Five-year clinical and radiological results of combined anteroposterior stabilization of thoracolumbar fractures

Clinical article

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Object

Despite promising early clinical results, the long-term outcome of the use of expandable titanium cages to reconstruct the anterior column after traumatic burst fractures is still unknown. The purpose of this prospective study was to assess the clinical and radiological outcomes of the use of expandable titanium cages 5 years postoperatively.

Methods

Eighty patients with traumatic thoracolumbar burst fractures (T4–L5) underwent posterior stabilization followed by anterior corpectomy and reconstruction using expandable titanium cages with or without additional anterior plating. After 5 years, fusion was evaluated by means of plain radiographs and CT scans, and the patients' scores on the Oswestry Disability Index (ODI), their neurological status, and clinical results were assessed.

Results

Forty-five (56%) of the 80 patients could be examined after 5 years. There was a relatively high rate of complications related to thoracotomy (26%), but there were no complications directly related to the cages. Revision surgery was required in 1 case. The average postoperative loss of correction was only 2.4° due to minimal subsidence of the cages. No cage showed a radiolucent line or instability in flexion-extension views. Bony fusion, as assessed by CT scan, was achieved in 41 patients (91%). On clinical examination, 96% of all patients were ambulatory and showed minimal restriction of spinal range of motion; 71% did not need analgesic medication at all; and 67% were able to work. The average ODI score was 12. Thirty-one percent of patients complained of some kind of anterior approach–related complications.

Conclusions

Combined anteroposterior stabilization of thoracolumbar burst fractures with expandable titanium cages is a relative safe procedure with satisfactory radiological and clinical long-term outcome. High fusion rates can be achieved, with only minor loss of correction, typically occurring in the 1st year. However, open thoracotomy carries the risks of additional complications and development of post-thoracotomy syndrome.

Abbreviations used in this paper:AIS = ASIA Impairment Scale; ASIA = American Spinal Injury Association; BKA = bisegmental kyphosis angle; ODI = Oswestry Disability Index; VAS = visual analog scale.

Abstract

Object

Despite promising early clinical results, the long-term outcome of the use of expandable titanium cages to reconstruct the anterior column after traumatic burst fractures is still unknown. The purpose of this prospective study was to assess the clinical and radiological outcomes of the use of expandable titanium cages 5 years postoperatively.

Methods

Eighty patients with traumatic thoracolumbar burst fractures (T4–L5) underwent posterior stabilization followed by anterior corpectomy and reconstruction using expandable titanium cages with or without additional anterior plating. After 5 years, fusion was evaluated by means of plain radiographs and CT scans, and the patients' scores on the Oswestry Disability Index (ODI), their neurological status, and clinical results were assessed.

Results

Forty-five (56%) of the 80 patients could be examined after 5 years. There was a relatively high rate of complications related to thoracotomy (26%), but there were no complications directly related to the cages. Revision surgery was required in 1 case. The average postoperative loss of correction was only 2.4° due to minimal subsidence of the cages. No cage showed a radiolucent line or instability in flexion-extension views. Bony fusion, as assessed by CT scan, was achieved in 41 patients (91%). On clinical examination, 96% of all patients were ambulatory and showed minimal restriction of spinal range of motion; 71% did not need analgesic medication at all; and 67% were able to work. The average ODI score was 12. Thirty-one percent of patients complained of some kind of anterior approach–related complications.

Conclusions

Combined anteroposterior stabilization of thoracolumbar burst fractures with expandable titanium cages is a relative safe procedure with satisfactory radiological and clinical long-term outcome. High fusion rates can be achieved, with only minor loss of correction, typically occurring in the 1st year. However, open thoracotomy carries the risks of additional complications and development of post-thoracotomy syndrome.

Ensuring adequate stability to prevent loss of fracture reduction and facilitate healing constitutes the primary aim of modern operative treatment of thoracolumbar spinal fractures. Although there appears to be a consensus concerning the importance of primary stability, there is still controversy regarding the optimal treatment concept, whether unstable thoracolumbar fractures should be treated with a posterior, anterior, or combined anteroposterior approach. Despite the fact that good results were reported for anterior-only approaches8,39 and the superiority of anteroposterior approaches still remains to be proven, anteroposterior stabilization of unstable thoracolumbar fractures is advocated by several authors.4,14,17,26,28,33 The advantages claimed for combined procedures are increased primary stability, optimal reduction capability, and decreased postoperative correction loss. As a result, the use of corpectomy cages has significantly increased in anterior column reconstruction in an effort to address the issues concerning donor-site morbidity by autologous iliac crest graft harvesting. Additionally, corpectomy cages were found to be biomechanically superior.7,17 Until now, reported results on the use of corpectomy cages have had either a short follow-up1,9 or have been based on heterogeneous case series.12,29,34

The aim of this prospective study was to investigate the long-term radiological and clinical results of the anteroposterior instrumentation of thoracolumbar fractures with use of expandable titanium corpectomy cages, with special attention to surgical access–related complications.

