Posterior implant removal in patients with thoracolumbar spine fractures: long-term results

Load Changes on a Short-Segment Posterior Instrumentation After Transosseous Disruption of L3 Vertebra - A Biomechanical Human Cadaveric Study

STUDY DESIGN

Biomechanical Cadaveric Study.

OBJECTIVES

Following the successful use of a novel implantable sensor (Monitor) in evaluating the progression of fracture healing in long bones and posterolateral fusion of the spine based on implant load monitoring, the aim of this study was to investigate its potential to assess healing of transosseous fractures of a lumbar vertebra stabilized with a pedicle-screw-rod construct.

METHODS

Six human cadaveric spines were instrumented with pedicle screws and rods spanning L3 vertebra. The spine was loaded in Flexion-Extension (FE), Lateral-Bending (LB) and Axial-Rotation (AR) with an intact L3 vertebra and after its transosseous disruption, creating an AO B1 type fracture. The implant load was measured on the one rod using the Monitor and on the contralateral rod by strain gauges to validate the Monitor's measurements. In parallel, the range of motion (ROM) was assessed.

RESULTS

ROM increased significantly in all directions in the fractured model (P ≤ 0.049). The Monitor measured a significant increase in implant load in FE (P = 0.002) and LB (P = 0.045), however, not in AR. The strain gauge - aligned with the rod axis and glued onto its posterior side - detected an increased implant load not only in FE (P = 0.001) and LB (P = 0.016) but also in AR (P = 0.047).

CONCLUSION

After a complete transosseous disruption of L3 vertebra, the implant load on the rods was considerably higher vs the state with an intact vertebral body. Innovative implantable sensors could monitor those changes, allowing assessment of the healing progression based on quantifiable data.

Thoracolumbar injuries: operative treatment: indications, techniques, timing and implant removal. Current practice

The operative treatment of thoracolumbar fractures is a rapidly evolving improvement in the care of patients with this injury after trauma. This article describes the different techniques and principles. Considerations and methods of treatment are scientifically addressed and illustrated according to the classification and severity of the fracture pattern. The use of computer navigation and optimisation of minimally invasive techniques is inevitable. The timing of surgery as well the removal of the material after fracture healing are also discussed. The operative treatment of spinal fractures is emerging and there is still much more knowledge to gain.

Describing an old trick in posterior thoracal and lumbar ımplant removal surgery: follow-up results for at least 10 years

STUDY DESIGN

Retrospective case series.

OBJECTIVES

We aimed to describe with a novel surgical approach for the removal of posterior thoracolumbar implant in patients with symptomatic failure of the implant and present our preliminary results with this method.

METHODS

This retrospective, single-center study was performed in the neurosurgery department of a university hospital. Data were gathered from the medical files of 314 patients (243 women, 77.39%; 71 men, 22.61%) with symptomatic thoracolumbar implant failure that underwent implant removal operation using our novel technique between 2010 and 2020. Symptoms, radiological findings, intraoperative findings as well as clinical outcomes were evaluated.

RESULTS

In our series, the average age was 46.5 years (range: 21-84) with a mean follow-up duration of 7 years (range: 3 months to 10 years). Preoperatively, the most common symptoms were leg pain and numbness of the lower extremity. Postoperatively, no major complications were noted. Clinical progression of symptoms was avoided by surgery in all patients, while we came across removal difficulties due to screw-screwdriver mismatch in 15 of 314 surgeries (4.78%). Our novel approach allowed successful screw removal including these challenging cases.

CONCLUSIONS

We suggest that our novel approach is a practical and effective for the removal of posterior thoracolumbar implant in cases with symptomatic failure attributed to screw-screwdriver mismatch. Further trials are warranted to assess the efficacy of this technique to overcome surgical problems associated with screw removal.

Risk factors for kyphosis recurrence after implant removal in percutaneous osteosynthesis for post-traumatic thoracolumbar fracture

PURPOSE

Short-segment minimally invasive percutaneous spinal osteosynthesis has now become one of the treatments of choice to treat thoracolumbar fractures. The question of implant removal once the fracture has healed is still a matter of debate since this procedure can be associated with loss of sagittal correction. Therefore, we analyzed risk factors for kyphosis recurrence after spinal implants removal in patients treated with short-segment minimally invasive percutaneous spinal instrumentation for a thoracolumbar fracture.

