Clinical and radiological results 6 years after treatment of traumatic thoracolumbar burst fractures with pedicle screw instrumentation and balloon assisted endplate reduction

Effective method of pedicle screw fixation in patients with neurologically intact thoracolumbar burst fractures: a systematic review of studies published over the last 20 years

OBJECTIVE

To conduct a systematic review of studies on various posterior pedicle screw fixation (PSF) methods used for treating neurologically intact thoracolumbar burst fractures and to identify the most effective and safe approaches.

METHODS

We conducted a systematic review adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, with the study registered in PROSPERO (CRD42024531093). The inclusion criteria were: (1) publication dates from January 1, 2004, to December 31, 2023; (2) availability of full-text articles in English; (3) thoracolumbar burst fractures without neurological deficits; (4) patients aged over 18; (5) reports on treatment outcomes or complications; (6) a mean follow-up period of at least 12 months.

RESULTS

A total of 69 articles covering 116 patient groups were included. Our analysis highlighted the advantages of short-segment fixation without fusion over monosegmental, short-segment and long-segment fusion in terms of shorter operation times and reduced intraoperative blood loss (p = 0.001 and p < 0.001, respectively). Extensive fusion was associated with a significantly higher frequency of deep surgical site infections compared to other PSF methods (p = 0.043). Percutaneous pedicle screw fixation, applied to patients with lower body compression rates and kyphotic deformities, led to less potential for correction (p = 0.004), yet significantly decreased blood loss (p = 0.011), operation duration (p < 0.0001), and hospitalization duration (p < 0.0001). No significant benefits were observed with the use of additional intermediate screws in short-segment PSF.

CONCLUSIONS

Short-segment pedicle screw fixation could be the optimal surgical treatment method for neurologically intact thoracolumbar burst fractures. The use of posterior lateral fusion in this context may increase the deep surgical site infection rate without reducing the frequency of implant-related complications or improving long-term treatment outcomes. The percutaneous approach remains the preferred technique; however, its limited reduction capabilities should be carefully considered during surgical planning for patients with severe kyphotic deformities. The application of intermediate screws in such patients has not demonstrated significant advantages. Removing the fixation system has not led to a significant decrease in implant-related complications or improvement in quality of life. The data obtained from the systematic review may assist surgeons in selecting the most appropriate surgical treatment method for patients with neurologically intact thoracolumbar burst fractures, thereby avoiding ineffective procedures and improving both short-term and long-term outcomes.

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.

EXPANDABLE INTRAVERTEBRAL IMPLANTS IN POST-TRAUMATIC VERTEBRAL NECROSIS - NEW CLASSIFICATION SUGGESTION

The progressive evolution of post-traumatic vertebral necrosis and consequent loss of structural integrity of the vertebral body along with neurological risk, makes it one of the most feared and unpredictable pathologies in spine traumatology. Several studies have addressed the role of vertebroplasty, kyphoplasty, and corpectomy in its treatment; however, it remains a controversial concept without a defined therapeutic algorithm. The recent emergence of expandable intravertebral implants, which allow, by a percutaneous transpedicular application, the capacity for intrasomatic filling and maintenance of the height of the vertebral body, makes them a viable option, not only in the treatment of acute vertebral fractures, but also in non-union cases. In this study, we present a review of the current evidence on the application of expandable intravertebral implants in cases of post-traumatic vertebral necrosis. Based on the available scientific literature, including previous classifications of post-traumatic necrosis, and on the mechanical characteristics of the main expandable intravertebral implants currently available, we propose a simplified classification of this pathology, considering parameters that influence surgical therapeutic guidance, the morphology and the dynamics of the necrotic vertebra's mobility. According to its stages and based on authors' experience and on the scarce literature, we propose an initial therapeutic algorithm and suggest preventive strategies for this disease, considering its main risk factors, that is, fracture comminution and impairment of vertebral vascularity. Therefore, expandable intravertebral implants have a promising role in this condition; however, large prospective studies are needed to confirm their efficacy, to clarify the indications of each of these devices, and to validate the algorithm suggestion regarding treatment and prevention of post-traumatic vertebral necrosis. Level of Evidence III, Systematic Review/Actualization.

