Effect of the percutaneous pedicle screw fixation at the fractured vertebra on the treatment of thoracolumbar fractures

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Factors associated with loss of vertebral height and kyphosis correction after intermediate screws in short segment pedicular fixation for type-A fractures of the thoracolumbar spine: A retrospective study

In this article, we attempted to identify risk factors affecting the loss of vertebral height and kyphosis correction on type A thoracolumbar fractures. Patients with type A thoracolumbar fractures who underwent short segments with intermediate screws at the fracture level management between 2017 and 2022 were included in this study. Clinical factors including patients' demographic characteristics (age, sex), history (smoking, hypertension and/or diabetes), value of height/kyphosis correction, the thoracolumbar injury classification and severity score (TLICS), the load sharing classification (LSC) scores and bone mineral density were collected. Correlation coefficient, simple linear regression analysis and multivariate regression analysis were performed to identify the clinical factors associated with the loss of vertebral height/kyphosis correction. Finally, 166 patients were included in this study. The mean height and kyphosis correction were 21.8% ± 7.5% and 9.9° ± 3.8°, respectively, the values of the loss were 6.5% ± 4.0% and 3.9° ± 1.9°, respectively. Simple linear regression analysis and multivariate regression analysis showed that age, value of height correction, LSC scores and bone mineral density were significantly associated with the loss of vertebral height and kyphosis correction (P < .01) We could draw the conclusion that patients with older age, lower bone mineral density, higher LSC scores and diabetes are at higher risk of vertebral height and kyphosis correction loss increase. For these patients, appropriate clinical measures such as long segment fixation, control of blood glucose, and increase of bone density must be taken to reduce the loss of correction.

Analysis of factors influencing the intravertebral shell phenomenon after posterior reduction internal fixation of thoracolumbar fracture: a retrospective study

STUDY DESIGN

A retrospective study.

PURPOSE

The study objectives were as follows: 1) to analyze the factors influencing the occurrence of the intravertebral shell phenomenon (ISP) after thoracolumbar spinal fracture surgery and the evolutionary outcome of this phenomenon; and 2) to make recommendations for the clinical prevention and treatment of ISP.

METHODS

We retrospectively analyzed 331 patients with single-segment fractures of the thoracolumbar spine treated with internal fixation via a pedicle screw-rod system. Univariate and multivariate logistic regression were used to analyze factors influencing ISP.

RESULTS

A total of 260 patients (78.5%) developed ISP after surgery. Reduced bone mineral density, screw insertion depth, degree of vertebral body injury, and excessive vertebral body spreading were significantly associated with the occurrence of ISP (P < 0.05). A total of 166 of the 260 patients were reviewed via CT at 1 year postoperatively. Among them, 104 patients (62.6%) showed shrinkage or healed vertebral cavities, and 62 patients (37.4%) showed enlarged vertebral cavities or collapsed endplates.

CONCLUSION

In clinical management, surgeons need to focus on risk factors for ISP, which include decreased bone density, preoperative vertebral overcompression, intraoperative vertebral overextension, screw insertion depth, and the degree of vertebral repositioning. At the 1-year postoperative follow-up, some of the vertebrae with ISP failed to heal or even showed vertebral cleft enlargement, which would affect the stability of the internal fracture fixation device and the quality of the patient's daily life.

A Rapid and Safe Minimally Invasive Procedure for Percutaneous Pedicle Screw Removal: A Case-Control Study and Technical Description

Purpose

Percutaneous pedicle screw fixation is a common minimally invasive treatment for traumatic thoracolumbar and lumbar fractures; however, research on hardware removal after successful healing is limited. We aimed to introduce a rapid, safe, minimally invasive, and cost-effective method for percutaneous pedicle screw removal.

Patients and Methods

We conducted a retrospective analysis of demographic (age, sex, body mass index, alcohol use, and current smoking), clinical (hypertension and diabetes mellitus), surgical (affected levels, number of screws, time of surgery, and blood loss), and treatment cost characteristics of 92 patients who had undergone percutaneous pedicle screw removal between May 2016 and February 2023. The first 57 patients underwent the conventional method, and the remaining 35 underwent the modified method. Independent-sample t-tests and chi-square tests were used to compare continuous and categorical variables, respectively, between the two groups.

