Fractured vertebra antedisplacement reconstruction technique: a feasible treatment choice for posttraumatic thoracolumbar kyphosis

OBJECTIVE

The goal of this study was to evaluate the feasibility of the fractured vertebra antedisplacement reconstruction technique for the treatment of posttraumatic thoracolumbar kyphosis (PTK).

METHODS

A total of 22 patients with PTK who were treated with the fractured vertebra antedisplacement reconstruction technique were retrospectively analyzed. The radiological evaluation included global kyphosis, thoracolumbar angle, and sagittal vertical axis. The clinical evaluation included visual analog scale pain score, Oswestry Disability Index score, SF-12 Health Survey score, and American Spinal Injury Association grade. The complications were recorded.

RESULTS

The mean global kyphosis was 55.0° ± 12.6° preoperatively, 8.5° ± 5.0° postoperatively, and 10.3° ± 4.8° at the latest follow-up (p < 0.001). The average total kyphosis correction achieved was 44.7° ± 14.2°, with a range of 23.4°-79.4°, indicating a mean final correction of 80.1%. The mean thoracolumbar angle was 46.2° ± 13.2° preoperatively, 6.6° ± 4.5° postoperatively, and 7.6° ± 4.2° at the latest follow-up (p < 0.001). The mean sagittal vertical axis was improved significantly, from 51.1 ± 24.2 mm preoperatively to 28.5 ± 17.4 mm at the latest follow-up (p = 0.001). One patient (4.5%) experienced single intervertebral fusion nonunion, and 1 patient (4.5%) experienced distal screw loosening. No patients experienced any neurological deterioration. The visual analog scale pain score, Oswestry Disability Index score, SF-12 Health Survey score, and American Spinal Injury Association grade achieved significant improvement at the latest follow-up.

CONCLUSIONS

Fractured vertebra antedisplacement reconstruction technique can effectively correct kyphosis, reconstruct spinal stability, and improve the patient's symptoms and neurological function. This technique is safer, minimally traumatic, and less technically demanding to avoid osteotomy-related complications. It is a feasible treatment choice for PTK.

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.

Thoracolumbar fractures after the 2023 Türkiye earthquake and controversial mechanism of occurrence

BACKGROUND

Earthquakes are devastating events that may severely injure the human body. The spine is one of the important parts of the human body that may be affected by earthquake trauma. The aim of this study is to focus on thoracolumbar fractures secondary to the 2023 Turkey Earthquake.

METHODS

The data of 15 patients who were affected by the earthquake, rescued from the rubble, and subsequently treated for spinal fractures in our department were reviewed retrospectively. The clinical, radiological, and surgical features of the patients were recorded, and the outcomes were investigated.

RESULTS

Among the 15 patients, 12 were female, and 3 were male. Their ages ranged from 22 to 79 years. The average duration of being trapped under debris was 4.7 hours. According to the Frankel classification, 12 patients (80%) were categorized as Frankel E, 2 patients (13.3%) as Frankel A, and 1 patient (6.6%) as Frankel C. Of these patients, 6 underwent surgical treatment, while a total of 9 patients received conservative treatment. Multiple vertebral fractures were identified in 4 patients. While 3 patients with multiple fractures were treated conservatively, 1 patient underwent surgery due to an L1 fracture. All surgeries consisted of spinal canal de-compression and spinal instrumentation. Among patients without thoracolumbar junction fractures, 1 had a T8 fracture, 1 had an L4 fracture, and 1 had a sacral fracture along with an accompanying lumbar plexus injury.

CONCLUSION

Thoracolumbar fractures are frequently observed after earthquakes. However, the exact mechanism of these fractures is not well known. Surgical management should be reserved for patients with progressive neurological deficits, while conservative treatment is the option for stable fractures.

Analysis of Influencing Factors of Vertebral Height Loss After Pedicle Screw Fixation of Thoracolumbar Fracture

STUDY DESIGN

Retrospective case-control study.

OBJECTIVE

To explore the related factors of vertebral height loss (VHL) after pedicle screw fixation of thoracolumbar fracture and to determine the optimum prediction point.

SUMMARY OF BACKGROUND DATA

With the widespread application of thoracolumbar fracture internal fixation, VHL after the operation is increasingly presented. However, there is no unified conclusion on the specific cause of VHL and how to predict it.

METHODS

A total of 186 patients were selected and divided into the loss group (n = 72) and the not-loss group (n = 114) according to whether the fractured vertebral height was lost after the operation. The two groups were compared concerning sex, age, body mass index, osteoporosis self-assessment tool for Asians (OSTA), fracture types, number of fractured vertebrae, preoperative Cobb angle and compression degree, number of screws, and extent of vertebral restore. Univariate analysis and Multivariate logistic regression analysis were performed to identify the independent factors for the VHL with the receiver operating characteristic curve and the optimal prediction value was calculated according to area under the curve.

RESULTS

Multivariate logistic regression analysis showed that OSTA ( P < 0.05) and preoperative vertebral compression ( P < 0.05) were significantly correlated with postoperative VHL, which were independent risk factors for postoperative VHL. The OSTA of 2.32 and the preoperative vertebral compression degree of 38.5% were the best prediction points for postoperative VHL based on the Youden Index analysis.

CONCLUSIONS

The OSTA and preoperative vertebral compression were independent risk factors for VHL. The risk of postoperative VHL was significantly higher when the OSTA was ≤2.32 or the preoperative vertebral compression was ≥38.5%.

LEVEL OF EVIDENCE

Level III.

Factors Associated with Intradiscal Vacuum Phenomenon after Traumatic Thoracolumbar Fracture

Introduction  Posttraumatic kyphosis of the thoracolumbar spine is a possible cause of deterioration of activities of daily living. Thus, postoperative kyphosis is an important issue in treating traumatic thoracolumbar fractures. The intradiscal vacuum phenomenon (IVP) after a traumatic thoracolumbar fracture is considered an important predictor of severe kyphosis after implant removal. However, the associated factors are not yet clear. Methods  The study included data from 94 intervertebral discs on the cephalocaudal side of 47 fractured vertebrae of 45 patients for traumatic thoracolumbar fracture due to high-energy trauma. We assessed the demographics of patients (age, sex, cause of injury, location of injured vertebra, fracture type, cephalocaudal side), imaging finding (kyphosis angle of fractured vertebra at the injury, endplate fracture on computed tomography [CT], intervertebral injury on magnetic resonance image [MRI]), and IVP on CT conducted more than 6 months after surgery. We divided the intervertebral discs into an IVP group and a non-IVP group. To identify factors associated with an IVP, univariate analysis and multivariate logistic regression analysis were conducted. Results  IVP was observed in 27 (29%) of 94 intervertebral discs on CTs conducted at an average of 14.0 months postoperatively. In univariate analysis, the IVP group ( n  = 27) had a significantly more cephalic side of the injured vertebra, endplate fracture on CT, and disc injury on MRI compared with the non-IVP group ( n  = 67). A multivariate logistic regression analysis was conducted to identify factors associated with IVP. The cephalic side (odds ratio [OR] = 4.183, 95% confidence interval [CI] = 1.269-13.785) and endplate fracture on CT (OR = 9.564, 95% CI = 1.940-47.143) were identified as independent factors associated with IVP. Conclusions  IVP was observed in 27 (29%) of 94 intervertebral discs. The cephalic side and endplate fracture on CT were identified as independent factors associated with IVP.

Finite element study of sagittal fracture location on thoracolumbar fracture treatment

Background: Posterior internal fixation is the main method used for the treatment of thoracolumbar fractures. Fractures often occur in the upper 1/3 of the vertebral body. However, they can also occur in the middle or lower 1/3 of the vertebral body. At present, there is no report discussing the potential effects of sagittal location on instrument biomechanics or surgical strategy. The object of this study was to investigate the effect of the sagittal location of the fracture region of the vertebral body on the biomechanics of the internal fixation system and surgical strategy. Methods: A finite element model of the T11-L3 thoracolumbar segment was established based on a healthy person's CT scan. Different sagittal fracture location finite element models were created by resection of the upper 1/3, middle 1/3, and lower 1/3 of the L1 vertebral body. Three surgical strategies were utilized in this study, namely, proximal 1 level and distal 1 level (P1-D1), proximal 2 level and distal 1 level (P2-D1), and proximal 1 level and distal 2 levels (P1-D2). Nine fixation finite element models were created by combining fracture location and fixation strategies. Range of motion, von Mises stress, and stress distribution were analyzed to evaluate the effects on the instrument biomechanics and the selection of surgical strategy. Results: In all three different fixation strategies, the maximum von Mises stress location on the screw did not change with the sagittal location of the fracture site; nevertheless, the maximum von Mises stress differed. The maximum rod stress was located at the fracture site, with its value and location changed slightly. In the same fixation strategy, a limited effect of sagittal location on the range of motion was observed. P2D1 resulted in a shorter range of motion and lower screw stress for all sagittal locations of the fracture compared with the other strategies; however, rod stress was similar between strategies. Conclusion: The sagittal location of a fracture may affect the intensity and distribution of stress on the fixation system but does not influence the selection of surgical strategy.

Percutaneous lordoplasty for the treatment of severe osteoporotic vertebral compression fractures with kyphosis

Objective

The study aimed to explore the safety and effectiveness of percutaneous lordoplasty (PLP) in the treatment of severe osteoporotic vertebral compression fracture (OVCF).

Methods

Included in this prospective study were patients with single-segment acute severe OVCF who were treated with PLP in our institution from July 2016 to October 2019. Patients' back pain and quality of life were assessed using the visual analog scale (VAS) and SF-36 scores. Lateral X-ray radiography of the spine was performed to measure the vertebral height, vertebral kyphotic angle, and segmental kyphotic angle, and to evaluate the outcome of fracture reduction and kyphotic correction. Intra-and postoperative complications were recorded.