Correction loss following short-segment posterior fixation for traumatic thoracolumbar burst fractures related to endplate and intervertebral disc destruction

BACKGROUND

There has been widespread use of short-segment posterior fixation (SSPF) for traumatic thoracolumbar burst fractures. The relationship between the destruction of the vertebral endplate and adjacent disc and postoperative correction loss has been studied in only a few studies. This study investigated the risk factors for correction loss following SSPF.

METHODS

Forty-eight patients (mean age 35.0 years) who underwent SSPF for thoracolumbar burst fractures were enrolled. The mean follow-up period was 25.7 months (12-98 months). The neurological status and postoperative back pain were assessed by the medical records. Segmental kyphotic angle (SKA) and anterior vertebral body height ratio (AVBHR) were measured radiographically to assess indirect vertebral body reduction and local kyphosis. Preoperative Sander's traumatic intervertebral disc lesion (TIDL) classification and AO classification were used to evaluate the severity of disc and vertebral endplate injury. The corrective loss was considered present if ΔSKA was ≥10°. A multivariate logistic regression analysis was performed to identify the risk factors associated with postoperative loss of correction.

RESULTS

The fracture distribution was as follows: 10 at T12, 17 at L1, 10 at L2, 9 at L3, and 2 at L4. Vertebral fractures were classified in the following way: A3 in 13 patients, A4 in 11, B1 in 11, and B2 in 13. In 47 patients (98%), a union of the fractured vertebrae was achieved. SKA and AVBHR improved significantly after surgery from 11.6° to 3.5° and from 67.2 to 90.0%, respectively. However, the correction loss at follow-up was 10.4° and 9.7%, respectively. Twenty patients (42%) had severe TIDL (grade 3). Postoperative ΔSKA and ΔAVBHR were significantly higher in patients with TIDL grade 3 than with TIDL grade 0-2. The presence of cranial TIDL grade 3 and older age were significant risk factors for ΔSKA ≥10° on multivariate logistic regression analysis. All patients could walk at follow-up. TIDL grade 3 and ΔSKA ≥10° were associated with severe postoperative back pain.

CONCLUSIONS

Risk factors for loss of correction after SSPF for thoracolumbar burst fractures were severe disc and endplate destruction at the time of injury and older age.

Internal replacement of a vertebral body in pseudarthrosis-Armed kyphoplasty with bone graft-filled stents: Case report

Background

Post-traumatic vertebral necrosis and pseudarthrosis represents one of the most concerning and unpredictable challenges in spinal traumatology. The evolution of this disease at the thoracolumbar transition usually courses with progressive bone resorption and necrosis, leading to vertebral collapse, retropulsion of the posterior wall and neurological injury. As such, the therapeutic goal is the interruption of this cascade, seeking to stabilize the vertebral body and avoid the negative consequences of its collapse.

Case description

We present a clinical case of a pseudarthrosis of T12 vertebral body with severe posterior wall collapse, treated with removal of intravertebral pseudarthrosis focus by transpedicular access, T12 armed kyphoplasty with VBS® stents filled with cancellous bone autograft, laminectomy and stabilization with T10-T11-L1-L2 pedicle screws. We present clinical and imaging detailed results at 2-year follow-up and discuss our option for this biological minimally invasive treatment for vertebral pseudarthrosis that mimics the general principles of atrophic pseudarthrosis therapeutic and allows to perform an internal replacement of the necrotic vertebral body, avoiding the aggression of a total corpectomy.

Conclusions

This clinical case demonstrates a successful outcome of the surgical treatment of pseudarthrosis of vertebral body (mobile nonunion vertebral body) in which expandable intravertebral stents allow to perform an internal replacement of the necrotic vertebral body by creating intrasomatic cavities and filling them with bone graft, obtaining a totally bony vertebra with a metallic endoskeleton, which is biomechanically and physiologically more similar to the original one. This biological internal replacement of the necrotic vertebral body technique can be a safe and effective alternative over cementoplasty procedures or total vertebral body corpectomy and replacement for vertebral pseudarthrosis and may have several advantages over them, however long-term prospective studies are needed in order to prove the effectiveness and advantages of this surgical option in this rare and difficult pathological entity.

