Open versus minimally invasive percutaneous surgery for surgical treatment of thoracolumbar spine fractures- a multicenter randomized controlled trial: study protocol

Percutaneous versus traditional open approaches for the treatment of thoracolumbar fractures in patients without neurologic deficits: a meta-analysis of 35 cohort studies

At present, percutaneous surgery is widely used to treat thoracolumbar fractures. However, the actual safety, feasibility, and effectiveness of percutaneous surgery are not clear. Through systematic review and meta-analysis, we compared the efficacies of percutaneous pedicle screw fixation and open pedicle screw fixation in the treatment of thoracolumbar fractures without nerve root symptoms. We systematically searched the PubMed, Embase, and Cochrane libraries for articles published on or before June 2023. All results were evaluated by standard methods recommended for meta-analysis, continuous data were expressed by standard mean differences (SMDs), and binary variables were analyzed by odds ratios (ORs) and 95% confidence intervals (95% CIs). We also explored the main sources of heterogeneity and the stability of the results through sensitivity analysis, Begg's funnel plots, and Egger's test. Thirty-five cohort studies with a total of 3039 patients were included. The study found that patients who undergo percutaneous approaches have less intraoperative blood loss (IBL), shorter length of hospital stay (LOS), shorter operation time, and shorter incision. Moreover, percutaneous approaches had more advantages in terms of visual analog scale (VAS) scores, Oswestry Disability Index (ODI) scores, and infection rates. However, there was no significant difference in anterior vertebral body height (AVB), Cobb angle (CA), or screw errors between the two groups. In the long run, the clinical and surgical results of the percutaneous approach are better than those of the open approach, but the radiological results of both operations do not seem to show an advantage for any specific approach. Because of publication bias and heterogeneity, our findings must be interpreted with caution. However, this paper will provide some support for clinicians to choose suitable surgical methods for the treatment of thoracolumbar fractures.

Our C-Arm-Free Minimally Invasive Technique for Spinal Surgery: The Thoracolumbar and Lumbar Spine-Based on Our Experiences

Background and Objectives: The implementation of intraoperative imaging in the procedures performed under the guidance of the same finds its history dating back to the early 1990s. This practice was abandoned due to many deficits and practicality. Later, fluoroscopy-dependent techniques were developed and have been used even in the present time, albeit with several disadvantages. With the recent advancement of several complex surgical techniques, which demand higher accuracy and are in conjunction with the existence of radiation exposure hazard, C-arm-free techniques were introduced. In this review study, we aim to demonstrate the various types of these techniques performed in our hospital. Materials and Methods: We have retrospectively analyzed and collected imaging data of C-arm-free, minimally invasive techniques performed in our hospital. The basic steps of the procedures are described, following with a discussion, along with the literature of findings, enlisting the merits and demerits. Results: MIS techniques of the thoracolumbar and lumbar spine that do not require the use of the C-arm can offer excellent results with high precision. However, several disadvantages may prevail in certain circumstances such as the navigation accuracy problem where in the possibility of perioperative complications comes a high morbidity rate. Conclusions: The accustomedness of performing these techniques requires a steep learning curve. The increase in accuracy and the decrease in radiation exposure in complex spinal surgery can overcome the burden hazards and can prove to be cost-effective.

Percutaneous versus open posterior stabilization and decompression in AOSpine-type A3 thoracolumbar fractures with neurological deficit

BACKGROUND

This retrospective cohort study aimed to compare the clinical and radiological outcomes between two treatment strategies focusing on non-osteoporotic AOSpine-type A3 fractures of the thoracolumbar spine with neurological deficits at levels T11 to L2.

METHODS

In total, 67 patients between 18 and 60 years of age who were treated operatively with either of the two treatment strategies were included. One treatment strategy included open posterior stabilization and decompression, whereas the other was based on percutaneous posterior stabilization and decompression via a tubular retraction system. Demographic data, surgical variables, and further parameters were assessed. Patient-reported outcomes (PROs), including the Visual Analog Scale (VAS), the Oswestry Disability Index (ODI), and the American Spinal Injury Association (ASIA) impairment score, were measured to assess functional outcomes. The regional Cobb angle (CA), the anterior height ratio of the fractured vertebrae (AHRV), and the degree of canal encroachment (DCE) were assessed. The ASIA score was used to assess neurological function recovery. The follow-up period was at least 12 months.

