Comparison of anterolateral and posterior approaches in the management of thoracolumbar burst fractures

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The authors undertook a retrospective cohort study of patients with T11–L2 thoracolumbar burst fractures who underwent decompression and the placement of instrumentation via the anterolateral or posterior approach.


There were 63 thoracolumbar burst fractures in 45 male and 18 female patients. The instrumentation was placed posteriorly in 25 patients and anterolaterally in 38. The mean follow-up duration after discharge from the hospital was 1.8 years (range 6 months–8 years).

The mean preoperative Frankel scores in the anterolateral and posterior groups were 3.7 ± 1.1 and 3.5 ± 1.4, respectively (p = 0.4155). Preoperative angular deformity in the anterolateral and posterior groups measured 11.9 ± 9.7 and 4.1 ± 7.1°, respectively (p = 0.0007). Postoperatively, angular deformity had been corrected to 2.0 ± 7.9 and 3.4 ± 7.5° in both groups, respectively (p = 0.565). The follow-up Frankel scores had improved to 4.2 ± 0.8 and 4.0 ± 1.4 (p = 0.461). At the latest follow-up examination, angular deformity had progressed to 4.5 ± 9.3° in the anterolateral group and to 9.8 ± 9.4° in the posterior group (p = 0.024).

Although surgeons’ fees were significantly (p = 0.0024) higher for patients who underwent anterolateral procedures ($27,940 ± 4390) than for those who underwent posterior surgery ($18,270 ± 6980), there was no intergroup difference in total cost of hospitalization.


Rigid guidelines for the selection of anterior or posterior approaches are lacking. Evaluation of the authors’ results and those of others shows that angular deformity is more successfully corrected and maintained when the anterior approach is used.

Abbreviations used in this paper:AP = anteroposterior; CFC = carbon fiber cage; CT = computed tomography; MR = magnetic resonance; PS = pedicle screw; SF-36 = 36-Item Short Form Health Survey; VB = vertebral body.

Article Information

Address reprint requests to: Patrick W. Hitchon, M.D., Department of Neurosurgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, Iowa 52240. email:

© AANS, except where prohibited by US copyright law.



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    Bar graph showing the distribution of thoracolumbar burst fractures by level in both anterior and posterior surgical groups.

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    The posterior approach. Studies obtained in a 47-year-old man who fell off a grain truck and sustained an L-1 burst fracture. He was neurologically intact but complained of back and hip pain. A: Plain lateral radiograph revealing significant VB height loss and canal compromise. B: Axial CT scan showing canal narrowing, retropulsion of bone, and increase in interpedicular distance. C: Sagittal T2-weighted MR image demonstrating cauda equina compression. Three days following his injury, the patient underwent placement of posterior instrumentation comprising PSs, hooks, and an iliac crest graft. D and E: Five-year follow-up plain AP (D) and lateral (E) radiographs showing a solid fusion at T-12, L-1, and L-2. The rostral hooks are dislodged but stable. The patient remains neurologically intact but is disabled from pain.

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    The anterolateral approach. Studies obtained in a 47-year-old man who fell off a horse and sustained an L-2 burst fracture. A: Plain lateral radiograph showing loss in VB height and retropulsion of bone into the canal. B: Axial CT scan obtained through the fracture showing the compromised canal with a 40% residual AP dimension. C: Sagittal T2-weighted MR image demonstrating retropulsion of bone and the compromised canal. D and E: To decompress the canal, a left-sided flank approach was selected for an L-2 corpectomy, anterior CFCs containing autologous strut graft, and lateral dual rod–screw fixation, as seen in the AP (D) and lateral (E) projections. Angulation was corrected from 0° on admission to −14° 10 months after surgery.

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    Bar graph showing deformity angles at admission, discharge, and latest follow up in the anterior (black bars) and posterior (white bars) instrumentation groups. Values on the y axis reflect degrees. The asterisks denote statistical significance (p < 0.05).

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    Bar graph showing preoperative and follow-up Frankel scores (y axis). At follow up, improvement in Frankel scores is noted irrespective of the approach (p > 0.05). The difference in Frankel scores between the two groups is not significant on admission or at follow up; however, the improvement in the Frankel score was significant within each group—anterolateral (p = 0.0009; black bars) and posterior (p = 0.004; white bars).

  • View in gallery

    Bar graph illustrating the distribution of mean SF-36 scores obtained in 22 patients who underwent anterolat-eral surgery (black bars) and 18 patients who underwent posterior surgery (white bars). No significant intergroup difference in scores is noted.

  • View in gallery

    Bar graph showing operating room charges, surgeon’s fee, implant cost, and total hospital charges. Asterisk indicates statistically significant difference. Black bars = anterior surgery; white bars = posterior surgery.



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