The use of intermediate pedicle screw fixation in burst fractures of the thoracolumbar transition
S. V. Likhachev,
V. V. Ostrovskij,
V. B. Arsenievich,
V. V. Zaretskov,
I. N. Shchanitsyn,
A. E. Shulga https://doi.org/10.17238/2226-2016-2023-1-25-35
Abstract
The implantation of the short-segment pedicle screw fixation hardware (PSFH) is a standard surgery for the management of thoracolumbar spine injuries. The disadvantage of this technique is the frequent implant failure along with the deformity and back pain recurrence. The intermediate PSFH supplemented with another two screws inserted into the fractured vertebrae has been described in the studies; however no outcomes of PSFH supplemented with just one intermediate screw and thus ensuring further anterior fusion without rearranging the system have even been presented.
Methods. We analyzed the surgical outcomes of 109 (71 men, 38 women) 36 (29; 43.5) years old patients with Th12, L1, L2 type A3 (78) or A4 (31) AOSpine fractures using retrospective, single-center, non-randomized methods. The patients were divided into two groups: Group I – 58 patients with the standard 4 screws short-segment fixation hardware; Group II – 51 patients who had their PSFH supplemented with another pedicle screw inserted into the fractured vertebrae. The outcomes were assessed by the severity pattern of pain and kyphotic deformity, the anterior column height, the implant failure and the loss of correction. The computer tomography findings were used to design solid finite element models of the spines and PSFH layout options including biomechanic bone-hardware simulation. This involved the simulation of the loading for the operated area that corresponded to normal physiology.
Results. The patients were comparable in their age and height, their division was determined by the level and type of their fractures, the anterior column height of the fractured vertebra, and the severity of back pain. The post-surgery follow-up revealed significant (p<0.05) positive differences in the patients who had their implants supplemented with additional pedicle screws. The 4-screw PSFH is biomechanically less stable than the 5-screw one and the load on the vertebrae osseous tissue in 5-screw PSFH is less loaded. Therefore, the PSFH layout that ensures lesser stress should be preferred.
Conclusion. The positive outcome of management with intermediate PSFH can be ensured by unilateral inserting of the screw into the fractured vertebra. Unlike the PSFH with two intermediate screws, that with just one ensures corpectomy or fusion avoiding PSFH rearrangement.
Supporting agencies: The study was carried out within the framework of the development of the topic «Optimization of surgical reconstruction techniques for injuries and diseases of the transitional spine using modern biomechanical modeling capabilities», state registration number of R&D AAAA17-1170707660038-0.
About the Authors
S. V. Likhachev
Orthopedics and Neurosurgery, V.I. Razumovsky Saratov State Medical University
Russian Federation
Russian Federation
Likhachev Sergey Vyacheslavovich – MD, PhD, Senior Research Assistant, Department of Neurosurgery and Vertebrology Innovations, Scientific Research Institute of Traumatology
410002, N.G. Chernyshevskogo str., 148, Saratov
V. V. Ostrovskij
Orthopedics and Neurosurgery, V.I. Razumovsky Saratov State Medical University
Russian Federation
Russian Federation
Ostrovskij Vladimir Vladimirovich – MD, DSc, Director of the Scientific Research Institute of Traumatology
410002, N.G. Chernyshevskogo str., 148, Saratov
V. B. Arsenievich
Orthopedics and Neurosurgery, V.I. Razumovsky Saratov State Medical University
Russian Federation
Russian Federation
Arsenievich Vladislav Brankovich – MD, PhD, Head of Trauma Orthopedic Dept. № 3, Scientific Research Institute of Traumatology
410002, N.G. Chernyshevskogo str., 148, Saratov
V. V. Zaretskov
Orthopedics and Neurosurgery, V.I. Razumovsky Saratov State Medical University
Russian Federation
Russian Federation
Zaretskov Vladimir Vladimirovich – MD, DSc, Leading Research Assistant, Department of Neurosurgery and Vertebrology Innovations, Scientific Research Institute of Traumatology
410002, N.G. Chernyshevskogo str., 148, Saratov
I. N. Shchanitsyn
Orthopedics and Neurosurgery, V.I. Razumovsky Saratov State Medical University
Russian Federation
Russian Federation
Shchanitsyn Ivan Nikolaevich – MD, PhD, Senior Research Assistant, Department of Neurosurgery and Vertebrology Innovations, Scientific Research Institute of Traumatology
410002, N.G. Chernyshevskogo str., 148, Saratov
A. E. Shulga
Orthopedics and Neurosurgery, V.I. Razumovsky Saratov State Medical University
Russian Federation
Russian Federation
Shulga Aleksey Evgenyevich – MD, PhD, Research Assistant, Department of Neurosurgery and Vertebrology Innovations, Scientific Research Institute of Traumatology
410002, N.G. Chernyshevskogo str., 148, Saratov
References
1. Leucht P., Fischer K., Muhr G., Mueller E.J. Epidemiology of traumatic spine fractures. Injury. 2009;40(2):166-72. DOI: 10.1016/j.injury.2008.06.040.
