Abstract
Introduction
Percutaneous minimally invasive spine surgery (MISS) is a treatment option for thoracolumbar fractures and we aim to evaluate its outcomes.
Methods
A retrospective matched cohort study of all patients with thoracolumbar fractures treated with MISS or open posterior approach.
Results
We included 100 MISS and 155 open patients. After controlling for patient characteristics, our results statistically favor MISS in mean operative time, mean intraoperative blood loss, and number of patients requiring postoperative blood transfusions within 48 h.
Conclusions
Advantages of using MISS for treatment of thoracolumbar fractures are decreased operative time, decreased blood loss, and fewer patients requiring transfusions.
Keywords: Minimally invasive spine surgery, Open posterior approach, Thoracolumbar fracture
1. Introduction
The surgical goals of treating unstable spine fractures are to provide spinal stability adequate for healing and rehabilitation, and to prevent neurological injury and post-traumatic deformity. With the introduction of pedicle screw fixation in the 1980s1 and improvements in minimally invasive spine surgery (MISS) over the past decade, controversy has developed regarding which surgical approach offers optimal stabilization and decreased patient morbidity.2,3 New advances in MISS, such as improved fixation and powerful cantilever reduction and rod passage maneuvers, have made it a more feasible and reliable treatment option in spine trauma.4 Currently published literature appears to demonstrate, relative to open approach, a lack of inferiority for MISS in terms of vertebral body height (VBH), kyphosis angle, and visual analog scores (VAS). When comparing open approach to MISS for thoracolumbar fractures, MISS has decreased blood loss and shorter operative time.5 Furthermore, it has been proposed that MISS may allow for earlier patient mobilization, improved pulmonary hygiene, and decreased respiratory complications.6
The purpose of this study was to systematically evaluate the short-term outcomes of MISS thoracolumbar fracture stabilization compared to traditional open posterior approach. Primary outcome measures were operative time, blood loss, and transfusion requirements. Additionally, we assessed pulmonary complications, specifically hospital-acquired pneumonia, and the length of stay of these two cohorts. We hypothesized that the treatment of thoracolumbar fractures with MISS is associated with decreased operative time, blood loss, postoperative complications, time to mobilization, days of mechanical ventilation, and length of hospital stay compared to the traditional open approaches.
2. Materials and methods
2.1. Study population
This a retrospective matched cohort analysis and there was no funding received for the study. After obtaining Institutional Review Board (IRB) approval, 425 patients were obtained by querying our surgical billing database from tertiary referral center to determine a consecutive series of patients who underwent posterior spinal instrumentation between January 2007 and May 2013. Exclusion criteria were: use of posterior spinal instrumentation for the treatment of cervical spine disorders, infections, osteomyelitis, tumor, pathological fractures, deformity, degenerative spine disease, sacral fractures, and combined anterior/posterior procedures (Fig. 1). Two hundred fifty-five patients with thoracic and lumbar spine fractures were treated with a posterior-only approach. MISS and open approach was used in 100 and 155 patients respectively.
Fig. 1.
Flow chart shows patient selection for study inclusion. Of the 425 patients initially screened, 255 were included in the final analysis.
We used the AOSpine Thoracolumbar Spine Injury Classification System to classify fracture morophology and the Thoracolumbar Injury Classification and Severity (TLICS) scoring system, was used to distinguish operative from nonoperative candidates.7,8 Per protocol at our institution, all operative fractures had a TLICS score of 3 or more. Stable compression and burst fractures were not treated with operative fixation. Open versus MISS technique was chosen at the surgeon's discretion based on the patient's neurological status and medical history at presentation. Single and multi-level contiguous fractures were included in the study. Our usual practice is to instrument 2 levels above and 2 levels below the fractured vertebra. However, in some patients, short constructs 1 level of instrumentation above and below the fractured level were used based on surgeon decision. All fractured levels were included in the constructs.