Results

No significant differences were observed in the demographic parameters, complications, or affected levels between the groups. However, the average surgical time (P=0.000) was significantly shorter, and the average blood loss volume (P=0.002) and total cost (P=0.000) were significantly lower in the modified group than in the conventional group.

Conclusion

Compared with the conventional method, our modified method can shorten the surgical time, reduce blood loss, and reduce the total cost of treatment. It is a quick and safe minimally invasive method that does not require additional surgical instruments and is suitable for implementation in primary hospitals.

Surgical treatment of traumatic fractures of the thoracic and lumbar spine: A systematic review

Introduction

The treatment of traumatic thoracic and lumbar spine fractures remains controversial. To date no consensus exists on the correct choice of surgical approach and technique.

Research question

to provide a comprehensive up-to-date overview of the available different surgical methods and their quantified outcomes.

Methods

PubMed and EMBASE were searched between 2001 and 2020 using the term 'spinal fractures'. Inclusion criteria were: adults, ≥10 cases, ≥12 months follow-up, thoracic or lumbar fractures, and surgery <3 weeks of trauma. Studies were categorized per surgical technique: Posterior open (PO), posterior percutaneous (PP), stand-alone vertebral body augmentation (SA), anterior scopic (AS), anterior open (AO), posterior percutaneous and anterior open (PPAO), posterior percutaneous and anterior scopic (PPAS), posterior open and anterior open (POAO) and posterior open and anterior scopic (POAS). The PO group was used as a reference group.

Results

After duplicate removal 6042 articles were identified. A total of 102 articles were Included, in which 137 separate surgical technique cohorts were described: PO (n = 75), PP, (n = 39), SA (n = 12), AO (n = 5), PPAO (n = 1), PPAS (n = 1), POAO (n = 2) and POAS (n = 2).

Discussion and conclusion

For type A3/A4 burst fractures, without severe neurological deficit, posterior percutaneous (PP) technique seems the safest and most feasible option in the past two decades. If needed, PP can be combined with anterior augmentation to prevent secondary kyphosis. Furthermore, posterior open (PO) technique is feasible in almost all types of fractures. Also, this technique can provide for an additional posterior decompression or fusion. Overall, no neurologic deterioration was reported following surgical intervention.

The efficacy of different segments fixation for treatment thoracolumbar fractures: A Bayesian network meta-analysis

BACKGROUND

We did this network meta-analysis to comprehensively compare the efficacy of different segments [intermediate segment (IS), short segment (SS) and long segment (LS)] in the fixation of thoracolumbar fractures.

METHODS

We searched studies from inception until January 20, 2023 through PubMed, Embase, Web of Science, and the Cochrane Library. All studies comparing different segments in the fixation of thoracolumbar fractures were included in this meta-analysis. Outcomes were anterior vertebral height ratio (AVHR), sagittal Cobb angle (SCA), visual analogue scale score, and implant failure rate. This network meta-analysis was performed by R software with gemtc package.

RESULTS

Finally, a total of 22 studies were finally included in this network meta-analysis. IS (WMD 2.43, 95% CrI 2.04-2.91) was more effective than SS in terms of the AVHR, and the difference was statistically significant. IS was more effective than LS in reducing SCA (WMD -2.87, 95% CrI -3.79 to -1.96) with statistically significant. Compared with SS, IS significantly reduced the SCA with statistically significant (WMD -2.52, 95% CrI -3.31 to -1.72). IS (WMD -2.87, 95% CrI -3.78 to -1.96) was more effective than LS, and the difference was statistically significant. Moreover, IS (WMD -2.52, 95% CrI -3.31 to -1.72) was more effective than SS, and the difference was statistically significant.

CONCLUSION

IS was associated with a significant reduction in SCA, implant failure rate, and visual analogue scale compared to SS and LS, while having the most favorable impact on AVHR among all the treatments assessed.

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.

Percutaneous pedicle screw fixation without arthrodesis of 368 thoracolumbar fractures: long-term clinical and radiological outcomes in a single institution

PURPOSE

Traumatic thoracolumbar (TL) fractures are the most common vertebral fractures. Although a consensus on the preferred treatment is missing, percutaneous pedicle screw fixation (PPSF) has been progressively accepted as treatment option, since it is related to lower soft tissues surgical-injury and perioperative complications rate. This study aims to evaluate the long-term clinical-radiological outcomes after PPSF for TL fractures at a single tertiary academic hospital.

