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Naftchi AF, Vazquez S, Spirollari E, Carpenter AB, Ng C, Zeller S, Feldstein E, Rawanduzy C, Das A, Gabriele C, Gandhi R, Stein A, Frid I, Dominguez JF, Hanft SJ, Houten JK, Kinon MD. Adult Trauma Patients With Thoracolumbar Injury Classification and Severity Score of 4: A Systematic Review. Clin Spine Surg 2023; 36:237-242. [PMID: 35994034 DOI: 10.1097/bsd.0000000000001380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 06/29/2022] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Systematic review. OBJECTIVE Evaluate characteristics of patients with thoracolumbar injury classification and severity (TLICS) score of 4 (To4) severity traumatic thoracolumbar injury. SUMMARY OF BACKGROUND DATA The TLICS score is used to predict the need for operative versus nonoperative management in adult patients with traumatic thoracolumbar injury. Ambiguity exists in its application and score categorization. METHODS A systematic review of the literature was performed. The databases of MEDLINE, Embase, Web of Science, and Cochrane Review were queried. Studies included adults with traumatic thoracolumbar injury with assigned TLICS score and description of management strategy. RESULTS A total of 16 studies met inclusion criteria representing 1911 adult patients with traumatic thoracolumbar injury. There were 503 (26.32%) patients with To4, of which 298 (59.24%) were operative. Studies focusing on the thoracolumbar junction and AO Type A fracture morphology had To4 patient incidences of 11.15% and 52.94%, respectively. Multiple studies describe better quality of life, pain scores, and radiographic outcomes in To4 who underwent operative treatment patients. CONCLUSION To4 injuries are more commonly AO Type A and located in the thoracolumbar junction in adult patients with traumatic thoracolumbar injury. Despite ambiguous recommendations regarding treatment provided by TLICS, outcomes favor operative intervention in this subset of traumatic thoracolumbar injury patients.
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Affiliation(s)
| | | | | | | | | | - Sabrina Zeller
- Department of Neurosurgery, Westchester Medical Center, Valhalla
| | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center, Valhalla
| | | | - Ankita Das
- School of Medicine, New York Medical College
| | | | - Ronan Gandhi
- Department of Neurosurgery, Westchester Medical Center, Valhalla
| | - Alan Stein
- Department of Neurosurgery, Westchester Medical Center, Valhalla
| | - Ilya Frid
- Department of Neurosurgery, Westchester Medical Center, Valhalla
| | - Jose F Dominguez
- Department of Neurosurgery, Westchester Medical Center, Valhalla
| | - Simon J Hanft
- Department of Neurosurgery, Westchester Medical Center, Valhalla
| | - John K Houten
- Department of Neurosurgery, Maimonides Medical Center, New York, NY
| | - Merritt D Kinon
- Department of Neurosurgery, Westchester Medical Center, Valhalla
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Nakashima H, Kanemura T, Satake K, Ito K, Tanaka S, Segi N, Ouchida J, Ando K, Kobayashi K, Imagama S. Transdiaphragmatic Approach as a Novel Less Invasive Retroperitoneal Approach at Thoracolumbar Junction: Comparison with Conventional Diaphragmatic Incision. Spine Surg Relat Res 2021; 5:405-411. [PMID: 34966867 PMCID: PMC8668210 DOI: 10.22603/ssrr.2020-0191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 01/21/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction Lateral corpectomy has been considered a minimally invasive surgery, allowing a “transdiaphragmatic approach” at the thoracolumbar junction. This approach allows for a small diaphragmatic incision directly in the retroperitoneal space and the affected vertebra. However, its effectiveness in comparison to a conventional approach remains unclear. Thus, in this present study, we compared the surgical outcomes between conventional diaphragmatic detachment and the transdiaphragmatic approach in patients with vertebral fracture at the thoracolumbar junction. Methods In total, 31 patients with a vertebral fracture at the thoracolumbar junction (T12-L2) were included in this study: 17 underwent a conventional approach, whereas 14 underwent a transdiaphragmatic approach, with a minimum 2-year follow-up. The effectiveness of surgery was evaluated in each category of the Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ). Results Operative time and estimated blood loss were determined to be significantly shorter in the transdiaphragmatic than in the conventional approach. Perioperative complications were observed in the conventional approach (one atelectasis and one pleural effusion), while no complication was noted in the transdiaphragmatic approach. There were no significant differences in postoperative quality of life as assessed by JOABPEQ in terms of pain-related disorders, lumbar spine dysfunction, gait disturbance, social life dysfunction, or psychological disorders between the conventional and transdiaphragmatic approaches. Conclusions A “transdiaphragmatic approach” using lateral access surgery has been found to be associated with a shorter operative time and less blood loss with fewer complications than the conventional approach. Given that equivalent clinical outcomes were achieved in both conventional and transdiaphragmatic approaches, this “transdiaphragmatic approach” could be useful because of its minimal invasiveness.
