Content uploaded by Flávio Ramalho Romero
Author content
All content in this area was uploaded by Flávio Ramalho Romero on Oct 29, 2017
Content may be subject to copyright.
Available via license: CC BY-NC-ND
Content may be subject to copyright.
Open vs. Percutaneous Pedicle Screw Insertion
for Thoracolumbar Traumatic A3 and A4 AO
Fractures - 18-Months Follow-Up
Comparação entre as técnicas convencional aberta e percutânea
para colocação de parafusos pediculares em fraturas
toracolombares AO A3 e A4 - seguimento de 18 meses
Flávio Ramalho Romero1,2 Rodolfo Brum Vieira1,2 Bruno da Costa Ancheschi3
1Division of Neurosurgery, Faculdade de Medicina de Botucatu,
Universidade do Estado de São Paulo, Botucatu, SP, Brazil
2Neurosurgery, Hospital das Clínicas & Hospital Unimed Botucatu,
Botucatu, SP, Brazil
3Department of Orthopedic and Spine Surgery, Universidade do
Estado de São Paulo, Botucatu, SP, Brazil
Arq Bras Neurocir
Address for correspondence Flávio Ramalho Romero, MD, MSc, PhD,
Departamento de Neurologia, Psiquiatria e Psicologia, Distrito de
Rubião Júnior s/n –Botucatu - SP, 18.618-970, Brazil
(e-mail: frromero@ig.com.br; romeroncr@gmail.com).
Keywords
►thoraco-lumbar
fracture
►percutaneous screw
fixation
►screw insertion
►minimally invasive
spine surgery
Abstract Purpose To com p a r e t h e ef ficacy and safety of the percutaneous screw fixation (PSF)
and the open pedicle screw fixation (OPSF) on thoracolumbar (TL) fracture.
Methods Sixty-four adult patients with TL vertebral fractures who underwent open or
percutaneous posterior short-segment transpedicular screw fixation between January
of 2013 and September of 2015 were retrospectively reviewed. All patients underwent
clinical, radiological and quality of life follow-up for at least 18 months.
Results There was no significant difference in age, gender, time between injury and
surgery, and preoperative percentage of anterior column height, preoperative sagittal
regional Cobb angle, or kyphotic angle of fractured vertebra between these two groups
(p>0.05). There was significantly less intraoperative blood loss in the PSF
(87.6 24.6 mL) than in the OPSF group (271.4 142.6 mL) (p<0.05). The mean
surgery time was 62 minutes (range 42–130 minutes) for open and 58 minutes (range
35 to 128 minutes) for percutaneous screw fixation. The surgery time was shorter in the
PSF group, but with no statistical significance (p>0.05). The mean Oswestry disability
index (ODI) scores after 18-months were 23.12 8.2 for the PSF and 24.12 9.2 for
the OPSF group, without any statistical significance (p>0.05).
Conclusion Both open and percutaneous screw fixations are safe and effective. The
percutaneous techniques significantly reduced the intraoperative blood loss compared
with the open techniques.
received
August 5, 2017
accepted
September 14, 2017
DOI https://doi.org/
10.1055/s-0037-1607439.
ISSN 0103-5355.
Copyright © by Thieme Revinter
Publicações Ltda, Rio de Janeiro, Brazil
THIEME
Original Article | Artigo Original
Introduction
The incidence of spinal cord injury (SCI) has been estimated
to be between 30 and 40 cases per million, per year, or
10,000 new cases annually.1–5The highest incidence occurs
in the 16- to 30-year-old range, with 54% of all injuries. The
most frequent cause of SCI has been motor vehicle crash,
followed by violence and falls.1,3,6,7 Thoracolumbar (TL)
fracture accounts for 50–74% of spinal injuries, with more
than 50% between T11 and L1.7–11 Fifty percent of TL
fractures are unstable and can result in significant anatomic
injury and deformity. Also, neurological deficit is present in
20–40% of TL fractures with most paraplegics sustaining
trauma in the T11 to L2 spinal segment.1,3–5,7–12
Although for some patients with TL fractures without
neurologic deficit non-operative treatments obtain good
clinical outcomes, many cases have to be submitted to
surgical intervention.13–15 The surgical treatment of thoracic
and lumbar spine fractures depends on various factors
because the pathological features of the vertebral lesion,
the neurological deficit and the general condition of health
affect the treatment and the final result.13–16 Many surgical
options have been used and, more recently, short-segment
pedicle screw fixation (SSPSF) without fusion is widely
adopted as an effective treatment with good functional
outcomes.17–20
There are few studies in the literature comparing these
two techniques. Our purpose was to evaluate the long-term
follow-up in patients with TL fractures treated with SSPSF
and compare open with percutaneous technique.