INTRAVERTEBRAL EXPANDABLE IMPLANTS IN THORACOLUMBAR VERTEBRAL COMPRESSION FRACTURES

Current scientific evidence enhances the importance of the anatomic restauration of vertebral bodies with compression fractures aiming, as with other human body joints, to obtain a biomechanic and functional spine as close as the one prior to the fracture as possible. We consider that anatomic reduction of these fractures is only completely possible using intravertebral expandable implants, restoring vertebral endplate morphology, and enabling a more adequate intervertebral disc healing. This enables avoiding disc and osteodegenerative changes to that vertebral segment and its adjacent levels, as well as the anterior overload of adjacent vertebral bodies in older adults - a consequence of post-traumatic vertebral flattening - thus minimizing the risk of adjacent vertebral fractures. The ability of vertebral body fracture reduction and height maintenance over time and its percutaneous transpedicular application make the intra-vertebral expandable implants a very attractive option for treating these fractures. The authors show the direct and indirect reduction concepts of vertebral fractures, review the biomechanics, characteristics and indications of intravertebral expandable implants and present a suggestion for updating the algorithm for the surgical treatment of vertebral compression fractures which includes the use of intravertebral expandable implants. Level of Evidence V, Expert Opinion.

Safety and efficacy studies of kyphoplasty, mesh-container-plasty, and pedicle screw fixation plus vertebroplasty for thoracolumbar osteoporotic vertebral burst fractures

Background

Percutaneous kyphoplasty (PKP), percutaneous mesh-container-plasty (PMCP), and pedicle screw fixation plus vertebroplasty (PSFV) were three methods for osteoporotic vertebral burst fractures (OVBF). The purpose of the current study was to evaluate the clinical safety and efficacy of PKP, PMCP, and PSFV for OVBFs.

Methods

This retrospective study included 338 consecutive patients with thoracolumbar OVBFs who underwent PKP (n = 111), PMCP (n = 109), or PSFV (n = 118) and compared their epidemiological data, surgical outcomes, and clinical and radiological features. Clinical evaluations of VAS and ODI and radiological evaluations of height restoration, deformity correction, cement leakage, and canal compromise were calculated preoperatively, postoperatively, and 2 years postoperatively.

Results

Cement leakage (31/111 vs. 13/109 and 16/118, P < 0.05) was significantly higher in group PKP than in groups PSFV and PMCP. VAS and ODI scores improved postoperatively from 7.04 ± 1.15 and 67.11 ± 13.49 to 2.27 ± 1.04 and 22.00 ± 11.20, respectively, in group PKP (P < 0.05); from 7.04 ± 1.29 and 67.26 ± 12.79 to 2.17 ± 0.98 and 21.01 ± 7.90, respectively, in group PMCP (P < 0.05); and from 7.10 ± 1.37 and 67.36 ± 13.11 to 3.19 ± 1.06 and 33.81 ± 8.81, respectively, in the PSFV group (P < 0.05). Moreover, postoperative VAS and ODI scores were significantly higher in group PSFV than in groups PKP and PMCP (P < 0.05). However, VAS scores were not significantly different in the three groups 2 years postoperatively (P > 0.05). Postoperative anterior (81.04 ± 10.18% and 87.51 ± 8.94% vs. 93.46 ± 6.42%, P < 0.05) and middle vertebral body height ratio (83.01 ± 10.16% and 87.79 ± 11.62% vs. 92.38 ± 6.00%, P < 0.05) were significantly higher in group PSFV than in groups PMCP and PKP. Postoperatively, Cobb angle (10.04 ± 4.26° and 8.16 ± 5.76° vs. 4.97 ± 4.60°, P < 0.05) and canal compromise (20.76 ± 6.32 and 19.85 ± 6.18 vs. 10.18 ± 6.99, P < 0.05) were significantly lower in group PSFV than in groups PMCP and PKP.

Conclusion

Despite relatively worse radiological results, PMCP is a safe and minimally invasive surgical method that can obtain better short-term clinical results than PKP and PSFV for OVBFs.

Management of thoracolumbar fracture in France. Analysis of practices and radiologic results of a cohort of 407 thoracolumbar fractures

BACKGROUND

Thoracolumbar fractures are a public health issue due to their severity and frequency. Management varies according to demographic, clinical and radiologic features, from non-operative treatment to extensive fusion. In the two last decades, improvements and new techniques have emerged, such as kyphoplasty and percutaneous approaches. The main goal of this study was to describe the management of thoracolumbar fractures in France in 2018.

