X-ray and CT scan predictors of damage to the posterior ligamentous complex in fractures of the vertebral bodies of the thoracolumbar junction: systematic review and meta-analysis

Objective of the review was to identify, basing on literature data, the most reliable X-ray and CT signs of damage to the posterior ligamentous complex (PLC) in fractures of the vertebral bodies of the thoracolumbar junction, initially interpreted as type A according to the AOSpine classification. The systematic review was carried out according to the recommendations of PRISMA. The search in PubMed, MEDLINE and Cochrane Library databases revealed 491 articles on relevant issues. Once the inclusion and exclusion criteria have been met, 7 original articles from peer-reviewed scientific journals for the last 10 years were selected for a systematic review, 6 of which were included in the meta-analysis. In all articles, the authors identified two groups of patients: with and without damage to the PLC. The PLC damages were confirmed by MRI and intraoperatively. Radiographic and CT spondylometric parameters were identified, which had statistically significant differences between the groups. To determine predictors of PLC damage, the values of these parameters were subjected to regression analysis. This was followed by a meta-analysis of random and fixed effects models depending on the homogeneity of the data. Statistical heterogeneity was assessed using the X-square test with the null hypothesis of the absence of significant differences in all studies, as well as the heterogeneity index – I2. For the graphical display of the results, forest plots were built. Local kyphosis angle >25°, Cobb angle >16° and difference between interspinous distances >2.54 mm are CT scan predictors of PLC damage. The parameters characterizing the interspinous relationship were studied in no more than two studies, but at the same time they always had statistically significant differences between the groups with and without PLC injuries, therefore, they cannot be ignored during diagnosis. Anterior/posterior vertebral height ratio, anterior vertebral height ratio, sagittal index and suprajacent/subjacent parameters are not the predictors of PLC damage.

Polymethylmethacrylate-augmented Cannulated Pedicle Screw Fixation for High-energy Vertebral Compression Fracture with Osteoporosis

Background: High-energy vertebral compression fractures (HVCFs) with osteoporosis puts forward higher requirement for the stability of pedicle screw internal fixation system. However, few studies have concentrated on the clinical outcomes of cannulated pedicle screw to augment fixation with polymethylmethacrylate (PMMA) under this condition. This study aims to investigate the mid-term efficacy of bone cement-injectable cannulated pedicle screw (CICPS) in HVCFs with osteoporosis.Methods: Eighteen patients with HVCFs (T < -2.5) were underwent spinal fixation by CICPS from 2012 to 2017. The operation time, blood loss, and hospitalization time were recorded. Pain and functional recovery were evaluated by Visual Analog Scale VAS) and Oswestry Disability Index (ODI), respectively. X-ray films were taken to evaluate the loss of vertebral height, kyphosis angle, pedicle screw loosening, and bony fusion. Surgical related complications were also recorded.Results: The average follow-up time was 18.5 ± 8.7 months (range, 6-54 months). VAS and ODI scores indicated significant improvements in postoperative pain and activity function (P < 0.05). Comparing the last follow-up with the postoperative imaging findings, the loss of vertebral height and kyphosis angle was 3.4 ± 1.2 mm and 7.8 ± 3.8°, respectively. The rate of bone graft fusion was 100% while no case was involved in screw loosening or extraction. 1 case of superficial infection, 2 cases of PMMA leakage, and 1 case of cerebrospinal fluid leakage were found.Conclusions: CICPS fixation using PMMA augmentation may be suggested as a feasible surgical technique in osteoporotic patients with HVCFs.

Efficiency of a Novel Vertebral Body Augmentation System (Tektona™) in Non-osteoporotic Spinal Fractures