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Affiliation(s)
- Hiroaki Nakashima
- Department of Orthopedic Surgery, Konan Kosei Hospital, Konan, Japan.,Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tokumi Kanemura
- Department of Orthopedic Surgery, Konan Kosei Hospital, Konan, Japan
| | - Kotaro Satake
- Department of Orthopedic Surgery, Konan Kosei Hospital, Konan, Japan
| | - Kenyu Ito
- Department of Orthopedic Surgery, Konan Kosei Hospital, Konan, Japan
| | - Satoshi Tanaka
- Department of Orthopedic Surgery, Konan Kosei Hospital, Konan, Japan
| | - Naoki Segi
- Department of Orthopedic Surgery, Konan Kosei Hospital, Konan, Japan.,Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Jun Ouchida
- Department of Orthopedic Surgery, Konan Kosei Hospital, Konan, Japan.,Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kei Ando
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuyoshi Kobayashi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Zhou F, Wang Q, Liu L, Han S, Jin W, Wang Z. Mid- and Long-Term Efficacy of Surgical Treatment of L1-2 Vertebral Tuberculosis with Subdiaphragmatic Extraperitoneal Approach. Med Sci Monit 2021; 27:e932284. [PMID: 34135300 PMCID: PMC8218605 DOI: 10.12659/msm.932284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background The L1–2 vertebral segment is the most common site of spinal tuberculosis. Traditional thoracoabdominal surgery in this segment risks trauma and complications. This study analyzed the surgical efficacy of the subdiaphragmatic extraperitoneal approach in the treatment of L1–2 spinal tuberculosis. Material/Methods Retrospective analysis of 67 patients with L1–2 vertebral tuberculosis who underwent posterior internal fixation was performed: 35 patients underwent the subdiaphragmatic extraperitoneal approach (group A) and 32 underwent the thoracoabdominal approach (group B). Operation time, intraoperative blood loss, postoperative hospital stay, postoperative nerve function recovery, deformity correction, bone graft fusion, lesion healing, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and complications were observed. Results In group A and group B, intraoperative blood loss was 712.00±64.66 mL and 1104.38±131.34 mL; average operation time was 3.16±0.67 h and 5.16±1.07 h; and postoperative hospital stay was 9.60±2.64 days and 13.69±3.87 days, respectively. At 6 months and 5 years after surgery, neurological function, visual analog scale score, and Cobb angle of all patients were significantly improved compared with those before surgery; ESR and CRP decreased to normal levels; lesions completely cured; and all patients had good bone graft fusion. Pulmonary complications occurred in 2 patients in group A and in 14 patients in group B. Conclusions The efficacy of subdiaphragmatic extraperitoneal approach was similar to that of the thoracoabdominal approach for L1–2 spinal tuberculosis, but the former has the advantages of less surgical trauma, shorter operation time, less intraoperative bleeding, and fewer postoperative pulmonary complications.
