ArticlePDF Available

Abstract and Figures

Purpose To compare the efficacy 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.
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
xation
screw insertion
minimally invasive
spine surgery
Abstract Purpose To com p a r e t h e ef cacy and safety of the percutaneous screw xation (PSF)
and the open pedicle screw xation (OPSF) on thoracolumbar (TL) fracture.
Methods Sixty-four adult patients with TL vertebral fractures who underwent open or
percutaneous posterior short-segment transpedicular screw xation 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 signicant 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 signicantly 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 42130 minutes) for open and 58 minutes (range
35 to 128 minutes) for percutaneous screw xation. The surgery time was shorter in the
PSF group, but with no statistical signicance (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 signicance (p>0.05).
Conclusion Both open and percutaneous screw xations are safe and effective. The
percutaneous techniques signicantly 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.15The 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 5074% of spinal injuries, with more
than 50% between T11 and L1.711 Fifty percent of TL
fractures are unstable and can result in signicant anatomic
injury and deformity. Also, neurological decit is present in
2040% of TL fractures with most paraplegics sustaining
trauma in the T11 to L2 spinal segment.1,35,712
Although for some patients with TL fractures without
neurologic decit non-operative treatments obtain good
clinical outcomes, many cases have to be submitted to
surgical intervention.1315 The surgical treatment of thoracic
and lumbar spine fractures depends on various factors
because the pathological features of the vertebral lesion,
the neurological decit and the general condition of health
affect the treatment and the nal result.1316 Many surgical
options have been used and, more recently, short-segment
pedicle screw xation (SSPSF) without fusion is widely
adopted as an effective treatment with good functional
outcomes.1720
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
xation 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 Classication
System13,14) TL fracture (T12L2) 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 xation
(OPSF) technique, the spine was exposed through a routine
posterior midline approach. After insertion, the pedicle
Resumo Objetivo Comparar a ecácia e segurança das técnicas de xação convencional e
percutânea para fraturas toracolombares.
Métodos Sessenta e quatro pacientes adultos com fraturas da transição toracolom-
bar que foram submetidos a xação 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 signicativa 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 signicante no
tempocirúrgicoentreosdoisgrupos(p>0,05). Em relação ao índice de incapacidade
de Oswestry após 18 meses do tratamento cirúrgico, também não houve diferença
signicante 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 ecazes e seguras para o tratamento de
fraturas da transição toracolombar. A técnica percutânea apresentou uma taxa de perda
sanguínea signicativamente menor em comparação à técnica aberta convencional.
Palavras-chave
fraturas
toracolombares
xação 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 xed with rods. Finally, one drainage tube was
placed in the suction (Fig. 1).
In the percutaneous screw xation (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 rst-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 nal 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 signicant for all the tests.
Results
Sixty-four adult patientswere treated by open or percutaneous
posterior short-segment transpedicular screw xation. The
mean age was 36.72 years (range 1654 years) and the male to
female ratio was 2:1. The mean surgery time was 62 minutes
(range 42130 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 signicant 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 signicance (p>0.05, Table 2). Also, there was no
statistically signicant difference between these two groups
(p>0.05, Table 2) in the immediate postoperative anterior
Fig. 1 Case example of the open pedicle screw xation (OPSF)
technique. A. preoperative CT scan sagittal image. B. postoperative
CT scan sagittal image.
Fig. 2 Case example of the percutaneous screw xation (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 rst postoperative day. There was signicantly
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 signicant 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 signicant 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 signicance (p>0.05).
Discussion
Few studies have compared the efcacy of the PSF versus the
OPSF xation for TL fractures.2226 Our results conrmed 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 fcaccident 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 xation; P,p-value; PSF, percutaneous screw xation.
Table 2 Outcomedatainopenpediclescrewxation (OPSF) and percutaneous screw xation (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 xation;PSF,percutaneousscrew
xation; 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.2224 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 signicance. 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 ndings could be ex-
plained by the greater experience of our institution with
open spine procedures.
