Implant removal after percutaneous short segment fixation for thoracolumbar burst fracture : does it preserve motion?

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.

Risk factors for kyphosis recurrence after implant removal in percutaneous osteosynthesis for post-traumatic thoracolumbar fracture

PURPOSE

Short-segment minimally invasive percutaneous spinal osteosynthesis has now become one of the treatments of choice to treat thoracolumbar fractures. The question of implant removal once the fracture has healed is still a matter of debate since this procedure can be associated with loss of sagittal correction. Therefore, we analyzed risk factors for kyphosis recurrence after spinal implants removal in patients treated with short-segment minimally invasive percutaneous spinal instrumentation for a thoracolumbar fracture.

METHODS

A total of 32 patients who underwent implant removal in percutaneous osteosynthesis for post-traumatic thoracolumbar fracture were enrolled in our study. Patient's medical record, operative report and imaging examinations carried out at the trauma and during the follow-up were analyzed.

RESULTS

Every patient experienced fracture union. Vertebral kyphotic angle (VKA) and Cobb angle (CA) improved significantly after stabilization surgery. VKA, CA, upper disk kyphotic angle (UDKA) and lower disk kyphotic angle (LDKA) significantly gradually decreased during follow-up. Traumatic disk injury (p: 0.001), younger age (p: 0.01), canal compromise (p: 0.04) and importance of surgical correction (p < 0.001) were significantly associated with kyphosis recurrence after implant removal. Anterior body augmentation did not affect loss of correction (CA and VKA) during the follow-up period (p: 0.57).

CONCLUSION

Despite correction of the fracture after stabilization, we observed a progressive loss of correction over time appearing even before implant removal. Particular attention should be paid to post-traumatic disk damage or canal invasion, to young patients and to surgical overcorrection of the traumatic kyphosis.

A Rapid and Safe Minimally Invasive Procedure for Percutaneous Pedicle Screw Removal: A Case-Control Study and Technical Description

Purpose

Percutaneous pedicle screw fixation is a common minimally invasive treatment for traumatic thoracolumbar and lumbar fractures; however, research on hardware removal after successful healing is limited. We aimed to introduce a rapid, safe, minimally invasive, and cost-effective method for percutaneous pedicle screw removal.

Patients and Methods

We conducted a retrospective analysis of demographic (age, sex, body mass index, alcohol use, and current smoking), clinical (hypertension and diabetes mellitus), surgical (affected levels, number of screws, time of surgery, and blood loss), and treatment cost characteristics of 92 patients who had undergone percutaneous pedicle screw removal between May 2016 and February 2023. The first 57 patients underwent the conventional method, and the remaining 35 underwent the modified method. Independent-sample t-tests and chi-square tests were used to compare continuous and categorical variables, respectively, between the two groups.

Results

No significant differences were observed in the demographic parameters, complications, or affected levels between the groups. However, the average surgical time (P=0.000) was significantly shorter, and the average blood loss volume (P=0.002) and total cost (P=0.000) were significantly lower in the modified group than in the conventional group.

Conclusion

Compared with the conventional method, our modified method can shorten the surgical time, reduce blood loss, and reduce the total cost of treatment. It is a quick and safe minimally invasive method that does not require additional surgical instruments and is suitable for implementation in primary hospitals.

Usefulness of Percutaneous Pedicle Screw Fixation for Treatment of Lower Lumbar Burst (A3-A4) Fractures: Comparative Study with Thoracolumbar Junction Fractures

Background

Percutaneous pedicle screw fixation (PPSF) without fusion has been recently recommended in the treatment of thoracolumbar fracture to reduce the adverse effects associated with the conventional open approaches and to restore range of motion. However, those studies report on the thoracolumbar junction, and there is no report on lower lumbar fracture.

Purpose

To assess effectiveness of PPSF without fusion for treating lower lumbar burst (A3 and A4) fractures.

Methods

A retrospective analysis was made to evaluate consecutive 50 patients with AO type A3 and A4 thoracolumbar fracture underwent PPSF. Patients were divided into a thoracolumbar junction (TLJ) group (T11-L2) and lower lumbar (LL) group (L3-5). The following items were measured and compared between the two groups. Vertebral height and consolidation, retropulsed fragment, sagittal curve and fixation failure were assessed with certain interval regularly.

