Approach to junctional fractures in spine: A systematic review and meta-analysis

Abstract

Background: The management of thoracolumbar burst fractures presents a challenge due to the absence of consensus on the most effective surgical approach. Surgeons commonly employ anterior, posterior, or combined anterior-posterior instrumentation methods to achieve fracture reduction, stabilization, and neural canal decompression. Despite the availability of these techniques, there is a lack of comparative studies evaluating their efficacy. This gap in the literature underscores the necessity for research to thoroughly assess and compare the various surgical approaches for thoracolumbar spine fractures. The present study aims to compare and critically evaluate the different approaches to surgical management of thoracolumbar spine fractures in order to identify the best treatment.

Material and method: A literature search was performed in 13 electronic databases for articles published between 2000 and August 31, 2023. Two separate reviews were conducted to ensure thoroughness and reliability in article selection. Ultimately, thirteen articles meeting the inclusion criteria were chosen, comprising nine non-randomized control trials (NRCTs) and four randomized control trials (RCTs). To assess the risk of bias in the NRCTs, the Newcastle-Ottawa scale was utilized, while the ROB-b tool was applied to evaluate the RCTs.

Results: Thirteen studies meeting the predefined inclusion and exclusion criteria were selected, comprising nine non-randomized control trials and four randomized control trials. A meta-analysis was conducted, revealing that patients undergoing the posterior approach tended to experience longer surgery durations (anterior vs posterior = 5.38) and higher blood loss (anterior vs posterior = 26.21) compared to those undergoing the anterior or combined anterior-posterior approaches. Additionally, immediate postoperative improvement in kyphotic correction (anterior vs posterior = 2.15 and anterior - posterior vs posterior-2.97) was observed in the posterior approach group. However, follow-up assessments indicated a subsequent loss of kyphotic angle in this group (anterior vs posterior = 1.41 and anterior - posterior vs posterior-2.00).The systematic review comprises only seven studies comparing anterior and posterior approaches and three studies evaluating posterior and combined approaches. Furthermore, the utilization of different clinical scales across the studies complicates drawing definitive conclusions. Also, heterogeneity of the population, including variations in comorbidities, types of fractures, follow-up duration, timing of intervention, surgeon expertise, and surgical techniques were noted across the included studies. Additionally, there is variability in sample sizes, ages, genders, and follow-up periods. Most of the included studies in the present study were performed on ventral cord compression and kyphosis correction cases rather than simple junctional fracture cases.

Conclusion: Each surgical approach possesses its own set of advantages and disadvantages. However, the lack of consensus and standardized protocols underscores the need for further research to establish definitive guidelines for surgical decision-making in thoracolumbar spine fractures.

Keywords: Approaches; Decompression; Meta-analysis; Surgical management; Systematic review; Thoracolumbar junction fractures.