METHODS

A total of 32 patients who underwent implant removal in percutaneous osteosynthesis for post-traumatic thoracolumbar fracture were enrolled in our study. Patient's medical record, operative report and imaging examinations carried out at the trauma and during the follow-up were analyzed.

RESULTS

Every patient experienced fracture union. Vertebral kyphotic angle (VKA) and Cobb angle (CA) improved significantly after stabilization surgery. VKA, CA, upper disk kyphotic angle (UDKA) and lower disk kyphotic angle (LDKA) significantly gradually decreased during follow-up. Traumatic disk injury (p: 0.001), younger age (p: 0.01), canal compromise (p: 0.04) and importance of surgical correction (p < 0.001) were significantly associated with kyphosis recurrence after implant removal. Anterior body augmentation did not affect loss of correction (CA and VKA) during the follow-up period (p: 0.57).

CONCLUSION

Despite correction of the fracture after stabilization, we observed a progressive loss of correction over time appearing even before implant removal. Particular attention should be paid to post-traumatic disk damage or canal invasion, to young patients and to surgical overcorrection of the traumatic kyphosis.

Hybrid kyphoplasty with short-versus intermediate- and long-segment pedicle screw fixations for the management of thoracolumbar burst fractures

BACKGROUND

This study aimed to determine if the hybrid short-segment (HSS) technique is a good alternative to the intermediate-segment (IS) and long-segment (LS) techniques in pedicle screw fixations for acute thoracolumbar burst fractures (TLBFs).

METHODS

In this retrospective evaluation, we examined 43 patients who underwent surgical treatments, including one- or two-level suprajacent (U) and infrajacent (L) pedicle screw fixations, for acute single-level TLBFs with neurological deficits between the T11 and L2 levels from July 2013 to December 2019. Among these patients, 15 individuals underwent HSS (U1L1), 12 received IS (U2L1), and 16 underwent LS (U2L2) fixations. Supplemental kyphoplasty of the fractured vertebral bodies was performed exclusively in the HSS group. Our analysis focused on assessing blood loss and surgical duration. Additionally, we compared postoperative thoracolumbar kyphotic degeneration using the data on Cobb angles on lateral radiographic images acquired at three time points (preoperatively, postoperative day 1, and follow-up). The end of follow-up was defined as the most recent postoperative radiographic image or implant complication occurrence.

RESULTS

Blood loss and surgical duration were significantly lower in the HSS group than in the IS and LS groups. Additionally, the HSS group exhibited the lowest implant complication rate (2/15, 13.33%), followed by the LS (6/16, 37.5%) and IS (8/12, 66.7%) group. Implant complications occurred at a mean follow-up of 7.5 (range: 6-9), 9 (range: 5-23), and 7 (range: 1-21) months in the HSS, IS, and LS groups. Among these implant complications, revision surgeries were performed in two patients in the HSS group, two in the IS group, and one in the LS group. One patient treated by HSS with balloon kyphoplasty underwent reoperation because of symptomatic cement leakage.

CONCLUSIONS

The HSS technique reduced intraoperative blood loss, surgical duration, and postoperative implant complications, indicating it is a good alternative to the IS and LS techniques for treating acute single-level TLBFs. This technique facilitates immediate kyphosis correction and successful maintenance of the corrected alignment within 1 year. Supplemental kyphoplasty with SpineJack® devices and high-viscosity bone cements for anterior reconstruction can potentially decrease the risk of cement leakage and related issues.

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.

Severe major vessel injury during peadicle screw removal: a case report

Introduction

Pedicle screw fixation (PSF) has been the standard therapy for the treatment of various spinal diseases. Although complications are identified regularly, iatrogenic vascular injury is one of the rare but life-threatening complications. In this literature, we describe the first case of inferior vena cava (IVC) injury during pedicle screw removal.

Case description

A 31-year-old man was treated by percutaneous pedicle screw fixation for an L1 compression fracture. After a year, the fracture healed well and hardware removal surgery was performed. During the procedure, the hardware on the right was removed unremarkably except for the L2 pedicle screw which slipped into the retroperitoneum because of the improper technique. The CT angiogram revealed the screw had breached the anterior cortex of the L2 vertebral body and penetrated the IVC. After multidisciplinary cooperation, the defect of IVC was reconstructed and the L2 screw was removed from the posterior approach in the end.

Result

The patient recovered well and was discharged after 3 weeks without further events. The removal of the contralateral implants was unremarkable at 7 months postoperatively. At the 3-year follow-up, the patient returned to his normal daily activity without any complaints.

