Vertebral body reconstruction system B-Twin® versus corset following non-osteoporotic Magerl A1.2 thoracic and lumbar fracture. Functional and radiological outcome at 12 month follow-up in a prospective randomized series of 50 patients

Surgical Versus Non-Surgical Treatment for Thoracolumbar Burst Fractures Without Neurological Deficit: A Systematic Review and Meta-Analysis

STUDY DESIGN

A systematic review and meta-analysis.

OBJECTIVE

To update the systematic review comparing the outcomes between surgical and non-surgical treatment for thoracolumbar burst fractures without neurological deficit.

METHODS

We registered a protocol in PROSPERO (ID: CRD42021291769) and searched Medline, Embase, Web of Science, and Google Scholar databases. Surgical and non-surgical treatments were compared in patients with thoracolumbar burst fractures without neurological deficits. Predefined outcomes at ≥6 months included pain (defined as a visual analog scale [VAS] of 0-100), functional outcomes (Oswestry Disability Index [ODI] of 0-50 and Roland-Morris Disability Questionnaire [RMDQ] of 0-24), and kyphotic angulation.

RESULTS

Nineteen studies involving 1056 patients were included in the analyses. For outcomes at ≥6 months, little to no difference was found in pain VAS score (mean difference, .95 [95% confidence interval {CI}, -6.02 to 7.92]; 827 participants; 15 studies; I2 = 92%), ODI (mean difference, -1.40 [95% CI, -5.11 to 2.31]; 446 participants; 7 studies; I2 = 79%), and RMDQ (mean difference, -.73 [95% CI, -5.13 to 3.66]; 216 participants; 5 studies; I2 = 77%). The kyphotic angulation in the surgery group was 6.35° lower than that in the non-surgery group (mean difference, -6.56° [95% CI, -10.26° to -2.87°]; 527 participants; ten studies; I2 = 86%). The trial sequential analysis indicated all outcomes reached adequate statistical power. The certainty of the evidence for all 4 outcomes was very low. For the analysis of minimally invasive procedures compared to traditional open surgeries, a statistically significant subgroup difference was found for VAS and ODI (P < .01 and P < .04, respectively).

CONCLUSION

Surgical and non-surgical treatments showed little or no difference in outcomes at ≥6 months. This review provides a conclusion with adequate statistical power by including non-randomized studies. However, non-randomized studies also lowered the certainty of the evidence to a very low level.

Vertebroplasty versus bracing in acute vertebral compression fractures: A prospective randomized trial

BACKGROUND

The treatment of stable vertebral compression fractures remains controversial.

OBJECTIVE

To compare the efficacy of vertebroplasty and bracing for acute vertebral compression fractures.

METHODS

We conducted a prospective, randomized, non-blinded, single-center study. Adult participants were randomized to undergo vertebroplasty or bracing. Both groups were stratified by age. The primary outcome was functional disability (Roland-Morris disability questionnaire [RMDQ]). Secondary outcomes were pain intensity (Visual Analogue Scale [VAS]), and change in vertebral body height and kyphosis angle. Outcomes were assessed on day 2, and 1, 3 and 6 months after treatment.

RESULTS

Ninety-nine people were included, 51 in the vertebroplasty group and 48 in the brace group. Treatment was performed within 2 weeks of the trauma. On day 2 post-treatment, pain was lower in the vertebroplasty group (mean [SD] 2.3 [1.5] versus 3.4 [2.1], p = 0.004) but the difference was no longer significant at 6 months. Functional disability was significantly lower in the vertebroplasty than brace group at all time-points (RMDQ score 7.5 [5.7] vs 11.4 [5.3], p<0.001 at 1 month). At 6 months, the increase in kyphosis angle was smaller in the vertebroplasty than the brace group (+1.5°versus +4°, p<0.001).

CONCLUSION

In people with acute vertebral compression fractures, the immediate effect of vertebroplasty was greater than that of bracing on pain and function, and for restoring sagittal balance. At 6 months, the superiority of vertebroplasty decreased, except for the maintenance of sagittal balance.

DATABASE REGISTRATION

ClinicalTrials.gov number, NCT01643395.

Invasive Treatments for Low Back Disorders

OBJECTIVE

This abbreviated version of the American College of Occupational and Environmental Medicine's Low Back Disorders guideline reviews the evidence and recommendations developed for invasive treatments used to manage low back disorders.

METHODS

Comprehensive systematic literature reviews were accomplished with article abstraction, critiquing, grading, evidence table compilation, and guideline finalization by a multidisciplinary expert panel and extensive peer-review to develop evidence-based guidance. Consensus recommendations were formulated when evidence was lacking and often relied on analogy to other disorders for which evidence exists. A total of 47 high-quality and 321 moderate-quality trials were identified for invasive management of low back disorders.

RESULTS

Guidance has been developed for the invasive management of acute, subacute, and chronic low back disorders and rehabilitation. This includes 49 specific recommendations.

CONCLUSION

Quality evidence should guide invasive treatment for all phases of managing low back disorders.

