Decision-making and technical choice in instrumental fixation for neurologically uncomplicated isolated burst fractures of the thoracic and lumbar vertebrae

Objective. To substantiate the principles of context-based optimal decision-making and technical choice in instrumental fixation of the spine in trauma patients with neurologically uncomplicated isolated burst fractures of the thoracic and lumbar vertebrae.

Material and Methods. A comparative retrospective analysis of treatment outcomes of 206 trauma patients was performed. Patients of Group 1 (n = 17) underwent anterior spinal fusion with anterior instrumental fixation through isolated open anterior approach, those of Group 2 (n = 80) – open pedicle screw fixation, of Group 3 (n = 70) – posterior mini-invasive percutaneous pedicle screw fixation, of Group 4 (n = 20) – open pedicle screw fixation with the extended laminectomy and reconstruction of the anterior column, and of Group 5 (n = 19) – open pedicle screw fixation and anterior fusion through an open approach. Non-parametric statistical methods were used.

Results. Open or minimally invasive posterior instrumental fixation of the spine with instrumentation systems including 6 screws for incomplete burst fractures and 8–10 screws for complete burst fractures should be considered the best operative option in the immediate post-traumatic period (up to 7 days) both from the point of view of convenience and safety of the patient and from the standpoint of maximally effective use of any hospital resources. The use of open anterior approaches for the reconstruction of the anterior spinal column can be justified only when the time from injury exceeds 7 days, as a part of combined procedure, primarily in combination with minimally invasive posterior pedicle screw fixation.

Conclusion. To date, decision-making and technical choice in instrumental fixation for neurologically uncomplicated isolated burst fractures of the thoracic and lumbar vertebrae should be context-based. The decision-making algorithm should be built on the basis of the experience of the operating surgeon, the time from injury, the trauma patient’s state of health, as well as the administrative and logistical context of provision of the specialized medical care.

1. Abudou M, Chen X, Kong X, Wu T. Surgical versus non-surgical treatment for thoracolumbar burst fractures without neurological deficit. Cochrane Database Syst Rev. 2013(6):CD005079. DOI: 10.1002/14651858.CD005079.pub3.

2. Cheng LM, Wang JJ, Zeng ZL, Zhu R, Yu Y, Li C, Wu ZR. Pedicle screw fixation for traumatic fractures of the thoracic and lumbar spine. Cochrane Database Syst Rev. 2013(5):CD009073. DOI: 10.1002/14651858.CD009073.pub2.

3. Xu GJ, Li ZJ, Ma JX, Zhang T, Fu X, Ma XL. Anterior versus posterior approach for treatment of thoracolumbar burst fractures: a meta-analysis. Eur Spine J. 2013;22:2176–2183. DOI: 10.1007/s00586-013-2987-y.

4. Zhu Q, Shi F, Cai W, Bai J, Fan J, Yang H. Comparison of anterior versus posterior approach in the treatment of thoracolumbar fractures: a systematic review. Int Surg. 2015;100:1124–1133. DOI: 10.9738/INTSURG-D-14-00135.1.

5. Dulaev AK, Manukovskiy VA, Kutyanov DI, Iskrovskiy SV, Brizhan SL, Zhelnov PV, Dulaeva NM. The еfficiency of the centralized system for delivery of specialized medical care to victims with acute spinal cord injury in a modern metropolis. Hir Pozvonoc. 2019;16(1):8–15. In Russian. DOI: 10.14531/ss2019.1.8-15.

6. Cherepanov EA. Russian version of the Oswestry Disability Index: cross-cultural adaptation and validity. Hir Pozvonoc. 2009(3):93–98. In Russian. DOI: 10.14531/ss2009.3.93-98.

7. Krylov VV, Grin AA, Lutsyk AA, Parfenov VE, Dulaev AK, Manukovskiy VA, Konovalov NA, Perl’mutter OA, Safin SM, Kravtsov MN, Manashchuk VI, Rerikh VV. An advisory protocol for treatment of acute complicated and uncomplicated spinal cord injury in adults (association of neurosurgeons of the Russian Federation). Part 3. Zh Vopr Neirokhir Im NN Burdenko. 2015;79(2):97–110. In Russian]. DOI: 10.17116/neiro201579297-110.

8. Wang J, Liu P. Analysis of surgical approaches for unstable thoracolumbar burst fracture: minimum of five year follow-up. J Pak Med Assoc. 2015;65:201–205.

9. Phan K, Rao PJ, Mobbs RJ. Percutaneous versus open pedicle screw fixation for treatment of thoracolumbar fractures: systematic review and meta-analysis of comparative studies. Clin Neurol Neurosurg. 2015;135:85–92. DOI: 10.1016/j.clineuro.2015.05.016.

10. Sun XY, Zhang XN, Hai Y. Percutaneous versus traditional and paraspinal posterior open approaches for treatment of thoracolumbar fractures without neurologic deficit: a meta-analysis. Eur Spine J. 2017;26:1418–1431. DOI: 10.1007/s00586-016-4818-4.

11. Rerikh VV, Baidarbekov MU, Sadovoy MA, Batpenov ND, Kirilova IA. Surgical treatment of thoracic and lumbar spine fractures using transpedicular vertebroplasty and fixation. Hir Pozvonoc. 2017;14(3):54–61. In Russian. DOI: 10.14531/ss2017.3.54-61.

12. Ghobrial GM, Jallo J. Thoracolumbar spine trauma: review of the evidence. J Neurosurg Sci. 2013;57:115–122.

13. Scheer JK, Bakhsheshian J, Fakurnejad S, Oh T, Dahdaleh NS, Smith ZA. Evidence-based medicine of traumatic thoracolumbar burst fractures: a systematic review of operative management across 20 years. Global Spine J. 2015;5:73–82. DOI: 10.1055/s-0034-1396047.

14. Landi A, Gregori F, Delfini R. Spinal trauma in Italy: actuality and future perspectives. Orthop Muscular Syst. 2015;4:e118. DOI: 10.4172/2161-0533.1000e118.

15. Dulaev AK, Manukovskiy VA, Kutyanov DI, Bulakhtin YY, Brizhan’ SL, Zhelnov PV. Development of management of emergency surgical care for patients with acute traumatic and nontraumatic spinal pathologies in conditions of megapolis. Vestn Khir Im II Grek. 2017;176(4):39–43. In Russian. DOI: 10.24884/0042-4625-2017-176-4-39-43.