typically aimed at restoring or maintaining neurological function and correction of the vertebral column.

Systematic Review

There are two commonly used approaches for surgery, the anterior and the posterior approach. Uncertainties remain regarding the best surgical approach for the treatment of traumatic thoracolumbar fractures. The results of studies comparing the anterior and posterior surgical approaches for treating thoraco-lumbar fractures have been compiled in this review. Numerous metrics, including neurological results, Cobb angle recovery, and post-operative complications, have been used. It was observed that both approaches yielded a similar result when considering the improvement in Frankel grades and recovery of the Cobb angle.

Conclusion

We further report that patients undergoing decompression using the anterior approach incurred higher blood loss, longer hospital stays, and higher operating costs; these findings support the posterior approach as being safer and more practical.

Is anterior fusion still necessary in patients with neurologically intact thoracolumbar burst fractures? A systematic review and meta-analysis

OBJECTIVES

To conduct a systematic review and single-arm meta-analysis to evaluate and compare radiological indicators, as well as short-term and long-term outcomes, in patients with neurologically intact thoracolumbar burst fractures (TLBF) who underwent anterior fusion, combined anterior-posterior procedure, or short-segment pedicle screw fixation (PSF).

METHODS

A systematic review following PRISMA guidelines was conducted. Inclusion criteria comprised articles published between 2004 and 2023, full-text availability in English, burst fractures without spinal cord or nerve root injuries at admission, short-segment PSF without fusion, anterior or combined fusion methods, patients aged 18 or older, and a minimum 12-month follow-up. Meta-analysis was carried out using Comprehensive Meta-Analysis software. Using a single-arm meta-analysis method, pooled indicators of short- and long-term outcomes for each studied group were determined. The obtained data were then compared using simple comparison.

RESULTS

The pooled mean Cobb angle at admission for the anterior, combined, and PSF groups was 18.2° (95% CI, 14.6-21.8), 11.7° (95% CI, 9.7-13.5), and 17.1° (95% CI, 15.1-19.1), respectively. Anterior fusion achieved a greater degree of kyphosis correction across all groups, but only the combined group showed a nonsignificant loss of correction after discharge (SMD = 0.809 [95% CI, 0.270, 1.348]). The anterior vertebral body compression rate at admission was 55.2% (95% CI, 46.3-64.0) in the combined group and 37.8% (95% CI, 33.7-41.9) in the PSF group. Operative time, blood loss, and hospitalization duration were lowest in the percutaneous PSF group, with means of 96.5 min (95% CI, 82.4-110.6), 83.8 ml (95% CI, 71.7-95.9), and 6.6 days (95% CI, 4.7-8.5), respectively. All techniques demonstrated a similar incidence of deep wound infections and implant-related complications. The pooled Oswestry Disability Index (ODI) scores were 17.2 (95% CI, 10.4-23.9) for the anterior group, 15.4 (95% CI, 11.5-19.3) for the combined group, and 13.4 (95% CI, 10.4-16.3) for the PSF group.

CONCLUSIONS

For patients with neurologically intact thoracolumbar burst fractures, with a kyphotic angle of less than 19.1° and an anterior vertebral body compression rate of less than 41.9%, short-segment pedicle screw fixation without fusion may be preferable option due to reduced intraoperative blood loss, shorter operation duration, shorter hospital stay, and better ODI scores at final follow-up. Routine anterior fusion has demonstrated high potential for kyphosis correction. The loss of the Cobb angle from surgery to final follow-up was nonsignificant only in patients who underwent combined surgery. When determining the surgical approach, surgeons should carefully weigh the advantages of anterior and combined fusion against the significantly higher surgical trauma compared to standard PSF.

Anatomical and biomechanical characteristics of basivertebral foramen and its clinical significance

Basivertebral foramen is a natural orifice in the posterior wall of the vertebral body existing in humans and mammals, through which the basal vertebral vein, branch of lumbar artery and recurrent branch of spinal nerve enter and exit the vertebral body. Basivertebral foramen changes the local microstructure of the vertebral body, resulting in cortical defect and sparse trabecular bone in the central region of the vertebral body, thus affecting its biomechanical characteristics and making its central region a "weak" area of the vertebra. Some characteristic injuries of the vertebra are related to basivertebral foramen, such as vertebral compression fracture and intervertebral cleft, vertebral burst fracture and posterior upper vertebral fracture fragment, and cement leakage during treatment. In this article, the anatomical and developmental biological characteristics of basivertebral foramen, the impact of basivertebral foramen on biomechanical characteristics, and the treatment of basivertebral foramen related vertebral diseases are reviewed, in order to provide references for the clinical diagnosis and treatment of vertebral injuries.

Is open anterior advantageous to posterior decompression and reconstruction in fresh A3 to C3/AO type thoracolumbar junction fractures? A systematic review

INTRODUCTION

Surgical outcomes of open anterior and open posterior approaches, for thoracolumbar A3 to C3/AO type fractures, are compared.

METHODS

A PubMed search was conducted from 1990 to 2024 related to anterior, posterior, and combined approaches. Inclusion criteria: Fresh traumatic T10 to L2 fractures, age ≥13 years, ≥10 cases, minimum follow-up 6 months. Exclusion criteria: Cadaveric studies, pathological fractures, reviews, thoracoscopy-assisted, mini-open lateral (MOLA) and minimal invasive anterior or posterior approaches. Coleman Methodology Scores (CMS) (modified for spinal trauma) indicated potential selection bias in the selected studies. PRISMA guidelines were adapted.