2.2. Data collection
We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines to enhance the quality and minimize the bias of this observational study.9 Only the in-hospital postoperative time period was evaluated, unless the patient had a documented secondary procedure. From chart review, initial neurological status, mechanism of injury, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), pulmonary injury at admission, length of hospital stay, duration of mechanical ventilation, and post-operative ambulatory status were collected. Operative data included procedure type, length of surgery, estimated blood loss (EBL), transfusions, construct length, and use of allograft for fusion. Patient outcomes obtained from chart review included length of stay, time from admission to surgery, day of mobilization, medical and surgical complications. Surgical complications included reoperation, surgical site infection (SSI), incision and drainage, pneumonia, death, decline in neurological status, and elective instrumentation removal.
2.3. Surgical technique
For MISS pedicle screw insertion a “True AP” technique was utilized. This involves the use of intraoperative fluoroscopy to localize and mark the skin at the 3 and 9 o'clock positions for the pedicle to be instrumented. A stab incision is made through skin and fascia, and, under fluoroscopic guidance, a Jamshidi needle is used to cannulate the pedicle. After confirming intact pedicle floor and walls, the pedicle is tapped and instrumented, with screw length determined from preoperative computed tomography and intraoperative fluoroscopy. Because no in situ contouring of the rod can be performed with the percutaneous approach, kyphosis is corrected via postural reduction on the operating table, and, should further reduction be needed, cantilever reduction of the rods into the screw heads.10 When a fracture dislocation could not be reduced with postural reduction, an open approach was utilized. An open approach was typically used in patients with incomplete or complete spinal cord injury (81 open vs 16 MISS).
2.4. Statistical analysis
Data was entered into Microsoft Excel for data cleaning and management (Microsoft Office Professional Plus 2016, Microsoft, Redmond, WA, USA). Stata 11.1 software (StataCorp LP, College Station, TX) was used for all statistical analysis. Mean and standard deviations or medians and interquartile ranges were calculated for continuous variables. Frequencies were calculated for categorical variables. Bivariate comparisons were made between the MISS and open approach groups using Student's t tests for continuous covariates and Fisher's exact tests for categorical variables. For data that did not demonstrate normal distributions, Kruskal-Wallis test was used as the nonparametric alternative to the Student's t-test. Separate multivariate logistic regression models were created using a backwards stepwise selection procedure for each of our primary outcome. Our main independent variable of interest, MISS, was forced into the models. Correlation of covariates was also assessed for independence prior to inclusion in the final model. The selection procedure was set to remove factors at a P > 0.05 threshold, starting with all variables thought to be potentially associated with outcome based on our conceptual model.
3. Results
3.1. Population characteristics
A total of 255 patients with 322 fractures were included in the study and of those, 155 patients underwent surgical fixation with open approach. There were, on average, 1.26 ± 0.5 fractures per patient. The most common spinal column injuries were burst/compression fractures (45%), with 44.7% of all fractures occurring at the thoracolumbar junction (T10–L2) (Table 1). The group with open approach had significantly more injuries in the upper thoracic (T1-T5) region (p < 0.001) and had fewer burst fractures (p < 0.001) but more fracture dislocations (p < 0.001).
Table 1.
Fracture characteristics stratified by surgical technique.
| Total | Surgical Technique |
p-Value | ||
|---|---|---|---|---|
| Open (n = 155) | MISS (n = 100) | |||
| Total fractures, n | 322 | 203 | 119 | – |
| Fractures per patient, mean ± SD | 1.26 ± 0.5 | 1.3 ± 0.6 | 1.2 ± 0.5 | 0.15 |
| Fracture level, n (%) | ||||
| Upper Thoracic (T1-T5) | 48 (14.9) | 43 (21.2) | 5 (4.2) | <0.001* |
| Middle Thoracic (T6-T10) | 88 (27.3) | 57 (28.1) | 31 (26.1) | 0.80 |
| Thoracolumbar (T10-L2) | 144 (44.7) | 84 (41.4) | 60 (50.4) | 0.13 |
| Upper lumbar (L2-L3) | 28 (8.7) | 9 (4.4) | 19 (16) | 0.001* |
| Lower lumbar (L4-L5) | 14 (4.3) | 10 (4.9) | 4 (3.4) | 0.58 |
| Fracture Morphology, n (%) | ||||
| Burst/compression (AO A1-A4) | 145 (45.0) | 71 (35.0) | 74 (62.2) | <0.001* |
| Flexion distraction (AO B1–B2) | 58 (18.0) | 38 (18.7) | 20 (16.8) | 0.76 |
| Extension distraction (AO B3) | 24 (7.5) | 13 (6.4) | 11 (9.2) | 0.38 |
| Fracture dislocation (AO C) | 95 (29.5) | 81 (39.9) | 14 (11.8) | <0.001* |
MISS indicates minimally invasive spine surgery. *Statistical significance was determined with a p-value less than 0.05.