Methods

Eighty consecutive patients who had suffered an unstable thoracolumbar injury (from T-4 to L-5) of Type A.3, B, or C according to the Magerl AO-classification20 were included in this prospective study. Patients with osteoporosis were excluded from the study.

Indications for a combined posterior-anterior procedure were defined as followed: Type A, B, or C injuries with severe comminution of the vertebral body and/or local kyphosis of more than 15°–20° (compared with physiological values).37

All patients were initially treated by posterior stabilization with an internal fixator (USS Fracture or USS II, Synthes).

Following placement of posterior instrumentation, the patients underwent an anterior corpectomy of the fractured vertebra and implantation of an expandable cage (VBR, Ulrich). Local autologous bone harvested from the corpectomy site was placed inside and around the cage to promote fusion. The cage implantation was performed through an open thoracotomy for corpectomies down to L-1 and through an open retroperitoneal approach for more caudal fractures.

In addition, in 43 cases (54%), a plate (“St. Georg” plate, Link, or LCP, Synthes) was placed anterolaterally during the same surgical session (“St. Georg” plate, Link, or LCP, Synthes). The application of a plate was based on intraoperative assessment of the local stability by the surgeons but was not related to the type of fracture.

All patients were evaluated clinically and radiologically at 1 year after surgery and annually thereafter until the last follow-up examination, 5 years postoperatively.

Radiological Evaluation

Conventional standing anteroposterior and lateral radiographs as well as flexion-extension lateral views of the surgically treated spinal region were obtained at the follow-up visits. Additionally, a CT scan with 2D reconstruction was performed at the 1- and 5-year follow-up visits (LightSpeed 8/16, General Electric; slice thickness 2.5 mm, reconstruction 1.5 mm).

Conventional radiographs were evaluated by use of the Osiris Software program for calculating the following parameters: 1) Bisegmental kyphosis angle (BKA). This was defined as the angle between the superior endplate of the cephalad intact vertebra and the inferior endplate of the caudad intact vertebra, as measured by the Cobb method in the lateral and in the flexion-extension views (Fig. 1); 2) Cage subsidence. The distance from the superior endplate of the cephalad intact vertebra to the inferior endplate of the caudad intact vertebra was measured along the longitudinal axis of the cage on lateral radiographs at each time point. The difference in this measurement was used for calculating cage subsidence (Fig. 2); 3) Cage tilting. The angle between the cage axis and the inferior endplate of the caudal intact vertebra was measured in both lateral and anteroposterior views, and these angles were used for calculating the sagittal and coronal tilting of the cage, respectively (Fig. 3).

Fig. 1.
Fig. 1.

Lateral radiograph showing the bisegmental kyphosis angle (BKA) as measured by the Cobb method. The BKA was measured on plain lateral radiographs and in flexion-extension views.

Fig. 2.
Fig. 2.

Lateral radiograph illustrating the method for calculating cage subsidence. The long double-headed arrow indicates the distance measured along the longitudinal axis of the cage.

Fig. 3.
Fig. 3.

Lateral radiograph showing the method for calculating cage tilting. The angle was calculated based on measurements in both the lateral and the anteroposterior view. The resulting angles were used for calculating sagittal and coronal tilting, respectively.

CT scans including transverse images and 2D reconstructions were used for evaluating the bony fusion.

Criteria used for fusion evaluation are listed in Table 1.

TABLE 1:

Criteria for fusion evaluation based on CT

Criteria for Fusion
bony bridge between endplates, assessed in radiographs, axial CT slices, & sagittal/coronal 2D reconstructions
bone formation in & around the cage in all axial CT slices & sagittal/coronal 2D reconstructions
no bisegmental kyphosis angle difference >3° in flexion-extension radiographs
no radiolucency around the cage, assessed in radiographs, axial CT slices, & sagittal/coronal 2D reconstructions

Clinical Evaluation

Perioperative and postoperative complications (related to either the dorsal or the ventral approach) were recorded.

