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1.  Bone Cement Augmentation of Short Segment Fixation for Unstable Burst Fracture in Severe Osteoporosis 
Objective
The purpose of this study was to determine the efficacy of short segment fixation following postural reduction for the re-expansion and stabilization of unstable burst fractures in patients with osteoporosis.
Methods
Twenty patients underwent short segment fixation following postural reduction using a soft roll at the involved vertebra in cases of severely collapsed vertebrae of more than half their original height. All patients had unstable burst fracture with canal compromise, but their motor power was intact. The surgical procedure included postural reduction for 2 days and bone cement-augmented pedicle screw fixations at one level above, one level below and the fractured level itself. Imaging and clinical findings, including the level of the vertebra involved, vertebral height restoration, injected cement volume, local kyphosis, clinical outcome and complications were analyzed.
Results
The mean follow-up period was 15 months. The mean pain score (visual analogue scale) prior to surgery was 8.1, which decreased to 2.8 at 7 days after surgery. The kyphotic angle improved significantly from 21.6±5.8° before surgery to 5.2±3.7° after surgery. The fraction of the height of the vertebra increased from 35% and 40% to 70% in the anterior and middle portion. There were no signs of hardware pull-out, cement leakage into the spinal canal or aggravation of kyphotic deformities.
Conclusion
In the management of unstable burst fracture in patients with severe osteoporosis, short segment pedicle screw fixation with bone cement augmentation following postural reduction can be used to reduce the total levels of pedicle screw fixation and to correct kyphotic deformities.
doi:10.3340/jkns.2008.44.1.8
PMCID: PMC2588283  PMID: 19096650
Unstable burst fracture; Osteoporosis; Short segment fixation
2.  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
3.  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
4.  Implant Removal after Percutaneous Short Segment Fixation for Thoracolumbar Burst Fracture : Does It Preserve Motion? 
Objective
The purpose of this study was to evaluate the efficacy of implant removal of percutaneous short segment fixation after vertebral fracture consolidation in terms of motion preservation.
Methods
Between May 2007 and January 2011, 44 patients underwent percutaneous short segment screw fixation due to a thoracolumbar burst fracture. Sixteen of these patients, who underwent implant removal 12 months after screw fixation, were enrolled in this study. Motor power was intact in all patients, despite significant vertebral height loss and canal compromise. The patients were divided into two groups by degree of osteoporosis : Group A (n=8), the non-osteoporotic group, and Group B (n=8), the osteoporotic group. Imaging and clinical findings including vertebral height loss, kyphotic angle, range of motion (ROM), and complications were analyzed.
Results
Significant pain relief was achieved in both groups at final follow-up versus preoperative values. In terms of vertebral height loss, both groups showed significant improvement at 12 months after screw fixation and restored vertebral height was maintained to final follow-up in spite of some correction loss. ROM (measured using Cobb's method) in flexion and extension in Group A was 10.5° (19.5/9.0°) at last follow-up, and in Group B was 10.2° (18.8/8.6°) at last follow-up. Both groups showed marked improvement in ROM as compared with the screw fixation state, which was considered motionless.
Conclusion
Removal of percutaneous implants after vertebral fracture consolidation can be an effective treatment to preserve motion regardless of osteoporosis for thoracolumbar burst fractures.
doi:10.3340/jkns.2014.55.2.73
PMCID: PMC3958576  PMID: 24653799
Fusion; Percutaneous; Removal
5.  Percutaneous Cement-Augmented Screws Fixation in the Fractures of the Aging Spine: Is It the Solution? 
BioMed Research International  2014;2014:610675.
Introduction. Management of elderly patients with thoracolumbar fractures is still challenging due to frequent osteoporosis and risk of screws pull-out. The aim of this study was to evaluate results of a percutaneous-only procedure to treat these fragile patients using cement-augmented screws. Methods. 12 patients diagnosed with a thoracolumbar fracture associated with an important loss of bone stock were included in this prospective study. Surgical procedure included systematically a percutaneous osteosynthesis using cemented fenestrated screws. When necessary, additional anterior support was performed using a kyphoplasty procedure. Clinical and radiographic evaluations were performed using CT scan. Results. On the whole series, 15 fractures were diagnosed and 96 cemented screws were inserted. The difference between the pre- and postoperative vertebral kyphosis was statistically significant (12.9° versus 4.4°, P = 0.0006). No extrapedicular screw was reported and one patient was diagnosed with a cement-related pulmonary embolism. During follow-up period, no infectious complications, implant failures, or pull-out screws were noticed. Discussion. Aging spine is becoming an increasing public health issue. Management of these patients requires specific attention due to the augmented risk of complications. Using percutaneous-only screws fixation with cemented screw provides satisfactory results. A rigorous technique is mandatory in order to achieve best outcomes.
