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: Object The optimal management of unstable thoracolumbar fractures remains unclear. The objective of the present study was to evaluate the results of using an expandable prosthetic vertebral body cage (EPVBC) in the management of unstable thoracolumbar fractures. Methods Eighty-five patients with unstable T7-L4 thoracolumbar fractures underwent implantation of an EPVBC via an anterior approach combined with posterior fixation. Long-term functional outcomes, including visual analog scale and Oswestry disability index scores, were evaluated. Results In a mean follow-up period of 16 months, anterior fixation led to a significant increase in vertebral body height, with an average gain of 19%. However, the vertebral regional kyphosis angle was not significantly increased by anterior fixation alone. No significant difference was found between early postoperative, 3-month, and 1-year postoperative regional kyphosis angle and vertebral body height. Postoperative impaction of the prosthetic cage in adjacent endplates was observed in 35% of the cases, without worsening at last follow-up. Complete fusion was observed at 1 year postoperatively and no cases of infections or revisions were observed in relation to the anterior approach. Conclusions The use of EPVBCs for unstable thoracolumbar fractures is safe and effective in providing long-term vertebral body height restoration and kyphosis correction, with a moderate surgical and sepsis risk. Anterior cage implantation is an alternative to iliac bone graft fusion and is a viable option in association with a posterior approach, in a single operation without additional risks.
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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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