Methods
Casuistic
Patients with TL vertebral fractures who underwent open or
percutaneous posterior short-segment transpedicular screw
fixation between January of 2013and September of 2015 at the
neurosurgical division of a hospital in Botucatu, SP, Brazil, were
retrospectively reviewed. The inclusion criteria were: 1) acute
A3 or A4 (AO Spine Thoracolumbar Spine Injury Classification
System13,14) TL fracture (T12–L2) at a single level; 2) interval
from injuryto surgery within 72 hours; and3) follow-up period
of more than 18 months. We excluded patients with pathologic
fractures, spinal cord or cauda equina injury, or those who had
previously received spine surgery due to trauma. The local
ethics committee approved the study.
All patients underwent posteroanterior and lateral X-ray
examination, computed tomography (CT) scan (including CT
in combination with a 3-dimensional reconstruction in some
cases), and magnetic resonance imaging (MRI) examination
to determine the types of fractures.
Surgical Procedure
All surgical procedures were performed under general anes-
thesia. The patients were placed in prone position with the
abdomen hanging free through a bolster set under the chest
and the iliac crest. The level of the fractured vertebra and the
pedicles above and below the injury level were marked by
C-arm X-ray examination. In the open pedicle screw fixation
(OPSF) technique, the spine was exposed through a routine
posterior midline approach. After insertion, the pedicle
Resumo Objetivo Comparar a eficácia e segurança das técnicas de fixação convencional e
percutânea para fraturas toracolombares.
Métodos Sessenta e quatro pacientes adultos com fraturas da transição toracolom-
bar que foram submetidos a fixação pedicular curta por técnicas aberta convencional e
percutânea entre janeiro de 2013 e setembro de 2015 foram retrospectivamente
avaliados. Todos foram submetidos a avaliação clínica, radiológica e de qualidade de
vida com no mínimo 18 meses do seguimento.
Resultados Não houve diferença significativa na idade, sexo, tempo entre o trauma e
o tratamento, porcentagem da redução da altura do corpo vertebral pré-operatório,
angulo de Cob sagital na região da fratura, ou ângulo de de cifose da vértebra fraturada
entreosdoisgrupos(p>0,05). Houve uma menor perda sanguínea no grupo
percutâneo (87,6 24,6 mL) em comparação com a técnica convencional (271,4
142,6 mL) (p <0,05). O tempo médio da cirurgia foi 62 minutos (42 - 130 minutos) para
a técnica convencional e 58 minutos (35 - 128 minutos) para a percutânea. Apesar de
mais curto na técnica percutânea, não houve diferença estatisticamente significante no
tempocirúrgicoentreosdoisgrupos(p>0,05). Em relação ao índice de incapacidade
de Oswestry após 18 meses do tratamento cirúrgico, também não houve diferença
significante do ponto de vista estatístico entre os dois grupos, sendo 23,12 8,2 para a
técnica percutânea e 24,12 9,2 para o grupo da técnica convencional (p >0,05).
Conclusão Ambas as técnicas mostraram-se eficazes e seguras para o tratamento de
fraturas da transição toracolombar. A técnica percutânea apresentou uma taxa de perda
sanguínea significativamente menor em comparação à técnica aberta convencional.