Results

Of the 51 included patients, 47 patients were followed up for 12 months. The VAS score decreased from preoperative 7.33 ± 1.92 to postoperative 1.76 ± 0.85 at the 12th month (p < 0.05), and the SF-36 score increased from preoperative 79.50 ± 9.22 to postoperative 136.94 ± 6.39 at the 12th month (p < 0.05). During the 1-year follow-up period, the anterior height of the vertebral body increased significantly from preoperative 10.49 ± 1.93 mm to 19.33 ± 1.86 mm (p < 0.05); the posterior height of the vertebral body increased insignificantly from preoperative 22.23 ± 2.36 mm to 23.05 ± 1.86 mm (p > 0.05); the vertebral kyphotic angle decreased significantly from preoperative 18.33° ± 11.49° to 8.73° ± 1.21° (p < 0.05); and the segmental kyphotic angle decreased significantly from preoperative 24.48° ± 4.64° to 11.70° ± 1.34° (p < 0.05). During the 1-year follow-up period, there was no significant difference in the radiologic parameters, VAS scores, and SF-36 scores, between the 1st day and the 12th month of post-operation (P > 0.05). No nerve damage occurred in any of the cases. Intraoperative cement leakage occurred in six cases, and the fracture of the adjacent vertebral body occurred in one case.

Conclusion

PLP can well reduce the risk of fracture and achieve good kyphotic correction and may prove to be a safe, cost-effective and minimally invasive alternative option for the treatment of severe OVCF with kyphotic deformity.

[Effects of different puncture levels in bilateral percutaneous vertebroplasty on distribution of bone cement and effectiveness of osteoporotic thoracolumbar compression fractures]

Objective

To investigate the effects of different puncture levels on bone cement distribution and effectiveness in bilateral percutaneous vertebroplasty for osteoporotic thoracolumbar compression fractures.

Methods

A clinical data of 274 patients with osteoporotic thoracolumbar compression fractures who met the selection criteria between December 2017 and December 2020 was retrospectively analyzed. All patients underwent bilateral percutaneous vertebroplasty. During operation, the final position of the puncture needle tip reached was observed by C-arm X-ray machine. And 118 cases of bilateral puncture needle tips were at the same level (group A); 156 cases of bilateral puncture needle tips were at different levels (group B), of which 87 cases were at the upper 1/3 layer and the lower 1/3 layer respectively (group B1), and 69 cases were at the adjacent levels (group B2). There was no significant difference in gender, age, fracture segment, degree of osteoporosis, disease duration, and preoperative visual analogue scale (VAS) score, and Oswestry disability index (ODI) between groups A and B and among groups A, B1, and B2 ( P>0.05). The operation time, bone cement injection volume, postoperative VAS score, ODI, and bone cement distribution were compared among the groups.

Results

All operations were successfully completed without pulmonary embolism, needle tract infection, or nerve compression caused by bone cement leakage. There was no significant difference in operation time and bone cement injection volume between groups A and B or among groups A, B1, and B2 ( P>0.05). All patients were followed up 3-32 months, with an average of 7.8 months. There was no significant difference in follow-up time between groups A and B and among groups A, B1, and B2 ( P>0.05). At 3 days after operation and last follow-up, VAS score and ODI were significantly lower in group B than in group A ( P<0.05), in groups B1 and B2 than in group A ( P<0.05), and in group B1 than in group B2 ( P<0.05). Imaging review showed that the distribution of bone cement in the coronal midline of injured vertebrae was significantly better in group B than in group A ( P<0.05), in groups B1 and B2 than in group A ( P<0.05), and in group B1 than in group B2 ( P<0.05). In group A, 7 cases had postoperative vertebral collapse and 8 cases had other vertebral fractures. In group B, only 1 case had postoperative vertebral collapse during follow-up.

Conclusion

Bilateral percutaneous vertebroplasty in the treatment of osteoporotic thoracolumbar compression fractures can obtain good bone cement distribution and effectiveness when the puncture needle tips locate at different levels during operation. When the puncture needle tips locate at the upper 1/3 layer and the lower 1/3 layer of the vertebral body, respectively, the puncture sites are closer to the upper and lower endplates, and the injected bone cement is easier to connect with the upper and lower endplates.

Clinical effect of kyphoplasty in the treatment of osteoporotic thoracolumbar compression fractures in patients with diabetes

Objective

To study the clinical effect and influencing factors of kyphoplasty in the treatment of osteoporotic thoracolumbar compression fractures (OTCF) complicated with type 2 diabetes mellitus (T2DM).

Methods

A total of 472 patients with OTCF complicated with diabetes who were enrolled in our hospital from January to December 2019 were selected as the study subjects, and all patients were treated with percutaneous kyphoplasty (PKP). The effects of gender, age, smoking, drinking, body mass index (BMI), bone mass density (T score), fasting blood glucose level, fasting C-peptide, glycosylated hemoglobin, course of T2DM, vertebral segment and surgical instrument on postoperative improvement were analyzed. The quality of life was evaluated by visual analog score (VAS) and Oswestry disability index (ODI) before PKP and 7 days, and 6 months after PKP, and the patient satisfaction was assessed by the modified Macnab criteria at 6 months postoperatively.

Results

The overall excellent and good rate of evaluation result was satisfactory. In multivariate regression, independent risk factors for poor patient satisfaction included: age ≥70 years (odds ratio (OR) = 2.298, 95% confidence interval [CI] 1.290-4.245, P = 0.025), fasting blood glucose ≥8 mmol/L [OR = 2.657, 95%(CI) 1.288-4.121, P = 0.016], glycosylated hemoglobin ≥6.5 mmol/L [OR = 3.438, 95%(CI) 2.543-4.628, P = 0.001], duration ≥8 years [OR = 1.732, 95%(CI) 1.471-3.253, P = 0.019] and Kyphon instrument [OR = 1.472, 95%(CI) 1.112-2.228, P = 0.018] were independent influencing factors of OTCF complicated with DM.

Conclusion

Kyphoplasty for patients with osteoporotic thoracolumbar compression fractures complicated with diabetes can achieve a satisfactory clinical effect, the curative effect is affected by many factors, attention to these factors can improve the clinical effect.

Long-Segment Versus Short-Segment Pedicle Screw Fixation Including Fractured Vertebrae for the Management of Unstable Thoracolumbar Burst Fractures

Background For the treatment of unstable thoracolumbar fractures, this study compared the results of short-segment fixation with fracture level inclusion (SSFIFL) with long-segment pedicle fixation (LSPF). Methodology In this prospective case series study conducted from January 2015 to January 2019, 80 patients with partial spinal cord lesions were investigated. For the comparison, two groups of 40 patients each were chosen and treated with SSFIFL and LSPF. The outcomes were measured using pre and postoperative radiological parameters and clinical parameters. The radiographic variables included the kyphotic angle with loss of correction, kyphotic deformation, and the Beck index. Mean blood loss, operative time, and cost-effectiveness were also examined for clinical indicators such as the American Spinal Injury Association Impairment Scale, Visual Analog Scale (VAS), and Oswestry Disability Index (ODI). Results There were no substantial variations between the groups regarding age or gender, trauma etiology, fracture level, or fracture pattern. Between the two categories, there appeared to be no notable change in radiological indicators such as kyphotic angle, kyphotic deformation, and Beck index at the end of follow-up (p = 0.120, 0.360, and 0.776, respectively). Both groups had similar neurological outcomes (p = 0.781). In terms of ODI and VAS, statistically, there was no discernible difference (p = 0.567 and 0.161, respectively). In this study, however, there was less surgical time, blood loss, and implant cost (p = 0.05). Conclusions When fracture level is included in a short-segment fixation, the radiological and clinical results are comparable to long-segment posterior fixation. Ultimately, this treatment has proven to be not only a motion segment-saving procedure but also cost-effective.

Imaging parameters and clinical significance of posterior ligament complex injury in thoracolumbar fracture

This study aims to investigate whether the combination of radiographs and computed tomography (CT) images can be used as an alternative means of magnetic resonance imaging examination or a preliminary screening method before examination, so as to improve the accuracy of determining the degree of posterior ligament complex injury in thoracolumbar fracture patients. From May 2011 to May 2019, the patients with thoracolumbar fracture were collected. A total of 150 patients were enrolled. The reference standard was 1.5T magnetic resonance imaging examination and lipid suppression sequence was applied. All radiographs and CT imaging results were measured in the Picture Archiving and Communication System workstation. The upper endplate angle and lower endplate angle, the percentage of vertebral height drop, the difference of inter-spinous process distance on CT images and the translation distance were statistically significant between the 2 groups (P < .05). Receiver operating characteristic curve showed that the diagnostic performance was excellent (all area under the curve > 0.7). To sum, the results showed that endplate angle + inter-spinous process distance on CT images combination had relatively high-quality diagnostic value for posterior ligamentous complex injury in thoracolumbar fracture patients.

[Effectiveness of trans-intervertebral space osteotomy combined with cage implantation for old thoracolumbar compression fracture with kyphosis]

Objective

To investigate the effectiveness of trans-intervertebral space osteotomy (TIO) combined with cage implantation in treatment of old thoracolumbar compression fracture with kyphosis.

Methods

A clinical data of 59 patients with old thoracolumbar compression fracture and kyphosis, who met the selection criteria between January 2010 and August 2020, was retrospectively analyzed. Among them, 20 cases underwent TIO combined with cage implantation (group A), 21 patients underwent TIO (group B), and 18 patients underwent pedicle subtraction osteotomy (PSO; group C). There was no significant difference in gender, age, time from injury to operation, fracture segment, and preoperative Cobb angle, average height of functional spinal unit (FSU), sagittal vertical axis (SVA), visual analogue scale (VAS) score, Japanese Orthopedic Association (JOA) score, and Oswestry disability index (ODI) between groups (P>0.05). The operation time, intraoperative blood loss, and postoperative complications were recorded. Imaging review was performed to observe the fusion of the bone graft. Cobb angle, average height of FSU, and SVA were measured. VAS score, JOA score, and ODI were used to evaluate the degree of low back pain and lumbar function. Frankel grading was used to evaluate neurological function.

Results

The operations of 3 groups were successfully completed. The operation time and intraoperative blood loss were significantly lower in groups A and B than in group C (P<0.05); there was no significant difference between group A and group B (P>0.05). All incisions healed by first intention. Patients in all groups were followed up 23-27 months, with an average of 24.8 months. There was no significant difference in follow-up time between groups (P>0.05). At last follow-up, VAS score, JOA score, ODI, and SVA of 3 groups significantly improved when compared with those before operation (P<0.05), there was no significant difference in the differences of pre- and post-operation between groups (P>0.05). The neurological function grading of 3 groups was Frankel grade E. The Cobb angle and the average height of FSU in 3 groups at immediate and last follow-up significantly improved when compared with preoperative ones (P<0.05), there was no significant difference between immediately after operation and last follow-up (P>0.05). And there were significant differences in above indexes between groups at each time point (P<0.05). At last follow-up, the osteotomy site fused without internal fixation failure or pseudarthrosis formation were observed in 3 groups.