BackgroundThe restauration of the local kyphosis is crucial for spinal fractures outcomes. Recently, the Tektona™, (Spine Art) system, constituted by a flexible lamella for reduction has emerged as a promising solution for osteoporotic fractures. However, no study has yet focused on its results on traumatic fractures. MethodsA retrospective longitudinal study on prospectively collected data was conducted on 53 patients. The data collected were clinical, surgical and scannographic (measurement of AVH, MVH and PVH (anterior/medium/posterior vertebral height), and RTA (regional traumatic angle) in°), preoperatively, early post-operative and at follow-up. ResultsFractures were mainly located at the upper lumbar spine and were Magerl A3.1 type for 51%. The mean RTA was 12° in pre-operative, 4° in post-operative (p=2e-9), and 8° at the last follow-up (p=0,01). The mean correction of RTA for the fixation group was -10±6° versus -7±4° for the vertebroplasty alone group (p=0,006). The mean correction for fractures located at T10-T12 was -9±3°, -9±5° for L1, -8±3° for L2 and -5±3° for L3-L5 (p=0,045). ConclusionsThe Tektona® system appears to be efficient for acute thoraco-lumbar fractures, comparable to other available systems, allowing a real intracorporeal reduction work. Its relevance, especially in the long term needs further investigation. The association of a percutaneous fixation allow to obtain a better correction of the RTA but did not seem to prevent the loss of correction at follow-up.

A Lateral Opening Injection Tool Used In Percutaneous Vertebroplasty To Treat Asymptomatic Osteoporotic Vertebral Burst Fractures: A Retrospective Study In 66 Cases

Background: This study aimed to assess the results of percutaneous vertebroplasty (PVP) with a lateral opening injection tool for treating asymptomatic osteoporotic vertebral burst fractures (OVBFs) patients.Methods: 66 patients diagnosed with acute asymptomatic OVBFs with a spinal canal occupational ratio under 20% were treated with bilateral PVP using a lateral opening injection tool in our study. The related clinical outcomes and images were assessed, including Visual Analogue Scale (VAS), vertebral height (VH) ratio (=fractured VH/ adjacent nonfractured VH), the bone union of the fractured vertebral posterior wall, bone cement distribution, and complications.Results: The VAS scores were 3.80±0.40 at postoperative one day and 0.59±0.41 at last follow-up, significantly lower than 8.37±0.49 at pre-operation (P<0.05). The vertical distribution of bone cement in 60 cases contacted the upper and lower endplates of fractured vertebras. There was no leakage of bone cement in the spinal canal or displacement of posterior wall fracture to the spinal canal in all cases. There was asymptomatic cement leakage in 7 cases. The mean anterior, middle and posterior vertebral height ratios were significantly increased after PVP compared with preoperative values in all patients (P<0.05). At 6 months follow-up, there was no significant height loss of the vertebral body. Three months postoperatively, the posterior wall of fractured vertebral bodies was healed in all cases according to CT images. Conclusions: PVP using a lateral opening injection tool was effective and safe for treating asymptomatic OVBF patients.

Is Osteoporotic Thoracolumbar Burst Fracture a Contraindication to Percutaneous Kyphoplasty? A Systematic Review

BACKGROUND: The management of pain after osteoporotic thoracolumbar burst fracture has not reached a treatment consensus. Percutaneous kyphoplasty has been shown to be efficient in reducing acute pain after burst fracture, although the topic remains highly controversial in this field. OBJECTIVE: This study aimed to conduct a systematic review of the current literature to evaluate the effectiveness and safety of percutaneous kyphoplasty on the treatment of osteoporotic thoracolumbar burst fracture. STUDY DESIGN: A systematic review. SETTING: University hospital. METHODS: A comprehensive literature search was performed through PubMed, EMBASE, Web of Science, and Cochrane library without time restriction. Among the studies meeting the eligible criteria, any study in which percutaneous kyphoplasty was utilized alone in the treatment of osteoporotic thoracolumbar burst fracture was included in the current review. For radiographic outcome evaluation, vertebral height and kyphotic angle were analyzed. VAS (Visual Analog Scale) and ODI (Oswestry Disability Index) were utilized for clinical outcome evaluation. Complications such as cement leakage and adjacent vertebral fracture or relapse were also analyzed. RESULTS: In total, 289 patients (338 vertebral bodies) were included in the 8 studies. Clinical outcomes indicated that patients achieved pain relief (VAS) from 6.8 preoperatively to 1.1 postoperatively, and improvement of quality of life (ODI) ranged from 87.0 ± 6.0% to 23.9 ± 4.4%. The radiological outcome indicated that anterior vertebral height restoration ranged from 20.1 ± 2.3 to 85.3 ± 10.6, and posterior vertebral height restoration ranged from 27.3 ± 1.7 to 83.3 ± 7.4. Kyphotic angle achieved correction ranged from 21.7 ± 7.8° preoperatively to 3.17° postoperatively. The main complications after PKP were cement leakage and adjacent vertebral fracture or relapse, which had an incidence of 7.7% -45.4% and 4.3% -74.1%, respectively. LIMITATIONS: Due to the good quality of the English publications, only English-language research searches were conducted, but they do not unduly affect our aggregate results impact. More prospective randomized controlled trials are needed to provide higher evidence for clinical practice. CONCLUSIONS: To osteoporotic thoracolumbar burst fracture is absolutely not a contraindication to percutaneous kyphoplasty. Percutaneous kyphoplasty can obtain satisfactory effectiveness for the treatment of osteoporotic thoracolumbar burst fractures. Complications can be effectively decreased by meticulous evaluation, careful manipulation, and appropriate precautionary measures. KEY WORDS: Percutaneous kyphoplasty, osteoporosis, burst fracture, cement leakage, adjacent fracture