The patients' neurological status was evaluated according to the American Spinal Injury Association (ASIA) Impairment Scale (AIS), though some patients were evaluated by emergency doctors at the accident site and did not receive a proper ASIA examination.

Patients' performed self-assessment using the Oswestry Disability Index (ODI).21

For assessment of spinal mobility, the range of motion of the thoracolumbar spine was evaluated by measuring of the following parameters: side bending (left, right), spinal rotation (left, right), and finger-to-ground distance.

A 100-point visual analog scale (VAS) was used for patients' self-evaluation of perceived back and leg pain. In addition, the patients were asked to categorize their rest and/or stress pain as permanent, frequent, occasional, or absent.

Finally, the evolution of pain intensity, the use of analgesics, patients' complaints regarding the ventral approach and their ability to walk, sit, and work were recorded at each time point.

Statistical Analysis

Normal distribution of the variables was assessed with the nonparametric Kolmogorov-Smirnov test. Paired sample values were compared with the Wilcoxon test; the Mann-Whitney test was used for independent sample values. Statistical correlations were calculated by use of the Spearman rank correlation coefficient, while the chi-square test was used for binomial distribution. For statistical correlations of interval-scaled, normally distributed sample values the Pearson correlation coefficient was used. Statistical analysis was conducted using SPSS 14 (SPSS, Inc.).

Results

Of the 80 patients who met the initial inclusion criteria, 45 (56%) were still available for follow-up and could be examined after 5 years. Twenty-four patients (30%) lived too far away to come to our center for a follow-up examination, 8 (10%) refused examination for personal reasons, and 3 (4%) had died of causes unrelated to surgery. Statistical analysis revealed that there was no statistically significant difference among the demographic characteristics between patients initially included in the study and those available for the final 5-year follow-up evaluation.

Radiological Results

Preoperatively, the mean BKA was 8.9° (kyphosis). Through surgical treatment a significant correction of the BKA was obtained (mean correction −9.1°) (p < 0.001), since a lordotic BKA of a mean of −0.2° could be achieved. At the 5-year follow-up evaluation, a significant loss of correction was present (mean 2.6°) (p < 0.001), resulting in a mean remaining BKA correction of −6.5° compared with the preoperative BKA values. Most of the correction loss (mean 2.4°) as well as most of the cage subsidence and cage tilting occurred within the first 12 months postoperatively. There was no significant difference in these parameters between the 1- and 5-year follow-up examinations (Table 2). There was a significant correlation between cage subsidence, cage tilting, and loss of correction (p < 0.05).

TABLE 2:

Radiological data from 45 patients

VariablePreopOperative CorrectionPostop12 Mos Postop60 Mos PostopCorrection Loss60 Mos PostopRemaining Correction
BKA(°)8.9–9.1*–0.2*2.22.42.6–6.5
cage subsidence (mm)
 into cranial endplate02.12.2
 into caudal endplate01.92.1
cage tilting (°)
 in coronal plane01.51.5
 in sagittal plane02.42.5

p < 0.001 (compared to preoperative values).

p < 0.001 (compared to postoperative values).

No statistically significant difference (compared to 12-month postoperative values).

According to the aforementioned criteria, bony fusion was judged as complete in 41 (91%) patients (Fig. 4), with 35 patients (78%) demonstrating a visible bony bridge between the endplates. Four patients (9%) displayed only incomplete fusion signs but no signs of instability, since no cage showed a radiolucent line or instability in flexion/extension views.

Fig. 4.
Fig. 4.

A plain radiograph (A) and CT images (B and C) showing solid fusion 5 years after posterior stabilization and anterior corpectomy and cage insertion for treatment of a complete burst fracture of L-1.

Clinical Results

The mean age of the patients who completed the 5-year follow-up was 44 years at the time of surgery (range 28–67 years; 67% male, 33% female).

Complications

In the entire patient group (80 patients), 42 complications occurred, resulting in a rate of 52.5% (Table 3). The complication rate due to the posterior approach was 13%. The overall peri- and postoperative complication rate (in all 80 cases) due to the anterior approach was 37.5%, but most of the complications were not clinically significant. The rate of complications due to the thoracotomy itself was 26.25%. Transient pulmonary complications were most frequent (with an overall rate of 18.75%). Revision surgery (repeat thoracotomy) was needed in 1 case (1.25%) of an extensive thoracic seroma. No cage-related complications requiring revision surgery were recorded.

