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1.  Fusion versus Nonfusion for Surgically Treated Thoracolumbar Burst Fractures: A Meta-Analysis 
PLoS ONE  2013;8(5):e63995.
Background
Posterior pedicle screw fixation has become a popular method for treating thoracolumbar burst fractures. However, it remains unclear whether additional fusion could improve clinical and radiological outcomes. This meta-analysis was performed to evaluate the effectiveness of fusion as a supplement to pedicle screw fixation for thoracolumbar burst fractures.
Methodology/Principal Findings
MEDLINE, OVID, Springer, and Google Scholar were searched for relevant randomized and quasi-randomized controlled trials that compared the clinical and radiological efficacy of fusion versus nonfusion for thoracolumbar burst fractures managed by posterior pedicle screw fixation. Risk of bias in included studies was assessed using the Cochrane Risk of Bias tool. We generated pooled risk ratios or weighted mean differences across studies. Based on predefined inclusion criteria, 4 eligible trials with a total of 220 patients were included in this meta-analysis. The mean age of the patients was 35.1 years. 96.8% of the fractures were located at T12 to L1 level. Baseline characteristics were similar between the fusion and nonfusion groups. No significant difference was identified between the two groups regarding radiological outcome, functional outcome, neurologic improvement, and implant failure rate. The pooled data showed that the nonfusion group was associated with significantly reduced operative time (p<0.0001) and blood loss (p  = 0.0003).
Conclusions/Significances
The results of this meta-analysis suggested that fusion was not necessary when thoracolumbar burst fracture was treated by posterior pedicle screw fixation. More randomized controlled trials with high quality are still needed in the future.
doi:10.1371/journal.pone.0063995
PMCID: PMC3660321  PMID: 23704968
2.  Posterior short segment pedicle screw fixation and TLIF for the treatment of unstable thoracolumbar/lumbar fracture 
Background
Currently, Posterior Short Segment Pedicle Screw Fixation is a popular procedure for treating unstable thoracolumbar/lumbar burst fracture. But progressive kyphosis and a high rate of hardware failure because of lack of the anterior column support remains a concern. The efficacy of different methods remains debatable and each technique has its advantages and disadvantages.
Methods
A consecutive series of 20 patients with isolated thoracolumbar/lumbar burst fractures were treated by posterior short segment pedicle screw fixation and transforaminal thoracolumbar/lumbar interbody fusion (TLIF) between January 2005 and December 2007. All patients were followed up for a minimum of 2 years. Demographic data, neurologic status, anterior vertebral body heights, segmental Cobb angle and treatment-related complications were evaluated.
Results
The mean operative time was 167 minutes (range, 150–220). Blood loss was 450 ~ 1200 ml, an average of 820 ml. All patients recovered with solid fusion of the intervertebral bone graft, without main complications like misplacement of the pedicle screw, nerve or vessel lesion or hard ware failure. The post-operative radiographs demonstrated a good fracture reduction and it was well maintained until the bone graft fusion. Neurological recovery of one to three Frankel grade was seen in 14 patients with partial neurological deficit, three grades of improvement was seen in one patient, two grades of improvement was observed in 6 patients and one grade of improvement was found in 6 patients. All the 6 patients with no paraplegia on admission remained neurological intact, and in one patient with Frankel D on admission no improvement was observed.
Conclusion
Posterior short-segment pedicle fixation in conjunction with TLIF seems to be a feasible option in the management of selected thoracolumbar/lumbar burst fractures, thereby addressing all the three columns through a single approach with less trauma and good results.
doi:10.1186/1471-2474-15-40
PMCID: PMC3930337  PMID: 24517217
Short segment fixation; Thoracic vertebrae; Lumbar vertebrae; Unstable burst fractures; Pedicle screw; TLIF
3.  Short segment fixation of thoracolumbar burst fractures without fusion 
European Spine Journal  1999;8(6):495-500.
There continues to be controversy surrounding the management of thoracolumbar burst fractures. Numerous methods of fixation have been described for this injury, but to our knowledge, spinal fusion has always been part of the stabilising procedure, whether this involves an anterior or a posterior approach. Apart from an earlier publication from this centre, there have been no reports on the use of internal fixation without fusion for this type of fracture. The aim of the study was to determine the outcome of patients with thoracolumbar burst fractures who were treated with short segment pedicle screw fixation without fusion. This is a retrospective review of 28 consecutive patients who had short segment pedicle screw fixation of thoracolumbar burst fractures without fusion performed between 1990 and 1993. All patients underwent a clinical and radiological assessment by an independent observer. Outcome was measured using the Low Back Outcome Score. The minimum follow-up period was 2 years (mean 3.1 years). Fifty percent of patients achieved an excellent result with the Low Back Outcome Score, while 12% were assessed as good, 20% fair and 16% obtained a poor result. The only significant factor affecting outcome was the influence of a compensation claim (P < 0.05). The implant failure rate (14% of patients) and the clinical outcome was similar to that from series where fusion had been performed in addition to pedicle screw fixation. The results of this study support the view that posterolateral bone grafting is not necessary when managing patients with thoracolumbar burst fractures by short segment pedicle screw fixation.
doi:10.1007/s005860050212
PMCID: PMC3611215  PMID: 10664310
Key words Burst fractures; Outcome; Short segment fixation; Fusion
4.  Short Segment Fixation for Thoracolumbar Burst Fracture Accompanying Osteopenia : A Comparative Study 
Objective
The purpose of this study was to compare the results of three types of short segment screw fixation for thoracolumbar burst fracture accompanying osteopenia.