Conclusion

For patients with old thoracolumbar compression fractures with kyphosis, the effectiveness of TIO combined with cage implantation is satisfactory. Compared with TIO and PSO, it can obtain more deformity correction degree and less invasive.

Short-segment fixation and transpedicular bone grafting for the treatment of thoracolumbar spine fracture

Purpose

Thoracolumbar fracture is one of the most common fractures of spine. And short-segment posterior fixation including the fractured vertebra (SSPFI) is usually used for the surgical treatment of it. However, the outcomes of SSPFI for different types of thoracolumbar fractures are not clear, and whether it is necessary to perform transpedicular bone grafting is still controversial. This study was conducted to determine the clinical efficacy of SSPFI for the treatment of different types of single-level thoracolumbar fracture, and make clear what kind of fractures need transpedicular bone grafting during the surgery.

Methods

Patients with single-level thoracolumbar fracture undergoing SSPFI surgery between January 2013 and June 2020 were included in this study. The operative duration, intraoperative blood loss, anterior vertebral height ratio (AVHR) and anterior vertebral height compressive ratio (AVHC) of the fractured vertebra, local kyphotic Cobb angle (LKA), vertebral wedge angle (VWA) and correction loss during follow up period were recorded. Outcomes between unilateral and bilateral pedicle screw fixation for fractured vertebra, between SSPFI with and without transpedicular bone grafting (TBG), and among different compressive degrees of fractured vertebrae were compared, respectively.

Results

A total of 161 patients were included in this study. All the patients were followed up, and the mean follow-upped duration was 25.2 ± 3.1 months (6-52 months). At the final follow-up, the AVHR was greater, and the LKA and VWA were smaller in patients with bilateral fixation (6-screw fixation) than those with unilateral fixation (5-screw fixation) of AO type A3/A4 fractures (P < 0.001). The correction loss of AVHR, LKA and VWA in fractured vertebra were significantly great when preoperative AVHC was >50% (P < 0.05). For patients with AVHC >50%, the correction loss in patients with TBG were less than those without TBG at the final follow-up (P < 0.05).

Conclusions

SSPFI using bilateral fixation was more effective than unilateral fixation in maintaining the fractured vertebral height for AO type A3/A4 fractures. For patients with AVHC >50%, the loss of correction was more obvious and it can be decreased by transpedicular bone grafting.

Efficacy of a novel percutaneous pedicle screw fixation and vertebral reconstruction versus the traditional open pedicle screw fixation in the treatment of single-level thoracolumbar fracture without neurologic deficit

Objective

The aim of this study was to compare the efficacy and safety of a novel percutaneous pedicle screw fixation and vertebral reconstruction (PPSR) vs. that of open pedicle screw fixation (OPSF) in the treatment of thoracolumbar fractures.

Methods

This retrospective study enrolled 153 patients who underwent PPSR and 176 patients who received OPSF. Periprocedural characteristics, radiographic parameters, and clinical outcomes were compared between the two groups.

Results

The operation duration was 93.843 ± 20.611 in PPSR group and 109.432 ± 11.903 in OPSF group; blood loss was 131.118 ± 23.673 in PPSR group and 442.163 ± 149.701 in OPSF group, incision length was 7.280 ± 1.289 in PPSR group and 14.527 ± 2.893 in OPSF group, postoperative stay was 8.732 ± 1.864 in PPSR group and 15.102 ± 2.117 in OPSF group, and total hospitalization costs were 59027.196 ± 8687.447 in PPSR group and 73144.432 ± 11747.567 in OPSF group. These results indicated that these parameters were significantly lower in PPSR compared with those in OPSF group. No significant difference was observed in the incidence of complications between the two groups. The radiographic parameters including height of the anterior vertebra, Cobb angle, and vertebral wedge angle were better in PPSR group than in OPSF group. Recovery rate of AVH was 0.449 ± 0.079 in PPSR group and 0.279 ± 0.088 in OPSF group. Analysis of clinical results revealed that during postoperative period, the VAS and ODI scores in PPSR group were lower than those in OPSF group.

Conclusions

Collectively, these results indicated that PPSR more effectively restored the height of anterior vertebra and alleviated local kyphosis compared with OPSF. Moreover, the VAS and ODI scores in PPSR group were better than those of OPSF group.

Reliability and repeatability of a modified thoracolumbar spine injury classification scoring system

Purpose

On the basis of the Thoracolumbar Injury Classification and Severity Score (TLICS), an modified TLICS classification system was presented, its reliability and repeatability were assessed, and the factors influencing classification consistency were examined.

Methods

Five spinal surgeons were chosen at random. The clinical data of 120 patients with thoracolumbar fractures admitted to the Department of Spine Surgery, Ningbo Sixth Hospital from December 2019 to June 2021 were categorized using the modified TLICS system. After 6 weeks, disrupt the order of data again. Using unweighted Cohen's kappa coefficients, the consistency of the modified TLICS system was assessed in five aspects: neurofunctional status, disc injury status, fracture morphology, posterior ligament complex (PLC) integrity, and treatment plan.

Results

In terms of reliability, the average kappa values for the subclasses of the modified TLICS system (neurofunctional status and disc injury status) were 0.920 and 0.815, respectively, reaching the category of complete confidence. Fracture morphology and treatment plan had average kappa values of 0.670 and 0.660, respectively, which were basically reliable. The average kappa value of PLC integrity was 0.453, which belonged to the category of moderate confidence. The average kappa coefficients of each subcategory (neurological status, disc injury status) had excellent consistency, and the kappa values were 0.936 and 0.879, respectively, which belonged to the completely credible category. The kappa values of fracture morphology and treatment plan repeatability were 0.772 and 0.749, respectively, reaching the basic credibility category. PLC integrity repeatability kappa value is low, 0.561, to moderate credibility category.

Conclusion

The modified TLICS system is intuitive and straightforward to understand. The examination of thoracolumbar fracture injuries is more exhaustive and precise, with excellent reliability and repeatability. The examination of neurological status and disc injury status is quite reliable and consistent. The consistency of fracture morphology is slightly poor, which is basically credible; the PLC integrity consistency is poor, reaching a reliability level of moderate, which may be associated with the subjectivity of clinical evaluation of PLC.

Outcome of percutaneous pedicle screw fixation for traumatic thoracic and lumbar fractures -six years experience

OBJECTIVES

This study discusses the experience at our centre with treating traumatic thoracolumbar fractures using percutaneous pedicle screw fixation.

METHODS

We reviewed the case notes and imaging retrospectively between January 2013 and June 2019.

RESULTS

A total of 257 patients were included, 123 males and 134 females aged between 17 and 70; the mean age was 47.6 years. The majority of injuries were from fall from significant height. The fractures involved the thoracic and lumbar vertebra in 98 and 151 of the cases respectively. Percutaneous pedicle screw fixation was performed either one or two levels above and below the fracture depending on the level of injury. Forty two cases were treated with additional short pedicle screws at the level of fracture. More than 15% (39) of the patients presented with a neurological deficit; more than 80% (32) of those showed post-operative improvement in their neurology as per Frankel Grading system. The mean operative time was 117 min ± 45 min; mean length of hospital stay was 7.2 days ± 3.8 days, with significant improvement in pain.

CONCLUSIONS

Percutaneous pedicle screw fixation is a safe surgical option with comparable outcomes to open surgery and a potential reduction in perioperative morbidity.

Effect of early continuously intravenous tranexamic acid on perioperative blood loss in thoracolumbar burst fractures with neurological symptoms

There is still a conflict between early surgical decompression and increased bleeding resulting from early surgery for thoracolumbar burst fractures (TBF) with neurological symptoms. The aim of this study is to investigate the effect of early continuously intravenous tranexamic acid (TXA) on perioperative blood loss in TBF with neurological symptoms who underwent early surgery. A retrospective comparative analysis was performed. The patients in study group were treated with intravenous TXA 15 mg/kg every 24 hours after admission besides intravenous TXA 15 mg/kg before skin incision and patients in control group were treated with intravenous TXA 15 mg/kg before skin incision only. Perioperative blood loss was compared between the 2 groups. The hemoglobin at admission, before surgery, 1 day and 3 days after surgery, the operation time, drainage time, blood transfusion and volume, incidence of complications and length of hospital stay were also compared. The operation time, preoperative, intraoperative, total, hidden amounts of blood loss in TXA group were significantly lower than those in control group (P < .001). The hemoglobin level in the TXA group was significantly higher than that in the control group before and 1 day after surgery (P < .05). The remove drainage time, hospitalization time, blood transfusion rate and volume in the TXA group were significantly lower than those in the control group (P < .001). There was no significant difference in the incidence of lower limb thrombosis between the 2 groups (P > .05). Early continuously intravenous TXA reduces the perioperative blood loss of patients with TBF who underwent early posterior fracture reduction, nerve decompression and pedicle screw fixation.

Effect of pedicle screw placement into the fractured vertebra in management of unstable thoracolumbar and lumbar fractures

BACKGROUND

Pedicle screw insertion at the level of the fractured vertebra has been shown to improve clinical and radiological outcomes in unstable thoracolumbar and lumbar fractures, albeit this requires further evidence. The study aims to evaluate the effect of pedicle screw placement on the fractured vertebra in such cases.

METHODS

A prospective study included adult patients with thoracolumbar and lumbar fractures treated with short-segment posterior instrumentation with a pedicle screw into the fractured vertebra. Anterior vertebral body height loss, kyphotic angle and degree of spinal canal compromise were measured preoperatively and postoperatively in radiographs and CT scans. The neurological status was followed up for one year of the postoperative period.

RESULTS

The study included a total of 30 patients. Five patients (16.7%) had grade C, three patients (10%) had grade D, and 22 patients (73.3%) had grade E neurological status. The mean (SD) preoperative kyphotic angle, vertebral body height and canal compromise were 5.54 (5.35), 39.67% (8.04), and 31.59% (10.62), respectively. Postoperatively there was a significant canal decompression, with a mean postoperative spinal canal compromise of 5.53% (SD=7.70; p-value <0.001). At the end of one year of follow-up, the radiological evaluation showed a correction of the kyphotic angle to 6.62 (SD=2.57; p-value <0.001), and the mean anterior vertebral body height was 70.38% (SD=11.25; p-value <0.001). At the end of one year, there was a significant overall neurological recovery with a final neurological status of grade D in 5 (16.7%) and grade E in 25 patients (83.3%). There was no significant association between canal decompression and neurology at the end of the one-year follow-up.

