A novel, percutaneous, self-expanding, forceful reduction screw system for the treatment of thoracolumbar fracture with severe vertebral height loss

Is anterior fusion still necessary in patients with neurologically intact thoracolumbar burst fractures? A systematic review and meta-analysis

OBJECTIVES

To conduct a systematic review and single-arm meta-analysis to evaluate and compare radiological indicators, as well as short-term and long-term outcomes, in patients with neurologically intact thoracolumbar burst fractures (TLBF) who underwent anterior fusion, combined anterior-posterior procedure, or short-segment pedicle screw fixation (PSF).

METHODS

A systematic review following PRISMA guidelines was conducted. Inclusion criteria comprised articles published between 2004 and 2023, full-text availability in English, burst fractures without spinal cord or nerve root injuries at admission, short-segment PSF without fusion, anterior or combined fusion methods, patients aged 18 or older, and a minimum 12-month follow-up. Meta-analysis was carried out using Comprehensive Meta-Analysis software. Using a single-arm meta-analysis method, pooled indicators of short- and long-term outcomes for each studied group were determined. The obtained data were then compared using simple comparison.

RESULTS

The pooled mean Cobb angle at admission for the anterior, combined, and PSF groups was 18.2° (95% CI, 14.6-21.8), 11.7° (95% CI, 9.7-13.5), and 17.1° (95% CI, 15.1-19.1), respectively. Anterior fusion achieved a greater degree of kyphosis correction across all groups, but only the combined group showed a nonsignificant loss of correction after discharge (SMD = 0.809 [95% CI, 0.270, 1.348]). The anterior vertebral body compression rate at admission was 55.2% (95% CI, 46.3-64.0) in the combined group and 37.8% (95% CI, 33.7-41.9) in the PSF group. Operative time, blood loss, and hospitalization duration were lowest in the percutaneous PSF group, with means of 96.5 min (95% CI, 82.4-110.6), 83.8 ml (95% CI, 71.7-95.9), and 6.6 days (95% CI, 4.7-8.5), respectively. All techniques demonstrated a similar incidence of deep wound infections and implant-related complications. The pooled Oswestry Disability Index (ODI) scores were 17.2 (95% CI, 10.4-23.9) for the anterior group, 15.4 (95% CI, 11.5-19.3) for the combined group, and 13.4 (95% CI, 10.4-16.3) for the PSF group.

CONCLUSIONS

For patients with neurologically intact thoracolumbar burst fractures, with a kyphotic angle of less than 19.1° and an anterior vertebral body compression rate of less than 41.9%, short-segment pedicle screw fixation without fusion may be preferable option due to reduced intraoperative blood loss, shorter operation duration, shorter hospital stay, and better ODI scores at final follow-up. Routine anterior fusion has demonstrated high potential for kyphosis correction. The loss of the Cobb angle from surgery to final follow-up was nonsignificant only in patients who underwent combined surgery. When determining the surgical approach, surgeons should carefully weigh the advantages of anterior and combined fusion against the significantly higher surgical trauma compared to standard PSF.

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.

Percutaneous Screw Distraction for Anatomic Restoration: Case Series

BACKGROUND AND OBJECTIVES

Percutaneous pedicle screw fixation with distraction reduces morbidity after traumatic thoracolumbar burst fractures; however, there are substantial limitations, particularly for correction of kyphosis. The use of fixed-angle screws may offer improved anatomic restoration, facilitating greater postdistraction vertebral height restoration and spinal canal fragment reduction. We examined the radiographic results of distraction across fixed-angle screws immediately after surgery and in long-term follow-up.

METHODS

Demographic and clinical characteristics were captured for patients with traumatic thoracolumbar fractures undergoing percutaneous pedicle screw fixation by a single surgeon. Radiographic measurements were collected at predistraction, postdistraction, and long-term follow-up time points. Paired t-tests, Student's t-tests, Mann-Whitney U tests, and χ2 tests were used to assess data where appropriate.

