Combined Anterior-Posterior Surgery Versus Posterior Surgery for Thoracolumbar Burst Fractures: A Systematic Review of the Literature

Abstract: Study Design: A systematic quantitative review of the literature. Objective: To compare combined anterior-posterior surgery versus posterior surgery for thoracolumbar fractures in order to identify better treatments. Summary of Background Data: Axial load of the anterior and middle column of the spine can lead to a burst fracture in the vertebral body. The management of thoracolumbar burst fractures remains controversial. The goals of operative treatment are fracture reduction, fixation and decompressing the neural canal. For this, different operative methods are developed, for instance, the posterior and the combined anterior-posterior approach. Recent systematic qualitative reviews comparing these methods are lacking. Methods: We conducted an electronic search of MEDLINE, EMBASE, LILACS and the Cochrane Central Register for Controlled Trials. Results: Five observational comparative studies and no randomized clinical trials comparing the combined anteriorposterior approach with the posterior approach were retrieved. The total enrollment of patients in these studies was 755 patients. The results were expressed as relative risk (RR) for dichotomous outcomes and weighted mean difference (WMD) for continuous outcomes with 95% confidence intervals (CI). Conclusions: A small significantly higher kyphotic correction and improvement of vertebral height (sagittal index) observed for the combined anterior-posterior group is cancelled out by more blood loss, longer operation time, longer hospital stay, higher costs and a possible higher intra- and postoperative complication rate requiring re-operation and the possibility of a worsened Hannover spine score. The surgeons’ choices regarding the operative approach are biased: worse cases tended to undergo the combined anterior-posterior approach

Complications and problems related to pedicle screw fixation of the spine

This retrospective study analyzes the complications and the problems developed during and after pedicle screw fixation in patients with spinal disorders and trauma. One hundred twelve patients were treated using the Cotrel-Dubousset pedicle screw fixation system for degenerative disease (57 patients), trauma (42 patients), infection (eight patients), and tumor (five patients) of the lumbar or thoracolumbar spine. T e average age of the patients was 47 years and the average followup was 35 months. Forty-seven general complications were seen in 41 patients (36.5%). In addition, hardware failures were observed in 12 patients (10.7%), junctional problems were seen in five patients (4.5%), problems in the instrumented segments were seen in 39 patients (34.7%), and problems of balance occurred in five patients (4.5%). Although the rate of the reported complications was high, the final outcome of the patients was not affected significantly. Placement of the pedicle screws in the thoracolumbar and lumbar spine is a technically demanding procedure. It should be used by experienced and qualified surgeons who are aware of the pitfalls associated with its use

Gertzbein and load sharing classifications for unstable thoracolumbar fractures

From 1996 to 1998, 30 consecutive patients with Level I thoracolumbar spinal injury were classified and treated according to the Gertzbein classification and the load sharing classification. A posterior short segment pedicle screw implant was used in 21 patients; anterior decompression with strut grafting and application of the Kaneda device was used in three patients; and six patients were treated with short posterior instrumentation and an anterior strut graft. The average followup was 32 months (range, 24-50 months). The clinical outcome was satisfactory in 22 of 30 patients. Five of nine patients had neurologic improvement. Radiographic imaging findings showed a slight loss of reduction, but the clinical outcome of the patients was not affected. No pseudarthrosis and no implant failures were recorded. The Gertzbein classification correlates the type of fracture with the degree of mechanical instability and neurologic lesion. The load sharing classification correlates fracture comminution and displacement with mechanical stability and implant failure. Patient selection is a fundamental component for a successful outcome. The best candidates for surgery are cooperative patients who require spinal mobility, patients who are able to tolerate a two-stage reconstruction, and patients in good general health

Classificação de McCormack e colapso sagital na fratura toracolombar explosão McCormack classification and kyphotic deformity in thoracolumbar burst fractures

O aumento da cifose toracolombar após tratamento conservador da fratura tipo explosão é complicação constatada por vários autores. Realizamos estudo retrospectivo com 33 portadores de fratura toracolombar do tipo explosão submetidos ao tratamento conservador entre 1992 a 2004 para verificar a correlação entre a cifose toracolombar e a Classificação de McCormack, que pontua a gravidade da fratura conforme a cominuição do corpo, o deslocamento dos fragmentos no corpo vertebral e a quantidade de correção da deformidade em cifose após o tratamento. Após 30 meses de seguimento médio, verificamos correlação entre a pontuação da Classificação de McCormack, conhecida na literatura como load sharing classification, e o colapso vertebral sagital nestes pacientes (p<0,05;r=0,65). A despeito de ser descrita para avaliação do colapso sagital após o tratamento cirúrgico, a aplicabilidade desta Classificação pode ser considerada para os portadores de fratura toracolombar explosão submetidos ao tratamento conservador.<br>The increasing incidence of thoracolumbar kyphosis after conservative treatment of burst fractures is a complication reported by several authors. We performed a retrospective study on a consecutive series of 33 patients with thoracolumbar burst fractures treated with cast or brace immobilization between 1992 and 2004 to check for a correlation between thoracolumbar kyphosis and Load Sharing Classification, which provides fracture severity scores according to body comminution, vertebral body fragments displacement and the amount of kyphosis correction delivered after treatment. After an average of 30 months of follow-up we found a correlation between Load Sharing Classification scores (also known as McCormack's Classification), and the sagittal kyphotic deformity on these patients (p<0.05;r=0.65). Despite of being described for assessing sagittal deformity after surgical treatment, the applicability of this Classification can be considered for patients with thoracolumbar burst fractures submitted to conservative treatment

