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Percutaneous short-segment pedicle screw placement without fusion in the treatment of thoracolumbar burst fractures: is it effective?: comparative study with open short-segment pedicle screw fixation with posterolateral fusion

  • Clinical Article - Spine
  • Published:
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Abstract

Background

Since introduction of the pedicle screw-rod system, short-segment pedicle screw fixation has been widely adopted for thoracolumbar burst fractures (TLBF). Recently, the percutaneous pedicle screw fixation (PPSF) systems have been introduced in spinal surgery; and it has become a popularly used method for the treatment of degenerative spinal disease. However, there are few clinical reports concerning the efficacy of PPSF without fusion in treatment of TLBF. The purpose of this study was to determine the efficacy and safety of short-segment PPSF without fusion in comparison to open short-segment pedicle screw fixation with bony fusion in treatment of TLBF.

Methods

This study included 59 patients, who underwent either percutaneous (n = 32) or open (n = 27) short-segment pedicle screw fixation for stabilization of TLBF between December 2003 and October 2009. Radiographs were obtained before surgery, immediately after surgery, and at the final follow-up for assessment of the restoration of the spinal column. For radiologic parameters, Cobb angle, vertebral wedge angle, and vertebral body compression ratio were assessed on a lateral thoracolumbar radiograph. For patient’s pain and functional assessment, the visual analogue scale (VAS), the Frankel grading system, and Low Back Outcome Score (LBOS) were measured. Operation time, and the amount of intraoperative bleeding loss were also evaluated.

Findings

In both groups, regional kyphosis (Cobb angle) showed significant improvement immediately after surgery, which was maintained until the last follow up, compared with preoperative regional kyphosis. Postoperative correction loss showed no significant difference between the two groups at the final follow-up. In the percutaneous surgery group, there were significant declines of intraoperative blood loss, and operation time compared with the open surgery group. Clinical results showed that the percutaneous surgery group had a lower VAS score and a better LBOS at three months and six months after surgery; however, the outcomes were similar in the last follow-up.

Conclusions

Both open and percutaneous short-segment pedicle fixation were safe and effective for treatment of TLBF. Although both groups showed favorable clinical and radiologic outcomes at the final follow-up, PPSF without bone graft provided earlier pain relief and functional improvement, compared with open TPSF with posterolateral bony fusion. Despite several shortcomings in this study, the result suggests that ongoing use of PPSF is recommended for the treatment of TLBF.

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Acknowledgments

This study was supported by a grant (CRI11064-1) from the Chonnam National University Hospital Research Institute of Clinical Medicine.

Conflicts of interest

None.

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Authors and Affiliations

  1. Department of Neurosurgery, Chonnam National University Medical School & Research Institute of Medical Sciences, Gwangju, South Korea

    Jung-Kil Lee, Jae-Won Jang, Tae-Wan Kim, Tae-Sun Kim & Soo-Han Kim

  2. Department of Neurosurgery, Gwangju Wooridul Spine Hospital, Gwangju, South Korea

    Sung-Jun Moon

  3. Department of Neurosurgery, Chonnam National University Hospital, 671, Jebongno, Dong-gu, Gwangju, 501-757, South Korea

    Jae-Won Jang

Authors
  1. Jung-Kil Lee
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  2. Jae-Won Jang
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Correspondence to Jae-Won Jang.

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Comment

Over the last decade, the “minimally invasive” spine surgery has been developing in the attempt to minimize the impact of spinal procedures on patients. Minimally invasive fixation techniques using a percutaneous approach have been also developed generally for degenerative spinal disorders.

This study supports the hypothesis that percutaneous spine fixation can be effectively applied to a subgroup of thoraco-lumbar spine fractures without neural compression and relevant spinal canal encroachment, producing a clinical advantage in terms of a reduction of immediate post-surgery and mid-term pain. Results of this non-randomized study also suggest that percutaneous surgery may limit bleeding and the need for blood transfusions, an issue that may increase the infection risk and the length of hospital stay.

The percutaneous technique may decrease muscle atrophy that causes postoperative pain and loss of muscle strength. This could possibly influence the degenerative process of adjacent levels over the long term, a point that was not analyzed in this study and so warranting further studies. Furthermore, this study does not address the issue of fixation without bony fusion in relation to different subtypes of thoraco-lumbar fractures with different degrees of disc and vertebral body involvement. Percutaneous fixation without grafting seems to be suitable for minimally displaced Magerl Type A1 and A2 fractures, Type A3 (but not A3.3 or complete burst) fractures and Type B2 fractures. For other fracture types, with disc disruption or extensive collapse of the vertebral body, a bone graft to be added through an anterior approach or by using combined miniopen/percutaneous techniques seems to grant better results in the long-term.

Alfredo Conti

University of Messina, ITALY

The authors present a retrospective review of thoracolumbar burst fractures treated with percutaneous, short-segment, pedicle screw stabilization compared to a similar group of patients stabilized using an open technique with fusion. Although not specifically stated, the percutaneous group was compared to a historical control group based on a mean follow-up that was nearly a year longer. Both groups had similar improvement in sagittal alignment after reduction and stabilization. Furthermore, the improvement in Cobb angle was maintained through final follow-up in both groups. Finally, the neurologic outcomes were the same for both groups. This suggests that the percutaneous technique for pedicle screw placement in thoracolumbar burst fractures is equivalent to an open, short-segment, pedicle screw stabilization with posterior fusion. Several advantages are attained with the percutaneous technique including less soft tissue trauma, minimal blood loss, decreased risk of deep infection and avoidance of graft donor site complications. This study corroborates the maintenance of sagittal correction seen in other recent studies using short segment pedicle screw constructs as well as those comparing pedicle screw stabilization with and without fusion.

H.Louis Harkey

Mississippi, USA

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Lee, JK., Jang, JW., Kim, TW. et al. Percutaneous short-segment pedicle screw placement without fusion in the treatment of thoracolumbar burst fractures: is it effective?: comparative study with open short-segment pedicle screw fixation with posterolateral fusion. Acta Neurochir 155, 2305–2312 (2013). https://doi.org/10.1007/s00701-013-1859-x

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