CONCLUSION

Unstable thoracolumbar and lumbar fractures surgically treated with short-segment fixation with an additional intermediate screw can achieve significant restoration of vertebral body height and correction of kyphotic angle without any added complications.

[Clinical study of Wiltse approach with fulcrum reduction technique in the treatment of AO-A type thoracolumbar fractures]

OBJECTIVE

To investigate the effectiveness of Wiltse approach with fulcrum reduction technique and pedicle internal fixation in the treatment of AO-A type thoracolumbar fractures.

METHODS

The clinical data of 16 patients with AO-A type thoracolumbar fractures treated with Wiltse approach with fulcrum reduction technique and pedicle internal fixation between September 2013 and January 2019 were retrospectively analyzed. There were 9 males and 7 females, the age ranged from 38 to 60 years, with an average age of 50.7 years. Causes of injury included 9 cases of falling from height, 3 cases of traffic accidents, 3 cases of falling, and 1 case crushed by heavy objects. Fractured segment involved T ₁₁ in 2 cases, T ₁₂ in 5 cases, L ₁ in 7 cases, and L ₂ in 2 cases. There were 6 cases of type A1, 3 cases of type A2, 5 cases of type A3, and 2 cases of type A4 according to AO fracture classification. The operation time, intraoperative blood loss, and removal time of internal fixator were recorded. Before operation, immediately after operation, before and after removal of internal fixator, the local kyphotic angle (LKA), anterior vertebral height (AVH), and posterior vertebral height (PVH) of fractured vertebral body were measured; visual analogue scale (VAS) score of back pain were evaluated before operation, at 3 days after operation, before and after removal of internal fixator.

RESULTS

The operation time of the patients was 50-95 minutes, with an average of 70.7 minutes; the intraoperative blood loss was 50-230 mL, with an average of 132.9 mL; the internal fixator was removed after 18-30 months, with an average of 23.6 months. All patients were followed up 20-32 months, with an average of 25.6 months. No incision infection, hematoma, and other surgery-related complications, and internal fixator rupture residual complications occurred. All 16 patients achieved satisfactory reduction results. Immediate postoperative LKA, AVH, and PVH were significantly improved when compared with preoperative ones ( P<0.05). There was a certain degree of reduction loss before internal fixator removal, and the difference in LKA was significant ( P<0.05), but the difference in AVH and PVH were not significant ( P>0.05). There was a certain degree of reduction loss after internal fixator removal, but only the difference in AVH was significant ( P<0.05), and there was no significant difference in LKA and PVH ( P>0.05). The VAS score of the back pain significantly improved at 3 days after operation and before internal fixator removal when compared with preoperative score ( P<0.05). The pain after internal fixator removal was significantly worse than that before internal fixator removal ( P<0.05).

CONCLUSION

The Wiltse approach with fulcrum reduction technique and pedicle internal fixation in the treatment of AO-A thoracolumbar fractures has a short operation time, less intraoperative blood loss, and the posterior soft tissue and other structures are well protected during the operation. It can provide satisfactory clinical reduction results.

Posterior pedicle screw fixation combined with transpedicular bone grafting for treatment of single-level thoracolumbar fractures with the aid of a vertebroplasty tool

OBJECTIVE

This study was performed to assess the efficacy of a novel tool to assist transpedicular bone grafting in short-segment pedicle screw fixation combined with pedicle fixation at the level of the fractured vertebra (six-screw fixation).

METHODS

We retrospectively analyzed 80 patients (40 in the control group and 40 in the tool-aided group) with single-level thoracolumbar fractures. Patients in the control group underwent traditional six-screw fixation combined with transpedicular bone grafting. In the tool-aided group, we introduced a novel vertebroplasty tool to assist transpedicular bone grafting. Basic information and related indicators were recorded.

RESULTS

There were no significant differences in the patients' baseline characteristics or surgical outcomes between the control group and tool-aided group. Both traditional surgery and tool-aided surgery restored the height of the fractured vertebrae and decreased the Cobb angle, visual analog scale score, and Oswestry Disability Index. However, tool-aided surgery more effectively restored the height of the fractured vertebrae and reduced the visual analog scale score and Oswestry Disability Index than did traditional surgery.

CONCLUSION

Vertebroplasty tool-aided surgery facilitated more precise and successful grafting of bone into damaged vertebrae than did traditional surgery and therefore might be recommended for treating single-level thoracolumbar fractures.

The Impact of D-Dimer on Postoperative Deep Vein Thrombosis in Patients with Thoracolumbar Fracture Caused by High-Energy Injuries

Objective

To investigate the dynamic variation of D-dimer and to evaluate the efficacy and accuracy of D-dimer level in patients with thoracolumbar fractures caused by high-energy injuries.

Methods

A total of 121 patients with thoracolumbar fractures caused by high-energy injuries were retrospectively identified and included in this study. There were 83 males and 38 females, with an average age of 48.6 ± 11.2 years. All patients were treated with either screw fixation surgery or decompression fixation surgery. The D-dimer levels were measured 1 day before surgery and on the first, third, and fifth days after surgery. The dynamic variation of D-dimer and the effects of risk factors on D-dimer levels were analysed. A receiver operating characteristic (ROC) curve analysis was performed and the appropriate D-dimer cut-off level was determined for deep vein thrombosis (DVT) screening.

Results

Due to a trough on the third day, D-dimer levels grew in an unsustainable manner following surgery (P < 0.001). Patients with the operation time >120 min (P = 0.009) and those with an American Spinal Injury Association (ASIA) score A-C (P < 0.001) had higher D-dimer levels. The area under the curve of D-dimer was the greatest on the third day. Applying stratified cut-off values did not change the sensitivity, specificity and negative predictive value in the group with an operation time >120 min, and ASIA score A-C group.

Conclusions

D-dimer levels elevated with fluctuation in patients with thoracolumbar fractures caused by high-energy injuries after surgery. Both operation time and ASIA score had an impact on D-dimer levels. Regarding DVT diagnoses, the diagnostic value of D-dimer was highest on the third day postoperatively, and stratified cut-off values by these two factors did not show better diagnostic efficacy compared with a collective one.

How Should Patients with a Thoracolumbar Injury Classification and Severity Score of 4 Be Treated?

The thoracolumbar injury classification and severity score (TLICS) system help surgeons decide whether patients should undergo initial operative treatment or nonoperative treatment. However, the best treatment for patients with TLICS 4 fracture remains unknown. The aim of this study was to identify the risk factors for nonoperative treatment failure in patients with TLICS 4 fracture and establish treatment standards for TLICS 4 fractures. This study included 44 patients with TLICS 4 fracture who initially received nonoperative treatment. We divided these patients into two groups: the successful nonoperative treatment group included 18 patients, and the operative treatment group after nonoperative treatment failure included 26 patients. In multiple logistic regression analysis, spinal canal compromise (odd ratio = 1.316) and kyphotic angle (odd ratio = 1.416) were associated with nonoperative treatment failure in patients with TLICS 4 fracture. Other factors, including age, sex, BMI, initial VAS score, and loss of vertebral body height, were not significantly associated with nonoperative treatment failure in these patients. Spinal canal compromise and kyphotic angle were associated with nonoperative treatment failure in patients with TLICS 4 fracture. Therefore, we recommend the surgeon observe spinal canal compromise and kyphotic angle more carefully when deciding on the treatment of patients with TLICS 4 fracture.

Biomechanical Evaluation of the Transcortical and Transpedicular Trajectories for Pedicle Screw Insertion in Thoracolumbar Fracture Fixation for Ankylosing Spondylitis

Background: Ankylosing spondylitis (AS) is a chronic disorder characterized by an imbalance between bone formation and resorption. Spinal fractures often occur after minor trauma in patients with AS. For thoracolumbar fractures, transpedicular screw (TPS) fixation through the posterior approach has been suggested. The cortical bone trajectory (CBT) technique has also been used to prevent screw pull-out in patients with poor bone quality. The aim of current study was to assess the biomechanical characteristics of the TPS and CBT technique in thoracolumbar AS fracture fixation by finite element analysis.

Methods: The three-dimensional finite element models of the AS spine were created. The CBT and TPS methods of screw insertion were used in AS spinal fracture models. An intact AS spine model was considered the control. An axial force and torsion in rotation, flexion/extension and lateral flexion were applied in all models in CBT, TPS, and control groups.

Results: The AS spine showed similar construct stiffness after posterior fixation by CBT and TPS techniques under axial, rotational, and flexion/extension loading conditions. The TPS technique showed better intact stability under all loading conditions. Similarly, the TPS technique provided superior fracture regional stability against axial and rotational loads than did the CBT technique. The maximum von Mises stresses were 1714.4 ± 129.8 MPa and 1208.7 ± 107.3 MPa (p < 0.001), which occurred in the CBT and TPS groups under compressive loading.

Conclusions: The TPS technique provides better biomechanical strength under axial, rotational, flexion/extension, and lateral flexion loading than does the CBT technique. Compared with CBT, TPS is more effective in maintaining the stability of AS thoracolumbar fractures from a finite element analysis perspective.

Pedicle Screw Fixation with Percutaneous Vertebroplasty for Traumatic Thoracolumbar Vertebral Compression Fracture

Objective

This study aims to evaluate the clinical efficacy of percutaneous pedicle screw fixation (PPSF) combined with percutaneous vertebroplasty (PVP) for the treatment of the thoracolumbar vertebral compression fracture (VCF) without neurologic deficits.

Materials and Methods

This was a prospective observational study. Between January 2015 and December 2018, 62 patients who had suffered from traumatic thoracolumbar (VCF) burst fractures without neurologic deficits were included in this study. The patients were divided into two groups as follows: patients who underwent PPSF combined with PVP (PPSF-PVP Group; n = 24) and patients who underwent only PPSF (PPSF Group; n = 38). The patients were (PPSF and PPSF-PVP Group) followed up for more than 9 months. The kyphotic angle, compression ratio, and visual analog scale (VAS) score for back pain were analyzed and compared between the two groups.

