POSTERIOR KEYHOLE CORPECTOMY WITH PERCUTANEOUS PEDICLE SCREW STABILIZATION IN THE SURGICAL MANAGEMENT OF LUMBAR BURST FRACTURES

Minimally invasive spine surgeries for treatment of thoracolumbar fractures of spine: A systematic review

PURPOSE

Many minimally invasive surgical (MIS) techniques have been developed for instrumentation of spine. These MIS techniques restore stability, alignment while achieving return to function quite early as compared to open spine surgeries. The main aim of this review was to evaluate role, indications and complications of these MIS techniques in Thoracolumbar and Lumbar fractures.

METHODS

Pubmed search using key words such as"Percutaneous pedicle screw for Thoracolumbar fractures" and "Video Assisted Thoracoscopy, Thoracoscopic, VATS for thoracolumbar, Lumbar and Spine fractures" were used till July 2016 while doing literature search. Authors analyzed all the articles, which came after search; the articles relevant to the topic were selected and used for the study. Both prospective and retrospective case control studies and randomized control trials (RCT's) were included in this review. Case reports and reviews were excluded. Studies demonstrating use of MIS in cases other than spine trauma and studies with lack of clinical follow up were excluded from this review. Variables such as number of patients, operative time and complications were evaluated in each study.

RESULTS

After pubmed search, we found total 68 studies till July 2016 out of which eight studies were relevant for analysis of Video Assisted Thoracoscopy for thoracolumbar and lumbar fractures. Total 72 articles for Percutaneous pedicle screws in thoracolumbar and lumbar fractures were retrieved out of which percutaneous pedicle screws were analyzed in eleven studies and twelve studies involved comparison of percutaneous pedicle screws and conventional open techniques.

CONCLUSION

Role and Indications of the MIS techniques in spinal trauma are expanding quite rapidly. MIS techniques restore stability, alignment while achieving early return to function and lower infection rates as compared to open spine surgeries. In long term, they provide good kyphosis correction and stable fixation and fusion of spine. They are associated with long learning curve and technical challenges but with careful patient selection and in expert hands, MIS techniques may produce better results than open trauma spine surgeries.

Transforaminal endoscopy in lumbar burst fracture: A case report

RATIONALE

Lumbar burst fractures are frequent injury resulting from high-energy trauma, and the patients suffer from pain and the neurologic dysfunction. Although minimally invasive techniques have advanced rapidly, it was the first time to apply transforaminal endoscopic combined with percutaneous pedicle screw fixation to treatment of lumbar burst fractures.

PATIENT CONCERNS

A 33-year-old man underwent Magerl type A3.1 burst fracture at L2 and compression fractures at L3 due to falling from a height with severe lower back pain, sensory loss, and atony of the right leg.

DIAGNOSES

Burst fracture at L2, compression fractures at L3.

INTERVENTIONS

The patient was presented to 1-stage operation of percutaneous pedicle screw fixation at L1, L2, L3, and L4 instead of delayed posterior open surgery. At 1 week after injury, the 2-stage operation with a percutaneous transforaminal endoscopic was undertaken for decompression.

OUTCOMES

No matter the function of nerve and imaging findings, all got ideal recoveries in just 3 days after 2-stage operation. At the 3-month follow-up, there was no loss of sagittal plane alignment, and spinal cord compression was completely relieved. The patient regained near-full neurologic function postoperatively.

LESSONS

A minimally invasive surgery (ie, transforaminal endoscopic combined with percutaneous pedicle screw fixation) for the treatment of Magerl type A3.1 burst fracture at lumbar was feasible. In addition, the key to the recovery of neurological function is the complete and effective decompression of spinal.

Percutaneous Transpedicular Fixation: Technical tips and Pitfalls of Sextant and Pathfinder Systems

Study Design

The efficacy of the operative techniques, possible benefits as well as pitfalls and limitations of the techniques are discussed. Potential drawbacks are also detected.

Purpose

This study aims to report indications, techniques, and our experience with the use of the Sextant and PathFinder percutaneous transpedicular screw fixation systems.

Overview of Literature

Percutaneous pedicle screw insertion is a novel technique. Successful percutaneous placement of pedicle screws requires surgical skill and experience because of lack of anatomic surface landmarks. Fluoroscopy-guided percutaneous placement of pedicle screws is effective. Many systems are now available.

Methods

We conducted a prospective operative and postoperative analysis of 40 patients with absolute indication for thoracic or lumbar instability between January 2009 and June 2013. All procedures were performed with the Sextant (group A) and PathFinder (group B) systems under fluoroscopic guidance. Operative techniques are discussed and the results compared.

