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

A single posterior approach for multilevel modified vertebral column resection in adults with severe rigid congenital kyphoscoliosis: a retrospective study of 13 cases

We report a multilevel modified vertebral column resection (MVCR) through a single posterior approach and clinical outcomes for treatment of severe congenital rigid kyphoscoliosis in adults. Transpedicular eggshell osteotomies and vertebral column resection are two techniques for the surgical treatment of rigid severe spine deformities. The authors developed a new technique combining the two surgical methods as a MVCR, through a single posterior approach, for surgical treatment of severe congenital rigid kyphoscoliosis in adults. Thirteen adult patients with severe rigid congenital kyphoscoliosis deformity were treated by a single posterior approach using a MVCR technique. The surgery processes included a one-stage posterior transpedicular eggshell technique first, and then expanded the eggshell technique to adjacent intervertebra space through abrasive reduction of the vertebral cortices from inside out. All posterior vertebral elements were removed including the cortical vertebral bone around the neural canal. Range of resection of the vertebral column at the apex of the deformity included apical vertebra and both cephalic and/or caudal adjacent wedged vertebrae. Totally, 32 vertebrae had been removed in 13 patients, with 2.42 vertebrae being removed on average in each case. The average fusion extent was 7.69 vertebrae. Mean operation time was 266 min with average blood loss of 2,411.54 ml during operation. Patients were followed up for an average duration of 2.54 years. Deformity correction was 59% in the coronal plane (from 79.7° to 32.4°) postoperatively and 33.7° (57% correction) at 2 years follow-up. In the sagittal plane, correction was from preoperative 85.9° to 27.5° immediately after operation, and 32.0° at 2 years follow-up. Postoperative pain was reduced from preoperative 1.77 to 0.54 at 2 years follow-up in visual analog scale. SRS-24 scale was from 38.2 preoperatively to 76.9 at 2 years follow-up postoperative. Complications were encountered in four patients (30.7%) with transient neurology that spontaneously improved without further treatment within 3 months. MVCR technique through a single posterior approach is an effective procedure for the surgical treatment of severe congenital rigid kyphoscoliosis in adults

Sagittal plane deformity: an overview of interpretation and management

The impact of sagittal plane alignment on the treatment of spinal disorders is of critical importance. A failure to recognise malalignment in this plane can have significant consequences for the patient not only in terms of pain and deformity, but also social interaction due to deficient forward gaze. A good understanding of the principles of sagittal balance is vital to achieve optimum outcomes when treating spinal disorders. Even when addressing problems in the coronal plane, an awareness of sagittal balance is necessary to avoid future complications. The normal spine has lordotic curves in the cephalad and caudal regions with a kyphotic curve in between. Overall, there is a positive correlation between thoracic kyphosis and lumbar lordosis. There are variations on the degree of normal curvature but nevertheless this shape allows equal distribution of forces across the spinal column. It is the disruption of this equilibrium by pathological processes or, as in most cases, ageing that results in deformity. This leads to adaptive changes in the pelvis and lower limbs. The effects of limb alignment on spinal posture are well documented. We now also know that changes in pelvic posture also affect spinal alignment. Sagittal malalignment presents as an exaggeration or deficiency of normal lordosis or kyphosis. Most cases seen in clinical practise are due to kyphotic deformity secondary to inflammatory, degenerative or post-traumatic disorders. They may also be secondary to infection or tumours. There is usually pain and functional disability along with concerns about self-image and social interaction due to inability to maintain a horizontal gaze. The resultant pelvic and lower limb posture is an attempt to restore normal alignment. Addressing this complex problem requires detailed expertise and awareness of the potential pitfalls surrounding its treatment