Thoracolumbar burst fractures in patients with neurological deficit: Anterior approach versus posterior percutaneous fixation with laminotomy

The location of pedicle screws (n = 42) in four human specimens of the lumbar spine and in 30 patients (n = 131 screws) after lumbar spinal fusion was assessed using computed tomography. To determine the accuracy of pedicle screw placement in lumbar vertebrae and the reproducibility and repeatability of the computed tomography examination. Failures in the placement of transpedicular screws for lumbar fusion are reported. The evaluation of such screws using computed tomography examination has not been investigated. After surgery, the specimens were dissected in transversal slices to observe macroscopically the location of the pedicle screw and to correlate these observations with the computed tomography images. All patients were examined by one observer. To determine the reproducibility and repeatability of the computed tomography examination, two observers studied computed tomography images of 12 patients (n = 58 screws) twice within 3 months. In the specimens, 10 screws were observed to penetrate the medial wall of the pedicle. This correlated fully with the images. In the patients' group, 40% of all screws penetrated the cortex of the vertebra. Of all screws, 29% penetrated the medial wall of the pedicle. From the computed tomography images, it appeared that a deviation of more than 6 mm medially was a high risk for nerve root damage. Three months after his first examination, Observer 1 documented a different position in three of 58 screws (kappa = 0.90). Observer 2 found a different position in eight screws (kappa = 0.65). The comparison between the reviews of the two observers showed a different opinion for the first evaluation, four disagreements (2-4 mm) and 17 disagreements (0-2 mm; kappa = 0.34), and for the second evaluation, four disagreements (2-4 mm) and 12 disagreements (0-2 mm; kappa = 0.43). Correct placement of transpedicular screws for spinal fusion seems to be more difficult than it looks. The computed tomography scanning is useful for differential diagnosis of postoperative radicular syndromes after lumbar transpedicular fixation.

Multicenter prospective randomized trial. To test the hypotheses that thoracolumbar AO Type A spine fractures without neurologic deficit, managed with short-segment posterior stabilization will show an improved radiographic outcome and at least the same functional outcome as compared with nonsurgically treated thoracolumbar fractures. There are various opinions regarding the ideal management of thoracolumbar Type A spine fractures without neurologic deficit. Both operative and nonsurgical approaches are advocated. Patients were randomized for operative or nonsurgical treatment. Data sampling involved demographics, fracture classifications, radiographic evaluation, and functional outcome. Sixteen patients received nonsurgical therapy, and 18 received surgical treatment. Follow-up was completed for 32 (94%) of the patients after a mean of 4.3 years. At the end of follow-up, both local and regional kyphotic deformity was significantly less in the operatively treated group. All functional outcome scores (VAS Pain, VAS Spine Score, and RMDQ-24) showed significantly better results in the operative group. The percentage of patients returning to their original jobs was found to be significantly higher in the operative treated group. Patients with a Type A3 thoracolumbar spine fracture without neurologic deficit should be treated by short-segment posterior stabilization.