2. Tian Y., Zhu Y., Yin B., Zhang F., Liu B., Chen W., Zhang Y. Age- and gender-specific clinical characteristics of acute adult spine fractures in China. Int Orthop. 2016;40(2):347-53. DOI: 10.1007/s00264-015-3025-y.
3. Likhachev S.V., Zaretskov V.V., Shulga A.E., Gramma S.A., Shchanitsyn I.N., Bazhanov S.P., Zaretskov A.V., Donnik A.M. Injuries to the thoracolumbar junction: bibliometric analysis of English-language literature. Hirurgiâ pozvonočnika (Spine Surgery). 2018;15(4):52-69. In Russian. DOI: 10.14531/ss2018.4.52–69.
4. Rosenthal B.D., Boody B.S., Jenkins T.J., Hsu W.K., Patel A.A., Savage J.W. Thoracolumbar Burst Fractures. Clin Spine Surg. 2018;31(4):143-151. DOI: 10.1097/BSD.0000000000000634.
5. Afaunov A.A., Chaikin N.S. Analysis of technical options for decompression and stabilization surgery for injuries of the lower thoracic and lumbar spine: a systematic review of the literature. Hirurgiâ pozvonočnika (Spine Surgery). 2022;19(3):22-37. In Russian DOI: 10.14531/ss2022.3.22-37.
6. McDonnell M., Shah K.N., Paller D.J., Thakur N.A., Koruprolu S., Palumbo M.A., Daniels A.H. Biomechanical Analysis of Pedicle Screw Fixation for Thoracolumbar Burst Fractures. Orthopedics. 2016;39(3):514-518. DOI: 10.3928/01477447-20160427-09.
7. Couvertier M., Germaneau A., Saget M., Dupré J.C., Doumalin P., Brémand F., Hesser F., Brèque C., Roulaud M., Monlezun O., Vendeuvre T., Rigoard P. Biomechanical analysis of the thoracolumbar spine under physiological loadings: Experimental motion data corridors for validation of finite element models. Proc Inst Mech Eng H. 2017; 231(10):975-981. DOI: 10.1177/0954411917719740.
8. Wang H., Zhao Y., Mo Z., Han J., Chen Y., Yu H., Wang Q., Liu J., Li C., Zhou Y., Xiang L. Comparison of short-segment monoaxial and polyaxial pedicle screw fixation combined with intermediate screws in traumatic thoracolumbar fractures: a finite element study and clinical radiographic review. Clinics (Sao Paulo). 2017;72(10):609-617. DOI: 10.6061/clinics/2017(10)04.
9. Bolesta M.J., Caron T., Chinthakunta S.R., Vazifeh P.N., Khalil S. Pedicle screw instrumentation of thoracolumbar burst fractures: Biomechanical evaluation of screw configuration with pedicle screws at the level of the fracture. Int J Spine Surg. 2012;6:200-5. DOI: 10.1016/j.ijsp.2012.09.002.
10. Liao J.C., Chen W.P., Wang H. Treatment of thoracolumbar burst fractures by short-segment pedicle screw fixation using a combination of two additional pedicle screws and vertebroplasty at the level of the fracture: a finite element analysis. BMC Musculoskelet Disord. 2017;18(1):262. DOI: 10.1186/s12891-017-1623-0.