TABLE 3:

Perioperative complications in 80 patients

Category or ComplicationNo. of Cases%
operative complications of the ventral approach
 peritoneal injury (due to adhesions)22.5
postop complications
 paresis of phrenic nerve following thoracotomy w/ diaphragm-splitting11.25
 hematoma of thoracic wall w/ ventilation problems following thoracotomy22.5
 subsplenic hematoma11.25
 deep venous thrombosis22.5
 high need for transfusion11.25
 gastritis/gastrointestinal bleeding33.75
 renal insufficiency11.25
 cardiac rhythm disorders22.5
 pulmonary complications1518.75
  pneumonia45
  pleural effusion67.5
  seroma of the thorax (requiring re-thoracotomy)11.25
  recurrent sero-/pneumothorax11.25
  repeat pneumothorax after drainage removal22.5
  dystelectasis, incomplete lung expansion, requiring prolonged ventilation11.25
operative complications of the dorsal approach
 wound dehiscence45
 wound infection33.75
 wound seroma/hematoma33.75
 drain attachment*11.25
 iliac crest wound seroma11.25

In one case a drain was accidentally sewed to a deep tissue layer and the wound had to be reopened in order to remove the drain.

Neurological Status

Data on neurological status were available for 42 (93.3%) of the 45 patients who completed the 5-year follow-up evaluation. Upon admission 7 (16.7%) of these 42 patients were classified as having a complete paralysis (AIS Grade A). Three of these patients could not be examined properly due to the fact that they were already anesthetized. Their neurological status had been assessed by the emergency physician at the accident site. Five patients (12%) presented with an incomplete paralysis (AIS Grade B, C, or D), while 30 patients (71.4%) were neurologically intact (Table 4).

TABLE 4:

Neurological status of 42 patients

Preop AIS GradeAIS Grade at Last Follow-Up
ABCDE
A1012+1*2*
B00000
C00101
D00012
E000129

Patients with questionable preoperative neurological evaluation.

The status of the neurologically impaired patients improved by a mean of 1.9 grades in the AIS between preoperative status and last follow-up examination.

ODI Score

At the 1-year follow-up examination the mean ODI score was 12.5 (range 0–35).

At the 5-year follow-up examination it remained practically unchanged (mean ODI score 12, range 0–33).

Spinal Mobility

According to recorded results, spinal mobility tended to improve at the 5-year examination compared with the 1-year follow-up, but this improvement failed to reach statistical significance (p > 0.05) (Table 5). Overall, at 5 years postoperatively, patients showed only a minimal restriction of spinal range of motion.

TABLE 5:

Range of spinal mobility in 45 patients

Assessment12 Mos Postop60 Mos Postop
side bending (right-0-left)17°-0°-17°28°-0°-26°*
spinal rotation (right-0-left)26°-0°-26°42°-0°-36°*
finger-to-ground-distance (cm)1714*

No statistically significant difference (compared to 12-month postoperative values).

Pain Intensity and Progress

Pain evaluation with use of the VAS demonstrated an overall significant improvement between the 1- and the 5-year follow-up visit for back pain, buttock pain, and leg pain (p < 0.001).

At the final follow-up visit, 40 patients (89%) reported no or only occasional rest pain, while 31 (69%) reported no or only occasional stress pain.

In terms of overall pain at the 5-year follow-up compared with previous follow-up visit (usually the 1-year evaluation), 5 patients (11%) reported a deterioration, 15 (33.3%) described their pain as unchanged, 21 (46.7%) reported an improvement, while 4 (9%) claimed to be pain free.

Thirty-one patients (69%) did not use any analgesics at all and 10 (22%) used them only occasionally, while 4 (9%) needed oral analgesics on a regular basis.

Walking, Sitting, and Working Capability

At the 5-year examination, 43 patients (96%) were able to walk unassisted, while 1 patient needed support to ambulate and 1 patient was not ambulatory. All patients were able to sit.

Concerning the patients' ability to work, 27 (60%) were working, 3 (6.6%) were unemployed, 12 (26.6%) were retired, and 3 patients (6.6%) reported that they were unable to work.

Anterior Approach–Related Complaints

Thirty-one patients (69%) felt that their anterior scar was unattractive, while 6 patients (13.3%) reported paresthesias in the region and 8 (17.7%) complained of a mild ache after pressure was applied. Overall, almost one-third of the patients complained of some kind of anterior approach–related complications.