RESULTS

Nineteen studies with 847 participants were selected. The average CMS quality score was fair. The anterior approach, although it better decompresses the compromised spinal canal, it is also associated with increased surgical complications compared to the posterior approach. The neurological outcome, the loss of correction and the reoperation rate, were similar to both approaches. This systematic review favors posterior approach.

CONCLUSIONS

The anterior approach is demanding and is associated with a higher rate of surgical complications compared to the posterior approach. The limitations of the selected studies included inconsistence in the: 1) approaches selection, 2) classifications of the fracture types and the neurological status and 3) variety of instrumentations used.

PROSPERO ID

CRD42023484222.

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.

Posterior-only approach in patients with poor general condition and spinal metastatic vertebral fracture

PURPOSE

The surgical treatment of spinal metastases is mostly palliative in nature and focuses on improving the quality of life of patients. The posterior transpedicular surgical approach provides circumferential 360° decompression, allows reconstruction and stabilisation to be achieved in a single session and can be performed using an open, mini-open or minimally invasive approach. We present and discuss the surgical techniques and outcomes for patients with single-level metastatic spinal disease and in poor general condition who underwent surgery via the posterior-only transpedicular corpectomy approach and reconstruction with expandable corpectomy cages.

METHODS

Patients with a single level thoracolumbar metastatic disease (T3-L5) and a Karnofsky score of ≤70, who underwent a complete posterior transpedicular corpectomy with expandable cage reconstruction of the anterior spinal column were retrospectively reviewed. Patients' demographics, SINS, modified Tokuhashi scores as well as preoperative and postoperative ASIA scale, Karnofsky scores, VAS scores and vertebral height/Cobb angle values were analysed.

RESULTS

A total of 44 patients (24 M/20 F) (mean age 53.25±21.26 years) met the inclusion criteria. The modified Tokuhashi scores were as follows: score 0-8, 5 (11.4%) patients; score 9-11, 14 (31.8%) patients; and score 12-15, 25 (56.8%) patients. There were significant improvements in the postoperative VAS scores (mean 7.7-2.9), Karnofsky scores (mean 63.3-79.6) as well as the Cobb angles (18.6-12.8°) and vertebral height. Thirtyfive patients showed improved neurological function by at least one ASIA grade, whereas 9 showed no improvement during the postoperative period.

CONCLUSIONS

This technique, which has a low complication rate and a short recovery time, can help achieve satisfactory results even in patients with poor metabolic profiles and Karnofsky scores in the preoperative period. Further clinical studies with large patient groups are warranted to confirm the results of this study.

Posterior unilateral small fenestration of lamina combined with a custom-made Y-shaped fracture reduction device for the treatment of severe thoracolumbar burst fracture: a prospective comparative study

BACKGROUND

The purpose was to evaluate the clinical effect of a custom-made Y-shaped fracture fragment reduction device and to assist in posterior unilateral small fenestration of lamina to reduce the fracture fragments.

METHODS

In this study, 40 patients were assigned to one of two groups: the traditional reduction device group (TRG) or the Y-shaped reduction device group (YRG). All patients underwent posterior unilateral small fenestration of the lamina and direct decompression through the spinal canal. And the operation time (OT), intraoperative bleeding (IB), preoperative, postoperative, and final follow-up data on the spinal stenosis rate (SSR), Cobb angle, the anterior compression ratio of injured vertebrae (ACRIV), and ASIA neurological function grade were compared between the two groups.

RESULT

There were no complications, including vascular and nerve injury, serious postoperative infection, internal fixation fracture, or loosening, for any of the patients. And the average follow-up time of the two groups was 14.2 months, the average operation time of the TRG was 236.6 min, and the average intraoperative blood loss was 357.20 ml. Moreover, the average operation time of the YRG was 190.6 min, and the average intraoperative blood loss was 241.5 ml. There were significant differences between the two groups in terms of operation duration and intraoperative blood loss. The YRG's was lower than that of the TRG. Besides, there was no difference in SSR, Cobb angle, ACRIV, or neurological recovery between the two groups before or immediately after the operation or at the last follow-up.

CONCLUSION

The Y-shaped fracture reduction device can reduce the fracture fragments and the OT and IB stably; it also has satisfactory postoperative curative effects and clinical utility.

Evaluation of vertebral shortening and interbody fusion with short segment pedicle screw fixation for unstable thoracolumbar fractures

Background

Various operative procedures have been described for the treatment of traumatic paraplegia caused by unstable thoracolumbar fractures. We prospectively evaluated interbody fusion (IBF) with SS-PSF in these cases with regard to clinico-radiological outcome with the objectives: (1) Does IBF and short segment pedicle screw fixation (SS-PSF) prevent progression of kyphotic angle after surgery? (2) Can this procedure be safely performed in the setting of acute trauma?.

Methods

Sixteen patients suffering from traumatic paraplegia caused by acute unstable thoracolumbar fractures were enrolled prospectively and underwent IBF with SS-PSF. They were evaluated for magnitude of shortening in spine, progression of kyphotic angle, and neurological improvement by American spinal injury association scale (ASIA).

