Thoracolumbar Burst Fractures: A Systematic Review and Meta-Analysis on the Anterior and Posterior Approaches

[Current surgical treatment concepts for traumatic thoracic and lumbar vertebral fractures in adults with good bone quality]

The surgical treatment of traumatic vertebral body fractures in patients with good bone quality is controversially discussed. The data situation is unclear and only of limited help due to mainly insufficient evidence. The surgical measures include an axially aligned reduction and an osteosynthesis which is stable under load so that immediate mobilization of the patient is possible. This requires anatomical restoration of the alignment and the biomechanical challenge of fracture healing or fusion in the correct position without relevant loss of reduction must be taken into account. The aim should be the lowest possible loss of function. In the case of existing or impending neurological deficits it is crucial to prevent deterioration of the neurological situation and to achieve the prerequisites for recovery. Posterior stabilization primarily plays the decisive role in the operative treatment. If possible, this should be a minimally invasive procedure and over short distances. For bisegmental treatment monoaxial screws and the use of index screws improve construct stability. In addition, stable cobalt rods should be used as 5mm longitudinal support. Special minimally invasive reduction instruments are helpful in restoring the sagittal and coronal relationships. The indications for an additional ventral column depend on the rigidity of the posterior stabilization, the extent of the injury of the anterior column and the intervertebral disc. Anterior fusion can often be delayed or avoided altogether, depending on the course with corresponding clinical signs.

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.

Analysis of influencing factors for complications of anterior thoracolumbar tuberculosis surgery in adults

This study analyzes the risk factors related to the complications of anterior thoracolumbar tuberculosis in adults and to provide clinical reference. A total of 98 adult patients with thoracolumbar tuberculosis undergoing anterior surgery in our hospital from February 2020 to December 2023 were selected, and the clinical data and postoperative complications were collected. The clinical characteristics were analyzed, and the risk factors related to surgical complications were analyzed by univariate analysis and multi-factor logistic regression model. A total of 54 patients had 75 postoperative complications of different degrees. Univariate analysis showed that patient age, preoperative hemoglobin (Hb) level, bone graft fusion method, intraoperative blood loss, and postoperative neurological function [Asian neurological function classification] were correlated with the occurrence of postoperative complications (P < .05). Multivariate Logistic regression analysis showed that age over 60 years old, preoperative Hb < 100 g/L, blood loss ≥ 800 mL, bone graft fusion method were independent risk factors for anterior postoperative complications of thoracolumbar tuberculosis (P < .05). The independent risk factors for surgical complications of anterior thoracolumbar tuberculosis were age over 60 years old, preoperative Hb < 100 g/L, blood loss ≥ 800 mL, titanium cage by bone graft fusion. Controlling these variable factors before operation can reduce the incidence of postoperative complications.

Anterior, Posterior and Anterior-Posterior Approaches for the Treatment of Thoracolumbar Burst Fractures: A Network Meta-Analysis of Randomized Controlled Trials

PURPOSE

To compare the clinical and radiological results of the anterior approach versus the posterior approach versus the anterior-posterior approach for the treatment of thoracolumbar burst fractures.

METHODS

The network meta-analysis was performed in accordance with the PRISMA Statement. Electronic searches of PubMed and Embase were conducted up to June 22, 2023, for relevant randomized controlled trials. STATA13.0 was used to perform network meta-analysis. p < .05 was considered significant.

RESULTS

Nine RCTs with a total of 550 patients receiving surgical treatment in at least two of the three approaches, including anterior, posterior and anterior-posterior approaches, were included. The surgical duration and intraoperative bleeding volume in the posterior approach were significantly lower than those in the anterior (SMD, -1.72; 95% CI, -2.82, -0.62) and anterior-posterior approaches (SMD, 3.33; 95% CI, 1.65, 5.00). The surgical duration in the anterior approach was significantly lower than that in the anterior-posterior approach (SMD, 1.61; 95% CI, 0.12, 3.10). The Cobb angle in the anterior-posterior approach was significantly lower than that in the anterior approach (MD, -4.83; 95% CI, -9.60, -0.05). The VAS score in the posterior approach was significantly higher than that in the anterior approach (MD, 0.85; 95% CI, 0.55, 1.16) and anterior-posterior approach (MD, -0.84; 95% CI, -1.12, -0.55). No significant difference was identified among the three surgical approaches in implant failure rate and infection rate.