Palavras-chave
►fraturas
toracolombares
►fixação percutânea de
parafusos
►inserção de parafusos
►cirurgia da coluna
minimamente invasiva
Arquivos Brasileiros de Neurocirurgia
Open vs. Percutaneous Techniques for Thoracolumbar Spine Fractures Romero et al.
screws were positioned by C-arm X-ray examination, and
were then fixed with rods. Finally, one drainage tube was
placed in the suction (►Fig. 1).
In the percutaneous screw fixation (PSF) technique, the
2.0 cm skin incisions were performed above the pedicles
markers. Under the C-arm guidance, the needles were inserted
through the pedicles into the vertebral bodies, and guide wires
were inserted into the vertebral bodies through these needles.
Dilation tubes were gradually placed through the guide wire,
and the last one was withheld. Pedicles advancing to the
junctions between the pedicles and the vertebral body were
tapped and then the screw insertions were performed. All
the screws had additional towers to guide rod insertion. Then,
the rods wereinserted through thesetowers and blocked at the
screw heads. Finally, all additional devices were removed and
the skin incisions were closed (►Fig. 2).
For all the patients, a first-day postoperative X-ray exami-
nation (posteroanterior and lateral) and a CT scan were
performed. All patients, except those with fractures in the
pelvis or lower limb, were encouraged to walk.
Follow-Up
All patients underwent clinical, radiological and quality of life
follow-up for at least 18 months. Visual analog scale (VAS) for
pain, time of hospital stay, and blood loss at procedure were
evaluated. X-ray images on posteroanterior and lateral view
were performed at 3 months, 12 months, and 18 months after
the surgery. Anterior column height, sagittal regional Cobb
angle, and fracture kyphotic angle were obtained on lateral
X-ray images before and immediately after the surgery, as well
as at the final follow-up, using the Osirix (Pixmeo SARL,
Bernex, Geneva, Switzerland) medical imaging viewer. The
Oswestry Disability Index (ODI) score was used to evaluatethe
quality of life 18 months after surgery.21 The statistical data
were analyzed using the SPSS software for Windows V13.0
(SPSS Inc., Chicago, IL, USA). A pvalue <0.05 was considered
statistically significant for all the tests.
Results
Sixty-four adult patientswere treated by open or percutaneous
posterior short-segment transpedicular screw fixation. The
mean age was 36.72 years (range 16–54 years) and the male to
female ratio was 2:1. The mean surgery time was 62 minutes
(range 42–130 minutes) for OPSF and 58 minutes (range 35 to
128 minutes) for PSF. The demographic data assessed were age,
sex, injury mechanisms, injured spine levels, interval between
injury and operation, and thepreoperative radiological param-
eters of the fractured vertebra were summarized on ►Table 1.
There was no significant difference in age, gender, interval
between injury and operation, and preoperative percentage of
anterior column height, preoperative sagittal regional Cobb
angle, or kyphotic angle of the fractured vertebra between
these 2 groups (p>0.05, ►Table 1).
Surgery time was shorter in the PSF group, but with no
statistical significance (p>0.05, ►Table 2). Also, there was no
statistically significant difference between these two groups
(p>0.05, ►Table 2) in the immediate postoperative anterior
Fig. 1 Case example of the open pedicle screw fixation (OPSF)
technique. A. preoperative CT scan sagittal image. B. postoperative
CT scan sagittal image.
Fig. 2 Case example of the percutaneous screw fixation (PSF)
technique. A. Preoperative lateral X-ray image. B. Preoperative
anterior X-Ray image. C. Postoperative 3D sagittal CT scan image.
D. Postoperative 3D posterior CT scan images.
Arquivos Brasileiros de Neurocirurgia
Open vs. Percutaneous Techniques for Thoracolumbar Spine Fractures Romero et al.
column height percentage correction, sagittal regional Cobb
angle correction, kyphotic fracture angle, hospital stay or pain
(VAS) on the first postoperative day. There was significantly
less intraoperative blood loss in the PSF (87.6 24.6 mL) than
in the OPSF group (271.4 142.6 mL) (p<0.05, ►Table 2).