11. Donnik A.M., Ivanov D.V., Kossovich L.Yu., Levchenko K.K., Kireev S.I., Morozov K.M., Ostrovsky N. V., Zaretskov V. V., Likhachev S.V. Creation of Three-Dimensional Solid-State Models of a Spine with Transpedicular Fixation Using a Specialized Software. Izvestiya Saratovskogo universiteta Novaya seriya Seriya Matematika Mekhanika Informatika (Izv. Saratov Univ. (N. S.), Ser. Math. Mech. Inform.). 2019;19(4):424-438. In Russian. DOI: 10.18500/1816-9791-2019-19-4-424-438.
12. Putzer M., Auer S., Malpica W., Suess F., Dendorfer S.. A numerical study to determine the effect of ligament stiffness on kinematics of the lumbar spine during flexion. BMC Musculoskelet Disord. 2016;17:95. DOI: 10.1186/s12891-016-0942-x.
13. Maknickas A., Alekna V., Ardatov O., Chabarova O., Zabulionis D., Tamulaitienė M., Kačianauskas R. FEM-Based Compression Fracture Risk Assessment in Osteoporotic Lumbar Vertebra L1. Appl. Sci. 2019;9(15):3013. DOI: 10.3390/app9153013.
14. Manickam P.S., Roy S. The biomechanical study of cervical spine: A Finite Element Analysis. Int J Artif Organs. 2022;45(1):89-95. DOI: 10.1177/0391398821995495.
15. Sasso R.C., Best N.M., Reilly T.M., McGuire R.A. Jr. Anterior-only stabilization of three-column thoracolumbar injuries. J Spinal Disord Tech. 2005;18 Suppl:S7-14. DOI: 10.1097/01.bsd.0000137157.82806.68.
16. Dai L.Y., Jiang L.S., Jiang S.D. Anterior-only stabilization using plating with bone structural autograft versus titanium mesh cages for two- or three-column thoracolumbar burst fractures: a prospective randomized study. Spine (Phila Pa 1976). 2009;34(14):1429-35. DOI: 10.1097/BRS.0b013e3181a4e667.
17. Haiyun Y., Rui G., Shucai D., Zhanhua J., Xiaolin Z., Xin L., Xue W., Gongyi L., Jiankun L. Three-column reconstruction through single posterior approach for the treatment of unstable thoracolumbar fracture. Spine (Phila Pa 1976). 2010;35(8):E295-302. DOI: 10.1097/BRS.0b013e3181c392b9.
18. Scholl B.M., Theiss S.M., Kirkpatrick J.S. Short segment fixation of thoracolumbar burst fractures. Orthopedics. 2006;29(8):703-708. DOI: 10.3928/01477447-20060801-14.
19. Mahar A.K.C., Wedemeyer M., Mitsunaga L., Odell T., Johnson B., Garfin S. Shortsegment fixation of lumbar burst fractures using pedicle fixation at the level of the fracture. Spine (Phila Pa 1976). 2007;32(14):1503-1507. DOI: 10.1097/BRS.0b013e318067dd24.
20. Dick J.C., Jones M.P., Zdeblick T.A., Kunz D.N., Horton W.C. A biomechanical comparison evaluating the use of intermediate screws and cross-linkage in lumbar pedicle fixation. J Spinal Disord. 1994;7(5):402-407.
21. Guven O., Kocaoglu B., Bezer M., Aydin N., Nalbantoglu U. The use of screw at the fracture level in the treatment of thoracolumbar burst fractures. J Spinal Disord Tech. 2009;22(6):417-421. DOI: 10.1097/BSD.0b013e3181870385.
22. Norton R.P., Milne E.L., Kaimrajh D.N., Eismont F.J., Latta L.L., Williams S.K. Biomechanical analysis of fourversus six-screw constructs for short-segment pedicle screw and rod instrumentation of unstable thoracolumbar fractures. Spine J. 2014;14(8):1734-1739. DOI: 10.1016/j.spinee.2014.01.035.
23. Xiong C., Huang B., Wei T., Kang H., Xu F. Effect of the short-segment internal fixation with intermediate inclined-angle polyaxial screw at the fractured vertebra on the treatment of Denis type B thoracolumbar fracture. J Orthop Surg Res. 2020;15(1):182. DOI: 10.1186/s13018-020-01686-7.