RESULTS

The case series included 22 patients (77.3% male; mean age 42.0 ± 18.4 years). Hounsfield density consistent with osteopenia was seen in 13.6% of patients at the time of injury. Sporting injuries and motor vehicle accidents were common (both 31.8%). Most injuries occurred at L1 (45.5%). Upon long-term follow-up, the mean injured-level predistraction cross-sectional area improved from 2.1 to 2.9 cm2 (P < .01). Compared with the superadjacent level, the injured-level cross-sectional canal area improved by 28.6% (P < .01). Vertebral body index also improved significantly (18.8° mean change, P < .01). The mean bisegmental Cobb angle improved by 6.2° (P = .01), and injured vertebral body compression decreased by 22.4% (P < .01). Significant improvement in correction was achieved with experience, with final technique yielding superior cross-sectional area (P = .04) and compression ratios (P = .03).

CONCLUSION

Distraction across fixed-angle percutaneous screw instrumentation systems stabilizes traumatic thoracolumbar burst fractures, corrects deformity, and decompresses the spinal canal. Further comparative research is necessary to demonstrate whether outcomes are different between percutaneous instrumentation vs open fusion for thoracolumbar trauma.

Short-segment percutaneous fusion versus open posterior fusion with screw in the fractured vertebra for thoracolumbar junction burst vertebral fracture treatment

Objectives

The treatment options for thoracolumbar junction burst fractures remain a topic of controversy. Short-segment percutaneous fixation (SSPF) and short-segment open fixation including the fractured level (SSOFIFL) are both viable procedures for managing these fractures. At present, there is a lack of evidence in the literature demonstrating the absolute superiority of one treatment over the other. This study aimed to compare these two surgical strategies with a focus on radiological and clinical outcomes.

Materials and Methods

This retrospective case-control multicenter analysis involved patients with A3 and A4 vertebral fractures at the thoracolumbar junction (T11-L2) who underwent surgical treatment with either SSPF or SSOFIFL in the participating centers. Clinical outcomes were measured using the Oswestry Disability Index and visual analogue scale (VAS) both pre- and postoperatively. Radiological outcomes included kyphotic deformity (KD), anterior vertebral body height (AVBH), segmental kyphosis, and sagittal alignment parameters.

Results

A total of 156 patients were enrolled in the study, with 81 patients in Group A (SSPF) and 75 patients in Group B (SSOFIFL). Group B demonstrated better correction of KD (Group B: 3.4 ± 2.7° vs. Group A: 8.3 ± 3.2°, P = 0.003), AVBH, and sagittal alignment. A minor loss of correction was observed in Group B with respect to Group A (0.9 ± 1.7° vs 4.3° ± 2.1°, P = 0.043). Blood losses were lower in Group A (78 ± 15 min vs. 118 ± 23 min, P = 0.021) as well as during surgery (121.3 ± 34 mL vs. 210.2 ± 52 mL, P = 0.031), but the post-operative hemoglobin levels were comparable between the two groups.

Conclusion

SSOFIFL appears to show a major amount of KD correction and prevent loss of correction. This technique should be the preferred choice whenever possible. However, SSPF can be considered a valid alternative for damage control in polytrauma patients and fractures with low KD.

Hidden blood loss between percutaneous pedicle screw fixation and the mini-open Wiltse approach with pedicle screw fixation for neurologically intact thoracolumbar fractures: a retrospective study

BACKGROUND

The aim of this study was to determine the proportion of hidden blood loss (HBL) in patients treated with minimally invasive surgery, and to compare the HBL between patients treated with percutaneous pedicle screw fixation (PPSF) and the mini-open Wiltse approach with pedicle screw fixation (MWPSF).

METHODS

From January 2017 to January 2019, a total of 119 patients with thoracolumbar fractures were included in the analysis, of which 58 cases received PPSF and 61 cases received MWPSF. The clinical information and demographic results were collected and compared. And the HBL of the patients is calculated by the combination formulas of Nadler, Gross and Sehat.

RESULTS

Compared with the PPSF group, operation time of MWPSF is shorter. The fluoroscopy times are 13.6 ± 3.0 in PPSF group and 5.6 ± 1.6 in MWPSF group (p < 0.001). As shown in Table 3, the intraoperative blood loss in PPSF group is 31.9 ± 9.6 ml, which is significantly less than that in the MWPSF group (44.0 ± 14.9 ml). The HBL (445.7 ± 228.9 ml), and HBL% (91.2 ± 7.7%) of the PPSF group are significantly higher than that in the MWPSF group (P < 0.05). And the total blood loss (TBL) of the PPSF group (477.6 ± 228.8 ml) is also more than that in the MWPSF group (401.0 ± 171.3 ml).

