Minimally invasive spine surgeries for treatment of thoracolumbar fractures of spine: A systematic review

      Abstract

      Purpose

      Many minimally invasive surgical (MIS) techniques have been developed for instrumentation of spine. These MIS techniques restore stability, alignment while achieving return to function quite early as compared to open spine surgeries. The main aim of this review was to evaluate role, indications and complications of these MIS techniques in Thoracolumbar and Lumbar fractures.

      Methods

      Pubmed search using key words such as“Percutaneous pedicle screw for Thoracolumbar fractures” and “Video Assisted Thoracoscopy, Thoracoscopic, VATS for thoracolumbar, Lumbar and Spine fractures” were used till July 2016 while doing literature search. Authors analyzed all the articles, which came after search; the articles relevant to the topic were selected and used for the study. Both prospective and retrospective case control studies and randomized control trials (RCT's) were included in this review. Case reports and reviews were excluded. Studies demonstrating use of MIS in cases other than spine trauma and studies with lack of clinical follow up were excluded from this review. Variables such as number of patients, operative time and complications were evaluated in each study.

      Results

      After pubmed search, we found total 68 studies till July 2016 out of which eight studies were relevant for analysis of Video Assisted Thoracoscopy for thoracolumbar and lumbar fractures. Total 72 articles for Percutaneous pedicle screws in thoracolumbar and lumbar fractures were retrieved out of which percutaneous pedicle screws were analyzed in eleven studies and twelve studies involved comparison of percutaneous pedicle screws and conventional open techniques.

      Conclusion

      Role and Indications of the MIS techniques in spinal trauma are expanding quite rapidly. MIS techniques restore stability, alignment while achieving early return to function and lower infection rates as compared to open spine surgeries. In long term, they provide good kyphosis correction and stable fixation and fusion of spine. They are associated with long learning curve and technical challenges but with careful patient selection and in expert hands, MIS techniques may produce better results than open trauma spine surgeries.

      Keywords

      1. Introduction

      In majority of cases, spinal fractures affect thoracolumbar region
      • Wood K.
      • Buttermann G.
      • Mehbod A.
      • Garvey T.
      • Jhanjee R.
      • Sechriest V.
      Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit.
      . Almost every type of injury described in the spine occurs in thoracolumbar region. There may be compression fractures, chance fractures, dislocations and any combination of all of these injuries. Conservative management can manage most of these patients if no neurological deficit is present.
      • Wood K.
      • Buttermann G.
      • Mehbod A.
      • Garvey T.
      • Jhanjee R.
      • Sechriest V.
      Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit.
      However if neurological deficit is present and injury pattern is of unstable nature involving all the three columns of spine, then patient should be managed by surgical procedures. Surgery improves the management and long-term outcome of these spinal fractures, although no definite clinical evidence confirming superiority of surgical over conservative management exists at present.
      • Charles Yann Philippe
      • Zairi Fahed
      • Vincent César
      • et al.
      Minimally invasive posterior surgery for thoracolumbar fractures. New trends to decrease muscle damage.
      Surgical management of spine has evolved quite a lot in the last couple of decades.
      Many minimally invasive surgical (MIS) techniques have been developed for instrumentation of spine. These MIS techniques have a common goal to achieve results similar to open surgeries while decreasing the morbidity associated with the open surgeries. These MIS techniques restore stability, alignment while achieving return to function quite early as compared to open spine surgeries. Most common MIS technique used in thoracolumbar trauma is percutaneous pedicle screw. The main aim of this review was to evaluate role of these MIS techniques in Thoracolumbar and lumbar fractures.
      Pubmed search using key words such as “Percutaneous pedicle screw for Thoracolumbar fractures” and “Video Assisted Thoracoscopy, Thoracoscopic, VATS for thoracolumbar and Spine fractures” were used till July 2016 while doing literature search. Authors analyzed all the articles, which came after search; the articles relevant to the topic were selected and used for the study. Both prospective and retrospective case control studies and randomized control trials (RCT's) were included in this review. Case reports, reviews and articles not in English Language were excluded. Studies demonstrating use of MIS in cases other than spine trauma and studies with lack of clinical follow up were excluded from this review. Variables such as number of patients, operative time, complications and outcomes were evaluated in each study (Fig. 1).

      2. Minimally invasive approaches

      Many thoracolumbar and lumbar spine injuries may present with neurologic deficits from retropulsed bone or significant communition resulting in loss of load bearing capacity of anterior column. Hence some form of anterior decompression or reconstruction is frequently indicated in these injuries. Before the advent of MIS, these fractures were treated with an extensive thoraco-abdominal approach. Conventional thoraco-abdominal approach involved detachment of the diaphragm to expose the thoracolumbar junction, which was associated with post thoracotomy syndromes, intercostals neuralgia and visceral herniation. Although standard posterior midline or para-midline approaches are associated with less morbidity, ischemia and revascularization injury associated with it results in atrophy, scarring, decreased strength and endurance.
      • Kawaguchi Y.
      • Matsui H.
      • Tsuji H.
      Back muscle injury after posterior lumbar spine surgery, Part 1. Histologic and histochemical analyses in rats.
      • Kawaguchi Y.
      • Matsui H.
      • Tsuji H.
      Back muscle injury after posterior lumbar spine surgery: Part 2. Histologic and histochemical analyses in humans.
      • Kawaguchi Y.
      • Matsui H.
      • Tsuji H.
      Back muscle injury after posterior lumbar spine surgery: a histologic and enzymatic analysis.
      • Styf J.
      • Willen H.
      • Rantanen J.
      • Hurme M.
      • Falck B.
      • et al.
      The lumbar multifidus muscle five years after surgery for a lumbar intervertebral disc.
      Hence in general an inference can be drawn from above discussion that the morbidity associated with conventional open procedures can be significant and, however, in some cases incompatible with the medical status of the patient.
      • Dajczman E.
      • Gordon A.
      • Kreisman H.
      • Wolkove N.
      • Faciszewski T.
      • Winter R.B.
      • Lonstein J.E.
      • et al.
      The surgical and medical perioperative complications of anterior spinal fusion surgery in the thoracic and lumbar spine in adults. A review of 1223 procedures.
      • Kalso E.
      • Perttunen K.
      • Kaasinen S.
      Pain after thoracic surgery.
      Reduced pain, better cosmesis, lower perioperative morbidity and earlier return to activity are some of the advantages associated with the MIS techniques for the thoracolumbar fractures.
      • Lee M.C.
      • Coert B.A.
      • Kim S.H.
      • Kim D.H.
      Endoscopic techniques for stabilization of the thoracic spine.
      Lee et al.
      • Lee M.C.
      • Coert B.A.
      • Kim S.H.
      • Kim D.H.
      Endoscopic techniques for stabilization of the thoracic spine.
      demonstrated reduction in duration of analgesic medicine by 31% and the overall dosage by 42% in patient treated endoscopically as compared with a group treated by open surgery.
      Size of the incision and the morbidity to the thoracoabdominal wall has been limited by these recently developed minimal invasive, open microscopic and even video assisted thoracoscopy.
      • Lee M.C.
      • Coert B.A.
      • Kim S.H.
      • Kim D.H.
      Endoscopic techniques for stabilization of the thoracic spine.
      • Kim D.H.
      • Jahng T.A.
      • Balabhadra R.S.V.
      • et al.
      Thoracoscopic transdiaphragmatic approach to thoracolumbar junction fractures.
      • Khoo L.T.
      • Beisee R.
      • Potulski M.
      Thoracoscopic-assisted treatment of thoracic and lumbar fractures: a series of 371 consecutive cases.