Results

Out of total sixteen, 14 patients were ASIA grade A and 2 were grade C, at the time of presentation. Thirteen out of these 14 remained grade A and one improved to B. Both the patients who had grade C involvement at the time of presentation improved to grade D at one-year follow-up. The mean blood loss was 750 ml (range; 650 ml-1150 ml). Mean kyphotic angle decreased from 20.6° (range; 13° to 37°) preoperatively to 6.2° (range; 3° to 10°) at postoperative day 2 (p = 0.002). Its mean value after 6 months was 6.5° (range; 3° to 11°). The procedure resulted in mean spinal column shortening of 18 mm (range; 16 mm-22 mm) in the spinal column. All the patients achieved bony union by a mean duration of 3.9 months (range; 3 months-6 months).

Conclusions

IBF with SS-PSF has the shortest possible instrumented construct for thoracolumbar junction fusion done by posterior approach. The interbody fusion for unstable thoracolumbar junction fractures prevents the progression of kyphotic angle post-operatively.

Level of evidence

Level 4.

Long- versus short-segment fixation with an index vertebral screw for management of thoracolumbar fractures

The choice of the best stabilization technique for thoracolumbar fractures remains controversial. While LSF includes too many motion segments, SSF is associated with a high rate of fixation failure and subsequent loss of kyphotic correction. Our objective is to compare the surgical, clinical, and radiological outcomes of thoracolumbar spine fixation using long-segment fixation (LSF) versus short-segment fixation (SSF) with a screw in the fractured vertebra. We retrospectively evaluated 63 patients with single- level thoracolumbar fracture types A and B treated during the period between 2010 and 2017 in our institution. Group A (30 patients) was treated by SSF with an intermediate screw in the fractured vertebra, while group B (33 patients) was treated by LSF. Both groups were compared in terms of surgical, clinical, and radiological outcomes. The mean operative blood loss was significantly lower in group A than in group B (451.3 ± 79.9 and 690 ± 92.1 ml, respectively). The mean operative time in Group A was significantly shorter than in group B (58.4 ± 14.8 and 81.5 ± 12.3 minutes, respectively). Both groups achieved a similar Visual Analogue Scale (VAS) for pain and Oswestry Disability Index (ODI) score. No significant difference was found as regards the kyphotic angle correction and the correction loss at final follow-up. In conclusion, SSF with a screw in the fractured vertebra achieved comparable functional and radiological outcomes to LSS with less blood loss and operative time.

Comparison of the Outcomes between AO Type B2 Thoracolumbar Fracture with and without Disc Injury after Posterior Surgery

Objective

The type AO B2 thoracolumbar fracture is a kind of flexion‐distraction injury and the effect of disc injury on treatment results of patients with B2 fracture remains unclear. The objective of the current study was to compare and analyze the outcomes in AO Type B2 thoracolumbar fracture patients with and without disc injuries in terms of the Cobb angle of kyphosis, the incidence of complication, and the rate of implant failure.

Methods

This is a retrospective study. Of the 486 patients with thoracolumbar fractures who underwent posterior fixation, 38 patients with AO type B2 injuries were included. All the patients were divided into two groups according to changes in the adjoining discs. Disc injury group A included 17 patients and no disc injury group included 21 patients. Clinical and radiologic parameters were evaluated before surgery, after surgery, and at follow‐up. Clinical outcomes included visual analogue scale (VAS) scores, incidence of complications, and incidence of implant failure. Radiologic assessment was accomplished with the Cobb angle (CA), local kyphosis (LK), percentage of anterior vertebral height (AVBH%), intervertebral disc height, and intervertebral disc angle. Fisher's precision probability tests were employed and chi square test were used to compare categorical variables. Paired sample t tests and independent‐sample t tests were used to compare continuous data.

Results

Disc injury mainly involved the cranial disc (15/19, 78.9%). The mean follow‐up period for the patients was 30.2 ± 20.1 months. No neurologic deterioration was reported in the patients at the last follow‐up. Radiological outcomes at the last follow‐up showed significant differences in the CA (18.59° ± 13.74° vs 8.16° ± 9.99°, P = 0.008), LK (12.74° ± 8.00° vs 6.55° ± 4.89°, P = 0.006), and %AVBH (77.16% vs 90.83%, P = 0.01) between the two groups.Implant failure occurred after posterior fixation in five patients with disc injury who did not undergo interbody fusion during the initial surgery. Additionally, in the subgroup analysis, interbody fusion in the implant failure group were significantly different than in the no implant failure group (0% vs 75%, P = 0.009).

Conclusions

AO B2 fracture patients with disc injury have higher risk of complications, especially implant failure after posterior surgery. Interbody fusion should be considered in AO type B2 fracture patients with disc injury.

Biomechanical Analysis of the External Fixation in a Lumbar Fracture Model: A Finite Element Study

Purpose

This study aimed to investigate the biomechanical characteristics of the external spinal fixation for treating lumbar fracture through finite element analysis (FEA) and provide a theoretical basis for its further application.

Methods

Two different models of L3 fracture fixed with the external spinal fixation and the internal fixation system respectively were constructed. The ROM, maximum stresses at L3, and the screws of the two models were measured under load control. Subsequently, the applied torque, the maximum stressed at L3, L1/2, L2/3, L3/4, L4/5 discs and the screws were analyzed under displacement control.

Results

Under load control, the external fixation model reserved more ROM than the internal fixation model (40.4–48.0% vs 30.5–41.0%). Compared to the internal fixation model, the maximum stresses at L3 and screws in the external fixation model were increased. Under displacement control, the external fixation model required fewer moments (N·mm) than the internal fixation model (flexion: 7500 vs 12,294; extension: 7500 vs 9027). Further, the maximum stresses at L3 and the screws in the external fixation model were greater than those of the internal fixation model, while the maximum stresses at the upper and lower adjacent discs of fixed segments were less than the internal fixation model.

