Primary studies included in this systematic review

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Outcome after thoracoscopic ventral stabilisation of thoracic and lumbar spine fractures.

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Journal Journal of trauma management & outcomes
Year 2012
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This article is included in 1 Systematic review Systematic reviews (1 reference)

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BACKGROUND AND PURPOSE: Thoracoscopic-assisted ventral stabilisation for thoracolumbar fractures has been shown to be associated with decreased recovery time and less morbidity when compared with open procedures. However, there are a limited number of studies evaluating late clinical and radiological results after thoracoscopic spinal surgery. METHODS: We performed an analysis of the late outcomes of thoracolumbar fractures after minimally invasive thoracoscopic ventral instrumentation. Between August 2003 and December 2008, 70 patients with thoracolumbar fractures (T5-L2) underwent ventral thoracoscopic stabilisation. Tricortical bone grafts, anterior plating systems (MACS-System), and cage implants were used for stabilisation. Outcomes measured include radiologic images (superior inferior endplate angle), Visual Analogue Scale (VAS), VAS Spine Score, quality of life scores SF-36 and Oswestry Disability Index (ODI). RESULTS: Forty seven patients (67%, 47 out of 70) were recruited for the follow up evaluation (2.2 ± 1.5 years). Lower VAS Spine scores were calculated in patients with intra- or postoperative complications (44.7 (± 16.7) vs. 65.8 (± 24.5), p=0.0447). There was no difference in outcome between patients treated with bone graft vs. cage implants. Loss of correction was observed in both bone graft and titanium cage groups. INTERPRETATION: The present study demonstrates diminished long-term quality of life in patients treated with thoracoscopic ventral spine when compared with the outcome of german reference population. In contrast to the other patients, those patients without intra-operative or post-operative complications were associated with improved outcome. The stabilisation method (bone graft versus spinal cage) did not affect the long-term clinical or radiographic results in this series.

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Delay in operative stabilization of spine fractures in multitrauma patients without neurologic injuries: effects on outcomes.

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Journal Canadian journal of surgery. Journal canadien de chirurgie
Year 2011
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This article is included in 1 Systematic review Systematic reviews (1 reference)

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BACKGROUND: Optimal timing for surgical stabilization of the fractured spine is controversial. Early stabilization facilitates mobilization and theoretically reduces associated complications. METHODS: We identified consecutive patients without neurologic injury requiring stabilization surgery for a spinal fracture at an academic tertiary-care hospital over a 12-year period. Incidences of postoperative complications were prospectively evaluated. We analyzed results based on the time elapsed before the final surgical stabilization procedure. Multivariate analyses were performed to explore the effects of potential confounders. RESULTS: A total of 83 patients (60 men, 23 women; mean age 39.4 yr) met the eligibility criteria and were enrolled. The mean Injury Severity Score (ISS) was 27.1 (range 12.0-57.0); 35% of patients had a cervical fracture and 65% had a thoraco-lumbar fracture. No statistically significant associations were uncovered between time to surgical stabilization and age, ISS or comorbidities. Comparing patients stabilized after 24 hours with those stabilized within 24 hours, there was an almost 8-fold greater risk of a complication related to prolonged recumbency (p = 0.007). We observed similar effects for other types of complications. Delays of more than 72 hours had a negative effect on complication rates; these effects remained significant after multivariate adjustments for age, comorbidity and ISS. CONCLUSION: This study demonstrates a strong relation between timing of surgical stabilization of spinal fractures in multitrauma patients without neurologic injuries and complications. Further studies with larger samples may allow for better adjustment of potentially confounding factors and identify subgroups in which this effect is most pronounced.

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Complications related to instrumentation in spine surgery: a prospective analysis.

