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Zhang XN, Su QJ, Pei BQ, Pan AX, Yang HH, Ding HT, Hai Y, Liu YZ. The accuracy of cortical bone trajectory screw placement guided by spinous process clamp hardware in lumbar spinal surgery: a retrospective study. Sci Rep 2023; 13:16447. [PMID: 37777594 PMCID: PMC10542810 DOI: 10.1038/s41598-023-43406-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 09/23/2023] [Indexed: 10/02/2023] Open
Abstract
This study aimed to assess the accuracy of cortical bone trajectory (CBT) screws placement guided by a spinous process clamp (SPC) guide. A total of 32 patients who received single-level midline lumbar fusion (MIDLF) surgery between June 2019 and January 2020 were retrospectively analyzed and divided into free-hand (FH) and SPC-guided groups according to the surgical approach. In the FH group, CBT screws was implanted with the assistance of fluoroscopy, while in the SPC group, CBT screws was implanted using the SPC navigator hardwire. A total of 128 screws were assessed in this study, with higher rates of clinically acceptable screw placement (grades A and B) and grade A screws in the SPC group than in the FH guide group (92.2% vs. 79.7%, P = 0.042 and 54.7% vs. 35.9%, P = 0.033, respectively). Misplacement screws (grades C, D, and E) occurred more often in the FH group than in the SPC guide group (20.3% vs. 7.8%, P = 0.042). The incidence of proximal facet joint violation (FJV) was higher in the FH group than in the SPC group (15.6% vs. 3.1%, P = 0.030). The radiation dose and time in the SPC guide group were comparable to those in the FH group (P = 0.063 and P = 0.078). The average operative time was significantly longer in the SPC guide group than in the FH group (267.8 ± 45.5 min vs. 210.9 ± 44.5 min, P = 0.001). Other clinical parameters, such as the average bone mineral density (BMD), intraoperative blood loss, and postoperative hospital stay, were not significantly different. Oswestry disability index (ODI) and back pain visual analogue scale (VAS) scores were significantly improved in both groups compared with preoperatively. SPC guided screw placement was more accurate than the fluoroscopy-assisted FH technique for single-level MIDLF at L4/5. Patients undergoing SPC-guided screw placement can achieve similar clinical outcomes as the fluoroscopy-assisted FH technique.
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Affiliation(s)
- Xi-Nuo Zhang
- Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gong Ti Nan Lu, Chaoyang District, Beijing, 100020, China
| | - Qing-Jun Su
- Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gong Ti Nan Lu, Chaoyang District, Beijing, 100020, China
| | - Bao-Qing Pei
- Beijing Key Laboratory for Design and Evaluation Technology of Advanced Implantable and Interventional Medical Devices, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China
| | - Ai-Xing Pan
- Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gong Ti Nan Lu, Chaoyang District, Beijing, 100020, China
| | - Hong-Hao Yang
- Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gong Ti Nan Lu, Chaoyang District, Beijing, 100020, China
| | - Hong-Tao Ding
- Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gong Ti Nan Lu, Chaoyang District, Beijing, 100020, China
| | - Yong Hai
- Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gong Ti Nan Lu, Chaoyang District, Beijing, 100020, China
| | - Yu-Zeng Liu
- Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gong Ti Nan Lu, Chaoyang District, Beijing, 100020, China.
