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

Levels of bone collagen markers in preterm infants: Relation to antenatal glucocorticoid treatment

Although the beneficial effects of antenatally administered glucocorticoids are well documented, data on the potential of adverse consequences are limited. The objective of this study was to determine the effects of antenatally administered glucocorticoids on biochemical markers of bone metabolism of 55 preterm infants with a gestational age of 24-34 weeks who were enrolled in the study. Neonates were divided into two groups according to antenatal exposure to corticosteroids. There were no significant differences between the groups in clinical characteristics and anthropometric variables. We studied blood levels of osteocalcin (OC), carboxy-terminal propeptide of type I procollagen (PICP), and carboxy-terminal telopeptide of type I collagen (ICTP) at the time of delivery, on postnatal day 10, and at 2 and 4 months of life. Comparing the groups, we found statistically significant reduction in PICP levels at birth in corticosteroid-exposed neonates (P < 0.05). The levels of bone markers increased progressively on the first days of life. There were no significant differences between groups in bone markers at 10 days or at 2 and 4 months of life. We found no significant difference for bone markers between groups of infants exposed to single or repeated maternal corticosteroid treatments. In summary, antenatal glucocorticoid treatments are suggested to have a negative impact on fetal bone formation as reflected by low PICP levels at birth. However, this negative effect on bone markers seems to be a temporary effect that subsides on the first days of life and afterward. © 2007 Springer-Verlag

Quantitative ultrasound measurements in premature infants at 1 year of age: The effects of antenatal administered corticosteroids

The aim of this study was to evaluate the effects of antenatally administered glucocorticoids on bone status of preterm infants at 1 year corrected age. The study population consisted of 32 preterm infants with a gestational age of 24-34 weeks. The infants were divided into two groups according to antenatal exposure to corticosteroids. Quantitative ultrasound (QUS) assessment of bone was performed in the study infants at the corrected age of 1 year. Blood levels of carboxy-terminal propeptide of type I procollagen (PICP) and carboxy-terminal telopeptide of type I collagen (ICTP) were measured at birth and at 1 year corrected age. Levels of PICP and ICTP were significantly lower at birth in corticosteroid-exposed neonates (P < 0.05). At corrected age of 12 months ICTP levels remained significantly lower in corticosteroid-exposed infants, but we found no significant difference in levels of the bone-formation marker PICP between corticosteroid-exposed and nonexposed infants. In the majority of participant preterm infants bone speed of sound (SOS) was within age-adjusted normal values of full-term infants. There was no significant difference in bone SOS between exposed and nonexposed infants at corrected age of 12 months. There was no correlation between SOS and levels of bone markers. The results of our study indicate that, despite the suppression of fetal bone turnover at birth in corticosteroid-exposed infants, antenatal glucocorticoid treatment seems to have no long-term impact on bone status of preterm infants assessed by QUS complementary to measurement of bone-turnover markers at 1 year corrected age. © 2010 Springer Science+Business Media, LLC

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