Table 6.
Study Characteristics—Radiological Outcomes.
| Author (Year) Study Design LoE | Treatment | FU (SD and Range) n/N (% FU) | Radiological Outcomes at Follow-up Mean ± SD; Median (Range) [As Available] | Measurement Method to Determine Kyphosis |
|---|---|---|---|---|
| Wood (2003) RCT II | Operative: Short-segment (2- to 5-level) posterolateral spinal arthrodesis with pedicle screw-hook instrumentation and ICBG or Anterior 2-level fibular and rib-strut construct arthrodesis with local autogenous bone-grafting and instrumentation. | Operative: 42.9 mo (SD: 14.8, range 24-72 mo) 24/26 (92%) | Operative: Mean kyphosis angle at admission: 10.1° (–10° to 32°) Mean kyphosis angle at discharge: 5° (–10° to 25°) Mean kyphosis angle at last FU: 13° (–3° to 42°) | Kyphosis and loss of the anterior height of the vertebral body were calculated according to the method of Atlas et al.47 |
| Nonoperative: Body cast with manual kyphosis reduction through anterior force, worn for 8-12 wk, followed by thoracolumbosacral orthosis for 8 wks or Thoracolumbosacral orthosis with the spine in hyperextension to reduce the kyphosis and subsequent molded plaster cast that was then converted to an encompassing plastic jacket, worn for 24 h/d except for showering for 12-16 wk | Nonoperative: 45.8 mo (SD: 21.9, range 24-118 mo) 23/27 (85%) | Nonoperative Mean kyphosis angle at admission: 11.3° (–12° to 30°) Mean kyphosis angle at discharge: 8.8° (–5.5° to 22°) Mean kyphosis angle at last FU: 13.8° (–3° to 28°) | ||
| Landi (2014) Retrospective cohort III | Operative: Percutaneous short stabilization: one level above and one below | Operative: 12 mo ND 25/25 (100%) | Operative and Nonoperative: Radiological outcome determined 6 mo postoperatively: No figures given, Results “in normal range, (ie, 20°-60°) in both groups, “Minimal differences” in favor of operative group | “Sagittal kyphotic angle measurement was manually performed, directly on lateral plane X-ray images, using as reference the upper and lower edges of vertebral bodies L1–L5 and S1 upper edge.” |
| Nonoperative: Rigid brace for 2 months followed by semirigid brace for another 2 mo | Nonoperative: 12 mo ND 25/25 (100%) | |||
| Post (2009) Retrospective cohort III | Operative: Short fixation (for A3 fractures: called MSPI by other authors) involving 1 or 2 segments (depending on fx type, ie, with 2 damaged endplates: 2-segmental fixation; with 1 damaged endplate: 1-segmental fixation) | Operative: 5.7 y (SD: 2.9, range 2.5-10.6 y) 38/46 (83%) | Operative and Nonoperative: ND | NA |
| Nonoperative: Bed rest (or rest on a Stryker frame) for 6 wk, followed by a reclination brace and mobilization. Weight bearing exercises after 3 months. Brace worn for 9 mo (24 h/d in first 6 mo, only during the day in last 3 mo). | Nonoperative: 4.8 y (SD: 2.9, range 2.1-10.4 y) 25/30 (83%) | |||
| Shen (2001) Prospective cohort III | Operative: Three level fixation: pedicle screws in the level above, in the fractured vertebrae, and in the level below the fractured vertebrae (3 levels, 6 screws). | Operative: 24 mo ND 33/33 (100%) | Operative: Mean kyphosis angle at injury: 23° ± 6° (12°-33°) Mean kyphosis angle at 2 y: 12° ± 8° (21°-25°) Initial kyphosis correction: 17° ± 8° Mean initial retropulsion of midsagittal canal diameter: 32% Mean retropulsion of midsagittal canal diameter on 1 y CT: No information | Sagittal plane kyphosis was measured, as described by Knight et al,46 from the inferior endplate of the vertebral body above the fracture to the inferior endplate of the fractured body |
| Nonoperative: Bed rest with activity allowed (including ambulation) as tolerated by pain with hyperextension brace fitted in slight hyperextension with the patient standing. Brace worn 24 h/d (except when bathing) for 3 months. (According to instructions, but no monitoring of compliance undertaken) | Nonoperative: 24 mo ND 47/50 (94%) | Nonoperative: Mean kyphosis angle at injury: 21° ± 6° (11°-35°) Mean kyphosis angle at 2 y: 24° ± 7° (11°-36°) Initial kyphosis correction: None Mean initial retropulsion of midsagittal canal diameter: 34% Mean retropulsion of midsagittal canal diameter on 1 y CT: 15% | ||