Discussion

Combined anteroposterior treatment of thoracolumbar fractures is advocated by several authors to improve fracture reduction and to minimize postoperative reduction loss.

According to our local treatment recommendations,37 we perform combined anteroposterior stabilization in burst fractures with severe comminution of the vertebral body and/or if local kyphosis exceeds 15°. The goals are to achieve anatomical reduction, long-lasting stability, and minor loss of reduction in the follow-up period. In cases of residual spinal stenosis after posterior stabilization, the anterior approach is further used to perform adequate decompression of the neural structures. The use of corpectomy cages for anterior reconstruction has significantly increased in the last years,1,8,9,14,26,28,39 tending to largely replace the use of autologous tricortical iliac graft, because of the cage's favorable biomechanical properties and the lack of donor-site morbidity, an issue traditionally associated with autologous iliac crest grafts.17,28 In a recent biomechanical study, the stiffness of titanium cages was similar to that of a fibular graft in a cadaveric model.5

The use of an anterior cage can significantly decrease the load on the posterior fixation system and avoid loosening or fatigue fracture of the screws,11,18 reduce the loss of anterior column height, and prevent secondary kyphotic deformity. There is evidence that anteroposterior treatment provides the most stable biomechanical solution for thoracolumbar vertebral traumas.3,11,19,25,26,36

In our study, an expandable titanium corpectomy cage was used for anterior column reconstruction following posterior reduction and stabilization. The cage was used to stabilize the anterior column but not for reduction, since anatomical reduction is difficult to achieve from an anterior approach and immediate cage subsidence may occur. In contrast to nonexpandable cages, expandable cages ease intraoperative handling and may reduce the operation time. However, correct positioning of nonexpandable cages can be challenging. Some distraction forces and shaping of the endplates may be necessary to insert a rigid implant. Even then, the position of the implant can be inadequate; endplates can weaken with consequent subsidence, and restoring sagittal alignment can be insufficient. One of the main advantages of expandable cages for vertebral body replacement is easy, nondistracted insertion of the cage. The height can be adjusted to the corpectomy defect in situ, and correction of deformity and restoration of height can be achieved.9

According to our results, bony fusion could be achieved in 91% of treated fractures, and there were no signs of a gross instability in any patient. These results are in concordance with existing literature, where high fusion rates are consistently reported, after anterior column reconstruction with corpectomy cages with or without posterior instrumentation.1,12

Although no significant instability was present in any of our patients and solid fusion could be achieved in most cases, we found a correction loss as well as subsidence and tilting of the cages (Fig. 4). These phenomena mainly occurred within the 1st postoperative year, when the whole construct “settles down,” reaching its final stable position. These objective expressions of cage subsidence are interdependent and their progression diminishes after the 1st year, with their values remaining practically unchanged between the 1- and 5-year follow-up assessments. This cage subsidence, which is often reported in the literature,1,4,14,39 appears to be an unavoidable effect, especially within the 1st postoperative year. In a recent study, a mean cage subsidence of 1.4 mm was documented in half of the studied population already after a mean follow-up period of 9 months.1 It seems that early cage subsidence causes a loss of tension within the stabilized construct, resulting in a decrease of the primary stability and an overload of the remaining load-bearing structures, especially the posterior fixator. Hence there appears to be a correlation between cage subsidence and postoperative loss of correction.32,35 Expandable cages carry the risk of overdistraction, because there is no clear sign to warn the surgeon to stop the expansion. In cases of posterior anatomical reduction with pedicle screws, further distraction is useless but it may lead to overdistraction of the segment and consequently to subsidence and tilting of the cage. Nevertheless, some authors reported a correlation between additional posterior instrumentation and reduced cage subsidence, although it failed to reach statistical significance.1,2 In a recent study, a loss of correction at a mean of 8° secondary to cage subsidence was reported when titanium corpectomy cages were solely used.16

Some kind of perioperative complication was reported for more than one-third of the patients, but none of these complications was life threatening, and reoperation was needed only in one patient. Existing literature provides varying data in this field, with studies reporting from rather high to very low rates of complications and reoperations.13,34

Concerning the clinical evaluation, the ODI, although not validated for spinal trauma, is widely accepted as being adequate for the clinical assessment of back problems and reproducible and sensitive enough to detect even minor changes that are clinically significant. In our study, as in the study of Salas et al.30 a satisfactory mean ODI score was already achieved at the 1-year follow-up and, unlike in other studies,16 it remained practically unchanged afterward. The spinal mobility of the examined patients tended to improve over time, but this improvement failed to reach statistical significance and was not reflected in the ODI score.