Results

Percutaneous transpedicular screw fixation minimizes the morbidity associated with open techniques without compromising the quality of fixation. A total of 190 screws were inserted. There was no additional morbidity. Postoperative computed tomography images and plain X-rays were analyzed. Reduction of visual analog scale scores of back pain was evident.

Conclusions

Fluoroscopy-guided percutaneous pedicular screws are feasible and can be safely done. Current systems allow multi-segmental fixation with significantly less difficulties. The described techniques have acceptable intra- and postoperative complication rates, and overall sufficient pain control with early mobilization of patients.

Posterior Cruciate Ligament Tibial Avulsion treated with Open Reduction and Internal Fixation

The optimal treatment for thoracolumbar fractures (TLF) without neurological deficit remains controversial. Majority of the systematic reviews and meta-analyses have evaluated open operative approaches but have yet to compare the outcomes of minimally invasive percutaneous pedicle fixation (MIPPF) versus non-operative treatment. A retrospective cohort study was performed to compare clinical and radiological outcomes between MIPPF and conservative groups for TLF AO Type A1 to Type B2 during a 2-year follow-up period. Pre-operative plain and CT films were evaluated and decision made for short segment (non-fusion) MIPPF. Patients who refused operation were treated conservatively with three months of body cast, brace, or corset. MIPPF group showed earlier Visual Analog Score(VAS) improvement at six months post-injury (0 vs 6.0- p<0.001), as well as better functional and radiological outcomes (p<0.050) at final follow-up. Progressions of regional kyphosis (RK) were noted in both groups but there was no significant difference within and between them(p>0.050). MIPPF as a method of internal bracing can be pursued in the treatment of TLF, with larger future cohorts and RCTs being called for to support and explore new findings.

Comparison of two-stage open versus percutaneous pedicle screw fixation in treating pyogenic spondylodiscitis

Background

Percutaneous pedicle screw instrumentation is a minimally invasive surgical technique; however, the effects of using percutaneous pedicle screw fixation in treating patients with spinal infections have not yet been well demonstrated. The aim of this study, therefore, was to determine whether percutaneous posterior pedicle screw instrumentation is superior to the traditional open approach in treating pyogenic spondylodiscitis.

Methods

We retrospectively reviewed data for 45 patients treated for pyogenic spondylodiscitis with anterior debridement and interbody fusion followed by a second-stage procedure involving either traditional open posterior pedicle screw fixation or percutaneous posterior pedicle screw fixation. Twenty patients underwent percutaneous fixation and 25 patients underwent open fixation. Demographic, operative, and perioperative data were collected and analyzed.

Results

The average operative time for the percutaneous procedure was 102.5 minutes, while the average time for the open procedure was 129 minutes. The average blood loss for the percutaneous patients was 89 ml versus a 344.8 ml average for the patients in the open group. Patients who underwent the minimally invasive surgery had lower visual analogue scale scores and required significantly less analgesia afterwards. After two years of follow-up, neither recurrent infection nor intraoperative complications, such as wound infection or screw loosening, were found in the percutaneous group. Moreover, there was no significant difference in outcome between the two groups in terms of Oswestry Disability Index scores.

Conclusions

Anterior debridement and interbody fusion with bone grafting followed by minimally invasive percutaneous posterior instrumentation is an alternative treatment for pyogenic spondylodiscitis which can result in less intraoperative blood loss, shorter operative time, and reduced postoperative pain with no adverse effect on infection control.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-443) contains supplementary material, which is available to authorized users.

Percutaneous pedicle screw placement in the thoracic spine: A cadaveric study

STUDY DESIGN

A cadaveric study to determine the accuracy of percutaneous screw placement in the thoracic spine using standard fluoroscopic guidance.

SUMMARY OF BACKGROUND DATA

While use of percutaneous pedicle screws in the lumbar spine has increased rapidly, its acceptance in the thoracic spine has been slower. As indications for pedicle screw fixation increase in the thoracic spine so will the need to perform accurate and safe placement of percutaneous screws with or without image navigation. To date, no study has determined the accuracy of percutaneous thoracic pedicle screw placement without use of stereotactic imaging guidance.

MATERIALS AND METHODS

Eighty-six thoracic pedicle screw placements were performed in four cadaveric thoracic spines from T1 to T12. At each level, Ferguson anterior-posterior fluoroscopy was used to localize the pedicle and define the entry point. Screw placement was attempted unless the borders of the pedicle could not be delineated solely using intraoperative fluoroscopic guidance. The cadavers were assessed using pre- and postprocedural computed tomography (CT) scans as well as dissected and visually inspected in order to determine the medial breach rate.