Population characteristics for patients in the study are shown in Table 2. Patients undergoing MISS were older than those who underwent open fixation, but this did not reach statistical significance (47.7 vs 41.8 years, p = 0.06). There was no significant difference in the overall ISS or GCS score between the 2 groups, with an overwhelming majority of patients in both groups having a GCS score of 14 or greater (MISS, 77; Open, 125). There was no statistically significant difference in the number of patients with pulmonary injury (MISS, 35 patients; open approach, 58 patients; p = 0.79). A sub analysis of patient's neurologic status revealed a significant portion who were deemed intact underwent MISS (82 vs. 71, p < 0.001) and conversely, those who were deemed to have incomplete or complete spinal cord injuries were more likely to undergo open fixation (Incomplete: 26 vs 4, p = 0.001; Complete: 55 vs 12, p = 0.001). The most common cause of injury was motor vehicle collisions (46%), with falls from height the second most common reason (35%).
Table 2.
Characteristics of patients undergoing minimally invasive spine surgery compared with traditional open approach surgery.
| Total (n = 255) | Open (n = 155) | MISS (n = 100) | p-value | |
|---|---|---|---|---|
| Age, mean ± SD | 44.1 ± 19.6 | 41.8 ± 17.9 | 47.7 ± 21.6 | 0.06 |
| Male, n (%) | 179 (70.2) | 113 (72.9) | 66 (66.0) | 0.26 |
| GCS, median, (range) | 15, (3–15) | 15, (3–15) | 15, (3–15) | 0.95 |
| ISS, mean ± SD | 26.0 ± 13.6 | 26.7 ± 13.9 | 25.0 ± 13.1 | 0.36 |
| Pulmonary Injury, n (%) | 93 (36.4) | 58 (37.4) | 35 (35.0) | 0.79 |
| Mech. ventilation (d), median, (range) | 3, (0–54) | 3, (0–54) | 3, (0–54) | 0.93 |
| Follow-up (wks), median, (range) | 24.1, (0.1–493.3) | 27.9, (0.3–493.3) | 20.9, (0.14–409.4) | 0.38 |
| Initial Neurologic Status, n (%) | ||||
| Complete | 67 (26.2) | 55 (35.5) | 12 (12.0) | <0.001* |
| Incomplete | 31 (12.2) | 26 (16.8) | 4 (4.0) | 0.001* |
| Intact | 153 (60.0) | 71 (45.8) | 82 (82.0) | <0.001* |
| Nerve Root | 1 (0.4) | 0 (0) | 1 (1.0) | 0.39 |
| Cauda Equina | 3 (1.2) | 3 (1.9) | 0 (0) | 0.29 |
| Mechanism of Injury, n (%) | ||||
| MVC | 118 (46.1) | 72 (45.9) | 46 (46.0) | 1.00 |
| Fall | 89 (34.8) | 53 (33.8) | 36 (36.0) | 0.69 |
| MCC/ATV | 26 (10.2) | 21 (13.4) | 5 (5.0) | 0.034* |
| Pedestrian Struck | 12 (4.7) | 5 (3.2) | 7 (7.0) | 0.22 |
| Othera | 11 (4.3) | 6 (3.8) | 5 (5.0) | 0.75 |
MISS indicates minimally invasive spine surgery; GCS, Glasgow Coma Scale; ISS, Injury Severity Score; Mech. ventilation, Mechanical Ventilation; MVC, Motor Vehicle Crash; MCC, Motor Cycle Crash; ATV, All Terrain Vehicle; *Statistical significance was determined with a p-value less than 0.05.
