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.

Department of Orthopedic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
Spine (Impact Factor: 2.16). 07/2009; 34(14):1429-35. DOI: 10.1097/BRS.0b013e3181a4e667
Source: PubMed

ABSTRACT A randomized, controlled follow-up study to review patients with acute thoracolumbar burst fractures treated by anterior instrumentation and reconstruction.
The objective of this study was to evaluate the results of anterior instrumentation in the treatment of thoracolumbar burst fractures and to determine whether anterior-only approach would be sufficient for highly unstable burst fractures. In this prospective follow-up study, we also compared the results of anterior reconstruction with structural grafting and with titanium mesh cage in a randomized fashion.
Anterior decompression and reconstruction supplemented with instrumentation is generally believed to be superior to fixation with posterior pedicle screw instrumentation for a highly unstable burst fracture, but the indications and methods for anterior approach has not been fully documented.
A total of 65 patients undergoing anterior plating for a thoracolumbar burst fracture with a load-sharing score of 7 or more between 2000 and 2003 were included this study. They were randomized to receive iliac crest autograft (group A, n = 32) or titanium mesh cages (group B, n = 33). The patients were similar in the distribution of 3-column injuries (n = 8 in group A vs. n = 9 in group B). During the minimum 4-year (range, 4-7 years) follow-up period, all patients were prospectively evaluated for clinical and radiologic outcomes. The Frankel scale, the ASIA motor score, and the Short Form 36 were used for clinical evaluation, whereas the fusion status and the loss of kyphosis correction for the local kyphosis angle were examined for radiologic outcome.
All patients in this study achieved solid fusion, with significant neurologic improvement and no significant correction loss as defined by loss of kyphosis correction. The clinical and radiologic results were not significantly different (P > 0.05) at all time points between the 2 groups A and B. Twenty-six of 32 patients in group A still complained of donor site pain to some degree at the final follow-up. No significant impact of 3-column injuries (P > 0.05) were identified on the results for all comparisons.
Anterior-only instrumentation and reconstruction with structural autograft or titanium mesh cages is sufficient for surgical treatment of thoracolumbar burst fractures with a load-sharing score of > or = 7 and even with 3-column injuries.

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    ABSTRACT: Study design Systematic review. Objective The aim of the present review is to assess the main outcomes of patients who underwent interventions to treat thoracolumbar fracture. Summary of background data In the literature, the parameters most commonly used to assess treatment success have been radiographic measurements, evolution of the kyphosis curve, and subjective parameters such as pain scores. Measures of quality of life and function, such as the Short-form 36 (SF36), Short-form 12 (SF12), and Oswestry Disability Index (ODI) protocols, as well as the Roland–Morris Disability Questionnaire, are more frequently used and helpful to evaluate the effectiveness (benefits and harms) of treatment. Methods This study is a literature review of studies that assess the quality of life and function of patients with thoracolumbar fracture. Results The search strategy resulted in 111 published studies. Based on the analysis of the titles of these studies, 52 were selected for abstract evaluation. After evaluating the abstracts, 25 were included in the present review. Conclusion The use of assessment questionnaires that utilize subjective parameters should be encouraged and increasingly used to aid in the selection of the therapeutic modalities that will provide the best clinical–functional outcomes, and a quality of life as close to normal as possible.
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    ABSTRACT: Object Despite promising early clinical results, the long-term outcome of the use of expandable titanium cages to reconstruct the anterior column after traumatic burst fractures is still unknown. The purpose of this prospective study was to assess the clinical and radiological outcomes of the use of expandable titanium cages 5 years postoperatively. Methods Eighty patients with traumatic thoracolumbar burst fractures (T4-L5) underwent posterior stabilization followed by anterior corpectomy and reconstruction using expandable titanium cages with or without additional anterior plating. After 5 years, fusion was evaluated by means of plain radiographs and CT scans, and the patients' scores on the Oswestry Disability Index (ODI), their neurological status, and clinical results were assessed. Results Forty-five (56%) of the 80 patients could be examined after 5 years. There was a relatively high rate of complications related to thoracotomy (26%), but there were no complications directly related to the cages. Revision surgery was required in 1 case. The average postoperative loss of correction was only 2.4° due to minimal subsidence of the cages. No cage showed a radiolucent line or instability in flexion-extension views. Bony fusion, as assessed by CT scan, was achieved in 41 patients (91%). On clinical examination, 96% of all patients were ambulatory and showed minimal restriction of spinal range of motion; 71% did not need analgesic medication at all; and 67% were able to work. The average ODI score was 12. Thirty-one percent of patients complained of some kind of anterior approach-related complications. Conclusions Combined anteroposterior stabilization of thoracolumbar burst fractures with expandable titanium cages is a relative safe procedure with satisfactory radiological and clinical long-term outcome. High fusion rates can be achieved, with only minor loss of correction, typically occurring in the 1st year. However, open thoracotomy carries the risks of additional complications and development of post-thoracotomy syndrome.
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    ABSTRACT: Background context Short-segment pedicle screw instrumentation constructs for the treatment of thoracolumbar fractures gained popularity in the 1980s. The load-sharing classification (LSC) is a straightforward way to describe the extent of bony comminution, amount of fracture displacement, and amount of correction of kyphotic deformity in a spinal fracture. There are no studies evaluating the relevance of fracture comminution/traumatic kyphosis on the long-term radiological outcome of burst fractures treated by short-segment instrumentation with screw insertion in the fractured level. Purpose The aim of this study is to evaluate the efficacy of the 6-screw construct in the treatment of thoracolumbar junction burst fractures and the influence of the load-sharing classification score on the 2-year radiological outcome. Study design Case series of consecutive patients of a single university hospital. Patient Sample Consecutive patients from one university hospital with non-osteoporotic thoracolumbar burst fractures. Outcome measures Being a radiology based study, the outcome measures are radiologic parameters (Regional Kyphosis, Local Kyphosis and Thoracolumbar Kyphosis) that evaluate the degree of correction and loss of correction. Methods Retrospective analysis of all consecutive patients with non-osteoporotic thoracolumbar burst fractures managed with a 6-screw construct in a single university hospital, and with more than 2 years’ post-operative follow-up. The authors disclose no study-specific conflicts of interest. The study was partially funded by K2M ,inc. for final data analysis and manuscript elaboration None of the cases included in this study were operated using K2M implants. (USD 17,000-20,000) Results 86 patients met the inclusion criteria, and 72 (83.7%) with available data were ultimately included in the study. The sample included 53 men and 19 women, with a mean (SD) age of 35.6 years (14.4) at the time of surgery. Mean load-sharing classification score was 6.3 (SD 1.6, range 2-9). 44 of 62 (70.9) fractures had a score >6. Mean (SD) regional kyphosis (RK) and thoracolumbar kyphosis (TLK) deteriorated significantly during the first 6 months of follow-up: 2.90° (4.54) p=0.005, and 2.78° (6.45) p=0.069, respectively. Surgical correction correlated significantly (r=0.521, p<0.0001) with the time elapsed until surgery. Loss of surgical correction (postoperative to 6-month RK and TLK increase) correlated significantly with the load-sharing score (r=0.57, p=.004; r=0.51, p=0.022, respectively). Further surgery due to correction loss was not required in any case. Conclusions The 6-screw construct is effective for treating thoracolumbar junction burst fractures. The medium to long-term loss of correction is affected by the amount of bony comminution of the fracture, objectified through the load-sharing classification score.
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