Thoracolumbar Burst Fractures

Abstract and Introduction

Abstract

Study Design: Meta-analysis.

Objective: To compare the clinical, functional, and radiological outcomes of posterior-only versus combined anterior-posterior instrumentation in order to determine the optimal surgical intervention for thoracolumbar burst fractures.

Summary of Background Data: Unstable thoracolumbar burst fractures warrant surgical intervention to prevent neurological deterioration and progressive kyphosis, which can lead to significant pain and functional morbidity. The available literature remains largely inconclusive in determining the optimal instrumentation strategy.

Methods: Electronic searches of MEDLINE (1948–May 2020), EMBASE (1947–May 2020), The Cochrane Library (1991–May 2020), and other databases were conducted. Cochrane Collaboration guidelines were used for data extraction and quality assessment. Outcomes of interest were divided into three categories: radiological (degree of postoperative kyphosis correction; loss of kyphosis correction at final follow-up), functional (visual analogue scale [VAS] pain score; Oswestry Disability Index [ODI] score), and clinical (intraoperative blood loss; length of stay [LOS]; operative time; the number and type of postoperative complications).

Results: Four randomized control trials (RCTs) were retrieved, including 145 randomized participants. Seventy-three patients underwent posterior-only instrumentation and 72 underwent combined instrumentation. No significant difference was found in the degree of postoperative kyphosis correction (P = 0.39), VAS (centimeters) at final follow-up (P = 0.67), ODI at final follow-up (P = 0.89) or the number of postoperative complications between the two approaches (P = 0.49). Posterior-only instrumentation was associated with lower blood loss (P < 0.001), operative time (P < 0.001), and LOS (P = 0.01). Combined instrumentation had a lower degree of kyphosis loss at final follow-up (P = 0.001). There was heterogeneity in the duration of follow-up between the included studies (mean follow-up range 24–121 months).

Conclusion: The available literature remains largely inconclusive. In order to reliably inform practice in this area, there is a need for large, high-quality, multicenter RCTs with standardized reporting of outcomes, with a particular focus on outcomes relating to patient function and severe complications causing long-term morbidity.

Level of Evidence: 2

Introduction

Approximately 90% of spine fractures occur in the thoracolumbar spine (T11–L2).^[1,2] The thoracolumbar spine represents the junction between a relatively immobile, kyphotic thoracic spine and a mobile, lordotic lumbar spinal segment, resulting in a concentration of stress forces and predisposition to injury.^[2,3] Of all fractures that occur in the thoracolumbar spine, 10% to 20% are burst fractures.^[2,3] The incidence in males is estimated to be four times higher than in females. The most common cause is motor vehicle accidents, followed by falls and sport-associated injuries.^[4] Thoracolumbar burst fractures (TLBFs) confer a significant degree of morbidity, with up to 50% associated with an injury to a second organ system.^[4]

TLBFs can range in severity. Stable injuries can be effectively managed nonoperatively with bracing and early mobilization.^[4,5] Unstable burst fractures with a significant degree of retropulsion and spinal canal compromise can lead to neurological injury in up to 60% of patients.^[6] TLBFs with a Thoracolumbar Injury Classification and Severity (TLICS) score^[7] greater than or equal to five warrant surgical intervention.^[2] Many options exist for the surgical stabilization of TLBFs. Fixation can be accomplished by posterior pedicle-screw and rod fixation, or by corpectomy and decompression of the anterior column with reconstruction using a static or expandable cage filled with autologous or synthetic graft. Supplemental anterior fixation with a plate and screw construct can also be used.^[2,8–10]