      3. Video assisted thoracoscopy

      Entire thoracic spine can be visualized easily by thoracoscopy. However nowadays advancement in the thoracoscopy has resulted in the advancement of the spine levels, which can be addressed by it. Now from thoracolumbar junction to L2 levels can be exposed by thoracoscopy with the help of small diaphragmatic opening of 6–8 cm. As compared to open techniques this is minimal in size. As liver elevates diaphragm on right side, left sided approaches are preferred. After anesthesia patient is positioned in right lateral position and corpectomy, discectomy and decompression of the spinal canal can be done using high-speed burrs and Kerrison Rongeurs through small working portals. Decompression of canal by endoscopic techniques has equal efficacy as compared to open thoracotomy surgery.
      • Kim D.H.
      • Jahng T.A.
      • Balabhadra R.S.V.
      • et al.
      Thoracoscopic transdiaphragmatic approach to thoracolumbar junction fractures.
      ,
      • Beisse R.
      Video-assisted techniques in the management of thoracolumbar fractures.
      Total of 68 studies were retrieved with keywords “Video Assisted Thoracoscopy, Thoracoscopic, VATS for thoracolumbar, Lumbar and Spine fractures”. Eight studies
      • Kim D.H.
      • Jahng T.A.
      • Balabhadra R.S.V.
      • et al.
      Thoracoscopic transdiaphragmatic approach to thoracolumbar junction fractures.
      • Khoo L.T.
      • Beisee R.
      • Potulski M.
      Thoracoscopic-assisted treatment of thoracic and lumbar fractures: a series of 371 consecutive cases.
      • Beisse R.
      Video-assisted techniques in the management of thoracolumbar fractures.
      • Peng M.
      • Cao X.F.
      • Peng G.D.
      • Ma X.C.
      Retrospective Study on Treating Thoracolumbar Fractures with Video-Assisted Thoracoscopic Surgery and Traditional Anterior Approach Surgery.
      • Kim S.J.
      • Sohn M.J.
      • Ryoo J.Y.
      • Kim Y.S.
      • Whang C.J.
      Clinical analysis of video-assisted thoracoscopic spinal surgery in the thoracic or thoracolumbar spinal pathologies.
      • Le Huec J.C.
      • Tournier C.
      • Aunoble S.
      • Madi K.
      • Leijssen P.
      Video-assisted treatment of thoracolumbar junction fractures using a specific distractor for reduction: prospective study of 50 cases.
      • Ray W.Z.
      • Krisht K.M.
      • Dailey A.T.
      • Schmidt M.H.
      Clinical outcomes of unstable thoracolumbar junction burst fractures: combined posterior short-segment correction followed by thoracoscopic corpectomy and fusion.
      • Shawky A.
      • Al-Sabrout A.M.
      • El-Meshtawy M.
      • Hasan K.M.
      • Boehm H.
      Thoracoscopically assisted corpectomy and percutaneous transpedicular instrumentation in management of burst thoracic and thoracolumbar fractures.
      were found to be relevant and are summarized in Table 1. They analyzed role of Video Assisted Thoracoscopy in Thoracolumbar and lumbar fractures.
      Table 1Studies summarizing role of Video Assisted Thoracoscopy in Thoracolumbar and Lumbar fractures.
      Study groupKim et al.
      • Kim D.H.
      • Jahng T.A.
      • Balabhadra R.S.V.
      • et al.
      Thoracoscopic transdiaphragmatic approach to thoracolumbar junction fractures.
      Khoo et al.
      • Khoo L.T.
      • Beisee R.
      • Potulski M.
      Thoracoscopic-assisted treatment of thoracic and lumbar fractures: a series of 371 consecutive cases.
      Beisse et al.
      • Beisse R.
      Video-assisted techniques in the management of thoracolumbar fractures.
      Peng M et al.
      • Peng M.
      • Cao X.F.
      • Peng G.D.
      • Ma X.C.
      Retrospective Study on Treating Thoracolumbar Fractures with Video-Assisted Thoracoscopic Surgery and Traditional Anterior Approach Surgery.
      Kim SJ et al.
      • Kim S.J.
      • Sohn M.J.
      • Ryoo J.Y.
      • Kim Y.S.
      • Whang C.J.
      Clinical analysis of video-assisted thoracoscopic spinal surgery in the thoracic or thoracolumbar spinal pathologies.
      Le Huec JC et al.
      • Le Huec J.C.
      • Tournier C.
      • Aunoble S.
      • Madi K.
      • Leijssen P.
      Video-assisted treatment of thoracolumbar junction fractures using a specific distractor for reduction: prospective study of 50 cases.
      RayWZ et al.
      • Ray W.Z.
      • Krisht K.M.
      • Dailey A.T.
      • Schmidt M.H.
      Clinical outcomes of unstable thoracolumbar junction burst fractures: combined posterior short-segment correction followed by thoracoscopic corpectomy and fusion.
      Shawky A et al.
      • Shawky A.
      • Al-Sabrout A.M.
      • El-Meshtawy M.
      • Hasan K.M.
      • Boehm H.
      Thoracoscopically assisted corpectomy and percutaneous transpedicular instrumentation in management of burst thoracic and thoracolumbar fractures.
      Number of patients21237122023

      23 in thoracoscopic group and 21 traditional group
      13503216 combined posterior percutaneous pedicle instrumentation and anterior Thoracoscopicapically assisted corpectomy
      75 (AO Type A) anterior alone and 137 (AO Type B and C) combined anterior and posterior instrumentation197 conventional open anterior plating and 174 total endoscopic78 (AO Type A) anteriorly and 142 (Type B and C) combined anterior and posterior instrumentationAll treated thoracoscopicallyAll treated thoracoscopically. Magerl type A and for some type C thoracolumbar junction fracturescombined posterior short-segment correction followed by thoracoscopic corpectomy and fusion
      Location of fracturesTLJ

      T12-86

      L1-126
      T3-L3. 73% i.e 271 at TLJ

      Most common L1-35%, L2-24%
      TLJ

      T12-89

      L1-131
      TLJTLJ

      T12-6

      Mid Thoracic-5

      T11-2

      L1-2

      L2-1
      TLJTLJTLJ
      PortalsFour portals. The working channel (10 mm) is centered over the target vertebrae. The optical channel (10 mm) is placed two or three intercostal spaces cranial. The approach for suction/irrigation (5 mm) and retractor (10 mm) is placed approximately 5–10 cm anterior to the working and optical channelThe 10-mm working channel mark was centered directly over the fracture vertebrae.10-mm optical channel for the endoscope should be placed between two or three intercostals spaces cranial to the target area in axis with the spine.Four Portals. Working portal directly above the fractured vertebra. 30-endoscope is placed over the spine two to three intercostal spaces. The portals for the retractor and the suction/irrigation instrument are situated ventrally from this pointNot ReportedWorking channel was centered over the target vertebrae and the optical channel was placed two or three intercostal spaces cranial to the target vertebra. The approach for suction and irrigation or retractor was placed approximately 5–10 cm anterior to the working and optical channel.first blunt trocar is inserted through a 2-cm incision along the anterior axillary line in the fifth or sixth intercostal space at the fracture level. Two other trocars are then set up along the median axillary line in order to insert a blunt pulmonary retractorThe 10-mm working channel was centered over the fracture site. 10-mm optical channel for the endoscope should be placed between two or three intercostals spaces cranial to the target area in axis with the spine.Two incisions: the first is about 2.5 cm minithoracotomy done in the mid-axillary line and the second is about 1 cm in the posterior axillary line for the 30° thoracoscopy optic
      Mean surgical time3.5 h3 h3.5 h170 ± 20.8 minN/A155 min (75–240 min)270 ± 65 min248 min ± 63 min
      Significant decrease in blood lossSignificant improvement in Cobb's and Kyphotic angle
      Blood LossNot reportedNot reported870 ml650.0 ± 65.4 mlNot Reported620 mlNot reported765 ± 466 ml
      Fusion Rate and screw loosening90% fusion rate and 2.5% (5 cases) screw loosening42% less need for narcotics90% fusion rate and 2.27% (5 cases) of screw loosening100% fusion rateNot reportedNot reported90% fusion100%
      Complication rate12 (5.7%) pleural effusion, pneumothorax and intercostal neuralgia. Three patients (1.4%) had superficial portal infections.1.3%one case each of aortic injury, splenic contusion, neurological deterioration, cerebrospinal fluid leak, and severe wound infection5.4% pleural effusions, persistent pneumothorax, or intercostal neuralgiaNot reported7.7% (3 patients) transitional pleural effusion, chylothorax followed by paraspinal abscess, and CSF leak.12% (6 patient) Five patients had a transient pulmonary atelectasia and there was one pulmonary infection9.4% (3 patients)One patient had superficial wound healing problem.