Treatment of unstable thoracolumbar junction burst fractures with short- or long-segment posterior fixation in magerl type a fractures

The treatment of thoracolumbar fractures remains controversial. A review of the literature showed that short-segment posterior fixation (SSPF) alone led to a high incidence of implant failure and correction loss. The aim of this retrospective study was to compare the outcomes of the SS- and long-segment posterior fixation (LSPF) in unstable thoracolumbar junction burst fractures (T12–L2) in Magerl Type A fractures. The patients were divided into two groups according to the number of instrumented levels. Group I included 32 patients treated by SSPF (four screws: one level above and below the fracture), and Group II included 31 patients treated by LSPF (eight screws: two levels above and below the fracture). Clinical outcomes and radiological parameters (sagittal index, SI; and canal compromise, CC) were compared according to demographic features, localizations, load-sharing classification (LSC) and Magerl subgroups, statistically. The fractures with more than 10° correction loss at sagittal plane were analyzed in each group. The groups were similar with regard to age, gender, LSC, SI, and CC preoperatively. The mean follow-ups were similar for both groups, 36 and 33 months, respectively. In Group II, the correction values of SI, and CC were more significant than in Group I. More than 10° correction loss occurred in six of the 32 fractures in Group I and in two of the 31 patients in Group II. SSPF was found inadequate in patients with high load sharing scores. Although radiological outcomes (SI and CC remodeling) were better in Group II for all fracture types and localizations, the clinical outcomes (according to Denis functional scores) were similar except Magerl type A33 fractures. We recommend that, especially in patients, who need more mobility, with LSC point 7 or less with Magerl Type A31 and A32 fractures (LSC point 6 or less in Magerl Type A3.3) without neurological deficit, SSPF achieves adequate fixation, without implant failure and correction loss. In Magerl Type A33 fractures with LSC point 7 or more (LSC points 8–9 in Magerl Type A31 and A32) without severe neurologic deficit, LSPF is more beneficial

Estudio comparativo del tratamiento ortésico en las fracturas toraco-lumbosacras según la gravedad del trauma Estudo comparativo do tratamento ortótico nas fraturas toraco-lombosacro segundo a gravidade do trauma Comparative study on orthotic treatment of thoraco-lumbo-sacral fractures according to severity of trauma