RESULTS

Ninety pedicles were attempted and 86 screws were placed. CT analysis of screw placement accuracy revealed that only one screw (1.2%) breached the medial aspect of the pedicle by more than 2 mm. A total of four screws (4.7%) were found to have breached medially by visual inspection (three Grade 1 and one Grade 2). One (1.2%) lateral breach was greater than 2 mm and no screw violated the neural foramen. The correlation coefficient of pedicle screw violations and pedicle diameter was found to be 0.96.

CONCLUSIONS

This cadaveric study shows that percutaneous pedicle screw placement can be performed in the thoracic spine without a significant increase in the pedicle breach rate as compared with standard open techniques. A small percentage (4.4%) of pedicles, especially high in the thoracic spine, may not be safely visualized.

Percutaneous fixation of thoracolumbar fractures: current concepts

Numerous improvements in minimally invasive spine surgery (MISS) have been made during the last decade. MISS in thoracolumbar spine trauma management must achieve the same results as conventional treatment but with less morbidity. The increased use of MISS technologies in spine trauma has been correlated to the availability of more versatile instrumentation, which makes the fixation of all thoracic and lumbar levels possible. Balloon-assisted techniques have been used to support the anterior column in a stand-alone manner or in combination with open or percutaneous pedicle screw fixation. Fluoroscopy-assisted pedicle screw insertion is associated with less pedicle wall violation when compared to open surgery, but with increased radiation exposure for the surgeon and patient. Surgeons must be aware of this issue and new technologies are available to decrease irradiation. The advantages of percutaneous pedicle screw fixation relative to open surgery are discussed: preservation of posterior musculature, less blood loss, shorter operative time, lower infection risk, less postoperative pain, shorter rehabilitation time as well as shorter hospital stay. Limitations of percutaneous fixation include the inability to achieve direct spinal canal decompression and not having the option to perform a fusion. Nevertheless, these limitations can be addressed by combining MISS with open techniques. Indications for percutaneous spine fixation alone or in combination with MISS or open techniques are discussed based on the AO classification. The benefits of percutaneous spinal fixation for unstable spine fractures in polytrauma patients are also discussed. Posterior instrumentation can be easily removed after bone union to allow young patients to regain their mobility. Large well-controlled prospective studies are needed to draw up guidelines for less invasive procedures in spine trauma. In the future, development of new technologies can expand the scope of indications and treatment possibilities using MISS techniques in spine trauma.

Minimally invasive thoracolumbar corpectomy and reconstruction

Minimally invasive surgical approaches have been advocated to approach ventrolateral thoracolumbar pathology. This article describes our technique for performing minimally invasive surgical thoracolumbar corpectomy and reconstruction. Twenty-five consecutive patients at a single institution were treated between 2006 and 2010 for a variety of diagnoses including tumors, infections, and trauma. Treatment variables, including operating time, estimated blood loss, number of levels treated, and complications, were collected, as were visual analog scale (VAS) scores for pain.Surgical times (mean, 188.5 minutes) and blood loss (mean, 423 mL) reflect a significant improvement over standard open corpectomy procedures. More than 60% of patients did not need blood products after the corpectomy procedure because substantial blood loss encountered during an open exposure to the spine was obviated. Similarly, operative times and anesthetic load was minimal enough for ≥80% of our patients to be extubated immediately after the corpectomy procedure. A 62% decrease in self-reported VAS scores was observed. No wound complications or radiographic evidence of implant subsidence or failure were observed at last follow-up.The advantages of the minimally invasive approach for corpectomies of the thoracolumbar spine were that an access surgeon was not needed; tissue dissection and surgical exposure were reduced, improving VAS scores postoperatively; and blood loss and operative times were minimized, preventing hemodynamic deterioration in these complex cases. Corpectomies may be performed in this fashion safely, with excellent pain relief and without many of the morbidities and difficulties associated with conventional open procedures.

Advances in the management of spinal cord and spinal column injuries

Spinal cord injury (SCI) is a significant public problem, with recent data suggesting that over 1 million people in the U.S.A. alone are affected by paralysis resulting from SCI. Recent advances in prehospital care have improved survival as well as reduced incidence and severity of SCI following spine trauma. Furthermore, increased understanding of the secondary mechanisms of injury following SCI has provided improvements in critical care and acute management in patients suffering from SCI, thus limiting morbidity following injury. In addition, improved technology and biomechanical understanding of the mechanisms of spine trauma have allowed further advances in available techniques for spinal decompression and stabilization. In this chapter we review the most recent data and salient literature regarding SCI and address current controversies, including the use of pharmacological adjuncts in the setting of acute SCI. We will also attempt to provide a reader with basic understanding of the classifications of SCI and spinal column injury. Finally, we review advances in spinal column stabilization including improvements in instrumented fusion and minimally invasive surgery.