RESULTS

Surgical time and postoperative hospital stay were significantly shorter in the minimally invasive surgery (MIS) group. Intraoperative blood loss was significantly less in the MIS group. Regarding radiological outcome, CA and AHRV at the time of follow-up did not show a significant difference. DCE at the time of follow-up was significantly improved in the MIS group. Lower VAS scores and better ODIs were observed in the MIS group at the 6-month follow-up, but similar outcomes were observed at the 12-month follow-up. The ASIA score was similar between both groups at the 12-month follow-up.

CONCLUSIONS

Both treatment strategies are safe and effective; however, MIS could provide earlier pain relief and better functional outcomes compared with OS.

Percutaneous Versus Open Pedicle Screw Fixation for Pyogenic Spondylodiscitis of the Thoracic and Lumbar Spine: Systematic Review and Meta-Analysis

STUDY DESIGN

A systematic review and meta-analysis.

OBJECTIVE

This meta-analysis aimed to compare percutaneous (PPS) versus open pedicle screw (OPS) fixation for treatment of thoracic and lumbar spondylodiscitis.

SUMMARY OF BACKGROUND DATA

Pyogenic spondylodiscitis of the thoracic and lumbar spine can produce instability, deformity, and/or neurological compromise. When medical treatment is unsuccessful, surgical treatment is indicated, with the conventional open approach the usual standard of care. However, percutaneous techniques can be advantageous in medically vulnerable patients.

MATERIALS AND METHODS

A literature search was performed using the PubMed, Web of Science, and Scopus databases, looking for comparative articles on pyogenic spondylodiscitis requiring surgical stabilization with pedicle screws. This systematic review is reported according to PRISMA guidelines.

RESULTS

From 215 articles initially identified, 7 retrospective studies were analyzed, encapsulating an overall sample of 722 patients: 405 male (56.1%) and 317 female (43.9%). The treatment modality was PPS fixation in 342 patients (47.4%) and OPS fixation in 380 (52.6%). For PPS, operating time was 29.75 minutes ( P <0.0001), blood loss 390.18 mL ( P <0.00001), postoperative pain 1.54 points ( P <0.00001), and length of stay 4.49 days ( P =0.001) less than with OPS fixation, and wound infection 7.2% ( P =0.003) less frequent. No difference in screw misplacement ( P =0.94) or loosening ( P =0.33) rates was observed.

CONCLUSION

Employing PPS fixation to treat pyogenic spondylodiscitis of the thoracic and lumbar spine is associated with significantly reduced operating time, blood loss, postoperative pain, length of stay, and rates of wound infection than OPS fixation, with no difference between the 2 treatments in rates of screw misplacement or screw loosening.

Outcome of percutaneous pedicle screw fixation for traumatic thoracic and lumbar fractures -six years experience

OBJECTIVES

This study discusses the experience at our centre with treating traumatic thoracolumbar fractures using percutaneous pedicle screw fixation.

METHODS

We reviewed the case notes and imaging retrospectively between January 2013 and June 2019.

RESULTS

A total of 257 patients were included, 123 males and 134 females aged between 17 and 70; the mean age was 47.6 years. The majority of injuries were from fall from significant height. The fractures involved the thoracic and lumbar vertebra in 98 and 151 of the cases respectively. Percutaneous pedicle screw fixation was performed either one or two levels above and below the fracture depending on the level of injury. Forty two cases were treated with additional short pedicle screws at the level of fracture. More than 15% (39) of the patients presented with a neurological deficit; more than 80% (32) of those showed post-operative improvement in their neurology as per Frankel Grading system. The mean operative time was 117 min ± 45 min; mean length of hospital stay was 7.2 days ± 3.8 days, with significant improvement in pain.

CONCLUSIONS

Percutaneous pedicle screw fixation is a safe surgical option with comparable outcomes to open surgery and a potential reduction in perioperative morbidity.

Pedicle screw fixation combined with posterior decompression and bone grafting for thoracolumbar spinal fractures can enhance curative effect and spinal cord function

OBJECTIVE

To explore the efficacy of pedicle screw fixation (PSF) combined with posterior decompression and bone grafting for thoracolumbar spinal fractures (TLSFs) and its influence on spinal cord function.