No statistically significant difference was observed in the
follow-up period between the two groups (p>0.05). There
were no infections in the PSF group and two cases of
infection in the OPSF group. Misplacement was found in
three cases, with two pedicle screws with a small converging
angle in the OPSF group, and one partly out of the pedicle
and vertebral body in the PSF group. In addition, there were
no cases of screw pull out. Also, no significant difference
was observed in the percentage of anterior column height
correction, in the sagittal regional Cobb angle loss, or in
the kyphotic fracture angle after 18-months follow-up (all
p>0.05). The mean ODI scores after 18 months were
23.12 8.2 for the PSF and 24.27 9.2 for the OPSF group,
and it did not show any statistical significance (p>0.05).
Discussion
Few studies have compared the efficacy of the PSF versus the
OPSF fixation for TL fractures.22–26 Our results confirmed that
Table 1 Demographic data assessed and preoperative radiological parameters of the fractured vertebra
PSF OPSF F/2P
Age (years) 34.32 38.64 0.837 0.439
Gender
Male 21 22
Female 10 11
Injury Mechanism
Tra fficaccident 19 24
Falls 12 09
Fracture level
T12 12 08
L1 11 13
L2 08 12
Interval between injury and surgery 3.4 1.4 3.7 1.8 0.297 0.813
Radiological preoperative parameters
% Anterior column height 66.1 10.8 67.3 11.3 1.789 0.132
Sagittal Cob angle 12.1 6.9 14.3 6.3 1.873 0.147
Kyphotic angle 16.8 5.3 17.3 5.9 1.979 0.135
Abbreviations: OPSF, open pedicle screw fixation; P,p-value; PSF, percutaneous screw fixation.
Table 2 Outcomedatainopenpediclescrewfixation (OPSF) and percutaneous screw fixation (PSF)
OPSF PSF F value pvalue
Operation time (min) 62 18.9 58 16.4 1.641 0.187
Intraoperative. blood loss (mL) 271.4 142.6 87.6 24.6 <0.05
VAS on op erative day 4.2 2.7 3.8 2.9 1.748 0.165
Hospital stay 3.2 2.7 2.3 3.7 1.879 0.179
18-months follow-up
VAS 4.3 1.9 3.7 2.2 1.789 0.157
ODI 24.27 9.2 23.12 8.2 1.673 0.193
Correction parameters
% anterior column height 21 11.7 17.3 12.7 8.579 0.147
Sagittal Cobb angle (°) 7.5 6.8 5.7 5.3 2.387 0.057
Kyphotic angle (°) 9.7 7.2 6.7 5.1 5.437 0.132
Abbreviations: F values, analisys of variance (ANOVA); ODI, Oswestry disability index; OPSF, open pedicle screw fixation;PSF,percutaneousscrew
fixation; VAS, visual analog scale,
Arquivos Brasileiros de Neurocirurgia
Open vs. Percutaneous Techniques for Thoracolumbar Spine Fractures Romero et al.
both PSF and OPSF are safe and effective for the treatment of TL
fractures.22–24 Our results indicated obvious correction of the
percentage of anterior column height, the sagittal regional
Cobb angle, and kyphotic angle of the fractured vertebra in all
patients immediately and 18 months after the surgery.
The mean operation time was a little shorter in the PSF
group compared with the OPSF group (58 versus 62 minutes),
but with no statistical significance. Some other clinical
studies reported shorter operation time for percutaneous
compared with open techniques.22,23 But another study did
not show any difference in operation time between these t wo
techniques.24 All the procedures of our study were per-
formed by the same senior surgeon, but the percutaneous
technique is relatively recent worldwide as well as in our
institution. So, one reason for these findings could be ex-
plained by the greater experience of our institution with
open spine procedures.
There was significantly less intraoperative blood loss in the
PSF than in the OPSF group, which is consistent with many
other studies.22–26 The reasons for thisdifference were smaller
incision and lessmuscular damage in thePSF group. The OPSF
technique required opening all the posterior muscle in the
middle line to expose the posterior elements of the vertebras.
Our data did not show any mortality and only two cases of
superficial wound infection, supporting the conclusion that
these two techniques are safe for treatment of TL fractures.