METHODS

This is a retrospective cohort study. Back pain was obtained at preoperative, postoperative and final follow-up using Visual Analog Scale. Patient-reported outcomes, the Oswestry Disability Index and the 36-Item Short Form, were obtained to asses disability during follow-up. Radiological measures included Cobb angle, mid-sagittal index, sagittal index (SI) and vertebral body height loss. A multivariate regression analysis on preoperative radiological features was performed to investigate independent risk factors for implant failure.

RESULTS

A total of 296 patients with 368 TL fractures met inclusion criteria. Mean follow-up was 124.3 months. The clinical and radiological parameters significantly improved from preoperative to last follow-up measurements. The multivariate analysis showed that Cobb angle (OR = 1.3, p < 0.001), SI (OR = 1.5, p < 0.001) and number of fractures (OR = 1.1, p = 0.05), were independent risk factors for implant failure. The overall complication rate was 5.1%, while the reoperation rate for implant failure was 3.4%.

CONCLUSIONS

In our case series, PPSF for TL injuries demonstrated good long-term clinical-radiological outcomes, along with low complication and reoperation rates. Accordingly, PPSF could be considered as a valuable treatment option for neurologically intact patients with TL fractures. Additionally, in this cohort, number of fractures ≥ 2, Cobb angle ≥ 15° and sagittal index ≥ 21° were independent risk factors for implant failure.

TREATMENT OF THORACOLUMBAR FRACTURES BY CLOSED REDUCTION VIA A PERCUTANEOUS SOLID PEDICLE SCREW

Objectives

Investigate the effect of closed reduction and per- cutaneous pedicle screw fixation in treating thoracolumbar fractures.

Methods

This retrospective study analyzed 12 cases of single-segment thoracolumbar spine fractures without spinal cord and nerve injury at our department from March 2016 to September 2017. Patients were treated with closed reduction, percutaneous reduction, and internal fixation with solid pedicle screws. The operation time, intraoperative blood loss, anterior vertebral body height ratio (AVHR), Cobb angle (CA) of sagittal kyphosis, and VAS of back pain were determined and statistically compared.

Results

The average operation time was 147.2 ± 45.6 min, and the average intraoperative bleeding was 67.8 ± 34.2 mL. All fractured vertebrae were completely reduced, their height was restored, and kyphosis was corrected. The average follow-up period was 10.6 ± 2.7 months, with significant improvements seen in the AVHR, CA of sagittal kyphosis, and VAS score (P < 0.01). One case had a broken rod after three months, and another had a postoperative infection. All the patients achieved bony healing.

Conclusion

The treatment of thoracolumbar fractures by closed reduction and internal fixation with a percutaneous solid pedicle screw is simple, effective, and economical. Level of Evidence VI; Therapeutic Study, Case Series .

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparison of different segments in the fixation of thoracolumbar fractures: a Bayesian network meta-analysis

BACKGROUND

Posterior internal fixation (PIF) is commonly used in the treatment of thoracolumbar fracture (TLF), but there is still no standard for the number of fixed segments. The objective of this meta-analysis was to evaluate the efficacy and safety of short segment (SS), intermediate segment (IS) and long segment (LS) in the fixation of TLF.

METHODS

Two authors independently searched through PubMed, Embase, Cochrane Library and Web of Science for studies of thoracolumbar fracture treated by posterior internal fixation, which were published until the end of April 2021. The Aggregate Data Drug Information System (ADDIS) software was used for data evaluation according to the Markov chain Monte Carlo (MCMC) method based on the Bayesian theorem.

RESULTS

Nineteen trials evaluating a total of 970 patients were enrolled in these studies, of which 340 in the SS group, 429 in the IS group and 201 in the LS group. For anterior vertebral height ratio (AVHR), IS had the highest AVHR, LS had the second highest AVHR. IS also ranked first in reducing visual analogue scale (VAS), SS ranked second. For sagittal Cobb's angle (SCA), LS had the lowest SCA and IS had the second lowest SCA. In terms of adverse events, IS had the lowest implant failure rate and LS had the second lowest implant failure rate.

CONCLUSIONS

IS may be the most desirable treatment option for TLF in reducing SCA, implant failure rate, VAS, and improving AVHR. However, more randomized controlled trials are needed to verify these results.