Other mechanisms include blunt trauma, crush injuries, and gunshot wounds.
3.2. Operative outcomes
Mean operative time was significantly different between MISS and open groups (109.0 ± 63.3 vs 157.5 ± 77.1, p < 0.001). A 4.4-fold decrease in mean intraoperative blood loss was observed in the MISS group at 136.5 mL versus 602.0 mL for open cases (p < 0.001) (Table 3). The open group had significantly more instrumented levels (5.0 vs 4.1; p < 0.0001). Short segments were more common in the MISS group (p < 0.001) whereas, compared with MISS group, medium (p = 0.005) and long segments (p = 0.13) were more common in open group. Combined allograft and autograft was used more commonly in open group compared with MISS (p < 0.001).
Table 3.
Operative details of patients undergoing minimally invasive spine surgery compared with traditional open approach surgery.
| Open (n = 155) | MISS (n = 100) | p-value | |
|---|---|---|---|
| Length of Surgery (mins), mean ± SD | 157.5 ± 77.1 | 109.0 ± 63.3 | <0.001* |
| Estimated blood loss (mL), mean ± SD | 602.0 ± 489.4 | 136.5 ± 141.2 | <0.001* |
| Instrumented Levels, mean ± SD | 5.0 ± 1.8 | 4.1 ± 1.5 | <0.001* |
| Number of Constructs per patient, n (%) | |||
| One | 154 (98.1) | 98 (98.0) | 1.00 |
| Two | 3 (1.9) | 1 (1.0) | |
| Instrumentation Segment Lengtha, n (%) | |||
| Short | 64 (40.0) | 64 (64.0) | <0.001* |
| Medium | 43 (26.9) | 12 (12.0) | 0.005* |
| Long | 53 (33.1) | 24 (24.0) | 0.13 |
| Fusion, n (%) | 152 (96.8) | 32 (32.0) | <0.001* |
| Allograft | 25 (15.9) | 30 (30.0) | 0.008* |
| Autograft | 36 (22.9) | 1 (1.0) | <0.001* |
| Allograft and Autograft | 90 (57.3) | 2 (2.0) | <0.001* |
| BMP | 5 (3.2) | 18 (18.0) | <0.001* |
The values are given as the mean and standard deviation (SD) or as the number with the percentage in parentheses. MISS indicates minimally invasive spine surgery, GCS, Glasgow Coma Scale; ISS, Injury Severity Score. *Statistical significance was determined with a p-value less than 0.05.
Short-segment includes construct instrumented one level above and below the injury level. Medium-segment includes constructs instrumented one level above or below, as well as two segments above or below the injury. Long-segment includes constructs instrumented at least two levels above and below the injury.
A multivariate model for length of surgery showed MISS operative time was 45 min less than that of open when controlling for surgeon experience, instrumented segment length, and multiple fractures (95% CI: −63.03 to 28.36, p < 0.001) (Table 4). When controlling for surgeon experience, instrumented segment length, and GCS, multivariate analysis revealed MISS surgery to be significantly associated with decreased blood loss when compared to open fixation (p = 0.001).
Table 4.
Multivariate analysis for length of surgery.
| Β (mins) | p-value | 95% Confidence Interval |
||
|---|---|---|---|---|
| Lower Limit | Upper Limit | |||
| MISS, ref. = open | −45.69 | <0.001* | −63.03 | −28.36 |
| Surgeon experience, ref. = <10 yrs | −69.18 | <0.001* | 95.09 | −43.27 |
| Multiple fractures, ref. = 1 fracture | 32.33 | 0.002* | 12.48 | 52.19 |
| Segment length, ref. = short segment | 21.60 | 0.012* | 4.71 | 38.50 |
The beta coefficient (β) is given in minutes (mins). MISS indicates minimally invasive spine surgery. *Statistical significance was determined with a p-value less than 0.05.
