The purpose of this study was to determine whether patients with a burst fracture of the thoracolumbar spine treated by short segment pedicle screw fixation fared better clinically and radiologically if the affected segment was fused at the same time. A total of 50 patients were enrolled in a prospective study and assigned to one of two groups. After the exclusion of three patients, there were 23 patients in the fusion group and 24 in the non-fusion group. Follow-up was at a mean of 23.9 months (18 to 30). Functional outcome was evaluated using the Greenough Low Back Outcome Score. Neurological function was graded using the American Spinal Injury Association Impairment Scale. Radiological outcome was assessed on the basis of the angle of kyphosis. Peri-operative blood transfusion requirements and duration of surgery were significantly higher in the fusion group (p = 0.029 and p < 0.001, respectively). There were no clinical or radiological differences in outcome between the groups (all outcomes p > 0.05). The results of this study suggest that adjunctive fusion is unnecessary when managing patients with a burst fracture of the thoracolumbar spine with short segment pedicle screw fixation.
OBJECTIVE: This prospective randomized controlled study compared the efficacy and safety of two paraspinal muscle-sparing surgical approaches for the management of neurologically intact patients with thoracolumbar burst fractures and posterior ligamentous complex injuries.
METHODS: Patients were randomized to undergo either percutaneous (n=31) or paraspinal (n=30) fluoroscopically-guided pedicle screw-rod fixation, and were followed for ≥3 years. Preoperative postural reduction was attempted in all patients.
RESULTS: The percutaneous approach was associated with significantly less intraoperative blood loss and shorter duration of surgery and hospitalization, as well as less pain and better functional recovery at 3 months after surgery compared with the paraspinal approach. Paraspinal surgery resulted in significantly better correction of kyphosis and restoration of vertebral height compared with percutaneous surgery. There were no differences in long-term clinical outcomes between the two groups.
CONCLUSIONS: The minimally invasive percutaneous approach appears to be better in cases of successful postural reduction. The paraspinal approach results in better surgical correction and is, therefore, recommended for patients without successful postural reduction.
BACKGROUND: The optimal treatment strategy for burst fractures of the thoracolumbar junction is discussed controversially in the literature. Whilst 360° fusion has shown to result in better radiological outcome, recent studies have failed to show its superiority concerning clinical outcome. The morbidity associated with the additional anterior approach may account for these findings. The aim of this prospective observational study was therefore to compare two different techniques for 360° fusion in thoracolumbar burst fractures using either thoracoscopy or a transforaminal approach (transforaminal lumbar interbody fusion (TLIF)) to support the anterior column.
METHODS: Posterior reduction and short-segmental fixation using angular stable pedicle screw systems were performed in all patients as a first step. Monocortical strut grafts were used for the anterior support in the TLIF group, whilst tricortical grafts or titanium vertebral body replacing implants of adjustable height were used in the combined posteroanterior group. At final follow-up, the radiological outcome was assessed by performing X-rays in a standing position. The clinical outcome was measured using five validated outcome scores. The morbidity associated with the approaches and the donor site was assessed as well.
RESULTS: There were 21 patients in the TLIF group and 14 patients in the posteroanterior group included. The postoperative loss of correction was higher in the TLIF group (4.9°±8.3° versus 3.4°±6.4°, p>0.05). There were no significant differences regarding the outcome scores between the two groups. There were no differences in terms of return to employment, leisure activities and back function either. More patients suffered from donor-site morbidity in the TLIF group, whilst the morbidity associated with the surgical approach was higher in the posteroanterior group.
CONCLUSION: The smaller donor-site morbidity in the posteroanterior group is counterbalanced by an additional morbidity associated with the anterior approach resulting in similar clinical outcome. Mastering both techniques will allow the spine surgeon to be more flexible in specific situations, for example, in patients with neurological deficits or severe concomitant thoracic trauma.
