Percutaneous fixation of thoracolumbar vertebral fractures

Abstract

Surgical treatment of patients with thoracolumbar vertebral fracture without neurological deficit is still controversial.Management of vertebral fracture with percutaneous fixation was first reported in 2004.Advantages of percutaneous fixation are: less tissue dissection; decreased post-operative pain; decreased bleeding and operative time (depending on the steep learning curve); better screw positioning with fluoroscopy compared with an open freehand technique; and a decreased infection rate.The limitations of percutaneous fixation of vertebral fractures include increased radiation exposure to the patient and the surgeon, together with the steep learning curve for this technique.Adding a screw at the level of the fractured vertebra has the advantages of incorporating fewer motion segments with less operative time and bleeding. This also increases the axial, sagittal and torsional stiffness of the construct.Percutaneous fixation alone without grafting is sufficient for treating type A and B1 (AO classification) thoracolumbar fractures with satisfactory results concerning kyphosis reduction when compared with open instrumentation and fusion and with open fixation.Type C and B2 fractures (ligamentous injuries) should undergo fusion since the ligamentous healing is mechanically weak, increasing the risk of instability.This review offers a detailed description of percutaneous screw insertion and discusses the advantages and disadvantages. Cite this article: EFORT Open Rev 2018;3:604-613. DOI: 10.1302/2058-5241.3.170026.

Keywords: fracture stability; percutaneous fixation; thoracolumbar fractures.

Fig. 1

Positioning of the patient with two fluoroscopy machines for anteroposterior and lateral imaging. (Adapted from Sebaaly et al).

Fig. 2

AP fluoroscopy showing the desired pedicular entry points at 2–3 o’clock in the right pedicle and 9–10 o’clock in the left pedicle.

Fig. 3

Described technique for screw insertion using fluoroscopy. (A) Entry point on the AP fluoroscopy; (B, C) When only the Jamshidi needle passes the posterior wall of the vertebral body, it is allowed to touch the inner border of the pedicle on the AP image; (D) The guide wire is then inserted in the cannula with care not to pass the anterior wall of the vertebral body; (E) After the insertion of all guidewires, taping is carried out with caution not to remove the guidewires; (F) Screw insertion is carried out and the guidewire may be removed when the screw tip reaches the posterior vertebral wall.

Fig. 4

Described technique for screw insertion using O-ARM. (A) We favor the use of the percutaneous navigation bolt; (B) The navigated pedicle finder is advanced with regular checks on the axial and sagittal views; (C) Navigated taping is carried out; (D) Screw insertion is carried out; (E) Final result.

Fig. 5

Postoperative CT scanner showing extrapedicular ‘safe’ trajectory of the right pedicle screw.

Fig. 6

A 55-year-old woman was the victim of a fall from the second floor. Initial X-ray and CT scanner showed A2 L3 fracture (A-B). She was operated with percutaneous fixation with instrumentation of the fractured vertebra in its left pedicle (C-D).

Fig. 7

Algorithm for treating thoracolumbar vertebral fractures.