Results

The average height at pre- and post-reduction were 56.2% (36.2-74.3), 95.3% (84.2-98.3) in TLJ group and 65.7% (45.7-86.2), 91% (73.1-100) in LL group. The average canal area occupancy rate at pre- and post-reduction were 46.1% (37.4%-67.5%), 38.1% (31.3%-40.8%) in TLJ group and 40.4% (15.0-65.7), 19.3% (9.4-26.6) in LL group. Consolidation was completed within 12 months after surgery in both groups. There was no significant difference between two groups in clinical and radiographic parameters except cobb angle loss.

Conclusion

Patients with lower lumbar fracture can be effectively managed with PPSF without fusion. PPSF following the implant removal can restore the movement of the lower lumbar spine, which is essential for daily life.

The Necessity of Implant Removal after Fixation of Thoracolumbar Burst Fractures—A Systematic Review

Background: Thoracolumbar burst fractures are a common traumatic vertebral fracture in the spine, and pedicle screw fixation has been widely performed as a safe and effective procedure. However, after the stabilization of the thoracolumbar burst fractures, whether or not to remove the pedicle screw implant remains controversial. This review aimed to assess the benefits and risks of pedicle screw instrument removal after fixation of thoracolumbar burst fractures. Methods: Data sources, including PubMed, EMBASE, Cochrane Library, Web of Science, Google Scholar, and Clinical trials.gov, were comprehensively searched. All types of human studies that reported the benefits and risks of implant removal after thoracolumbar burst fractures, were selected for inclusion. Clinical outcomes after implant removal were collected for further evaluation. Results: A total of 4051 papers were retrieved, of which 35 studies were eligible for inclusion in the review, including four case reports, four case series, and 27 observational studies. The possible risks of pedicle screw removal after fixation of thoracolumbar burst fractures include the progression of the kyphotic deformity and surgical complications (e.g., surgical site infection, neurovascular injury, worsening pain, revision surgery), while the potential benefits of pedicle screw removal mainly include improved segmental range of motion and alleviated pain and disability. Therefore, the potential benefits and possible risks should be weighed to support patient-specific clinical decision-making about the removal of pedicle screws after the successful fusion of thoracolumbar burst fractures. Conclusions: There was conflicting evidence regarding the benefits and harms of implant removal after successful fixation of thoracolumbar burst fractures, and the current literature does not support the general recommendation for removal of the pedicle screw instruments, which may expose the patients to unnecessary complications and costs. Both surgeons and patients should be aware of the indications and have appropriate expectations of the benefits and risks of implant removal. The decision to remove the implant or not should be made individually and cautiously by the surgeon in consultation with the patient. Further studies are warranted to clarify this issue. Level of evidence: level 1.

Removal or retention of minimally invasive screws in thoracolumbar fractures? Systematic review and case-control study

BACKGROUND

There is uncertainty regarding delayed removal versus retention of minimally invasive screws following percutaneous fixation for thoracolumbar fractures. We conducted a systematic review and case-control study to test the hypothesis that delayed metalwork removal following percutaneous fixation for thoracolumbar fractures improves outcome.

METHODS

A systematic review was performed in accordance with the PRISMA guidelines. Our case-control study retrospectively evaluated 55 consecutive patients with thoracolumbar fractures who underwent percutaneous fixation in a single unit: 19 with metalwork retained (controls) and 36 with metalwork removed. Outcomes were the Oswestry Disability Index (ODI), a supplemental questionnaire, and complications.

RESULTS

The systematic review evaluated nine articles. Back pain was reduced in most patients after metalwork removal. One study found no difference in the ODI after versus before metalwork removal, whereas three studies reported significant improvement. Six studies noted no significant alterations in radiological markers of stability after metalwork removal. Mean complication rate was 1.7% (0-6.7). Complications were superficial wound infection, screw breakage at the time of removal, pull-out screw, and a broken rod. In the case-control study, both groups were well matched. For metalwork removal, mean operative time was 69.5 min (range 30-120) and length of stay was 1.3 days (0-4). After metalwork removal, 24 (68.6%) patients felt better, 10 (28.6%) the same and one felt worse. Two patients had superficial hematomas, one had a superficial wound infection, and none required re-operation. Metalwork removal was a significant predictor of return to work or baseline household duties (odds ratio 5.0 [1.4-18.9]). The ODI was not different between groups.