24. Cho D.Y., Lee W.Y., Sheu P.C. Treatment of thoracolumbar burst fractures with polymethyl methacrylate vertebroplasty and short-segment pedicle screw fixation. Neurosurgery. 2003;53(6):1354-1360; discussion 1360-1361. DOI: 10.1227/01.neu.0000093200.74828.2f.
25. Elmasry S.S., Asfour S.S., Travascio F. Finite Element Study to Evaluate the Biomechanical Performance of the Spine After Augmenting Percutaneous Pedicle Screw Fixation With Kyphoplasty in the Treatment of Burst Fractures. J Biomech Eng. 2018;140(6). doi: 10.1115/1.4039174.
26. Formica M., Zanirato A., Cavagnaro L., Basso M., Divano S., Lamartina C., Berjano P., Felli L., Formica C. Vertebral body osteonecrosis: proposal of a treatment-oriented classification system. Eur Spine J. 2018;27(Suppl 2):190-197. DOI: 10.1007/s00586-018-5600-6.
27. Knop C., Fabian H.F., Bastian L., Blauth M. Late results of thoracolumbar fractures after posterior instrumentation and transpedicular bone grafting. Spine (Phila Pa 1976). 2001;26(1):88-99. DOI: 10.1097/00007632-200101010-00016.
28. Shen Y.X., Zhang P., Zhao J.G., Xu W., Fan Z.H., Lu Z.F., Li L.B. Pedicle screw instrumentation plus augmentation vertebroplasty using calcium sulfate for thoracolumbar burst fractures without neurologic deficits. Orthop Surg. 2011;3(1):1-6. DOI: 10.1111/j.1757-7861.2010.00114.x.
29. Marco R.A., Kushwaha V.P. Thoracolumbar burst fractures treated with posterior decompression and pedicle screw instrumentation supplemented with balloon-assisted vertebroplasty and calcium phosphate reconstruction. J Bone Joint Surg Am. 2009;91(1):20-8. DOI: 10.2106/JBJS.G.01668.
30. Jindal R., Jasani V., Sandal D., Garg S.K. Current status of short segment fixation in thoracolumbar spine injuries. J Clin Orthop Trauma. 2020;11(5):770-777. DOI: 10.1016/j.jcot.2020.06.008.
31. Chokshi J.J., Shah M. Outcomes of Including Fracture Level in Short-Segment Fixation for Thoracolumbar Fracture Dislocation. Asian Spine J. 2019;13(1):56-60. DOI: 10.31616/asj.2018.0064.
32. Norton R.P., Milne E.L., Kaimrajh D.N., Eismont F.J., Latta L.L., Williams S.K. Biomechanical analysis of fourversus six-screw constructs for short-segment pedicle screw and rod instrumentation of unstable thoracolumbar fractures. Spine J. 2014;14(8):1734-1739. DOI: 10.1016/j.spinee.2014.01.035.
33. Baaj A.A., Reyes P.M., Yaqoobi A.S., Uribe J.S., Vale F.L., Theodore N., Sonntag V.K., Crawford N.R. Biomechanical advantage of the index-level pedicle screw in unstable thoracolumbar junction fractures. J Neurosurg Spine. 2011;14(2):192-197. DOI: 10.3171/2010.10.SPINE10222.
34. Wang H., Li C., Liu T., Zhao W.D., Zhou Y. Biomechanical efficacy of monoaxial or polyaxial pedicle screw and additional screw insertion at the level of fracture, in lumbar burst fracture: An experimental study. Indian J Orthop. 2012;46(4):395-401. DOI: 10.4103/0019-5413.98827.
35. Kapoen C., Liu Y., Bloemers F.W., Deunk J. Pedicle screw fixation of thoracolumbar fractures: conventional short segment versus short segment with intermediate screws at the fracture level-a systematic review and meta-analysis. Eur Spine J. 2020;29(10):2491-2504. DOI: 10.1007/s00586-020-06479-4.
Review
For citations:
Likhachev S.V., Ostrovskij V.V., Arsenievich V.B., Zaretskov V.V., Shchanitsyn I.N., Shulga A.E. The use of intermediate pedicle screw fixation in burst fractures of the thoracolumbar transition. Department of Traumatology and Orthopaedics. 2023;(1):25-35. (In Russ.) https://doi.org/10.17238/2226-2016-2023-1-25-35
Views:
39
JATS XML
Email this article 