There was signicantly less intraoperative blood loss in the
PSF than in the OPSF group, which is consistent with many
other studies.2226 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
supercial 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 rst postoperative day did not represent
a statistically signicant difference between the PSF and the
OPSF groupaccording tothe other studiescomparing thesetwo
techniques.2224 The ODI and VAS in the 18-months follow-up
did not exhibit any signicant difference. Other studies did not
demonstrate any signicant differences between these two
techniques in the long-term follow-up either.2730
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 insufcient 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 xation signicantly reduced the intraoperative
blood loss compared with OPSF. No signicant 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 signicant difference
in the correction loss angle between the OPSFand PSF xation
groups at the nal follow-up.
References
1Alpantaki K, Bano A, Pasku D, et al. Thoracolumbar burst frac-
tures: a systematic review of management. Orthopedics 2010;33
(06):422429
2Mumford J, Weinstein JN, Spratt KF, Goel VK. Thoracolum bar burst
fractures. The clinical efcacy and outcome of nonoperative
management. Spine 1993;18(08):955970
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):26462652, discussion 2653
4Rajasekaran S, Kanna RM, Shetty AP. Management of thoracolumbar
spine trauma: An overview. Indian J Orthop 2015;49(01):7282
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):10061017
6Anderson MW. Imaging of Thoracic and Lumbar Spine Fractures.
Semin Spine Surg 2010;22:819
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):11421150
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):E156E165
9Reinhold M, Audigé L, Schnake KJ, Bellabarba C, Dai LY, Oner FC. AO
spine injury classication system: a revision proposal for the
thoracic and lumbar spine. Eur Spine J 2013;22(10):21842201
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):390396
11 Denis F. The three column spine and its signicance in the
classication of acute thoracolumbar spinal injuries. Spine
1983;8(08):817831
12 Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S. A compre-
hensive classication of thoracic and lumbar injuries. Eur Spine J
1994;3(04):184201
13 Vaccaro AR, Lehman RA Jr, Hurlbert RJ, et al. A new classication of
thoracolumbar injuries: the impor tance of injury morphology,
the integrity of the posterior ligamentous complex, and neuro-
logic status. Spine 2005;30(20):23252333
14 Vaccaro AR, Oner C, Kepler CK, et al; AOSpine Spinal Cord Injury &
Trauma Knowledge Forum. AOSpine thoracolumbar spine injury
classication system: fracture description, neurological status,
and key modiers. Spine 2013;38(23):20282037
15 Schroeder GD, Vaccaro AR, Kepler CK, et al. Establishing the injury
severity of thoracolumbar trauma: conrmation of the hierarch-
ical structure of the AOSpine Thoracolumbar Spine Injury Classi-
cation System. Spine 2015;40(08):E498E503
16 Vaccaro AR, Schroeder GD, Kepler CK, et al. The sur gical algorithm
for the AOSpine thoracol umbar spine injury classication system.
Eur Spine J 2016;25(04):10871094
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):378382
18 Weber BR, Grob D, Dvorák J, Müntener M. Posterior surgical
approach to the lumbar spine and its effect on the multidus
muscle. Spine 1997;22(15):17651772
19 Foley KT, Gupta SK, Justis JR, Sherman MC. Percutaneous pedicle
screw xation 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):401408, 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):29402952, 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):857863
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;
22:17
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):E239E246
25 Schmidt OI, Strasser S, Kaufmann V, Strasser E, Gahr RH. Role of
early minimal-invasive spine xation in acute thoracic and lum-
bar spine trauma. Indian J Orthop 2007;41(04):374380
26 Merom L, Raz N, Hamud C, Weisz I, Hanani A. Minimally invasive
burst fracture xation in the thoracolumbar region. Orthopedics
2009;32(04):273278
27 Palmisani M, Gasbarrini A, Brodano GB, et al. Minimally invasive
percutaneous xation in the treatment of thoracic and lumbar
spine fractures. Eur Spine J 2009;18(Suppl 1):7174
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):293301
29 Kim HY, Kim HS, Kim SW, Ju CI, Lee SM, Park HJ. Short segment
screw xation without fusion for unstable thoracolumbar and
lumbar burst fracture: A prospective study on selective consecu-
tive patients. J Korean Neurosurg Soc 2012;51(04):203207
30 Khare S, Sharma V. Surgical outcome of posterior short segment
trans-pedicle screw xation for thoracolumbar fractures. J Orthop
2013;10(04):162167
Arquivos Brasileiros de Neurocirurgia
Open vs. Percutaneous Techniques for Thoracolumbar Spine Fractures Romero et al.
