Long-term results of surgical treatment of patients with neurologically intact burst fractures of the thoracolumbar junction

Objective. To analyze long-term radiological and clinical outcomes of treatment of neurologically intact burst fractures of the thoracolumbar junction and to determine the optimal method of surgical treatment.

Material and Methods. A single-center retrospective cohort study was conducted. Inclusion criteria were: AOSpine type A3 or A4 fracture at the T11–L2 level; absence of spinal cord and its nerve root injury; patient availability for a follow-up examination 12 months or later
after surgery. Surgical treatment methods were divided into six groups depending on surgical approach (posterior, anterior, or combined) and whether decompression was performed. Standard radiological parameters were evaluated at admission, immediately after surgery, and at the final examination. Clinical outcomes were assessed using the Visual Analogue Scale (VAS) and the Oswestry Disability Index (ODI).

Results. A total of 57 patients (50.9% female, 49.1% male; mean age 41.1 ± 14.6 years) were included in the study. The median follow-up period was 57.6 months [28.9–110.4]. The study groups were homogeneous in terms of sex, age, and most radiological parameters. The dynamics of radiological parameters did not differ significantly between the groups, with the exception of spinal canal stenosis (SS), which was significantly lower (p = 0.008) in the groups without decompression upon admission. Among patients who underwent stabilization procedures, a separate subgroup of patients with stenosis of more than 30% (n = 10, Me 34.8% [32.6–48.8]) on admission was identified. This subgroup showed the greatest reduction in stenosis over time, with a median decrease of –28.9% [–31.3; –13.6]. The  overall incidence of Grade Ia complications according to Landriel-Ibañez classification was 26.3%. Grades IIb and IIIa were detected in four patients (7.0%), predominantly from groups with decompression (p = 0.025). Bony fusion was detected in the majority of patients (n = 50, 87.7%), including stable pseudarthrosis in four patients (7.0%) and unstable pseudarthrosis in three cases (5.3%). There were no significant differences in radiological outcomes between the groups (χ² test, p = 0.535), however, decompression was found to be a significant risk factor for pseudarthrosis (p = 0.039). Pseudarthrosis developed significantly more often in cases involving bilateral facet joint resection (p = 0.010). When assessing the clinical results, the pain severity at the surgical site did not differ significantly between the groups (p = 0.944). The lowest ODI scores were observed in the group of transpedicular fixation without decompression.

Conclusion. Short-segment posterior pedicle screw fixation without laminectomy could be an effective treatment option for patients with neurologically intact burst fractures of the thoracolumbar junction with kyphotic deformity up to 21.5°, a decrease in the vertebral body anterior height down to 53.2%, and a vertebral body index over 0.53. In cases of spinal canal stenosis up to 49%, spontaneous bone fragment lysis with partial or complete canal remodeling can occur without decompressive surgery, provided rigid internal immobilization of the segment is achieved. Further prospective studies with a high level of evidence are necessary to determine the optimal surgical approach for treating neurologically intact thoracolumbar junction fractures.

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