CONCLUSION

All three approaches were safe approaches with advantages and disadvantages. The selection of surgical approaches for the treatment of thoracolumbar burst fractures may be individualized.

Minimally-invasive lateral thoracic and lumbar interbody fusion (LLIF) with expandable interbody cages - Considerations, complications & outcomes

Introduction

Reports about lateral lumbar or thoracic interbody fusion (LLIF) using expandable interbody spacers are sparse.

Research question

To report our experience with the use of expandable spacers for LLIF.

Material and methods

We reviewed all consecutive LLIF patients with use of an expandable titanium interbody implant (ELSA® Expandable Integrated LLIF Spacer, Globus Medical Inc, PA (USA)) between September 2018 and January 2024.

Results

We identified 503 patients, in which we performed LLIF at 732 levels. In 63 patients (12.5%) and 70 levels (9.6%) an expandable spacer was used. The mean age was 61.4 years, 57.1% were females. LLIF was performed between T11/12 - L4/5 in the setting of fusion procedures (mono-/bisegmental (20; 28.6%), 3-7 segments (29; 41.4%); >7 segments (21; 30.0%)), of which 21 (33.3%), 20 (31.8%) and 22 (34.9%) were for traumatic, deformity/revision and other diagnoses. Surgery included release of the anterior longitudinal ligament in 30 cases (42.9%). Intraoperative adverse events (AEs) were noted in 2 (3.2%), postoperative AEs in 27 (42.9%) at discharge, 17 (27.0%) at 3 months and 14 (22.2%) at 12 months. Segmental sagittal Cobb angle changed from 1.3° (preoperative) to 13.0° at discharge (p < 0.001), 12.7° at 3 months (p < 0.001) and 13.3° at 12 months (p < 0.001). Functional outcome was excellent/good in 43 (68.3%; 5 missing) at 3 months and in 37 (58.7%; 10 missing) at 12 months.

Discussion and conclusion

The use of LLIF with an expandable spacer was safe, promoted solid fusion and enabled powerful correction of sagittal segmental Cobb angle, which was maintained during follow-up.

Posterior Pedicle Screw Fixation With Indirect Decompression Versus Direct Decompression in Treating Thoracolumbar Burst Fracture: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare the safety and efficacy between posterior pedicle screw fixation with direct versus indirect decompression in treating patients with thoracolumbar burst fracture.

METHODS

This study was conducted on the basis of PRISMA statement. We systematically searched the PubMed and Embase databases up to July 3, 2023. Relevant studies comparing indirect decompression and direct decompression were recruited. Weighted mean differences (WMDs), odds ratios (ORs) and 95% confidence intervals (CIs) were analyzed for continuous and dichotomous data, respectively. P < 0.05 was considered statistically significant.

RESULTS

The operation time (WMD: -37.14, 95% CI: [-42.64, 31.64], P < 0.00001, I2 = 0%) and intraoperative blood loss (WMD: -316.82, 95% CI: [-469.80, -163.85], P < 0.0001, I2 = 99%) of indirect decompression group were significantly lower. Percentage of anterior vertebral body height (WMD: 3.98, 95% CI: [2.36, 5.60], P < 0.00001, I2 = 32%) and encroachment rate of the spinal canal (WMD: 1.48, 95% CI: [0.56, 2.40], P = 0.002, I2 = 35%) of indirect decompression group were significantly higher. No statistical difference was identified in grades of neurologic recovery and Cobb angle.

CONCLUSIONS

Posterior pedicle screw fixation with indirect decompression was safe and effective for thoracolumbar burst fracture with or without neurologic deficits when posterior longitudinal ligament was intact.