ResearchGate has not been able to resolve any citations for this publication.
Article
Full-text available
Introduction The AOSpine Thoracolumbar Spine Injury Classification System was recently published and combines elements of both the Magerl system and the Thoracolumbar Injury Classification System (TLICS); however, the injury severity of each fracture has yet to be established. The objective of this study is to develop a validated regional and global injury severity scoring system for thoracolumbar trauma. Material and Methods A survey was sent to 100 AOSpine members from all six AO regions of the world (North America, South America, Europe, Africa, Asia, and the Middle East). Each respondent was asked to numerically grade the severity of each variable of the AOSpine Thoracolumbar Spine Injury Classification System including the morphology, neurologic grade, and patient-specific modifiers. A grade of zero was considered to be not severe at all, and a grade of 100 was the most severe injury possible. Results A total of 74 AOSpine surgeons from all six AO regions of the world numerically graded the severity of each variable of the AOSpine Thoracolumbar Spine Injury Classification System to establish the injury severity score. The reported fracture severity increased significantly ( p < 0.0001) as the subtypes of fracture type A and type B increased, and a significant difference ( p < 0.0001) in severity was established for burst fractures with involvement of two versus one end plates. Finally, no regional or experiential difference in severity or classification was identified. Conclusion Development of a globally applicable injury severity scoring system for thoracolumbar trauma is possible. This study demonstrates no regional or experiential difference in perceived severity or thoracolumbar spine trauma. The AOSpine Thoracolumbar Spine Injury Classification System provides a logical approach to assessing these injuries and enables rational strategies for treatment.
Article
Full-text available
Study Design Survey of spine surgeons. Objective To determine the reliability with which international spine surgeons identify a posterior ligamentous complex (PLC) injury in a patient with a compression-type vertebral body fracture (type A). Methods A survey was sent to all AOSpine members from the six AO regions of the world. The survey consisted of 10 cases of type A fractures (2 subtype A1, 2 subtype A2, 3 subtype A3, and 3 subtype A4 fractures) with appropriate imaging (plain radiographs, computed tomography, and/or magnetic resonance imaging), and the respondent was asked to identify fractures with a PLC disruption, as well as to indicate if the integrity of the PLC would affect their treatment recommendation. Results Five hundred twenty-nine spine surgeons from all six AO regions of the world completed the survey. The overall interobserver reliability in determining the integrity of the PLC was slight (kappa = 0.11). No substantial regional or experiential difference was identified in determining PLC integrity or its absence; however, a regional difference was identified (p < 0.001) in how PLC integrity influenced the treatment of type A fractures. Conclusion The results of this survey indicate that there is only slight international reliability in determining the integrity of the PLC in type A fractures. Although the biomechanical importance of the PLC is not in doubt, the inability to reliably determine the integrity of the PLC may limit the utility of the M1 modifier in the AOSpine Thoracolumbar Spine Injury Classification System.
