The use of screw at the fracture level in the treatment of thoracolumbar burst fractures. Long segment instrumentation of thoracolumbar burst fracture: fusion versus nonfusion. Posterior fixation of thoracolumbar burst fracture: short-segment pedicle fixation versus long-segment instrumentation. Is fusion necessary for surgically treated burst fractures of the thoracolumbar and lumbar spine?: a prospective, randomized study. Short-segment pedicle instrumentation of thoracolumbar burst fractures: does transpedicular intracorporeal grafting prevent early failure? Transpedicular fixation in management of thoracolumbar burst fractures: monosegmental fixation versus short-segment instrumentation. Posterior short-segment fixation with or without fusion for thoracolumbar burst fractures. a five to seven-year prospective randomized study. Inclusion of the fracture level in short segment fixation of thoracolumbar fractures.
In this prospective randomized study, the results of treating unstable thoracolumbar burst fractures by pedicle instrumentation with and without fracture level screw combination were given.
                Our aim was to evaluate the efficacy of fracture level screw combination in achieving and maintaining correction in the treatment of unstable thoracolumbar burst fractures.
                Most authors reported that intraoperative correction of sagittal deformity is important for the maintenance of fracture reduction and is one of the most consistent predictor of satisfactory functional outcome.
                Seventy-two patients with unstable thoracolumbar burst fractures were randomized into 4 groups with equal number of patients. In group 1, patients were treated by segmental posterior instrumentation with 2 levels above and 2 levels below the fracture level fixation, in group 2 they were treated as in group 1 with fracture level screw incorporation. In group 3, patients were treated by short-segment posterior instrumentation with 1 level above and 1 level below, in group 4 they were treated by short-segment posterior instrumentation with fracture level screw incorporation. Clinical and radiologic parameters were evaluated before surgery, after surgery, and at follow-up.
                The average follow-up was 50 months. Fracture level screw combination provided better intraoperative correction and maintenance in the treatment of unstable thoracolumbar burst fractures, which was more prevalent in short-segment fixation group.
                Reinforcement with fracture level screw combination can help to provide better kyphosis correction and offers immediate spinal stability in patients with thoracolumbar burst fracture. The treatment of thoracolumbar burst fracture is a controversial issue. Although spinal fusion has been a touchstone of spinal fixation, nonfusion technique have become raising its popularity recently. Some studies suggested that nonfusion had several advantages over fusion. The aim of this prospective study was to compare long segment posterior instrumentation with fusion versus long-segment posterior instrumentation without fusion.
                For this purpose, 42 consecutive patients were assigned to two groups. Group 1 included 21 patients treated by long segment instrumentation with fusion (WF), whereas Group 2 included 21 patients treated by long segment instrumentation without fusion (WOF). Long segment instrumentation was hook fixation (claw hooks attached to second upper vertebra and infralaminar hooks attached to first upper vertebra) above and pedicle fixation (pedicle screws attached to first and second lower vertebrae) below the fractured vertebra.
                Measurements of local kyphosis, sagittal index and anterior vertebral height compression showed that both group had similar outcome at final follow-up. Moreover, there was no difference between the two groups according to low back outcome score. Also, implant failure rate (4.7%) was quite low in both groups. However, WF group had prolonged operative time, increased blood loss and donor site morbidity.
                Radiological and clinical parameters demonstrated that spinal fusion is not necessary in long segment posterior instrumentation for the management of thoracolumbar burst fractures. The treatment of thoracolumbar burst fracture is a controversial issue. Short-segment (SS) pedicle fixation has become a popular treatment option. However, there are several studies regarding the high rate of failure. The aim of this prospective study was to compare SS versus long-segment (LS) instrumentation.
                For this purpose, 18 consecutive patients were assigned to two groups. Group 1 included nine patients treated by SS pedicle fixation, whereas group 2 included nine patients treated by LS instrumentation. SS instrumentation was pedicle fixation one level above and below the fractured vertebra. LS instrumentation was hook fixation (claw hooks attached to second upper vertebra and infralaminar hooks attached to first upper vertebra) above and pedicle fixation (pedicle screws attached to first and second lower vertebrae) below the fractured vertebra.
                As a result, measurements of local kyphosis, sagittal index, and anterior vertebral height compression showed that the LS group had a better outcome at final follow-up (P < 0.05). Also, the SS group had a 55% failure rate, whereas the LS group had prolonged operative time and increased blood loss. However, there was no difference between the two groups according to Low Back Outcome Score.