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Zhang XN, Zhou LJ, Su QJ, Guan L, Li DY, Pei BQ, Pan AX, Yang HH, Ding HT, Liu YZ, Hai Y. Accuracy of cortical bone trajectory screw fixation guided by spinous process clamp guide in lumbosacral vertebrae: A cadaver study. Int J Med Robot 2023; 19:e2484. [PMID: 36413096 DOI: 10.1002/rcs.2484] [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: 08/17/2022] [Revised: 11/19/2022] [Accepted: 11/21/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND The purpose of this study was to access the accuracy of cortical bone trajectory screw placement guided by spinous process clamp (SPC). METHODS Eight formalin-treated cadaveric lumbar specimens with T12-S1 were used. A total of 96 screws were implanted in eight lumbar specimens. RESULTS In the freehand (FH) group, clinically acceptable placement (grade A and B) was 40 screws (83.3%), meanwhile 44 screws (91.7%) in the SPC guide group (p = 0.217). The grade A screws in the SPC guide group were much more than that in the FH group (n = 40 vs. n = 31, p = 0.036). The misplacement screws (grade C, D, and E) and proximal facet joint violation (FJV) in the SPC group was comparable to the FH group. CONCLUSIONS This cadaveric study demonstrate that implanting CBT screws guided by SPC guide was more accuracy and reduces severe deviations in important directions.
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Affiliation(s)
- Xi-Nuo Zhang
- Department of Orthopedic Surgery, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China
| | - Li-Jin Zhou
- Department of Orthopedic Surgery, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China
| | - Qing-Jun Su
- Department of Orthopedic Surgery, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China
| | - Li Guan
- Department of Orthopedic Surgery, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China
| | - Dong-Yue Li
- Department of Orthopedic Surgery, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China
| | - Bao-Qing Pei
- Beijing Key Laboratory for Design and Evaluation Technology of Advanced Implantable & Interventional Medical Devices, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Ai-Xing Pan
- Department of Orthopedic Surgery, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China
| | - Hong-Hao Yang
- Department of Orthopedic Surgery, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China
| | - Hong-Tao Ding
- Department of Orthopedic Surgery, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China
| | - Yu-Zeng Liu
- Department of Orthopedic Surgery, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China
| | - Yong Hai
- Department of Orthopedic Surgery, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China
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Zhang XN, Zhang YQ, Liu YZ, Su QJ, Guan L, Li DY, Pei BQ, Pan AX, Yang HH, Ding HT, Hai Y, Zhou LJ. Cortical screw placement with a spinous process clamp guide: a cadaver study accessing accuracy. BMC Surg 2022; 22:384. [PMID: 36348354 PMCID: PMC9644622 DOI: 10.1186/s12893-022-01829-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/17/2022] [Indexed: 11/09/2022] Open
Abstract
Background and objective The Cortical Bone Trajectory (CBT) technique provides an alternative method for fixation in the lumbar spine in patients with osteoporosis. An accuracy CBT screw placement could improve mechanical stability and reduce complication rates. Purpose The purpose of this study is to explore the accuracy of cortical screw placement with the application of implanted spinous process clip (SPC) guide. Methods and materials Four lumbar specimens with T12-S1 were used to access the accuracy of the cortical screw. The SPC-guided planning screws were compared to the actual inserted screws by superimposing the vertebrae and screws preoperative and postoperative CT scans. According to preoperative planning, the SPC guide was adjusted to the appropriate posture to allow the K-wire drilling along the planned trajectory. Pre and postoperative 3D-CT reconstructions was used to evaluate the screw accuracy according to Gertzbein and Robbins classification. Intraclass correlation coefficients (ICCs) and Bland–Altman plots were used to examine SPC-guided agreements for CBT screw placement. Results A total of 48 screws were documented in the study. Clinically acceptable trajectory (grades A and B) was accessed in 100% of 48 screws in the planning screws group, and 93.8% of 48 screws in the inserted screws group (p = 0.242). The incidence of proximal facet joint violation (FJV) in the planning screws group (2.1%) was comparable to the inserted screws group (6.3%) (p = 0.617). The lateral angle and cranial angle of the planned screws (9.2 ± 1.8° and 22.8 ± 5.6°) were similar to inserted screws (9.1 ± 1.7° and 23.0 ± 5.1°, p = 0.662 and p = 0.760). Reliability evaluated by intraclass correlation coefficients and Bland–Altman showed good consistency in cranial angle and excellent results in lateral angle and distance of screw tip. Conclusions Compared with preoperative planning screws and the actually inserted screws, the SPC guide could achieve reliable execution for cortical screw placement.
