Bony Healing of Unstable Thoracolumbar Burst Fractures in the Elderly Using Percutaneously Applied Titanium Mesh Cages and a Transpedicular Fixation System with Expandable Screws

<div><p>Introduction</p><p>There is a high incidence of vertebral burst fractures following low velocity trauma in the elderly. Treatment of unstable vertebral burst fractures using the same principles like in stable vertebral burst fractures may show less favourable results in terms of fracture reduction, maintenance of reduction and cement leakage. In order to address these shortcomings this study introduces cementless fixation of unstable vertebral burst fractures using internal fixators and expandable intravertebral titanium mesh cages in a one-stage procedure via minimum-invasive techniques.</p><p>Material and Methods</p><p>A total of 16 consecutive patients (median age 76 years, range 58–94) with unstable thoracolumbar burst fractures and concomitant osteoporosis were treated by an internal fixator inserted via minimum invasive technique one level above and below the fractured vertebra. Fracture reduction was achieved and maintained by transpedicular placement of two titanium mesh cages into the fractured vertebral body during the same procedure. Intra- and postoperative safety of the procedure as well as analysis of reduction quality was analysed by 3D C-arm imaging or CT, respectively. Clinical and radiographic follow-up averaged 10.4 months (range 4.5–24.5).</p><p>Results</p><p>Stabilization of the collapsed vertebral body was achieved in all 16 cases without any intraoperative complication. Surgical time averaged 102±6.6 minutes (71–194). The postoperative kyphotic angle (KA) and Cobb angle revealed significant improvements (KA 13.7° to 7.4°, p<0.001; Cobb 9.6° to 6.0°, p<0.002) with partial loss of reduction at final follow-up (KA 8.3°, Cobb 8.7°). VAS (Visual Analogue Scale) improved from 7.6 to 2.6 (p<0.001). Adjacent fractures were not observed. One minor (malposition of pedicle screw) complication was encountered.</p><p>Conclusion</p><p>Cementless fixation of osteoporotic burst fractures revealed substantial pain relief, adequate maintenance of reduction and a low complication rate. Bony healing after unstable osteoporotic burst fractures is possible.</p><p>Trial Registration</p><p>www.germanctr.de <a href="http://www.germanctr.de/DRKS00005657" target="_blank">DRKS00005657</a></p></div

Radiographic evaluation for changes in vertebral body kyphotic angel (KA) and and Cobb angle alignment pre-/postoperatively and for final follow-up.

<p>* pre-surgery vs. post-surgery p<0.001, pre-surgery vs. follow-up p<0.001; # post-surgery vs. follow-up p<0.026;° pre-surgery vs. post-surgery p<0.002.</p

Pain level rated by VAS during the study period (0 = no pain, 10 = maximum pain).

<p>* p<0.001 0 p.o.d.- 1 p.o.d., p<0.001 1 p.o.d.- 3 p.o.d., p<0.001 0 p.o.d.– 3 p.o.d, p<0.001 0 p.o.d. / 1 p.o.d.—final follow-up.</p><p>** Secondary diagnosis: c cardiovascular, p pulmonary, r renal, h haematological, n neurological, g gastrointestinal, e endocrine.</p><p>Pain level rated by VAS during the study period (0 = no pain, 10 = maximum pain).</p

Radiographic measurement of vertebral body height in sagittal alignment using 6 defined points: A and B on the most dorsal-superior and—inferior endplate margins, E and F correspond to the most anterior-superior and—inferior margins, C and D are on the midpoint of a perpendicular line drawn from A to E and B to F on the superior and inferior vertebral endplates.

<p>Cobb- and vertebra body kyphotic angle.</p

Radiographs pre- (a-e), post-surgery (f-l) and for final follow-up (m,n) showing a T1 burst fracture and operative treatment by an internal fixateur one level above and below the fractured vertebra body and reduction by transpedicular placement of two titanium mesh cages, all via minimum invasive technique.

<p>Radiographs pre- (a-e), post-surgery (f-l) and for final follow-up (m,n) showing a T1 burst fracture and operative treatment by an internal fixateur one level above and below the fractured vertebra body and reduction by transpedicular placement of two titanium mesh cages, all via minimum invasive technique.</p

Radiographic evaluation for vertebral body reduction in sagittal alignment pre-/postoperatively and for final follow-up (Ha = anterior vertebral body height, Hm = middle vertebral body height, Hp = posterior vertebral body height).

<p>* pre-surgery vs. post-surgery p<0.033; # post-surgery vs. follow-up p<0.008.</p

Consort 2010 flowchart.

<p>Consort 2010 flowchart.</p

Radiological angle determination.

<p><b>(a and b): Radiological follow up evaluation. Determining the α- and γ-kyphotic angles.</b></p

Changes in ODI and VAS.

<p>(32 fractures in 24 patients) – preoperative, 3 days postoperative and at 12-month follow-up.</p

Changes in sagittal spine alignment.

<p>(32 fractures in 24 patients) – preoperative, 3 days postoperative and after 12-month follow-up.</p