Surgical consideration for thoracolumbar burst fractures with spinal canal compromise without neurological deficit

Effectiveness of bone-filled mesh bag technology and angle vertebroplasty in the treatment of osteoporotic thoracic vertebral compression fractures in the elderly

OBJECTIVE

To evaluate the effectiveness, pain level, and lung function in elderly patients with osteoporotic thoracic vertebral compression fractures using bone filling mesh bag technology compared to curved vertebroplasty.

METHODS

This retrospective analysis reviewed 72 elderly patients with osteoporotic thoracic vertebral compression fractures treated at Xindu District People's Hospital of Chengdu between February 2021 and January 2022. The patients were separated into two groups according to surgery approach: an observation group using bone filling mesh bag technology and a control group using curved vertebroplasty. The overall response rate, pain degree, pulmonary function, life quality grades, surgical indicators, and bone cement leakage rates of the two groups were evaluated.

RESULTS

The variation in overall response rate (P=0.420), pain degree (P=0.270), pulmonary function (peak expiratory flow: P=0.660, forced expiratory volume in the first second: P=0.775, forced vital capacity: 0.062), and life quality grades (physical health: P=0.949, social function: P=0.935, physiological function: P=0.970, vitality: P=0.778) between the observation group and the control group after treatment was not statistically meaningful. The Cobb angle (P<0.001) and vertebral height (P<0.001) of patients in the observation group were significantly higher than those in the control group after therapy. The leakage rates of bone cement (intervertebral disc leakage, paravertebral vein leakage, paravertebral soft tissue leakage) of patients in the observation group were notably lower than those in the control group after therapy (P=0.029).

CONCLUSION

Bone filling mesh bag technology offers significant improvements in Cobb angle and vertebral height for treating elderly patients with osteoporotic thoracic vertebral compression fractures, and reduced the leakage rate of bone cement. This technique achieves comparable therapeutic outcomes to curved vertebroplasty.

Posterior Pedicle Screw Fixation With Indirect Decompression Versus Direct Decompression in Treating Thoracolumbar Burst Fracture: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare the safety and efficacy between posterior pedicle screw fixation with direct versus indirect decompression in treating patients with thoracolumbar burst fracture.

METHODS

This study was conducted on the basis of PRISMA statement. We systematically searched the PubMed and Embase databases up to July 3, 2023. Relevant studies comparing indirect decompression and direct decompression were recruited. Weighted mean differences (WMDs), odds ratios (ORs) and 95% confidence intervals (CIs) were analyzed for continuous and dichotomous data, respectively. P < 0.05 was considered statistically significant.

RESULTS

The operation time (WMD: -37.14, 95% CI: [-42.64, 31.64], P < 0.00001, I2 = 0%) and intraoperative blood loss (WMD: -316.82, 95% CI: [-469.80, -163.85], P < 0.0001, I2 = 99%) of indirect decompression group were significantly lower. Percentage of anterior vertebral body height (WMD: 3.98, 95% CI: [2.36, 5.60], P < 0.00001, I2 = 32%) and encroachment rate of the spinal canal (WMD: 1.48, 95% CI: [0.56, 2.40], P = 0.002, I2 = 35%) of indirect decompression group were significantly higher. No statistical difference was identified in grades of neurologic recovery and Cobb angle.

CONCLUSIONS

Posterior pedicle screw fixation with indirect decompression was safe and effective for thoracolumbar burst fracture with or without neurologic deficits when posterior longitudinal ligament was intact.

Patient-reported outcomes after posterior surgical stabilization for thoracolumbar junction fractures: A pilot study with combined patient-reported outcome measure methodology

Background

Thoracolumbar junction fractures (TLJFs) attract controversy for several parameters, including surgery versus conservative treatment, fusion versus stabilization, open versus percutaneous surgery, construct length, and downstream metalwork extraction.

Aims and Objectives

The aim of this pilot study was to assess the effectiveness of surgical treatment in patients with burst (AO Classification Type A4) TLJFs using patient-reported outcome measures (PROMs) and evaluate and compare different PROMs in this clinical scenario.