HYPOTHESIS

The study hypothesis was that management of thoracolumbar fractures in France has progressed in recent decades.

MATERIAL AND METHODS

The files of 407 adult patients operated on between January 1, 2015 and December 31, 2016 for T4-L5 thoracolumbar fracture in 6 French teaching hospitals were retrospectively reviewed, at a mean follow-up at 10.2±8.2 [1; 42] months. Demographic, surgical and postoperative radiological data were collected. p-values<0.05 on Student test were considered significant.

RESULTS

Five hundred and thirty-one fractures were analyzed (27% of patients presented more than one fracture). Surgery consisted in internal fixation for 56% of patients, including 17% with associated kyphoplasty; 29% had fusion, and 15% stand-alone kyphoplasty. Surgery used an open posterior approach in 54% of cases, and a percutaneous approach in 46%. Initial sagittal angulation was not a significant decision criterion for screwing (p=0.8) or for a secondary anterior approach in case of fusion (p=0.6). Immediate postoperative sagittal correction was significantly better with an open than a percutaneous approach (p=0.004), but without significant difference at last follow-up (p=0.8). Correction at last follow-up was significantly better with anterior associated to posterior fusion (p=0.003).

DISCUSSION

Management of the thoracolumbar fractures has progressed in France in recent years: 46% of surgeries used a percutaneous approach, compared to 28% in 2013; 90% used a posterior approach only, compared to 83% in 2013; rates of combined approach were unchanged, at 6%. Twenty-five percent of burst fractures were treated by fusion, possibly due to lack of preoperative MRI in 79% of cases.

LEVEL OF EVIDENCE

IV, retrospective cohort study.

Bisegmental posterior stabilisation of thoracolumbar fractures with polyaxial pedicle screws: Does additional balloon kyphoplasty retain vertebral height?

We retrospectively evaluated single-level compression fractures (T12-L3) scheduled for a short-segment POS (posterior-only stabilization) using polyaxial screws. Patients averaged 55.7 years (range, 19–65). Patients received either POS or, concomitantly, BK (balloon kyphoplasty) of the fractured vertebrae as well. Primary endpoint was the radiological outcome at the last radiographic follow-up prior to implant removal. POS together with BK of the fractured vertebrae resulted in a significant improvement of the local kyphosis angle and vertebral body compression rates immediately post-OP. During the further course of FU, a considerable loss of correction was observed post-OP in both groups. (Local KA: pre-OP/ post-OP/ FU: 12.6±4.8/ 3.35±4.8/ 11.6±6.0; anterior vertebral body compression%: pre-OP/post-OP/ FU: 71.94±12.3/ 94.78±19.95/ 78.17±14.74). VAS was significantly improved from 7.2±1.3 pre-OP to 2.7±1.3 (P<0.001) at FU. We found a significant restoration of the vertebral body height by BK. Nevertheless, follow-up revealed a noticeable loss of reduction. Given the fact that BK used together with polyaxial screws did not maintain intra-operative reduction, our data do not support this additional maneuver when used together with bi-segmental polyaxial pedicle screw fixation.

[Hybrid stabilization and geriatric complex treatment of type A spinal fractures]

Approximately 200,000 spinal fractures occur each year in Germany. The decimated stability of the vertebra often leads to type A fractures with a substantial influence by osteoporosis. A mobility preserving and gentle treatment has clear advantages compared to conservative treatment. The hybrid stabilization as a combination of minimally invasive dorsal stabilization and vertebral augmentation has become an established method. In the period from July 2014 to June 2015 a total of 205 spinal operations were documented. In the group of very old patients more than 80% were treated for a geriatric type A vertebral fracture, 24 with hybrid stabilization, 5 by percutaneous bisegmental, 22 by kyphoplasty stabilization and 13 by percutaneous polysegmental procedures. Furthermore, these 4 groups were also considered with respect to the treatment in geriatric trauma centers (GTC). The 4 forms of treatment achieved a mean remuneration of 11,238.77 €. For the individual treatment form of kyphoplasty there was an increase in the remuneration of 4276.54 €, when patients undergo geriatric complex treatment and the remuneration is according to the diagnosis-related groups (DRG) classification I34Z. In the field of operative treatment of geriatric vertebral fractures, the augmentative procedures of kyphoplasty and vertebroplasty are well-established but an injury-related involvement of adjacent spinal segments and continuity fractures are frequent occurrences so that a bisegmental hybrid stabilization is advantageous. In addition, the perioperative stress in hybrid stabilization is only negligibly longer so that hybrid stabilization and geriatric complex treatment can be recommended as the new standard in spinal surgery for the treatment of type A fractures in aged patients.