doi:10.1155/2014/610675
PMCID: PMC3950552
6.  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
7.  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
8.  Short segment pedicle screw instrumentation and augmentation vertebroplasty in lumbar burst fractures: an experience 
European Spine Journal  2008;17(3):336-341.
To assess the efficacy and feasibility of vertebroplasty and posterior short-segment pedicle screw fixation for the treatment of traumatic lumbar burst fractures. Short-segment pedicle screw instrumentation is a well described technique to reduce and stabilize thoracic and lumbar spine fractures. It is relatively a easy procedure but can only indirectly reduce a fractured vertebral body, and the means of augmenting the anterior column are limited. Hardware failure and a loss of reduction are recognized complications caused by insufficient anterior column support. Patients with traumatic lumbar burst fractures without neurologic deficits were included. After a short segment posterior reduction and fixation, bilateral transpedicular reduction of the endplate was performed using a balloon, and polymethyl methacrylate cement was injected. Pre-operative and post-operative central and anterior heights were assessed with radiographs and MRI. Sixteen patients underwent this procedure, and a substantial reduction of the endplates could be achieved with the technique. All patients recovered uneventfully, and the neurologic examination revealed no deficits. The post-operative radiographs and magnetic resonance images demonstrated a good fracture reduction and filling of the bone defect without unwarranted bone displacement. The central and anterior height of the vertebral body could be restored to 72 and 82% of the estimated intact height, respectively. Complications were cement leakage in three cases without clinical implications and one superficial wound infection. Posterior short-segment pedicle fixation in conjunction with balloon vertebroplasty seems to be a feasible option in the management of lumbar burst fractures, thereby addressing all the three columns through a single approach. Although cement leakage occurred but had no clinical consequences or neurological deficit.
doi:10.1007/s00586-008-0587-z
PMCID: PMC2270394  PMID: 18193300
Burst fractures; Spinal trauma; Pedicle screw; Kyphoplasty; Bone cement
9.  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
10.  Percutaneous augmented instrumentation of unstable thoracolumbar burst fractures 
European Spine Journal  2011;21(5):850-854.
Background
Internal fixation of unstable thoracolumbar spine fractures requires correction of the lacking anterior column support. This usually entails insertion of a vertebral body replacement strut through an anterior approach, or a long posterior construct spanning at least two vertebrae above and two vertebrae below the fracture. Posterior short-segment pedicle instrumentation (SSPI)—one vertebra above and below—is suitable for approximately 40% of fractures, but not for all.
Methods
A total of 52 patients with unstable thoracolumbar burst fractures meeting our inclusion criteria were instrumented using a novel approach, combining percutaneous SSPI, pedicle screw augmentation with polymethyl methacrylate (PMMA) and fractured vertebra kyphoplasty. We retrospectively reviewed patient and fracture data, operative results and 1 year radiographic follow-up postoperatively in 40 of the patients. We reviewed operative complications of all 52 patients.
Results
Most fractures were AO/Magerl type A3.1, A3.2 and A3.3. They were instrumented within 72 h and ambulated without additional external bracing. Operative time averaged 2 h and blood loss was less than 50 cc in most cases. Complications were mostly related to PMMA leakage. On average, 3.3° (0–13) of correction was lost after 3 months, but remained constant afterward.
Conclusions
Percutaneous augmented short-segment pedicle instrumentation of unstable thoracolumbar fractures can be done with short operative times, minimal blood loss and a low complication rate. The radiographical results at 1 year are equal to anterior stabilization and are better than other posterior-only techniques.