                In conclusion, radiographic parameters demonstrated that LS instrumentation is a more effective management of thoracolumbar burst fractures. Nevertheless, clinical outcome was the same between the two groups. However, our conclusions were based on posterior-only surgery. Anterior column support would negate the need for LS fixation. Also, SS would have been more successful if two above and two below pedicle screws were used. A prospective clinical trial was conducted.
                To compare the results of fusion versus nonfusion for surgically treated burst fractures of the thoracolumbar and lumbar spine.
                The operative results of surgically treated burst fractures with short segmental fixation have been well documented. There is no report comparing the results of fusion and nonfusion.
                Fifty-eight patients were included in this study, with the inclusion criteria as follows: neurologically intact spine with a kyphotic angle > or = 20 degrees, decreased vertebral body height > or = 50% or a canal compromise > or = 50%, incomplete neurologic deficit with a canal compromise 50%, complete neurologic deficit, and multilevel spinal injury or multiple traumas. All patients were randomly assigned to fusion or nonfusion groups, and operative treatment with posterior reduction and instrumentation was carried out. Posterior fusion with autogenous bone graft was performed for the fusion group (n = 30), and no fusion procedure was done for the nonfusion group (n = 28). The average follow-up period was 41 months (range, 24-71 months).
                The average loss of kyphotic angle was not statistically significant between these 2 groups. The radiographic parameters were statistically significantly better in the nonfusion group, including angular change in the flexion-extension lateral view (4.8 degrees vs. 1.0 degrees), lost correction of decreased vertebral body height (3.6% vs. 8.3%), intraoperative estimated blood loss (303 mL vs. 572 mL), and operative time (162 minutes vs. 224 minutes). The scores on the low back outcome scale were not statistically significant for these 2 groups.
                The short-term results of short segmental fixation without fusion for surgically treated burst fractures of the thoracolumbar spine were satisfactory. The advantages of instrumentation without fusion are the elimination of donor site complications, saving more motion segments, and reducing blood loss and operative time. A prospective, randomized study comparing two treatment methods for thoracolumbar burst fractures: short-segment instrumentation with transpedicular grafting and the same procedure without transpedicular grafting.
                To evaluate the efficacy of transpedicular grafting in preventing failure of short-segment fixation for the treatment of thoracolumbar burst fractures.
                Short-segment pedicle instrumentation for thoracolumbar burst fractures is known to fail early because of the absence of anterior support. Additional transpedicular grafting has been offered as an alternative to prevent this failure. However, there is controversy about the results of transpedicular grafting.
                Twenty patients with thoracolumbar burst fractures were included in the study. The inclusion criterion was the presence of fractures through the T11-L3 vertebrae without neurologic compromise. The patients were randomized by a simple method into two groups. Group 1 patients were treated using short-segment instrumentation with transpedicular grafting (TPG) (n = 10), and Group 2 patients were treated by short-segment fixation alone (NTPG) (n = 10). Clinical (Likert's questionnaire) and radiologic (sagittal index, percentage of anterior body height compression, and local kyphosis) outcomes were analyzed.
                The two groups were similar in age, follow-up period, and severity of the deformity and fracture. The postoperative and follow-up sagittal index, percentage of anterior body height compression, and average correction loss in local kyphosis in both groups were not significantly different. The failure rate, defined as an increase of 10 degrees or more in local kyphosis and/or screw breakage, was also not significantly different (TPG = 50%, NTPG = 40%, P = 0.99).
                Short-segment transpedicular instrumentation of thoracolumbar burst fractures is associated with a high rate of failure that cannot be decreased by additional transpedicular intracorporeal grafting. A prospective clinical trial was conducted.
                To compare the clinical and radiologic late results of monosegmental transpedicular fixation versus short-segment pedicle instrumentation (SSPI) in management of thoracolumbar burst fractures and evaluate the efficacy of monosegmental transpedicular fixation.
                SSPI (1 level above and 1 below the fracture level) are accepted by many surgeons as an accepted technique for the treatment of thoracolumbar burst fractures. To preserve more motion segments, some authors have advocated monosegmental pedicle instrumentation (MSPI). The recent developments showed that MSPI yielded good clinical results; however, there were no report about comparison of clinical outcome between monosegmental and biosegmental transpedicular fixation in management of thoracolumbar burst fractures.