Materials and Methods

Patient records of consecutive patients who underwent posterior stabilization surgery for TLJFs were retrospectively reviewed. Data were collected on demographics, medical and social history, neurological examination, and postoperative complications. Telephone interviews and a combined PROM methodology (Numerical Rating Scale [NRS], EuroQol [EQ]-5D-5L, and Oswestry Disability Index [ODI]) were utilized to assess the effectiveness of intervention. Descriptive statistics were used to analyze exposure variables and outcome measures. Spearman's rank correlation was used for the outcome measures.

Results

Thirteen patients were included. The mean age was 42 ± 16 years; the male: female ratio was 8:5; the mean follow-up was 18.9 ± 6.4 months. The mean NRS score was 3.3 ± 2.5, in line with a median score of 2 (2) on EQ-5D-5L pain/discomfort scale. Statistically significant correlations were found between several PROMs: pain-EQ-5D-5L and NRS (rs = 0.8, P = 0.002), pain-EQ-5D-5L and ODI (rs = 0.8, P = 0.001), usual anxiety/depression-EQ-5D-5L, and ODI (rs = 0.7, P = 0.008).

Conclusion

A combined PROM methodology showed supportive evidence for safety and efficacy in the surgical stabilization of burst TLJFs. This alleviated significant pain and prevented neurological deficit and major disability. The preliminary widespread correlation between these PROMs supports further larger studies of their combined use in clinical practice, to measure the outcomes of spine trauma patients.

Clinical effect of limited posterior decompression and 13-mm titanium mesh implantation on severe thoracolumbar burst fractures: A case series

Background

Posterior incision with 270° spinal canal decompression and reconstruction surgery is a treatment option for thoracolumbar burst fractures (TLBF), but the large diameter titanium mesh placement is difficult. This study evaluated the characteristics and clinical effects of limited posterior decompression and 13-mm titanium mesh implantation to treat TLBF.

Hypothesis

13-mm titanium meshes could be used to fix thoracolumbar burst fractures.

Patients and methods

This case series included patients who underwent limited posterior decompression and 13-mm titanium mesh implantation at China Medical University Shaoxing Hospital (01/2015–12/2019). The Cobb angle, injury vertebral anterior edge height loss percentage, and spinal canal occupancy rate were analyzed. The degree of spinal cord injury was evaluated according to the ASIA grade.

Results

Fifteen patients were included (eight males and seven females). The patients were 32.2 ± 4.6 years of age. The American Association of Spinal Injury improved after surgery (A/B/C/D/E: from 2/6/5/2/0 to 0/0/2/8/5, P &lt; 0.001). The Cobb angle decreased after surgery (from 20.1 ± 4.8° to 7.1 ± 1.4°, P &lt; 0.001) but increased to 8.2 ± 0.9° at 1 year (P = 0.003). The percentage of loss of the anterior edge height of the injured vertebrae decreased after surgery (from 40.9% ± 6.1% to 7.5% ± 1.8%, P &lt; 0.001) and decreased at 1 year (7.0% ± 1.5%, P = 0.044). The spinal canal occupancy rate decreased after surgery (from 64.8% ± 7.8% to 20.1% ± 4.2%, P &lt; 0.001) but did not decrease further at 1 year (19.4% ± 3.4%, P = 0.166).

Discussion

Spinal canal limited posterior decompression, and 13-mm titanium mesh implantation in the treatment of TLBF can achieve one-stage spinal canal decompression and three-column reconstruction. The curative effect was satisfying.

Level of evidence

Level IV; case series.

Predictors of adverse events after percutaneous pedicle screws fixation in patients with single-segment thoracolumbar burst fractures

BACKGROUND

Percutaneous pedicle screw fixation (PPSF) is the primary approach for single-segment thoracolumbar burst fractures (TLBF). The healing angle at the thoracolumbar junction is one of the most significant criteria for evaluating the efficacy of PPSF. Therefore, the purpose of this study was to analyze the predictors associated with the poor postoperative alignment of the thoracolumbar region from routine variables using a support vector machine (SVM) model.

METHODS

We retrospectively analyzed patients with TLBF operated at our academic institute between March 1, 2014 and December 31, 2019. Stepwise logistic regression analysis was performed to assess potential statistical differences between all clinical and radiological variables and the adverse events. Based on multivariate logistic results, a series of independent risk factors were fed into the SVM model. Meanwhile, the feature importance of radiologic outcome for each parameter was explored. The predictive performance of the SVM classifier was evaluated using the area under the receiver operating characteristic curve (AUC), accuracy (ACC) and confusion matrices with 10-fold cross-validation, respectively.