Methods
The records of 70 patients who underwent short segment screw fixation for a thoracolumbar burst fracture accompanying osteopenia (-2.5< mean T score by bone mineral densitometry <-1.0) from January 2005 to January 2008 were reviewed. Patients were divided into three groups based on whether or not bone fusion and bone cement augmentation procedure 1) Group I (n=26) : short segment fixation with posterolateral bone fusion; 2) Group II (n=23) : bone cement augmented short segment fixation with posterolateral bone fusion; 3) Group III (n=21) : bone cement augmented, short segment percutaneous screw fixation without bone fusion. Clinical outcomes were assessed using a visual analogue scale and modified MacNab's criteria. Radiological findings, including kyphotic angle and vertebral height, and procedure-related complications, such as screw loosening or pull-out, were analyzed.
Results
No significant difference in radiographic or clinical outcomes was noted between patients managed using the three different techniques at last follow up. However, Group I showed more correction loss of kyphotic deformities and vertebral height loss at final follow-up, and Group I had higher screw loosening and implant failure rates than Group II or III.
Conclusion
Bone cement augmented procedure can be an efficient and safe surgical techniques in terms of achieving better outcomes with minimal complications for thoracolumbar burst fracture accompanying osteopenia.
doi:10.3340/jkns.2013.53.1.26
PMCID: PMC3579078  PMID: 23440679
Burst fracture; Osteopenia; Fusion
5.  Outcome of Pedicle Screw Fixation and Monosegmental Fusion in Patients with Fresh Thoracolumbar Fractures 
Asian Spine Journal  2014;8(3):298-308.
Study Design
Prospective clinical study.
Purpose
The present prospective study aims to evaluate the clinical, radiological, and functional and quality of life outcomes in patients with fresh thoracolumbar fractures managed by posterior instrumentation of the spine, using pedicle screw fixation and monosegmental fusion.
Overview of Literature
The goals of treatment in thoracolumbar fractures are restoring vertebral column stability and obtaining spinal canal decompression, leading to early mobilization of the patient.
Methods
Sixty-six patients (46 males and 20 females) of thoracolumbar fractures with neurological deficit were stabilized with pedicle screw fixation and monosegmental fusion. Clinical, radiological and functional outcomes were evaluated.
Results
The mean preoperative values of Sagittal index, and compression percentage of the height of the fractured vertebra were 22.75° and 46.73, respectively, improved (statistically significant) to 12.39°, and 24.91, postoperatively. The loss of correction of these values at one year follow-up was not statistically significant. The mean preoperative canal compromise (%) improved from 65.22±17.61 to 10.06±5.31 at one year follow-up. There was a mean improvement in the grade of 1.03 in neurological status from the preoperative to final follow-up at one year. Average Denis work scale index was 4.1. Average Denis pain scale index was 2.5. Average WHOQOL-BREF showed reduced quality of life in these patients. Patients of early surgery group (operated within 7 days of injury) had a greater mean improvement of neurological grade, radiological and functional outcomes than those in the late surgery group, but it was not statistically significant.
Conclusions
Posterior surgical instrumentation using pedicle screws with posterolateral fusion is safe, reliable and effective method in the management of fresh thoracolumbar fractures. Fusion helps to decrease the postoperative correction loss of radiological parameters. There is no correlation between radiographic corrections achieved for deformities and functional outcome and quality of life post spinal cord injury.
doi:10.4184/asj.2014.8.3.298
PMCID: PMC4068849  PMID: 24967043
Thoracolumbar; Fractures; Pedicle screws; Neurological involvement; Functional outcome; Radiological outcome
6.  Treatment of acute thoracolumbar burst fractures with kyphoplasty and short pedicle screw fixation: Transpedicular intracorporeal grafting with calcium phosphate: A prospective study 
Indian Journal of Orthopaedics  2007;41(4):354-361.
Background:
In the surgical treatment of thoracolumbar fractures, the major problem after posterior correction and transpedicular instrumentation is failure to support the anterior spinal column, leading to loss of correction and instrumentation failure with associated complaints. We conducted this prospective study to evaluate the outcome of the treatment of acute thoracolumbar burst fractures by transpedicular balloon kyphoplasty, grafting with calcium phosphate cement and short pedicle screw fixation plus fusion.
Materials and Methods:
Twenty-three consecutive patients of thoracolumbar (T9 to L4) burst fracture with or without neurologic deficit with an average age of 43 years, were included in this prospective study. Twenty-one from the 23 patients had single burst fracture while the remaining two patients had a burst fracture and additionally an adjacent A1-type fracture. On admission six (26%) out of 23 patients had neurological deficit (five incomplete, one complete). Bilateral transpedicular balloon kyphoplasty with liquid calcium phosphate to reduce segmental kyphosis and restore vertebral body height and short (three vertebrae) pedicle screw instrumentation with posterolateral fusion was performed. Gardner kyphosis angle, anterior and posterior vertebral body height ratio and spinal canal encroachment were calculated pre- to postoperatively.
