STUDY RATIONALE AND CONTEXT
Thoracolumbar fractures are the most common spinal fractures, with an incidence ranging
between 18 and 30 cases per 100,000 inhabitants/year [1 ], [2 ]. Patients requiring surgical treatment usually undergo either open surgery, including
pedicle screw fixations or thoracoscopic approaches. Recently, percutaneous pedicle
screw fixation techniques have gained popularity as minimally invasive procedures
able to provide spinal stability with a lower rate of morbidity.
KEY QUESTIONS
With respect to fractures of the thoracolumbar junction:
CLINICAL GUIDELINES
Fig 1
Results of literature search.
Table 1
Characteristics of included studies.
Study (y)
Study design
Population
Diagnosis
Treatment
Follow-up
Wang et al
[5 ]
(2010)
Retrospective cohort study
N = 38
Minimally invasive surgery (MIS; Sextant percutaneous pedicle screw fixation)
n = 17
Mean age: 41.6 (range, 28–54) y
Male: 76.5%
Open surgery (open pedicle screw fixation)
n = 21
Mean age: 45.0 (range, 37–61) y
Male: 85.7%
MIS (Sextant percutaneous pedicle screw fixation)
Mechanism of injury
Falling: 41.2% (7/17 patients)
Traffic injuries: 41.2% (7/17 patients)
Tumble: 17.6% (3/17 patients)
AO fracture classification
A1: 35.3% (6/17 patients)
A2: 23.5% (4/17 patients)
A3: 41.2% (7/17 patients)
ASIA score
Open surgery (open pedicle screw fixation)
Mechanism of injury
Falling: 71.4% (15/21 patients)
Traffic injuries: 9.5% (2/21 patients)
Tumble: 14.3% (3/21 patients)
Strike by dropping heavy object: 4.8% (1/21 patient)
AO fracture classification
ASIA score
MIS (Sextant percutaneous pedicle screw fixation)
Injury segments
– T12: 17.6% (3/17 patients)
– L1: 58.8% (10/17 patients)
– L2: 23.5% (4/17 patients)
Open surgery (open pedicle screw fixation)
Injury segments
– T12: 33.3%(7/21 patients)
– L1: 28.6%(6/21 patients)
– L2: 38.1%(8/21 patients)
Mean f/u: 11.6 (range, 8–24) mo
100% f/u
Wild et al
[4 ]
(2006)
Retrospective cohort study
N = 23
MIS (percutaneous pedicle fixation)
n = 10
Mean age: 49.1 y*
Male: 90%*
Open surgery (conventionally open posterior surgery with pedicle fixation)
n = 11
Mean age: 33.5 y*
Male: 63.6%*
AO fracture classification:
– 100% (21/21) type A fracture
Both groups used Synthes universal spine system’s fixateur interne
Mean f/u: 25.5 and 67.9 mo for both groups
91.3% f/u
* After loss to follow-up (f/u).
Table 2
Comparative effectiveness between percutaneous minimally invasive and open surgery
for thoracolumbar fracture.
Outcome
Minimally invasive
Open
P
Radiographic
Mean change
Mean change
Sagittal Cobb angle,°
– Wang et al [5 ]
10.3 ± 6.1
9.3 ± 7.3
.651
Fractured vertebral body angle, °
– Wang et al [5 ]
6.6 ± 4.0
7.9 ± 4.9
.396
– Wild et al [4 ]
7.7
12.2
Anterior vertebral body height, %
– Wang et al [5 ]
21.0 ± 11.8
28.6 ± 18.7
.155
Posterior vertebral body height, %
– Wang et al [5 ]
4.4 ± 3.2
6.2 ± 4.8
.196
Bisegmental wedge angle, °
– Wild et al [4 ]
2.6
2.4
Clinical
VAS (incisional pain)
– Wang et al [5 ]
1.5 ± 0.9
2.2 ± 0.8
< .05
MacNab criteria
– Wang et al [5 ]
88.2
85.7
Hannover spine score
– Wild et al [4 ]
84.8
78
SF-36
– Wild et al [4 ]
59.1
50
.069
Table 3
Comparative safety between percutaneous minimally invasive and open surgery for thoracolumbar
fracture.