RESULTS

In the recruited 150 TLBFs, unfavorable radiological outcomes were observed in 53 patients (35.33%). The relationship between osteoporosis (p = 0.036), preoperative Cobb angle (p = 0.001), immediate postoperative Cobb angle (p = 0.029), surgically corrected Cobb angle (p = 0.001), intervertebral disc injury (Score 2 p = 0.001, Score 3 p = 0.001), interpedicular distance (IPD) (p = 0.001), vertebral body compression rate (VBCR) (p = 0.010) and adverse events was confirmed by univariate regression. Thereafter, independent risk factors including preoperative Cobb angle, the disc status and IPD and independent protective factors surgical correction angle were identified by multivariable logistic regression. The established SVM classifier demonstrated favorable predictive performance with the best AUC = 0.93, average AUC = 0.88, and average ACC = 0.87. The variables associated with radiological outcomes, in order of correlation strength, were intervertebral disc injury (42%), surgically corrected Cobb angle (25%), preoperative Cobb angle (18%), and IPD (15%). The confusion matrix reveals the classification results of the discriminant analysis.

CONCLUSIONS

Critical radiographic indicators and surgical purposes were confirmed to be associated with an unfavorable radiographic outcome of TLBF. This SVM model demonstrated good predictive ability for endpoints in terms of adverse events in patients after PPSF surgery.

Reconstructing Nanohydroxyapatite Prosthesis Based on CT-Scanning Data and Its Application in Spinal Injury

This study investigated the nanohydroxyapatite (nHA) prosthesis application effect based on CT-scanning data in spinal injury. This study chose 26 spinal injury patients treated in our hospital from September 2017 to September 2018, who were randomly divided into two groups. nHA prosthesis based on CT-scanning data was implanted in the nHA group, whereas titanium mesh was implanted in the titanium mesh group. Consequently, osteoblasts were cultured to test the biological activity of nHA and titanium alloy. In cell tests, we found osteoblasts could better adhere to nHA, and proliferation and activity were higher when planted on nHA material. After surgical treatment, all patients' spinal symptoms (VAS score, JOA score, and Cobb angle) had improved and did not cause obvious inflammatory foreign body reactions. During a two-year follow-up, the fusion time and support settlement in the nHA group was lower, and the vertebral fusion rate and ASIA score were higher than those in the titanium mesh group. Thus, CT-scanning data could further improve the vertebral fusion rate in the nHA group. Consequentially, nHA prosthesis based on CT-scanning data is a better choice for spinal injury therapy.

Necessity of Direct Decompression for Thoracolumbar Junction Burst Fractures with Neurological Compromise

BACKGROUND

Surgical management of burst fractures is controversial, with many different operative options. From a posterior approach, decompression of the spinal cord can be performed through both indirect and direct methods, the former relying on ligamentotaxis. It is unclear whether indirect decompression with ligamentotaxis is as effective as direct decompression.

METHODS

Prospective, randomized controlled data were retrospectively analyzed to include only burst fractures of the thoracolumbar junction. Patients were treated with either direct decompression, involving wide posterior decompression in addition to operative stabilization, or indirect decompression, where decompression was performed solely through ligamentotaxis. Patients were followed up at 6 months with clinical assessment and imaging. Additional clinical assessment was performed at 1 year. For all analyses, P < 0.05 was significant.

RESULTS

The study included 46 patients, with 18 patients in the direct decompression subgroup and 28 patients in the indirect decompression subgroup. The average age of the full cohort was 35.1 ± 13.1 years (range, 16-60 years). Most patients had L1 fractures (21/46; 46%), with an AOSpine classification type A4 fracture morphology (17/46; 37%), and were American Spinal Injury Association grade B (18/46; 39%). Both treatments resulted in similar increases in canal diameter and decreases in dural sac compromise (P > 0.5) at 6-month follow-up. Both treatments resulted in similar grades of neurological improvement (P = 0.575) at 1 year.

CONCLUSIONS

There were no significant differences in clinical and imaging outcomes when comparing direct decompression with ligamentotaxis. Ligamentotaxis alone may be effective in carefully selected cases.