Conclusion

Compared to the internal fixation system, the external fixation has a better stress distribution with the greater overall mobility. It theoretically reduces the stress concentration of the adjacent discs and the stress shielding of the fractured vertebral body.

Efficacy of anterior-posterior decompression on thoracolumbar spine fracture with spinal cord injury and analysis of risk factors for postoperative deep vein thrombosis

OBJECTIVE

To investigate the efficacy of anterior-posterior decompression on thoracolumbar spine fracture (TSF) and spinal cord injury (SCI), and assess hazard factors for postoperative deep vein thrombosis (DVT) through logistics regression.

METHODS

A retrospective analysis was made on 130 patients with TSF and SCI admitted to our hospital between Jan 2018 and Jan 2020. Specifically, 72 were treated with anterior decompression (experimental group) and 58 were posterior decompression (control group). The intraoperative blood loss, procedure time, hospitalization, incision size, tactile and motor scores, injured vertebral body height, Cobb angle and complications were observed. Patients were grouped based on DVT occurrence. The risk factors were assessed through logistics regression.

RESULTS

In comparison to experimental group, the intraoperative blood loss, procedure time and incision size in the control group were lower (P<0.05), while the hospitalization time was shorter (P<0.05). After treatment, the tactile and motor scores were improved 3 months after operation, and the experimental group was better (P<0.05). Additionally, injured vertebral body height and Cobb angle increased, and the experimental group was higher (P<0.05). Incidence of postoperative complications revealed no marked difference (P>0.05). Logistics regression analysis manifested that ASIA rating, diabetes, obesity and age were tied to postoperative DVT.

CONCLUSION

Anterior decompression therapy can effectively improve the clinical outcome of patients with thoracolumbar spinal fractures and spinal cord injury on the improvement of tactile and motor functions, but posterior decompression is better than anterior surgery in terms of bleeding, incision length, operating time, and hospital stay. Surgical treatment needs to be selected according to the condition of patients. Furthermore, it was identified that ASIA rating, history of diabetes, obesity and age are risk factors affecting patients with postoperative lower extremity DVT.

Outcomes of Anterior Decompression and Anterior Instrumentation in Thoracolumbar Burst Fractures-A Prospective Observational Study With Mid-Term Follow-up

OBJECTIVE

To analyze the functional, neurological, and radiological outcomes after anterior surgery in thoracolumbar burst fractures.

DESIGN

Prospective observational study.

SETTING

Tertiary care hospital.

PATIENTS

Thirty-six patients with thoracolumbar burst fractures (T11-L2).

INTERVENTION

Anterior decompression, anterior column reconstruction with mesh cage, and instrumented stabilization.

OUTCOME

Functional (Visual Analog Score, Oswestry Disability Index, and Spinal Cord Independence Measure), neurological (ASIA Impairment Scale), and radiological (kyphosis, anterior vertebral height loss, canal encroachment %) parameters.

RESULTS

Patients were prospectively followed for a mean duration of 5.9 ± 3.2 years (2.4-10 years). Statistically significant improvement was noted in functional outcomes from preop values (P-value < 0.001). 29 patients (80.5%) had improvement in neurology after surgery at the final follow-up with a positive correlation with % change in canal encroachment (r = 0.64, P -0.018). The mean preoperative kyphosis of 29.1 ± 11.9 degrees got corrected to 9.4 ± 3.8 degrees in immediate postop and 15.7 ± 11.8 at the final follow-up(P < 0.001). Preoperative mean canal encroachment of 58.5 ± 15.7% was reduced to 6.5 ± 3.2% postoperatively (P < 0.001). Two patients developed neurological complications (subacute progressive ascending myelopathy), and 5 patients developed pulmonary complications. No pseudarthrosis, implant loosening, or cage migration was noted in any patient.

CONCLUSION

Anterior surgery performed in 36 patients with thoracolumbar burst fractures in our study showed good outcomes. 80.5% of patients improved in neurology after surgery by at least one ASIA Impairment Scale grade. There was statistically significant improvement noted in radiological outcome (Kyphosis and Canal encroachment %) and functional outcome (Visual Analog Score, Oswestry Disability Index, and Spinal Cord Independence Measure score) after surgery in immediate postop and at the final follow-up. Only 13.8% of patients developed pulmonary complications that were managed successfully with chest drain.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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.

Modified minimally invasive technique for decompression and reduction of thoracolumbar burst fracture with neurological symptoms: Technical Note

Purpose

There are few reports about minimally invasive decompression and fixation for patients with thoracolumbar fracture and neurological symptoms. The previously reported method requires complete laminectomy, and removal of the medial part of the pedicle to expose the spinal canal for reduction. Thus, some approach-related damage to the bony structure and soft tissue still occurs. This study was performed to describe a modified minimally invasive tube technique for decompression and reduction of thoracolumbar fracture with neurological symptoms. This modified technique preserves most of the posterior structures of the spine as well as the muscle.

Methods

Percutaneous pedicle screws were placed on the vertebrae superior and inferior to the fracture and at the fracture segment on the side with less severe symptoms. After retraction, the tube for decompression was placed on the facet joint where the decompression was needed. Under microscopic vision, part of the lamina and ligamentum flavum were removed to expose the spinal canal, and an L-shaped probe was used to reduce the bone fragment.