Results

The patients were followed up for an average of 9.1 months. Hospital stay significantly decreased in PPSF-PVP Group (P < 0.001). The median VAS score significantly decreased after the surgery in both the groups (P < 0.005), and mean VAS scores in PPSF-PVP Group were significantly lower than those in PPSF Group. No significant (P > 0.005) changes in local kyphosis and the vertebral body height gains obtained at the end of the follow-up period in PPSF-PVP Group. However, local kyphosis increased significantly (P < 0.005) and the central and anterior vertebral body height decreased significantly (P < 0.005) when compared with the PPSF-PVP Group.

Conclusion

PPSF combined with PVP procedure is a good choice for the treatment of traumatic thoracolumbar VCF; however, due to the lack of long-term follow-up data, concern still exists regarding the effects of pedicle screw procedure after PVP.

[The safety of TiRobot-guided percutaneous transpedicular screw implantation]

OBJECTIVE

To evaluate the safety of TiRobot-guided percutaneous transpedicular screw implantation.

METHODS

The medical records of 158 patients with thoracolumbar fractures and lumbar degenerative diseases who underwent percutaneous transpedicular screw implantation were retrospectively analyzed between January 2018 and December 2020. The patients were divided into trial group (TiRobot-guided screw implantation, 86 cases) and control group (fluoroscopy-guided screw implantation, 72 cases). There was no significant difference in gender, age, pathology, lesion segment, and the average number of screw implantation per case ( P>0.05). The operation time, fluoroscopic dose, fluoroscopic time, and fluoroscopic frequency were compared between the two groups. One day postoperatively, the convergence angle was measured and the penetration of the pedicle cortex was evaluated according to Gertzbein-Robbins classification standard.

RESULTS

The operation time, fluoroscopic dose, fluoroscopic time, and fluoroscopic frequency of the trial group were significantly lesser than those of control group ( P<0.05). One day postoperatively, the convergence angle of trial group was (21.10±4.08)°, which was significantly larger than control group (19.17±3.48)° ( t=6.810, P=0.000). According to the Gertzbein-Robbins classification standard, 446 pedicle screws were implanted in trial group, trajectories were grade A in 377 screws, grade B in 46 screws, grade C in 23 screws, and the accuracy of screw implantation was 94.8%; 380 pedicle screws were implanted in control group, trajectories were grade A in 283 screws, grade B in 45 screws, grade C in 44 screws, grade D in 6 screws, grade E in 2 screws, and the accuracy of screw implantation was 86.3%. There was significant difference in the accuracy of screw implantation between the two groups ( χ 2=25.950, P=0.000).

CONCLUSION

Compared with traditional percutaneous transpedicular screw implantation, TiRobot-guided percutaneous transpedicular screw implantation can improve the accuracy of screw implantation, reduce radiation exposure, and improve surgical safety, which has a good application prospect.

Thoracolumbar Fracture in Disseminated Idiopathic Skeletal Hyperostosis

Disseminated idiopathic skeletal hyperostosis (DISH) is a form of ankylosing spinal disorders, which is at high risk of fracture because of the rigidity of the spinal column and reduced bone quality. The patients with DISH are at higher risk of fall because of the poor muscle tone, rigid spine column, and positive sagittal balance. The management of spinal fractures in these patients proves to be challenging because of the altered biomechanics and alignment of the spine. Furthermore, most patients have multiple comorbidities with high intraoperative burden, and osteoporosis itself will impair any implant purchase of the bone. Here, we report a case of thoracolumbar fracture in DISH where both conservative and surgical approaches were utilized, with unfortunate results in both, and a brief review of the literature on its management.

Rapid efficacy of percutaneous kyphoplasty (PKP) in treating thoracolumbar fractures in elderly patients

OBJECTIVE

This study aims to investigate the effects of percutaneous kyphoplasty (PKP) on the elderly patients with thoracolumbar fractures and its influence on their complications and quality of life.

METHODS

Totally 175 elderly patients with thoracolumbar fractures admitted to our hospital from June 2017 to January 2019 were selected as the research participants. Seventy patients in the control group (CG) were treated with conventional therapy, and 105 in the research group (RG) were treated by percutaneous kyphoplasty (PKP). The surgical indications (time of hospitalization and ground exercise), pressure injury and pain (VAS score) of patients in both groups were tested and compared. The ODI score, quality of life GQOLI-74 scale score, height of anterior vertebral border and cobb angle of patients were compared, and their total effective and complication rates were statistically analyzed.

RESULTS

The surgical indications of patients in the RG were better than those in the CG. Those with pressure injury in stages 1 and 2 were fewer, and VAS and ODI scores were lower; GQOLI-74 scale score was higher, height of anterior vertebral border was higher than that in the CG, and the cobb angle was smaller The total effective rate was higher and the incidence of complications was lower than that in the CG.

CONCLUSION

PKP is more effective and faster in treating thoracolumbar fractures in elderly patients with fewer postoperative complications, and can promote the recovery of function and quality of life.

A comparison of monoaxial pedicle screw versus polyaxial pedicle screw in short-segment posterior fixation for the treatment of thoracolumbar fractured vertebra

Background

Posterior pedicle screw fixation had been applied to maintain spinal stability and avoid further nerve damage in thoracolumbar fracture. This study aimed to evaluate the efficacy of short-segment posterior fixation with monoaxial pedicle screws versus polyaxial pedicle screws in treating thoracolumbar fracture.

Methods

A total of 75 patients with thoracolumbar fracture who underwent short-segment posterior fixation with monoaxial pedicle screw (group A) or polyaxial pedicle screw (group B) were retrospectively enrolled. The patient demographic and radiological data were analyzed between the two groups.

Results

A total of 63 patients with an average age of 44.7±11.5 years were finally recruited in this study. There were no significant differences in age, gender, fracture level, thoracolumbar injury classification and severity scale (TLISS) score, American Spinal Injury Association (ASIA) score, Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification, and hospital stay between the two groups (P>0.05). At the last follow-up, the prevertebral height ratio and normal-to-injured vertebral height ratio were significantly decreased in group A compared to group B (P=0.027 and P=0.007, respectively).

Conclusions

Short-segment posterior fixation with monoaxial or polyaxial pedicle screw for fractured thoracolumbar vertebra can restore injured vertebral height. Compared with polyaxial pedicle screw, monoaxial pedicle screw endows stronger leverage which is more beneficial for restoring injured vertebral height and recovery of the damaged endplate in thoracolumbar short-segment posterior fixation.

[Treatment of chronic thoracolumbar osteoporotic fractures combined with kyphosis with cement-injectable cannulated pedicle screw and multiple level Schwab grade osteotomy]

Objective

To evaluate the effectiveness of cement-injectable cannulated pedicle screw combined with multiple level Schwab grade Ⅰ osteotomy for chronic thoracolumbar osteoporotic fractures with kyphosis.

Methods

The clinical data of 27 patients with symptomatic chronic thoracolumbar osteoporotic fractures combined with kyphosis treated between June 2015 and June 2017 were retrospectively analysed. Among them, there were 8 males and 19 females, with an average age of 69.5 years (range, 56-81 years). The damage segment (kyphosis vertex) included T ₁₁ in 4 cases, T ₁₂ in 12 cases, L ₁ in 10 cases, and L ₂ in 1 case. The disease duration ranged from 3 to 21 months, with an average of 12.5 months. The T value of lumbar vertebral bone mineral density ranged from -4.9 to -2.5, with an average value of -3.61. The American Spinal Injury Association (ASIA) classification was used to evaluate spinal cord injury, there were 1 case of grade D and 26 cases of grade E. The visual analogue scale (VAS) score, Oswestry disability index (ODI), kyphosis Cobb angle of fracture site, and sagittal vertical axis (SVA) data were obtained before operation, at 2 weeks after operation, 3 months after operation, and last follow-up, to evaluate the quality of life and improvement of sagittal spine parameters.

Results

No complications related to pedicle screw and bone cement occurred. The incisions healed by first intention in 26 cases, and 1 incision healed after dressing change due to poor blood glucose control. There were no complications such as bedsore, hypostatic pneumonia, or deep venous thrombosis. All patients were followed up 8-24 months, with an average of 16.6 months. The VAS score, ODI score, Cobb angle, and SVA were significantly improved when compared with those before operation ( P<0.05). There was no significant difference in Cobb angle between each time point after operation ( P>0.05); the VAS score and ODI score at 3 months after operation and last follow-up were significantly better than those at 2 weeks after operation ( P<0.05), and the ODI score at last follow-up was further improved when compared with the score at 3 months ( P<0.05), but there was no significant difference in VAS score ( P>0.05); SVA at last follow-up was significantly worse than that at 2 weeks and 3 months after operation ( P<0.05), but there was no significant difference between at 2 weeks and 3 months after operation ( P>0.05). During the follow-up period, there was no complication such as pedicle screw loosening, breakage or cutting, adjacent vertebral fracture, proximal junctional kyphosis, and so on.

Conclusion

For the chronic thoracolumbar osteoporotic fractures combined with kyphosis, the cement-injectable cannulated pedicle screw and multiple level Schwab grade Ⅰ osteotomy has the advantages of less operation trauma, quick recovery, and remarkable effectiveness.

Radiographic Evaluation of Minimally Invasive Instrumentation and Fusion for Treating Unstable Spinal Column Injuries

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

Facet fusion in minimally invasive spine surgery (MISS) may reduce morbidity and promote long-term construct stability. The study compares the maintenance of correction of thoracolumbar (TL) trauma patients who underwent MISS with facet fusion (FF) and without facet fusion (WOFF) and evaluates instrumentation loosening and failure.

METHODS

TL trauma patients who underwent MISS between 2006 and 2013 were identified and stratified into FF and WOFF groups. To evaluate progressive kyphosis and loss of correction, Cobb angles were measured at immediate postoperative, short-term, and long-term follow-up. Evidence of >2 mm of radiolucency on radiographs indicated screw loosening. If instrumentation was removed, postremoval kyphosis angle was obtained.

