Abstract
Purpose
To critically review and summarize the literature comparing the results of surgery via an anterior approach and that via a posterior approach for the treatment of thoracolumbar burst fractures to identify the better approach.
Methods
In this meta-analysis, we conducted electronic searches of MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and other databases using the search terms “thoracolumbar fractures”, “anterior”, “posterior”, “controlled clinical trials”. Relevant journals or conference proceedings were also searched manually. Data extraction and quality assessment were in accordance with Cochrane Collaboration guidelines. The analysis was performed on individual patient data from all the trials that met the selection criteria. Sensitivity analysis was performed when there was significant heterogeneity. Results were expressed as risk difference for dichotomous outcomes and mean difference for continuous outcomes with 95 % confidence interval.
Results
Four randomized clinical trials and three controlled clinical trials comparing the results of the anterior versus posterior approach in the treatment of thoracolumbar burst fractures were retrieved; these studies included 179 and 152 patients in the anterior and posterior approach groups, respectively. There were no differences in terms of neurological recovery, return to work, complications and Cobb angle between the two groups. The anterior approach was associated with longer operative time, greater blood loss and higher cost than the posterior approach.
Conclusions
The posterior approach may be more effective than the anterior approach. However, more high-quality, randomized controlled trials are required to compare these approaches and guide clinical decision-making.
Level of Evidence Level II, therapeutic study. See the Guidelines for Authors for a complete description of level of evidence.
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References
Muller U, Berlemann U, Sledge J, Schwarzenbach O (1999) Treatment of thoracolumbar burst fractures without neurologic deficit by indirect reduction and posterior instrumentation: bisegmental stabilization with monosegmental fusion. Eur Spine J 8(4):284–289
Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S (1994) A comprehensive classification of thoracic and lumbar injuries. Eur Spine J 3(4):184–201
Oner FC, Ramos LM, Simmermacher RK, Kingma PT, Diekerhof CH, Dhert WJ, Verbout AJ (2002) Classification of thoracic and lumbar spine fractures: problems of reproducibility. A study of 53 patients using CT and MRI. Eur Spine J 11(3):235–245
Petersilge CA, Emery SE (1996) Thoracolumbar burst fracture: evaluating stability. Semin Ultrasound CT MR 17(2):105–113
Cho WS, Chung CK, Jahng TA, Kim HJ (2008) Post-laminectomy kyphosis in patients with cervical ossification of the posterior longitudinal ligament: does it cause neurological deterioration? J Korean Neurosurg Soc 43(6):259–264
Dai LY, Jiang LS, Jiang SD (2008) Conservative treatment of thoracolumbar burst fractures: a long-term follow-up results with special reference to the load sharing classification. Spine (Phila Pa 1976) 33(23):2536–2544
Post RB, van der Sluis CK, Leferink VJ, Ten DH (2009) Long-term functional outcome after type A3 spinal fractures: operative versus non-operative treatment. Acta Orthop Belgica 75(3):389–395
Thomas KC, Bailey CS, Dvorak MF, Kwon B, Fisher C (2006) Comparison of operative and nonoperative treatment for thoracolumbar burst fractures in patients without neurological deficit: a systematic review. J Neurosurg Spine 4(5):351–358
Heary RF, Salas S, Bono CM, Kumar S (2006) Complication avoidance: thoracolumbar and lumbar burst fractures. Neurosurg Clin N Am 17(3):377–388
Kim HS, Lee SY, Nanda A, Kim JY, Park JO, Moon SH, Lee HM, Kim HJ, Wei H, Moon ES (2009) Comparison of surgical outcomes in thoracolumbar fractures operated with posterior constructs having varying fixation length with selective anterior fusion. Yonsei Med J 50(4):546–554
Cresswell TR, Marshall PD, Smith RB (1998) Mechanical stability of the AO internal spinal fixation system compared with that of the Hartshill rectangle and sublaminar wiring in the management of unstable burst fractures of the thoracic and lumbar spine. Spine (Phila Pa 1976) 23(1):111–115
Parker JW, Lane JR, Karaikovic EE, Gaines RW (2000) Successful short-segment instrumentation and fusion for thoracolumbar spine fractures: a consecutive 41/2-year series. Spine (Phila Pa 1976) 25(9):1157–1170
Sjostrom L, Karlstrom G, Pech P, Rauschning W (1996) Indirect spinal canal decompression in burst fractures treated with pedicle screw instrumentation. Spine (Phila Pa 1976) 21(1):113–123
Carl AL, Tranmer BI, Sachs BL (1997) Anterolateral dynamized instrumentation and fusion for unstable thoracolumbar and lumbar burst fractures. Spine (Phila Pa 1976) 22(6):686–690
Dai LY, Jiang LS, Jiang SD (2009) Anterior-only stabilization using plating with bone structural autograft versus titanium mesh cages for two- or three-column thoracolumbar burst fractures: a prospective randomized study. Spine (Phila Pa 1976) 34(14):1429–1435
Kaneda K, Taneichi H, Abumi K, Hashimoto T, Satoh S, Fujiya M (1997) Anterior decompression and stabilization with the Kaneda device for thoracolumbar burst fractures associated with neurological deficits. J Bone Joint Surg Am 79(1):69–83