METHODS

In this retrospective study, 94 patients with TLSFs treated in the China-Japan Friendship Hospital rom June 2015 and September 2020 were selected, including 53 cases in the joint group treated with PSF combined with posterior decompression and bone grafting, and 41 cases in the control group with PSF alone. The two groups were compared in terms of operation time, intra-operational blood loss, length of hospital stay and wound healing as well as the pre- and post-treatment spinal cord function, and patients' clinical outcomes. Pre- and post-operatively, the pain severity was evaluated by the Visual Analogue Scale (VAS), the spinal dysfunction was assessed by Oswestry Disability Index (ODI), and the injured vertebral height and Cobb angles of the thoracolumbar spine (TLS) were compared. The clinical efficacy and postoperative complication rates of the two groups were observed and compared.

RESULTS

Less operative time, intraoperative bleeding, hospitalization time and wound healing time were determined in the joint group compared with the control group (all P<0.05). The postoperative sensory function and motor function were also better in the joint group (all P<0.05). Postoperatively, the joint group showed lower VAS and ODI scores than in the control group, with lower upper and lower TLS Cobb angles, and higher height of the anterior and posterior margins of the fractured vertebra (all P<0.05). The total effective rate was higher, and the incidence of postoperative complications was significantly lower in the joint group compared with the control group.

CONCLUSION

PSF combined with posterior decompression and bone grafting is effective in the treatment of TLSFs, which can not only significantly improve the spinal cord function and alleviate spinal dysfunction, but also help to relieve pain and reduce postoperative complications.

The arthroscopic minimally-invasive technique improves the clinical symptoms and facilitates the functional recovery of the lower limbs in knee joint bone trauma patients

OBJECTIVE

This study aims to demonstrate the effect of the arthroscopic minimally invasive technique on the clinical symptoms and lower limb functional recovery in knee joint bone trauma patients.

METHODS

From January 2015 to January 2020, 150 knee joint bone trauma patients were recruited as the study cohort and divided into two groups according to the different intervention method each patient underwent. The patients in the control group (the CG, n=68) were administered routine treatment, and the patients in the research group (the RG, n=82) were treated using the arthroscopic minimally invasive technique. The postoperative clinical operative indexes and the clinical effectiveness, as well as the intraoperative complications were observed in the two groups. The inflammatory factor levels before and after the surgeries were compared. The Visual Analogue Scale (VAS) was employed to evaluate the pain levels before and after the surgeries, the Hospital for Special Surgery Knee Scores (HSS) were used to assess the knee joint recoveries before and at six months after the operations, and the Fugl-Meyer Assessment Scale (FMAS) was used to determine the lower limb functional recovery before and at six months after the operations.

RESULTS

The RG had significantly shorter operation times, lower intraoperative blood losses, shorter average ambulation times, shorter hospital stays, shorter fracture healing times, and smaller incisions than the CG. Postoperatively, the IL-8 and TNF-α levels were significantly lower in the RG than in the CG. The RG exhibited observably lower VAS scores after the operations, as well as evidently higher HSS scores and FMAS scores at six months postoperatively than the CG. In comparison with the CG, the RG had a significantly higher total effective rate and a noticeably lower incidence of postoperative complications.

CONCLUSIONS

The arthroscopic minimally invasive technique is effective at treating patients with knee joint bone trauma, and it can promote the surgical recovery of patients and facilitate the functional recovery of the knee joint and the lower limbs.

Occupational hazard of fluoroscopy: An invisible threat to orthopaedic surgeons

The use of fluoroscopy is widespread within different medical specialties. Improper protection may cause significant radiation hazard to medical personnel. To evaluate the concepts on radiation safety and fluoroscopy use among orthopaedic surgeons and to reflect our current training on this issue, a survey was distributed to perform an audit in our department, an academic unit. Twenty-eight orthopaedic surgeons replied. Amongst our participants, 96.4% used a lead apron at all times. Only 33% used a thyroid shield, 67% never used radiation goggles and 96% never used radiation protection gloves. 53.6% and 46.4% of participants position the fluoroscopy incorrectly in the anteroposterior and lateral positions, respectively, during use. There is clearly a need for improved safety amongst orthopaedic surgeons. A literature review was further performed, showing the hazards of fluoroscopy for doctors, including the risk of cataracts, radiation dermatitis, skin cancer and thyroid cancer. Hazards specific to females, including breast cancer risk, and in-utero irradiation of foetus were also thoroughly discussed. Recommendations towards radiation safety and practical measures to reduce fluoroscopy radiation hazard during procedure were made. Education and training to doctors on this invisible hazard is strongly advised.