Results:
All 23 patients were operated within two days after admission and were followed for at least 12 months after index surgery. Operating time and blood loss averaged 45 min and 60 cc respectively. The five patients with incomplete neurological lesions improved by at least one ASIA grade, while no neurological deterioration was observed in any case. The VAS and SF-36 (Role physical and Bodily pain domains) were significantly improved postoperatively. Overall sagittal alignment was improved from an average preoperative 16° to one degree kyphosis at final followup observation. The anterior vertebral body height ratio improved from 0.6 preoperatively to 0.9 (P<0.001) postoperatively, while posterior vertebral body height improved from 0.95 to 1 (P<0.01). Spinal canal encroachment was reduced from an average 32% preoperatively to 20% postoperatively. Cement leakage was observed in four cases (three anterior to vertebral body and one into the disc without sequalae). In the last CT evaluation, there was a continuity between calcium phosphate and cancellous vertebral body bone. Posterolateral radiological fusion was achieved within six months after index operation. There was no instrumentation failure or measurable loss of sagittal curve and vertebral height correction in any group of patients.
Conclusions:
Balloon kyphoplasty with calcium phosphate cement secured with posterior short fixation in the thoracolumbar spine provided excellent immediate reduction of posttraumatic segmental kyphosis and significant spinal canal clearance and restored vertebral body height in the fracture level.
doi:10.4103/0019-5413.37000
PMCID: PMC2989509  PMID: 21139791
Balloon kyphoplasty; calcium phosphate; neurological deficit; pedicle screw; short internal fixation; thoracolumbar vertebral fracture; transpedicular grafting
7.  Transpedicular hydroxyapatite grafting with indirect reduction for thoracolumbar burst fractures with neurological deficit: A prospective study 
Indian Journal of Orthopaedics  2007;41(4):368-373.
Background:
The major problem after posterior correction and instrumentation in the treatment of thoracolumbar burst fractures is failure to support the anterior spinal column leading to loss of correction of kyphosis and hardware breakage. We conducted a prospective consecutive series to evaluate the outcome of the management of acute thoracolumbar burst fractures by transpedicular hydroxyapatite (HA) grafting following indirect reduction and pedicle screw fixation.
Materials and Methods:
Eighteen consecutive patients who had thoracolumbar burst fractures and associated incomplete neurological deficit were operatively treated within four days of admission. Following indirect reduction and pedicle screw fixation, transpedicular intracorporeal HA grafting to the fractured vertebrae was performed. Mean operative time was 125 min and mean blood loss was 150 ml. Their implants were removed within one year and were prospectively followed for at least two years.
Results:
The neurological function of all 18 patients improved by at least one ASIA grade, with nine (50%) patients demonstrating complete neurological recovery. Sagittal alignment was improved from a mean preoperative kyphosis of 17°to −2°(lordosis) by operation, but was found to have slightly deteriorated to 1° at final followup observation. The CT images demonstrated a mean spinal canal narrowing preoperatively, immediate postoperative and at final followup of 60%, 22% and 11%, respectively. There were no instances of hardware failure. No patient reported severe pain or needed daily dosages of analgesics at the final followup. The two-year postoperative MRI demonstrated an increase of one grade in disc degeneration (n = 17) at the disc above and in 11 patients below the fractured vertebra. At the final followup, flexion-extension radiographs revealed that a median range of motion was 4, 6 and 34 degrees at the cranial segment of the fractured vertebra, caudal segment and L1-S1, respectively. Bone formation by osteoconduction in HA granules was unclear, but final radiographs showed healed fractures.
Conclusions:
Posterior indirect reduction, transpedicular HA grafting and pedicle screw fixation could prevent the development of kyphosis and should lead to reliable neurological improvement in patients with incomplete neurological deficit. This technique does not require fusion to a segment, thereby preserves thoracolumbar motion.
doi:10.4103/0019-5413.37002
PMCID: PMC2989521  PMID: 21139793
Pedicle screw fixation; thoracolumbar burst fracture; transpedicular hydroxyapatite grafting
8.  Posterior lumbar interbody fusion versus posterolateral fusion in spondylolisthesis: a prospective controlled study in the Han nationality 
International Orthopaedics  2008;33(4):1043-1047.
In this prospective study, our aim was to compare the clinical outcome of posterior lumbar interbody fusion (PLIF) and posterolateral fusion (PLF) in spondylolisthesis. A total of 138 patients with spondylolisthesis were randomly assigned to two groups: those operated on with pedicle screw fixation and posterior lumbar interbody fusion by autografting (PLIF), and those operated on with pedicle screw fixation and posterolateral fusion by autografting (PLF). The patients were followed-up for four years. Clinical evaluation was carried out using the Oswestry disability index (ODI) and pain index (VAS). Radiography was performed preoperatively and postoperatively to assess the fusion. Both surgical procedures were effective, but the PLF group showed more complications related to hardware biomechanics. There was no significant statistical difference in clinical and functional outcome in the two groups. The PLIF group presented a better fusion rate than the PLF group.
doi:10.1007/s00264-008-0588-x
PMCID: PMC2898976  PMID: 18521599
9.  Treatment of unstable thoracolumbar junction burst fractures with short- or long-segment posterior fixation in magerl type a fractures 
European Spine Journal  2007;16(8):1145-1155.
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.
doi:10.1007/s00586-007-0310-5
PMCID: PMC2200786  PMID: 17252216
Thoracolumbar fracture; Classification; Spinal instrumentation; Short/long
10.  Two levels above and one level below pedicle screw fixation for the treatment of unstable thoracolumbar fracture with partial or intact neurology 
Background
Treatment of unstable thoracolumbar fractures is controversial regarding short or long segment pedicle screw fixation. Although long level fixation is better, it can decrease one motion segment distally, thus increasing load to lower discs.