Surgical or non-surgical treatment of traumatic skeletal fractures in adults: systematic review and meta-analysis of benefits and harms

BACKGROUND

A comprehensive overview of treatments of common fractures is missing, although it would be important for shared decision-making in clinical practice. The aim was to determine benefits and harms of surgical compared to non-surgical treatments for traumatic skeletal fractures.

METHODS

We searched Medline, Embase, CINAHL, Web of Science, and CENTRAL until November 2018, for randomized trials of surgical treatment in comparison with or in addition to non-surgical treatment of fractures in adults. For harms, only trials with patient enrollment in 2000 or later were included, while no time restriction was applied to benefits. Two reviewers independently assessed studies for inclusion, extracted data from full-text trials, and performed risk of bias assessment. Outcomes were self-reported pain, function, and quality of life, and serious adverse events (SAEs). Random effects model (Hedges' g) was used.

RESULTS

Out of 28375 records screened, we included 61 trials and performed meta-analysis on 12 fracture types in 11 sites: calcaneus, clavicula, femur, humerus, malleolus, metacarpus, metatarsus, radius, rib, scaphoideum, and thoraco-lumbar spine. Seven other fracture types only had one trial available. For distal radius fractures, the standardized mean difference (SMD) was 0.31 (95% CI 0.10 to 0.53, n = 378 participants) for function, favoring surgery, however, with greater risk of SAEs (RR = 3.10 (1.42 to 6.77), n = 436). For displaced intra-articular calcaneus fractures, SMD was 0.64 (0.13 to 1.16) for function (n = 244) and 0.19 (0.01 to 0.36) for quality of life (n = 506) favoring surgery. Surgery was associated with a smaller risk of SAE than non-surgical treatment for displaced midshaft clavicular fractures (RR = 0.62 (0.42 to 0.92), n = 1394). None of the other comparisons showed statistical significance differences and insufficient data existed for most of the common fracture types.

CONCLUSIONS

Of 12 fracture types with more than one trial, only two demonstrated a difference in favor of surgery (distal radius fractures and displaced intra-articular calcaneus fractures), one of which demonstrated a greater risk of harms in the surgical group (distal radius fractures). Our results highlight the current paucity of high-quality randomized trials for common fracture types and a considerable heterogeneity and risk of bias in several of the available trials.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015020805.

Percutaneous cement augmentation for osteoporotic vertebral fractures

Thoracolumbar vertebral fracture incidents usually occur secondary to a high velocity trauma in young patients and to minor trauma or spontaneously in older people.

Osteoporotic vertebral fractures are the most common osteoporotic fractures and affect one-fifth of the osteoporotic population.

Percutaneous fixation by ‘vertebroplasty’ is a tempting alternative for open surgical management of these fractures.

Despite discouraging initial results of early trials for vertebroplasty, cement augmentation proved its superiority for the treatment of symptomatic osteoporotic vertebral fracture when compared with optimal medical treatment.

Early intervention is also gaining ground recently.

Kyphoplasty has the advantage over vertebroplasty of reducing kyphosis and cement leak.

Stentoplasty, a new variant of cement augmentation, is also showing promising outcomes.

In this review, we describe the additional techniques of cement augmentation, stressing the important aspects for success, and recommend a thorough evaluation of thoracolumbar fractures in osteoporotic patients to select eligible patients that will benefit the most from percutaneous augmentation. A detailed treatment algorithm is then proposed.

Cite this article: EFORT Open Rev 2017;2:293–299. DOI: 10.1302/2058-5241.2.160057

Percutaneous kyphoplasty combined with the posterior screw-rod system in treatment of osteoporotic thoracolumbar fractures

BACKGROUND

The osteoporotic vertebral compression fractures (OVCF) have attracted more and more attention due to increase in life span globally and aging population. Percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) have been popularized rapidly by virtue of their unique advantage in minimal invasiveness. We analysed our results in osteoporotic thoracolumbar fractures using percutaneous kyphoplasty and posterior screw rod system. To investigate the possibility of treatment of rupture of the posterior vertebral osteoporotic fractures by means of kyphoplasty combined with the posterior screw-rod system.

MATERIALS AND METHODS

Twenty six patients (65 years of age or older) with the single spine fractures included in study. The preoperative bone mineral density was measured by dual-energy X-ray. The PKP was done in all the cases. Decompression was done if neurological symptoms were present.

RESULTS

The results demonstrated osteoporosis with BMD T value ≤ -2.5; injured posterior vertebral body (3 cases) had shown the whole damage accompanied by neurological symptoms through X-ray or CT. After 2 days, the remaining patients of back pain symptoms were relieved or disappeared except for three cases of patients with decompression incision. VAS score and Cobb angle changed from preoperative 8.23 ± 0.17 and 28.7 ± 0.33° respectively to postoperative 3.77 ± 0.44 and 3.8 ± 0.2° respectively.

CONCLUSION

Treatment of rupture of the posterior vertebral osteoporotic thoracolumbar fractures by means of kyphoplasty combined with posterior screw-rod system is a safe, effective procedure.