Thoracolumbar Burst Fractures: A Systematic Review and Meta-Analysis Comparing Posterior-Only Instrumentation Versus Combined Anterior-Posterior Instrumentation.

ABSTRACT

STUDY DESIGN: Meta-analysis. OBJECTIVE: To compare the clinical, functional, and radiological outcomes of posterior-only versus combined anterior-posterior instrumentation in order to determine the optimal surgical intervention for thoracolumbar burst fractures. SUMMARY OF BACKGROUND DATA Unstable thoracolumbar burst fractures warrant surgical intervention to prevent neurological deterioration and progressive kyphosis, which can lead to significant pain and functional morbidity. The available literature remains largely inconclusive in determining the optimal instrumentation strategy. METHODS: Electronic searches of MEDLINE (1948-May 2020), EMBASE (1947-May 2020), The Cochrane Library (1991-May 2020), and other databases were conducted. Cochrane Collaboration guidelines were used for data extraction and quality assessment. Outcomes of interest were divided into three categories radiological (degree of postoperative kyphosis correction; loss of kyphosis correction at final follow-up), functional (visual analogue scale [VAS] pain score; Oswestry Disability Index [ODI] score), and clinical (intraoperative blood loss; length of stay [LOS]; operative time; the number and type of postoperative complications). RESULTS: Four randomized control trials (RCTs) were retrieved, including 145 randomized participants. Seventy-three patients underwent posterior-only instrumentation and 72 underwent combined instrumentation. No significant difference was found in the degree of postoperative kyphosis correction (P = 0.39), VAS (centimeters) at final follow-up (P = 0.67), ODI at final follow-up (P = 0.89) or the number of postoperative complications between the two approaches (P = 0.49). Posterior-only instrumentation was associated with lower blood loss (P < 0.001), operative time (P < 0.001), and LOS (P = 0.01). Combined instrumentation had a lower degree of kyphosis loss at final follow-up (P = 0.001). There was heterogeneity in the duration of follow-up between the included studies (mean follow-up range 24-121 months). CONCLUSION: The available literature remains largely inconclusive. In order to reliably inform practice in this area, there is a need for large, high-quality, multicenter RCTs with standardized reporting of outcomes, with a particular focus on outcomes relating to patient function and severe complications causing long-term morbidity.Level of Evidence 2.