Correction of the percentage of anterior column height of
the fractured vertebra did not represent and advantage of the
PSF technique in comparison with the OPSF technique, neither
did the correction of the sagittal regional Cobb angle and the
kyphotic angle of the fractured vertebra. Also, the VAS on
surgery day and in the first postoperative day did not represent
a statistically significant difference between the PSF and the
OPSF groupaccording tothe other studiescomparing thesetwo
techniques.22–24 The ODI and VAS in the 18-months follow-up
did not exhibit any significant difference. Other studies did not
demonstrate any significant differences between these two
techniques in the long-term follow-up either.27–30
Some limitations are found in our study. First, it was a
retrospective study based on reviewing the collected clinical
information of the patients. Second, the number of patients
included was insufficient for statistical analysis. Third, the
follow-up period was relatively short. Thus, future prospec-
tive controlled studies with a larger number of patients and
longer follow-up period are warranted.
Conclusion
Both OPSF and PSFare safe and effectivefor the treatment of TL
fractures, with good results at long-term follow-up. Percuta-
neous screw fixation significantly reduced the intraoperative
blood loss compared with OPSF. No significant differences
were found between the PSF and the OPSF groups in terms
of correction of the percentage of anterior column height, of
sagittal regional Cobb angle correction or in the kyphotic angle
of fractured vertebra. Also, we found no significant difference
in the correction loss angle between the OPSFand PSF fixation
groups at the final follow-up.
References
1Alpantaki K, Bano A, Pasku D, et al. Thoracolumbar burst frac-
tures: a systematic review of management. Orthopedics 2010;33
(06):422–429
2Mumford J, Weinstein JN, Spratt KF, Goel VK. Thoracolum bar burst
fractures. The clinical efficacy and outcome of nonoperative
management. Spine 1993;18(08):955–970
3Wang ST, Ma HL, Liu CL, Yu WK, Chang MC, Chen TH. Is fusion
necessary for surgically treated burst fractures of the thoraco-
lumbar and lumbar spine?: a prospective, randomized study
Spine 2006;31(23):2646–2652, discussion 2653
4Rajasekaran S, Kanna RM, Shetty AP. Management of thoracolumbar
spine trauma: An overview. Indian J Orthop 2015;49(01):72–82
5Stadhouder A, Buskens E, de Klerk LW, et al. Traumatic thoracic
and lumbar spinal fractures: operative or nonoperative treat-
ment: comparison of two treatment strategies by means of
surgeon equipoise. Spine 2008;33(09):1006–1017
6Anderson MW. Imaging of Thoracic and Lumbar Spine Fractures.
Semin Spine Surg 2010;22:8–19
7Radcliff K, Su BW, Kepler CK, et al. Correlation of posterior
ligamentous complex injury and neurological injury to loss of
vertebral body height, kyphosis, and canal compromise. Spine
2012;37(13):1142–1150
8Keynan O, Fisher CG, Vaccaro A, et al. Radiographic measurement
parameters in thoracolumbar fractures: a systematic review and
consensus statement of the spine trauma study group. Spine
2006;31(05):E156–E165
9Reinhold M, Audigé L, Schnake KJ, Bellabarba C, Dai LY, Oner FC. AO
spine injury classification system: a revision proposal for the
thoracic and lumbar spine. Eur Spine J 2013;22(10):2184–2201
10 Pizones J, Izquierdo E, Alvarez P, et al. Impact of magnetic
resonance imaging on decision making for thoracolumbar trau-
matic fracture diagnosis and treatment. Eur Spine J 2011;20
(Suppl 3):390–396
11 Denis F. The three column spine and its significance in the
classification of acute thoracolumbar spinal injuries. Spine
1983;8(08):817–831
12 Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S. A compre-
hensive classification of thoracic and lumbar injuries. Eur Spine J
1994;3(04):184–201
13 Vaccaro AR, Lehman RA Jr, Hurlbert RJ, et al. A new classification of
thoracolumbar injuries: the impor tance of injury morphology,
the integrity of the posterior ligamentous complex, and neuro-
logic status. Spine 2005;30(20):2325–2333
14 Vaccaro AR, Oner C, Kepler CK, et al; AOSpine Spinal Cord Injury &
Trauma Knowledge Forum. AOSpine thoracolumbar spine injury
classification system: fracture description, neurological status,
and key modifiers. Spine 2013;38(23):2028–2037
15 Schroeder GD, Vaccaro AR, Kepler CK, et al. Establishing the injury
severity of thoracolumbar trauma: confirmation of the hierarch-
ical structure of the AOSpine Thoracolumbar Spine Injury Classi-
fication System. Spine 2015;40(08):E498–E503
16 Vaccaro AR, Schroeder GD, Kepler CK, et al. The sur gical algorithm
for the AOSpine thoracol umbar spine injury classification system.
