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Purpose: To assess the safety and efficacy of the extra-facet puncture technique applied in unilateral percutaneous vertebroplasty (PVP) for treating osteoporotic vertebral compression fractures., Methods: Demographics (age, gender, body mass index and underlying diseases) were recorded for analyzing. Visual analog scale (VAS) and Oswestry Disability Index (ODI) scores as well as their corresponding minimal clinically important difference (MCID) were used to evaluate clinical outcomes. The segmental kyphotic angle, the vertebral compression ratio and bone cement distribution pattern were evaluated by the plain radiographs. The facet joint violation (FJV) was defined by the postoperative computed tomography scan. Binary logistic regression analysis was performed to investigate relationships between multiple risk factors and residual back pain., Results: VAS and ODI scores in both traditional puncture group and extra-facet puncture group were significantly decreased after PVP surgery (p < 0.05). However, no significant difference was observed between the two groups according to VAS and ODI scores. The proportion of patients achieving MCID of VAS and ODI scores was higher in extra-facet puncture group as compared to traditional puncture group within a month (p < 0.05). Finally, multivariate logistic regression analysis showed that FJV (odds ratio 16.38, p < 0.001) and unilateral bone cement distribution (OR 5.576, p = 0.020) were significant predictors of residual back pain after PVP surgery., Conclusions: Extra-facet puncture percutaneous vertebroplasty can decrease the risk of FJV and it also has the advantage of more satisfied bone cement distribution., (© 2023. The Author(s).)

Introduction: To our knowledge, thoracolumbar burst fractures with a neurological deficit treated with posterior decompression and interlaminar fusion have never been reported. Our study was to assess the outcome of posterior decompression and interlaminar fusion in treating thoracolumbar burst fractures with a neurological deficit., Materials and Methods: Forty-one patients suffering from thoracolumbar burst fractures with a neurological deficit were included this study. All patients were treated with posterior decompression, interlaminar fusion and short-segment fixation of the vertebrae above and below the fracture level and the fractured vertebrae., Results: All patients were followed up for at least 24 months after surgery. Operative time and blood loss averaged 72 min and 325 ml, respectively. Thirty-eight patients with incomplete neurological lesions improved, by at least one American Spine Injury Association grade, whereas no neurological deterioration was observed in any case. Overall sagittal alignment improved from an average preoperative 22.4°-4.6° kyphosis at the final follow-up observation. The anterior vertebral body height ratio improved from 0.61 before surgery to 0.90 after surgery, whereas posterior vertebral body height ratio improved from 0.90 to 0.95. Spinal canal encroachment was reduced from an average 61.5% before surgery to 8.7% after surgery. Interlaminar radiological fusion was achieved within 6-8 months after surgery. No instrumentation failure was found in any patients., Conclusion: Posterior decompression, interlaminar fusion with posterior short-segment fixation provided excellent immediate reduction for traumatic segmental kyphosis and significant spinal canal clearance, and restored vertebral body height in the fracture level in patients with a thoracolumbar burst fracture and associated neurological deficit.

Study Design: A randomized, controlled follow-up study to review patients with acute thoracolumbar burst fractures treated by anterior instrumentation and reconstruction., Objective: The objective of this study was to evaluate the results of anterior instrumentation in the treatment of thoracolumbar burst fractures and to determine whether anterior-only approach would be sufficient for highly unstable burst fractures. In this prospective follow-up study, we also compared the results of anterior reconstruction with structural grafting and with titanium mesh cage in a randomized fashion., Summary of Background Data: Anterior decompression and reconstruction supplemented with instrumentation is generally believed to be superior to fixation with posterior pedicle screw instrumentation for a highly unstable burst fracture, but the indications and methods for anterior approach has not been fully documented., Methods: A total of 65 patients undergoing anterior plating for a thoracolumbar burst fracture with a load-sharing score of 7 or more between 2000 and 2003 were included this study. They were randomized to receive iliac crest autograft (group A, n = 32) or titanium mesh cages (group B, n = 33). The patients were similar in the distribution of 3-column injuries (n = 8 in group A vs. n = 9 in group B). During the minimum 4-year (range, 4-7 years) follow-up period, all patients were prospectively evaluated for clinical and radiologic outcomes. The Frankel scale, the ASIA motor score, and the Short Form 36 were used for clinical evaluation, whereas the fusion status and the loss of kyphosis correction for the local kyphosis angle were examined for radiologic outcome., Results: All patients in this study achieved solid fusion, with significant neurologic improvement and no significant correction loss as defined by loss of kyphosis correction. The clinical and radiologic results were not significantly different (P > 0.05) at all time points between the 2 groups A and B. Twenty-six of 32 patients in group A still complained of donor site pain to some degree at the final follow-up. No significant impact of 3-column injuries (P > 0.05) were identified on the results for all comparisons., Conclusion: Anterior-only instrumentation and reconstruction with structural autograft or titanium mesh cages is sufficient for surgical treatment of thoracolumbar burst fractures with a load-sharing score of > or = 7 and even with 3-column injuries.