                Eighty-five patients with thoracolumbar burst fractures fulfilling the inclusion criteria were included in the study. The patients were randomized by a simple method into 2 groups. Group 1 were treated with monosegmental transpedicular fixation (n = 47), and group 2 were treated with biosegmental transpedicular fixation (n = 38). Clinical (Low Back Outcome Score and Oswestry Disability Index) and radiologic (load-sharing classification index, sagittal index, and percentage of anterior body height compression) outcomes were analyzed.
                The 2 groups were similar in age, follow-up period, and severity of the deformity and fracture. The postoperative and follow-up sagittal index, local kyphosis, percentage of anterior body height compression, and average correction loss in local kyphosis in both groups were not significantly different. The failure rate between the 2 surgical approaches was also not significantly different (group 1 = 6.38% and group 2 = 5.26%). Oswestry Disability Index improved in both groups by >25 points in a similar amount (P = 0.23). The average follow-up Low Back Outcome Score was 74.9 and 60.2 for group 1 and group 2, respectively (P = 0.033).
                In conclusion, radiologic parameters demonstrated that both MSPI and SSPI are the effective and reliable operative techniques for selected thoracolumbar burst fractures. MSPI shortened the operative time and decreased the amount of blood loss significantly and, thus, offered better clinical results. Nevertheless, long-term studies are supposed to be performed to support the outcomes. The impact of fusion as a supplement to short-segment instrumentation for the treatment of thoracolumbar burst fractures is unclear. We conducted a controlled clinical trial to define the effect of fusion on lumbar spine and patient-related functional outcomes.
                From 2000 to 2002, seventy-three consecutive patients with a single-level Denis type-B burst fracture involving the thoracolumbar spine and a load-sharing score of <or=6 were managed with posterior pedicle screw instrumentation. The patients were randomly assigned to treatment with posterolateral fusion (fusion group, n = 37) or without posterolateral fusion (nonfusion group, n = 36). The patients were followed for at least five years after surgery and were assessed with regard to clinical and radiographic outcomes. Clinical outcomes were evaluated with use of the Frankel scale, the motor score of the American Spinal Injury Association, a visual analog scale, and the Short Form-36 (SF-36) questionnaire. Radiographic outcomes were assessed on the basis of the local kyphosis angle and loss of kyphosis correction.
                No significant difference in radiographic or clinical outcomes was noted between the patients managed with the two techniques. Both operative time and blood loss were significantly less in the nonfusion group compared with the fusion group (p < 0.05). Twenty-five of the thirty-seven patients in the fusion group still had some degree of donor-site pain at the time of the latest examination.
                Posterolateral bone-grafting is not necessary when a Denis type-B thoracolumbar burst fracture associated with a load-sharing score of <or=6 is treated with short-segment pedicle screw fixation. Short segment posterior fixation is the preferred method for stabilizing thoracolumbar fractures. In case of significant disruption of the anterior column, the simple short segment construct does not ensure adequate stability. In this study, we tried to evaluate the effect of inclusion of the fractured vertebra in short segment fixation of thoracolumbar fractures. In a prospective randomized study, eighty patients with thoracolumbar fractures treated just with posterior pedicular fixation were randomized into two groups receiving either the one level above and one level below excluding the fracture level (bridging group), or including the fracture level (including group). Different clinical and radiological parameters were recorded and followed. A sum of 80 patients (42 patients in group 1 and 38 patients in group 2) were enrolled in the study. The patients in both the groups showed similar clinical outcome. There was a high rate of instrumentation failure in the "bridging" group. The "bridging" group showed a mean worsening (29%) in kyphosis, whereas the "including" group improved significantly by a mean of 6%. The significant effect of the "including" technique on the reduction of kyphotic deformity was most prominent in type C fractures. In conclusion, inclusion of the fracture level into the construct offers a better kyphosis correction, in addition to fewer instrument failures, without additional complications, and with a comparable-if not better-clinical and functional outcome. We recommend insertion of screws into pedicles of the fractured thoracolumbar vertebra when considering a short segment posterior fixation, especially in Magerl type C fractures.
This review included only eight small trials and five different comparisons of methods of pedicle fixation in various participants while looking at a variety of outcomes at different time points. Overall, evidence is insufficient to inform the selection of different methods of pedicle screw fixation or the combined use of fusion. However, in the absence of robust evidence to support fusion, it is important to factor the risk of long-term donor site pain related to bone harvesting into the decision of whether to use this intervention. Further research involving high-quality randomised trials is needed.