Electronic supplementary material
The online version of this article (doi:10.1007/s00586-011-2106-x) contains supplementary material, which is available to authorized users.
doi:10.1007/s00586-011-2106-x
PMCID: PMC3337906  PMID: 22160173
Spine; Fracture; Kyphoplasty; Pedicle; Trauma; Percutaneous instrumentation
11.  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
12.  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
13.  Radiological study on disc degeneration of thoracolumbar burst fractures treated by percutaneous pedicle screw fixation 
European Spine Journal  2012;22(3):489-494.
Objective
To examine disc degeneration at levels adjacent and next adjacent to the fractured vertebra and to analyses, if the disc degeneration is determined by the endplate fracture.
Summary of background data
Thoracolumbar burst fracture is one of the most common spinal injuries. The diagnostic (clinical and imaging) approach and treatment of a fractured vertebra is well established; however, some controversy remains. The associated disc degeneration is less well known after 9–12 months of the short segment pedicle screw fixations. There is a major controversy whether spinal trauma with vertebral endplate fractures can result in posttraumatic disc degeneration. No study to date, however, has assessed disc degeneration of the AO type A3 thoracolumbar fractures without neurologic deficits after pedicle screw fixations.
Methods
Twenty-six patients with single-level AO type A3 thoracolumbar fractures and no neurological deficit were treated by using postural reduction and short segment percutaneous pedicle screw fixation. No laminectomy and fusion were performed. Implants were removed 9–12 months after the first operation. The thoracolumbar magnetic resonance imaging (MRI) was used to assess disc degeneration at levels adjacent and next adjacent to the fractured vertebra before the first operation and after the second operation in a retrospective study.
Results
After the instrumentation removal, new disc degeneration was usually found at level adjacent to the cranial endplate of fractured vertebra by MRI examination in 24 patients. The average Pfirrmann grade of degenerative discs adjacent to the cranial fractured endplates deteriorated from 2.1 pre-operatively to 3.4 after the second operation. No change of disc degeneration was seen at the caudal disc space adjacent to the fractured vertebra and the levels next adjacent to the fractured vertebra. The discs next adjacent to the fractured vertebra were showed to be relatively normal without changes of degeneration during the study period.
Conclusions
Disc degeneration usually occurs at level adjacent to the fractured endplate of thoracolumbar burst fractures. Endplate fracture is strongly associated with disc degeneration. No correlation between fixation level and disc degeneration is seen in this study.
doi:10.1007/s00586-012-2462-1
PMCID: PMC3585651  PMID: 22890568
Disc degeneration; Thoracolumbar fracture; Endplate; Pedicle screw fixation; Minimally invasive surgery
14.  Failure of Cement-Augmented Pedicle Screws in the Osteoporotic Spine 
The treatment of patients with osteoporosis and spinal abnormalities that require surgical intervention is difficult because of the challenge of achieving fixation in osteoporotic bone. As the population ages, this challenge is becoming a common problem in the field of spinal surgery. Although numerous publications exist about the biomechanical benefits of various fixation devices and techniques, no standard of care has emerged that offers a clear method for accomplishing spinal stabilization in such patients. This case presents the failure mode of cement-augmented pedicle screws in a patient with severe osteoporosis, a description of the methods used to attain fixation and spinal stability during the revision surgery, and the outcome achieved for the patient 1 year after surgery. An 82-year-old female with a T9 burst fracture and a history of osteoporosis underwent minimally invasive instrumentation from T5 to T12, fusion from T7 to T11, and decompression from T8 to T10. Four weeks after surgery, the patient returned to the hospital because of back pain. Imaging studies showed that the pedicle screws at T11 and T12, which were augmented with polymethylmethacrylate (PMMA), had pulled out of the vertebral bodies. The pedicle screws failed by disengaging from the PMMA and displacing posteriorly and inferiorly. The PMMA did not appear to move during this process. A revision surgery was performed, in which the posterior construct was extended caudally and cephalad, the pedicle screws were augmented with PMMA, and a titanium hook and woven polyester band were used to increase the points of fixation. At 1-year follow-up after revision, our patient showed radiographic evidence of fusion, and the construct continued to maintain stability in the osteoporotic spine.
doi:10.1177/2151458513500787
PMCID: PMC3848329  PMID: 24319620
osteoporosis; bone cement; polymethylmethacrylate; cement augmentation; pedicle screw; failure
15.  Pedicle Screw Configuration for Thoracolumbar Burst Fracture Treatment: Short versus Long Posterior Fixation Constructs with and without Anterior Column Augmentation 
Asian Spine Journal  2014;8(1):35-43.