Comparison of monoplanar and polyaxial screw fixation systems in percutaneous intermediate fixation for thoracolumbar fractures

Background

The newly developed monoplanar pedicle screws (MPPSs) can mobile in axial plane but fixed in the sagittal plane, which holds potential to combine ease of rod placement with sagittal plane strength theoretically. So far, few clinical studies focused on the outcomes of MPPSs for treatment of thoracolumbar fractures (TLFs). The aim of this study was to compare the efficacy of MPPSs to polyaxial pedicle screws (PAPSs) in percutaneous intermediate fixation of TLFs.

Methods

Seventy-eight patients who sustained TLFs without neurological deficits and underwent percutaneous intermediate fixation using MPPSs (40 patients) or PAPSs (38 patients) with a minimum 1-year follow-up were included in this study. The operation time, blood loss, local Cobb angle (LCA), vertebral wedge angle (VWA), anterior body height ratio (ABHR), visual analogue scale (VAS) and Oswestry Disability Index (ODI) were collected.

Results

No significant differences were observed in baseline demographics, clinical characteristics, operation time or blood loss between the two groups (P > 0.05). The postoperative LCA, VWA and ABHR were significantly corrected compared to these parameters preoperatively in both groups (^#P < 0.05). The postoperative LCA, VWA and ABHR in the MPPS group were significantly better corrected than those in the PAPS group (*P < 0.05). Furthermore, the correction loss of LCA, VWA and ABHR in the MPPS group was significantly lower than that in the PAPS group (*P < 0.05). However, no significant difference in VAS and ODI scores was observed between the two groups.

Conclusions

MPPSs showed similar efficiency as PAPSs in percutaneous intermediate fixation surgical procedures. More importantly, MPPSs achieved better radiological performance than PAPSs in the correction of TLFs and the prevention of correction loss.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05129-8.

Surgical Techniques for Thoracolumbar Spine Fractures: WFNS Spine Committee Recommendations

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

A real-time 3D electromagnetic navigation system for percutaneous pedicle screw fixation in traumatic thoraco-lumbar fractures: implications for efficiency, fluoroscopic time, and accuracy compared with those of conventional fluoroscopic guidance

PURPOSE

Navigation is becoming more useful in percutaneous pedicle screw fixation (PPSF). The aim of this study was to compare the efficiency, fluoroscopic time, accuracy, and clinical outcomes of PPSF with a novel electromagnetic navigation (EMN) system for thoraco-lumbar (TL) fractures with those of PPSF with conventional C-arm fluoroscopic (CF) guidance.

METHODS

A retrospective study was conducted. A total of 162 screws were implanted in 29 patients with the assistance of the EMN system (EMN group), and 220 screws were inserted in 40 patients by using CF guidance (CF group). The duration of surgery, placement time per screw, fluoroscopic time per screw, accuracy of pedicle screw placement, and clinical outcomes were compared between the two groups.

RESULTS

The duration of surgery and placement time per screw in the EMN group were significantly lower than those in the CF group (P < 0.05). The fluoroscopic time per screw in the CF group was significantly longer than that in the EMN group (P < 0.05). The learning curve of PPSF in the EMN group was steeper than that in the CF group. The accuracy of pedicle screw placement in the EMN group was more precise than that in the CF group (P < 0.05). The VAS scores in the EMN group were significantly lower than those in the CF group at one-week postoperatively (P < 0.05).

CONCLUSION

Compared with PPSF by using conventional fluoroscopic guidance, PPSF with the aid of the EMN system can increase the efficiency and accuracy of pedicle screw placement and reduce the fluoroscopic time.

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

STUDY DESIGN

Retrospective matched cohort study.

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

EFFECT OF PKP ON SERUM SOST IN PATIENTS WITH VERTEaBRAL COMPRESSION FRACTURES

Objective:

This study sought to determine serum sclerostin (SOST) expression in patients with osteoporotic thoracolumbar vertebral compression fractures before and after percutaneous kyphoplasty (PKP).

Methods:

Serum SOST levels were quantified with a sandwich enzyme-linked immunosorbent assay (ELISA) preoperatively and six months postoperatively. Anterior vertebral height, kyphotic angles, and Visual Analogue Scale (VAS) scores were also recorded.

Results:

Serum SOST was highly expressed in patients and remained negatively correlated with bone mineral density (BMD). Vertebral heights, local kyphotic angles, and VAS scores were all significantly improved after PKP. However, serum SOST was positively correlated with BMD six months after surgery.