      3.1 Indications

      In most of the studies fracture were classified according to AO classification. For AO Type A exclusive anterior thoracoscopic fixation was considered satisfactory and for Type B and Type C fractures posterior pedicle screw fixation before anterior thoracoscopic decompression and reconstruction was done
      • Kim D.H.
      • Jahng T.A.
      • Balabhadra R.S.V.
      • et al.
      Thoracoscopic transdiaphragmatic approach to thoracolumbar junction fractures.
      • Beisse R.
      Video-assisted techniques in the management of thoracolumbar fractures.
      • Ray W.Z.
      • Krisht K.M.
      • Dailey A.T.
      • Schmidt M.H.
      Clinical outcomes of unstable thoracolumbar junction burst fractures: combined posterior short-segment correction followed by thoracoscopic corpectomy and fusion.
      • Shawky A.
      • Al-Sabrout A.M.
      • El-Meshtawy M.
      • Hasan K.M.
      • Boehm H.
      Thoracoscopically assisted corpectomy and percutaneous transpedicular instrumentation in management of burst thoracic and thoracolumbar fractures.
      .
      Contraindications for endoscopic approaches for reconstruction of the thoracolumbar spine are presence of restricted cardiopulmonary function, acute post-traumatic lung failure, pleural adhesions, or severe medical comorbidities.
      • Lee M.C.
      • Coert B.A.
      • Kim S.H.
      • Kim D.H.
      Endoscopic techniques for stabilization of the thoracic spine.
      Most common levels operated levels are T12 and L1 with L1 fractures being maximum in most studies
      • Kim D.H.
      • Jahng T.A.
      • Balabhadra R.S.V.
      • et al.
      Thoracoscopic transdiaphragmatic approach to thoracolumbar junction fractures.
      • Khoo L.T.
      • Beisee R.
      • Potulski M.
      Thoracoscopic-assisted treatment of thoracic and lumbar fractures: a series of 371 consecutive cases.
      • Beisse R.
      Video-assisted techniques in the management of thoracolumbar fractures.
      • Le Huec J.C.
      • Tournier C.
      • Aunoble S.
      • Madi K.
      • Leijssen P.
      Video-assisted treatment of thoracolumbar junction fractures using a specific distractor for reduction: prospective study of 50 cases.
      • Ray W.Z.
      • Krisht K.M.
      • Dailey A.T.
      • Schmidt M.H.
      Clinical outcomes of unstable thoracolumbar junction burst fractures: combined posterior short-segment correction followed by thoracoscopic corpectomy and fusion.
      . In all the studies, thoracoscopy was done in right lateral decubitus position.
      Most commonly four portals were used which involved placing the working channel (10 mm) is centered over the target vertebrae. The optical channel (10 mm) is placed two or three intercostal spaces cranial. The approach for suction/irrigation (5 mm) and retractor (10 mm) is placed approximately 5–10 cm anterior to the working and optical channel.
      Mean surgical time ranged from 189 to 300 min s. Blood loss ranges from 600 to 900 mls. Fusion rates ranges from 90 to 100%.
      • Kim D.H.
      • Jahng T.A.
      • Balabhadra R.S.V.
      • et al.
      Thoracoscopic transdiaphragmatic approach to thoracolumbar junction fractures.
      • Beisse R.
      Video-assisted techniques in the management of thoracolumbar fractures.
      • Peng M.
      • Cao X.F.
      • Peng G.D.
      • Ma X.C.
      Retrospective Study on Treating Thoracolumbar Fractures with Video-Assisted Thoracoscopic Surgery and Traditional Anterior Approach Surgery.
      • Ray W.Z.
      • Krisht K.M.
      • Dailey A.T.
      • Schmidt M.H.
      Clinical outcomes of unstable thoracolumbar junction burst fractures: combined posterior short-segment correction followed by thoracoscopic corpectomy and fusion.
      • Shawky A.
      • Al-Sabrout A.M.
      • El-Meshtawy M.
      • Hasan K.M.
      • Boehm H.
      Thoracoscopically assisted corpectomy and percutaneous transpedicular instrumentation in management of burst thoracic and thoracolumbar fractures.

      3.2 Complications

      Superficial wound infection
      • Kim D.H.
      • Jahng T.A.
      • Balabhadra R.S.V.
      • et al.
      Thoracoscopic transdiaphragmatic approach to thoracolumbar junction fractures.
      • Khoo L.T.
      • Beisee R.
      • Potulski M.
      Thoracoscopic-assisted treatment of thoracic and lumbar fractures: a series of 371 consecutive cases.
      • Ray W.Z.
      • Krisht K.M.
      • Dailey A.T.
      • Schmidt M.H.
      Clinical outcomes of unstable thoracolumbar junction burst fractures: combined posterior short-segment correction followed by thoracoscopic corpectomy and fusion.
      • Shawky A.
      • Al-Sabrout A.M.
      • El-Meshtawy M.
      • Hasan K.M.
      • Boehm H.
      Thoracoscopically assisted corpectomy and percutaneous transpedicular instrumentation in management of burst thoracic and thoracolumbar fractures.
      and transient pleural effusion
      • Kim D.H.
      • Jahng T.A.
      • Balabhadra R.S.V.
      • et al.
      Thoracoscopic transdiaphragmatic approach to thoracolumbar junction fractures.
      • Beisse R.
      Video-assisted techniques in the management of thoracolumbar fractures.
      • Kim S.J.
      • Sohn M.J.
      • Ryoo J.Y.
      • Kim Y.S.
      • Whang C.J.
      Clinical analysis of video-assisted thoracoscopic spinal surgery in the thoracic or thoracolumbar spinal pathologies.
      are most commonly reported complications. As working field is near to lungs, pulmonary complications are commonly reported such as transient pleural effusion, pneumothorax, pulmonary atelectasis and pulmonary infection. Apart from pulmonary complications, injuries of adjacent structures such as spleen, aorta and bile duct resulting into chylothorax has been reported.