Our multivariate model of the need for transfusion showed those in the MISS group were 37% less likely to require a transfusion (95% CI, 0.18–0.76) than those in the open group. The presence of pulmonary injury independently contributed 2 times higher odds (95% CI, 1.05–4.01, p = 0.04) of transfusion requirement compared to patients with no pulmonary injury. Additionally, patient age (per year) and GCS (decreased requirement per point increase) were again found to be significantly associated with transfusion requirement (OR, 1.03; 95% CI, 1.01–1.05; and OR, 0.83; 95% CI, 0.74–0.94, respectively).
3.3. Postoperative outcomes
MISS patients had significantly greater time from admission to surgery than those in the open group (50.4 ± 68.8 h vs 33.0 ± 50.7 h, p = 0.04) (Table 5). When controlling for GCS, this observation still proved significant, with MISS patients waiting, on average, 15 more hours to surgery than those in the open group (p = 0.5, CI: 0.04–30.24). MISS patients had a 3-fold decrease in number of patients requiring postoperative blood transfusions within 48 h after surgery (24 versus 81 patients, p < 0.001). No statistically significant difference was shown in length of hospital stay. Patients were first mobilized, on average, on postoperative day 4 in MISS and open approach cases. Findings of an all-complications analysis assessing hospital-acquired pneumonia, surgical site infection, revision, and mortality were not statistically significant between MISS and open groups (MISS, n = 17; open approach, n = 23; p = 0.6). After excluding revisions for elective instrumentation removal, no statistically significant difference was shown between revision surgery for MISS and open groups, with 4 revisions in the MISS group and 2 in the open approach group (p = 0.21). Of the 4 MISS patients with revision, two had SSI or osteomyelitis and the other two had failure of hardware or loss of reduction. Both of the open patients had concern for SSI or osteomyelitis. All 12 patients who underwent elective hardware removal had hardware prominence or local pain due to hardware prominence. MISS patients underwent elective hardware removal more often than open patients (p = 0.002). No statistically significant difference was observed for deep infections that required formal irrigation and debridement in the operating room (MISS, 5 cases; open approach, 7 cases; p = 1.0). The mortality rate between the two groups was not different (p = 1.0). Of the two deaths in MISS patients, one had hypovolemic shock and heart failure on postoperative day 3 and the other had multiple operations during admission and eventually developed mutli-organ failure and was made DNR/DNI. Of the five deaths in open patients, three were made DNR/DNI because of respiratory failure and subsequent sepsis. The other two had multiple operations during admission and eventually developed mutli-organ failure and were made DNR/DNI.
Table 5.
Outcomes of patients undergoing minimally invasive spine surgery compared with traditional open approach surgery.
| Open (n = 155) | MISS (n = 100) | p-value | |
|---|---|---|---|
| Length of Stay (d), mean ± SD | 12.4 ± 12.7 | 14.3 ± 14.5 | 0.27 |
| Time to Surgery (hrs), mean ± SD | 33.0 ± 50.7 | 50.4 ± 68.8 | 0.04* |
| POD to Mobilization (d), mean ± SD | 3.6 ± 4.9 | 4.0 ± 6.4 | 0.55 |
| Transfusions, n (%) | 81 (51.6) | 24 (24.0) | <0.001* |
| Complications, n (%) | 23 (14.6) | 17 (17.0) | 0.60 |
| Total Unplanned Reoperation | 9 (5.7) | 9 (9.0) | 0.32 |
| Incision and Drainage | 7 (4.5) | 5 (5.0) | 1.00 |
| Revision of Instrumentation | 2 (1.3) | 4 (4.0) | 0.21 |
| Elective Instrumentation Removal, n (%) | 2 (1.3) | 10 (10.0) | 0.002* |
| Hospital Acquired Pneumonia | 10 (6.4) | 6 (6.0) | 1.00 |
| Mortality | 5 (2.0) | 2 (2.0) | 1.00 |
| Neurologic Status Decline | 0 (0) | 0 (0) | 1.00 |
MISS indicates minimally invasive spine surgery; d, days; POD, postoperative day; *Statistical significance was determined with a p-value less than 0.05.