Treating surgical site infection following posterior instrumentation with free-style deepithelialized propeller flap: A case report

Surgical site infection is a challenging situation for all types of surgeons. Extensive debridement with or without implant removal can create soft tissue defects. A well-vascularized, adequate soft tissue is needed to cover the wound and to fill the dead space for proper healing. Herein, we describe our approach to a large posterior trunk defect with dead space and our solution to manage an intraoperative complication using a free-style deepithelialized propeller flap.

Effect of pedicle screw angles on the fracture risk of the human vertebra: A patient-specific computational model

The assessment of a human vertebra's stability after a screws fixation procedure and its fracture risk is still an open clinical problem. The accurate evaluation of fracture risk requires that all fracture mechanical determinants such as geometry, constitutive behavior, loading modes, and screws angulation are accounted for, which requires biomechanics-based analyses. As such, in the present work we investigate the effect of pedicle screws angulation on a patient-specific model of non osteoporotic lumbar vertebra, derived from clinical CT images. We propose a novel computational approach of fracture analysis and compare the effects of fixation stability in the lumbar spine. We considered a CT-based three-dimensional FE model of bilaterally instrumented L4 vertebra virtually implanting pedicle screws according to clinical guidelines. Nine screws trajectories were selected combining three craniocaudal and mediolateral angles, thus investigated through a parametric computational analysis. Bone was modeled as an elastic material with element-wise inhomogeneous properties fine-tuned on CT data. We implemented a custom algorithm to identify the thin cortical layer correctly from CT images ensuring reliable material properties in the computational model. Physiological motion (i.e., flexion, extension, axial rotation, lateral bending) was further accomplished by simultaneously loading the vertebra and the implant. We simulated local progressive damage of the bone by using a quasi-static force-driven incremental approach and considering a stress-based fracture criterion. Ductile-like and brittle-like fractures were found. Statistical analyses show significant differences comparing screws trajectories and averaging the results among six loading modes. In particular, we identified the caudomedial trajectory as the least critical case, thus safer from a clinical perspective. Instead, medial and craniolaterally oriented screws entailed higher peak and average stresses, though no statistical evidence classified such loads as the most critical scenarios. A quantitative validation procedure will be required in the future to translate our findings into clinical practice. Besides, to apply the results to the target osteoporotic population, new studies will be needed, including a specimen from an osteoporotic patient and the effect of osteoporosis on the constitutive model of bone.

Percutaneous pedicle screw fixation combined with transforaminal endoscopic spinal canal decompression for the treatment of thoracolumbar burst fracture with severe neurologic deficit: A case report

RATIONALE

The most common fractures of the spine are associated with the thoracolumbar junction (T10-L2). And burst fractures make up 15% of all traumatic thoracolumbar fractures, which are often accompanied by neurological deficits and require open surgeries. Common surgeries include either anterior, posterior or a combination of these approaches. Here, we report the first attempt to treat thoracolumbar burst fracture (TLBF) with severe neurologic deficits by percutaneous pedicle screw fixation (PPSF) and transforaminal endoscopic spinal canal decompression (TESCD).

PATIENT CONCERNS

A 46-year-old Chinese woman suffered from severe lower back pain with grade 0 muscle strength of lower limbs, without any sensory function below the injury level, with an inability to urinate or defecate after a motor vehicle accident. Imaging studies confirmed that she had Magerl type A 3.2 L1 burst fracture.

DIAGNOSES

Burst fracture at L1.

INTERVENTIONS

The patient underwent PPSF at the level of T12 to L2, but her neurological function did not fully recover after the operation. One week after the injury, we performed TESCD on her.

OUTCOMES

There was an immediate improvement in her neurological function in just 1 day after 2-stage operation. During the 6-month follow-up period, her neurological functions gradually recovered, and she was able to defecate and urinate. At the last follow-up visit, her spinal cord function was assessed to be at Frankel grade D.

LESSONS

PPSF plus TESCD can achieve complete spinal cord decompression, promote neurological recovery, and is therefore an effective method for the treating lumbar burst fractures with severe neurologic deficits.