The reported rate of ability to return to work in our study is similar to rates in the existing literature.22,23 Since spinal fractures mainly involve younger patients usually lacking significant comorbidities, the reported rates are justified.

An interesting finding of our study was that almost one-third of our patients reported some kind of complaints related to the anterior approach, even 5 years postoperatively. It could be argued that this high incidence of anterior approach–related complaints represents a significant drawback of performing an anteroposterior stabilization of thoracolumbar fractures, taken into consideration that the superiority of such a treatment compared with a posterior-only approach still remains unclear. This is correct, but it should be pointed out that cage placement in this study population was performed via an open thoracotomy, which was our standard approach at that time. We believe that new anterior approaches, such as the video-assisted thoracoscopic approach, which has replaced open thoracotomy in our practice, will significantly contribute to reducing these approach-related complications. Comparative data from the area of thoracic surgery6,38 as well as early data from spinal surgery15,27 support this notion, by showing a significant reduction in complication rates for thoracoscopically assisted approaches in comparison with open thoracotomies, but these results must be validated in larger comparative studies from the area of spinal surgery. Posterior-only approaches for corpectomy and cage insertion have been recently described, but their potential advantages still remain unclear.16,24,31

Our study also has some disadvantages. First of all, the relatively low percentage (56%) of the patients able to complete the 5-year follow-up might raise some questions concerning the results of the study. Secondly, the overall number of patients participated in our study is not that large, but it is comparable to the numbers of patients in similar studies reported in the literature.

Another limitation involves the preoperative assessment of neurological deficits in some patients. The excellent neurological recovery of some patients may be due to an inadequate preoperative neurological examination. However, we believe that early decompression and stabilization should be performed in any patient with a thoracolumbar burst fracture presenting with neurological deficits.10 Indications to perform surgery in trauma differ widely. The need for additional anterior support, in particular, is a matter of ongoing discussion. It is likely that in other geographical regions, some of our patients would have been treated with posterior stabilization only. Since no comparative studies are available, the decision whether to perform an additional anterior stabilization mainly depends on the surgeon's experience, local treatment recommendations, and biomechanical considerations.

Since the anterior approach carries an increased risk of additional complications, our study does not provide further evidence for a clinical benefit of additional anterior treatment.

Among the strengths of this study is the increased homogeneity of the studied population. All patients initially underwent dorsal surgery, followed by an anterior corpectomy, in which a single cage type was inserted in all cases. Reported results on the use of corpectomy cages, usually refer to inhomogeneous case series with various indications (trauma, tumor, degenerative) for surgery, various corpectomy localization (cervical, thoracic, lumbar), and use of various surgical procedures (anterior, anteroposterior)34 and implants,30 or have quite small patient's numbers.31 To our knowledge, this is the first report of long-term results of a single-center homogeneous case series of anteroposteriorly stabilized thoracolumbar fractures, where corpectomy cages were used. Furthermore, it is a prospective study with a relatively long duration of follow-up and used CT scans and strict criteria for the evaluation of fusion.

Conclusions

Our results demonstrate that anteroposterior instrumentation of unstable thoracolumbar fractures with the use of a titanium expandable cage for anterior reconstruction following anterior corpectomy is a safe and effective procedure. A significant correction of kyphotic deformity and high fusion rates could be achieved. Furthermore, a successful clinical result was obtained early and was sustained and slightly improved over the 5-year follow-up period.

The relatively high complication rate resulting from thoracotomy may improve through application of less-invasive thoracoscopic procedures. With the classic open thoracotomy approach however, a postoperative thoracotomy syndrome should be expected in about one-third of the patients.

Disclosure

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author contributions to the study and manuscript preparation include the following. Conception and design: Schnake, Kandziora. Acquisition of data: Schnake, Stavridis. Analysis and interpretation of data: all authors. Drafting the article: Schnake, Stavridis. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Schnake. Statistical analysis: Schnake, Stavridis. Study supervision: Kandziora.

This article contains some figures that are displayed in color online but in black-and-white in the print edition.