Conclusion:

PKP was an effective treatment strategy for osteoporotic thoracolumbar vertebral compression fractures, improving BMD and decreasing serum SOST levels. Level of Evidence II, Prospective comparative study.

Pedicle screw fixation of thoracolumbar fractures: conventional short segment versus short segment with intermediate screws at the fracture level-a systematic review and meta-analysis

OBJECTIVE

Posterior short-segment fixation (4-screw construct = 4S) is the conventional surgical technique for thoracolumbar fractures. The effect of adding two intermediate pedicle screws at the fractured level (6-screw construct = 6S) is still a matter of debate. This review aims to compare the results between 4 and 6S pedicle screw fixation for thoracolumbar fractures.

METHODS

A systematic review and meta-analysis were performed. The databases PubMed, Embase and Google Scholar were searched until January 2020. Inclusion criteria were studies comparing 4S and 6S techniques in patients with thoracolumbar fractures. Non-comparative studies and studies without full text were excluded. Cochrane risk of bias was assessed, and the GRADE approach was used to present the quality of evidence.

RESULTS

Twenty-seven studies, of which 21 randomized controlled trials, with a total of 1890 patients (940 with 4S and 950 with 6S) were included. Meta-analysis showed that the 6S technique resulted in significantly lower pain scores, better short-term and long-term Cobb angles, less loss of correction and less implant failures. However, longer operation time and more blood loss were seen with the 6S technique. Length of hospital stay, Oswestry Disability Index scores and infections did not differ significantly between the 6S and 4S techniques. Quality of the evidence according to GRADE was moderate to low.

CONCLUSION

In the treatment of thoracolumbar fractures, adding intermediate screws at the fracture level (6S) results in less post-operative pain, better radiological outcomes and less implant failure at the cost of a longer operation time and higher blood loss.

Effect of the short-segment internal fixation with intermediate inclined-angle polyaxial screw at the fractured vertebra on the treatment of Denis type B thoracolumbar fracture

BACKGROUND

Short-segment internal fixation with intermediate straight-forward monoaxial screws (SSIF-SFM) and long-segment internal fixation (LSIF) are the two major surgical options for thoracolumbar (TL) fracture. However, SSIF-SFM might not provide adequate support to the spine, and LSIF is unnecessarily extensive. SSIF with intermediate inclined-angle polyxial screw (SSIF-IAP) might offer an alternative solution for the treatment of TL fracture.

METHODS

A retrospective study was conducted. Sixty-nine patients (47 males and 22 females; average 34.5 years) with Denis type B TL fracture who met the criteria for inclusion were enrolled. Sagittal Cobb's angle (SCA), anterior vertebral body height (AVBH), vertebral body index (VBI), and spinal canal encroachment (SCE) were measured and assessed. Visual analogue scale (VAS) and Oswestry disability index (ODI) were also evaluated.

RESULTS

The average values of incision length, blood loss, duration of operation, and hospital stay in the SSIF-IAP group and SSIF-SFM group were significantly decreased compared with those in the LSIF group. The AVBH and VBI in the SSIF-IAP group and LSIF group were significantly improved than those in the SSIF-SFM group at 6-month and the latest follow-ups (P < 0.05). The correction losses of AVBH and VBI (calculated by the reduction of AVBH and VBI) in the SSIF-IAP group and LSIF group were also significantly decreased compared with those in the SSIF-SFM group at 6-month and the latest follow-ups (P < 0.05). There was no significant difference of SCE among the three groups postoperatively. The VAS and ODI in the SSIF-IAP group and SSIF-SFM group were significantly decreased compared with those in the LSIF group at 6-month and the latest follow-ups (P < 0.05).

CONCLUSION

Both SSIF-IAP and LSIF can improve the biomechanical stability as compared with SSIF-SFM. Moreover, SSIF-IAP was less extensive compared to LSIF. SSIF-IAP was an effective and reliable operative technique for patients with Denis type B TL fracture.

Effect of RTS versus percutaneous conventional pedicle screw fixation on type A thoracolumbar fractures: a retrospective cohort study

PURPOSE

This study aims at evaluating the effects of RTS (rotation softened trauma fixation system) compared with PCPSF (percutaneous conventional pedicle screw fixation) on type A thoracolumbar fractures.