Outcome
Minimally invasive
Open
P
Perioperative
Mean ± SD
Mean ± SD
Surgical blood loss, mL
– Wang et al [5 ]
83.5 ± 51.8
304.8 ± 209.1
.000
– Wild et al [4 ]
194.4 ± 72.6
380 ± 198.9
.017
Postoperative blood loss, mL
– Wang et al [5 ]
14.4 ± 4.3
350.1 ± 204.5
.000
– Wild et al [4 ]
155.6 ± 35.0
441.1 ± 162.3
.000
Operation time, min
– Wang et al [5 ]
97.1 ± 15.3
161.0 ± 72.5
– Wild et al [4 ]
87.4
80.9
Hospital stay, days
– Wang et al [5 ]
11.1 ± 3.8
22.9 ± 14.1
Complications
%
%
Screw malposition
– Wang et al [5 ]
0.0
2.1
– Wild et al [4 ]
0.0
0.0
Infection
– Wild et al [4 ]
0.0
0.0
Neurological symptoms
– Wild et al [4 ]
0.0
0.0
Incisional stagger
– Wild et al [4 ]
0.0
11.8
Deep vein thrombosis
– Wild et al [4 ]
0.0
5.9
* From preoperative to postoperative.
ILLUSTRATIVE CASE
A 67-year-old woman presented with a 3-month history of severe pain in the dorsal
and lumbar regions of her spine. Symptoms made her ambulation difficult, as well as
sitting and sleeping.
Her medical history was remarkable for myocardial infarction; insulin-dependent diabetes;
HCV-related hepatitis; and diabetes-related retinopathy and neuropathy. She reported
to have undergone, in 2010, a vertebroplasty for a fracture of Th12 ([Fig 2 ]). Postoperatively, she improved considerably and remained well until October 2011,
when a new spinal trauma caused a type B1.2 fracture of the same vertebra associated
with a fracture of the anteroinferior portion of the 11th posterior vertebra and a
minor lesion of the posterosuperior end plate of L1 ([Fig 3 ]).
The patient was consented for a Th10-Th11-L1-L2 percutaneous pedicle screw fixation.
Following this procedure, a satisfactory spinal stability and alignment was obtained
as well as improvement of the 12th vertebral body’s height ([Fig 4 ]). At 1-year follow-up, the patient remains unchanged ([Fig 5 ]).
Fig 2
Lateral thoracolumbar x-ray showing a vertebroplasty of Th12.
Fig 3a
Lateral thoracolumbar x-ray showing the recurrent posttraumatic fracture of Th12
as well as the fracture of the anteroinferior surface of the Th11 vertebral body.
An obvious kyphosis at the same levels is also seen.
Fig 3b
Sagittal reformatted CT image revealing the Th11 and Th12 vertebral bodies' fractures.
Also perceived is a signal change in the posterosuperior area of the L1 vertebra.
Fig 3c
Sagittal T2-weighted MR image confirming the Th11 and Th12 fractures. A signal change
in keeping with an impact fracture of the posterosuperior bone of the L1 vertebra
is also seen.
Fig 4
Postoperative lateral thoracolumbar x‑ray showing the reduced kyphosis and correct
sagittal alignment following the percutaneous Th10-Th11-L1-L2 fixation.
Fig 5
AP (a) and sagittal (b) thoracolumbar, 1-year follow-up x-ray confirming the acquired
stability of the thoracolumbar junction, with marked reduction of the focal kyphosis.
Table 4
Rating of overall strength of evidence for each key question.
Question 1: What is the comparative effectiveness of percutaneous minimally invasive
versus open spine surgery for thoracolumbar fractures?
Outcome
Strength of evidence
Conclusions/comments
Baseline
Downgrade
Upgrade
Radiographic
Radiographic outcomes that include sagittal angle, fractured vertebral body angle,
anterior and posterior vertebral body height, and bisegmental wedge angle were similar
between percutaneous minimally invasive and open surgery
Low
Imprecision (1)
No
Clinical
Postoperative incisional pain was less following percutaneous minimally invasive surgery
(MIS)
Patient-reported and clinician-based outcomes were similar at follow-up between groups
Low
Single study (1)
No
Question 2: What is the comparative safety of percutaneous minimally invasive versus
open spine surgery for thoracolumbar fractures?
Outcome
Conclusions/comments
Baseline
Downgrade
Upgrade
Perioperative
Blood loss at surgery and in the postoperative period was less with percutaneous MIS
compared with open
Low
No
No
Complications
There were no complications reported for percutaneous MIS in two small studies
Low
No
No
* Baseline quality: High indicates majority of article Level I/II; low, majority of
articles Level III/IV.Upgrade: Large magnitude of effect (1 or 2 levels); dose response
gradient (1 level).Downgrade: Inconsistency of results (1 or 2 levels); indirectness
of evidence (1 or 2 levels); imprecision of effect estimates (1 or 2 levels).