Clinical, radiological, and patient-reported outcomes 13 years after pedicle screw fixation with balloon-assisted endplate reduction and cement injection

PURPOSE

In management of traumatic thoracolumbar burst fractures, short-segment pedicle screw fixation with balloon-assisted endplate reduction (BAER) and cement injection is a safe, feasible, and effective technique to maintain radiological alignment with minimum spinal segments involved. However, 20% of patients report daily discomfort despite good spinal alignment and fusion after this technique. This study provides clinical, radiological, and patient-reported outcomes after a minimum 13 years of follow-up.

METHODS

Eighteen patients were invited at the outpatient clinic for clinical/radiological examinations. The cohort (originally 20 patients) was treated 13-14 years earlier with pedicle screw fixation, BAER, and cement injection for traumatic thoracolumbar burst fractures. Patient-reported outcome measures were obtained at time of examinations. Current data were compared with data obtained at 6 years of follow-up.

RESULTS

Seventeen patients (median age 50; range 32-80) cooperated. No/minimal back pain was reported by 15 patients, and 12 patients returned to their previous heavy labor work. Median visual analog score of health (80%; 50-100%) was similar to results at 6 years (80%; 60-100% p = 0.259). An Oswestry Disability Index score of less than 20% (reflecting minimal disability) was reported by 14 patients, compared with 15 patients at 6 years of follow-up. No significant differences were found in wedge or Cobb angle between the time points. Intravertebral cement resorption was not observed.

CONCLUSION

Results from this study suggest that, 13 years after pedicle screw fixation with BAER and cement injection for traumatic thoracolumbar burst fractures, functional performance, pain and radiological outcomes of the current cohort were stable or had slightly improved. These slides can be retrieved under Electronic Supplementary Material.

Which anatomic structures are responsible for the reduction loss after hybrid stabilization of osteoporotic fractures of the thoracolumbar spine?

Introduction

Hybrid stabilization is an accepted therapy strategy for unstable osteoporotic thoracolumbar fractures. However, a moderate reduction loss has been reported and it remains unclear which anatomic structure is responsible for the reduction loss.

Methods

This retrospective study was performed at a level I trauma center. Patients aged 61 and older were stabilized using hybrid stabilization after suffering acute and unstable osteoporotic vertebral body fractures at the thoracolumbar spine. Posterior stabilization was done short-segmental and minimal invasive with cement-augmentation of all pedicle screws. The minimum follow-up has been 2 years. The outcome parameters were the reduction loss and the relative loss of height of both intervertebral discs adjacent to the fractured vertebral body, the fractured vertebral body and a reference disc (intervertebral disc superior of the stabilization) between the postoperative and latest lateral radiographs. Additionally, implant positioning and loosening was analyzed.

Results

29 mainly female (72%) patients (73.3 ± 6.0 years) were included. Fractures consisted of 26 incomplete burst fractures and 3 complete burst fractures of the thoracolumbar junction (Th11 – L2: 86%) and the midlumbar spine. The mean follow-up time was 36 months (range: 24–58 months). The mean reduction loss was 7.7° (range: 1–25). The relative loss of heights of both intervertebral discs adjacent to the fractured vertebral body, the reference disc, and the central vertebral body were significant. Thereby, the relative loss of the superior disc height was significant higher compared to the reference disc. Additionally, only the relative loss of central vertebral body height and reduction loss correlated significantly. There were no signs of implant loosening in any patient.

Conclusions

The mean reduction loss was moderate 3 years after hybrid stabilization of unstable osteoporotic vertebral fractures of the thoracolumbar spine. A significant loss of both adjacent disc heights and the central vertebral body was seen, with the highest loss in the superior adjacent disc significantly outranging the reference disc. The superior adjacent intervertebral disc and the central part of the fractured vertebral body seem to be responsible for the majority of reduction loss.