RESULTS

Of the 80 patients, 24 were in FF and 56 were in WOFF group. Between immediate postoperative and short-term follow-up, kyphosis angle changed by 4.0° (standard error [SE] 1.3°) in the FF and by 3.0° (SE 0.4°) in the WOFF group. The change between immediate postoperative and long-term follow-up kyphosis angles was 3.4° (S.E 1.1°) and 5.2° (S.E 1.6°) degrees in the FF and WOFF groups, respectively. Facet fusion had no impact on the change in kyphosis at short term (P = .49) or long term (P = .39). The screw loosening rate was 20.5% for the 80 patients with short-term follow-up and 68.8% for the 16 patients with long-term follow-up. There was no difference in screw loosening rate. Fifteen patients underwent instrumentation removal-all from the FF group.

CONCLUSION

FF in MISS does not impact the correction achieved and maintenance of correction in patients with traumatic spine injuries.

Minimally Invasive Spine (MIS) Surgery in Traumatic Thoracolumbar Fractures: A Single-Center Experience

Objective:

Traumatic thoracolumbar fractures are common, and surgical fixation is a well-established treatment option, with the aim to achieve spinal stability and preserve neurological function. Pedicle screw fixation using a minimally invasive spine (MIS) surgical approach has emerged as an alternative approach for the treatment of thoracolumbar fractures. The aim of this study is to collect data regarding epidemiology, management, and outcomes of patients treated with MIS pedicle screw fixation for traumatic thoracolumbar fractures in our neurosurgical department.

Materials and Methods:

This was a retrospective cohort study including all patients who underwent MIS fixation from March 2013 to March 2017.

Results:

A total of 125 patients were included, 61 males and 64 females; the mean age was 59 years. The majority of injuries were from falls. In 48 cases, the fracture involved a thoracic vertebra and in 77 cases a lumbar vertebra. More than 10% of the patients presented with a neurological deficit on admission and 75% of those showed postoperative improvement in their neurology. The average length of hospital stay was 14 days. MIS fixation achieved a satisfactory regional sagittal angle (RSA) postoperatively in all patients. The vast majority of patients had no or mild postoperative pain and achieved a good functional outcome.

Conclusions:

MIS fixation is a safe surgical option with comparable outcomes to open surgery and a potential reduction in perioperative morbidity. MIS surgery achieves a rapid and significant improvement in pain score, functional outcome, Frankel Grade, and RSA. We expect that MIS fixation will become the predominant technique in the management of traumatic thoracolumbar fractures.

Patients with ankylosing spondylitis suffering from AO Type B3 traumatic thoracolumbar fractures are associated with increased frailty and morbidity when compared with patients with diffuse idiopathic skeletal hyperostosis

Background

AO Type B3 hyperextension thoracolumbar fractures are the commonest fracture subtype in ankylosing spinal disorders. Although often considered together in spinal fractures, ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) are distinct spondyloarthropathies with different pathophysiology. Few studies have compared the two entities in the setting of traumatic thoracolumbar fractures. The authors compare demographic metrics, injury profile, clinical and radiographical outcomes between patients with AS and DISH in patients suffering from AO Type B3 traumatic thoracolumbar fractures.

Methods

From January 2008 to December 2018, a retrospective analysis of consecutive surgically-managed patients with AO Type B3 fractures was performed. Demographic metrics, co-morbidity [Charlson-comorbidity index, modified frailty index (mFI), etc.], injury profile (level of injury, mechanism of injury, etc.), clinical (postoperative complication, etc.) and radiographical variables were collected. Differences between patients with AS and DISH were compared.

Results

Fourteen patients were identified. All patients had AS (n=6) or DISH (n=8). The mean age was 72.8±10.2 years and 78.6% of patients were neurologically intact at presentation. Medical and/or surgical complications occurred in 10 of 14 (71.4%) patients. As compared to patients with DISH, patients with AS were more likely to have low falls as the injury mechanism [odds ratio (OR): 35.0, P=0.026], have higher mFI (OR: 30.6, P=0.015), and experience a higher number of postoperative complications per patient (AS: 1.8/patient vs. DISH: 0.5/patient, P=0.024).

Conclusions

In the setting of AO Type B3 fractures, patients with AS are more frail and have higher in-hospital morbidity compared to patients with DISH. Despite both pathologies being ankylosing in nature, further studies are required to fully understand the clinical differences between the two entities to enable clinicians to apply a more targeted and nuanced approach in managing fractures in ankylosing spinal disorders.

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.

[Short-term effectiveness comparison between robotic-guided percutaneous minimally invasive pedicle screw internal fixation and traditional open internal fixation in treatment of thoracolumbar fractures]

Objective

To compare short-term effectiveness between robot-guided percutaneous minimally invasive pedicle screw internal fixation and traditional open internal fixation in the treatment of thoracolumbar fractures.

Methods

The clinical data of 52 cases of thoracolumbar fracture without neurological injury symptoms admitted between January 2018 and May 2018 were retrospectively analyzed. According to the different surgical methods, they were divided into minimally invasive group (24 cases, treated with robot-assisted percutaneous minimally invasive pedicle screw internal fixation) and open group (28 cases, treated with traditional open internal fixation). There was no significant difference between the two groups in the general data such as gender, age, cause of injury, fracture segment, thoracolumbar injury classification and severity score (TLICS), preoperative back pain visual analogue scale (VAS) score, Oswestry disability index (ODI) score, fixed segment height, and fixed segment kyphosis Cobb angle ( P>0.05). The operation time, intraoperative blood loss, and hospitalization time of the two groups were recorded and compared; as well as the VAS score, ODI score, fixed segment height, and fixed segment kyphosis Cobb angle of the two groups before operation and at 3 days, 1 month, 6 months, and 10 months after operation. CT scan was reexamined at 1-3 days after operation, and the pedicle screw insertion accuracy rate was determined and calculated according to Gertzbein-Robbins classification standard.

Results

The operation time of the minimally invasive group was significantly longer than that of the open group, but the intraoperative blood loss and hospitalization time were significantly shorter than those of the open group ( P<0.05). There were 132 pedicle screws and 158 pedicle screws implanted in the minimally invasive group and the open group respectively. According to the Gertzbein-Robbins classification standard, the accuracy of pedicle screws was 97.7% (129/132) and 96.8% (153/158), respectively, showing no significant difference between the two groups ( χ ²=0.505, P=0.777). The patients in both groups were followed up 10 months, and there was no rejection or internal fixation fracture. In the minimally invasive group, the internal fixator was removed at 10 months after operation, but not in the open group. The VAS score, ODI score, fixed segment heigh, and fixed segment kyphotic Cobb angle of the two groups were improved in different degrees when compared with preoperative ones ( P<0.05). Except that the VAS score and ODI score of the minimally invasive group were significantly better than those of the open group at 3 days after operation ( P<0.05), there was no significant difference between the two groups at other time points ( P>0.05).

Conclusion

Robot-assisted percutaneous minimally invasive pedicle screw internal fixation for thoracolumbar fractures has significant advantages in intraoperative blood loss, hospitalization time, and early postoperative effectiveness and other aspects, and the effect of fracture reduction is good.

[A comparative study of spinal robot-assisted and traditional fluoroscopy-assisted percutaneous reduction and internal fixation for single-level thoracolumbar fractures without neurological symptoms]

Objective

To compare the effectiveness and screw planting accuracy of percutaneous reduction and internal fixation with robot and traditional fluoroscopy-assisted in the treatment of single-level thoracolumbar fractures without neurological symptoms.

Methods

The clinical data of 58 patients with single-level thoracolumbar fractures without neurological symptoms between December 2016 and January 2018 were retrospectively analysed. According to different surgical methods, the patients were divided into group A (28 cases underwent robot-assisted percutaneous reduction and internal fixation) and group B (30 cases underwent fluoroscopy-assisted percutaneous reduction and internal fixation). There was no neurological symptoms, other fractures or organ injuries in the two groups. There was no significant difference in general data of age, gender, fracture location, AO classification, time from injury to surgery, and preoperative vertebral anterior height ratio, sagittal Cobb angle, visual analogue scale (VAS) score, and Oswestry disability index (ODI) score between the two groups ( P>0.05). The screw placement time, operation time, intraoperative blood loss, intraoperative fluoroscopy frequency, hospitalization time, operation cost, postoperative complications, VAS score, ODI score, anterior vertebral height ratio, and sagittal Cobb angle before operation, at 3 days, 6 months after operation, and at last follow-up were recorded and compared between the two groups. The accuracy of the pedicle screw placement was evaluated by Neo's criteria.

Results

The screw placement time, operation time, and intraoperative fluoroscopy frequency of group A were significantly less than those of group B, and the operation cost was significantly higher than that of group B ( P<0.05). But there was no significant difference in intraoperative blood loss and hospitalization time between the two groups ( P>0.05). Both groups were followed up 12-24 months, with an average of 15.2 months. The accuracy rate of screw placement in groups A and B was 93.75% (150/160) and 84.71% (144/170), respectively, and the difference was significant ( χ ²=5.820, P=0.008). Except for 1 case of postoperative superficial infection in group A and wound healing after dressing change, there was no complication such as neurovascular injury, screw loosening and fracture in both groups, and there was no significant difference in the incidence of complications between the two groups ( χ ²=0.625, P=0.547). The anterior vertebral height ratio, sagittal Cobb angle, VAS score, and ODI score of the two groups were significantly improved ( P<0.05); there was no significant difference between the two groups at all time points after operation ( P>0.05).

Conclusion

The spinal robot and traditional fluoroscopy-assisted percutaneous reduction and internal fixation can both achieve satisfactory effectiveness in the treatment of single-level thoracolumbar fractures without neurological symptoms. However, the former has higher accuracy, fewer fluoroscopy times, shorter time of screw placement, and lower technical requirements for the operator. It has wide application potential.

Comparison of the modified Wiltse's approach with spinal minimally invasive system and traditional approach for the therapy of thoracolumbar fracture

Thoracolumbar fractures are usually treated by open posterior pedicle screw fixation. However, this procedure involves massive paraspinal muscle stripping, inflicting surgical trauma, and prolonged X-ray exposure. In this study, we observed 127 patients with single-segment injury thoracolumbar fractures. Thirty-six patients were treated by the modified Wiltse's paraspinal approach with minimally invasive channel system, while 91 patients were treated via traditional posterior approach. Operation time, intraoperative blood loss, intraoperative fluoroscopy frequency, screw placement accuracy, visual analogue scale score, and Cobb's angle of two groups were compared. The X-ray exposure times were notably reduced (4.2±1.6) in the new approach group (P<0.05). The pedicle screw placement accuracy and Cobb's angle after surgery were similar in the two groups. We conclude that modified Wiltse's paraspinal approach with spinal minimally invasive channel system surgery can significantly reduce the X-ray exposure times and is an alternative therapy for the thoracolumbar fracture.