Osteoporotic Burst Fracture in a Young Male Adult as First Presentation of a Rare PLS3 Mutation: A Case Report

Low-impact spinal fractures in young patients are rare and should raise suspicion of an underlying condition, as these injuries are typically the result of high-energy trauma. We describe a case of a young male patient who sustained a burst fracture of the first lumbar vertebra (L1) following low-energy trauma. The patient underwent percutaneous posterior spinal instrumentation, yet the poor bone quality detected intraoperatively prompted further diagnostic evaluation. Subsequently, low bone mineral density (BMD) was detected, and a rare plastine-3 (PLS3) gene mutation was revealed in the genetic analysis. The patient was initiated on teriparatide therapy after the discovery of osteoporosis postoperatively. It is, therefore, imperative to investigate all young patients with low-energy spinal fractures preoperatively to discover the underlying pathology promptly.

The efficacy of different segments fixation for treatment thoracolumbar fractures: A Bayesian network meta-analysis

BACKGROUND

We did this network meta-analysis to comprehensively compare the efficacy of different segments [intermediate segment (IS), short segment (SS) and long segment (LS)] in the fixation of thoracolumbar fractures.

METHODS

We searched studies from inception until January 20, 2023 through PubMed, Embase, Web of Science, and the Cochrane Library. All studies comparing different segments in the fixation of thoracolumbar fractures were included in this meta-analysis. Outcomes were anterior vertebral height ratio (AVHR), sagittal Cobb angle (SCA), visual analogue scale score, and implant failure rate. This network meta-analysis was performed by R software with gemtc package.

RESULTS

Finally, a total of 22 studies were finally included in this network meta-analysis. IS (WMD 2.43, 95% CrI 2.04-2.91) was more effective than SS in terms of the AVHR, and the difference was statistically significant. IS was more effective than LS in reducing SCA (WMD -2.87, 95% CrI -3.79 to -1.96) with statistically significant. Compared with SS, IS significantly reduced the SCA with statistically significant (WMD -2.52, 95% CrI -3.31 to -1.72). IS (WMD -2.87, 95% CrI -3.78 to -1.96) was more effective than LS, and the difference was statistically significant. Moreover, IS (WMD -2.52, 95% CrI -3.31 to -1.72) was more effective than SS, and the difference was statistically significant.

CONCLUSION

IS was associated with a significant reduction in SCA, implant failure rate, and visual analogue scale compared to SS and LS, while having the most favorable impact on AVHR among all the treatments assessed.

Endoscopic Decompression Combined with Percutaneous Pedicle Screw Fixation for Treating Thoracolumbar Burst Fractures with Neurological Deficits: Technical Note and Early Outcomes

OBJECTIVE

The aim of this study is to introduce surgical technique of endoscopic decompression combined with percutaneous pedicle screw fixation (PPSF) for thoracolumbar burst fractures (TLBFs) with neurological deficits and evaluate its efficacy.

METHODS

A total of 32 patients with TLBFs and neurological deficits who were treated by endoscopic decompression combined with PPSF from June 2018 to August 2019 were included in this study. The effect of decompression was analyzed using canal encroachment ratio, while deformity correction was assessed using the sagittal Cobb angle and the percentage of anterior vertebral height. We also analyzed other clinical outcomes such as visual analog scale, Oswestry Disability Index, and American Spinal Injury Association impairment scale dose.

RESULTS

The patients were followed up for an average of 16 months. Our data showed that the patients' mean operation time was 153.75 minutes, the mean intraoperative blood loss was 48.84 mL, and the mean incision length was 7.78 cm. The canal encroachment ratio decreased from 55.91% ± 12.27% to 12.44% ± 3.91% (P < 0.05), sagittal Cobb angle decreased from 17.09° ± 5.46° to 5.72° ± 3.68° (P < 0.05), while the percentage of anterior vertebral height increased from 53.72% ± 8.99% to 83.22% ± 8.21% (P < 0.05). In addition, there was a significant improvement in the visual analog scale score, Oswestry Disability Index, and American Spinal Injury Association impairment scale classification (P < 0.05). Screw fracture occurred only in one patient during follow-up.

CONCLUSIONS

Endoscopic decompression combined with PPSF in the treatment of TLBFs with neurological deficits is safe and effective, which is a new minimally invasive method for the treatment of such diseases.