METHODS

In this retrospective cohort study, 116 patients with type A thoracolumbar fractures from March 2014 to June 2018 were enrolled. PCPSF was performed in 60 patients, meanwhile the other 56 patients accepted RTS. VAS scores, Cobb angle, anterior vertebral height (AVH) and perioperative data were compared between the two groups.

RESULTS

Both groups were consistent with baseline on demographic and clinical characteristics. No significant difference was observed in VAS score between-group before and after operation. One year after surgery, the VAS score of RTS group was lower than that of PCPSF group (0.7 ± 0.3 vs. 1.5 ± 0.4). The postoperative AVH (%) in PCPSF was 82.3% (95%CI, 81.7-84.6), and 91.78% (95% CI, 91.1-92.4) in RTS. The postoperative improvement rate of AVH (%) in RTS was higher than that in PCPSF (30.6 ± 5.0 [95% CI, 29.2-32.0] vs. 22.0 ± 7.3 [95% CI, 20.2-24.2]). The postoperative Cobb angle (°) in PCPSF was 2.6 ± 3.4 (95%CI,11.7-13.5), and 7.5 ± 2.0 (95%CI,7.0-8.0) in RTS. The postoperative correction of Cobb angle (°) in RTS was higher than that in PCPSF (16.1 ± 3.8 95%CI,15.1-17.1] vs. 11.6 ± 5.2 95%CI,10.3-13.1]).

CONCLUSIONS

Compared with PCPSF, RTS has advantages in restoring the anterior vertebral height and reducing local kyphosis.

Percutaneous Pedicle Screw Fixation in Thoracolumbar Fractures: Comparison of Results According to Implant Removal Time

Background

The purpose of this study was to determine whether restoration of range of motion (ROM) could be achieved by implant removal after natural bone healing and consolidation of fractured vertebrae and examine whether early removal of the implant could maximize restoration of ROM.

Methods

This study included 30 cases of thoracolumbar fractures without neurological deficit requiring surgery (nine cases of flexion-distraction injuries and 21 cases of burst fractures). Percutaneous pedicle screw fixation (PPSF) was performed at the fractured vertebrae and one level above and one level below the fracture level. Pedicle screws were removed at an average of 12 months after surgery upon healing of fractured vertebrae. The following radiological and clinical findings were evaluated: restoration of anterior vertebral height ratio (AVHR), Cobb angle (CA), ROM, and complications. Sixteen patients who were checked for ROM were divided into two groups based on the time of implant removal: nine patients within 12 months and seven patients after 12 months. Restoration of vertebral height loss and ROM were compared between the two groups.

Results

At the final follow-up, significant pain relief and restoration of AVHR and CA were achieved in patients who underwent PPSF. Patients who had implant removed within 12 months after surgery had better ROM recovery than those who had implant removed after 12 months postoperatively. There were no significant differences in AVHR and CA between the two groups.

Conclusions

PPSF followed by implant removal after healing of fractured body appears to be effective in achieving restoration of ROM. In our study, early removal of implant within 12 months after surgery was associated with better achievement of ROM than removal after 12 months. In addition, there were no significant differences in restoration of vertebral height between the two groups.

Biomechanical comparison of posterior intermediate screw fixation techniques with hybrid monoaxial and polyaxial pedicle screws in the treatment of thoracolumbar burst fracture: a finite element study

BACKGROUND

To compare the biomechanical characteristics of different posterior intermediate screw fixation techniques (ISFTs) with hybrid monoaxial pedicle screws (Mps) and polyaxial pedicle screws (Pps) used in thoracolumbar burst fractures.

METHODS

Fixation techniques are compared with regard to the von Mises stress (VMS) of the instrumentations and intradiscal pressures (IDPs) of the adjacent segments by finite element method (FEM).

RESULTS

The redistributed ROM of the fixation models with Pps fixed at the lowest segment was twice of the other fixation models in flexion and extension. The largest value of maximal VMS of a pedicle screw was located at the lowest pedicle screws when Mps are fixed at the lowest segment. The largest value of maximal VMS of the rods was decreased when more Pps are fixed at the models. Maximal IDPs of the upper adjacent segments were all larger than those of the lower adjacent segments. The maximal IDPs of the fixation model with MPs fixed at the lowest segment were larger than the other fixation models in flexion and extension.

CONCLUSIONS

Polyaxial pedicle screws could be placed at the upper or the median segment for the facilitated efficient application of the connecting rod. We should focus on the adjacent segmental degeneration especially the upper adjacent segment in the fixation model with Mps fixed at the lowest segment.