Long Term Survival of Pathological Thoracolumbar Fractures Treated with Vertebroplasty: Analysis Using a Nationwide Insurance Claim Database

Background: There are still debates on the long-term outcome of treating pathological thoracolumbar fractures, including osteoporosis and oncologic problems, using vertebroplasty. Methods: We collected 8625 patients with pathological thoracolumbar fractures (ICD-9-CM codes 733.13 combined with 805.2 or 805.4) between the years of 2003 to 2013, from the two million random samples from the National Health Insurance Research Database in Taiwan. Survival analysis was conducted to estimate the mortality risks of different treatments, including vertebroplasty (n = 1389), conventional open surgery (n = 1219), or conservative treatment (n = 6017). A multivariable Cox proportional hazard model was constructed for adjustment of age, gender, comorbidities and complications. Results: Crude incidence rate of patients with pathological thoracolumbar fractures in Taiwan gradually increased year by year. Compared with conservative treatment, conventional open surgery and vertebroplasty seemed to improve long-term survival with adjusted hazard ratios (aHR) of 0.80 (95% confidence interval (CI) 0.70–0.93), and 0.87 (95% CI 0.77–0.99), respectively. The survival advantage of vertebroplasty appeared more evident for those aged over 75. However, we were unable to rule out confounding by indication. Conclusion: Although conventional open surgery would usually be the best choice for the treatment of patients with pathological thoracolumbar fractures, database information from current real-world practice appears to support vertebroplasty as a viable choice for elderly people over 75 years of age.

Residual mobility after removal of instrumentation in patient, with type a2-a3 vertebral fractures, treated with percutaneous pedicle screw fixation

Percutaneous techniques for treatment of thoraco-lumbar fractures type A2 and A3 are widely used. These techniques are considered temporary fixations and instrumentation must be removed with fracture healing. The aim of the study is to analyze clinical results, motility of treated segments and any loss of correction after the removal of instrumentation. We evaluated 36 patients who underwent surgery for removal of the instrumentation. Standard and dynamics x-ray before surgery and at 1 and 12 months after surgery were obtained. Radiographic evaluation was performed by comparing loss of correction after removal of the instrumentation, residual mobility of fractured vertebra, upper and lower level with values defined by Dvorak. For clinical assessment were used SF-12, Oswestry Disability Index (ODI) and Visual Analog Scale (VAS), administered before surgery and at 1 and 12 months after the removal. We analyzed a total of 108 levels in 36 patients. After removal of the instrumentation a normal range of motion was restored in the proximal and distal segment of the fracture, while at level of fractured segment we noticed a decrease in motility. Clinically, patients had a significant decrease in VAS and ODI at 1 month after removal. Our study shows that percutaneous fixation for treatment of thoraco-lumbar fractures type A2 and A3, allows to preserve motility of the treated segments after the removal of the instrumentation until 12 months. The removal of instrumentation is associated with good clinical results without of loss of correction in treated segment.

Therapeutic effect of MIPPSO in the thoracolumbar vertebra fracture

The purpose of this study was to compare the efficacy of minimally invasive percutaneous pedicle screw osteosynthesis (MIPPSO) and traditional open pedicle screw osteosynthesis (TOPSO) in the treatment of thoracolumbar vertebra fracture. A retrospective case-control study was conducted in 120 patients with thoracolumbar vertebral fractures treated in the Affiliated Jiangyin Hospital of Southeast University Medical School (Jiangyin, China) from January 2013 to September 2014. They were randomly divided into two groups: MIPPSO and TOPSO groups with 60 cases in each group. The operation time, blood loss, incision length, post-operative bed rest time, hospital stay, visual analogue scale (VAS) pain scores and Oswestry disability index (ODI) scores before and after operation were recorded and analyzed. Inflammatory indexes including serum C-reactive protein (CRP) and creatine kinase (CK), the anterior vertebral height ratio and kyphosis Cobb's angle changes were also observed. The basic data of the two groups were similar, and there was no significant difference in the operation time between the two groups. The perioperative blood loss, length of incision, bed rest time and total hospital stay in the minimally invasive group were less than those in the open group. Levels of post-operative inflammation indicators such as CRP and CK were significantly higher than those of pre-operative (P<0.05), which was more obvious in the TOPSO group (P<0.05). VAS, ODI scores, anterior vertebral height and Cobb's angle were significantly improved at three days, one and 12 months after surgery compared with those before operation. MIPPSO for the treatment of thoracolumbar fractures can achieve similar clinical effects with traditional incision surgery. In addition, it has the advantages of less trauma, less bleeding and shorter post-operative bed rest time and hospital stay.

Clinical Effects of Posterior Limited Long-Segment Pedicle Instrumentation for the Treatment of Thoracolumbar Fractures

Objective: The purpose of this study was to assess the clinical effects of treating thoracolumbar fractures with posterior limited long-segment pedicle instrumentation (LLSPI). Methods: A total of 58 thoracolumbar fracture patients were retrospectively analyzed, including 31 cases that were fixed by skipping the fractured vertebra with 6 screws using LLSPI and 27 cases that were fixed by skipping the fractured vertebra with 4 screws using short-segment pedicle instrumentation (SSPI). Surgery time, blood loss, hospital stay, Oswestry disability index (ODI), neurological function, sagittal kyphotic Cobb angle (SKA), percentage of anterior vertebral height (PAVH), instrumentation failure, and the loss of SKA and PAVH were recorded before and after surgery. Results: No significant differences were observed in either the surgery time or hospital stay (P < 0.05), while there were significant differences in blood loss between the two groups. At the final follow-up, both the ODI and the neurological status were notably improved compared to those at the preoperative state (P < 0.05), but the difference between the two groups was relatively small. Furthermore, the SKA and PAVH were notably improved at the final follow-up compared to postoperative values (P < 0.05), but no significant difference was observed between the two groups. During long-term follow-up, the loss of SKA and PAVH in the LLSPI group was significantly less than that in the SSPI group (P < 0.05). Conclusion: Based on strict criteria for data collection and analysis, the clinical effects of LLSPI for the treatment of thoracolumbar fractures were satisfactory, especially for maintaining the height of the fractured vertebra and reducing the loss of SKA and instrumentation failure rates.

Thoracolumbar traumatic nucleus pulposus sequestration combined with a slight flexion distraction fracture: A rare case report and literature review

RATIONALE

Traumatic nucleus pulposus sequestration (TNPS) usually occurs concurrently with severe destruction of bone. TNPS combined with a slight thoracolumbar flexion- distraction fracture, triggering a disastrous nerve injury, has rarely been reported. Due to the atypical radiologic manifestations, such a patient can easily be overlooked.

PATIENT CONCERNS

Hereby, we present a TNPS patient as well as a slight thoracolumbar flexion-distraction fracture and serious neurologic symptoms.

DIAGNOSES

T12 spinous process fracture, L1 flexion distraction fracture, thoracolumbar traumatic nucleus pulposuse sequestration and lower limbs incomplete paralysis INTERVENTIONS:: To avoid further neurologic compromise, an urgent laminectomy and exploration of the spinal canal was performed.

OUTCOMES

After decompression OR and 4 months rehabilitation, the patient's neurologic function improved remarkably.

LESSONS

A slight flexion-distraction fracture following injury is liable to eclipse the concurrence of TPNS. For this patient, a high-resolution MRI was needed to make a definitive diagnosis and guide surgery. Once TPNS has been diagnosed, sufficient decompression and discectomy surgery should be performed without delay.

Extent and location of fixation affects the biomechanical stability of short- or long-segment pedicle screw technique with screwing of fractured vertebra for the treatment of thoracolumbar burst fractures: An observational study using finite element analysis

Intermediate screw fixation at the fracture level has been widely accepted to treat thoracolumbar burst fractures, but no study has shown the effect of the extent and location of fixation. The effect of the extent and location of fixation on short- or long-segment pedicle screw fixation through intermediate screw fixation at the fracture level in the treatment of thoracolumbar burst fractures is discussed.Posterior intermediate screw fixation techniques in treating T12 vertebral fracture models were simulated and compared using finite element methods; the fixation techniques included M3-L1 (bilateral 3 monoaxial pedicle screw fixation from L1 to T11), M3-L2, M4-L1 (bilateral 4 monoaxial pedicle screw fixation from L1 to T10), M4-L2, M4-L3, and M5-L2 (bilateral 5 monoaxial pedicle screw fixation from L2 to T10). Range of motion (ROM) and largest von Mises stress (LVMS) of the instrumentations were recorded and analyzed.No significant differences were observed in the mean ROM of all states of motion between the M3-L1 model and the other fixation models except for M5-L2. The LVMS of the pedicle screws and rods all occurred during flexion. The LVMS values of the pedicle screws were larger in the M3-L2 fixation model and M4-L3 fixation model than in the other fixation models. The M3-L1 model presented a significantly smaller mean LVMS of the pedicle screws in all states of motion than the M3-L2 model (P = .026). The LVMS values of the rods were larger in the M3-L2 fixation model, M4-L3 fixation model, and M4-L2 fixation model than in the other fixation models. No significant differences were observed in the mean LVMS of the rods in all states of motion among all the fixation models.When choosing short-segment pedicle screw fixation with the screwing of fractured vertebrae to treat thoracolumbar fractures, we suggest M3-L1 over M3-L2. More severe injuries can be considered to identify an alternative treatment to long-segment monoaxial pedicle fixation constructs such as the M4-L1 and M5-L2 techniques.