OBJETIVO: Determinar si la gravedad del trauma en lesiones toracolumbosacras mayores estables permite decidir la selección del tipo de ortesis en un tratamiento ortopédico. MÉTODOS: Estudio Retrospectivo de casos 12/1990 - 12/2006 (16 años). Criterios de Selección: 1) Seguimiento mínimo: 2 años. 2) Estudios radiológicos convencionales completos. 3) Ausencia de Litigio. 4) Tratamiento ortésico con TLSO a medida para los traumas de alta energía cinética y con ortesis prefabricadas para los de baja energía. 5) Tratamiento efectuado o supervisado por el autor Sénior. Evaluación por observadores independientes de Parámetros Geométricos (ángulo de Cobb sagital, cifosis vertebral, grado de colapso vertebral) pretratamiento y seguimiento en Rx simple, y Parámetros Funcionales (Dolor según SRS, Índice de Oswestry, Retorno a la Actividad Previa). Subdivisión de los diferentes tipos de fracturas (según AO y Denis) en Alta (Grupo A) y Baja Energía [Grupo B] de acuerdo con la energía cinética del trauma. Comparación de Parámetros Geométricos con Grupo Control. Análisis Estadístico: chi cuadrado y t-test de Student. RESULTADOS: 41 pacientes (44 fracturas] tratados (23 mujeres/18 varones), con 25 fracturas Grupo "A", y 19 Grupo "B". Edad promedio: 46 años (12 - 83). Seguimiento promedio: 4,5 años (2.2 - 15.5). Localización predominante: T11 - L2. Tipos Predominantes: tipo A (AO) o por compresión y por estallido. No hubo diferencias significativas en las mediciones efectuadas en cada grupo pretratamiento y al seguimiento. La única diferencia significativa entre grupos fue en la cifosis vertebral inicial tanto en general como según la clasificación AO entre los tipos A de alta y baja energía. La comparación al seguimiento de los parámetros geométricos entre grupo control y grupos A y B así como entre grupo control y cada tipo (AO/Denis) subdivididos en alta o baja energía, arrojó siempre diferencias significativas. Los parámetros funcionales al seguimiento mostraron siempre puntuaciones promedio buenas, con variaciones significativas entre grupos A y B. El retorno a la actividad previa fue del 90,6%, sin diferencias entre trabajadores de esfuerzo físico y de escritorio. CONCLUSIONES: Es posible lograr un Resultado Clínico Funcional satisfactorio a mediano plazo en las lesiones toracolumbosacras mayores estables seleccionando el tipo de ortesis según que el trauma sea de alta o baja energía cinética. Los resultados clínicos funcionales parecen ser mejores en los casos de Trauma de Alta Energía. Sin embargo, este tratamiento no mejora ni empeora los parámetros radiológicos sagitales.<br>OBJETIVO: Determinar se a gravidade do trauma toraco-lombo-sacro estável permite decidir o tipo de órteses na seleção do tratamento ortopédico. MÉTODOS: Estudo retrospectivo (16 anos). Critérios de inclusão: 1) Seguimento mínimo: 2 anos. 2) Estudos radiológicos convencionais completos. 3) Ausência de litígio. 4) Tratamento com TLSO feito à medida para trauma de alta energia cinética e órteses pré-fabricadas para trauma de baixa energia. 5) Tratamentos realizados ou supervisionados pelo autor sênior. Avaliação por observadores independentes de parâmetros geométricos (Cobb sagital, cifose da vértebra, grau de colapso vertebral anterior) iniciais e ao seguimento, e parâmetros funcionais (dor de acordo com a SRS, índice de Oswestry, retorno à atividade anterior). Subdivisão de diferentes tipos de fraturas (AO e Denis) proporcional à energia cinética do trauma, em (grupo A) alta energia e (grupo B) baixa energia. Comparação com o grupo de controle. Análise estatística: qui quadrado e teste tStudent. RESULTADOS: Estudos até 41 pacientes (44 fraturas, 23 mulheres/18 homens), 25 fraturas grupo "A" e 19 grupo "B". Média de idade: 46 anos (12-83). Seguimento médio: 4,5 anos (2,2 -15,5). Localização predominante: T11 - L2. Tipos predominantes: Tipo A (AO) ou por compressão e estalido. Não houve nenhuma diferença significativa entre medições iniciais e seguimento. A única diferença significativa entre os grupos foi a cifose inicial da coluna vertebral. Sempre houve dife renças na comparação dos parâmetros geométricos do grupo controle e os grupos A e B, e entre o grupo controle e cada tipo (AO/Denis) subdividido em alta ou baixa energia. As pontuações dos parâmetros funcionais finais sempre foram boas, com variações significativas entre os grupos A e B. CONCLUSÕES: É possível um bom resultado funcional em lesões toraco-lombo-sacrais estáveis, selecionando o tipo de órteses de acordo com a energia cinética do trauma. Esses resultados parecem ser melhores em traumas de alta energia tratados com dispositivos ortopédicos feitos à medida. No entanto, o tratamento ortésico diferenciado de acordo com a energia do trauma não altera os parâmetros radiológicos sagitais.<br>OBJECTIVE: To determine whether the severity of stable thoraco-lumbo-sacral trauma is useful for deciding the selection of brace type in orthopedic treatment. METHODS: Retrospective study (16 years length). Inclusion criteria: 1) Minimum follow-up: 2 years. 2) Complete conventional radiologic studies. 3) no litigation. 4) TLSO custom-made treatment for high kinetic energy trauma and pre-fabricated orthoses for low energy one. 5) Treatment performed or supervised by the senior author. Evaluation by independent observers of geometric Parameters (sagittal Cobb, vertebral kyphosis, anterior vertebral collapse) initially and at follow-up, and Functional Parameters (SRS pain scale, Oswestry Index, Return to Previous Activity). Subdivision of different fractures types (of AO and Denis classifications) in High (group A) and Low Energy (group b) according to the amount of kinetic energy of trauma. Comparison with a control group. Statistical analysis: chi square and Student t-test. RESULTS: Forty-one patients were studied (44 fractures, 23 females/18 males), 25 fractures group A and 19 group b. Average age: 46 years (12 - 83). Average follow-up: 4.5 years (2.2 - 15.5). Predominant location: T11 - L2. Predominant types: Type A (AO) or compression and burst. There were no significant differences between initial and follow-up measurements. The only significant difference between groups was in the initial vertebral kyphosis. However, there were always differences when comparing the geometric Parameters between control group and groups A and b, and between control group and each type (AO/Denis) subdivided into high or low energy. The final functional parameters scores were always good, with significant variations between groups A and b. CONCLUSIONS: A satisfactory functional result in stable thoraco-lumbo-sacral injuries is possible by selecting the type of brace according to the kinetic energy involved. Results appear to be better in High Energy Trauma treated with custom-made orthosis. However, the orthotic treatment according to trauma energy does not change the sagittal radiographic parameters