Minimally Invasive Surgery for the Treatment of Traumatic Monosegmental Thoracolumbar Burst Fractures: Clinical and Radiologic Outcomes of 144 Patients With a 6-year Follow-Up Comparing Two Groups With or Without Intermediate Screw

STUDY DESIGN

This was a retrospective study of the clinical and radiologic outcomes of traumatic thoracolumbar (TL) burst fractures.

OBJECTIVES

We aimed to evaluate the clinical and radiologic outcomes after 6 years of follow-up of 144 patients with monosegmental TL burst fractures treated with percutaneous short-segment pedicle screw fixation, comparing two groups with versus without placement of an intermediate screw at the fractured vertebra.

SUMMARY OF BACKGROUND DATA

Traumatic TL fractures are the most common vertebral fractures, especially at the TL junction (T10-L2). Minimally invasive surgery (MIS) is a valuable treatment option for traumatic TL burst fractures.

MATERIALS AND METHODS

The clinical outcomes and radiologic parameters (Cobb angle, midsagittal index, and sagittal index) of 144 patients with traumatic monosegmental TL fractures treated with MIS were evaluated preoperatively, postoperatively, and after 3 and 6 years of follow-up. Patients were categorized into a nonintermediate screw group (nISG) and an intermediate screw group (ISG), and the groups were compared.

RESULTS

There were 71 patients (49.3%) in the nISG and 73 patients (50.7%) in the ISG. The radiologic parameters improved significantly more from the preoperative evaluation to the 6-year follow-up in the ISG than in the nISG (P<0.025). There were no significant differences in the mean Oswestry Disability Index (ODI) and Visual Analog Scale scores at the 6-year follow-up between the ISG and the nISG: 15.6% (ISG) versus 16.8% (nISG) for ODI (P<0.1) and 2.2 (ISG) versus 2.4 (nISG) for Visual Analog Scale score (P<0.85) (P<0.73).

CONCLUSIONS

MIS showed good clinical outcomes 6 years after surgery in both the ISG and the nISG. The additional intermediate screw significantly improved radiologic parameters but not clinical outcomes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Posterior paraspinal muscle versus post-middle approach for the treatment of thoracolumbar burst fractures: A randomized controlled trial

BACKGROUND

This randomized controlled trial (RCT) aimed to compare the clinical outcomes of thoracolumbar burst fractures (TLBFs) treated with open reduction and internal fixation via the posterior paraspinal muscle approach (PPMA) and the post-middle approach (PA).

METHODS

Patients with a traumatic single-level TLBFs (T10-L2), treated at our hospital between December 2009 and December 2014, were randomly allocated to Group A (PPMA) and Group B (PA). Sex, age, time from injury to surgery, the American Spinal Injury Association Impairment Scale score (ASIAIS), comorbidities, vertebral level, pre- and postoperative kyphotic angle (KA), visual analog scale (VAS) pain score, and the Oswestry Disability Index (ODI) scores were included in the analysis. Operative time, intraoperative blood loss, x-ray exposure time, postoperative drainage volume, superficial infection, and occurrence of deep infection were documented. The patients were followed up at 2 weeks; 1, 3, and 6 months; 1 and 2 years; and every 6 months thereafter. Radiological assessments were performed to assess fracture union and detect potential loosening and breakage of the pedicle screws and rods at each follow-up. Postoperative VAS and ODI scores were used to evaluate the clinical outcomes.

RESULTS

A total of 62 patients were enrolled (30 in Group A and 32 in Group B, respectively). The operative time (P < .001) and x-ray exposure time (P < .001) in Group A were significantly longer than those in Group B. However, compared to Group B, there were less intraoperative blood loss (P < .001), lower postoperative drainage volume (P < .001), lower VAS scores (2-week (P = .029), 1-month (P = .023), 3-month (P = .047), and 6-month follow-up (P = .010)), and lower ODI scores (2-week, P = .010; 1-month, P < .001; 3-month, P = .028; and 6-month follow-up, P = .033) in Group A.

CONCLUSIONS

Although PPMA required a longer operative time and x-ray exposure time, PPMA provided several advantages over PA, including less intra-operative blood loss and lower postoperative drainage volume, and greater satisfaction with postoperative pain relief and functional improvement, than PA, especially at the 6-month follow-up after surgery. Further high-quality multicenter studies are warranted to validate our findings.