      4. Percutaneous pedicle screws

      Roy Camille first reported use of pedicle screws in 1963.
      • Roy-Camille R.
      • Roy-Camille M.
      • Saillant G.
      • Demeulenaere C.
      • Lelièvre J.F.
      Surgical therapeutic indications in vertebral injuries with spinal cord syndrome or cauda equina syndrome.
      Later in 1977, Margrel developed the technique of percutaneous pedicle screw placement primarily for temporary fixation of spine and later removed them.
      • Magerl F.P.
      Stabilization of the lower thoracic and lumbar spine with external skeletal fixation.
      Open posterior approaches to the thoracolumbar and lumbar region are associated with pain and functional impairment resulting from muscle trauma.
      • Kawaguchi Y.
      • Matsui H.
      • Tsuji H.
      Back muscle injury after posterior lumbar spine surgery, Part 1. Histologic and histochemical analyses in rats.
      • Kawaguchi Y.
      • Matsui H.
      • Tsuji H.
      Back muscle injury after posterior lumbar spine surgery: Part 2. Histologic and histochemical analyses in humans.
      • Kawaguchi Y.
      • Matsui H.
      • Tsuji H.
      Back muscle injury after posterior lumbar spine surgery: a histologic and enzymatic analysis.
      • Styf J.
      • Willen H.
      • Rantanen J.
      • Hurme M.
      • Falck B.
      • et al.
      The lumbar multifidus muscle five years after surgery for a lumbar intervertebral disc.
      Assaker R et al. first reported thoracolumbar trauma as indication for the percutaneous pedicle screw in 2004.
      • Assaker R.
      Minimal access spinal technologies: state-of-the-art, indications, and techniques.
      Many studies have now come up in English literature, which are demonstrating the efficacy of percutaneous pedicle screw fixation for traumatic spine fractures.
      • Styf J.
      • Willen H.
      • Rantanen J.
      • Hurme M.
      • Falck B.
      • et al.
      The lumbar multifidus muscle five years after surgery for a lumbar intervertebral disc.
      • Dajczman E.
      • Gordon A.
      • Kreisman H.
      • Wolkove N.
      • Faciszewski T.
      • Winter R.B.
      • Lonstein J.E.
      • et al.
      The surgical and medical perioperative complications of anterior spinal fusion surgery in the thoracic and lumbar spine in adults. A review of 1223 procedures.
      • Kalso E.
      • Perttunen K.
      • Kaasinen S.
      Pain after thoracic surgery.
      • Lee M.C.
      • Coert B.A.
      • Kim S.H.
      • Kim D.H.
      Endoscopic techniques for stabilization of the thoracic spine.
      • Kim D.H.
      • Jahng T.A.
      • Balabhadra R.S.V.
      • et al.
      Thoracoscopic transdiaphragmatic approach to thoracolumbar junction fractures.
      Percutaneous pedicle screw fixation is associated with less muscle damage as compared with open surgical technique.
      • Kim D.Y.
      • Lee S.H.
      • Chung S.K.
      • Lee H.Y.
      Comparison of multifidus muscle atrophy and trunk extension muscle strength: percutaneous versus open pedicle screw fixation.
      For level confirmation and percutaneous pedicle screw insertion, this technique is highly dependent on the use of imaging under fluoroscopic guidance.
      • Rampersaud Y.R.
      • Foley K.T.
      • Shen A.C.
      • Williams S.
      • Solomito M.
      Radiation exposure to the spine surgeon during fluoroscopically assisted pedicle screw insertion.
      However all the situations such as rotational deformities, obesity and osteopenia, in which there is difficulty in imaging is relative contraindication for the percutaneous pedicle screw insertion.
      • Ahmad F.U.
      • Wang M.Y.
      Use of anteroposterior view fluoroscopy for targeting percutaneous pedicle screws in cases of spinal deformity with axial rotation.
      Other relative contraindications for percutaneous pedicle screw insertion are multilevel vertebral fractures, pedicle fractures, adjacent body fracture and patient with significant kyphosis or saggital malalignment. However absolute contraindication for it is severe neural deficits, which require canal decompression.
      • Rao P.J.
      • Maharaj M.M.
      • Phan K.
      • Abeygunasekara M.
      • Mobbs R.J.
      Indirect foraminal decompression following anterior lumbar interbody fusion (ALIF): a prospective radiographic study using a new pedicle to pedicle (P-P) technique.
      Main indication of percutaneous screw insertion in spine trauma includes fractures, which don't require significant reduction and decompression. Magrel type A1, A2 and certain type A3 fractures, fractures having TLICS score < 5
      • Assaker R.
      Minimal access spinal technologies: state-of-the-art, indications, and techniques.
      ,
      • Court C.
      • Vincent C.
      Percutaneous fixation of thoracolumbar fractures: current concepts.
      ,
      • Mobbs R.J.
      • Sivabalan P.
      • Li J.
      Technique, challenges and indications for percutaneous pedicle screw fixation.
      and fractures associated with posterior ligament disruption without subluxation or dislocation.
      • Court C.
      • Vincent C.
      Percutaneous fixation of thoracolumbar fractures: current concepts.
      Percutaneous pedicle screws can be put by a minimal incision of 1–2 cm para medially. Through this incision junction of facet and transverse processes is felt. Then spinal access needle or jamshidi needle with trocar is inserted and progressed after confirming on antero-posterior and lateral images. General dictum is that needle should not breach medial pedicle wall in any image. Then trocar is replaced by guide wire. On that guide wire serial dilators of increasing size are put. These dilators bluntly split the paraspinous muscles avoiding dissection, which reduces postoperative pain and intra-operative blood loss. Then after putting maximum size dilator, screws of adequate size are put and their position is confirmed in C- arm. Decrease in intra-operative blood loss is quite advantageous in high-risk geriatric patients and patients who are already in shock due to hypovolumeia attributable to poly-trauma. Less trauma to muscles and early stabilization promotes early mobilization of the patients. Although as far as surgeons concerned, technique of percutaneous pedicle insertion has long learning curve. After Literature search, we found a total of 72 studies out of which we were able to find eleven studies
      • Vanek P.
      • Bradac O.
      • Konopkova R.
      • et al.
      Treatment of thoracolumbar trauma by short-segment percutaneous transpedicular screw instrumentation: prospective comparative study with a minimum 2-year follow-up.
      • Cimatti Marco
      • Forcato Stefano
      • Polli Filippo
      • Miscus Massimo
      Pure percutaneous pedicle screw fixation without arthrodesis of 32 thoraco-lumbar fractures: clinical and radiological outcome with 36-month follow-up.
      • yang W.E.
      • Ng Z.X.
      • Koh K.M.R.
      • et al.
      Percutaneous pedicle screw fixation for thoracolumbar burst fracture: a Singapore experience Singapore.
      • Fang L.M.
      • Zhang Y.J.
      • Zhang J.
      • et al.
      Minimally invasive percutaneous pedicle screw fixation for the treatment of thoracolumbar fractures and posterior ligamentous complex injuries Beijing.
      • Bironneau A.
      • Bouquet C.
      • Millet-Barbe B.
      • Leclercq N.
      • Pries P.
      • et al.
      Percutaneous internal fixation combined with kyphoplasty for neurologically intact thoracolumbar fractures: a prospective cohort study of 24 patients with one year of follow-up.
      • Blondel B.
      • Fuentes S.
      • Pech-Gourg G.
      • Adetchessi T.
      • Tropiano P.
      • et al.
      Percutaneous management of thoracolumbar burst fractures: evolution of techniques and strategy.
      • Ni W.F.
      • Huang Y.X.
      • Chi Y.L.
      • Xu H.Z.
      • Lin Y.
      • et al.
      Percutaneous pedicle screw fixation for neurologic intact thoracolumbar burst fractures.
      • Palmisani M.
      • Gasbarrini A.
      • Brodano G.B.
      • De Iure F.
      • Cappuccio M.
      • et al.
      Minimally invasive percutaneous fixation in the treatment of thoracic and lumbar spine fractures.
      • Merom L.
      • Raz N.
      • Hamud C.
      • Weisz I.
      • Hanani A.
      Minimally invasive burst fracture fixation in the thoracolumbar region.
      • Wild M.H.
      • Glees M.
      • Plieschnegger C.
      • Wenda K.
      Five-year follow-up examination after purely minimally invasive posterior stabilization of thoracolumbar fractures: a comparison of minimally invasive percutaneously and conventionally open treated patients.
      • Maciejczak A.
      • Barnas P.
      • Dudziak P.
      • Jagiełło-_Bajer B.
      • Litwora B.
      • et al.
      Posterior keyhole corpectomy with percutaneous pedicle screw stabilization in the surgical management of lumbar burst fractures.
      [Table 2] involving the analysis of role of percutaneous pedicle screws fixation in thoracolumbar and lumbar fractures. Almost all of them suggested that percutaneous pedicle screws fixation in thoracolumbar and lumbar fractures is helpful in achieving significant pain relief, kyphosis correction usually in the range of 5- 10°, early post op mobilization and decrease in peri-operative morbidity.
      Table 2Studies demonstrating role of Percutaneous Pedicle Screw fixation.
      StudyYearNumber of patientsMean AgeSex RatioSpinal LocationFracture classificationAverage duration of Surgery in MinsAverage Blood lossCobb's angleNeurologyComplicationOutcomeImplant removal done
      Pre-opPost-opFollow upPre-opPost-op
      1Cimatti M et al.
      • Cimatti Marco
      • Forcato Stefano
      • Polli Filippo
      • Miscus Massimo
      Pure percutaneous pedicle screw fixation without arthrodesis of 32 thoraco-lumbar fractures: clinical and radiological outcome with 36-month follow-up.
      20133248 (17–78)16:16TLF