Armed Kyphoplasty: An Indirect Central Canal Decompression Technique in Burst Fractures

BACKGROUND AND PURPOSE

Burst fractures are characterized by middle column disruption and may feature posterior wall retropulsion. Indications for treatment remain controversial. Recently introduced vertebral augmentation techniques using intravertebral distraction devices, such as vertebral body stents and SpineJack, could be effective in fracture reduction and fixation and might obtain central canal clearance through ligamentotaxis. This study assesses the results of armed kyphoplasty using vertebral body stents or SpineJack in traumatic, osteoporotic, and neoplastic burst fractures with respect to vertebral body height restoration and correction of posterior wall retropulsion.

MATERIALS AND METHODS

This was a retrospective assessment of 53 burst fractures with posterior wall retropulsion and no neurologic deficit in 51 consecutive patients treated with armed kyphoplasty. Posterior wall retropulsion and vertebral body height were measured on pre- and postprocedural CT. Clinical and radiologic follow-up charts were reviewed.

RESULTS

Armed kyphoplasty was performed as a stand-alone treatment in 43 patients, combined with posterior instrumentation in 8 and laminectomy in 4. Pre-armed kyphoplasty and post-armed kyphoplasty mean posterior wall retropulsion was 5.8 and 4.5 mm, respectively (P < .001), and mean vertebral body height was 10.8 and 16.7 mm, respectively (P < .001). No significant clinical complications occurred. Clinical and radiologic follow-up (1-36 months; mean, 8 months) was available in 39 patients. Three treated levels showed a new fracture during follow-up without neurologic deterioration, and no retreatment was deemed necessary.

CONCLUSIONS

In the treatment of burst fractures with posterior wall retropulsion and no neurologic deficit, armed kyphoplasty yields fracture reduction, internal fixation, and indirect central canal decompression. In selected cases, it might represent a suitable minimally invasive treatment option, stand-alone or in combination with posterior stabilization.

Hybrid stabilization of unstable osteoporotic thoracolumbar vertebral body fractures: clinical and radiological outcome after a mean of 4 years

PURPOSE

The aim of this study was to evaluate midterm results after hybrid stabilization of unstable osteoporotic fractures of the thoracolumbar junction.

METHODS

This retrospective study was performed at a level I trauma center. A total of 113 patients aged 61 and older were stabilized using hybrid stabilization consisting of short-segmental posterior instrumentation and augmentation of the fractured vertebral body after suffering an unstable osteoporotic vertebral body fracture at the thoracolumbar spine. All patients were treated by hybrid stabilization. The primary outcome parameters were the ODI score and loss of reduction. Secondary radiological outcome parameters were the sagittal alignment parameters.

RESULTS

Seventy-two women and 41 men (74.6 ± 6.8 years) were included. Sixty-nine patients (61%) were re-evaluated after a mean of 48 months. Seventeen patients have died during the follow-up period (15%). A total of five in-patient complications were documented (4.4%). Additionally, 12 patients (17.4%) suffered from further osteoporotic vertebral body fractures affecting vertebral bodies of different levels. The average ODI score at the final follow-up was 29.9 (± 22.0). Thereby, 66.6% of all patients had low to moderate limitations. The average regional sagittal loss of reduction was 7.4% (± 5.6%). Loss of reduction was below 10° in 78% of the patients. There were statistically significant correlations between the loss of reduction and the ODI score, pelvic incidence and latest Cobb angle, and between the ODI scores and the lumbar lordosis.

CONCLUSIONS

The majority of patients had low or moderate limitations and low to moderate reduction loss. Thereby, high loss of reduction correlated directly with inferior outcomes. These slides can be retrieved under Electronic Supplementary Material.

Treatment of Fractures of the Thoracolumbar Spine: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU)

STUDY DESIGN

consensus paper with systematic literature review.

OBJECTIVE

The aim of this study was to establish recommendations for treatment of thoracolumbar spine fractures based on systematic review of current literature and consensus of several spine surgery experts.

METHODS

The project was initiated in September 2008 and published in Germany in 2011. It was redone in 2017 based on systematic literature review, including new AOSpine classification. Members of the expert group were recruited from all over Germany working in hospitals of all levels of care. In total, the consensus process included 9 meetings and 20 hours of video conferences.