A multivariate model revealed MISS patients were at no significant increased risk of complications postoperatively as compared to patients who underwent an open approach (OR, 1.82; 95% CI, 0.76–4.33, p = 0.18).
4. Discussion
Appropriate operative management in patients with thoracolumbar spine fractures should consider minimizing the operative burden, thus making MISS a potentially beneficial treatment option. The results of this study demonstrate decreased operating time, decreased blood loss, and fewer patients requiring postoperative blood transfusions in the MISS group. Mean operative time was found to be significantly shorter in percutaneous fixation group (109 min versus 158 min for open approach cases; p < 0.001). A 4.4-fold decrease in median intraoperative blood loss was observed in the MISS group at 137 mL versus 602 mL for open approach cases (p < 0.001). This finding correlated with a 3-fold decrease in number of patients requiring postoperative blood transfusions within 48 h after surgery (24 versus 81 patients) (p < 0.0001).
Results from our study are in agreement with earlier studies evaluating the MISS approach in thoracolumbar trauma. Wang et al. studied 100 patients with type A thoracolumbar fractures and showed statistically significant differences favoring the MISS group due to shorter hospital stay, intraoperative blood loss, and operating time (all p < 0.05).11 Operating time was 98.4 min (Inter Quartile Range (IQR), 67.5–90 min) for the MISS group versus 140.3 min (IQR, 90–112 min) for the open approach group (p < 0.05). The authors also reported a 6-fold decrease in surgical blood loss with MISS (p < 0.05). Fu et al. reported on 98 patients who underwent 4 or 6-screw open and MISS pedicle screw fixation of thoracolumbar fractures.12 They noted no significant difference in operative time between the two groups, but significantly higher intraoperative blood loss in the open cohort (251.4 vs 97.5 ml, p < 0.05).
Palmisani et al. also studied patients treated with MISS for thoracolumbar fractures.13 Their study group included 51 patients with 57 type A (compression-burst), 4 type B (distraction), and 3 type C (translation) fractures. Although the authors reported results favoring percutaneous MISS, they noted that MISS was limited to treatment of stable vertebral fractures (mostly type A) “because of the impossibility to perform a fusion.” Our study included a larger number of patients with unstable fractures spanning all AO classification types. The fractures were treated with MISS techniques with favorable results. Our results indicate that MISS can be utilized for treatment of unstable thoracolumbar fracture patterns.
Palmisani et al. recommended mandatory removal of implants when fixation involved L2 or lower lumbar segments and in cases of complications or symptoms.13 In our study, routine implant removal was done in 12 patients: 10 in the MISS and 2 in the open approach group. The majority of these routine device explants were done in 2007. Since then removal of implants is not routinely employed but only performed in cases of infection, or painful, prominent devices.
Several authors have suggested that with smaller incisions and less dissection or muscle stripping, MISS should result in lower infection rates.4,14,15 Palmisani et al. reported 1 case of infection in their series of 51 MISS patients.13 A systematic review of 26 studies by Goldstein et al. reported no significant difference in postoperative superficial or deep infections between MISS and open cohorts.16 The current study is the largest cohort on this topic, and found no statistically significant difference in infection rates between MISS and open approach.
In our study, preoperative pulmonary injuries, such as pneumothorax and pulmonary contusion, were identified in all the patients. Controlling for the above risk factors that were not statistically different in our population (patient age, GCS score, and ISS), we were able to show that no difference existed in postoperative patient mobilization or respiratory complication rates or incidence of pneumonia between MISS and open approach groups. Respiratory failure and complications in patients who undergo surgical stabilization of thoracolumbar fractures are a major concern.17 McHenry et al. reviewed their database of 1032 patients. and showed that early spinal stabilization (within 48 h) decreased the risk of respiratory failure.6 They identified 5 independent risk factors that predisposed patients to respiratory failure: age older than 35 years, GCS<12, ISS>25, blunt chest wall injury, and surgical stabilization performed more than 2 days after admission.