Methods
We retrospectively analyzed 31 unstable thoracolumbar fractures with partial or intact neurology. All patients were operated with posterior approach using pedicle screws fixed two levels above and one level below the fracture vertebra. No laminectomy, discectomy or decompression procedure was done. Posterior fusion was achieved in all. Post operative and at final follow-up radiological evaluation was done by measuring the correction and maintenance of kyphotic angle at thoracolumbar junction. Complications were also reported including implant failure.
Results
Average follow-up was 34 months. All patients had full recovery at final follow-up. Average kyphosis was improved from 26.7° to 4.1° postoperatively and to 6.3° at final follow-up. And mean pain scale was improved from 7.5 to 3.9 postoperatively and to 1.6 at final follow-up, All patients resumed their activity within six months. Only 4 (12%) complications were noted including only one hardware failure.
Conclusion
Two levels above and one level below pedicle screw fixation in unstable thoracolumbar burst fracture is useful to prevent progressive kyphosis and preserves one motion segment distally.
doi:10.1186/1749-799X-4-28
PMCID: PMC2724433  PMID: 19635134
11.  Posterior pedicle screw fixation with supplemental laminar hook fixation for the treatment of thoracolumbar burst fractures 
Canadian Journal of Surgery  2008;51(1):35-40.
Surgical treatment of thoracolumbar burst fractures with posterior short-segment pedicle fixation usually provides excellent initial correction of kyphotic deformity, but a significant amount of correction can be lost afterwards. This study evaluates the clinical relevance of the short-segment pedicle fixation supplemented by laminar hooks (2HS-1SH) construct in the surgical treatment of thoracolumbar burst fractures. Twenty-five patients with a single-level thoracolumbar burst fracture were assessed in this retrospective study. All patients were followed for a minimum of 1 year (mean 2.9 [standard deviation {SD}] 1.5 y). Preoperative vertebral height loss and local kyphosis were 35% (SD 14%) and 19° (SD 9°), respectively. Mean corrections of vertebral height and kyphosis were 10% (SD 16%) and 12° (SD 9°), respectively. Mean loss of correction at last follow-up was 2% (SD 6%) and 4° (SD 3°) for vertebral height and kyphosis, respectively. Loss of correction was significant for local kyphosis (p < 0.001) but not for vertebral height (p = 0.20). Despite the significant loss of correction for local kyphosis, it remained improved at latest follow-up when compared with the preoperative value (p < 0.001). For patients with more than 2 years of follow-up, most of the loss of correction in local kyphosis occurred during the first postoperative year. There was no evidence of instrumentation failure or pseudarthrosis in any patient. The 2HS-1SH construct provides significant correction of vertebral body height and local kyphosis. It also preserves the initial correction and minimizes the risk of instrumentation failure.
PMCID: PMC2386299  PMID: 18248703
12.  Thoracolumbar burst fractures with a neurological deficit treated with posterior decompression and interlaminar fusion 
European Spine Journal  2011;20(12):2195-2201.
Introduction
To our knowledge, thoracolumbar burst fractures with a neurological deficit treated with posterior decompression and interlaminar fusion have never been reported. Our study was to assess the outcome of posterior decompression and interlaminar fusion in treating thoracolumbar burst fractures with a neurological deficit.
Materials and methods
Forty-one patients suffering from thoracolumbar burst fractures with a neurological deficit were included this study. All patients were treated with posterior decompression, interlaminar fusion and short-segment fixation of the vertebrae above and below the fracture level and the fractured vertebrae.
Results
All patients were followed up for at least 24 months after surgery. Operative time and blood loss averaged 72 min and 325 ml, respectively. Thirty-eight patients with incomplete neurological lesions improved, by at least one American Spine Injury Association grade, whereas no neurological deterioration was observed in any case. Overall sagittal alignment improved from an average preoperative 22.4°–4.6° kyphosis at the final follow-up observation. The anterior vertebral body height ratio improved from 0.61 before surgery to 0.90 after surgery, whereas posterior vertebral body height ratio improved from 0.90 to 0.95. Spinal canal encroachment was reduced from an average 61.5% before surgery to 8.7% after surgery. Interlaminar radiological fusion was achieved within 6–8 months after surgery. No instrumentation failure was found in any patients.
Conclusion
Posterior decompression, interlaminar fusion with posterior short-segment fixation provided excellent immediate reduction for traumatic segmental kyphosis and significant spinal canal clearance, and restored vertebral body height in the fracture level in patients with a thoracolumbar burst fracture and associated neurological deficit.
doi:10.1007/s00586-011-1875-6
PMCID: PMC3229728  PMID: 21688000
Burst fracture; Neurological deficit; Thoracolumbar spine; Fusion
13.  Comparison of Surgical Outcomes in Thoracolumbar Fractures Operated with Posterior Constructs Having Varying Fixation Length with Selective Anterior Fusion 
Yonsei Medical Journal  2009;50(4):546-554.
Purpose
Surgical treatment in the case of thoracolumbar burst fractures is very controversial. Posterior instrumentation is most frequently used, however, but the number of levels to be instrumented still remains a matter of debate.
Materials and Methods
A total of 94 patients who had a single burst fracture between T11 and L2 were selected and were managed using posterior instrumentation with anterior fusion when necessary. They were divided into three groups as follows; Group I (n = 28) included patients who were operated by intermediate segment fixation, Group II (n = 32) included patients operated by long segment fixation, and Group III (n = 34) included those operated by intermediate segment fixation with a pair of additional screws in the fractured vertebra. The mean follow-up period was twenty one months. The outcomes were analyzed in terms of kyphosis angle (KA), regional kyphosis angle (RA), sagittal index (SI), anterior height compression rate, Frankel classification, and Oswestry Disability Index questionnaire.