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Affiliation(s)
- Fubiao Zhou
- Department of Spinal Surgery, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China (mainland)
| | - Qian Wang
- Hillsborough Community College, Tampa, FL, USA
| | - Liehua Liu
- Department of Spinal Surgery, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China (mainland)
| | - Shuanqiang Han
- Department of Spinal Surgery, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China (mainland)
| | - Weidong Jin
- Department of Spinal Surgery, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China (mainland)
| | - Zili Wang
- Department of Spinal Surgery, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China (mainland)
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Overview of Minimally Invasive Spine Surgery. World Neurosurg 2020; 142:43-56. [PMID: 32544619 DOI: 10.1016/j.wneu.2020.06.043] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/02/2020] [Accepted: 06/04/2020] [Indexed: 12/21/2022]
Abstract
Minimally invasive spine surgery (MISS) has continued to evolve over the past few decades, with significant advancements in technology and technical skills. From endonasal cervical approaches to extreme lateral lumbar interbody fusions, MISS has showcased its usefulness across all practice areas of the spine, with unique points of access to avoid pertinent neurovascular structures. Adult spine deformity has also recognized the importance of minimally invasive techniques in its ability to limit complications and to provide adequate sagittal alignment correction and improvements in patients' functional status. Although MISS has continued to make significant progress clinically, consideration must also be given to its economic impact and the learning curve surgeons experience in adding these procedures to their armamentarium. This review examines current innovations in MISS, as well as the economic impact and future directions of the field.
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Minimally invasive spine surgeries for treatment of thoracolumbar fractures of spine: A systematic review. J Clin Orthop Trauma 2019; 10:S147-S155. [PMID: 31695274 PMCID: PMC6823763 DOI: 10.1016/j.jcot.2019.04.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 04/18/2019] [Accepted: 04/19/2019] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Many minimally invasive surgical (MIS) techniques have been developed for instrumentation of spine. These MIS techniques restore stability, alignment while achieving return to function quite early as compared to open spine surgeries. The main aim of this review was to evaluate role, indications and complications of these MIS techniques in Thoracolumbar and Lumbar fractures. METHODS Pubmed search using key words such as"Percutaneous pedicle screw for Thoracolumbar fractures" and "Video Assisted Thoracoscopy, Thoracoscopic, VATS for thoracolumbar, Lumbar and Spine fractures" were used till July 2016 while doing literature search. Authors analyzed all the articles, which came after search; the articles relevant to the topic were selected and used for the study. Both prospective and retrospective case control studies and randomized control trials (RCT's) were included in this review. Case reports and reviews were excluded. Studies demonstrating use of MIS in cases other than spine trauma and studies with lack of clinical follow up were excluded from this review. Variables such as number of patients, operative time and complications were evaluated in each study. RESULTS After pubmed search, we found total 68 studies till July 2016 out of which eight studies were relevant for analysis of Video Assisted Thoracoscopy for thoracolumbar and lumbar fractures. Total 72 articles for Percutaneous pedicle screws in thoracolumbar and lumbar fractures were retrieved out of which percutaneous pedicle screws were analyzed in eleven studies and twelve studies involved comparison of percutaneous pedicle screws and conventional open techniques. CONCLUSION Role and Indications of the MIS techniques in spinal trauma are expanding quite rapidly. MIS techniques restore stability, alignment while achieving early return to function and lower infection rates as compared to open spine surgeries. In long term, they provide good kyphosis correction and stable fixation and fusion of spine. They are associated with long learning curve and technical challenges but with careful patient selection and in expert hands, MIS techniques may produce better results than open trauma spine surgeries.