A significant degree of uncertainty exists in relation to the optimal strategy for the surgical management of TLBFs. Advantages of anterior instrumentation include the ability to perform a thorough decompression of the spinal canal and reconstruction of the anterior and middle spinal columns.^[9] Posterior-only fixation is associated with hardware loosening, which is postulated to be due to the fact that the anterior column of the spine accounts for 80% of its stability.^[8,11] As a result, the rate of combined anterior-posterior instrumentation has increased by approximately 15% from 2000 to 2009.^[8] Evidence has shown that circumferential fusion provided by combined anterior-posterior instrumentation is superior in maintaining postoperative kyphosis compared with posterior-only fixation.^[6,12] However, studies to date have been unable to demonstrate superiority in relation to clinical outcomes.^[6,13] The morbidity associated with the anterior approach may account for this to some degree.^[12]

The evidence to date comparing posterior and combined instrumentation for TLBFs has been inconclusive.^[6,14] In light of this, we endeavored to systematically review existing evidence from randomized control trials (RCTs) to compare the clinical, functional, and radiological outcomes of these approaches for patients with TLBFs through the methodology of meta-analysis.

Table 1. Characteristics of the Studies Included in the Meta-analysis
Study	Journal	Year	Country	Study Period	Total Number of Patients	Total Number in Each Trial Arm
Posterior	Anterior	Combined
Gummusuyu et al	Turkish Neurosurgery	2019	Turkey	2003–2006	27	13	a	14
Scholz et al	European Spine Journal	2017	Germany	2010–2011	17	10	a	7
Wang et al	Journal of the Pakistan Medical Association	2015	China	2004–2006	66	23	22	21
Hao et al	Spine	2014	China	2010–2011	57	27	a	30

Table 2. Clinical and Operative Characteristics of the Patients Included in the Meta-analysis
Study	Number of Patients	Mean Age	Gender (Male, Female)	Fracture Levels	Preoperative Kyphosis (degree)	Mean Follow Up (months)	Details of Surgical Approach and Instrumentation
P	C	P	C	P	C	P	C	P	C	P	C	P	C
Gummusuyu et al	13	14	40.7	37.7	10, 3	9,5	3 T12, 5 L1,5 L2	1 T12, 11 L1, 2 L2	5	4.2	114.1	121	Three-segment posterior instrumentation and fusion with transpedicular screws (two levels above the fracture site and one level below)	Posterior instrumentation and fusion with transpedicular screws (one level above and below the fracture site) combined with anterior corpus screws (one level above and below the fracture site) with anterior rods, anterior corpectomy cage and bone graft to the corpectomy site
Scholz et al	10	7	a	a	5, 5	4, 3	2 T12, 8 L1	5 T12, 2 L1	4.9	3.6	24	24	Posterior four-segment instrumentation with transpedicular screws (two levels above the fracture site and two levels below) and monosegmental fusion with decortication of the fracture-level facet joint and application of demineralized bone matrix	Posterior instrumentation with transpedicular screws (as outlined) combined with anterior monosegmental fusion with an angle-stable plate, four screws and tricortical iliac crest bone graft
Wang et al	23	21	40.5	41.2	15, 8	16, 5	5 T12, 15 L1, 3 L2	3 T12, 14 L1, 4 L2	1	0.9	69	71	Posterior two-segment instrumentation with posterior rods and pedicle screws (one level above the fracture site and one level below), posterior decompression and posterolateral fusion with autogenous bone graft	Posterior instrumentation (as outlined) combined with anterior subtotal corpectomy with titanium mesh cage filled with autogenous bone graft and screw-plate instrumentation
Hao et al	27	30	39.4	38.3	17, 10	20, 10	4 T12, 14 L1, 9 L2	5 T12, 14 L1, 11 L2	a	a	24	24	Posterior four-segment instrumentation (two levels above the fracture site and two levels below) with posterior decompression, endplate removal and autogenous iliac crest bone graft to the anterior disc space	Posterior four-segment instrumentation (two levels above the fracture site and two levels below) and posterolateral fusion with anterior subtotal corpectomy, titanium mesh cage filled with autogenous iliac bone strut graft and angular screw-plate instrumentation

