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  • br Traumatic thoracolumbar spine fractures br Traumatic frac

    2018-10-29


    Traumatic thoracolumbar spine fractures
    Traumatic fractures of the thoracolumbar spine, particularly the thoracolumbar junction (T10–L2), are the most common fractures of the spinal column. Percutaneous pedicle screw instrumentation (PPSI) has been used for treating various trauma patterns. For patients with thoracolumbar AP1903 fractures (type A3 according to Magerl/AO classification) without neurological deficits, PPSI was reported to have comparable outcomes with open pedicle screw instrumentation (OPSI) and a shorter postoperative recovery period. In a retrospective study of 21 patients, patients who received PPSI treatment had significantly less intraoperative blood loss but a longer operative time, and most importantly, comparable radiographic or clinical outcomes relative to those who received traditional open treatment 5 years after implant removal. Another retrospective study of 38 patients who had similar injuries and received PPSI at an average follow-up of 11.6 months revealed significant reductions in blood loss, operative time, hospital stay duration, blood transfusion, the proportion of antalgic supplements, and the postoperative incisional VAS pain score. However, the anterior height of the fractured vertebra was shorter in patients treated using PPSI, indicating that PPSI may be less effective in restoring the anterior height of the fractured vertebra than OPSI. A retrospective study examined 35 patients treated with short-segment fixation by using PPSI or OPSI (fixation 1 level above and below the injury). Patients treated using PPSI had significantly shorter operative times, less blood loss, less postoperative pain, and comparable radiographic and clinical outcomes relative to those treated using OPSI at 2-year follow ups. Another retrospective comparative study of 59 patients confirmed that both OPSI and PPSI were safe and effective for treating thoracolumbar burst fractures. Although both groups showed favorable clinical and radiologic outcomes at the final follow up, PPSI without bone grafts provided early pain relief and more favorable functional outcomes. Only one prospective randomized trial compared OPSI (paraspinal approach) and PPSI. Similar to the retrospective studies, the prospective randomized trial reported that PPSI was associated with significantly less intraoperative blood loss, shorter operative times, shorter hospital stays, less pain, and more favorable functional outcomes at 3 months and had comparable outcomes for more than 3 years relative to OPSI. However, the author reported that compared with PPSI, OPSI resulted in more satisfactory correction of kyphosis and restoration of vertebral height for patients in whom intraoperative postural reduction could not be achieved. For patients with flexion–distraction injury (type B according to Magerl/AO classification), a retrospective study of 38 patients showed similar benefits of PPSI over a mean follow-up period of 18.5 months. However, the authors used PPSI only in patients without neurological deficits. In conclusion, the advantages of PPSI relative to OPSI include preservation of posterior musculature, less blood loss, shorter operative time, lower infection risk, less postoperative pain, shorter rehabilitation time, and shorter hospital stay; however, its limitations include the inability to achieve direct spinal canal decompression and lack of the option to perform a fusion. Although substantial evidence has shown that PPSI is both effective and safe for patients with thoracolumbar compression fractures (type B according to Magerl/AO classification), only a few studies have addressed thoracolumbar fractures with neurological deficits or flexion rotation fractures (type C according to Magerl/AO classification). In a retrospective analysis of patients with thoracolumbar junction fractures, the authors used video-assisted thoracoscopic surgery with a minimally invasive approach (minithoracotomy) for reconstructing the anterior spinal column followed by PPSI for treating four patients with type C fractures, and the patients were satisfied with the outcomes. There is an obvious tendency to treat such patients by using PPSI with a minimally invasive approach for decompressing the spinal canal or reconstructing the anterior column. However, the efficacy and safety of these methods for treating patients with advanced-type thoracolumbar fractures or neurological deficits remain debatable.