RESULTS

As regards existing studies with highest level of evidence, a clear recommendation regarding treatment (operative vs conservative) or regarding type of surgery (posterior vs anterior vs combined anterior-posterior) cannot be given. Treatment has to be indicated individually based on clinical presentation, general condition of the patient, and radiological parameters. The following specific parameters have to be regarded and are proposed as morphological modifiers in addition to AOSpine classification: sagittal and coronal alignment of spine, degree of vertebral body destruction, stenosis of spinal canal, and intervertebral disc lesion. Meanwhile, the recommendations are used as standard algorithm in many German spine clinics and trauma centers.

CONCLUSION

Clinical presentation and general condition of the patient are basic requirements for decision making. Additionally, treatment recommendations offer the physician a standardized, reproducible, and in Germany commonly accepted algorithm based on AOSpine classification and 4 morphological modifiers.

Modified Posterior Short-Segment Pedicle Screw Instrumentation for Lumbar Burst Fractures with Incomplete Neurological Deficit

PURPOSE

We have introduced a method of modified posterior short-segment pedicle screw fixation and evaluated its clinical effects in treating lumbar burst fractures with incomplete neurological deficits.

METHODS

The data from 22 patients with lumbar burst fracture and incomplete neurological deficits who had undergone modified posterior short-segment instrumentation with Schanz screw fixation from January 2012 to February 2018 in our clinic were evaluated in the present retrospective study. All Schanz screws were implanted in an oblique downward direction into the vertebrae above and below the injured vertebra (insertion depth, 90%-100%). The implants were removed ∼1 year after surgery. Neurological function, back pain, anterior and posterior body height ratio, kyphosis angle, percentage of canal compromise, fracture severity, and treatment-related complications were evaluated.

RESULTS

Technical success was achieved in all 22 patients. No infection, instrument loosening or failure, or breakage was observed. Statistically significant improvements with regard to the anterior body height (P < 0.05) and posterior body height (P < 0.05) ratios, kyphosis angle, and percentage of canal compromise (P < 0.05) were observed at 1 week postoperatively or the final follow-up visit. No correction loss had occurred at the final follow-up examination. Postoperatively, all patients with neurological deficits had functional improvement equivalent to ≥1 grade on the American Spinal Injury Association impairment scale and fracture union. Back pain was greatly improved postoperatively.

CONCLUSIONS

Short-segment Schanz screw fixation implanted in an oblique downward direction seems to be a promising method for lumbar burst fractures with incomplete neurological deficits because it provided good clinical and radiographic outcomes.

Morphological changes in the human cervical intervertebral disc post trauma: response to fracture-type and degeneration grade over time

PURPOSE

In the first 24 h post-intervertebral disc (IVD) trauma, up to 75 % cell death has been reported. In addition, burst fractures cause post-traumatic disc degeneration by elevated pro-apoptotic and pro-inflammatory gene transcription. Moreover, some patients have pre-trauma degenerative disc disease. The aim of the study was to assess histological changes and cell-death over a time period of up to 1 year caused by mechanical and structural factors.

METHODS

116 anterior portions of IVDs of the cervical spine were studied histologically by light microscopy and ultrastructurally by transmission electron microscopy (TEM). The group was investigated with regard to three main parameters: fracture mechanism (compressive vs. tensile/shear loads), degeneration grade (low vs. high) and endplate fracture (with vs. without). Disc architecture (e.g. ruptures) was studied histologically. Cell morphology was examined ultrastructurally to quantify cell-death, healthy and balloon cells. According to ultrastructural observations, two time-groups (up to 6 days vs. later) were established. Statistical analyses were carried out within and between time-groups.

RESULTS

Histological changes were obvious in the annulus fibrosus where ruptures with haematoma were replaced by granulation tissue. Significant differences in cell-death were seen in the first few days due to different loads. In contrast to the more degenerated segments, low degenerated ones revealed significantly less cell death with time post-trauma. Interestingly, no difference was found between groups after the sixth day. Cell-death (mean 44 % for all investigated groups) remained high after day 6 post-trauma.

CONCLUSION

IVDs retrieved from low grade degenerated segments revealed a significant recovery, with less cell-death and a partially restored disc matrix, although cell-death remained high. Long-term clinical studies of stabilized segments arising from different fracture mechanisms are required.