Conclusion

Although pedicle screw removal is a rather simple procedure, severe complications may have occurred from this procedure. Surgeons should keep vigilant to avoid the complication noted in this case.

Radiological analysis of minimally invasive treatment of type A thoracolumbar fractures based on a series of 135 fractures

INTRODUCTION

Although the reduction of traumatic fractures of the thoracolumbar spine is of good quality during conventional so-called open procedures, the alternative minimally invasive approach also appears to confer good results. The aim of this study was to measure the radiological parameters before and after minimally invasive surgery, in order to assess the quality of the reduction of thoracolumbar compression fractures.

MATERIALS AND METHODS

This retrospective, monocentric study included 112 patients with a mean age of 48.9years, presenting with 135 type A thoracolumbar compression fractures treated by a posterior minimally invasive surgical approach comprising vertebral augmentation or posterior osteosynthesis or a mixed procedure.

RESULTS

The parameters analyzed were significantly lower whatever the procedure in the immediate postoperative period. Mean regional and local kyphosis, posterior wall displacement, and mean vertebral height were significantly lower (p<0.01). Fracture reduction was better when osteosynthesis was associated with vertebral augmentation. In the osteosynthesis subgroup with osteosynthesis hardware removal but without vertebral augmentation, we found a significant worsening of the regional kyphosis (p<0.05).

CONCLUSION

The management of thoracolumbar compression fractures by a posterior minimally invasive approach allows excellent fracture reduction with a restoration of the spinal canal, vertebral height and kyphosis.

LEVEL OF EVIDENCE

IV.

The Necessity of Implant Removal after Fixation of Thoracolumbar Burst Fractures—A Systematic Review

Background: Thoracolumbar burst fractures are a common traumatic vertebral fracture in the spine, and pedicle screw fixation has been widely performed as a safe and effective procedure. However, after the stabilization of the thoracolumbar burst fractures, whether or not to remove the pedicle screw implant remains controversial. This review aimed to assess the benefits and risks of pedicle screw instrument removal after fixation of thoracolumbar burst fractures. Methods: Data sources, including PubMed, EMBASE, Cochrane Library, Web of Science, Google Scholar, and Clinical trials.gov, were comprehensively searched. All types of human studies that reported the benefits and risks of implant removal after thoracolumbar burst fractures, were selected for inclusion. Clinical outcomes after implant removal were collected for further evaluation. Results: A total of 4051 papers were retrieved, of which 35 studies were eligible for inclusion in the review, including four case reports, four case series, and 27 observational studies. The possible risks of pedicle screw removal after fixation of thoracolumbar burst fractures include the progression of the kyphotic deformity and surgical complications (e.g., surgical site infection, neurovascular injury, worsening pain, revision surgery), while the potential benefits of pedicle screw removal mainly include improved segmental range of motion and alleviated pain and disability. Therefore, the potential benefits and possible risks should be weighed to support patient-specific clinical decision-making about the removal of pedicle screws after the successful fusion of thoracolumbar burst fractures. Conclusions: There was conflicting evidence regarding the benefits and harms of implant removal after successful fixation of thoracolumbar burst fractures, and the current literature does not support the general recommendation for removal of the pedicle screw instruments, which may expose the patients to unnecessary complications and costs. Both surgeons and patients should be aware of the indications and have appropriate expectations of the benefits and risks of implant removal. The decision to remove the implant or not should be made individually and cautiously by the surgeon in consultation with the patient. Further studies are warranted to clarify this issue. Level of evidence: level 1.

Is It Necessary to Remove the Implants After Fixation of Thoracolumbar and Lumbar Burst Fractures Without Fusion? A Retrospective Cohort Study of Elderly Patients

Objective

Fractures of the thoracolumbar spine are the most common fractures of the spinal column. This retrospective cohort study aimed to determine whether it is necessary to remove implants of patients aged over 65 years after the fixation of thoracolumbar and lumbar burst fractures without fusion.

Methods

This retrospective cohort study included 107 consecutive patients aged ≥65 years without neurological deficits, who underwent non-fusion short posterior segmental fixation for thoracolumbar or lumbar burst fractures. Outcome measures included the visual analog score (VAS), Oswestry Disability Index (ODI), residual symptoms, complications, and imaging parameters. Patients were divided into groups A (underwent implant removal) and B (implant retention) and were examined clinically at 1, 3, 6, and 12 months postoperatively and annually thereafter, with a final follow-up at 48.5 months.