      T11–2,T12–6,L1-16,L2-4,L3-4
      Margrel A1-1,A2-8,A3-21,B1-1,B2-360NR6.22.72.9NRNRNRPain improvement: Significant

      Kyphosis correction: Significant
      No
      2Takami et al.
      • Takami M.
      • Yamada H.
      • Nohda K.
      • Yoshida M.
      A minimally invasive surgery combining temporary percutaneous pedicle screw fixation without fusion and vertebroplasty with transpedicular intracorporeal hydroxyapatite blocks grafting for fresh thoracolumbar burst fractures: prospective study.
      20132145.4 (23–73)17:4TLF

      T11-1

      T12-2

      L1-7

      L2-4

      L3-5

      L4-2
      Margrel A3 fracture

      HA block vertebroplasty along with Pedicle screws
      95.738.68.5−4.2−0.6EE100% fusion, 1 loosening of screwPain improvement score: 7.5, Neuro Improved: N/A

      Kyphosis correction:3.1
      Implant removed in all patients within 5 months
      3Yang WE et al.
      • yang W.E.
      • Ng Z.X.
      • Koh K.M.R.
      • et al.
      Percutaneous pedicle screw fixation for thoracolumbar burst fracture: a Singapore experience Singapore.
      20122139.6 (21–68)14:7TLFNR17917517.11113.8A-2

      B-2

      C-3

      D-4

      E−10
      1

      0

      1

      6

      13
      4 superficial wound dehiscence

      3 pedicle screw pull outs
      Pain improvement: N/A

      Kyphosis correction: 6.1°
      Yes
      4Fang LM et al.
      • Fang L.M.
      • Zhang Y.J.
      • Zhang J.
      • et al.
      Minimally invasive percutaneous pedicle screw fixation for the treatment of thoracolumbar fractures and posterior ligamentous complex injuries Beijing.
      20123534.1 (18–52)20:15TLF

      T11-5,

      T12-9,

      L1-14,

      L2-7
      TLICS Score

      5–13

      7–22
      95.88310.31−1.481.03EE2 superficial wound infection

      Screw misplacement 9/140 (6.4%)
      Pain improvement score: significant

      Kyphosis Correction: No loss
      NR
      5Bironneau A et al.
      • Bironneau A.
      • Bouquet C.
      • Millet-Barbe B.
      • Leclercq N.
      • Pries P.
      • et al.
      Percutaneous internal fixation combined with kyphoplasty for neurologically intact thoracolumbar fractures: a prospective cohort study of 24 patients with one year of follow-up.
      20112458 (20–88)12:12TLF

      T12-2

      L1-12

      L2-5

      L3-2

      L4-2

      L5-1
      Margrel

      A1-1,A2-2,A3-19,B2-3

      Kyphoplasty with cement and pedicle screws
      9915.256.6EE8 cases cement leaked, 3 hematoma at the scarPain Improved Score: 6.3

      Neuro Improved: N/A

      Kyphosis correction: 8.6°
      NR
      6Blondel B et al.
      • Blondel B.
      • Fuentes S.
      • Pech-Gourg G.
      • Adetchessi T.
      • Tropiano P.
      • et al.
      Percutaneous management of thoracolumbar burst fractures: evolution of techniques and strategy.
      20112951 (22–78)TLF

      Burst fracture

      T-9

      T11-3

      T12-6

      L1-13

      L2-4

      L5-2
      Magerl A3NRNR133.25.2EEHematoma: 1Pain Improved Score: 5.6

      Neuro Improved: N/A

      Kyphosis correction: 11°
      Can be removed percutaneously
      7N.W et al.
      • Ni W.F.
      • Huang Y.X.
      • Chi Y.L.
      • Xu H.Z.
      • Lin Y.
      • et al.
      Percutaneous pedicle screw fixation for neurologic intact thoracolumbar burst fractures.
      20103643 (19–58)25:11TLF

      T11-4

      T12-8

      L1-17

      L2-7
      AO type A3 with load sharing classification of 6 or less787518.73.67.6EE7 screws (6.7%) misplaced, No neurological deficit.1 superficial infection, 1 screw looseningPain Improved Score: N/A

      Neuro Improved: N/A

      Kyphosis correction: 9.1°
      Removed in 26 patients and rest 10 refused
      8Palmisani M et al.
      • Palmisani M.
      • Gasbarrini A.
      • Brodano G.B.
      • De Iure F.
      • Cappuccio M.
      • et al.
      Minimally invasive percutaneous fixation in the treatment of thoracic and lumbar spine fractures.
      20095145 (21–82)34:17TLF (T1-T10)-6

      (T11-L1)-31

      Lumbar spine-14, Max L1-20
      AO

      A1-20

      A2-10

      A3-27

      B1-1

      B2-3

      C1-1

      C2-2
      NRNR4.2−2.22.7EEInfection: 1

      Misplaced Screw: 1

      Pseudoarthrosis: 2
      Pain Improved Score: N/A

      Neuro Improved: N/A

      Kyphosis correction: 6.2°
      Removed in 10 patients (19%)
      9Merom L et al.
      • Merom L.
      • Raz N.
      • Hamud C.
      • Weisz I.
      • Hanani A.
      Minimally invasive burst fracture fixation in the thoracolumbar region.
      20091042 (21–63)TLF5078–102EENonePain Improved Score: N/A

      Neuro Improved: N/A

      Kyphosis correction: N/A0
      NR
      10Maclejczak A et al.
      • Maciejczak A.
      • Barnas P.
      • Dudziak P.
      • Jagiełło-_Bajer B.
      • Litwora B.
      • et al.
      Posterior keyhole corpectomy with percutaneous pedicle screw stabilization in the surgical management of lumbar burst fractures.
      2007445 (28–59)3:1TLF