Outcome of thoracolumbar burst fractures treated with indirect reduction and fixation without fusion

Indirect reduction and fixation is not a new method in the treatment of thoracolumbar burst fractures but the indications and efficacy are controversial. The current study was designed to evaluate the efficacy of indirect reduction without fusion. Sixty-four patients with single-level thoracolumbar burst fractures were identified and treated by this method. The outcome was analyzed by the Frankel method, radiographic measurements, and at the latest follow-up the Denis Pain Scale and Oswestry disability index (ODI) were used to assess back pain and functional outcome. The average follow-up period was 40.1 months. The anterior vertebral height (AVH) was corrected from 55.2 to 97.2% post-operatively and decreased to 88.9% after hardware removal. The posterior vertebral height (PVH) increased from 88.9 to 99.1% post-operatively and decreased slightly after implant removal to 93.7%. The average pre-operative canal compromise was 41.4%, which decreased to 13.7% at last follow-up. Except for three paraplegic patients, neurological status significantly improved or stayed normal in the study's remaining 61 patients. Fifty-two of sixty-four patients had excellent or good function. At latest follow-up the average ODI score was 16.7 and the Denis pain score improved in all patients but one. Indirect reduction and fixation can not only restore vertebral column structure but also, more importantly, patients' functional outcome.

Image guided percutaneous trans-pedicular screw fixation of the thoracic spine. A clinical evaluation

OBJECTIVE

We report our preliminary experience with a minimally invasive image guided percutaneous trans-pedicular fixation technique of the thoracic spine in patients with significant co-morbidity. This study aims to demonstrate the feasibility and efficacy of the presented operative technique as well as to detect potential drawbacks.

METHOD

A navigated percutaneous application of trans-pedicular screws was performed in 14 patients with radiological validated instability of the thoracic spine and significant medical co-morbidity. Due to poor bone quality, vertebroplasty of the affected levels had to be performed in nine patients. The levels involved were (T9-12) in ten patients, the middle (T5-8) in two patients and the upper thoracic (T1-4) segments in two others. VAS scores for local back pain were used to assess clinical outcome.

RESULTS

A total of 56 screws were inserted. There was no additional morbidity associated with the procedure. Post-operative CT scans and plain X-rays were obtained in all patients. In 2 (3.5%) medial penetration of the pedicle border occurred without neurological sequelae for the patient. Reduction of VAS scores regarding back pain during the first post-operative week was noted. Follow up ranged between 6 months and 12 months.

CONCLUSION

Navigated percutaneous trans-pedicular fixation of the thoracic spine is feasible and can be performed safely in patients where open surgery is of significant risk. Pre-operative planning is essential in order to avoid intra-operative complications with the instrumentation system.

Minimally invasive spine stabilisation with long implants

Originally aimed at treating degenerative syndromes of the lumbar spine, percutaneous minimally invasive posterior fixation is nowadays even more frequently used to treat some thoracolumbar fractures. According to the modern principles of saving segment of motion, a short implant (one level above and one level below the injured vertebra) is generally used to stabilise the injured spine. Although the authors generally use a short percutaneous fixation in treating thoracolumbar fractures with good results, they observed some cases in which the high fragmentation of the vertebral body and the presence of other associated diseases (co-morbidities) did not recommend the use of a short construct. The authors identified nine cases, in which a long implant (two levels above and two levels below the injured vertebra) was performed by a percutaneous minimally invasive approach. Seven patients (five males/two females) were affected by thoracolumbar fractures. T12 vertebra was involved in three cases, L1 in two cases, T10 and L2 in one case, respectively. Two fractures were classified as type A 3.1, two as A 3.2, two as A 3.3 and one as B 2.3, according to Magerl. In the present series, there were also two patients affected by a severe osteolysis of the spine (T9 and T12) due to tumoral localisation. All patients operated on with long instrumentation had a good outcome with prompt and uneventful clinical recovery. At the 1-year follow-up, all patients except one, who died 11 months after the operation, did not show any radiologic signs of mobilisation or failure of the implant. Based on the results of the present series, the long percutaneous fixation seems to represent an effective and safe system to treat particular cases of vertebral lesions. In conclusion, the authors believe that a long implant might be an alternative surgical method compared to more aggressive or demanding procedures, which in a few patients could represent an overtreatment.