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Journal Neurosurgical focus
Year 2011
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This article is included in 1 Systematic review Systematic reviews (1 reference)

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OBJECT: Prospective examination of perioperative complications in spine surgery is limited in the literature. The authors prospectively collected data on patients who underwent spinal fusion at a tertiary care center and evaluated the effect of spinal fusion and comorbidities on perioperative complications. METHODS: Between May and December 2008 data were collected prospectively in 248 patients admitted to the authors' institution for spine surgery. The 202 patients undergoing spine surgery with instrumentation were further analyzed in this report. Perioperative complications occurring within the initial 30 days after surgery were included. All adverse occurrences, whether directly related to surgery, were included in the analysis. RESULTS: Overall, 114 (56.4%) of 202 patients experienced at least one perioperative complication. Instrumented fusions were associated with more minor complications (p = 0.001) and more overall complications (0.0024). Furthermore, in the thoracic and lumbar spine, complications increased based on the number of levels fused. Advanced patient age and certain comorbidities such as diabetes, cardiac disease, or a history of malignancy were also associated with an increased incidence of complications. CONCLUSIONS: Using a prospective methodology with a broad definition of complications, the authors report a significantly higher perioperative incidence of complications than previously indicated after spinal fusion procedures. Given the increased application of instrumentation, especially for degenerative disease, a better estimate of clinically relevant surgical complications could aid spine surgeons and patients in an individualized complication index to facilitate a more thorough risk-benefit analysis prior to surgery.

Primary study

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Transpedicular fixation in management of thoracolumbar burst fractures: Monosegmental fixation versus short-segment instrumentation

Authors Wei FX , Liu SY , Liang CX , Li HM , Long HQ , Yu BS , Chen BL , Chen KB
Journal Spine
Year 2010
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This article is included in 3 Systematic reviews Systematic reviews (3 references)

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Study Design. A prospective clinical trial was conducted. Objective. To compare the clinical and radiologic late results of monosegmental transpedicular fixation versus short-segment pedicle instrumentation (SSPI) in management of thoracolumbar burst fractures and evaluate the efficacy of monosegmental transpedicular fixation. Summary of Background Data. SSPI (1 level above and 1 below the fracture level) are accepted by many surgeons as an accepted technique for the treatment of thoracolumbar burst fractures. To preserve more motion segments, some authors have advocated monosegmental pedicle instrumentation (MSPI). The recent developments showed that MSPI yielded good clinical results; however, there were no report about comparison of clinical outcome between monosegmental and biosegmental transpedicular fixation in management of thoracolumbar burst fractures. Methods. Eighty-five patients with thoracolumbar burst fractures fulfilling the inclusion criteria were included in the study. The patients were randomized by a simple method into 2 groups. Group 1 were treated with monosegmental transpedicular fixation (n = 47), and group 2 were treated with biosegmental transpedicular fixation (n = 38). Clinical (Low Back Outcome Score and Oswestry Disability Index) and radiologic (load-sharing classification index, sagittal index, and percentage of anterior body height compression) outcomes were analyzed. Results. The 2 groups were similar in age, follow-up period, and severity of the deformity and fracture. The postoperative and follow-up sagittal index, local kyphosis, percentage of anterior body height compression, and average correction loss in local kyphosis in both groups were not significantly different. The failure rate between the 2 surgical approaches was also not significantly different (group 1 = 6.38% and group 2 = 5.26%). Oswestry Disability Index improved in both groups by >25 points in a similar amount (P = 0.23). The average follow-up Low Back Outcome Score was 74.9 and 60.2 for group 1 and group 2, respectively (P = 0.033). Conclusion. In conclusion, radiologic parameters demonstrated that both MSPI and SSPI are the effective and reliable operative techniques for selected thoracolumbar burst fractures. MSPI shortened the operative time and decreased the amount of blood loss significantly and, thus, offered better clinical results. Nevertheless, long-term studies are supposed to be performed to support the outcomes. © 2010, Lippincott Williams & Wilkins.

Primary study

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Three-column reconstruction through single posterior approach for the treatment of unstable thoracolumbar fracture.