BACKGROUND: The impact of fusion as a supplement to short-segment instrumentation for the treatment of thoracolumbar burst fractures is unclear. We conducted a controlled clinical trial to define the effect of fusion on lumbar spine and patient-related functional outcomes.
METHODS: From 2000 to 2002, seventy-three consecutive patients with a single-level Denis type-B burst fracture involving the thoracolumbar spine and a load-sharing score of <or=6 were managed with posterior pedicle screw instrumentation. The patients were randomly assigned to treatment with posterolateral fusion (fusion group, n = 37) or without posterolateral fusion (nonfusion group, n = 36). The patients were followed for at least five years after surgery and were assessed with regard to clinical and radiographic outcomes. Clinical outcomes were evaluated with use of the Frankel scale, the motor score of the American Spinal Injury Association, a visual analog scale, and the Short Form-36 (SF-36) questionnaire. Radiographic outcomes were assessed on the basis of the local kyphosis angle and loss of kyphosis correction.
RESULTS: No significant difference in radiographic or clinical outcomes was noted between the patients managed with the two techniques. Both operative time and blood loss were significantly less in the nonfusion group compared with the fusion group (p < 0.05). Twenty-five of the thirty-seven patients in the fusion group still had some degree of donor-site pain at the time of the latest examination.
CONCLUSIONS: Posterolateral bone-grafting is not necessary when a Denis type-B thoracolumbar burst fracture associated with a load-sharing score of <or=6 is treated with short-segment pedicle screw fixation.
OBJECTIVE: The treatment of thoracolumbar burst fracture is a controversial issue. Although spinal fusion has been a touchstone of spinal fixation, nonfusion technique have become raising its popularity recently. Some studies suggested that nonfusion had several advantages over fusion. The aim of this prospective study was to compare long segment posterior instrumentation with fusion versus long-segment posterior instrumentation without fusion.
METHODS: For this purpose, 42 consecutive patients were assigned to two groups. Group 1 included 21 patients treated by long segment instrumentation with fusion (WF), whereas Group 2 included 21 patients treated by long segment instrumentation without fusion (WOF). Long segment instrumentation was hook fixation (claw hooks attached to second upper vertebra and infralaminar hooks attached to first upper vertebra) above and pedicle fixation (pedicle screws attached to first and second lower vertebrae) below the fractured vertebra.
RESULTS: Measurements of local kyphosis, sagittal index and anterior vertebral height compression showed that both group had similar outcome at final follow-up. Moreover, there was no difference between the two groups according to low back outcome score. Also, implant failure rate (4.7%) was quite low in both groups. However, WF group had prolonged operative time, increased blood loss and donor site morbidity.
CONCLUSIONS: Radiological and clinical parameters demonstrated that spinal fusion is not necessary in long segment posterior instrumentation for the management of thoracolumbar burst fractures.
OBJECTIVE: To investigate the methods for, and clinical outcome of, the operative treatment of thoracolumbar fractures through an approach via the paravertebral muscle (PVM).
METHODS: From June 2005 to August 2006, 62 patients, comprising 48 men and 14 women with an average age of 45.2 years (range, 21-58) with thoracolumbar fractures without neurological involvement underwent surgical treatment. Twenty-one fractures were located at T12, 24 at L1 and 17 at L2. The study comprised 15 compression and 47 burst fractures with an intact posterior column. Thirty-four cases were selected randomly to undergo surgery through the above approach, while the other 28 cases underwent the traditional procedure. After making a posterior midline incision, which not only facilitates insertion of pedicle screws and fusion of the graft bone at facet joints, but spares the attachment of PVM, the interval between the longissimus and multifidus muscles was undermined. Drainage was not routinely needed and the patients became ambulant with a brace earlier post-operatively.