      L2-2

      L3-3
      Dennis B5.9 h s for decompression + FusionNR−1.25−7.7−2.7EEPseudoarthrosis: 1Pain Improved Score: N/A

      Neuro Improved: N/A

      Kyphosis correction: 11.6°
      NR
      11Schmidt et al.
      • Takami M.
      • Yamada H.
      • Nohda K.
      • Yoshida M.
      A minimally invasive surgery combining temporary percutaneous pedicle screw fixation without fusion and vertebroplasty with transpedicular intracorporeal hydroxyapatite blocks grafting for fresh thoracolumbar burst fractures: prospective study.
      20077653.3NRTLF

      Unstable type B fractures, Type A1 and A2 fractures with >25% anterior height loss or additional disc injury (in need for combined anterior surgery), Type A1 fractures in obese and geriatric patients as well as burst fractures, Type A3 in patients younger than 40 years of age
      Magrel Type A1.2 most common fracture

      A1-36

      A2-6

      A3-22

      B-12

      Si
      47Blood transfusion required in 3 (3.9%) PatientsNRNRNR6 (7.9%) patients Neurological deficitNo neurological deficit and one patient recovered completelyThree patients (3.9%)

      One paravertebral hematoma, one persistent skin irritation and one implant failure
      Pain improvement: NR