CONCLUSIONS

The findings of both the systematic review and our case-control study suggest that removal of metalwork following percutaneous fixation of thoracolumbar fractures is safe and is associated with improved outcome in most patients.

Is It Necessary to Remove the Implants After Fixation of Thoracolumbar and Lumbar Burst Fractures Without Fusion? A Retrospective Cohort Study of Elderly Patients

Objective

Fractures of the thoracolumbar spine are the most common fractures of the spinal column. This retrospective cohort study aimed to determine whether it is necessary to remove implants of patients aged over 65 years after the fixation of thoracolumbar and lumbar burst fractures without fusion.

Methods

This retrospective cohort study included 107 consecutive patients aged ≥65 years without neurological deficits, who underwent non-fusion short posterior segmental fixation for thoracolumbar or lumbar burst fractures. Outcome measures included the visual analog score (VAS), Oswestry Disability Index (ODI), residual symptoms, complications, and imaging parameters. Patients were divided into groups A (underwent implant removal) and B (implant retention) and were examined clinically at 1, 3, 6, and 12 months postoperatively and annually thereafter, with a final follow-up at 48.5 months.

Results

Overall, 96 patients with a mean age of 69.4 (range, 65–77) years were analyzed. At the latest follow-up, no significant differences were observed in functional outcomes and radiological parameters between both groups, except in the local motion range (LMR) (P = 0.006). Similarly, between preimplant removal and the latest follow-up in group A, significant differences were found only in LMR (P < 0.001). Two patients experienced screw breakage without clinical symptoms. Significant differences were only found in operation time, blood loss, ODI, and fracture type between minimally invasive group and open group.

Conclusions

Similar radiological and functional outcomes were observed in elderly patients, regardless of implant removal. Implant removal may not be necessary after weighing the risks and benefits for elderly patients. Patients should be informed about the possibility of implant breakage and accelerating degeneration of adjacent segments in advance.

Implant Removal Versus Implant Retention Following Posterior Surgical Stabilization of Thoracolumbar Burst Fractures: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVES

To compare biomechanical and functional outcomes between implant removal and implant retention following posterior surgical fixation of thoracolumbar burst fractures.

METHODS

A search of the MEDLINE, EMBASE, Google Scholar and Cochrane Databases was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Of the 751 articles initially retrieved, 13 published articles pooling 673 patients were included. Meta-analysis revealed there was a statistically significant improvement in sagittal Cobb Angle by 16.48 degrees (9.13-23.83, p < 0.01) after surgical stabilization of thoracolumbar burst fractures. This correction decremented to 9.68 degrees (2.02-17.35, p < 0.01) but remained significant at the time of implant removal approximately 12 months later. At final follow-up, the implant removal group demonstrated a 10.13 degree loss (3.00-23.26, p = 0.13) of reduction, while the implant retention group experienced a 10.17 degree loss (1.79-22.12, p = 0.10). There was no statistically significant difference in correction loss between implant retention and removal cohorts (p = 0.97). Pooled VAS scores improved by a mean of 3.32 points (0.18 to 6.45, p = 0.04) in the combined removal group, but by only 2.50 points (-1.81 to 6.81, p = 0.26) in the retention group. Oswestry Disability Index scores also improved after implant removal by 7.80 points (2.95-12.64, p < 0.01) at 1 year and 11.10 points (5.24-16.96, p < 0.01) at final follow-up.

CONCLUSIONS

In younger patients with thoracolumbar burst fractures who undergo posterior surgical stabilization, planned implant removal results in superior functional outcomes without significant difference in kyphotic angle correction loss compared to implant retention.

Outcomes in Thoracolumbar and Lumbar Traumatic Fractures: Does Restoration of Unfused Segmental Mobility Correlated to Implant Removal Time?

BACKGROUND

Posterior fixation without fusion can treat thoracolumbar and lumbar traumatic fractures effectively in certain cases. However, whether patients benefit from implant removal and the correlation between the range of motion (ROM) of the involved segments and the removal time have not been determined.