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Journal Spine
Year 2010
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This article is included in 1 Systematic review Systematic reviews (1 reference)

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STUDY DESIGN: A prospective study was performed. OBJECTIVE: To assess a technique, three-column reconstruction through single posterior (TRSP) approach, in treatment of highly unstable thoracolumbar fracture. SUMMARY OF BACKGROUND DATA: The goal of surgical intervention for treatment of unstable thoracolumbar fractures is to decompress the neural elements, restore vertebral body height, correct angular deformity, and stabilize the columns of the spine. Operative approaches remain disputed. Common opinions include short-segment posterior fixation, multiple-segment posterior fixation, stand-alone anterior approach fixation, and combined anterior-posterior approach. Each technique has its advantages and disadvantages. METHODS: A consecutive series of 37 thoracolumbar fractures with load sharing scores > or =6 were managed with TRSP between May 2004 and September 2006. All patients were observed up for a minimum of 2 years. Demographic data, neurologic status, segmental kyphosis, segmental height, the fracture severity score, Visual Analogue Scale, and treatment-related complications were evaluated. RESULTS: The mean operative time was 157 minutes (range, 120-240). The mean blood loss was 1086 mL (range, 700-3100). Averagely Frankel score improved from 3.46 to 4.46; kyphotic angulation improved from 25.75 degrees before surgery to 4.49 degrees at last follow-up, and the loss of segmental height improved from a mean of 35.22% before surgery to 7.01% at the time of the last follow-up. The mean preoperative Visual Analogue Scale score was 7.92, and most patients had no complain of pain at last follow-up. No patient experienced worsening of neurologic deficits and other severe complications at last follow-up. One patient developed titanium mess cage subsidence, but revision was not necessary. CONCLUSION: The technique of TRSP approach is safe, effective, and offers some advantages over the classic posterior, anterior, combined anterior-posterior approach for some specific highly unstable thoracolumbar fractures.

Primary study

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Traumatic thoracic and lumbar spinal fractures: operative or nonoperative treatment: comparison of two treatment strategies by means of surgeon equipoise.

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Journal Spine
Year 2008
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This article is included in 2 Systematic reviews Systematic reviews (2 references)

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STUDY DESIGN: A center parallel cohort study with blinded inclusion based on clinical equipoise. OBJECTIVE: To compare outcomes of nonoperative and operative treatment strategies in terms of quality of life and neurologic and functional status. SUMMARY OF BACKGROUND DATA: Despite a considerable body of literature, sound evidence regarding the optimal treatment for traumatic thoracic and lumbar spine fractures is lacking. METHODS: Medical records of patients hospitalized for traumatic spinal fractures between 1991 and 2002 were identified in 2 trauma centers in the same country with established and different treatment strategies. Eligibility was retrospectively assessed for each case by a panel of orthopaedic surgeons who were representative of the 2 medical centers, and who were blinded to the treatment actually administered. Patients were included in the study when there was disagreement on the suggested treatment method. Thus, 2 comparable groups were identified undergoing nonoperative or operative treatment. Outcome assessment and comparison across groups focused on quality of life, residual pain, neurologic recovery, and employment in the middle-long-term follow-up. RESULTS: Discordance in regards to choice of treatment was identified in 190 (95 treated nonoperative, 95 operative) of 636 potentially eligible patients. Patients were comparable regarding baseline characteristics, except for a somewhat higher proportion of males and neurologic impairment in the operative group. Seventeen percent of the nonoperative and 21% of the operative group developed complications and 3 patients displayed neurologic deterioration for which a treatment change was considered necessary. Follow-up was complete in 79%; mean follow-up time was 6.2 years with a minimum of 2 years. Pain scores, disability indexes, and general health outcome were comparable at follow-up. Compared with matched population norms, outcomes were poorer regardless of treatment method. Neurologic recovery was better in the operative group, but this difference did not reach statistical significance. Multivariate regression analyses revealed that female gender and neurologic impairment were independent predictors of poor functional outcome. Eighty-eight and 83% of the nonoperatively and operatively treated patients were employed at some point after a rehabilitation period. CONCLUSION: Overall outcome of nonoperative and operative treatment in middle-long-term follow up is comparable, although there seems to be a difference in neurologic recovery patterns. Studies on the cost-effectiveness of treatment options and the patterns of recovery within 2 years after injury would assist in guideline development and stimulate interest for future research.

Primary study

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Thoracolumbar flexion-distraction injuries: associated morbidity and neurological outcomes.