Study Design
An in-vitro study.
Purpose
The current study is aimed at investigating the differences in stability between short posterior fixation (SPF), hybrid posterior fixation (HPF), and long posterior fixation (LPF) with and without anterior column augmentation using calcium phosphate bone cement (CaP) for treating burst fractures (BFs).
Overview of Literature
The ideal treatment for thoracolumbar BF is controversial regarding the use of short or LPF constructs.
Methods
Seven human thoracolumbar spines (T9-L4) were tested on a six degree of freedom spine simulator in three physiologic planes, flexion-extension (FE), lateral bending (LB), and axial rotation (AR). Tested surgical constructs included the following: intact, injury (BF), SPF (T12-L2), HPF (T11-L2), LPF (T11-L3), SPF+CaP, HPF+CaP, LPF+CaP, and CaP alone (CaP). Range of motion (ROM) was recorded at T12-L2 in FE, LB, and AR.
Results
The reduction in mean ROM trended as follows: LPF>HPF>SPF. Only LPF constructs and HPF with anterior column augmentation significantly reduced mean ROM in FE and LB compared to the intact state. All instrumented constructs (SPF, HPF, and LPF) significantly reduced ROM in FE and LB compared to the injured condition. Furthermore, the instrumented constructs did not provide significant rotational stability. Injecting CaP provided minimal additional stability.
Conclusions
For the injury created, LPF and HPF provided better stability than SPF with and without anterior column augmentation. Therefore, highly unstable fractures may require extended, long or hybrid fusion constructs for optimum stability.
doi:10.4184/asj.2014.8.1.35
PMCID: PMC3939367  PMID: 24596603
Spine; Fracture fixations; Bone screws; Bone cements
16.  Percutaneous kyphoplasty and pedicle screw fixation for the management of thoraco-lumbar burst fractures 
European Spine Journal  2010;19(8):1281-1287.
The study design includes prospective evaluation of percutaneous osteosynthesis associated with cement kyphoplasty on 18 patients. The objective of the study is to assess the efficacy of a percutaneous method of treating burst vertebral fractures in patients without neurological deficits. Even if burst fractures are frequent, no therapeutic agreement is available at the moment. We report in this study the results at 2 years with a percutaneous approach for the treatment of burst fractures. 18 patients were included in this study. All the patients had burst vertebral fractures classified type A3 on the Magerl scale, between levels T9 and L2. The patients’ mean age was 53 years (range 22–78 years) and the neurological examination was normal. A percutaneous approach was systematically used and a kyphoplasty was performed via the transpedicular pathway associated with percutaneous short-segment pedicle screw osteosynthesis. The patients’ follow-up included CT scan analysis, measurement of vertebral height recovery and local kyphosis, and clinical pain assessments. With this surgical approach, the mean vertebral height was improved by 25% and a mean improvement of 11.28° in the local kyphotic angle was obtained. 3 months after the operation, none of the patients were taking class II analgesics. The mean duration of their hospital stay was 4.5 days (range 3–7 days) and the mean follow-up period was 26 months (range 17–30 months). No significant changes in the results obtained were observed at the end of the follow-up period. Minimally invasive methods of treating burst vertebral fractures can be performed via the percutaneous pathway. This approach gives similar vertebral height recovery and kyphosis correction rates to those obtained with open surgery. It provides a short hospital stay, however, and might therefore constitute a useful alternative to open surgical methods.
doi:10.1007/s00586-010-1444-4
PMCID: PMC2989205  PMID: 20496038
Percutaneous surgery; Burst fracture; Kyphoplasty; Pedicle screw fixation
17.  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
18.  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
19.  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
20.  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
21.  Short-segment Pedicle Instrumentation of Thoracolumbar Burst-compression Fractures; Short Term Follow-up Results 
Objective
The current literature implies that the use of short-segment pedicle screw fixation for spinal fractures is dangerous and inappropriate because of its high failure rate, but favorable results have been reported. The purpose of this study is to report the short term results of thoracolumbar burst and compression fractures treated with short-segment pedicle instrumentation.