Article
Full-text available
The goal of the current study is to establish a surgical algorithm to accompany the AOSpine thoracolumbar spine injury classification system. A survey was sent to AOSpine members from the six AO regions of the world, and surgeons were asked if a patient should undergo an initial trial of conservative management or if surgical management was warranted. The survey consisted of controversial injury patterns. Using the results of the survey, a surgical algorithm was developed. The AOSpine Trauma Knowledge forum defined that the injuries in which less than 30 % of surgeons would recommend surgical intervention should undergo a trial of non-operative care, and injuries in which 70 % of surgeons would recommend surgery should undergo surgical intervention. Using these thresholds, it was determined that injuries with a thoracolumbar AOSpine injury score (TL AOSIS) of three or less should undergo a trial of conservative treatment, and injuries with a TL AOSIS of more than five should undergo surgical intervention. Operative or non-operative treatment is acceptable for injuries with a TL AOSIS of four or five. The current algorithm uses a meaningful injury classification and worldwide surgeon input to determine the initial treatment recommendation for thoracolumbar injuries. This allows for a globally accepted surgical algorithm for the treatment of thoracolumbar trauma.
Article
Full-text available
STUDY DESIGN: Reliability and agreement study, retrospective case series. OBJECTIVE: To develop a widely accepted, comprehensive yet simple classification system with clinically acceptable intra- and interobserver reliability for use in both clinical practice and research. SUMMARY OF BACKGROUND DATA: Although the Magerl classification and thoracolumbar injury classification system (TLICS) are both well-known schemes to describe thoracolumbar (TL) fractures, no TL injury classification system has achieved universal international adoption. This lack of consensus limits communication between clinicians and researchers complicating the study of these injuries and the development of treatment algorithms. METHODS: A simple and reproducible classification system of TL injuries was developed using a structured international consensus process. This classification system consists of a morphologic classification of the fracture, a grading system for the neurological status, and description of relevant patient-specific modifiers. Forty cases with a broad range of injuries were classified independently twice by group members 1 month apart and analyzed for classification reliability using the Kappa coefficient (κ). RESULTS: The morphologic classification is based on 3 main injury patterns: type A (compression), type B (tension band disruption), and type C (displacement/translation) injuries. Reliability in the identification of a morphologic injury type was substantial (κ= 0.72). CONCLUSION: The AOSpine TL injury classification system is clinically relevant according to the consensus agreement of our international team of spine trauma experts. Final evaluation data showed reasonable reliability and accuracy, but further clinical validation of the proposed system requires prospective observational data collection documenting use of the classification system, therapeutic decision making, and clinical follow-up evaluation by a large number of surgeons from different countries.
Article
Full-text available
Vast majority of spine fractures in thoracolumbar region are unstable and often associated with neurological deficit. With the advancement of technology, these fractures are now more often managed operatively. The present study aimed at evaluating the role of open reduction & internal fixation using pedicle screws and short segment fixation in patients with Thoracic and Lumbar spine fractures. In this prospective study, 25 patients in age group of 15-65 years (mean age 28.25 years) with thoracolumbar fractures with associated neurological deficit or compression fractures with loss of more than 50% vertebral height or angulations more than 20° with or without neurological deficit were included. The results were evaluated based on restoration and maintenance of vertebral body height, spinal lordosis/kyphosis and evaluation of the neurological recovery which was done at regular intervals using Frankel's grading. The mean follow-up period was 20.3 months. The average preoperative kyphotic angle as measured by Cobbs method was 20° which improved to 7.8° following instrumentation. The average preoperative vertebral height was 58.65% which improved to 78.55% postoperatively. Preoperatively, only 20% of patients had useful paraplegia (Frankel grade D and E) while 80% had useless paraplegia (Frankel's grade C and below). Following surgery, 60% patients had useful paraplegia while 40% had useless paraplegia. Short segment trans-pedicle posterior fixation is helpful for not only stabilization of the fractures and restoration of anatomy, but also maintaining the same over a period with good functional outcome.