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Delgado-Fernández J, Gil Simoes R, García Pallero MÁ, Penanes Cuesta JR, Blasco G, Pulido P, Sola RG. Morphometrical evaluation of decompression obtained through corpectomy. Heading towards to posterior approaches. Neurocirugia (Astur) 2018; 30:60-68. [PMID: 30580932 DOI: 10.1016/j.neucir.2018.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 09/05/2018] [Accepted: 11/03/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION We analysed the decompression obtained by dorsal or dorsolumbar corpectomy measured by Cobb angle and the spinal area prior to and after surgery and compared the evolution of the technique over the last five years of the study. MATERIAL AND METHOD A retrospective review of patients operated between 2005 and 2015 through anterior or posterior approaches was performed. RESULTS 24 patients were studied and a significant improvement was observed between the preoperative and postoperative morphometrical measurement (4.18° correction of the kyphosis and an increase of 130.8mm2 in the spinal canal, p<.001 in both cases) and in clinical parameters (45.8% of patients improved in ASIA, and Karnofsky showed 13 points of improvement, p<.001 in both cases). However, there was no correlation between clinical and morphological parameters. We also observed that in the last five years of the study posterior approaches were more frequently used with good results. CONCLUSIONS Dorsal corpectomy allows significant spinal decompression, with neurological improvement but this does not correlate with the measurement of decompression. Thanks to technical improvements, less invasive techniques (posterior approaches and MISS) allow good clinical results, which are similar to those obtained by anterior techniques.
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Affiliation(s)
- Juan Delgado-Fernández
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, University College of London Hospitals, NHS Foundation Trust, Queens Square, Londres, Reino Unido.
| | - Ricardo Gil Simoes
- Servicio de Neurocirugía, Hospital Universitario de La Princesa, Madrid, España
| | | | | | - Guillermo Blasco
- Servicio de Neurocirugía, Hospital Universitario de La Princesa, Madrid, España
| | - Paloma Pulido
- Servicio de Neurocirugía, Hospital Universitario de La Princesa, Madrid, España
| | - Rafael G Sola
- Servicio de Neurocirugía, Hospital Nuestra Señora del Rosario, Madrid, España
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Thoracoscopic anterior stabilization for thoracolumbar fractures in patients without spinal cord injury: quality of life and long-term results. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:1593-1603. [DOI: 10.1007/s00586-018-5571-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 03/11/2018] [Accepted: 03/27/2018] [Indexed: 10/17/2022]
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Lindtner RA, Mueller M, Schmid R, Spicher A, Zegg M, Kammerlander C, Krappinger D. Monosegmental anterior column reconstruction using an expandable vertebral body replacement device in combined posterior-anterior stabilization of thoracolumbar burst fractures. Arch Orthop Trauma Surg 2018; 138:939-951. [PMID: 29623406 PMCID: PMC5999121 DOI: 10.1007/s00402-018-2926-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Indexed: 12/26/2022]
Abstract
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.
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Affiliation(s)
- Richard A Lindtner
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Max Mueller
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Rene Schmid
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Anna Spicher
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Michael Zegg
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Christian Kammerlander
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
- Department of General, Trauma and Reconstructive Surgery, Ludwig Maximilian University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Dietmar Krappinger
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.
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Smits AJ, Polack M, Deunk J, Bloemers FW. Combined anteroposterior fixation using a titanium cage versus solely posterior fixation for traumatic thoracolumbar fractures: A systematic review and meta-analysis. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2017; 8:168-178. [PMID: 29021667 PMCID: PMC5634102 DOI: 10.4103/jcvjs.jcvjs_8_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Arjen Johannes Smits
- Department of Trauma Surgery, VU University Medical Centre, Amsterdam, The Netherlands
| | - Meaghan Polack
- Department of Trauma Surgery, VU University Medical Centre, Amsterdam, The Netherlands
| | - Jaap Deunk
- Department of Trauma Surgery, VU University Medical Centre, Amsterdam, The Netherlands
| | - Frank Willem Bloemers
- Department of Trauma Surgery, VU University Medical Centre, Amsterdam, The Netherlands
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Shi J, Yue X, Niu N, Zhao C, Qiu H, Wang Z. Application of a modified thoracoabdominal approach that avoids cutting open the costal portion of diaphragm during anterior thoracolumbar spine surgery. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 26:1852-1861. [DOI: 10.1007/s00586-016-4917-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 11/09/2016] [Accepted: 12/06/2016] [Indexed: 10/20/2022]
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