Results

The modified method was successfully used in eight patients. Complete decompression was achieved and the bone fragment was safely reduced through the tube under microscopy in all cases. Fluoroscopy confirmed that the positioning of the percutaneous pedicle screw was good and the bone fragment was reduced. The neurological status was improved in all patients at last follow up.

Conclusion

The modified method of minimally invasive decompression and fusion is effective in treating thoracolumbar fractures with neurological symptoms and preserves most of the ligaments and bone structure.

Thoracolumbar Burst Fractures: A Systematic Review and Meta-Analysis Comparing Posterior-Only Instrumentation Versus Combined Anterior-Posterior Instrumentation

STUDY DESIGN

Meta-analysis.

OBJECTIVE

To compare the clinical, functional, and radiological outcomes of posterior-only versus combined anterior-posterior instrumentation in order to determine the optimal surgical intervention for thoracolumbar burst fractures.

SUMMARY OF BACKGROUND DATA

Unstable thoracolumbar burst fractures warrant surgical intervention to prevent neurological deterioration and progressive kyphosis, which can lead to significant pain and functional morbidity. The available literature remains largely inconclusive in determining the optimal instrumentation strategy.

METHODS

Electronic searches of MEDLINE (1948-May 2020), EMBASE (1947-May 2020), The Cochrane Library (1991-May 2020), and other databases were conducted. Cochrane Collaboration guidelines were used for data extraction and quality assessment. Outcomes of interest were divided into three categories: radiological (degree of postoperative kyphosis correction; loss of kyphosis correction at final follow-up), functional (visual analogue scale [VAS] pain score; Oswestry Disability Index [ODI] score), and clinical (intraoperative blood loss; length of stay [LOS]; operative time; the number and type of postoperative complications).

RESULTS

Four randomized control trials (RCTs) were retrieved, including 145 randomized participants. Seventy-three patients underwent posterior-only instrumentation and 72 underwent combined instrumentation. No significant difference was found in the degree of postoperative kyphosis correction (P = 0.39), VAS (centimeters) at final follow-up (P = 0.67), ODI at final follow-up (P = 0.89) or the number of postoperative complications between the two approaches (P = 0.49). Posterior-only instrumentation was associated with lower blood loss (P < 0.001), operative time (P < 0.001), and LOS (P = 0.01). Combined instrumentation had a lower degree of kyphosis loss at final follow-up (P = 0.001). There was heterogeneity in the duration of follow-up between the included studies (mean follow-up range 24-121 months).

CONCLUSION

The available literature remains largely inconclusive. In order to reliably inform practice in this area, there is a need for large, high-quality, multicenter RCTs with standardized reporting of outcomes, with a particular focus on outcomes relating to patient function and severe complications causing long-term morbidity.Level of Evidence: 2.

Transforaminal Interbody Impaction of Bone Graft to Treat Collapsed Nonhealed Vertebral Fractures with Endplate Destruction: A Report of Two Cases

Background

A collapsed nonhealed vertebral fracture with endplate destruction is a challenging injury to address, as there is no single definitive treatment. We present two cases using an innovative transforaminal grafting technique to treat these patients. Case Presentation. Case 1: a 72-year-old woman had nonunion of an L1 compression fracture with destruction of both endplates. T12/L1 and L1/L2 transforaminal debridement and impaction of bone graft were performed followed by posterior instrumentation. At three years follow-up, the fusion mass between T12/L1 and L1/L2 was solid and the patient had minimal pain. Case 2: a 62-year-old woman had nonunion of an L1 burst fracture with destruction of the lower endplate. Hemilaminectomy and transforaminal interbody impaction of bone graft was performed. At three years follow-up, the patient had no back pain and a solid fusion. In both cases, local kyphosis was corrected and fusion obtained.

Conclusions

Collapsed nonhealed vertebral body fractures combined with endplate destruction can be successfully treated with a one-step posterior surgery consisting of transforaminal debridement and impaction of bone graft in combination with posterior pedicle instrumentation.

Management of thoracic spine dislocation by total vertebrectomy and spine shortening: case report

INTRODUCTION

The treatment of thoracic spine fracture-dislocations is now well established with the recent progress in spine surgery. Although most affected individuals have a degree of spinal cord injury (SCI), early surgical reduction, and stabilization of the unstable deformity allow an immediate program of rehabilitation. Vertebrectomy is considered as the last surgical technique reserved for the most persistent spinal deformities that cannot be brought to an acceptable correction with less invasive methods.

CASE PRESENTATION

We present a case of a 19-year-old male with a sub-acute thoracic spine fracture-dislocation at the level of T7-T8 who underwent a posterior T8 vertebrectomy with reduction and instrumentation from T4 down to T1. The individual had excellent results during follow-ups regarding alignment, fusion, and rehab program.

DISCUSSION

In this case, we present the good outcome of vertebrectomy and spine shortening in an individual with thoracic spine fracture-dislocation, and the advantages of posterior approach.