| Wei (2010) RCT Ib | MSPI (monosegmental pedicle instrumentation): Screws inserted into the vertebrae adjacent to the injured endplate (if the broken endplate was the superior and the adjacent vertebra was the upper, or if the broken endplate was the inferior and the adjacent vertebra was the lower). | MSPI: ND (only complete population) No. of pts: ND, assume 47/47 (100%) | MSPI: Preop SI: 13.1° ± 5.4° Postop SI: 4.5° ± 2.7° SI at FU: 7.1° ± 4.2° Preop LSC: 6.8 ±1 LSC at FU: 2.9 ±1.1 | Sagittal index determined on plain radiographs according to Farcy et al52 |
| SSPI (short-segment pedicle instrumentation): Pedicle screws in one level above and one level below the injured vertebra. | SSPI: ND (only complete population) No. of pts: ND, assume 38/38 (100%) | SSPI: Preop SI: 11° ± 6.5° Postop SI: 2.3° ±1.6° SI at FU: 4.8° ±2.9° Preop LSC: 6.5 ± 0.7 LSC at FU: 2.7 ± 0.6 | ||
| Complete population: 27.8 mo (SD: 7.0, range 19-52 mo) ND, assume 95/95 (100%) | ||||
| Li (2012) Retrospective cohort III | MSPI (monosegmental pedicle instrumentation): Screws inserted into the vertebrae adjacent to the injured endplate (if the broken endplate was the superior and the adjacent vertebra was the upper, or if the broken endplate was the inferior and the adjacent vertebra was the lower). | MSPI: 13.2 mo (range 12-26 mo) NA (30/30, retrospective, only pts w/ FU) | MSPI: Kyphotic angles: Before surgery, 17.3° ± 9.3° 1 wk after surgery: 6.5° ± 6.5° Latest FU: 9.5° ± 6.4° | “The vertebral kyphotic angle was measured” |
| SSPI (short-segment pedicle instrumentation): Pedicle screws in one level above and one level below the injured vertebra. | SSPI: 34.6 mo (range 12-64 mo) NA (30/30, retrospective, only pts w/ FU) | SSPI: Kyphotic angles: Before surgery, 16.5° ± 9.1° 1 wk after surgery: 7.1° ± 6.9° Latest FU: 7.5° ± 5.2° | ||
| Bailey (2014) RCT Ib | No orthosis (NO): Immediate mobilization as tolerated with restrictions to limit bending and rotating through the trunk. Return to normal activities encouraged after 8 wk. | NO: 24 mo ND 36/49 (73%) 12 mo: 40/49 (82%) | NO group kyphosis angle: Admission: 14° ±6° Discharge: 20° ±8° 12 mo: 21° ± 9° 24 mo: 21° ± 9° | Kyphosis was measured based on the Cobb technique, as the angle succumbed between the perpendicular to the superior and inferior end plate of the vertebral body above and below the fractured level, respectively |
| Early mobilization with “off-the-shelf” adjustable thoracolumbosacral orthosis (TSLO): Strict bed rest until fitted with a TLSO and mobilization in the brace. The TLSO worn at all times except when lying flat in bed for a total of 10 wk with start of weaning from the brace at 8 wk. | TSLO: 24 mo ND 32/47 (68%) 12 mo: ND 41/47 (87%) | TLSO group kyphosis angle: Admission: 15° ± 8° Discharge: 18° ± 7° 12 mo: 22° ± 6° 24 mo: 22° ± 5° | ||
| Proietti (2014) retrospective cohort III | All patients (group A* + group B**): Short stabilization: one level above and one below *Group A: SI > 10° ≤ 15° **Group B: SI > 15° | Total population (group A + group B) Minimum 12 mo (range 12-48 mo) 60/63 (95%) | Group A: SI at 1 y: 9.3° (10°-15°) Correction loss 2.1° | Sagittal index: Sagittal index (SI) in accordance to Farcy’s criteria52 Definition: The measurement of segmental kyphosis at the level of a given mobile segment (1 vertebra and 1 disc) adjusted for the baseline sagittal contour at that level. The sagittal index is derived by subtracting the baseline values from the measured segmental kyphosis at the injured level. Farcy et al used the following baseline estimates for the intact sagittal curve: 5° in the thoracic spine, 0° in the thoracolumbar junction, and 10° in the lumbar spine. Segmental kyphosis at the fracture level was defined as a positive value. Subtracting the baseline values from the segmental kyphosis was used to derive the sagittal index. |