Results

Overall, 96 patients with a mean age of 69.4 (range, 65–77) years were analyzed. At the latest follow-up, no significant differences were observed in functional outcomes and radiological parameters between both groups, except in the local motion range (LMR) (P = 0.006). Similarly, between preimplant removal and the latest follow-up in group A, significant differences were found only in LMR (P < 0.001). Two patients experienced screw breakage without clinical symptoms. Significant differences were only found in operation time, blood loss, ODI, and fracture type between minimally invasive group and open group.

Conclusions

Similar radiological and functional outcomes were observed in elderly patients, regardless of implant removal. Implant removal may not be necessary after weighing the risks and benefits for elderly patients. Patients should be informed about the possibility of implant breakage and accelerating degeneration of adjacent segments in advance.

Surgical Site Infection Management following Spinal Instrumentation Surgery: Implant Removal vs. Implant Retention: an Updated Systematical Review

Background

The number of lumbar spine surgery increased in recent years. Spinal instrumentation surgery was an integral component in the treatment of spinal pathologies, which can cause surgical site infection (SSI). Surgical site infections (SSIs) are the leading cause of mortality and morbidity after spinal instrumentation surgery. The management of SSI was implant retention and removal is still unclear.

Objective

The objective of this literature is to systematically review the implant removal and retention method for SSI management after spinal instrumentation surgery.

Methods

We searched in PubMed and ScienceDirect for cohort and randomized control trial studies in English, published between 2002 and 2022, which had data on patients with spinal instrumentation surgery. The underlying disease, comorbidities, common bacteria, type of infection, the onset of infection, implant removal, and retention percentage and recommendation were analyzed. Bias analysis using Newcastle-Ottawa Quality Assessment.

Results

We included 15 studies with a total sample were 2.584 with an average of age 15 to 66 years old. The most common organism detected were S. Aureus, MRSA, and S. Epidermis. The most common surgical procedure indications were degenerative followed by scoliosis. Implant removal and retention rate were 0-100% and 0-90,32% respectively. Implant removal is more frequently used in patients after spinal instrumentation surgery than the implant retention method.

Conclusion

Implant retention can be performed in case of SSI is < 3 months after surgery. Implant removal is recommended if the incidence of SSI is > 3 months. Empirical antibiotics therapy is necessary to reduce the possibility of implant removal after debridement. Further studies on the effect of implant removal and retention in patients on infection recurrence, pain, and quality of life of patients are needed.

Implant Removal Versus Implant Retention Following Posterior Surgical Stabilization of Thoracolumbar Burst Fractures: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVES

To compare biomechanical and functional outcomes between implant removal and implant retention following posterior surgical fixation of thoracolumbar burst fractures.

METHODS

A search of the MEDLINE, EMBASE, Google Scholar and Cochrane Databases was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Of the 751 articles initially retrieved, 13 published articles pooling 673 patients were included. Meta-analysis revealed there was a statistically significant improvement in sagittal Cobb Angle by 16.48 degrees (9.13-23.83, p < 0.01) after surgical stabilization of thoracolumbar burst fractures. This correction decremented to 9.68 degrees (2.02-17.35, p < 0.01) but remained significant at the time of implant removal approximately 12 months later. At final follow-up, the implant removal group demonstrated a 10.13 degree loss (3.00-23.26, p = 0.13) of reduction, while the implant retention group experienced a 10.17 degree loss (1.79-22.12, p = 0.10). There was no statistically significant difference in correction loss between implant retention and removal cohorts (p = 0.97). Pooled VAS scores improved by a mean of 3.32 points (0.18 to 6.45, p = 0.04) in the combined removal group, but by only 2.50 points (-1.81 to 6.81, p = 0.26) in the retention group. Oswestry Disability Index scores also improved after implant removal by 7.80 points (2.95-12.64, p < 0.01) at 1 year and 11.10 points (5.24-16.96, p < 0.01) at final follow-up.

CONCLUSIONS

In younger patients with thoracolumbar burst fractures who undergo posterior surgical stabilization, planned implant removal results in superior functional outcomes without significant difference in kyphotic angle correction loss compared to implant retention.