Reprint of: Thoracolumbar burst fractures associated with incomplete neurological deficit in patients under the age of 40: Is the posterior approach enough? Surgical treatment and results in a case series of 10 patients with a minimum follow-up of 2 years

INTRODUCTION

Surgical management of thoracolumbar burst fractures is controversial. While the goals of surgical treatment are well accepted (i.e., fracture reduction and stabilization, neural elements decompression, and segmental angular deformity correction), the choice of the best surgical approach (i.e., posterior vs. anterior vs. combined approach) remains controversial. Several studies have debated the advantages of each surgical approach but there is no definitive evidence available to date, particularly in young adult patients. The aim of this study was to assess whether posterior approach alone can be a valid surgical treatment for patient under the age of 40 affected by thoracolumbar burst fractures and incomplete neurological deficits.

MATERIAL AND METHODS

A total of 10 consecutive patients affected by thoracolumbar burst fractures associated with incomplete neurological deficits treated at our institution from January 2015 to February 2017 were included in our study. All patients were under the age of 40 at the time of injury and underwent decompression and stabilization using the posterior surgical approach alone. Demographics, clinical, and radiographic parameters were recorded preoperatively, postoperatively and at the latest available follow-up. The minimum follow-up was set at 2 years post-operatively.

RESULTS

The mean operative time was 303.6 min (range, 138-486). Average blood loss was 756 mL (range, 440-2100). Nine out of ten patients returned to a normal neurological status after surgery while 1 patient showed some improvement but did not recover completely. Segmental kyphotic deformity improved from a mean of 21.8° before surgery to 14.8° at the time of the last follow-up. The anterior and posterior wall height of the fractured vertebra was restored with an average of 4 mm. The Visual Analogue Scale score reported an improvement from the mean preoperative value of 7.92 to 1.24 at the last follow-up; 8 out of 10 patients resumed physical activity while all of them returned to work.

CONCLUSIONS

A single posterior surgical approach is an acceptable option in terms of clinical, radiological and functional outcomes at 2 years follow-up in patients under the age of 40 presenting with a thoracolumbar burst fracture and neurological deficit.

Thoracolumbar burst fractures associated with incomplete neurological deficit in patients under the age of 40: Is the posterior approach enough? Surgical treatment and results in a case series of 10 patients with a minimum follow-up of 2 years

INTRODUCTION

Surgical management of thoracolumbar burst fractures is controversial. While the goals of surgical treatment are well accepted (i.e., fracture reduction and stabilization, neural elements decompression, and segmental angular deformity correction), the choice of the best surgical approach (i.e., posterior vs. anterior vs. combined approach) remains controversial. Several studies have debated the advantages of each surgical approach but there is no definitive evidence available to date, particularly in young adult patients. The aim of this study was to assess whether posterior approach alone can be a valid surgical treatment for patient under the age of 40 affected by thoracolumbar burst fractures and incomplete neurological deficits.

MATERIAL AND METHODS

A total of 10 consecutive patients affected by thoracolumbar burst fractures associated with incomplete neurological deficits treated at our institution from January 2015 to February 2017 were included in our study. All patients were under the age of 40 at the time of injury and underwent decompression and stabilization using the posterior surgical approach alone. Demographics, clinical, and radiographic parameters were recorded preoperatively, postoperatively and at the latest available follow-up. The minimum follow-up was set at 2 years post-operatively.

RESULTS

The mean operative time was 303.6 min (range, 138-486). Average blood loss was 756 mL (range, 440-2100). Nine out of ten patients returned to a normal neurological status after surgery while 1 patient showed some improvement but did not recover completely. Segmental kyphotic deformity improved from a mean of 21.8° before surgery to 14.8° at the time of the last follow-up. The anterior and posterior wall height of the fractured vertebra was restored with an average of 4 mm. The Visual Analogue Scale score reported an improvement from the mean preoperative value of 7.92 to 1.24 at the last follow-up; 8 out of 10 patients resumed physical activity while all of them returned to work.

CONCLUSIONS

A single posterior surgical approach is an acceptable option in terms of clinical, radiological and functional outcomes at 2 years follow-up in patients under the age of 40 presenting with a thoracolumbar burst fracture and neurological deficit.

Does Combined Anterior-Posterior Approach Improve Outcomes Compared with Posterioronly Approach in Traumatic Thoracolumbar Burst Fractures?: A Systematic Review

The aim of this systematic review was to evaluate the surgical, radiological, and functional outcomes of posterior-only versus combined anterior-posterior approaches in patients with traumatic thoracolumbar burst fractures. The ideal approach (anterior-only, posterior-only, or combined anterior-posterior) for the surgical management of thoracolumbar burst fracture remains controversial, with each approach having its advantages and disadvantages. A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed (registration no., CRD42018115120). The authors reviewed comparative studies evaluating posterior-only approach compared with combined anterior-posterior approaches with respect to clinical, surgical, radiographic, and functional outcome measures. Five retrospective cohort studies were included. Postoperative neurological deterioration was not reported in either group. Operative time, estimated blood loss, and postoperative length of stay were increased among patients in the combined anterior-posterior group in one study and equivalent between groups in another study. No significant difference was observed between the two approaches with regards to long-term postoperative Cobb angle (mean difference, -0.2; 95% confidence interval, -5.2 to 4.8; p =0.936). Moreover, no significant difference in functional patient outcomes was observed in the 36item Short-Form Health Survey, Visual Analog Scale, and return-to-work rates between the two groups. The available evidence does not indicate improved clinical, radiologic (including kyphotic deformity), and functional outcomes in the combined anterior-posterior and posterior-only approaches in the management of traumatic thoracolumbar burst fractures. Further studies are required to ascertain if a subset of patients will benefit from a combined anterior-posterior approach.