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Journal Spine
Year 2008
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This article is included in 1 Systematic review Systematic reviews (1 reference)

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STUDY DESIGN: Retrospective study, prospectively gathered databases. OBJECTIVE: To assess abdominal comorbidities, missed injuries, and complications associated with thoracolumbar flexion-distraction injuries (FDI). SUMMARY OF BACKGROUND DATA: From 1989 to 2003, 153 patients with flexion-distraction type injuries were identified. Predominant injury mechanisms consisted of motor vehicle crashes, falls, and motorcycle crashes. METHODS: Spinal injuries were categorized by region, injury pattern, American Spinal Injury Association grade, and motor score. Diagnostic methods, delayed diagnoses, and complications were recorded and compared with variables of spinal injury, abdominal injury, and neurologic outcome. Treatment variables included nonoperative care, posterior surgery alone, anterior surgery alone, or combination treatment. Primary outcomes were neurologic status, unintended secondary procedures, complications, and kyphosis angle. RESULTS: Spinal cord injury (SCI) was found in 37 of 151 patients (25%). SCI was correlated with high-grade posterior element dissociation. Intra-abdominal injury (IAI) was found in 46 of 151 of patients (30%). There was a statistically significant correlation between presence of FDI and IAI in the lumbar (L2-L4) region. There was a 3.9% incidence of delayed diagnosis of FDI and a 0.9% incidence of delayed diagnosis of IAI. Presence of a "lapbelt-sign" had a positive predictive value of 0.69 and a negative predictive value of 0.91 for IAI. Presence of a lumbar injury due to a motor vehicle crash in the presence of a lapbelt sign was positively associated with IAI. There was no increase in complications in the subpopulation of patients with concurrent SCI and FDI. CONCLUSION: Both IAI and SCI remain commonly associated with FDI of the thoracolumbar spinal column. The presence of an abdominal wall contusion (lapbelt sign) is a strong indicator of IAI. Adherence to an established trauma algorithm can minimize the risk of delayed diagnosis. Disruption of an established work-up paradigm, however, can lead to potentially life and spinal cord threatening complications.

Primary study

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The effect of early surgical treatment of traumatic spine injuries on patient mortality.

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Journal The Journal of trauma
Year 2007
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This article is included in 1 Systematic review Systematic reviews (1 reference)

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INTRODUCTION: The ideal timing of spinal fixation is controversial. A recent study showed that early spine fixation reduced morbidity and resource utilization. We previously noted a trend toward higher mortality in patients undergoing early spinal fixation. This study was done to analyze whether the timing of spinal fixation had a significant effect on mortality. METHODS: The registry of our Level I trauma program was queried for all patients with at least one spinal vertebral injury. Anatomic and physiologic variables included age, initial Glasgow Coma Scale score, systolic blood pressure, heart rate, and Injury Severity Score. Outcome was evaluated in terms of ventilator days, intensive care unit length of stay, hospital length of stay (HLOS), and mortality. Patients were stratified by day of spinal operative fixation as early when done within 48 hours and late when done after 48 hours. Data were analyzed using chi and an unpaired t test, accepting p < 0.05 as significant. RESULTS: Three hundred sixty-one patients between January 1988 and February 2003 required operative spinal fixation (158 early, within 48 hours vs. 203 late, beyond 48 hours). There was no significant difference between the two groups except mortality, which was significantly higher in the early group (7.6 vs. 2.5%; p = 0.0257), and HLOS, which was significantly shorter in the early group (14.42 vs. 17.64 days; p = 0.025). CONCLUSION: Spinal fixation within 48 hours after vertebral fractures and dislocations appears to increase mortality despite similar anatomic and physiologic parameters in the later operative group. Incomplete resuscitation of patients before surgery may have contributed to this result. The shorter HLOS may have been because of the higher number of early deaths. Prospective studies to identify the optimal timing of spinal fixation and the reason for these outcome differences are warranted.

Primary study

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Is fusion necessary for surgically treated burst fractures of the thoracolumbar and lumbar spine?: a prospective, randomized study.