Is removal of the internal fixation after successful intervertebral fusion necessary? A case-control study based on patient-reported quality of life

BACKGROUND

Intervertebral fusion and internal fixation are often applied to patients with lumbar spinal disease. Whether to remove the internal fixation after successful fusion remains uncertain, but such a question needs to be explored in light of concerns regarding patients' quality of life and health insurance. We sought to probe if the removal of internal fixation after successful lumbar intervertebral fusion affects patients' quality of life.

METHODS

This was a real-world retrospective case-control study. Data of 102 patients who had undergone posterior lumbar fusion with cage and internal fixation to treat lumbar degenerative diseases were extracted from a single center from 2012 to 2020. Fifty-one patients had undergone internal fixation removal surgery, and 51 controls who retained internal fixations were matched according to demographic and medical characteristics. The quality of life of patients based on the Medical Outcomes Study Short Form 36 (SF-36) scale and their self-assessment were surveyed.

RESULTS

There was no statistical difference in the overall score of the SF-36 questionnaire between the two groups, but the general health (GH) subscore was lower in the case group than in the control group (P = 0.0284). Among those patients who underwent internal fixation removal, the quality of life was improved after instrument removal as indicated by an increased overall score (P = 0.0040), physical functioning (PF) (P = 0.0045), and bodily pain (BP) (P = 0.0008). Among patients with pre-surgery discomfort, instrument removal generated better outcomes in 25% and poor outcomes in 4.2%. Among patients without pre-surgery discomfort, instrument removal generated better outcomes in 7.4% and poor outcomes in 11.1%.

CONCLUSION

Among patients who achieved successful posterior lumbar internal fixation, whether or not to remove the fixation instruments should be evaluated carefully. In patients experiencing discomfort, instrument removal could improve their quality of life, but the benefits and risks should be comprehensively explained to these patients. Instrument removal should not be routinely performed due to its limited or even negative effect in patients who do not report discomfort before surgery.

Safety and utility of implant removal after percutaneous osteosynthesis of type A thoracolumbar and lumbar fracture

INTRODUCTION

Implant removal represents almost one third of all elective surgeries in orthopedics. There is no consensus regarding the time and need to remove the implants after vertebral fractures consolidation. The aim of this study was to assess the clinical and radiological effects of implant removal in patients with vertebral type A fracture who underwent a percutaneous intervention.

MATERIAL AND METHODS

We evaluated 31 patients (mean age of 38.2±7.5 years) with thoracolumbar vertebral fracture (T11-L5) who underwent implant removal surgery after 24 months of fracture first surgery by a percutaneous approach. Inclusion criteria focused on patients' preferences. The radiological parameters included fracture angle, initial sagittal index, compression percentage, degree displacement and deformation angle. The clinical variables included Visual Analog Scale and Oswestry Disability index.

RESULTS

There was no significant correction loss after removal surgery (before surgery and after 24 months): Fracture angle (16.8±0.5 vs 17.1±0.5; p˃0.05), initial sagittal index (12.5±0.5 vs 12.7±0.5; p˃0.05), kyphotic deformity (17.5±0.6 vs 17.8±0.7; p˃0.05), compression percentage (35.6±0.8 vs 36.0±0.7; p˃0.05), degree displacement (4.4±0.4 vs 4.5±0.3; p˃0.05) and deformation angle (23.0±0.7 vs 23.1±0.7; p˃0.05). Patients who presented symptoms before the surgery showed better Visual Analog Scale (1.2±0.6 pre vs 0.6±0.3 post, p˂0.05) and Oswestry Disability Index (20.1±6.8 pre vs 15.7±0.5, p˂0.05). No complications were reported.

DISCUSSION

Routine implant removal in patients undergoing a percutaneous approach to vertebral type A fracture is a safe technique and is associated with good clinical results without loss of radiological correction. In addition, this procedure could be indicated to patients who manifest symptoms since there is a clinical-radiological benefit.

LEVEL OF PROOF

II; A multicenter prospective cohort study.

Outcomes in Thoracolumbar and Lumbar Traumatic Fractures: Does Restoration of Unfused Segmental Mobility Correlated to Implant Removal Time?

BACKGROUND

Posterior fixation without fusion can treat thoracolumbar and lumbar traumatic fractures effectively in certain cases. However, whether patients benefit from implant removal and the correlation between the range of motion (ROM) of the involved segments and the removal time have not been determined.