4.1. Study strengths
This study has several strengths. It is the largest single center study comparing the outcomes between percutaneous MISS and an open approach in the treatment of traumatic thoracolumbar fractures, and unique it its wider inclusion criteria to capture clinical outcomes of patients with and without preoperative neurological deficit. This is the first study that attempted to objectively assess patient outcomes in regards to earlier patient mobilization and pulmonary complications post MISS versus open surgery. The heterogeneous fracture patterns observed in this study allows the results to be more generalizable to the trauma spine population. Based on the results of this study, future studies would evaluate these approaches in a prospective fashion.
4.2. Study limitations
As is common to retrospective reviews, this study is inherently prone to selection bias. In particular, our analysis showed that intact neurological status and lower lumbar injury made it more likely to undergo MISS. Therefore, patient selection was potentially biased. The surgeons likely selected healthier patients for MISS which in turn could have influenced the operative outcomes. A multivariate analysis for length of surgery and complications was performed to account for factors that could influence outcomes. We assessed only a trauma population with thoracolumbar spine fractures, so caution should be used when generalizing the results to all patients with thoracolumbar spine conditions. Patients with tumors and/or infections might require a supplemental procedure to adequately stabilize the spine. Patients were selected to undergo percutaneous MISS based on several important operative and practical factors that might not reflect how the technique is used in the general population. For instance, factors such as the institution's culture, patient's body habitus or hemodynamic instability, and surgeon's comfort with technique impact its use among general spine community.
We recognize lack of radiological analysis and limited follow-up of clinical results may invite criticism. However, including radiological and clinical follow up will have dropped the sample size and as a result decrease the power of the study and the value of the outcomes. The purpose was to show differences in operative outcomes during hospitalizations between surgical approaches and to assess rates of return to the operating room to address device complications or to manage infections. We suggest that for the patient with multiple traumatic injuries and intact neurological status, a percutaneous MISS technique is a reasonable option for stabilizing the thoracolumbar spine compared to the standard open approach.
5. Conclusions
With decreased operative time, blood loss, and need for postoperative transfusions, percutaneous posterior MISS fixation is a reasonable treatment option for thoracolumbar fractures in hemodynamically unstable patients with multiple traumatic injuries and intact neurological status.
Source of funding
No outside funding was received for this work.
Disclaimers
The views expressed in the submitted article are our own and not an official position of the institution.
Declaration of competing interest
Dr. Gelb is a board member and fellowship committee chair for AOSpine NA. He receives payment for lectures and for development of educational presentations from AOSpine NA. He receives royalties from DePuy Synthes Spine and Globus Medical. He has stock in the American Society for Investigative Pathology. Dr. Koh receives payment for consultancy from Biomet. His institution receives RO1 grant money from the National Institutes of Health. Dr. Ludwig is a board member for Globus Medical, the American Board of Orthopaedic Surgery, the American Orthopaedic Association, the Cervical Spine Research Society, and the Society for Minimally Invasive Spine Surgery. He is a paid consultant for DePuy Synthes, K2M, and Globus Medical. He receives payment for lectures and travel accommodations from DePuy Synthes and K2M. He receives payment for patents and royalties from DePuy Synthes and Globus Medical. He has stock in Innovative Surgical Designs and the American Society for Investigative Pathology. He receives research support from AO Spine North America Spine Fellowship support, Pacira Pharmaceutical, and AOA Omega Grant. He is a board member of Maryland Development Corporation. He receives royalties from Thieme, Quality Medical Publishers. He is on the governing board of Journal of Spinal Disorders and Techniques, The Spine Journal, and Contemporary Spine Surgery. The authors have no further potential conflicts of interest to disclose.
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