Methods
A retrospective review of all surgically managed thoracolumbar fractures during six years were performed. The 19 surgically managed patients were instrumented by the short-segment technique. Patients' charts, operation notes, preoperative and postoperative radiographs (sagittal index, sagittal plane kyphosis, anterior body compression, vertebral kyphosis, regional kyphosis), computed tomography scans, neurological findings (Frankel functional classification), and follow-up records up to 12-month follow-up were reviewed.
Results
No patients showed an increase in neurological deficit. A statistically significant difference existed between the patients preoperative, postoperative and follow-up sagittal index, sagittal plane kyphosis, anterior body compression, vertebral kyphosis and regional kyphosis. One screw pullout resulted in kyphotic angulation, one screw was misplaced and one patient suffered angulation of the proximal segment on follow-up, but these findings were not related to the radiographic findings. Significant bending of screws or hardware breakage were not encountered.
Conclusion
Although long term follow-up evaluation needs to verified, the short term follow-up results suggest a favorable outcome for short-segment instrumentation. When applied to patients with isolated spinal fractures who were cooperative with 3-4 months of spinal bracing, short-segment pedicle screw fixation using the posterior approach seems to provide satisfactory result.
doi:10.3340/jkns.2007.42.4.265
PMCID: PMC2588206  PMID: 19096554
Pedicle screw instrumentation; Thoracolumbar fracture; Short-segment; Fixation
22.  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
23.  Spondylolisthesis Accompanying Bilateral Pedicle Stress Fracture at Two Vertebrae 
There has been no report of bilateral pedicle stress fractures involving two vertebrae. The authors describe a unique case of spondylolisthesis accompanying a bilateral pedicle stress fracture involving two vertebrae. De novo development of spondylolisthesis at the L5-S1 vertebrae accompanying a bilateral pedicle stress fracture at L4 and L5 was observed in a 70-year-old woman. The patient's medical history was unremarkable and she did not have any predisposing factors except severe osteoporosis. Interbody fusion with bone cement augmented screw fixation was performed. Surgical treatment resulted in good pain management and improved functional recovery.
doi:10.3340/jkns.2012.51.6.388
PMCID: PMC3424184  PMID: 22949973
Spondylolisthesis; Bilateral pedicle fracture; Osteoporosis
24.  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
25.  Fenestrated pedicle screws for cement-augmented purchase in patients with bone softening: a review of 21 cases 
Background
This prospective mixed cohort study was designed to evaluate the middle- to long-term purchase of cement-augmented pedicular screws in patients with poor bone quality. The growing number of surgical procedures performed in the spine has highlighted the problem of screws loosening in patients with poor bone stock due to osteoporosis and/or tumors. Different methods of increasing screw purchase have been reported in the literature, including polymethylmethacrylate (PMMA) augmentation.
Materials and methods
From September 2006 to April 2008, 21 patients with a poor bone stock condition due to osteoporosis or tumor underwent posterior stabilization by fenestrated pedicle screws and PMMA augmentation. Pain improvement and long-term clinical outcome were assessed by visual analogue scale (VAS) score and SF-36 health survey (SF-36) questionnaire. Implant stability was evaluated by plain radiography and CT scans performed three days after surgery and every three months thereafter. After the first 12 months, radiologic controls were taken once a year in all surviving patients. Complications were evaluated in all cases.
Results
All patients were clinically and radiographically followed up for a mean of 36 months. VAS scores and SF-36 questionnaires showed a statistically significant reduction in pain and improvement in the quality of life. No radiological loosening or pulling out of screws was observed. In two cases, cement leakage occurred intraoperatively: one patient who suffered from a transitory nerve root palsy improved spontaneously, while the surgeon immediately removed the excess cement before setting in the other case. In three cases, the post-op CT scan revealed a small amount of cement in the canal without clinical relevance.
Conclusions
Fenestrated screws for cement augmentation provided effective and lasting purchase in patients with poor bone quality due to osteoporosis or tumors. No case of loosening was recorded after a mean follow-up of 36 months. The only clinical complication strictly related to PMMA screw augmentation did not require further surgery.
doi:10.1007/s10195-011-0164-9
PMCID: PMC3225622  PMID: 22065147
Fenestrated pedicle screw; Polymethylmethacrylate; Osteoporotic bone; Spine tumor

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