METHODS

From 2018 to 2020, we retrospectively reviewed data of patients with AO spine type A or B thoracolumbar or lumbar traumatic fractures who underwent implant removal. A total of 17 patients (group A), 21 patients (group B), and 12 patients (group C) underwent implant removal after the index surgery within 12 months, between 12 and 24 months, and over 24 months, respectively. Clinical and radiological outcomes, including visual analog scale for back pain, patient satisfaction, Oswestry disability index, and EuroQol 5 dimensions questionnaire, for quality of life and segmental ROM were analyzed.

RESULTS

The average follow-up time was 9.1 ± 5.7 months after implant removal. There were no significant differences in visual analog scale and patient satisfaction among the 3 groups at the same observation time point. Among the 3 groups, patients in group A gained the lowest Oswestry disability index and highest EuroQol 5 dimensions questionnaire scores after removal and at the final follow-up. The best ROM was obtained in group A followed by groups B and C (11.5° ± 6.2°, 5.5° ± 1.6°, and 2.4° ± 0.6°, respectively).

CONCLUSIONS

Immobilization of the involved segments over 24 months may lead to loss of ROM. Regained segmental ROM is correlated negatively with implant removal time, and removal within 12 months promises a better ROM and quality of life.

Incidence of Chronic Periscapular Pain After Adult Thoracolumbar Deformity Correction and Impact on Outcomes

OBJECTIVE

Extension of the posterior upper-most instrumented vertebra (UIV) into the upper thoracic (UT) spine allows for greater deformity correction and reduced incidence of proximal junction kyphosis (PJK) in adult spinal deformity (ASD) patients. However, it may be associated with chronic postoperative scapular pain (POSP). The goal of this study was to assess the relationship between UT UIV and persistent POSP, describe the pain, and assess its impact on patient disability.

METHODS

ASD patients who underwent multilevel posterior fusion were retrospectively identified then administered a survey regarding scapular pain and the Oswestry Disability Index (ODI), by telephone. Univariate and multivariate analysis were utilized.

RESULTS

A total of 74 ASD patients were included in the study: 37 patients with chronic POSP and 37 without scapular pain. The mean age was 70.5 years, and 63.9% were women. There were no significant differences in clinical characteristics, including mechanical complications (PJK, pseudarthrosis, and rod fracture) or reoperation between groups. Patients with persistent POSP were more likely to have a UT than a lower thoracic UIV (p = 0.018). UT UIV was independently associated with chronic POSP on multivariate analysis (p = 0.022). ODI score was significantly higher in patients with scapular pain (p = 0.001). Chronic POSP (p = 0.001) and prior spine surgery (p = 0.037) were independently associated with ODI on multivariate analysis.

CONCLUSION

A UT UIV is independently associated with increased odds of chronic POSP, and this pain is associated with significant increases in patient disability. It is a significant clinical problem despite solid radiographic fusion and the absence of PJK.

Risks and benefits of timely screw removal after thoracolumbar spine fractures treated with non-fusion technique

BACKGROUND

Percutaneous-short segment screw fixation (SSSF) without bone fusion has proven to be a safe and effective modality for thoracolumbar spine fractures (TLSFs). When fracture consolidation is confirmed, pedicle screws are no longer essential, but clear indications for screw removal following fracture consolidation have not been established.

METHODS

In total, we enrolled 31 patients with TLSFs who underwent screw removal following treatment using percutaneous-SSSF without fusion. Plain radiographs, taken at different intervals, measured local kyphosis using Cobb' angle (CA), vertebra body height (VBH), and the segmental motion angle (SMA). A visual analogue scale (VAS) and the Oswestry disability index (ODI) were applied pre-screw removal and at the last follow-up.

RESULTS

The overall mean CA deteriorated by 1.58° (p < 0.05) and the overall mean VBH decreased by 0.52 mm (p = 0.001). SMA preservation was achieved in 18 patients (58.1%) and kyphotic recurrence occurred in 4 patients (12.9%). SMA preservation was statistically significant in patients who underwent screw removal within 12 months following the primary operation (p = 0.002). Kyphotic recurrence occurred in patients with a CA ≥ 20° at injury (p < 0.001) with a median interval of 16.5 months after screw removal. No patients reported worsening pain or an increased ODI score after screw removal.

CONCLUSION

Screw removal within 12 months can be recommended for restoration of SMA with improvement in clinical outcomes. Although, TLSFs with CA ≥ 20° at the time of injury can help to predict kyphotic recurrence after screw removal, the clinical outcomes are less relevant.