METHODS

From 2018 to 2020, we retrospectively reviewed data of patients with AO spine type A or B thoracolumbar or lumbar traumatic fractures who underwent implant removal. A total of 17 patients (group A), 21 patients (group B), and 12 patients (group C) underwent implant removal after the index surgery within 12 months, between 12 and 24 months, and over 24 months, respectively. Clinical and radiological outcomes, including visual analog scale for back pain, patient satisfaction, Oswestry disability index, and EuroQol 5 dimensions questionnaire, for quality of life and segmental ROM were analyzed.

RESULTS

The average follow-up time was 9.1 ± 5.7 months after implant removal. There were no significant differences in visual analog scale and patient satisfaction among the 3 groups at the same observation time point. Among the 3 groups, patients in group A gained the lowest Oswestry disability index and highest EuroQol 5 dimensions questionnaire scores after removal and at the final follow-up. The best ROM was obtained in group A followed by groups B and C (11.5° ± 6.2°, 5.5° ± 1.6°, and 2.4° ± 0.6°, respectively).

CONCLUSIONS

Immobilization of the involved segments over 24 months may lead to loss of ROM. Regained segmental ROM is correlated negatively with implant removal time, and removal within 12 months promises a better ROM and quality of life.

Risks and benefits of timely screw removal after thoracolumbar spine fractures treated with non-fusion technique

BACKGROUND

Percutaneous-short segment screw fixation (SSSF) without bone fusion has proven to be a safe and effective modality for thoracolumbar spine fractures (TLSFs). When fracture consolidation is confirmed, pedicle screws are no longer essential, but clear indications for screw removal following fracture consolidation have not been established.

METHODS

In total, we enrolled 31 patients with TLSFs who underwent screw removal following treatment using percutaneous-SSSF without fusion. Plain radiographs, taken at different intervals, measured local kyphosis using Cobb' angle (CA), vertebra body height (VBH), and the segmental motion angle (SMA). A visual analogue scale (VAS) and the Oswestry disability index (ODI) were applied pre-screw removal and at the last follow-up.

RESULTS

The overall mean CA deteriorated by 1.58° (p < 0.05) and the overall mean VBH decreased by 0.52 mm (p = 0.001). SMA preservation was achieved in 18 patients (58.1%) and kyphotic recurrence occurred in 4 patients (12.9%). SMA preservation was statistically significant in patients who underwent screw removal within 12 months following the primary operation (p = 0.002). Kyphotic recurrence occurred in patients with a CA ≥ 20° at injury (p < 0.001) with a median interval of 16.5 months after screw removal. No patients reported worsening pain or an increased ODI score after screw removal.

CONCLUSION

Screw removal within 12 months can be recommended for restoration of SMA with improvement in clinical outcomes. Although, TLSFs with CA ≥ 20° at the time of injury can help to predict kyphotic recurrence after screw removal, the clinical outcomes are less relevant.

Clinical efficacy and outcome of intelligently inflatable reduction in conjunction with percutaneous pedicle screw fixation for treating thoracolumbar burst fractures

Objective

This study was performed to describe a new minimally invasive surgical technique and to explore its effects and practical use in the clinical setting.

Methods

In total, 22 patients with single-segment thoracolumbar burst fractures underwent treatment with an intelligently inflatable reduction device before common percutaneous pedicle screw fixation. Complications were recorded and short-term effectiveness was evaluated using the visual analogue scale (VAS) score for pain, Oswestry Disability Index (ODI), kyphotic Cobb angle, and anterior edge height of the fractured vertebra preoperatively and postoperatively.

Results

The patients were followed up from 2 to 5 years. The differences in the VAS score and ODI reached statistical significance at different time points. Similar significant differences were observed in the kyphotic Cobb angle and the vertebral body anterior height except between the two postoperative measurements.

Conclusions

The current study indicated that use of the intelligently inflatable reduction device with conventional percutaneous pedicle screw fixation can improve the reduction and healing of single-segment thoracolumbar burst fractures in adult patients. This technique induces minimal trauma, provides reliable fixation, and has few complications.

Percutaneous Pedicle Screw Fixation in Thoracolumbar Fractures: Comparison of Results According to Implant Removal Time

Background

The purpose of this study was to determine whether restoration of range of motion (ROM) could be achieved by implant removal after natural bone healing and consolidation of fractured vertebrae and examine whether early removal of the implant could maximize restoration of ROM.