Results
In Groups II and III, the correction values of KA, RA, and SI were much better than in Group I. At the final follow up, the correction values of KA (6.3 and 12.1, respectively) and SI (6.2 and 12.0, respectively) were in Groups II and III found to be better in the latter.
Conclusion
The intermediate segment fixation with an additional pair of screws at the fracture level vertebra gives results that are comparable or even better than long segment fixation and gives an advantage of preserving an extra mobile segment.
doi:10.3349/ymj.2009.50.4.546
PMCID: PMC2730618  PMID: 19718404
Thoracolumbar burst fracture; posterior instrumentation; intermediate segment fixation; fixation length; selective anterior fusion
14.  Short Same-Segment Fixation of Thoracolumbar Burst Fractures 
Introduction
Minimizing the number of vertebral levels involved in fusion of a spine fracture is a common goal of internal fixation. This is achievable by utilizing traditional short-segment posterior fixation (SSPF). However, in SSPF there is reported up to a 54% incidence of instrument failure or unfavorable clinical outcome. Short-segment posterior fixation with pedicle fixation at the level of the fracture (short same-segment fixation) suggests biomechanical advantages toward maintenance of kyphosis correction and reducing failure rates. However its clinical efficacy is largely unknown.
Methods
The team conducted a retrospective review of 25 thoracolumbar burst fracture patients who were treated with short same-segment fixation between September 2005 and April 2009. The primary outcome measure was incidence of reoperation and loss of kyphosis correction within the follow-up period. Long-term functional status and pain was also assessed.
Results
Average duration of the most recent follow-up was 21.64 months (range 3 to 42 months). Two patients (8%) required reoperation due to either hardware failure or pseudoarthrosis. Mean pre-operative kyphosis was 14.49°. Average post-operative kyphosis was −0.74° (lordosis). Average follow-up kyphosis of all cases was 10.78°. Excluding failures, average follow-up kyphosis was 8.67°. A mean of 15.23° of kyphosis correction was attained from pre-operation to post-operation (P < 0.0001). Average loss of kyphosis correction from immediate post-operation to most recent follow-up was −11.51° and −9.51 excluding the two failures (P < 0.0001). Average pre-operative to most-recent follow-up kyphosis correction was 3.72° (P = 0.067) and 5.51° excluding failures (P = 0.0024). At initial one-month follow-up, average disability score was 52.63% (range 16% to 84%). At most recent follow-up, average disability score was 5.5% (range 0% to 16%). One patient was lost to long-term follow-up. Mean difference from one-month follow-up to most recent follow-up (excluding failures) was 47.27% (P < 0.0001).
Conclusions
Short same-segment fixation decreases implantation failure rate and reoperation rate compared to traditional SSPF, however long-term kyphosis correction was not maintained. Despite this loss of kyphosis correction, clinical pain and disability improved at long-term follow-up.
PMCID: PMC3298433  PMID: 22413100
short-segment posterior fixation; thoracolumbar burst fracture; kyphosis correction
15.  Fluoroscopically-guided indirect posterior reduction and fixation of thoracolumbar burst fractures without fusion 
International Orthopaedics  2008;33(5):1329-1334.
This article presents an evaluation of fluoroscopy for indirect, posterior reduction and fixation of thoracolumbar burst fractures. A prospective study of 25 patients with thoracolumbar burst fractures who underwent C-arm machine-guided posterior indirect reduction and short segment fixation without fusion is described. No laminotomies were performed. All patients had a mean follow-up of 30.4 months. At postoperative review, the average anterior and posterior vertebral heights were corrected from 57.9% to 99.0% and 89.0% to 99.5%, respectively. The Cobb angle was corrected from 18.4° to 0.17°. The canal compromise ratio was improved from 35.2% to 8.6%. In all 25 cases, neurological status was intact at last follow-up. Fluoroscopy guidance is an effective method to accomplish indirect reduction and fixation. Reduction was confirmed on lateral fluoroscopic views by looking for a “one-line sign,” which is the reconstitution of the posterior border of the vertebral body.
doi:10.1007/s00264-008-0626-8
PMCID: PMC2899138  PMID: 18661132
16.  Open reduction and internal fixation of posterior pilon fractures with buttress plate 
Acta Ortopedica Brasileira  2014;22(1):48-53.
Objective:
Posterior pilon fractures are rare injuries and have not yet gained well recognition. The purpose of this study was to present the treatment outcome for patients with posterior pilon fractures treated with buttress plate.
Method:
In this retrospective study we identified patients with posterior pilon fractures of the distal tibia who had undergone open reduction and internal fixation at our institute. Between January 2007 and December 2009, 10 patients (mean age, 46.5 years) who had undergone buttress plating via either a posterolateral approach or a dual posterolateral-posteromedial approach, were selected. All 10 patients were available for follow-up. The clinical outcome was evaluated with the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and the visual analogue scale (VAS). The radiological evaluation was performed using the osteoarthritis-score (OA-score).
Results:
Satisfactory reduction and stable fixation were accomplished in all patients. At a mean follow-up of 36.2 months, all patients had good radiological results and showed satisfactory clinical recovery. The mean AOFAS sore was 87.8, the mean OA-score was 0.6, and the mean VAS scores during rest, active motion, and weight-bearing walking were 0.6, 0.8, and 1.4, respectively.
