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Radiological Evaluation Does Not Reflect the Clinical Outcome After Surgery in Unstable Thoracolumbar and Lumbar Type A Fractures Without Neurological Symptoms

A Comparative Study of 2 Cohorts Treated by Open or Percutaneous Surgery

Lorente, Rafael, MD, PhD*; Lorente, Alejandro, MD, PhD; Palacios, Pablo, MD, PhD; Barrios, Carlos, MD, PhD§; Rosa, Bárbara, MD; Vaccaro, Alexander, MD, PhD

doi: 10.1097/BSD.0000000000000737

Study design: This is a prospective study of 2 cohorts.

Objective: Compare the clinical and radiologic outcome of 2 cohorts of unstable thoracolumbar and lumbar fractures treated by open posterior fixation (OPF) with bone graft or by percutaneous fixation (PCF) without grafting.

Summary of Background Data: In recent years, PCF is the most common treatment of thoracolumbar fractures. To date, no studies have analyzed clinical outcomes in terms of return to work.

Material and Methods: Two cohorts of patients with unstable thoracolumbar and lumbar fractures fractures (type A2, A3, and A4) without neurological symptoms underwent OPF (n=91) or PCF (n=54) between 2010 and 2015. A conventional radiologic study was performed in the preoperative, immediate postoperative period, 1-year, and 2-year follow-up. Clinical outcomes were evaluated by Visual Analog Scale and Oswestry Disability Index scores at 1-year and 2-year follow-up. The period to return to work and the type of work were also recorded.

Results: The percentages of correction were significantly higher in cases operated by OPF: fracture angle (P<0.001), kyphotic deformity (P<0.001), vertebral compression (P<0.001), and displacement (P<0.001). Cases operated by PCF experienced greater loss of correction at 2-year follow-up, especially in fracture displacement (P<0.001), deformity angle (P<0.001), kyphotic deformity (P<0.001), and in the sagittal index (P<0.001). Besides this greater loss of correction, PCF cases showed better Visual Analog Scale (P<0.001) and Oswestry Disability Index scores (P<0.001) at final follow-up. The percentage of patients returning to the same heavy work position was higher in the PCF group (P<0.001) and in a shorter period of time (P<0.001).

Conclusions: The greater loss of correction of patients undergoing PCF does not reflect the clinical outcomes that were significantly better as compared to patients undergoing open fixation with grafting. It would be useful to further evaluate if the radiological changes could have a long-term clinical significance.

*Department of Orthopedic Surgery and Traumatology, Hospital Infanta Cristina, Badajoz

Department of Orthopedic Surgery, Hospital Ramón y Cajal

Department of Orthopedic Surgery and Traumatology, Hospital Madrid Sanchinarro, Madrid

§Institute for Research on Musculoskeletal Disorders, School of Medicine, Valencia Catholic University, Valencia, Spain

Department of Orthopedic Surgery and Traumatology, Hospital Vila Franca de Xira, Vila Franca de Xira, Portugal

Department of Spine Surgery of Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, PA

Dr Vaccaro has consulted or has done independent contracting for DePuy, Medtronic, Stryker Spine, Globus, Stout Medical, Gerson Lehrman Group, Guidepoint Global, Medacorp, Innovative Surgical Design, Orthobullets, Ellipse, and Vertex. He has also served on the scientific advisory board/board of directors/committees for Flagship Surgical, AO Spine, Innovative Surgical Design, and Association of Collaborative Spine Research. Dr Vaccaro has received royalty payments from Medtronic, Stryker Spine, Globus, Aesculap, Thieme, Jaypee, Elsevier, and Taylor Francis/Hodder and Stoughton. He has stock/stock option ownership interests in Replication Medica, Globus, Paradigm Spine, Stout Medical, Progressive Spinal Technologies, Advanced Spinal Intellectual Properties, Spine Medica, Computational Biodynamics, Spinology, In Vivo, Flagship Surgical, Cytonics, Bonovo Orthopaedics, Electrocore, Gamma Spine, Location Based Intelligence, FlowPharma, R.S.I., Rothman Institute and Related Properties, Innovative Surgical Design, and Avaz Surgical. He has also served as deputy editor/editor of Spine. In addition, Dr Vaccaro has also provided expert testimony. The remaining authors declare no conflict of interest.

Reprints: Carlos Barrios, MD, PhD, Institute for Research on Musculoskeletal Disorders, School of Medicine, Valencia Catholic University, Quevedo 2, Valencia 46001, Spain (e-mail:

Received February 28, 2018

Accepted October 1, 2018

© 2019 by Lippincott Williams & Wilkins, Inc.