CONCLUSIONS

Our results suggest that in the minimally invasive surgical treatment of thoracolumbar fractures, the perioperative HBL is much higher than visible blood loss (VBL). Although PPSF has less intraoperative blood loss, it has higher TBL and HBL than those of MWPSF. Compared with MWPSF, we should pay more attention to the postoperative anemia status of patients with thoracolumbar fractures undergoing PPSF surgery.

Efficacy of a novel percutaneous pedicle screw fixation and vertebral reconstruction versus the traditional open pedicle screw fixation in the treatment of single-level thoracolumbar fracture without neurologic deficit

Objective

The aim of this study was to compare the efficacy and safety of a novel percutaneous pedicle screw fixation and vertebral reconstruction (PPSR) vs. that of open pedicle screw fixation (OPSF) in the treatment of thoracolumbar fractures.

Methods

This retrospective study enrolled 153 patients who underwent PPSR and 176 patients who received OPSF. Periprocedural characteristics, radiographic parameters, and clinical outcomes were compared between the two groups.

Results

The operation duration was 93.843 ± 20.611 in PPSR group and 109.432 ± 11.903 in OPSF group; blood loss was 131.118 ± 23.673 in PPSR group and 442.163 ± 149.701 in OPSF group, incision length was 7.280 ± 1.289 in PPSR group and 14.527 ± 2.893 in OPSF group, postoperative stay was 8.732 ± 1.864 in PPSR group and 15.102 ± 2.117 in OPSF group, and total hospitalization costs were 59027.196 ± 8687.447 in PPSR group and 73144.432 ± 11747.567 in OPSF group. These results indicated that these parameters were significantly lower in PPSR compared with those in OPSF group. No significant difference was observed in the incidence of complications between the two groups. The radiographic parameters including height of the anterior vertebra, Cobb angle, and vertebral wedge angle were better in PPSR group than in OPSF group. Recovery rate of AVH was 0.449 ± 0.079 in PPSR group and 0.279 ± 0.088 in OPSF group. Analysis of clinical results revealed that during postoperative period, the VAS and ODI scores in PPSR group were lower than those in OPSF group.

Conclusions

Collectively, these results indicated that PPSR more effectively restored the height of anterior vertebra and alleviated local kyphosis compared with OPSF. Moreover, the VAS and ODI scores in PPSR group were better than those of OPSF group.

TREATMENT OF THORACOLUMBAR FRACTURES BY CLOSED REDUCTION VIA A PERCUTANEOUS SOLID PEDICLE SCREW

Objectives

Investigate the effect of closed reduction and per- cutaneous pedicle screw fixation in treating thoracolumbar fractures.

Methods

This retrospective study analyzed 12 cases of single-segment thoracolumbar spine fractures without spinal cord and nerve injury at our department from March 2016 to September 2017. Patients were treated with closed reduction, percutaneous reduction, and internal fixation with solid pedicle screws. The operation time, intraoperative blood loss, anterior vertebral body height ratio (AVHR), Cobb angle (CA) of sagittal kyphosis, and VAS of back pain were determined and statistically compared.

Results

The average operation time was 147.2 ± 45.6 min, and the average intraoperative bleeding was 67.8 ± 34.2 mL. All fractured vertebrae were completely reduced, their height was restored, and kyphosis was corrected. The average follow-up period was 10.6 ± 2.7 months, with significant improvements seen in the AVHR, CA of sagittal kyphosis, and VAS score (P < 0.01). One case had a broken rod after three months, and another had a postoperative infection. All the patients achieved bony healing.

Conclusion

The treatment of thoracolumbar fractures by closed reduction and internal fixation with a percutaneous solid pedicle screw is simple, effective, and economical. Level of Evidence VI; Therapeutic Study, Case Series .