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Authors Wang ST , Ma HL , Liu CL , Yu WK , Chang MC , Chen TH
Journal Spine
Year 2006
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This article is included in 3 Systematic reviews Systematic reviews (3 references)

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STUDY DESIGN: A prospective clinical trial was conducted. OBJECTIVES: To compare the results of fusion versus nonfusion for surgically treated burst fractures of the thoracolumbar and lumbar spine. SUMMARY OF BACKGROUND DATA: The operative results of surgically treated burst fractures with short segmental fixation have been well documented. There is no report comparing the results of fusion and nonfusion. METHODS: Fifty-eight patients were included in this study, with the inclusion criteria as follows: neurologically intact spine with a kyphotic angle > or = 20 degrees, decreased vertebral body height > or = 50% or a canal compromise > or = 50%, incomplete neurologic deficit with a canal compromise 50%, complete neurologic deficit, and multilevel spinal injury or multiple traumas. All patients were randomly assigned to fusion or nonfusion groups, and operative treatment with posterior reduction and instrumentation was carried out. Posterior fusion with autogenous bone graft was performed for the fusion group (n = 30), and no fusion procedure was done for the nonfusion group (n = 28). The average follow-up period was 41 months (range, 24-71 months). RESULTS: The average loss of kyphotic angle was not statistically significant between these 2 groups. The radiographic parameters were statistically significantly better in the nonfusion group, including angular change in the flexion-extension lateral view (4.8 degrees vs. 1.0 degrees), lost correction of decreased vertebral body height (3.6% vs. 8.3%), intraoperative estimated blood loss (303 mL vs. 572 mL), and operative time (162 minutes vs. 224 minutes). The scores on the low back outcome scale were not statistically significant for these 2 groups. CONCLUSIONS: The short-term results of short segmental fixation without fusion for surgically treated burst fractures of the thoracolumbar spine were satisfactory. The advantages of instrumentation without fusion are the elimination of donor site complications, saving more motion segments, and reducing blood loss and operative time.

Primary study

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Osteoporotic vertebral burst fractures with neurologic compromise.

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Authors Nguyen HV , Ludwig S , Gelb D
Journal Journal of spinal disorders & techniques
Year 2003
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This article is included in 1 Systematic review Systematic reviews (1 reference)

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A retrospective study was performed on the operative results following osteoporotic burst fractures with neurologic compromise. We sought to investigate the results of operative decompression and stabilization in patients with neurologic deficit as a result of an osteoporotic burst fractures. We examined the postoperative radiographic outcomes, level of disability, functional outcomes, and complications. Compression fractures of the anterior vertebral column secondary to osteoporosis and minimal trauma are a common clinical entity. These fractures are often effectively treated by nonoperative means. However, compressive failure of the middle vertebral column can lead to retropulsion of vertebral body fragments with significant canal compromise and neurologic injury. Treatment of these more severe injuries becomes more difficult and is less well established. Functional outcomes and disability from pain have not been examined. Previous reports on this subject have documented generally good results but have given few specific data regarding outcomes. We retrospectively report on a series of 10 patients, from 1995 to 1998, with osteoporotic burst fractures, which led to varying degrees of neurologic compromise. There were nine female and one male patient with a mean age of 76 years. Nine of the 10 patients presented more than 1 month following the onset of neurologic symptoms; 70% of the fractures occurred at the thoracolumbar junction (T11-L2). Mean loss of anterior column height was 59%, with significant kyphosis (mean 28 degrees) in nine of the 10 fractures. Mean canal compromise was 41%. At presentation, seven patients were Frankel grade D and three were Frankel grade C. All patients were treated operatively with decompression and arthrodesis. Mean time to follow-up was 16 months. Six of the 10 patients had improvement of their Frankel grade postoperatively and one deteriorated neurologically. Seven of the eight surviving patients completed the Oswestry questionnaire with a mean score of 44%, representing severe disability secondary to low back pain. The Physical Component score of the SF-36 was at or below the national mean for each patient. Complications were present in six of the eight surviving patients. Osteoporotic fractures are not benign. Careful evaluation for neurologic deterioration is warranted. Neurologic recovery occurred in six of the 10 patients; however, significant disability secondary to pain was common.