A Comparison of Three Different Methods of Fixation in the Management of Thoracolumbar Fractures

Background

Management of thoracolumbar fractures remains controversial in the literature. The primary aims of this study were to assess different levels of fixation with respect to radiological outcomes in terms of fracture reduction and future loss of correction.

Methods

This is a single center, retrospective study. Fifty-five patients presenting with thoracolumbar fractures between January 2012 and December 2015 were analyzed in the study. The levels of fixation were divided in 3 groups: 1 vertebra above and 1 below the fracture (1/1), 2 above and 2 below (2/2), and 2 above and 1 below (2/1).

Results

The most common mechanism was high fall injury, and the most common vertebra L1. Burst fractures were the ones with the highest incidence. The 2/2 fixation achieved the best reduction of the fracture, but with no statistical significance. The correction is maintained better by the 2/2 fixation, but there is no statistical difference compared to the other fixations. Insertion of screws at the fracture level did not improve outcomes.

Conclusion

The data of this study identified a trend toward better radiological outcomes for fracture reduction and maintenance of the correction in the 2/2 fixations. However, these results are not statistically significant. Future multicenter prospective clinical trials are needed in order to agree on the ideal management and method of fixation for thoracolumbar fractures.

A Comparison of Three Different Methods of Fixation in the Management of Thoracolumbar Fractures

Introduction

Management of thoracolumbar fractures remains controversial in the literature. The primary aims of this study were to assess different levels of fixation with respect to radiological outcomes in terms of fracture reduction and future loss of correction.

Methods

This is a single center, retrospective study. Fifty-five patients presenting with thoracolumbar fractures between January 2012 and December 2015 were analyzed in the study. The levels of fixation were divided in 3 groups, 1 vertebra above and 1 below the fracture (1/1), 2 above and 2 below (2/2), and 2 above and 1 below (2/1).

Results

The most common mechanism was high fall injury and the most common vertebra L1. Burst fractures were the ones with the highest incidence. The 2/2 fixation achieved the best reduction of the fracture but with no statistical significance. The correction is maintained better by the 2/2 fixation but there is no statistical difference compared to the other fixations. Insertion of screws at the fracture level did not improve outcomes.

Conclusion

The data of this study identified a trend towards better radiological outcomes for fracture reduction and maintenance of the correction in the 2/2 fixations. However these results are not statistically significant. Future multicenter prospective clinical trials are needed in order to agree on the ideal management and method of fixation for thoracolumbar fractures.

A retrospective study comparing percutaneous and open pedicle screw fixation for thoracolumbar fractures with spinal injuries

BACKGROUND

The purpose of this study was to evaluate the effectiveness between percutaneous and open pedicle screw fixation for treating thoracolumbar fractures with spinal injuries.

METHODS

A total of 105 patients with thoracolumbar fractures and spinal injuries were divided into a percutaneous pedicle screw fixation (PPSF) group with 56 patients, who underwent percutaneous pedicle screw fixation, and an open pedicle screw fixation (OPSF) group with 49 patients, who underwent open pedicle screw fixation in accordance with the treatment project. Relative operation indexes, radiologic, and effectiveness parameters were assessed and compared between the 2 groups.

RESULTS

Demographic and clinical features including age, body mass index, gender, fracture level, fracture classification, and Frankel grade in both groups were not significantly different (all P >.05). The PPSF group exhibits significantly lower operation time, intraoperative blood loss, postoperative drainage volume, and hospital stay on average compared with the OPSF group (all P < .05). Besides, the average postoperative radiologic parameters, including Cobb angle (CA), vertebral wedge angle (VWA), vertebral front height percentage (VFHP), and sagittal index (SI), in both the groups were not significantly different (all P > .05). Nevertheless, both visual analogue scale (VAS) and Oswestry disability index (ODI) after surgery decreased more substantially in the PPSF group than in the OPSF group (all P < .05) while no significant difference in VAS scores or ODI during the last follow-up period was demonstrated in both the groups (both P > .05). Frankel classifications were stimulated in both the groups during the last follow-up period.

CONCLUSION

PPSF has a smaller incision, less intraoperative blood loss, shorter recovery time, higher safety measures on average compared with OPSF with respect to managing thoracolumbar fractures with spinal injuries.