| Group B: SI at 1 y: 15.4° (13°-22°) Correction loss 3.7° | ||||
| Schmid (2011) prospective cohort III | Short segmental posterior fixation with angular stable pedicle screw systems Group A: plus posterolateral fusion Group B: plus unilateral TLIF with monocortical strut grafts and cancellous bone (ICBG) implant removal at a mean of 15.1±3.7months The analysis was performed separately for two patient groups, but only group B (“TLIF group”) was large enough to be eligible for this review, so the group A is not considered here | 20.2 mo (SD: 6.1) 21/21 (100%) | Initial monosegmental angle: −16.0° ± 10.0° Initial spinal canal narrowing: 34.3% ±16.4% Postoperative monosegmental angle: −0.8° ± 6.8° Monosegmental surgical correction: 15.1° ± 8.3° Postoperative spinal canal narrowing: 9.3% ± 9.3% Monosegmental angle at final FU: −5.6° ±7.6° Postoperative loss of correction 4.9° ±8.3° | Monosegmental angles were measured as endplate angles between both end plates adjacent to the fused segment in a lateral projection. The narrowing of the spinal canal was measured on axial CT scans and described in percentages with the width of the adjacent intact vertebra serving as a 100% reference |
| Jeong (2013) Retrospective cohort III | Pedicle screws 1 level above and 1 level below the fracture level | 27.6 mo (range 12-66 mo) NA (23/23, retrospective, only pts w/ FU) | Cobb angle: Preop 17.4° (7.7°-38.1°) Postop 4.9° (0.03°-18.9°) At last FU 9.3° (1.7°-29.6°) Anterior vertical compression ratio: Preop 37.5% (11.3%-60.7%) Postop 14.0% (6.3%-30.2%) At last FU 20.9% (4.5%-38.4%) | The Cobb’s angle and the anterior vertical compression ratio were calculated according to Jiang et al45 |
| Koller (2008) Retrospective case series IV | Manual kyphosis reduction through anterior force, then 3 months of brace (24 h/d) | 112.8 mo (SD: 47 mo) NA (21/21, retrospective, only pts w/ FU) | Regional kyphosis angle at FU: 4.7° ± 10.9° Segmental kyphosis angle at FU: 12.1° ± 6.3° | Regional kyphosis angle (RKA): Injury RKA was indicated as the Cobb angle on supine lateral and on standing full length radiographs Segmental kyphosis angle (SKA): angle between the inferior end plate of the vertebral body above the fracture and the inferior end plate of the fractured body |
| Andress (2002) Retrospective case series IV | Internal fixator either with or without transpedicular spongiosa grafting with fixed-angle pedicle screw instrumentation and pedicle screws above and below the fractured vertebral body In cases where the kyphotic angle was large or where the fractured vertebral body was completely destroyed: transpedicular inter- and intracorporal autologous bone grafting after transpedicular discectomy Transpedicular spongiosa grafting: 29 pts (58%) No grafting: 21 pts (42%) | 68 mo (range 36-103 mo) NA (50/50, retrospective, only pts w/ FU) | SI at FU stratified acc. to fx type (mean ± SD) A 3.1 0.82 ± 0.15 A 3.2 0.79 ± 0.12 A 3.3 0.81 ± 0.13 Sagittal plane kyphosis at FU stratified according to fx type (mean ± SD) A 3.1 −15.5 ± 6.5 A 3.2 −19.0 ± 7.1 A 3.3 −14.0 ± 6.6 | Using the ratio of the heights of the anterior and posterior vertebral wall (on lateral views of the injured vertebral body) we calculated the sagittal index (SI). Sagittal plane kyphosis (SPK): angle between the superior end plate of the vertebral body above the fracture and the inferior end plate of the fractured body |
Abbreviations; ND, not documented; w/, with, w/o; without, pt, patient; pts, patients; NA, not applicable; fx, fracture, FU, follow-up; SI: Sagittal Index, LSC: Load Sharing Classfication.53