Comparison of Hidden Blood Loss Between Three Different Surgical Approaches for Treatment of Thoracolumbar Fracture

Purpose: To examine the hidden blood loss (HBL) in treatment of AO type A1-A3 thoracolumbar fractures with three different approaches and to explore the influential factors of HBL among patients after the surgery of internal fixation for thoracolumbar fractures. Methods: We retrospectively studied 85 patients in treatment of thoracolumbar fractures: 25 patients via percutaneous approach (Group A), 33 patients via paraspinal approach (Group B), and 27 patients via conventional open approach (Group C). The demographic information of the patients was collected. Each patient's preoperative and postoperative hematocrit were recorded and used for calculating the blood loss according to the Gross's formula. The difference of blood loss between the three groups was measured by ANOVA. And influential factors were further analyzed by multivariate linear regression analysis in each group. Results: The average HBL was 240.0 ± 65.1 mL in Group A, 313.7 ± 138.1 mL in Group B, and 382 ± 153.8 mL in Group C. There was statistical difference in the HBL between three groups (P = 0.000). However, multivariate linear regression analysis revealed that HBL of three approaches was not associated with age, gender, body mass index (BMI), percentage of height loss, percentage of height restoration, fracture type, or operation time. Conclusion: There was a substantial HBL in the treatment of thoracolumbar fractures, which was neglected by surgeons. Further investigation is necessary to study the risk factors for surgery on HBL in treatment of thoracolumbar fractures.

Muscular changes after minimally invasive versus open spinal stabilization of thoracolumbar fractures: A literature review

PURPOSE

This review addressed the question of whether minimally invasive surgery after traumatic thoracolumbar spine fractures can reduce paraspinal muscle injury, limit changes in muscular structure and function, and lead to better functional outcome. Special emphasis was given to studies using imaging techniques or electromyography to evaluate the lumbar multifidus muscle structure and function.

METHODS

The authors searched the literature in the PubMed/Medline, EMBASE, by cross-referencing and additional hand search. Included were comparative studies between conventional open and minimally invasive or percutaneous surgical approaches. Twelve studies were included.

RESULTS AND CONCLUSIONS

The literature review supports the assumption that minimally invasive surgery preserves muscles for the early post-operative period, even though the level of evidence is still low. The correlation of changes in muscular structure to pain, strength, disability, and quality of life remains ambiguous and should be addressed in further studies with a focus on the surgical approach.

Clinical outcome and surgical strategies for late post-traumatic kyphosis after failed thoracolumbar fracture operation: Case report and literature review

RATIONALE

Thoracic-lumbar vertebral fracture is very common in clinic, and late post-traumatic kyphosis is the main cause closely related to the patients' life quality, which has evocated extensive concern for the surgical treatment of the disease. This study aimed to analyze the clinical outcomes and surgical strategies for late post-traumatic kyphosis after failed thoracolumbar fracture operation.

PATIENT CONCERNS

All patients presented back pain with kyphotic apex vertebrae between T12 and L3. According to Frankel classification grading system, among them, 3 patients were classified as grade D, with the ability to live independently.

DIAGNOSES

A systematic review of 12 case series of post-traumatic kyphosis after failed thoracolumbar fracture operation was involved.

INTERVENTIONS

Wedge osteotomy was performed as indicated-posterior closing osteotomy correction in 5 patients and anterior open-posterior close correction in 7 patients.Postoperatively, thoracolumbar x-rays were obtained to evaluate the correction of kyphotic deformity, visual analog scales (VAS) and Frankel grading system were used for access the clinical outcomes.

OUTCOMES

All the patients were followed up, with the average period of 38.5 months (range 24-56 months). The Kyphotic Cobb angle was improved from preoperative (28.65 ± 11.41) to postoperative (1.14 ± 2.79), with the correction rate of 96.02%. There was 1 case of intraoperative dural tear, without complications such as death, neurological injury, and wound infection. According to Frankel grading system, no patient suffered deteriorated neurological symptoms after surgery, and 2 patients (2/3) experienced significant relief after surgery. The main VAS score of back pain was improved from preoperative (4.41 ± 1.08) to postoperative (1.5 ± 0.91) at final follow-up, with an improvement rate of 65.89%.

LESSONS

Surgical treatment of late post-traumatic kyphosis after failed thoracolumbar fracture operation can obtain good radiologic and clinical outcomes by kyphosis correction, decompression, and posterior stability.

Combined anteroposterior fixation using a titanium cage versus solely posterior fixation for traumatic thoracolumbar fractures: A systematic review and meta-analysis

Study Design:

Systematic review with meta-analysis.

Objective:

Additional anterior stabilization might prevent posterior implant failure, but over time, the disadvantageous of bone grafts have become evident. The objective of this systematic review was to compare risks and advantages of additional anterior stabilization with a titanium cage to solely posterior fixation for traumatic thoracolumbar fractures.

Methods:

An electronic search was performed in the literature from 1980 to March 2016. Studies comparing only posterior with anteroposterior fixation by means of a titanium cage were included in this study. Data extraction and Cochrane risk of bias assessment were done by two independent authors. In addition, the PRISMA statement was followed, and the GRADE approach was used to present results.

Results:

Of the 1584 studies, two randomized controlled trials (RCTs) and one retrospective cohort study were included in the meta-analysis. The RCTs reported evidence of high quality that anteroposterior stabilization maintained better kyphosis correction than posterior stabilization alone. However, these results were neutralized in the meta-analysis by the cohort study. Implant failure was reported by one study, in the posterior group. No differences in follow-up visual analog scale scores, neurologic improvement, and complications were found. Operation time, blood loss, and hospital stay all increased in the anteroposterior group.

Conclusions:

Patients with a highly comminuted or unstable fracture could benefit from combined anteroposterior stabilization with a titanium cage, for some evidence suggests this prevents loss of correction. However, large randomized studies still lack. There is a risk of cage subsidence, and increased perioperative risks have to be considered when choosing the optimal treatment.

Surgical treatment of secondary fractures after percutaneous vertebroplasty: A retrospective study

BACKGROUND

Percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) are effective procedures for the treatment of vertebral compression fractures (VCFs). However, recent studies have reported that secondary VCFs develop in patients after PVP or PKP treatment. This study aimed to investigate the clinical characteristics and management of secondary fractures after PVP or PKP.

MATERIALS AND METHODS

599 cases who had vertebral compression fracture and underwent PVP or PKP between September 2008 and June 2014 were enrolled, including 121 males and 478 females. Secondary fractures were observed in 52 cases, including 3 males and 49 females, who were treated by re-operation with PVP or PKP.

RESULTS

The ratio of secondary fracture after PVP or PKP was 8.68% in all cases. The age ranged from 59 to 92 years (74.41 ± 6.83 average). A composition of 44.44% of the secondary fracture occurred near the initial fracture vertebrae. After re-operation with PVP or PKP, visual analog scale score significantly decreased to 2.72 ± 0.88 or 2.52 ± 1.12, respectively, anterior height of vertebral bodies increased to 24.69 ± 4.59 or 24.54 ± 5.97 mm, respectively, and middle height of vertebral bodies increased to 20.90 ± 3.72 or 20.36 ± 6.33 mm, respectively.

CONCLUSIONS

There is a high chance of secondary fracture near the initially operated vertebrae after PVP or PKP. Re-operation with PVP or PKP achieves satisfactory outcomes in these patients such as pain relief and the recovery of the vertebrae height.

Pedicle screw fixation combined with intermediate screw at the fracture level for treatment of thoracolumbar fractures: A meta-analysis

BACKGROUND

Use of a pedicle screw at the level of fracture, also known as an intermediate screw, has been shown to improve clinical results in managing thoracolumbar(TL) fractures, but there is a paucity of powerful evidence to support the claim. The aim of this study was to compare outcomes between pedicle screw fixation combined with intermediate screw at the fracture level and conventional pedicle screw fixation (one level above and one level below the fracture level) for thoracolumbar (TL) fractures.

METHODS

A meta-analysis of cohort studies was conducted between pedicle screw fixation combined with intermediate screw at the fracture level (combined screw group) and conventional pedicle screw fixation (conventional group) for the treatment of TL fractures from their inception to December 2015. An extensive search of studies was performed in PubMed, Medline, Embase, and the Cochrane library. The following outcome measures were extracted: visual analogue scale (VAS), operation time and intraoperative blood loss, Cobb angle and anterior vertebral height (AVH), and complications. Data analysis was conducted with RevMan 5.3.5.

RESULTS

From 10 relevant studies identified, 283 patients undergoing pedicle screw fixation combined with intermediate screw at the fracture level were compared with 285 conventional pedicle screw procedures. The pooled analysis showed that there was statistically significant difference in terms of postoperative Cobb angle (95% confidence interval (CI), -3.00, -0.75; P = 0.001) and AVH (95% CI, 0.04, 12.23; P = 0.05), correction loss (Cobb angle: P < 0.0001; AVH: P < 0.0001) and implant failure rate (95% CI, 0.06, 0.62; P = 0.006), and blood loss (W 95% CI, 2.22, 23.60; P = 0.02) between 2 groups. But in terms of other complications, there were no differences between 2 groups (95% CI, 0.23, 2.04; P = 0.50). No difference was found in operation time (95% CI, -5.36, 14.67; P = 0.36) and VAS scores (95% CI, -0.44, 0.01; P = 0.06).

CONCLUSIONS

The combined screw fixation technique was associated with better reduction of the fractured vertebrae, less correction loss in the follow-up, and lower implant failure rate. Given the lack of robust clinical evidence, these findings warrant verification in large prospective registries and randomized trials with long-term follow-up.

The Reverse Thomas Position for Thoracolumbar Fracture Height Restoration: Relative Contribution of Patient Positioning in Percutaneous Balloon Kyphoplasty for Acute Vertebral Compressions

BACKGROUND

Standard positioning for percutaneous balloon kyphoplasty requires placing a patient prone with supports under the iliac crests and upper thorax. The authors believe that hip hyperextension maximises pelvic anteversion creating anterior longitudinal ligamentotaxis, thus facilitating restoration of vertebral height.

METHODS

Radiographic imaging including pre-operative, post-positioning, post balloon tamp inflation and post-operative lateral radiographs were analysed for anterior and posterior column height, wedge angle of the affected vertebra and 3-level Cobb angle in patients with recent fractures of T11-L1. Fracture dimensions of the index vertebra were expressed as percentage of the analogous dimension of the referent vertebra.

RESULTS

From a total of 149 patients, a full imaging sequence was available on 21 cases of vertebral compression fractures. The described positioning technique created a mean anterior column height increase from 68.3% to 75.3% with positioning (p = 0.15), increasing to 82.3% post balloon inflation. Average Cobb and wedge angle improvement of 4.7° (p = 0.004)and 3.6° (p = 0.002) from positioning along were also recorded.

CONCLUSION

The Reverse Thomas Position is a safe and effective technique for augmenting thoracolumbar fracture height restoration in percutaneous balloon kyphoplasty.