Table 2. Clinical and Operative Characteristics of the Patients Included in the Meta-analysis

Study

Number of Patients

Mean Age

Gender (Male, Female)

Fracture Levels

Preoperative Kyphosis (degree)

Mean Follow Up (months)

Details of Surgical Approach and Instrumentation

Gummusuyu et al

40.7

37.7

10, 3

9,5

3 T12, 5 L1,5 L2

1 T12, 11 L1, 2 L2

4.2

114.1

121

Three-segment posterior instrumentation and fusion with transpedicular screws (two levels above the fracture site and one level below)

Posterior instrumentation and fusion with transpedicular screws (one level above and below the fracture site) combined with anterior corpus screws (one level above and below the fracture site) with anterior rods, anterior corpectomy cage and bone graft to the corpectomy site

Scholz et al

5, 5

4, 3

2 T12, 8 L1

5 T12, 2 L1

4.9

3.6

Posterior four-segment instrumentation with transpedicular screws (two levels above the fracture site and two levels below) and monosegmental fusion with decortication of the fracture-level facet joint and application of demineralized bone matrix

Posterior instrumentation with transpedicular screws (as outlined) combined with anterior monosegmental fusion with an angle-stable plate, four screws and tricortical iliac crest bone graft

Wang et al

40.5

41.2

15, 8

16, 5

5 T12, 15 L1, 3 L2

3 T12, 14 L1, 4 L2

0.9

Posterior two-segment instrumentation with posterior rods and pedicle screws (one level above the fracture site and one level below), posterior decompression and posterolateral fusion with autogenous bone graft

Posterior instrumentation (as outlined) combined with anterior subtotal corpectomy with titanium mesh cage filled with autogenous bone graft and screw-plate instrumentation

Hao et al

39.4

38.3

17, 10

20, 10

4 T12, 14 L1, 9 L2

5 T12, 14 L1, 11 L2

Posterior four-segment instrumentation (two levels above the fracture site and two levels below) with posterior decompression, endplate removal and autogenous iliac crest bone graft to the anterior disc space

Posterior four-segment instrumentation (two levels above the fracture site and two levels below) and posterolateral fusion with anterior subtotal corpectomy, titanium mesh cage filled with autogenous iliac bone strut graft and angular screw-plate instrumentation

Study	Mean Blood Loss, mL		Mean LOS, days		Mean Operative Time, mins		VAS (cm) at Final Follow Up		ODI (%) at Final Follow Up		Postoperative Kyphosis Correction (degree)		Loss of Kyphosis Correction (degree)		Postoperative Complications (Number and Type)
Study	P	C	P	C	P	C	P	C	P	C	P	C	P	C	P	C
Gummusuyu et al	195.7	358.5	1.3	10.6	a	a	1.6	1.8	15	17.7	14.2	5.3	2.1	1.2	One temporary nerve root irritation	One postoperative ileus, one deep infection
Scholz et al	a	a	21	31	a	a	a	a	13.3	19.3	5.8	7.4	10.9	1.9	One delayed wound healing, 1 severe loss of kyphosis correction requiring additional anterior bisegmental fusion	No complications
Wang et al	357	780.3	13.5	21.4	110	248.5	2	1.1	a	a	17.5	17.2	8.8	3.4	One wound infection, two instrumentation failures	Two wound infections
Hao et al	825	1307	a	a	172	229	4.1	4.4	28.1	27.5	24.7	25.4	6.8	5	Two cerebrospinal fluid leakages	Three pulmonary atelectasis, three intrathoracic bleeding, two cerebrospinal fluid leakages, one pleural effusion, one pneumothorax

Thoracolumbar Burst Fractures

A Systematic Review and Meta-Analysis Comparing Posterior-Only Instrumentation Versus Combined Anterior-Posterior Instrumentation

Abstract and Introduction

Abstract

Introduction

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Tables

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Authors and Disclosures

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