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Goldberg JL, Härtl R, Elowitz E. Minimally Invasive Spine Surgery: An Overview. World Neurosurg 2022; 163:214-227. [PMID: 35729823 DOI: 10.1016/j.wneu.2022.03.114] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 03/25/2022] [Indexed: 12/29/2022]
Abstract
Spinal surgery is undergoing a major transformation toward a minimally invasive paradigm. This shift is being driven by multiple factors, including the need to address spinal problems in an older and sicker population, as well as changes in patient preferences and reimbursement patterns. Increasingly, minimally invasive surgical techniques are being used in place of traditional open approaches due to significant advancements and implementation of intraoperative imaging and navigation technologies. However, in some patients, due to specific anatomic or pathologic factors, minimally invasive techniques are not always possible. Numerous algorithms have been described, and additional efforts are underway to better optimize patient selection for minimally invasive spinal surgery (MISS) procedures in order to achieve optimal outcomes. Numerous unique MISS approaches and techniques have been described, and several have become fundamental. Investigators are evaluating combinations of MISS techniques to further enhance the surgical workflow, patient safety, and efficiency.
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Affiliation(s)
- Jacob L Goldberg
- Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Roger Härtl
- Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Eric Elowitz
- Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA.
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Bielecki M, Kunert P, Balasa A, Kujawski S, Marchel A. Clinical and radiological results of treating lumbar spondylosis with cortical bone trajectory screws. Medicine (Baltimore) 2021; 100:e27670. [PMID: 34871243 PMCID: PMC8568361 DOI: 10.1097/md.0000000000027670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 10/14/2021] [Indexed: 01/02/2023] Open
Abstract
The cortical bone trajectory screws technique (CBTT) is a popular minimally invasive spine surgery. Few studies have reported long-term outcomes. We aimed to evaluate the complication profile and long-term follow-up results of patients with lumbar degenerative disease treated with the CBTT.This retrospective analysis included the first 40 consecutive patients that underwent the CBTT. The indication for surgery was critical stenosis of the intervertebral foramen, which required removal of the entire intervertebral joint, on at least 1 side, during decompression.The last follow-up showed minimal clinically important differences in the numerical rating scale of leg pain, the numerical rating scale of back pain, and the Oswestry Disability Index, in 97%, 95%, and 95% of patients, respectively. Thirty-nine patients completed long-term radiological follow-up. Computed tomography demonstrated solid bone union on 47 (92%) operated levels, collapsed union on 2 (4%) levels, nonunion on 1 (2%) level, and 1 (2%) patient was lost to follow-up. Seven patients experienced complications (4 hardware-related). Three patients required 4 revision surgeries.The CBTT effectively achieved spinal fusion; over 90% of patients achieved clinical improvement at a mean follow-up of 4.4 years (range: 3-5.75 years).