The Mini-Open Wiltse Approach with Pedicle Screw Fixation Versus Percutaneous Pedicle Screw Fixation for Treatment of Neurologically Intact Thoracolumbar Fractures: A Systematic Review and Meta-Analysis

OBJECTIVE

The purpose of the present study was to compare the clinical outcomes and complications between the mini-open Wiltse approach with pedicle screw fixation (MWPSF) and percutaneous pedicle screw fixation (PPSF) in treating neurologically intact thoracolumbar fractures.

METHODS

We comprehensively searched PubMed, Web of Science, Embase, and the Cochrane Library and performed a systematic review and meta-analysis of all randomized controlled trials and retrospective comparative studies assessing these important indexes of the 2 methods using Review Manager, version 5.4. The clinical outcomes are presented as the risk difference for dichotomous outcomes and the mean difference for continuous outcomes with the 95% confidence intervals. Heterogeneity was assessed using the χ² test and I² statistics. The study was registered with PROSPERO (CRD 42021290078).

RESULTS

Two randomized controlled trials and six retrospective cohort studies were included in the present analysis. The percutaneous approach was associated with less intraoperative blood loss compared with the mini-open Wiltse approach. No significant differences were found in the total length of the incisions, hospitalization time, postoperative visual analog scale scores, postoperative Oswestry disability index, postoperative Cobb angle, postoperative Cobb angle correction, postoperative Cobb angle correction loss, accuracy rate of pedicle screw placement, and postoperative complications between MWPSF and PPSF. However, the incidence of facet joint violation was significantly higher in the PPSF group. In addition, MWPSF was associated with a shorter operative time, shorter intraoperative fluoroscopy time, lower hospitalization costs, better postoperative vertebral body angle and percentage of vertebral body height compared with PPSF.

CONCLUSIONS

Both MWPSF and PPSF are safe and effective treatments of neurologically intact thoracolumbar fractures. Nevertheless, our results have indicated that MWPSF might be the better choice, because it has a shorter learning curve and decreased facet joint violation, operative time, hospitalization costs, and radiation exposure. In addition, MWPSF was associated with better improvement of the postoperative vertebral body angle and percentage of vertebral body height.

Comparison of outcome between percutaneous pedicle screw fixation and the Mini-Open Wiltse Approach with pedicle screw fixation for neurologically intact thoracolumbar fractures: A retrospective study

BACKGROUND

The purpose of this study was to compare the outcome between percutaneous pedicle screw fixation (PPSF) and the mini-open Wiltse approach with pedicle screw fixation (MWPSF) for neurologically intact thoracolumbar fractures.

METHODS

From January 2017 to January 2019, ninety-four patients with neurologically intact thoracolumbar fractures were included in this study. In this retrospective study, forty-nine patients were operated with the PPSF and forty-five patients received MWPSF. The clinical information, surgery-related results and radiographic outcome were collected and compared between the two groups.

RESULTS

There was no significant difference between the two groups in total length of incisions, blood loss, post-operative hospitalization time, visual analog scale (VAS) score and Oswestry disability index (ODI) score. There was also no significant difference in the accuracy rate of pedicle screw placement between two groups; however, the facet joint violation (FJV) was significantly higher in the PPSF group. The atrophic area of multifidus muscle in the PPSF group is significantly larger than that in the MWPSF group and the operative time of MWPSF group was shorter than that in the PPSF group. Meanwhile, the PPSF group obtaining significantly more cumulative exposure to radiation (p < 0.001). The result of vertebral body angle (VBA), Cobb's angle and AVH rate in the MWPSF group were significantly better than those in the PPSF group at the last post-operative follow-up.

CONCLUSIONS

Both minimally invasive treatment techniques (PPSF and MWPSF) are safe and effective in treatment of neurologically intact thoracolumbar fractures. Nevertheless, our results indicate that MWPSF may be a better choice for neurologically intact thoracolumbar fractures, since it protects multifidus muscle, and decreases facet joint violation, operation time, as well as radiation exposure. In addition, MWPSF was associated with better reduction of kyphosis.

The Impact of D-Dimer on Postoperative Deep Vein Thrombosis in Patients with Thoracolumbar Fracture Caused by High-Energy Injuries

Objective

To investigate the dynamic variation of D-dimer and to evaluate the efficacy and accuracy of D-dimer level in patients with thoracolumbar fractures caused by high-energy injuries.