Instrumentation Removal following Minimally Invasive Posterior Percutaneous Pedicle Screw-Rod Stabilization (PercStab) of Thoracolumbar Fractures Is Not Always Required

BACKGROUND

Percutaneous stabilization for spinal trauma confers less blood loss, reduces postoperative pain, and is less invasive than open stabilization and fusion. The current standard of care includes instrumentation removal.

OBJECTIVE

1. Reporting patient outcomes following minimally invasive posterior percutaneous pedicle screw-rod stabilization (PercStab). 2. Evaluating the results of instrumentation retention.

METHODS

A prospective observational study of 32 consecutive patients receiving PercStab without direct decompression or fusion. Baseline data demographics were collected. Operative outcomes of interest were operative room (OR) time, blood loss, and length of hospital stay. Follow-up variables of interest included patient satisfaction, Numeric Rating Scales for Back and Leg (NRS-B/L) pain, Oswestry Disability Index (ODI), and return to work. Clinical outcome data (ODI and NRS-B/L) were collected at 3, 12, 24 months and continued at a 24-month interval up to a maximum of 8 years postoperatively.

RESULTS

81.25% of patients (n = 26) retained their instrumentation and reported minimal disability, mild pain, and satisfaction with their surgery and returned to work (mean = 6 months). Six patients required instrumentation removal due to prominence of the instrumentation or screw loosening, causing discomfort/pain. Instrumentation removal patients reported moderate back and leg pain until removal occurred; after removal, they reported minimal disability and mild pain. Neither instrumentation removal nor retention resulted in complications or further surgical intervention.

CONCLUSIONS

PercStab without instrumentation removal provided high patient satisfaction, mild pain, and minimal disability and relieved the patient from the burden of finances and resources allocation of a second surgery.

Monosegmental anterior column reconstruction using an expandable vertebral body replacement device in combined posterior-anterior stabilization of thoracolumbar burst fractures

INTRODUCTION

In combined posterior-anterior stabilization of thoracolumbar burst fractures, the expandable vertebral body replacement device (VBRD) is typically placed bisegmentally for anterior column reconstruction (ACR). The aim of this study, however, was to assess feasibility, outcome and potential pitfalls of monosegmental ACR using a VBRD. In addition, clinical and radiological outcome of monosegmental ACR was related to that of bisegmental ACR using the same thoracoscopic technique.

METHODS

Thirty-seven consecutive neurologically intact patients with burst fractures of the thoracolumbar junction (T11-L2) treated by combined posterior-anterior stabilization were included. Monosegmental ACR was performed in 18 and bisegmental ACR in 19 patients. Fracture type and extent of vertebral body comminution were determined on preoperative CT scans. Monosegmental and bisegmental kyphosis angles were analyzed preoperatively, postoperatively and at final radiological follow-up. Clinical outcome was assessed after a minimum of 2 years (74 ± 45 months; range 24-154; follow-up rate 89.2%) using VAS Spine Score, RMDQ, ODI and WHOQOL-BREF.

RESULTS

Monosegmental ACR resulted in a mean monosegmental and bisegmental surgical correction of - 15.6 ± 7.7° and - 14.7 ± 8.1°, respectively. Postoperative monosegmental and bisegmental loss of correction averaged 2.7 ± 2.7° and 5.2 ± 3.7°, respectively. Two surgical pitfalls of monosegmental ACR were identified: VBRD positioning (1) onto the weak cancellous bone (too far cranially to the inferior endplate of the fractured vertebra) and (2) onto a significantly compromised inferior endplate with at least two (even subtle) fracture lines. Ignoring these pitfalls resulted in VBRD subsidence in five cases. When relating the clinical and radiological outcome of monosegmental ACR to that of bisegmental ACR, no significant differences were found, except for frequency of VBRD subsidence (5 vs. 0, P = 0.02) and bisegmental loss of correction (5.2 ± 3.7° vs. 2.6 ± 2.5°, P = 0.022). After exclusion of cases with VBRD subsidence, the latter did not reach significance anymore (4.9 ± 4.0° vs. 2.6 ± 2.5°, P = 0.084).

CONCLUSIONS

This study indicates that monosegmental ACR using a VBRD is feasible in thoracolumbar burst fractures if the inferior endplate is intact (incomplete burst fractures) or features only a single simple split fracture line (burst-split fractures). If the two identified pitfalls are avoided, monosegmental ACR may be a viable alternative to bisegmental ACR in selected thoracolumbar burst fractures to spare a motion segment and to reduce the distance for bony fusion.