Dai LY, Jiang SD, Wang XY, Jiang LS (2007) A review of the management of thoracolumbar burst fractures. Surg Neurol 67(3):221–231
Tasdemiroglu E, Tibbs PA (1995) Long-term follow-up results of thoracolumbar fractures after posterior instrumentation. Spine (Phila Pa 1976) 20(15):1704–1708
Verlaan JJ, Diekerhof CH, Buskens E, van der Tweel I, Verbout AJ, Dhert WJ, Oner FC (2004) Surgical treatment of traumatic fractures of the thoracic and lumbar spine: a systematic review of the literature on techniques, complications, and outcome. Spine (Phila Pa 1976) 29(7):803–814
Handoll HH, Gillespie WJ, Gillespie LD, Madhok R (2008) The Cochrane Collaboration: a leading role in producing reliable evidence to inform healthcare decisions in musculoskeletal trauma and disorders. Indian J Orthop 42(3):247–251
Higgins JP, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses. BMJ 327(7414):557–560
Lau J, Ioannidis JP, Schmid CH (1997) Quantitative synthesis in systematic reviews. Ann Intern Med 127(9):820–826
Esses SI, Botsford DJ, Kostuik JP (1990) Evaluation of surgical treatment for burst fractures. Spine (Phila Pa 1976) 15(7):667–673
Danisa OA, Shaffrey CI, Jane JA, Whitehill R, Wang GJ, Szabo TA, Hansen CA, Shaffrey ME, Chan DP (1995) Surgical approaches for the correction of unstable thoracolumbar burst fractures: a retrospective analysis of treatment outcomes. J Neurosurg 83(6):977–983
Stancic MF, Gregorovic E, Nozica E, Penezic L (2001) Anterior decompression and fixation versus posterior reposition and semirigid fixation in the treatment of unstable burst thoracolumbar fracture: prospective clinical trial. Croat Med J 42(1):49–53
Wood KB, Bohn D, Mehbod A (2005) Anterior versus posterior treatment of stable thoracolumbar burst fractures without neurologic deficit: a prospective, randomized study. J Spinal Disord Tech 18(Suppl):S15–S23
Hitchon PW, Torner J, Eichholz KM, Beeler SN (2006) Comparison of anterolateral and posterior approaches in the management of thoracolumbar burst fractures. J Neurosurg Spine 5(2):117–125
Sasso RC, Renkens K, Hanson D, Reilly T, McGuire RJ, Best NM (2006) Unstable thoracolumbar burst fractures: anterior-only versus short-segment posterior fixation. J Spinal Disord Tech 19(4):242–248
Lin B, Chen ZW, Guo ZM, Liu H, Yi ZK (2011) Anterior approach versus posterior approach with subtotal corpectomy, decompression, and reconstruction of spine in the treatment of thoracolumbar burst fractures: a prospective randomized controlled study. J Spinal Disord Tech. doi:10.1097/BSD.0b013e3182204c53
Falavigna A, Righesso NO, Polesso MA, Franceschini PR (2007) Anterior approach in patients with traumatic compression fracture type of thoracolumbar spine (T11–L2). Arq Neuropsiquiatr 65(3B):906–911
Kuner EH, Kuner A, Schlickewei W, Mullaji AB (1994) Ligamentotaxis with an internal spinal fixator for thoracolumbar fractures. J Bone Joint Surg Br 76(1):107–112
Ha KI, Han SH, Chung M, Yang BK, Youn GH (1996) A clinical study of the natural remodeling of burst fractures of the lumbar spine. Clin Orthop Relat Res 323:210–214
Allain J (2011) Anterior spine surgery in recent thoracolumbar fractures: an update. Orthop Traumatol Surg Res 97(5):541–554
Scapinelli R, Candiotto S (1995) Spontaneous remodeling of the spinal canal after burst fractures of the low thoracic and lumbar region. J Spinal Disord 8(6):486–493
Shi R, Liu H, Zhao X, Liu X, Gong Q, Li T, Liu L, Zeng J, Song Y (2011) Anterior single segmental decompression and fixation for Denis B type thoracolumbar burst fracture with neurological deficiency: thirty-four cases with average twenty-six month follow-up. Spine (Phila Pa 1976) 36(9):E598–E605
Dai LY, Wang XY, Jiang LS (2007) Neurologic recovery from thoracolumbar burst fractures: is it predicted by the amount of initial canal encroachment and kyphotic deformity? Surg Neurol 67(3):232–237, 238
Tropiano P, Huang RC, Louis CA, Poitout DG, Louis RP (2003) Functional and radiographic outcome of thoracolumbar and lumbar burst fractures managed by closed orthopaedic reduction and casting. Spine (Phila Pa 1976) 28(21):2459–2465
McLain RF (2004) Functional outcomes after surgery for spinal fractures: return to work and activity. Spine (Phila Pa 1976) 29(4):470–477, Z6
Acknowledgments
The authors are grateful for the financial support of the Project of National Natural Science Foundation of China (No. 11072021) and Wu Jie Ping Medical Foundation (No. 320.6750.11017).
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Each author certifies that he has no commercial associations that might pose a conflict of interest with the submitted article.
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G. J. Xu and Z. J. Li equally contributed to the study.
X. Fu and X. L. Ma equally contributed to the corresponding author.
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Xu, G.J., Li, Z.J., Ma, J.X. et al. Anterior versus posterior approach for treatment of thoracolumbar burst fractures: a meta-analysis. Eur Spine J 22, 2176–2183 (2013). https://doi.org/10.1007/s00586-013-2987-y
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DOI: https://doi.org/10.1007/s00586-013-2987-y