Anterior versus posterior approach in the management of AO Type B1 & B2 traumatic thoracolumbar fractures: A level 1 trauma centre study

The authors perform a retrospective trauma registry study to compare clinical, surgical and radiographical variables between anterior and posterior approaches in the management of AO Type B1 and B2 traumatic thoracolumbar fractures. Consecutive patients with surgically-managed AO Type B1 and B2 thoracolumbar fractures were included. Baseline demographics, surgical outcomes (including duration of surgery, postoperative morbidity etc.), neurological outcomes and radiographical outcomes (Cobb angle, Gardner angle) were compared between the anterior and posterior approaches. A total of 108 patients (anterior: n = 25, posterior: n = 83) were included. There were no significant between-group differences in baseline demographics and co-morbidities. Duration of surgery was longer in the anterior compared to posterior group (251 ± 91 min vs. 175 ± 69 min respectively, p < 0.00003). At six-months post-surgery, there was a trend towards improvement of at least one AIS grade in the posterior compared to the anterior group (85.7% vs. 33.3% respectively, p = 0.08). Postoperative complication profile showed no difference between approaches. The posterior approach resulted in better sagittal correction (Cobb angle; anterior: +1.05 ± 8.61 deg, posterior: -3.87 ± 9.88 deg, p = 0.03) and smaller loss of correction at 6-months post-surgery (Cobb angle; anterior: 8.36 ± 9.47 deg, posterior: 4.88 ± 6.62 deg, p = 0.048). This is the first study investigating surgical approach in flexion-distraction thoracolumbar fractures. Besides a shorter operative duration, the posterior approach seems to portend more favourable radiological correction at 6 months when compared to the anterior approach. Given the inherent selection bias of this study, definitive recommendations regarding the anterior versus posterior approach cannot be made. Further well-defined, prospective studies are necessary.

Anterior versus posterior approach in traumatic thoracolumbar burst fractures deemed for surgical management: Systematic review and meta-analysis

Uncertainties remain regarding the optimal surgical approach in the treatment of traumatic thoracolumbar burst fractures. We aim to compare the surgical, radiological and functional outcomes in anterior versus posterior approaches in patients with traumatic thoracolumbar burst fractures deemed for surgical management. A systematic review adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. Qualitative analysis and where suitable, meta-analysis were performed to compute pooled estimates of the differences between anterior and posterior approaches. A total of six studies (three observational, one prospective non-randomized trial, two randomized controlled trials) were included. There were no cases of postoperative neurological decline. Meta-analysis demonstrates a longer duration (Mean Difference (MD) + 81.68, 95% CI 39.20 to 123.16, p < 0.001) and increased estimated blood loss (MD + 426.27, 95% CI 119.84 to 732.70, p = 0.006) for the anterior approach. No difference between approaches was found regarding length of hospital stay, late postoperative kyphotic angle, construct failure rate, instrumentation revision rate, rate of return to work, and total hospital charges. Limitations include the small number of, and heterogeneity across studies. Given the similarities in neurological, radiological and functional outcomes between the two approaches, the longer duration and estimated blood loss in the anterior approach should be a point of consideration when selecting the surgical approach. There is an urgent need for contemporary, high quality research in this area.

Influence of Gender on Health-Related Quality of Life and Disability at 1 Year After Surgery for Thoracolumbar Burst Fractures

STUDY DESIGN

Case series.

OBJECTIVE

Thoracolumbar burst fractures (TLBF) are the most frequent type of spinal fractures. Approximately half of the patients are neurologically intact and their treatment is still debatable. Gender could influence outcome after surgical procedures, but this is still unclear in patients sustaining a spinal fracture. The aim of this study was to investigate how gender influences health-related quality of life (HRQOL) and disability in patients operated on for TLBF.

METHODS

We identified 44 neurologically intact patients from a consecutive series of patients treated surgically for a single-level traumatic burst fracture (AOSpine Subaxial Classification System A3) in the thoracolumbar transition area (Th12-L2). At 1 year after surgery, they were evaluated using the SF-36v2 questionnaire to assess HRQOL and Oswestry Disability Index (ODI) questionnaire to evaluate disability.

RESULTS

Male patients scored higher in each item of the SF-36v2, with significant differences (P < .05) for Physical Function (PF), Bodily Pain (BP), and Social Function (SF). Male patients also had lower disability scores. Overall ODI score had a strong correlation with Physical Function, Role-Physical, Bodily Pain, Vitality, Mental Health, and overall Physical Component Summary (PCS) of the SF-36 in women, but only with Physical Function, Role-Physical, Role-Emotional, and PCS in men.

CONCLUSIONS

In this study, male patients reported better outcomes at 1 year after surgery for TLBF than women. Disability strongly correlated with the overall HRQOL, physical and mental health in women, but not in men. We found gender-related differences favoring men after surgical interventions for spinal fractures.

The mechanism of thoracolumbar burst fracture may be related to the basivertebral foramen

BACKGROUND CONTEXT

The basivertebral foramen (BF), located in the middle posterior wall of the vertebral body, may induce local weakness and contribute to the formation of a retropulsed bone fragment (RBF) in thoracolumbar burst fracture (TLBF). We hypothesize that the mechanism of TLBF is related to the BF.

PURPOSE

This study aimed to clarify the relationship between RBFs and the BF in TLBFs, and to explain the results using biomechanical experiments and micro-computed tomography (micro-CT).

STUDY DESIGN

A comprehensive research involving clinical radiology, micro-CT, and biomechanical experiments on cadaveric spines was carried out.