Conclusion:
Buttress plating for posterior pilon fractures gave satisfactory clinical outcomes. It also ensured rigid fixation which in turn enabled earlier postoperative mobilization. Level of Evidence IV, Retrospective Study.
doi:10.1590/S1413-78522014000100009
PMCID: PMC3952872  PMID: 24644421
Tibial fractures; Ankle injuries; Internal fixators; Bone plates
17.  Recombinant bone morphogenetic protein-7 as an intracorporal bone growth stimulator in unstable thoracolumbar burst fractures in humans: preliminary results 
European Spine Journal  1999;8(6):485-490.
The study presented here is a pilot study in five patients with unstable thoracolumbar spine fractures treated with transpedicular OP-1 transplantation, short segment instrumentation and posterolateral fusion. Recombinant bone morphogenetic protein-7 in combination with a collagen carrier, also referred to as OP-1, has demonstrated ability to induce healing in long-bone segmental defects in dogs, rabbits and monkeys and to induce successful posterolateral spinal fusion in dogs without need for autogenous bone graft. Furthermore OP-1 has been demonstrated to be effective as a bone graft substitute when performing the PLIF maneuver in a sheep model. Five patients with single-level unstable burst fracture and no neurological impairment were treated with intracorporal OP-1 transplantation, posterior fixation (USS) and posterolateral fusion. One patient with osteomalacia and an L2 burst fracture had an additional intracorporal transplantation performed proximal to the instrumented segment, i.e. OP-1 into T 12 and autogenous bone into T 11. Follow-up time was 12–18 months. On serial radiographs, Cobb and kyphotic angles, as well as anterior, middle and posterior column heights, were measured. Serial CT scans were performed to determine the bone mineral density at fracture level.
In one case, radiographic and CT evaluation after 3 and 6 months showed severe resorption at the site of transplantation, but after 12 months, new bone had started to fill in at the area of resorption. In all cases there was loss of correction with regard to anterior and middle column height and sagittal balance at the latest follow-up. These preliminary results regarding OP-1 as a bone graft substitute and stimulator of new bone formation have been disappointing, as the OP-1 device in this study was not capable of inducing an early sufficient structural bone support. There are indications to suggest that OP-1 application to a fracture site in humans might result in detrimental enhanced bone resorption as a primary event.
doi:10.1007/s005860050210
PMCID: PMC3611219  PMID: 10664308
Key words Thoracolumbar burst fractures; Recombinant human bone morphogenetic protein-7; Transpedicular transplantation; Clinical results; Bone graft; substitute
18.  Short Segment Screw Fixation without Fusion for Unstable Thoracolumbar and Lumbar Burst Fracture : A Prospective Study on Selective Consecutive Patients 
Objective
The purpose of this prospective study was to evaluate the efficacy and safety of screw fixation without bone fusion for unstable thoracolumbar and lumbar burst fracture.
Methods
Nine patients younger than 40 years underwent screw fixation without bone fusion, following postural reduction using a soft roll at the involved vertebra, in cases of burst fracture. Their motor power was intact in spite of severe canal compromise. The surgical procedure included postural reduction for 3 days and screw fixations at one level above, one level below and at the fractured level itself. The patients underwent removal of implants 12 months after the initial operation, due to possibility of implant failure. Imaging and clinical findings, including canal encroachment, vertebral height, clinical outcome, and complications were analyzed.
Results
Prior to surgery, the mean pain score (visual analogue scale) was 8.2, which decreased to 2.2 at 12 months after screw fixation. None of the patients complained of worsening of pain during 6 months after implant removal. All patients were graded as having excellent or good outcomes at 6 months after implant removal. The proportion of canal compromise at the fractured level improved from 55% to 35% at 12 months after surgery. The mean preoperative vertebral height loss was 45.3%, which improved to 20.6% at 6 months after implant removal. There were no neurological deficits related to neural injury. The improved vertebral height and canal compromise were maintained at 6 months after implant removal.
Conclusion
Short segment pedicle screw fixation, including fractured level itself, without bone fusion following postural reduction can be an effective and safe operative technique in the management of selected young patients suffering from unstable burst fracture.
doi:10.3340/jkns.2012.51.4.203
PMCID: PMC3377876  PMID: 22737299
Screw fixation; Burst fracture; Bone fusion
19.  Inclusion of the fracture level in short segment fixation of thoracolumbar fractures 
European Spine Journal  2010;19(10):1651-1656.
Short segment posterior fixation is the preferred method for stabilizing thoracolumbar fractures. In case of significant disruption of the anterior column, the simple short segment construct does not ensure adequate stability. In this study, we tried to evaluate the effect of inclusion of the fractured vertebra in short segment fixation of thoracolumbar fractures. In a prospective randomized study, eighty patients with thoracolumbar fractures treated just with posterior pedicular fixation were randomized into two groups receiving either the one level above and one level below excluding the fracture level (bridging group), or including the fracture level (including group). Different clinical and radiological parameters were recorded and followed. A sum of 80 patients (42 patients in group 1 and 38 patients in group 2) were enrolled in the study. The patients in both the groups showed similar clinical outcome. There was a high rate of instrumentation failure in the “bridging” group. The “bridging” group showed a mean worsening (29%) in kyphosis, whereas the “including” group improved significantly by a mean of 6%. The significant effect of the “including” technique on the reduction of kyphotic deformity was most prominent in type C fractures. In conclusion, inclusion of the fracture level into the construct offers a better kyphosis correction, in addition to fewer instrument failures, without additional complications, and with a comparable-if not better-clinical and functional outcome. We recommend insertion of screws into pedicles of the fractured thoracolumbar vertebra when considering a short segment posterior fixation, especially in Magerl type C fractures.
doi:10.1007/s00586-010-1449-z
PMCID: PMC2989232  PMID: 20495932
Thoracolumbar instrumentation; Short segment; Including; Pedicular fixation; Fracture level
20.  Long-term results of transpedicle body augmenter in treating burst fractures 
Indian Journal of Orthopaedics  2007;41(4):362-367.