RESULTS: The new approach had statistically significant advantages (P < 0.005) over the traditional one in regard to blood loss, drainage, duration of recumbency and visual analogue scale (VAS), although the time required was almost the same for the two procedures. Till August 2007, 56 patients were successfully followed up for 12 to 26 months (mean, 18.6) and bone fusion was identified in all cases. Neither reduction loss nor loosening or breakage of the fixation occurred.
CONCLUSION: The technique of operating through an approach between the PVM is recommended for thoracolumbar fractures because it is much less invasive, can reduce blood loss and accelerates rehabilitation.
STUDY DESIGN: Prospective randomized study. OBJECTIVES.: To compare the results of the combined anterior-posterior surgery (Group A) with posterior "short-segment" transpedicular fixation (SSTF) (Group B) in mid-lumbar burst fractures.
SUMMARY OF BACKGROUND DATA: There are no comparative randomized clinical studies on the outcome following operative treatment of mid-lumbar fractures.
METHODS: Forty consecutive patients with L2-L4 fresh single A3-type/AO burst fractures and load sharing score up to 6 were randomly selected to underwent either combined one-stage anterior stabilization with mesh cage and SSTF (Group A) or solely SSTF with intermediate screws in the fractured vertebra (Group B). Kyphotic Gardner angle, anterior and posterior vertebral body height (PVBHr, AVBHr), spinal canal encroachment (SCE), SF-36, VAS, and Frankel classification were used.
RESULTS: The follow-up observation averaged 46 and 48 months for Group A and B, respectively. Operative time, blood loss, and hospital stay were significant more in Group A. More surgical complications were observed in the Group A. After surgery, VAS was reduced to 4.3 and 3.6 for Group A and Group B, respectively. The SF-36 domains Role physical and Bodily pain improved significantly only in Group B (P = 0.05) and (P = 0.06), respectively. Correction of AVBHr, PVBHr, and spinal canal clearance was similar in both groups. Spinal canal clearance did not differ between the two groups, but it was continuous until the last evaluation in Group B. The final Gardner angle loss of correction averaged 2 degrees and 5 degrees for Group A and Group B, respectively. The posttraumatic Gardner deformity did not significantly improve by SSTF at the final evaluation in the spines of Group B. Gardner angle correlated significantly with SCE in Group B and Group A in all three periods and in the last evaluation, respectively. Frankel grade did not correlate with loss of correction of AVBHr and PVBHr in Group A, while it significantly correlated with loss of PVBHr correction and SCE in the patients of Group B. There was no neurologic deterioration after surgery in any patient. VAS and SF-36 scores did not significantly correlate with the loss of kyphotic angle correction and AVBHr, PVBHr at the final observation in any patient of both groups.
CONCLUSIONS: SSTF offered similar significant short-term correction of posttraumatic deformities associated with mid-lumbar A3-burst fractures, but better clinical results as compared to combined surgery. However, SSTF did not significantly maintain the after surgery achieved correction of local posttraumatic kyphosis at the final evaluation. Thus, SSTF is not recommended for operative stabilization of fractures with this severity.
The purpose of this study was to determine whether patients with a burst fracture of the thoracolumbar spine treated by short segment pedicle screw fixation fared better clinically and radiologically if the affected segment was fused at the same time. A total of 50 patients were enrolled in a prospective study and assigned to one of two groups. After the exclusion of three patients, there were 23 patients in the fusion group and 24 in the non-fusion group. Follow-up was at a mean of 23.9 months (18 to 30). Functional outcome was evaluated using the Greenough Low Back Outcome Score. Neurological function was graded using the American Spinal Injury Association Impairment Scale. Radiological outcome was assessed on the basis of the angle of kyphosis. Peri-operative blood transfusion requirements and duration of surgery were significantly higher in the fusion group (p = 0.029 and p < 0.001, respectively). There were no clinical or radiological differences in outcome between the groups (all outcomes p > 0.05). The results of this study suggest that adjunctive fusion is unnecessary when managing patients with a burst fracture of the thoracolumbar spine with short segment pedicle screw fixation.