Article
In view of the current level of knowledge and the numerous treatment possibilities, none of the existing classification systems of thoracic and lumbar injuries is completely satisfactory. As a result of more than a decade of consideration of the subject matter and a review of 1445 consecutive thoracolumbar injuries, a comprehensive classification of thoracic and lumbar injuries is proposed. The classification is primarily based on pathomorphological criteria. Categories are established according to the main mechanism of injury, pathomorphological uniformity, and in consideration of prognostic aspects regarding healing potential. The classification reflects a progressive scale of morphological damage by which the degree of instability is determined. The severity of the injury in terms of instability is expressed by its ranking within the classification system. A simple grid, the 3-3-3 scheme of the AO fracture classification, was used in grouping the injuries. This grid consists of three types: A, B, and C. Every type has three groups, each of which contains three subgroups with specifications. The types have a fundamental injury pattern which is determined by the three most important mechanisms acting on the spine: compression, distraction, and axial torque. Type A (vertebral body compression) focuses on injury patterns of the vertebral body. Type B injuries (anterior and posterior element injuries with distraction) are characterized by transverse disruption either anteriorly or posteriorly. Type C lesions (anterior and posterior element injuries with rotation) describe injury patterns resulting from axial torque. The latter are most often superimposed on either type A or type B lesions. Morphological criteria are predominantly used for further subdivision of the injuries. Severity progresses from type A through type C as well as within the types, groups, and further subdivisions. The 1445 cases were analyzed with regard to the level of the main injury, the frequency of types and groups, and the incidence of neurological deficit. Most injuries occurred around the thoracolumbar junction. The upper and lower end of the thoracolumbar spine and the T10 level were most infrequently injured. Type A fractures were found in 66.1%, type B in 14.5%, and type C in 19.4% of the cases. Stable type A1 fractures accounted for 34.7% of the total. Some injury patterns are typical for certain sections of the thoracolumbar spine and others for age groups. The neurological deficit, ranging from complete paraplegia to a single root lesion, was evaluated in 1212 cases.(ABSTRACT TRUNCATED AT 400 WORDS)
Article
Thoracolumbar spine fractures are common injuries that can result in significant disability, deformity and neurological deficit. Controversies exist regarding the appropriate radiological investigations, the indications for surgical management and the timing, approach and type of surgery. This review provides an overview of the epidemiology, biomechanical principles, radiological and clinical evaluation, classification and management principles. Literature review of all relevant articles published in PubMed covering thoracolumbar spine fractures with or without neurologic deficit was performed. The search terms used were thoracolumbar, thoracic, lumbar, fracture, trauma and management. All relevant articles and abstracts covering thoracolumbar spine fractures with and without neurologic deficit were reviewed. Biomechanically the thoracolumbar spine is predisposed to a higher incidence of spinal injuries. Computed tomography provides adequate bony detail for assessing spinal stability while magnetic resonance imaging shows injuries to soft tissues (posterior ligamentous complex [PLC]) and neurological structures. Different classification systems exist and the most recent is the AO spine knowledge forum classification of thoracolumbar trauma. Treatment includes both nonoperative and operative methods and selected based on the degree of bony injury, neurological involvement, presence of associated injuries and the integrity of the PLC. Significant advances in imaging have helped in the better understanding of thoracolumbar fractures, including information on canal morphology and injury to soft tissue structures. The ideal classification that is simple, comprehensive and guides management is still elusive. Involvement of three columns, progressive neurological deficit, significant kyphosis and canal compromise with neurological deficit are accepted indications for surgical stabilization through anterior, posterior or combined approaches.
Article
We retrospectively reviewed 100 patients who were posterior stabilized without graft fusion. Using the Sextant system, 22 patients underwent minimally invasive short-segment 4 pedicle screw fixation (MIF 4) and 39 patients underwent minimally invasive short-segment combined with intermediate screws fixation that is 6 pedicle screw fixation (MIF 6). The conventional open posterior short-segment 4 pedicle screw fixation (OPF 4) technique was used in 39 patients.
Article
Fractures of the thoracic and lumbar spine are common in patients who have sustained high energy spinal trauma, and are associated with injury to the spinal cord in up to 50% of cases. Accurate early assessment is essential because delay in diagnosis may result in the development of neurologic complications. Clinical assessment of these patients is often challenging, and as a result, diagnostic imaging usually plays a central role in their management. The purpose of this chapter is to explore this role by answering the following questions: What are the imaging options? Who should be imaged? How should they be imaged? and What are the imaging findings for the most common types of thoracolumbar fractures?