Eur Spine J 2016;25(04):1087–1094
17 Schroeder GD, Kepler CK, Koerner JD, et al. A worldwide analysis
of the reliability and perceived importance of an injury to the
posterior ligamentous complex in AO type A fractures. Global
Spine J 2015;5(05):378–382
18 Weber BR, Grob D, Dvorák J, Müntener M. Posterior surgical
approach to the lumbar spine and its effect on the multifidus
muscle. Spine 1997;22(15):1765–1772
19 Foley KT, Gupta SK, Justis JR, Sherman MC. Percutaneous pedicle
screw fixation of the lumbar spine. Neurosurg Focus 2001;10(04):
E10
20 Anderson DG, Samartzis D, Shen FH, Tannoury C. Percutaneous
instrumentation of the thoracic and lumbar spine. Orthop Clin
North Am 2007;38(03):401–408, abstract vii
Arquivos Brasileiros de Neurocirurgia
Open vs. Percutaneous Techniques for Thoracolumbar Spine Fractures Romero et al.
21 Fairbank JCT, Pynsent PB. The Oswestry Disability Index. Spine
2000;25(22):2940–2952, discussion 2952
22 Lehmann W, Ushmaev A, Ruecker A, et al. Comparison of open
versus percutaneous pedicle screw insertion in a sheep model.
Eur Spine J 2008;17(06):857–863
23 Charles YP, Zairi F, Vincent C, et al. Minimally-invasive poster-
ior surgery for thoracolumbar fractures: new trends to de-
crease muscle damage. Eur J Orthop Surg Traumatol 2012;
22:1–7
24 Wang H, Zhou Y, Li C, Liu J, Xiang L. Comparison of Open Versus
Percutaneous Pedicle Screw Fixation Using the Sextant System in
the Treatment of Traumatic Thoracolumbar Fractures. Clin Spine
Surg 2017;30(03):E239–E246
25 Schmidt OI, Strasser S, Kaufmann V, Strasser E, Gahr RH. Role of
early minimal-invasive spine fixation in acute thoracic and lum-
bar spine trauma. Indian J Orthop 2007;41(04):374–380
26 Merom L, Raz N, Hamud C, Weisz I, Hanani A. Minimally invasive
burst fracture fixation in the thoracolumbar region. Orthopedics
2009;32(04):273–278
27 Palmisani M, Gasbarrini A, Brodano GB, et al. Minimally invasive
percutaneous fixation in the treatment of thoracic and lumbar
spine fractures. Eur Spine J 2009;18(Suppl 1):71–74
28 Gelb D, Ludwig S, Karp JE, et al. Successful treatment of thoraco-
lumbar fractures with short-segment pedicle instrumentation.
J Spinal Disord Tech 2010;23(05):293–301
29 Kim HY, Kim HS, Kim SW, Ju CI, Lee SM, Park HJ. Short segment
screw fixation without fusion for unstable thoracolumbar and
lumbar burst fracture: A prospective study on selective consecu-
tive patients. J Korean Neurosurg Soc 2012;51(04):203–207
30 Khare S, Sharma V. Surgical outcome of posterior short segment
trans-pedicle screw fixation for thoracolumbar fractures. J Orthop
2013;10(04):162–167
Arquivos Brasileiros de Neurocirurgia
Open vs. Percutaneous Techniques for Thoracolumbar Spine Fractures Romero et al.