Percutaneous pedicle screw fixation may be effective for unstable spinal fractures

The technique with reduction, with or without fusion, was shown to be safe, especially in multitrauma.

A recent investigation indicates that closed reduction and percutaneous pedicle screw fixation may be safe and effective for patients with thoracolumbar fractures with and without fusion.

“It is far less surgery than the gold standard now: open surgery,” lead investigator Tony Y. Tannoury, MD, said. “It is safe and also allows you to perform exactly what you are going to do: fracture reduction and stabilization, especially when you are not planning on fusing the spine. It is a great option for multisystem-injured patients.”

In a retrospective review, Tannoury and his colleagues studied 55 consecutive patients with unstable burst fractures who were admitted to a Level I trauma center and treated with closed reduction and percutaneous pedicle screw fixation (CRPF). Patients with deteriorating neurologic results with spinal cord compression or those with incomplete spinal cord injury underwent direct decompression supported with posterior percutaneous pedicle screw fixation, according to the study abstract.

All of the patients underwent short-level fixation without fusion and had pre- and postoperative radiographs and preoperative CT scans. Thirty-three patients (230 screws) also had postoperative CT scans. The study group had an average follow-up of 13 months.

Breaches

The investigators discovered 10 screw breaches of the pedicle wall. They categorized five of these breaches as critical, defined as greater than 2 mm, and five as noncritical breaches, defined as less than 2 mm. One patient had two critical breaches with cord compression at T9 and developed leg weakness postoperatively. Screw revision was performed percutaneously with full neurological recovery.

The investigators also noted in the study abstract that there were no cases of infection in the study group and kyphosis was corrected from an average of 16.4° preoperatively to 1.8° postoperatively.

Blood loss

The study group had an average blood loss of 380 mL and they required an average of 608 mL of blood transfusion. There were 27 planned hardware removals, and patients had an average Visual Analog Scale (VAS) pain score of 1.8 at the last postoperative follow-up evaluation.

“The closed reduction and percutaneous fixation, with or without fusion, is a safe and reliable technique and every surgeon should give it a strong consideration while planning for managing a spinal injury,” Tannoury said during a presentation at the 24th Annual Meeting of the Orthopaedic Trauma Association. “The infection rate is almost nonexistent.”

In addition, "Percutaneous fixation allows you to manage synchronous spinal burst fractures in fragile multitrauma patients individually, because the surgeon is not tied up to the open incision and fusion."

He cited less OR time and blood loss as advantages of CRPF. However, Tannoury noted that prospective, randomized studies of the procedure are needed and are underway.

For more information:
Tony Y. Tannoury, MD, can be reached at Boston University, Boston Medical Center, 818 Harrison Avenue, Dowling 2 North, Boston, MA 02118; 617-414-6281; e-mail:tannoury@bu.edu. He heads the spine program and spinal fellowship at Boston University and is a consultant and designer for DePuy Spine.

Reference:
Tannoury TY, Macko J. Closed reduction and percutaneous pedicle screw fixation (CRPF) of thoracolumbar fractures with or without fusion: Safety and outcome. Paper #4. Presented at the 24th Annual Meeting of the Orthopaedic Trauma Association. Oct. 16-18, 2008. Denver.