PATIENT SAMPLE

A total of 162 consecutive patients diagnosed with TLBF with RBFs, drawn from 256 patients who had reported accidents or injuries to their thoracolumbar spine, comprised the patient sample.

OUTCOME MEASURES

Dimensions and location of the RBFs in relation to the BF were the outcome measures.

MATERIALS AND METHODS

Computed tomography reconstruction imaging was used to measure the dimensions and location of RBFs in 162 patients (length, height, width of RBF and vertebral body). Furthermore, micro-CT scans were obtained of 10 cadaveric spines. Each vertebral body was divided into three layers (superior, middle, and inferior), and each layer was divided further into nine regions (R1-R9). Microarchitecture parameters were calculated from micro-CT scans, including bone volume fraction (BV/TV), connectivity (Conn.D), trabecular number (Tb.N), trabecular thickness (Tb.Th), and bone mineral density (BMD). Differences were analyzed between regions and layers. Burst fractures were simulated on cadaveric spines to explore the fracture line location and test the relationship between RBFs and BF.

RESULTS

Retropulsed bone fragment width was usually one-third of the width of the vertebral body, whereas RBF length and height were approximately half of the corresponding vertebral body dimensions. Measures of trabecular bone quality were generally lowest in those central and superior regions of the vertebral body which are adjacent to the BF and which are most affected by burst fracture. In simulated TLBFs, the fracture line went across the vertex or upper surface of the BF.

CONCLUSIONS

The most vulnerable regions in the vertebral body lie within or just superior to the BF. The central MR2 region in particular is at risk of fracture and RBF formation.

[Rationale and complications of the anterior-lateral extrapleural retroperitoneal approach for unstable thoracolumbar fractures: Experience in 86 consecutive patients]

OBJECTIVES

To describe the rationale, pros and cons, and complications of the anterior-lateral extrapleural retroperitoneal approach for unstable (TLICS>4) thoracolumbar fractures.

PATIENTS AND METHODS

Clinical and radiological data and outcomes from a cohort treated surgically via said approach were retrospectively reviewed. All patients were operated on exclusively by 5 neurosurgeons trained in spine surgery.

RESULTS

Between June 1999 and December 2015, 86 patients underwent surgery (median age 42years, most common level: L1). Approximately 32.5% presented with a preoperative neurological defect. After surgery (mean duration: 275minutes), 75.6% presented with no neurological sequelae and only one-third required blood transfusion. Median postoperative stay was 7days. Correction of kyphosis was considered adequate and suboptimal but acceptable in 91% and 9% of the patients, respectively. Complications occurred in 36 patients, the majority being transient. We observed failure of the construct in 2 cases (collapse of an expandable cage and extrusion of a locking screw). No infections, vascular or visceral lesions, permanent neurological worsening or mortality occurred during hospitalisation. One patient ultimately needed additional posterior fixation due to persistence of pain. Median follow-up was 252days (27.9% was lost to follow-up).

CONCLUSIONS

The extrapleural extraperitoneal approach provides solid anterior reconstruction, allows wide decompression of the spinal canal, and permits adequate and long-lasting correction of kyphosis. The rates of infection, construct failure, need for reoperation and vascular or visceral lesions are minimal.

Minimally Invasive Posterior Decompression Combined With Percutaneous Pedicle Screw Fixation for the Treatment of Thoracolumbar Fractures With Neurological Deficits: A Prospective Randomized Study Versus Traditional Open Posterior Surgery

STUDY DESIGN

Prospective randomized cohort study.

OBJECTIVE

To compare the surgical results of minimally invasive posterior decompression combined with percutaneous pedicle screws fixation (minimally invasive surgery [MIS]) and posterior open surgery (OS) for the treatment of thoracolumbar fracture with neurological deficits.

SUMMARY OF BACKGROUND DATA

Thoracolumbar fracture with neurological deficits usually undergoes surgical intervention. OS can achieve satisfied results, but the main disadvantage is approach-related complications. No study, however, focused on the treatment of this disease by MIS through posterior approach.

METHODS

Sixty consecutive cases of thoracolumbar fractures with neurological deficits were randomized into MIS group and OS group. Incision length, blood loss, postoperative drainage volume, hospitalization days, blood transfusion rate, analgesic use rate, and x-ray exposure time were used to evaluate the perioperative information and Visual Analog Scale (VAS), Japanese Orthopedics Association (JOA) score, and American Spinal Injury Association grade for patients' symptom. For radiological assessment, sagittal Cobb angle, percentage of vertebral height, and vertebral wedging angle were measured.

RESULTS

Fifty-nine of sixty patients were followed-up for at least 12 months. MIS group was superior in perioperative information (P < 0.05), except in the operative time (P = 0.165) and x-ray time (P = 0.000). The operative time seemed longer in MIS group, but no significant difference was found. The x-ray time was significantly higher in MIS group. The mean Visual Analog Scale and Japanese Orthopedics Association scores of the final follow-up in MIS group were better than that in OS group (P < 0.05). Patients in both group achieved a similar neurological recovery according to American Spinal Injury Association grade (P = 0.760). A broken screw was found in one patient in MIS group and a broken rod in one patient in OS group.

CONCLUSION

MIS group has achieved the similar effect of OS group and it can minimize the approach-related complication. It also faced with some shortages, such as larger radiation dose and longer learning curve.

LEVEL OF EVIDENCE

2.