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  • 23

    McLain RFBurkus JKBenson DR: Segmental instrumentation for thoracic and thoracolumbar fractures: prospective analysis of construct survival and five-year follow-up. Spine J 1:3103232001

  • 24

    Mouchaty HConti RConti PDesogus NMaleci ADi Lorenzo N: A one-session circumferential reconstruction in thoracic and lumbar spine fractures using a small expandable cage. J Neurosurg Sci 52:1011062008

  • 25

    Oxland TRLund T: Biomechanics of stand-alone cages and cages in combination with posterior fixation: a literature review. Eur Spine J 9:1 Suppl 1S95S1012000

  • 26

    Payer M: Unstable burst fractures of the thoraco-lumbar junction: treatment by posterior bisegmental correction/fixation and staged anterior corpectomy and titanium cage implantation. Acta Neurochir (Wien) 148:2993062006

  • 27

    Ragel BTAmini ASchmidt MH: Thoracoscopic vertebral body replacement with an expandable cage after ventral spinal canal decompression. Neurosurgery 61:5 Suppl 23173232007

  • 28

    Reinhold MKnop CBeisse RAudigé LKandziora FPizanis A: Operative treatment of 733 patients with acute thoracolumbar spinal injuries: comprehensive results from the second, prospective, Internet-based multicenter study of the Spine Study Group of the German Association of Trauma Surgery. Eur Spine J 19:165716762010

  • 29

    Robertson PARawlinson HJHadlow AT: Radiologic stability of titanium mesh cages for anterior spinal reconstruction following thoracolumbar corpectomy. J Spinal Disord Tech 17:44522004

  • 30

    Salas NPrébet RGuenoun BGayet LEPries P: Vertebral body cage use in thoracolumbar fractures: outcomes in a prospective series of 23 cases at 2 years' follow-up. Orthop Traumatol Surg Res 97:6026072011

  • 31

    Sasani MOzer AF: Single-stage posterior corpectomy and expandable cage placement for treatment of thoracic or lumbar burst fractures. Spine (Phila Pa 1976) 34:E33E402009

  • 32

    Schmieder KWolzik-Grossmann MPechlivanis IEngelhardt MScholz MHarders A: Subsidence of the wing titanium cage after anterior cervical interbody fusion: 2-year follow-up study. J Neurosurg Spine 4:4474532006

  • 33

    Schnee CLAnsell LV: Selection criteria and outcome of operative approaches for thoracolumbar burst fractures with and without neurological deficit. J Neurosurg 86:48551997

  • 34

    Smith WDDakwar ELe TVChristian GSerrano SUribe JS: Minimally invasive surgery for traumatic spinal pathologies: a mini-open, lateral approach in the thoracic and lumbar spine. Spine (Phila Pa 1976) 35:S338S3462010

  • 35

    Steffen TTsantrizos AAebi M: Effect of implant design and endplate preparation on the compressive strength of interbody fusion constructs. Spine (Phila Pa 1976) 25:107710842000

  • 36

    Ulmar BErhart SUnger SWeise KSchmoelz W: Biomechanical analysis of a new expandable vertebral body replacement combined with a new polyaxial antero-lateral plate and/or pedicle screws and rods. Eur Spine J 21:5465532012

  • 37

    Verheyden APHölzl AEkkerlein HGercek EHauck SJosten C: [Recommendations for the treatment of thoracolumbar and lumbar spine injuries.]. Unfallchirurg 114:9162011. (Ger)

  • 38

    Villamizar NRDarrabie MDBurfeind WRPetersen RPOnaitis MWToloza E: Thoracoscopic lobectomy is associated with lower morbidity compared with thoracotomy. J Thorac Cardiovasc Surg 138:4194252009

  • 39

    Xu JGZeng BFZhou WKong WQFu YSZhao BZ: Anterior Z-plate and titanic mesh fixation for acute burst thoracolumbar fracture. Spine (Phila Pa 1976) 36:E498E5042011

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Article Information

Address correspondence to: Klaus John Schnake, M.D., Zentrum für Wirbelsäulentherapie, Schön Klinik Nürnberg Fürth, Europa-Allee 1, Fürth 90763, Germany. email: kschnake@schoen-kliniken.de.

Please include this information when citing this paper: published online March 7, 2014; DOI: 10.3171/2014.1.SPINE13246.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Lateral radiograph showing the bisegmental kyphosis angle (BKA) as measured by the Cobb method. The BKA was measured on plain lateral radiographs and in flexion-extension views.

  • View in gallery

    Lateral radiograph illustrating the method for calculating cage subsidence. The long double-headed arrow indicates the distance measured along the longitudinal axis of the cage.