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Affiliation(s)
- Mateusz Bielecki
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Przemysław Kunert
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Artur Balasa
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Sławomir Kujawski
- Department of Exercise Physiology and Functional Anatomy, Collegium, Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, M. Sklodowskiej-Curie 9, Bydgoszcz, Poland
| | - Andrzej Marchel
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
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Delgado-Fernández J, Frade-Porto N, Blasco G, Gonzalez-Tarno P, Gil-Simoes R, Pulido P, Sola RG. Simulation with 3D Neuronavigation for Learning Cortical Bone Trajectory Screw Placement. J Neurol Surg A Cent Eur Neurosurg 2020; 82:262-269. [PMID: 33260245 DOI: 10.1055/s-0040-1715485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND OBJECTIVE Learning a new technique in neurosurgery is a big challenge especially for trainees. In recent years, simulations and simulators got into the focus as a teaching tool. Our objective is to propose a simulator for placement of cortical bone trajectory (CBT) screws to improve results and reduce complications. METHODS We have created a platform consisting of a sawbone navigated with a 3D fluoroscope to familiarize our trainees and consultants with CBT technique and later implement it in our department. Objective Structured Assessment of Technical Skills (OSATS) and Physician Performance Diagnostic Inventory Scale (PPDI) were obtained before and after the use of the simulator by the five participants in the study. Patients who were operated on after the implementation of the technique were retrospectively reviewed. RESULTS During the simulation, there were 4 cases of pedicle breach out of 24 screws inserted (16.6%). After having completed simulation, participants demonstrated an improvement in OSATS and PPDI (p = 0.039 and 0.042, respectively). Analyzing the answers to the different items of the tests, participants mainly improved in the knowledge (p = 0.038), the performance (p = 0.041), and understanding of the procedure (p = 0.034). In our retrospective series, eight patients with L4-L5 instability were operated on using CBT, improving their Oswestry Disability Index (ODI) score (preoperative ODI 58.5 [SD 16.7] vs. postoperative ODI 31 [SD 13.4]; p = 0.028). One intraoperative complication due to a dural tear was observed. In the follow-up, we found a case of pseudoarthrosis and a facet joint violation, but no other complications related to misplacement, pedicle fracture, or hardware failure. CONCLUSION The simulation we have created is useful for the implementation of CBT. In our study, consultants and trainees have valued very positively the learning obtained using the system. Moreover, simulation facilitated the learning of the technique and the understanding of surgical anatomy. We hope that simulation helps reducing complications in the future.
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Affiliation(s)
| | | | - Guillermo Blasco
- Division of Neurosurgery, University Hospital La Princesa, Madrid, Spain
| | | | - Ricardo Gil-Simoes
- Division of Neurosurgery, University Hospital La Princesa, Madrid, Spain
| | - Paloma Pulido
- Division of Neurosurgery, University Hospital La Princesa, Madrid, Spain
| | - R G Sola
- Department of Innovation in Neurosurgery, Universidad Autónoma de Madrid, Madrid, Spain.,Neurosurgical Department Hospital Nuestra Señora del Rosario, Madrid, Spain
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Accuracy and safety of cortical bone trajectory screw placement by an inexperienced surgeon using 3D patient-specific guides for transforaminal lumbar interbody fusion. J Clin Neurosci 2020; 78:147-152. [DOI: 10.1016/j.jocn.2020.04.090] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 04/15/2020] [Indexed: 12/15/2022]
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To CY, Cheung P, Ng W, Mok WY. Comparison of facet joint violation in lumbar posterior spinal instrumentation using different techniques including cortical bone trajectory. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2020. [DOI: 10.1177/2210491720903471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Study background: A retrospective study to compare the rate of facet joint violation (FJV) in lumbar posterior spinal instrumentation using open pedicle screw, percutaneous pedicle screw, and cortical bone trajectory (CBT) technique. CBT is a new posterior spinal instrumentation technique in which a more caudal entry point can minimize iatrogenic damage to the cranial facet joint. Only one recent study reports incidence of FJV of 11%; however, no previous reports comment on radiological outcomes comparing to traditional open and percutaneous screws. Methods: We reviewed 90 patients who underwent lumbar posterior spinal instrumentation from January 2016 to June 2017. Postoperative computer tomography scans were performed to evaluate FJV. Incidence of FJV was graded by three reviewers according to Seo classification. Results: Totally, 446 screws (open 43.4%, percutaneous 37.8%, CBT 18.9%) were inserted. Among these, 6.3% (28/446) had screw head or rod in contact with facet joint and 0.9% (4/446) had screws directly invaded the facet joint. Overall, FJV was 7.2% (CTB = 3.4%, open = 10.4%, and percutaneous = 4.5%, p = 0.075). Conclusion: CBT technique has potential advantage in reducing FJV. It has a unique entry site at lateral aspect of pars interarticular with a caudomedial to craniolateral pathway. It is a reasonable alternative to open or percutaneous techniques in lumbar posterior spinal instrumentation.