      Neuro

      Improvement:1 patient

      Kyphosis correction:NR
      NR
      TLF- Thoracolumbar Fracture, NR- Not reported.
      Twelve comparative studies
      • Vanek P.
      • Bradac O.
      • Konopkova R.
      • et al.
      Treatment of thoracolumbar trauma by short-segment percutaneous transpedicular screw instrumentation: prospective comparative study with a minimum 2-year follow-up.
      ,
      • Wild M.H.
      • Glees M.
      • Plieschnegger C.
      • Wenda K.
      Five-year follow-up examination after purely minimally invasive posterior stabilization of thoracolumbar fractures: a comparison of minimally invasive percutaneously and conventionally open treated patients.
      ,
      • Wang H.
      • Zhou Y.
      • Li C.
      • Liu J.
      • Xiang L.
      Comparison of open versus percutaneous pedicle screw fixation using the Sextant system in the treatment of traumatic thoracolumbar fractures.
      • Lee J.K.
      • Jang J.W.
      • Kim T.W.
      • Kim T.S.
      • Kim S.H.
      • Moon S.J.
      Percutaneous shortsegment pedicle screw placement without fusion in the treatment of thoracolumbar burst fractures: is it effective?: comparative study with open short-segment pedicle screw fixation with posterolateral fusion.
      • Grossbach A.J.
      • Dahdaleh N.S.
      • Abel T.J.
      • Woods G.D.
      • Dlouhy B.J.
      • Hitchon P.W.
      Flexion-distraction injuries of the thoracolumbar spine: open fusion versus percutaneous pedicle screw fixation.
      • Bronsard N.
      • Boli T.
      • Challali M.
      • et al.
      Comparison between percutaneous and traditional fixation of lumbar spine fracture: intraoperative radiation exposure levels and outcomes.
      • Song H.P.
      • Lu J.W.
      • Liu H.
      • Zhang C.
      Case-control studies between two methods of minimally invasive surgery and traditional open operation for thoracolumbar fractures.
      • Jiang X.Z.
      • Tian W.
      • Liu B.
      • et al.
      Comparison of a paraspinal approach with a percutaneous approach in the treatment of thoracolumbar burst fractures with posterior ligamentous complex injury: a prospective randomized controlled trial.
      • Tian W.
      • Han X.
      • He D.
      • et al.
      The comparison of computer assisted minimally invasive spine surgery and traditional open treatment for thoracolumbar fractures.
      • Wang H.W.
      • Li C.Q.
      • Zhou Y.
      • Zhang Z.F.
      • Wang J.
      • Chu T.W.
      Percutaneous pedicle screw fixation through the pedicle of fractured vertebra in the treatment of type A thoracolumbar fractures using Sextant system: an analysis of 38 cases.
      • Huang Q.S.
      • Chi Y.L.
      • Wang X.Y.
      • et al.
      Comparative percutaneous with open pedicle screw fixation in the treatment of thoracolumbar burst fractures without neurological deficit.
      • Grass R.
      • Biewener A.
      • Dickopf A.
      • Rammelt S.
      • Heineck J.
      • Zwipp H.
      Percutaneous dorsal versus open instrumentation for fractures of the thoracolumbar border. A comparative, prospective study.
      have been published by July 2016. Of these studies two were prospective randomized studies
      • Jiang X.Z.
      • Tian W.
      • Liu B.
      • et al.
      Comparison of a paraspinal approach with a percutaneous approach in the treatment of thoracolumbar burst fractures with posterior ligamentous complex injury: a prospective randomized controlled trial.
      ,
      • Tian W.
      • Han X.
      • He D.
      • et al.
      The comparison of computer assisted minimally invasive spine surgery and traditional open treatment for thoracolumbar fractures.
      and ten were observational studies. Out of these ten observational studies five
      • Vanek P.
      • Bradac O.
      • Konopkova R.
      • et al.
      Treatment of thoracolumbar trauma by short-segment percutaneous transpedicular screw instrumentation: prospective comparative study with a minimum 2-year follow-up.
      ,
      • Wang H.
      • Zhou Y.
      • Li C.
      • Liu J.
      • Xiang L.
      Comparison of open versus percutaneous pedicle screw fixation using the Sextant system in the treatment of traumatic thoracolumbar fractures.
      ,
      • Grossbach A.J.
      • Dahdaleh N.S.
      • Abel T.J.
      • Woods G.D.
      • Dlouhy B.J.
      • Hitchon P.W.
      Flexion-distraction injuries of the thoracolumbar spine: open fusion versus percutaneous pedicle screw fixation.
      ,
      • Wang H.W.
      • Li C.Q.
      • Zhou Y.
      • Zhang Z.F.
      • Wang J.
      • Chu T.W.
      Percutaneous pedicle screw fixation through the pedicle of fractured vertebra in the treatment of type A thoracolumbar fractures using Sextant system: an analysis of 38 cases.
      ,
      • Grass R.
      • Biewener A.
      • Dickopf A.
      • Rammelt S.
      • Heineck J.
      • Zwipp H.
      Percutaneous dorsal versus open instrumentation for fractures of the thoracolumbar border. A comparative, prospective study.
      are prospective and five
      • Wild M.H.
      • Glees M.
      • Plieschnegger C.
      • Wenda K.
      Five-year follow-up examination after purely minimally invasive posterior stabilization of thoracolumbar fractures: a comparison of minimally invasive percutaneously and conventionally open treated patients.
      ,
      • Lee J.K.
      • Jang J.W.
      • Kim T.W.
      • Kim T.S.
      • Kim S.H.
      • Moon S.J.
      Percutaneous shortsegment pedicle screw placement without fusion in the treatment of thoracolumbar burst fractures: is it effective?: comparative study with open short-segment pedicle screw fixation with posterolateral fusion.
      ,
      • Bronsard N.
      • Boli T.
      • Challali M.
      • et al.
      Comparison between percutaneous and traditional fixation of lumbar spine fracture: intraoperative radiation exposure levels and outcomes.
      ,
      • Song H.P.
      • Lu J.W.
      • Liu H.
      • Zhang C.
      Case-control studies between two methods of minimally invasive surgery and traditional open operation for thoracolumbar fractures.
      ,
      • Huang Q.S.
      • Chi Y.L.
      • Wang X.Y.
      • et al.
      Comparative percutaneous with open pedicle screw fixation in the treatment of thoracolumbar burst fractures without neurological deficit.
      are retrospective. These comparative studies have shown that for AO type A fractures percutaneous pedicle screws alone offers a stable fixation. N.W et al.
      • Ni W.F.
      • Huang Y.X.
      • Chi Y.L.
      • Xu H.Z.
      • Lin Y.
      • et al.
      Percutaneous pedicle screw fixation for neurologic intact thoracolumbar burst fractures.
      recommended that for AO type A3 with load sharing classification of 6 or less percutaneous pedicle screw fixation alone is adequate and for A3 with load sharing classification of more than 6, Type B and C fractures percutaneous pedicle screws may require additional procedure in the form of vertebroplasty with cement augmentation
      • Bironneau A.
      • Bouquet C.
      • Millet-Barbe B.
      • Leclercq N.
      • Pries P.
      • et al.
      Percutaneous internal fixation combined with kyphoplasty for neurologically intact thoracolumbar fractures: a prospective cohort study of 24 patients with one year of follow-up.
      , vertebroplasty with hydroxyapetitie block augmentation
      • Takami M.
      • Yamada H.
      • Nohda K.
      • Yoshida M.
      A minimally invasive surgery combining temporary percutaneous pedicle screw fixation without fusion and vertebroplasty with transpedicular intracorporeal hydroxyapatite blocks grafting for fresh thoracolumbar burst fractures: prospective study.
      and minimal invasive approach for decompression
      • Schmidt Oliver I.
      • Strasser Sergej
      • Kaufmann Victoria
      • Strasser Ewald
      • Gahr Ralf H.
      Role of early minimal-invasive spine fixation in acute thoracic and lumbar spine trauma.
      . Schmidt et al.
      • Schmidt Oliver I.
      • Strasser Sergej
      • Kaufmann Victoria
      • Strasser Ewald
      • Gahr Ralf H.
      Role of early minimal-invasive spine fixation in acute thoracic and lumbar spine trauma.
      have shown that minimal invasive fixation with pedicle screws is effective option for Unstable type B fractures, Type A1 and A2 fractures with >25% anterior height loss or additional disc injury (in need for combined anterior surgery), Type A1 fractures in obese and geriatric patients as well as burst fractures, Type A3 in patients younger than 40 years of age. Most commonly operated levels were T12 and L1
      • Cimatti Marco
      • Forcato Stefano
      • Polli Filippo
      • Miscus Massimo
      Pure percutaneous pedicle screw fixation without arthrodesis of 32 thoraco-lumbar fractures: clinical and radiological outcome with 36-month follow-up.
      • Fang L.M.
      • Zhang Y.J.
      • Zhang J.
      • et al.
      Minimally invasive percutaneous pedicle screw fixation for the treatment of thoracolumbar fractures and posterior ligamentous complex injuries Beijing.
      • Bironneau A.
      • Bouquet C.
      • Millet-Barbe B.
      • Leclercq N.
      • Pries P.
      • et al.
      Percutaneous internal fixation combined with kyphoplasty for neurologically intact thoracolumbar fractures: a prospective cohort study of 24 patients with one year of follow-up.
      • Blondel B.
      • Fuentes S.
      • Pech-Gourg G.
      • Adetchessi T.
      • Tropiano P.
      • et al.
      Percutaneous management of thoracolumbar burst fractures: evolution of techniques and strategy.
      • Ni W.F.
      • Huang Y.X.
      • Chi Y.L.
      • Xu H.Z.
      • Lin Y.
      • et al.
      Percutaneous pedicle screw fixation for neurologic intact thoracolumbar burst fractures.
      • Palmisani M.
      • Gasbarrini A.
      • Brodano G.B.
      • De Iure F.
      • Cappuccio M.
      • et al.
      Minimally invasive percutaneous fixation in the treatment of thoracic and lumbar spine fractures.
      . Most common age group appears to be in 30–50 with a wide range and in all the studies there was male predominance. Percutaneous pedicle screws are associated with significantly shorter operative duration, smaller incision size, less blood loss, shorter hospital stays and improved peri-operative pain scores.
      • Mobbs R.J.
      • Sivabalan P.
      • Li J.
      Technique, challenges and indications for percutaneous pedicle screw fixation.
      From Table 2, we can conclude that percutaneous pedicle screws alone and with other techniques are associated with significant khyphosis correction and maintained the correction of kyphosis at the final follow up. In some cases, it also resulted in improvement of the neurological deficit
      • yang W.E.
      • Ng Z.X.
      • Koh K.M.R.
      • et al.
      Percutaneous pedicle screw fixation for thoracolumbar burst fracture: a Singapore experience Singapore.
      ,
      • Schmidt Oliver I.
      • Strasser Sergej
      • Kaufmann Victoria
      • Strasser Ewald
      • Gahr Ralf H.
      Role of early minimal-invasive spine fixation in acute thoracic and lumbar spine trauma.
      . Stable fixation and fusion appear to be hundred percent as puedoarthosis has been reported rarely. Two main complications are screw malpositioning and infection in spine surgeries. No differences have been found in screw malpositioning rates between percutaneous and open spine surgeries while infection rates are significantly lower in percutaneous as compared to open spine surgeries. Implant removal was also done after variable period in some studies
      • yang W.E.
      • Ng Z.X.
      • Koh K.M.R.
      • et al.
      Percutaneous pedicle screw fixation for thoracolumbar burst fracture: a Singapore experience Singapore.
      ,
      • Ni W.F.
      • Huang Y.X.
      • Chi Y.L.
      • Xu H.Z.
      • Lin Y.
      • et al.
      Percutaneous pedicle screw fixation for neurologic intact thoracolumbar burst fractures.
      ,
      • Palmisani M.
      • Gasbarrini A.
      • Brodano G.B.
      • De Iure F.
      • Cappuccio M.
      • et al.
      Minimally invasive percutaneous fixation in the treatment of thoracic and lumbar spine fractures.
      ,
      • Takami M.
      • Yamada H.
      • Nohda K.
      • Yoshida M.
      A minimally invasive surgery combining temporary percutaneous pedicle screw fixation without fusion and vertebroplasty with transpedicular intracorporeal hydroxyapatite blocks grafting for fresh thoracolumbar burst fractures: prospective study.
      . A systemic review and meta-analysis published by Kevin Phan et al.
      • Phan Kevin
      • Rao Prashanth J.
      • Mobbs Ralph J.
      Percutaneous versus open pedicle screw fixation for treatment of thoracolumbar fractures: systematic review and meta-analysis of comparative studies.
      has included all the 12 comparative studies mentioned in Table 3. It has proved statistically that percutaneous pedicle screws are associated with significantly shorter operative duration, less intra-operative blood loss, smaller incision size, lower infection rates, better pain relief and shorter hospital stay as compared to conventional open spine surgeries. It didn't find any significant difference in radiological parameters such as postoperative cobb's angle, postoperative body angle and postoperative anterior vertebral height. It found no strong evidence that percutaneous approach reduces disruption of muscle and tissue as compared to open spine surgeries.
      Table 3Showing Comparartive studies of Open spinal surgeries and Percutaneous pedicle Screw Fiaxation
      StudyPeriodStudy DesignPatients treated percutaneouslyPatients treated by open surgerySpinal LocationFollow up for percutaneous PatientsNeurologic deficitFusion
      No of patientsAverage AgeSex RatioOperative time in minsBlood loss in mLScrew MalpositioningInfectionHospital StayNo of patientsAverage AgeSex RatioOperative time in minsBlood loss in mLScrew MalpositioningInfectionHospital Stay
      1Wang (2014)
      • Wang H.
      • Zhou Y.
      • Li C.
      • Liu J.
      • Xiang L.
      Comparison of open versus percutaneous pedicle screw fixation using the Sextant system in the treatment of traumatic thoracolumbar fractures.
      5 yrP,OSMIF4-22,MIF6-39MIF4-45.8,MIF-45.11MIF4-17:5,MIF6-32:7MIF4-98.4,MIF6-114.1MIF4 49.3,MIF6-87.7MIF4-2,MIF6-0MIF4-0,MIF6-0MIF4-9.7,MIF6-12.93943.325:14140.3311.51117.6TLF max L1-60 AO type A max A1-6320NoNo
      2Vanek (2014)
      • Vanek P.
      • Bradac O.
      • Konopkova R.
      • et al.
      Treatment of thoracolumbar trauma by short-segment percutaneous transpedicular screw instrumentation: prospective comparative study with a minimum 2-year follow-up.
      16 monthP,OS1845.614:4535601NR1739.414:36033101NRTLF max T12 and L1 14 each AO A3.1-A3.3. Max A3.324NoNo
      3Lee (2013)
      • Lee J.K.
      • Jang J.W.
      • Kim T.W.
      • Kim T.S.
      • Kim S.H.
      • Moon S.J.
      Percutaneous shortsegment pedicle screw placement without fusion in the treatment of thoracolumbar burst fractures: is it effective?: comparative study with open short-segment pedicle screw fixation with posterolateral fusion.
      6 yrR,OS3236.320/1283.2262.510NR2736.319:8154.9684.312NRSingle levelTLF Dennis Type A/B12/20 in MISS and 12/15 in open group30.2Frenkel C 2,Frenkel D-12(7,5) Frenkel E31(16,15)No
      4Grossbach (2013)
      • Grossbach A.J.
      • Dahdaleh N.S.
      • Abel T.J.
      • Woods G.D.
      • Dlouhy B.J.
      • Hitchon P.W.
      Flexion-distraction injuries of the thoracolumbar spine: open fusion versus percutaneous pedicle screw fixation.
      10 yrP,OS1127.411:019593.6007.62740.118:92574980111.2Thoracolumbar- flexion distraction.AO B1.2 most common9ASIA E(5 score) in MIS and ASIA(4.41) in open groupNo
      5Bronsard (2013)
      • Bronsard N.
      • Boli T.
      • Challali M.
      • et al.
      Comparison between percutaneous and traditional fixation of lumbar spine fracture: intraoperative radiation exposure levels and outcomes.
      7 yrR,OS3040.412:1883.550.3300NR3043.521:9148.5318.8313NRTLF from T9-L4 out of which T11-L2 are 24 ORIF and CRIF 30. Most common MargerlA3- 15 ORIF, 20 CRIF25.5NoNo
      6Song (2012)
      • Song H.P.
      • Lu J.W.
      • Liu H.
      • Zhang C.
      Case-control studies between two methods of minimally invasive surgery and traditional open operation for thoracolumbar fractures.
      6 yrR,OS2036.48268.52011.83236.490.1330.75021TLF12NoNo
      7Jiang (2012)
      • Jiang X.Z.
      • Tian W.
      • Liu B.
      • et al.
      Comparison of a paraspinal approach with a percutaneous approach in the treatment of thoracolumbar burst fractures with posterior ligamentous complex injury: a prospective randomized controlled trial.
      3 yrP,RCT3142.479.779209.73042.489.81451110.8TLF67.7NoNo
      8Tian (2011)
      • Tian W.
      • Han X.
      • He D.
      • et al.
      The comparison of computer assisted minimally invasive spine surgery and traditional open treatment for thoracolumbar fractures.
      5 yrP,RCT4712591NR0NR50122204NR1TLF12NoNo
      9Wang (2010)
      • Wang H.W.
      • Li C.Q.
      • Zhou Y.
      • Zhang Z.F.
      • Wang J.
      • Chu T.W.
      Percutaneous pedicle screw fixation through the pedicle of fractured vertebra in the treatment of type A thoracolumbar fractures using Sextant system: an analysis of 38 cases.
      3 yrP,OS1741.613:497.183.50011.1214518:3161304.82022.9TLF Type A11.6Grade D(12) and Grade E(5)No
      10Huang (2008)
      • Huang Q.S.
      • Chi Y.L.
      • Wang X.Y.
      • et al.
      Comparative percutaneous with open pedicle screw fixation in the treatment of thoracolumbar burst fractures without neurological deficit.
      3 yrR,OS308075NANA83080292NANA12TLF24NANo
      11Wild (2007)
      • Wild M.H.
      • Glees M.
      • Plieschnegger C.
      • Wenda K.
      Five-year follow-up examination after purely minimally invasive posterior stabilization of thoracolumbar fractures: a comparison of minimally invasive percutaneously and conventionally open treated patients.
      1 yrR,OS1049.19:187.4194.400NR1133.57:480.938000NRTLF mostly AO type A3. Implant removal done at 10 months60NRNo
      12Grass (2006)
      • Grass R.
      • Biewener A.
      • Dickopf A.
      • Rammelt S.
      • Heineck J.
      • Zwipp H.
      Percutaneous dorsal versus open instrumentation for fractures of the thoracolumbar border. A comparative, prospective study.
      3 yrP,OS3349.720:13854010NR2435.716:810087001NRTLF mainly from T12-L2 and two patients of L4NRNoNo