Background:
Short-segment fixation alone to treat thoracolumbar burst fractures is common but it has a 20-50% incidence of implant failure and rekyphosis. A transpedicle body augmenter (TpBA) to reinforce the vertebral body via posterior approach has been reported to prevent implant failure and increase the clinical success rate in treating burst fracture. This article is to evaluate the longterm results of short-segment fixation with TpBA for treatment of thoracolumbar burst fractures.
Materials and Methods:
Patients included in the study had a single-level burst fracture involving T11-L2 and no distraction or rotation element with limited neurological deficit. Patients in the control group (n = 42) were treated with short-segment posterior instrumentation alone, whereas patients in the augmented group (n = 90) were treated with a titanium spacer designed for transpedicle body reconstruction. The followup was 48-101 months. The radiographic and clinical results were evaluated and compared by Student's t test and Fisher's exact test.
Results:
The blood loss, operation time and hospitalization were similar in both the groups. The immediate postoperative anterior vertebral restoration rate of the augmented group was similar to that of the control group (97.6% ± 2.4% vs. 96.6% ± 3.2%). The final anterior vertebral restoration was greater in the augmented group than in the control group (93.3% ± 3.4% vs. 62.5% ± 11.2%). Immediate postoperative kyphotic angles were not significantly different between the groups (3.0° ± 1.8° vs. 5.1° ± 2.3°). The final kyphotic angles were less in the augmented group than the control group (7.3° ± 3.5° vs. 20.1° ± 5.4°). The augmented group had less (P < 0.001) implant failure [0% (n=0) vs. 23.8% (n=10)] for the control group) and more patients (P < 0.001) with no pain or minimal or occasional pain (Grade P1 or P2) than the control group [90.0% (n=81) vs. 66.7% (n=28)]. All patients in the augmented group and 39 (92.8%) patients in the control group experienced neurological recovery to Frankel Grade E. Three patients in the control group had improvement to Frankel Grade D from Frankel Grade C, but later had deterioration to Frankel Grade C because of loosening and dislodgement of the implant.
Conclusion:
Posterior body reconstruction with TpBA can maintain kyphosis correction and vertebral restoration, prevent implant failure and lead to better clinical results.
doi:10.4103/0019-5413.37001
PMCID: PMC2989517  PMID: 21139792
Burst fractures; kyphosis; posterior instrumentation; spinal trauma; thoracolumbar injury; transpedicle body augmenter
21.  Posterior internal fixation plus vertebral bone implantation under navigational aid for thoracolumbar fracture treatment 
The aim of this study was to investigate the method of posterior thoracolumbar vertebral pedicle screw reduction and fixation combined with vertebral bone implantation via the affected vertebral body under navigational aid for the treatment of thoracolumbar fractures. The efficacy of the procedure was also measured. Between June 2005 and March 2011, posterior thoracolumbar vertebral pedicle screw reduction and fixation plus artificial bone implantation via the affected vertebral pedicle under navigational aid was used to treat 30 patients with thoracolumbar fractures, including 18 males and 12 females, ranging in age from 21 to 57 years. Compared with the values prior to surgery, intraspinal occupation, vertebral height ratio and Cobb angle at the follow-up were significantly improved. At the long-term follow-up, the postoperative Cobb angle loss was <1° and the anterior vertebral body height loss was <2 mm. Posterior thoracolumbar vertebral pedicle screw reduction and fixation combined with vertebral bone implantation via the affected vertebral body under navigational aid may increase the accuracy and safety of surgery, and it is an ideal method of internal implantation. Bone implantation via the affected vertebral body may increase vertebral stability.
doi:10.3892/etm.2013.1087
PMCID: PMC3735901  PMID: 23935737
spine surgery; thoracolumbar fracture; internal fixation; computer-assisted surgery; bone transplantation
22.  Management of Unstable Thoracolumbar Spinal Fractures by Pedicle Screws and Rods Fixation 
Background: The thoracolumbar junction is the most common area of injury to the axial skeleton. Forces along the long stiff kyphotic thoracic spine switch abruptly into the mobile lordotic lumbar spine at the thoracolumbar junction. Goals of treatment are to obtain a painless, balanced, stable spine with optimum neurological function and maximum spine mobility. The present prospective study has evaluated the effectiveness of pedicle screw instrumentation in various fractures around the TL spine to overcome the complications encountered in the conservative line of management of these fractures.
Materials & Methods: Thirty cases of fractures around the TL spine were operated with posterior pedicle screw fixation one or two level above and below the fracture. The cases were followed up for a mean of 9.5 months with radiological and neurological evaluation.
Results: The average age groups of the patients studied were 21 to 53 years majority were males, fall from height being the predominant mode of injury involving the T12 and L1 vertebral body. The unstable burst fractures the most common type of fracture, radiological parameters sagittal angle and index were recorded pre and post-operatively. The neurological grading was done using the ASIA score. Follow-up was done for a minimum of 5 months where sagittal angle reduction achieved was 10.75 at final follow-up from 23.5 pre-operative. The sagittal index achieved at final follow-up was 72% compared to the pre-operative mean of 53%. The neurological improvement was regarded to be fair enough for the type of injury sustained and fixation achieved.