Development and Validation of a Nomogram for Prediction of the Risk of Positive Hidden Blood Loss in the Perioperative Period of Thoracolumbar Burst Fracture

Background: This study aimed to develop and validate an individualized nomogram to predict the risk of positive hidden blood loss (HBL) in patients with thoracolumbar burst fracture (TBF) during the perioperative period.Methods: We conducted a retrospective investigation including 161 consecutive patients with TBL, and the corresponding patient data was extracted from March 2013 to March 2019. The independent risk factors for positive HBL were screened using univariate and multivariate logistic regression analyses. According to published literature and clinical experience, a series of variables were selected to develop a nomogram prediction model for positive HBL. The area under the receiver operating characteristic curves (AUC), C-index, calibration plot, and decision curve analysis (DCA) were used to evaluate the performance of the prediction model. Bootstrapping validation was performed to evaluate the performance of the model.Results: Among the 161 consecutive patients, 62 patients were negative for HBL (14.13%). The Multivariate logistic regression analysis showed that the six risk factors of age, length of surgical incision, duration of operation, percentage of vertebral height restoration (P1%), preoperative total cholesterol, and preoperative fibrinogen were independent risk factors of positive HBL. The C-index was 0.862 (95% CI 0.788–0.903) and 0.8884 in bootstrapping validation, respectively. The calibration curve showed that the predicted probability of the model was consistent with the actual probability. Decision curve analysis (DCA) showed that the nomogram had clinical utility.Conclusion: Overall, we explored the relationship between the positive HBL requirement and predictors: age, duration from admission to surgery, duration of operation, percentages of vertebral height restoration (P1%), preoperative total cholesterol, and preoperative fibrinogen. The individualized prediction model for patients with TBF can accurately assess the risk of positive HBL and facilitate clinical decision making. However, external validation will be needed in the future.

Risk Factor Analysis for Predicting Kyphosis Reoccurrence of Thoracolumbar Burst Fracture Patients Treated with Posterior Short-Segment Fixation

Background: The thresholds of risk factors of kyphosis recurrence in thoracolumbar burst fracture patients were still controversial. The aim of this multi-center study was to identify these thresholds.Methods: 169 patients were included in this study. Upper intervertebral angle (UIVA), lower intervertebral angle (LIVA), Cobb angle (CA), anterior vertebral height ratio (AVH%), regional angle (RA), posterior vertebral height ratio (PVH%), vertebral wedge angle (VWA), anteroposterior ratio (A/P%), Clinical assessment included Load Sharing Classification (LSC) score, Thoracolumbar Injury Classification and Severity (TLICS) score, Visual Analogue Scale (VAS), and Body mass index (BMI) were perioperatively evaluated. Patients were divided into KR group and none KR (NKR) group according to whether the loss of CA correction was less than 15˚ or not. The risk factors of KR before or after implant removal were analyzed, respectively. Result: There were significant improvements in postoperative parameters compared with preoperative parameters, such as AVH%, A/P%, VAS, CA, VWA, PVH% (P < 0.001, respectively), and UIVA (P = 0.02). Age (AUC = 0.828) and BMI (AUC = 0.846) were good predictors of KR before implant removal. BMI (AUC = 0.871) was a good predictor of KR after implant removal. Conclusion: There were significant differences in risk factors of KR at different postoperative follow-up stages: age > 49 years, BMI > 24 were risk factors of KR before implant removal; BMI > 25.17 was a risk factor of KR.