Methods

This study included 30 cases of thoracolumbar fractures without neurological deficit requiring surgery (nine cases of flexion-distraction injuries and 21 cases of burst fractures). Percutaneous pedicle screw fixation (PPSF) was performed at the fractured vertebrae and one level above and one level below the fracture level. Pedicle screws were removed at an average of 12 months after surgery upon healing of fractured vertebrae. The following radiological and clinical findings were evaluated: restoration of anterior vertebral height ratio (AVHR), Cobb angle (CA), ROM, and complications. Sixteen patients who were checked for ROM were divided into two groups based on the time of implant removal: nine patients within 12 months and seven patients after 12 months. Restoration of vertebral height loss and ROM were compared between the two groups.

Results

At the final follow-up, significant pain relief and restoration of AVHR and CA were achieved in patients who underwent PPSF. Patients who had implant removed within 12 months after surgery had better ROM recovery than those who had implant removed after 12 months postoperatively. There were no significant differences in AVHR and CA between the two groups.

Conclusions

PPSF followed by implant removal after healing of fractured body appears to be effective in achieving restoration of ROM. In our study, early removal of implant within 12 months after surgery was associated with better achievement of ROM than removal after 12 months. In addition, there were no significant differences in restoration of vertebral height between the two groups.

Percutaneous fixation of thoracolumbar vertebral fractures

Surgical treatment of patients with thoracolumbar vertebral fracture without neurological deficit is still controversial.

Management of vertebral fracture with percutaneous fixation was first reported in 2004.

Advantages of percutaneous fixation are: less tissue dissection; decreased post-operative pain; decreased bleeding and operative time (depending on the steep learning curve); better screw positioning with fluoroscopy compared with an open freehand technique; and a decreased infection rate.

The limitations of percutaneous fixation of vertebral fractures include increased radiation exposure to the patient and the surgeon, together with the steep learning curve for this technique.

Adding a screw at the level of the fractured vertebra has the advantages of incorporating fewer motion segments with less operative time and bleeding. This also increases the axial, sagittal and torsional stiffness of the construct.

Percutaneous fixation alone without grafting is sufficient for treating type A and B1 (AO classification) thoracolumbar fractures with satisfactory results concerning kyphosis reduction when compared with open instrumentation and fusion and with open fixation.

Type C and B2 fractures (ligamentous injuries) should undergo fusion since the ligamentous healing is mechanically weak, increasing the risk of instability.

This review offers a detailed description of percutaneous screw insertion and discusses the advantages and disadvantages.

Cite this article: EFORT Open Rev 2018;3:604-613. DOI: 10.1302/2058-5241.3.170026.

A minimally invasive surgical technique for the management of U-shape sacral fractures

INTRODUCTION

We present a small case series for the rare U-shape sacral fracture. The U-shape sacral fracture is characterised by bilateral longitudinal sacral fractures and a transverse sacral fracture through the S2 vertebral body. Historically it has been described following falls from a height and a high velocity mechanism is often required for this injury. We also describe a surgical technique for fixation of U-shape sacral fractures and subsequent implant removal 6 months post-operatively.

CASE PRESENTATION

We present the cases of three patients who presented to our institution with this injury. All patients were treated with minimally invasive, lumbo-sacro-pelvic (LSP) fixation. One patient was lost to follow-up. The remaining two patients had complete resolution of neurological function. These two patients had restoration of lumbosacral motion after removal of implants and had returned to pre-injury function.

DISCUSSION

We describe a new technique for treating U-shape sacral fractures which reduces the morbidity associated with surgery and maintains lumbosacral motion.

Temporary stabilization of unstable spine fractures

PURPOSE OF REVIEW

We will review the recent literature concerning the necessity of supplemental fusion to spinal instrumentation and discuss if temporal spinal fixation is a viable option for the treatment of unstable spine fractures. Advancements in minimally invasive techniques offer an alternative approach to traditional open stabilization for unstable spine fractures. The use of minimally invasive surgery offers many advantages concerning operative morbidly; fusion is not utilized and instrumentation can be removed in a delayed fashion.

RECENT FINDINGS

There are limited differences in amount of correction loss over time, and multiple studies report equivocal to superior results in patient's functional outcomes when comparing temporary internal stabilization to long segment instrumentation with fusion. Removal of implants can restore segmental motion. Review of the literature demonstrates that temporary internal stabilization for unstable fractures is a viable option. Close clinical and radiographic follow-up is recommended to avoid delayed spinal deformity.