Conclusion: We found that the application of posterior instrumentation using pedicle screw and rod resulted in a reasonable correction of the deformity with a significant reduction in recumbency-associated complications; the limiting factor being the small study group and short follow-up period.
doi:10.7860/JCDR/2014/5505.4025
PMCID: PMC3972526  PMID: 24701500
Thoracolumbars; pedicle screw and rod instrumentation
23.  Treatment of thoracolumbar burst fractures without neurologic deficit by indirect reduction and posterior instrumentation: bisegmental stabilization with monosegmental fusion 
European Spine Journal  1999;8(4):284-289.
This study retrospectively reviews 20 sequential patients with thoracolumbar burst fractures without neurologic deficit. All patients were treated by indirect reduction, bisegmental posterior transpedicular instrumentation and monosegmental fusion. Clinical and radiological outcome was analyzed after an average follow-up of 6.4 years. Re-kyphosis of the entire segment including the cephaled disc was significant with loss of the entire postoperative correction over time. This did not influence the generally benign clinical outcome. Compared to its normal height the fused cephalad disc was reduced by 70% and the temporarily spanned caudal disc by 40%. Motion at the temporarily spanned segment could be detected in 11 patients at follow-up, with no relation to the clinical result. Posterior instrumentation of thoracolumbar burst fractures can initially reduce the segmental kyphosis completely. The loss of correction within the fractured vertebral body is small. However, disc space collapse leads to eventual complete loss of segmental reduction. Therefore, posterolateral fusion alone does not prevent disc space collapse. Nevertheless, clinical long-term results are favorable. However, if disc space collapse has to prevented, an interbody disc clearance and fusion is recommended.
doi:10.1007/s005860050175
PMCID: PMC3611180  PMID: 10483830
Key words Lumbar spine; Burst fracture; Transpedicular; instrumentation; Monosegmental; fusion
24.  The effect of postoperative immobilization on short-segment fixation without bone grafting for unstable fractures of thoracolumbar spine 
Indian Journal of Orthopaedics  2009;43(2):197-204.
Background:
Controversy regarding the fixation level for the management of unstable thoracolumbar spine fractures exists. Often poor results are reported with short-segment fixation. The present study is undertaken to compare the effect of fixation level and variable duration of postoperative immobilization on the outcome of unstable thoracolumbar burst fractures treated by posterior stabilization without bone grafting.
Patients and Methods:
A randomized, prospective, and consecutive series was conducted at a tertiary level medical center. Thirty-six neurologically intact (Frankel type E) thoracolumbar burst fracture patients admitted at our institute between February 2003 and December 2005 were randomly divided into three groups. Group I (n = 15) and II (n = 11) patients were treated by short-segment fixation, while Group III (n = 10) patients were treated by long-segment fixation. In Group I ambulation was delayed to 10th-14th postoperative day, while group II and III patients were mobilized on third postoperative day. Anterior body height loss (ABHL) percentage and increase in kyphosis as measured by Cobb's angle were calculated preoperatively, postoperatively, and at follow-up. Denis Pain Scale and Work Scales were obtained during follow-up.
Results:
Mean follow-up was 13.7 months (range 3-27 months). At the final follow-up the mean ABHL was 4.73% in group I compared with 16.2% in group II and 6.20% in group III. The mean Cobb's angle loss was 1.8° in group I compared with 5.91° in group II and 2.3° in group III. The ABHL difference between groups I and II was significant (P = 0.0002), while between groups I and III was not significant (P = 0.49).
Conclusion:
The short-segment fixation with amenable delayed ambulation is a valid option for the management of thoracolumbar burst fractures, as radiological results are comparable to that of long-segment fixation with the advantage of preserving maximum number of motion segments.
doi:10.4103/0019-5413.41870
PMCID: PMC2762247  PMID: 19838371
Delayed ambulation; dorsolumbar spine fracture; posterior fixation; short segment vs long segment
25.  Efficacy analysis of pedicle screw internal fixation of fractured vertebrae in the treatment of thoracolumbar fractures 
The present study aimed to discuss the method and effect of posterior internal fixation of thoracolumbar fractures strengthened by the vertical stress pedicle screw fixation of fractured vertebrae. Patients with single thoracolumbar fractures were examined retrospectively. Fourteen patients (group A) had been treated with vertical stress pedicle screw fixation of a fractured vertebra and sixteen patients (group B) received traditional double-plate fixation, as a control. All patients were diagnosed with fresh fractures with a complete unilateral or bilateral pedicle and no explosion of the inferior half of the vertebral body or inferior endplate. In group A, patients received conventional posterior distraction and lumbar lordosis restoration, as well as pedicle screws in the fractured vertebra in a vertical direction to relieve stress to achieve a local stress balance. All patients were followed up postoperatively for 4–18 months (average, 12.6 months). The vertical stress pedicle screw fixation assisted in the reduction of vertebrae fracture, which reduced the postoperative Cobb’s angle loss. There was a significant difference in the change of Cobb’s angle between the two groups one year after surgery (P<0.01). Conditional application of pedicle screws in a single thoracolumbar fracture enhances the stability of the internal fixation system and is conducive to the correction of kyphosis and maintenance of the corrective effects.
doi:10.3892/etm.2013.914
PMCID: PMC3570186  PMID: 23407593
vertical stress; pedicle screw; fractured vertebra

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