      5. Conclusion

      In conclusion we can say that role and Indications of the MIS techniques in spinal trauma are expanding quite rapidly. Minimal invasive spine surgeries in thoracolumbar fractures are associated with significantly shorter operative duration, less intra-operative blood loss, smaller incision size, lower infection rates, better pain relief and shorter hospital stay as compared to conventional open spine surgeries. In long term, they provide good kyphosis correction and stable fixation and fusion of spine. Despite all these advantages, it should be used alone in specifically indicated cases (AO type A fractures) only however for AO Type B and C cases it can be conjugated with other techniques such as vertebroplasty and minimal invasive decompression
      • Kim D.H.
      • Jahng T.A.
      • Balabhadra R.S.V.
      • et al.
      Thoracoscopic transdiaphragmatic approach to thoracolumbar junction fractures.
      • Beisse R.
      Video-assisted techniques in the management of thoracolumbar fractures.
      • Ray W.Z.
      • Krisht K.M.
      • Dailey A.T.
      • Schmidt M.H.
      Clinical outcomes of unstable thoracolumbar junction burst fractures: combined posterior short-segment correction followed by thoracoscopic corpectomy and fusion.
      • Shawky A.
      • Al-Sabrout A.M.
      • El-Meshtawy M.
      • Hasan K.M.
      • Boehm H.
      Thoracoscopically assisted corpectomy and percutaneous transpedicular instrumentation in management of burst thoracic and thoracolumbar fractures.
      • Ni W.F.
      • Huang Y.X.
      • Chi Y.L.
      • Xu H.Z.
      • Lin Y.
      • et al.
      Percutaneous pedicle screw fixation for neurologic intact thoracolumbar burst fractures.
      . Thoracoscopic surgeries may have rarely pulmonary complications and inadvertent injury to other nearby structures and percutaneous pedicle screws may rarely have malpositioning of screws. Both these techniques are associated with stable fixation and good fusion rates. Minimal Invasive spine surgeries should be done by expert surgeons as it involves long learning curve. In terms of efficacy, both minimally invasive spine surgeries as well as open spine surgeries are equally efficacious in treating thoracolumbar spine fractures.

      Conflicts of interest

      None.

      Funding

      None.

      Appendix A. Supplementary data

      The following is the Supplementary data to this article:

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