Methods

A total of 121 patients with thoracolumbar fractures caused by high-energy injuries were retrospectively identified and included in this study. There were 83 males and 38 females, with an average age of 48.6 ± 11.2 years. All patients were treated with either screw fixation surgery or decompression fixation surgery. The D-dimer levels were measured 1 day before surgery and on the first, third, and fifth days after surgery. The dynamic variation of D-dimer and the effects of risk factors on D-dimer levels were analysed. A receiver operating characteristic (ROC) curve analysis was performed and the appropriate D-dimer cut-off level was determined for deep vein thrombosis (DVT) screening.

Results

Due to a trough on the third day, D-dimer levels grew in an unsustainable manner following surgery (P < 0.001). Patients with the operation time >120 min (P = 0.009) and those with an American Spinal Injury Association (ASIA) score A-C (P < 0.001) had higher D-dimer levels. The area under the curve of D-dimer was the greatest on the third day. Applying stratified cut-off values did not change the sensitivity, specificity and negative predictive value in the group with an operation time >120 min, and ASIA score A-C group.

Conclusions

D-dimer levels elevated with fluctuation in patients with thoracolumbar fractures caused by high-energy injuries after surgery. Both operation time and ASIA score had an impact on D-dimer levels. Regarding DVT diagnoses, the diagnostic value of D-dimer was highest on the third day postoperatively, and stratified cut-off values by these two factors did not show better diagnostic efficacy compared with a collective one.

A novel bone cement screw system combined with vertebroplasty for the treatment of Kummell disease with bone deficiency at the vertebral anterior border: A minimum 3-year follow-up study

OBJECTIVES

When vertebroplasty is used to treat Kummell disease with bone deficiency at the vertebral anterior border, bone cement displacement often occurs intraoperatively or postoperatively. We designed and used a new bone cement screw system to avoid this serious complication. The purpose of this study was to evaluate the safety and effectiveness of this novel operation method through more than 3 years of follow-up.

PATIENTS AND METHODS

From January 2014 to August 2016, 27 patients suffering from single-segment Kummell disease with bone deficiency at the vertebral anterior border were treated by vertebroplasty combined with a novel bone cement screw. Bone cement was released into the diseased vertebrae through the screw to fully fill the intravertebral vacuum cleft. Screw fixation of bone cement can avoid intraoperatively or postoperatively displacement. All patients received surgery involving a unilateral technique, and only one screw was implanted in each patient. The clinical efficacy was evaluated using Odom's criteria and statistical analysis of the vertebral body index (VBI), vertebral body angle (VBA), bisegmental Cobb angle (BCA), visual analogue scale (VAS), Oswestry disability index (ODI), and the results of the MOS 36-item short form health survey (SF-36).

RESULTS

The operation was completed successfully in 27 cases. The average operation time was 49.63 ± 10.82 min, and the average volume of cement injected was 4.70 ± 0.87 mL. The patients' preoperative VBI, VBA, BCA, VAS and ODI scores were 43.11 ± 5.94, 21.04 ± 2.55, 45.00 ± 6.26, 7.59 ± 0.84, and 79.85 ± 7.58, respectively. The postoperative measurements were 78.70 ± 2.55, 12.70 ± 2.11, 26.11 ± 4.73, 3.22 ± 0.93 and 50.04 ± 9.28, respectively. At the last follow-up, the measurements were 78.04 ± 2.30, 13.15 ± 2.38, 27.07 ± 4.87, 2.04 ± 0.65, and 22.85 ± 5.06, respectively. There was a significant difference between the preoperative and postoperative data, as well as the preoperative and the last follow-up data (P < 0.05). Comparing the results of SF-36 before operation and at the last follow-up revealed significant differences in physical function, role-physical, body pain, vitality, and social function (P < 0.05). However, there were no significant differences in general health, emotional function and mental health. Finally, 26 patients (96.3 %) had good to excellent clinical outcomes according to Odom's criteria.

CONCLUSIONS

This 3-year follow-up study shows that the novel bone cement screw system combined with vertebroplasty has a good short and medium-term therapeutic effect in patients with Kummell disease and bone deficiency at the vertebral anterior border, while its long-term efficacy is subject to further studies.