Background: No consensus has been reached on the optimal radiographic evaluation of thoracolumbar burst fractures. The role of MRI in the treatment decision is not fully documented. The objectives was to measure the agreement of MRI in detecting posterior ligamentous complex (PLC) and posterior longitudinal ligament (PLL) injury, and to determine whether the findings by MRI is correlated with the results of plain radiography and computed tomography (CT) scanning as well as neurological examination and with the treatment planning., Methods: Sixty-one patients with acute thoracolumbar burst fracture were retrospectively reviewed for the presence of supraspinous ligament (SSL), interspinous ligament (ISL) or posterior longitudinal ligament (PLL) injury. The overall interobserver agreement between the three different observers was assessed by a kappa coefficient for multiple raters. The status of ligaments was correlated with the neurological function as assessed by Frankel scale and fracture severity as defined by the Load Sharing Classification. These patients were surgically treated according to the Load Sharing Classification and followed up for at least 5 years., Results: The kappa coefficients for ISL or SSL injury ranged 0.601 to 0.736, representing substantial to almost perfect agreement, whereas the kappa coefficients for PLL injury were 0.441 to 0.574, representing moderate agreement. No significant difference (P > 0.05) of Frankel scale or load sharing score was found between patients with and without ligamentous injuries. Satisfactory results were achieved in all patients regarding the clinical and radiological assessment., Conclusions: MRI is reliable for detecting the ligamentous injury, especially PLC injury in thoracolumbar burst fractures but the ligamentous injury as shown by MRI is not correlated with the neurological function or fracture severity. As MRI finding is of little value in treatment planning of thoracolumbar burst fractures, MRI examination is not necessary to be used routinely for excluding occult ligamentous injury.

Background: 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., Methods: 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

Study Design: A retrospective study to review patients with acute thoracolumbar burst fractures who were conservatively treated., Objectives: The purpose of this study was to analyze the efficacy of conservative treatment of thoracolumbar burst fractures in terms of long-term results, and to determine whether the long-term results of conservative treatment would be predicted by the Load Sharing Classification., Summary of Background Data: The optimal management of thoracolumbar burst fractures remains controversial, with advocates for nonoperative or operative approaches. Different criteria for treatment options have been advocated for classifying the fractures, guiding treatment decision-making, and predicting the prognosis., Methods: A total of 127 patients with an acute thoracolumbar burst fracture (Denis type B) were treated conservatively. Their Load Sharing score ranged from 3 to 9 (average, 5.3). Twenty-two (17.3%) of these patients presented with a neurologic deficit. They were followed up for at least 3 years (range, 3-12 years; average, 7.2 years) and assessed for clinical and radiologic outcomes. The motor score of the American Spinal Injury Association, and Denis pain and work scales were used for clinical evaluation, whereas the loss of kyphosis correction (LKC) for the local kyphosis angle was examined for radiologic outcome., Results: None of the patients had neurologic deterioration during the reduction. All 22 patients with neurologic deficit experienced improvement with average recovery rate of 93%. Significant correlation (P < 0.05) was found between the Load Sharing score on admission and the LKC for local kyphosis angle at final follow-up. Most patients reported acceptable results regarding pain (111/127, 87.4%) and work (110/127, 86.6%). A positive correlation was found between the LKC and the severity of pain (r = 0.194, P < 0.05). Seven patients (5.5%) required or had undergone late surgery for correction of loss-related back pain and/or poor functional outcome., Conclusion: Conservative treatment is safe and effective for selected patients with thoracolumbar burst fractures, even in some cases with neurologic deficit. The Load Sharing Classification could be used for guiding the treatment of thoracolumbar burst fractures not only in surgical approach choice but also in surgical decision-making.