  • View in gallery

    Lateral radiograph showing the method for calculating cage tilting. The angle was calculated based on measurements in both the lateral and the anteroposterior view. The resulting angles were used for calculating sagittal and coronal tilting, respectively.

  • View in gallery

    A plain radiograph (A) and CT images (B and C) showing solid fusion 5 years after posterior stabilization and anterior corpectomy and cage insertion for treatment of a complete burst fracture of L-1.

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Korovessis PBaikousis AZacharatos SPetsinis GKoureas GIliopoulos P: Combined anterior plus posterior stabilization versus posterior short-segment instrumentation and fusion for mid-lumbar (L2–L4) burst fractures. Spine (Phila Pa 1976) 31:8598682006

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McLain RFBurkus JKBenson DR: Segmental instrumentation for thoracic and thoracolumbar fractures: prospective analysis of construct survival and five-year follow-up. Spine J 1:3103232001

24

Mouchaty HConti RConti PDesogus NMaleci ADi Lorenzo N: A one-session circumferential reconstruction in thoracic and lumbar spine fractures using a small expandable cage. J Neurosurg Sci 52:1011062008

25

Oxland TRLund T: Biomechanics of stand-alone cages and cages in combination with posterior fixation: a literature review. Eur Spine J 9:1 Suppl 1S95S1012000

26

Payer M: Unstable burst fractures of the thoraco-lumbar junction: treatment by posterior bisegmental correction/fixation and staged anterior corpectomy and titanium cage implantation. Acta Neurochir (Wien) 148:2993062006

27

Ragel BTAmini ASchmidt MH: Thoracoscopic vertebral body replacement with an expandable cage after ventral spinal canal decompression. Neurosurgery 61:5 Suppl 23173232007

28

Reinhold MKnop CBeisse RAudigé LKandziora FPizanis A: Operative treatment of 733 patients with acute thoracolumbar spinal injuries: comprehensive results from the second, prospective, Internet-based multicenter study of the Spine Study Group of the German Association of Trauma Surgery. Eur Spine J 19:165716762010

29

Robertson PARawlinson HJHadlow AT: Radiologic stability of titanium mesh cages for anterior spinal reconstruction following thoracolumbar corpectomy. J Spinal Disord Tech 17:44522004

30

Salas NPrébet RGuenoun BGayet LEPries P: Vertebral body cage use in thoracolumbar fractures: outcomes in a prospective series of 23 cases at 2 years' follow-up. Orthop Traumatol Surg Res 97:6026072011

31

Sasani MOzer AF: Single-stage posterior corpectomy and expandable cage placement for treatment of thoracic or lumbar burst fractures. Spine (Phila Pa 1976) 34:E33E402009

32

Schmieder KWolzik-Grossmann MPechlivanis IEngelhardt MScholz MHarders A: Subsidence of the wing titanium cage after anterior cervical interbody fusion: 2-year follow-up study. J Neurosurg Spine 4:4474532006

33

Schnee CLAnsell LV: Selection criteria and outcome of operative approaches for thoracolumbar burst fractures with and without neurological deficit. J Neurosurg 86:48551997

34

Smith WDDakwar ELe TVChristian GSerrano SUribe JS: Minimally invasive surgery for traumatic spinal pathologies: a mini-open, lateral approach in the thoracic and lumbar spine. Spine (Phila Pa 1976) 35:S338S3462010

35

Steffen TTsantrizos AAebi M: Effect of implant design and endplate preparation on the compressive strength of interbody fusion constructs. Spine (Phila Pa 1976) 25:107710842000

36

Ulmar BErhart SUnger SWeise KSchmoelz W: Biomechanical analysis of a new expandable vertebral body replacement combined with a new polyaxial antero-lateral plate and/or pedicle screws and rods. Eur Spine J 21:5465532012

37

Verheyden APHölzl AEkkerlein HGercek EHauck SJosten C: [Recommendations for the treatment of thoracolumbar and lumbar spine injuries.]. Unfallchirurg 114:9162011. (Ger)

38

Villamizar NRDarrabie MDBurfeind WRPetersen RPOnaitis MWToloza E: Thoracoscopic lobectomy is associated with lower morbidity compared with thoracotomy. J Thorac Cardiovasc Surg 138:4194252009

39

Xu JGZeng BFZhou WKong WQFu YSZhao BZ: Anterior Z-plate and titanic mesh fixation for acute burst thoracolumbar fracture. Spine (Phila Pa 1976) 36:E498E5042011

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