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Affiliation(s)
- CY To
- Department of Orthopaedics and Traumatology, Pamela Youde Nethersole Eastern Hospital, Hong Kong
| | - P Cheung
- Department of Orthopaedics and Traumatology, Pamela Youde Nethersole Eastern Hospital, Hong Kong
| | - W Ng
- Department of Orthopaedics and Traumatology, Pamela Youde Nethersole Eastern Hospital, Hong Kong
| | - WY Mok
- Department of Orthopaedics and Traumatology, Pamela Youde Nethersole Eastern Hospital, Hong Kong
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Cofano F, Marengo N, Ajello M, Penner F, Mammi M, Petrone S, Lavorato A, Zenga F, Garbossa D. The Era of Cortical Bone Trajectory Screws in Spine Surgery: A Qualitative Review with Rating of Evidence. World Neurosurg 2020; 134:14-24. [DOI: 10.1016/j.wneu.2019.10.079] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 10/11/2019] [Accepted: 10/13/2019] [Indexed: 12/14/2022]
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Wochna JC, Marciano R, Catanescu I, Katz J, Spalding MC, Narayan K. Cortical Trajectory Pedicle Screws for the Fixation of Traumatic Thoracolumbar Fractures. Cureus 2018; 10:e2891. [PMID: 30167347 PMCID: PMC6112911 DOI: 10.7759/cureus.2891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Objective Cortical bone trajectory pedicle screws (CBT) have a different trajectory compared to traditional pedicle screws (PS) and they may confer biomechanical advantages in some patient populations. We hypothesize that the placement of CBT in traumatic thoracolumbar fractures could be an alternative technique to the traditional utilization of PS. Methods Single surgeon, retrospective study was performed at a Level 1 Trauma Center from 2013 to 2017. All patients aged between 18 and 90 years with operative AO classification A, B, and C traumatic thoracolumbar fractures were included. Patients with pathological fractures, active spinal infections, or history of vertebral augmentation were excluded. Age, injury severity score (ISS), AO classification, operative time, estimated blood loss (EBL), length of stay (LOS), and presence of proximal junctional kyphosis (PJK) or construct failure were compared between CBT and PS groups. The PS group was further separated into open reduction internal fixation (ORIF) and minimally invasive spine (MIS) groups. All CBT and ORIF cases were completed via open incisions allowing arthrodesis of the involved lamina and facet joints whereas no arthrodesis was completed in the MIS patients. Choice of technique was at the attending surgeon’s discretion. Results The study included 71 patients, out of which 12 received CBT and 59 received PS. Of the 59 PS patients, 39 were ORIF and 20 were MIS. The average operative time was 22.9 minutes less in CBT compared to ORIF (p = 0.24). EBL was 337.50 mL for CBT, 184.33 mL for MIS, and 503.33 mL for ORIF (p = 0.01) demonstrating that MIS technique results in a significantly reduced blood loss. However, EBL was comparable for CBT versus MIS (p > 0.05). ISS was not significantly different between the three groups (p = 0.89). LOS was 4.06 days fewer for CBT patients compared to ORIF patients (p = 0.36). There was one case of construct failure as well as one case of incisional site infection in the PS group, but none were found in the CBT group. Instances of PJK complications were determined by the change in the Cobb angle over time and they were not statistically different between the three groups (p = 0.68). Conclusions CBT is noninferior to PS in the fixation of unstable adult traumatic thoracolumbar fractures. With the exception of EBL, CBT was not statistically different compared to MIS and ORIF. This study establishes a precedent to expand the application of this new technique and investigate with larger sample sizes.
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Affiliation(s)
- Jacob C Wochna
- Medical Student, Ohio University Heritage College of Osteopathic Medicine, Athens, USA
| | | | | | - Joel Katz
- Neurological Surgery, OhioHealth, Columbus, USA
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