Study Design: The role of plain radiography in the diagnosis and management of thoracolumbar burst fractures was evaluated when compared with computed tomography (CT) scans., Objective: To determine the accuracy of plain radiography in detecting thoracolumbar burst fractures when CT scans were used as the gold standard, and to assess the impact of disagreement of the results between plain radiographs and CT scans on treatment plan., Summary of Background Data: There have been few studies comparing the value of plain radiography with that of CT scans in the diagnosis and management of thoracolumbar burst fractures., Methods: Radiographs of 73 patients with a compression or burst fracture were reviewed independently by 3 residents and 3 spine surgeons. The results of CT scans were used as the gold standard to determine the accuracy of plain radiography for the diagnosis. More quantitative results of 57 patients with a burst fracture based on plain radiographs alone were compared with those after addition of CT scans. The disagreement between the results was analyzed, and the impact of disagreement on treatment plan was defined as the changes of load sharing score between or=7., Results: The accuracy of plain radiography improved with the experience of observers. The results on the load sharing score agreed between plain radiographs alone and radiographs with CT scans only for 56%, indicating moderate agreement. The impact of disagreement on treatment plan was significant (P < 0.05). This disagreement was most contributed by the underestimation for vertebral body comminution based on plain radiographs., Conclusion: The accuracy of plain radiography is acceptable in the qualitative sense, and would improve with the experience of observers. However, plain radiography alone would not be adequate when used for more quantitatively assessing the fractures. Addition of CT scanning is necessary for treatment planning.

Background: Burst fractures account for more than half of all thoracolumbar fractures, which often cause a neurologic deficit and present a significant economic burden to the family and society. Accepted methods of treatment of thoracolumbar burst fractures include conservative therapy, posterior reduction and instrumentation, and anterior decompression and instrumentation. However, the management of thoracolumbar burst fractures has been the subject of much controversy., Methods: Publications reporting clinical data relating to the thoracolumbar burst fractures were reviewed. These articles were determined via review of the results of PubMed searches and articles gathered through compilation of references from those articles., Results: There exist different criteria for the choice of the management based on the severity of kyphotic deformity, canal compromise, vertebral height loss, and neurologic status. To our knowledge, none of the existing criteria for the treatment of thoracolumbar burst fractures are generally accepted., Conclusions: In thoracolumbar burst fractures without a neurologic deficit, there is no superiority of conservative therapy over operative therapy. When the neurologic involvement is significant, the choice of operative management is advised. Also, there is no obvious superiority of one approach over the other.

Background: The association between neurologic recovery and initial compromise of spinal canal and sagittal alignment has been rarely documented. This study was performed to better understand whether the degree of neurologic recovery from thoracolumbar burst fractures is affected and predicted by initial compromise of spinal canal and sagittal alignment., Methods: Eighty-seven patients who underwent conservative or surgical treatment for thoracolumbar burst fractures between 1993 and 2001 were prospectively followed up for 3 to 10 years (average, 5.5 years). They were assessed for neurologic deficit and improvement as defined by the scoring system of ASIA, the stenotic ratio of spinal canal and kyphosis angle., Results: The ASIA score in 52 patients with neurologic deficit averaged 34.0 (range, 0-50) on admission and 46.1 (range, 27-50) at final follow-up. All these patients except 2 with neurologic deficit experienced improvement with an average recovery rate of 72.7% (range, 0%-100%). No statistically significant difference (P > .05) in the stenotic ratio of spinal canal or kyphotic deformity was demonstrated among the patients with no neurologic deficit, with incomplete lesions, and with complete lesions. The stenotic ratio of spinal canal or kyphosis angle was not significantly correlated with initial and final ASIA score and recovery rate (P > .05)., Conclusions: The neurologic recovery from thoracolumbar burst fractures is not predicted by the amount of initial canal encroachment and kyphotic deformity. When deciding on the treatment for patients with thoracolumbar burst fractures, both neurologic function and spinal stability should be taken into account.

The most common pattern among thoracolumbar burst fractures involves failure of the superior vertebra end-plate. There have been many biomechanical studies of thoracolumbar burst fractures, but the biomechanics related to the internal architecture of thoracolumbar vertebrae has been rarely documented. The objective of this study was to test the hypotheses that distribution of the bone mineral density (BMD) of the thoracolumbar spine is related to the stress concentration in this region and therefore, supports the pattern of burst fractures that occur most commonly. We measured spinal BMD of the first lumbar vertebra in 22 individuals using quantitative computed tomography (QCT) in three levels. At each level, the BMD for the trabecular compartment was determined from each of six sites and from one site within each pedicle. Thus the trabecular density was measured at a total of 20 sites for each person. The highest average QCT BMD was in the pedicle (sites 13 and 14), whereas the BMD was abruptly decreased at the posterior part of the vertebral body near the pedicles. The results of the study indicate that stress concentration of the spine related to the regional variation in vertebral bone density may be implicated in the biomechanical mechanism underlying thoracolumbar burst fractures. This finding may be correlated with the injury mechanism of thoracolumbar burst fractures and of clinical significance.