The Open Orthopaedics Journal, 2010, 4, 7-13 7

Open Access
Treatment of Unstable Thoracolumbar Burst Fractures by Indirect
Reduction and Posterior Stabilization: Short-Segment Versus Long-
Segment Stabilization
George Sapkas1, Konstantinos Kateros2, Stamatios A. Papadakis*,3, Emmanouel Brilakis2,
George Macheras3 and Pavlos Katonis4

1
A’ Department of Orthopaedics, Medical School of Athens University, Athens, Greece
2
B’ Department of Orthopaedics, Medical School of Athens University, Athens, Agia Olga General Hospital, Greece
3
D’ Department of Orthopaedics, “KAT” General Hospital, Kifissia, Greece
4
Orthopaedic Department, University of Crete, Herakleion, Greece

Abstract: In order to compare short-segment stabilization with long-segment stabilization for treating unstable
thoracolumbar fractures, we studied fifty patients suffered from unstable thoracolumbar burst fractures. Thirty of them
were managed with long-segment posterior transpedicular instrumentation and twenty patients with short-segment
stabilization. The mean follow up period was 5.2 years. Pre-operative and post-operative radiological parameters, like the
Cobb angle, the kyphotic deformation and the Beck index were evaluated. A statistically significant difference between
the two under study groups was noted for the Cobb angle and the kyphotic deformation, while, as far as the Beck index is
concerned, no significant difference was noted. In conclusion, either the long-segment or the short-segment stabilization is
able for reducing the segmental kyphosis and the vertebral body deformation postoperatively. However, as time goes by,
the long-segment stabilization is associated with better results as far as the radiological parameters, the indexes and the
patient’s satisfaction are concerned.
Keywords: Transpedicular instrumentation, short-segment, long-segment, radiological parameters, spine.

INTRODUCTION The current study is based on the operative treatment of a

single type of fractures (fractures classified as AO “A3.3”).
The restoration of the vertebral column stability and the
The particular question addressed by this study was whether
decompression of the spinal canal are the goals of the
LS posterior stabilization gives significantly better results
treatment of thoracolumbar fractures. Earlier mobilization of
comparing to SS stabilization.
the patient is the profit when they are achieved. By leaving
uninjured segments intact, transpedicular constructs diminish MATERIALS AND METHODOLOGY
the number of segments stabilized and fused, preserving the
Fifty patients operated for unstable thoracolumbar burst
maximal thoracolumbar motion.
fractures were reviewed as part of a prospective randomized
It has been demonstrated that short-segment (SS) study. Indirect reduction and stabilization was performed
instrumentation is associated with an unacceptable rate of using the Miami-Moss system (DePuy Orthopaedics, Inc.,
failure [1]. The highest rate of the instrumentation failure USA). Long-segment posterior transpedicular instrumenta-
resulting in re-kyphosis of the entire segment is associated tion combined with short-segment fusion was performed in
with SS posterior reduction and stabilization of burst 30 cases and short-segment stabilization and fusion in 20
fractures showing the inadequacy of the SS transpedicular cases.
instrumentation used for the treatment of thoracolumbar and
Patients with pathological fractures or multilevel injuries
lumbar fractures [2]. Bent screws and kyphosis did not
were excluded from the study. In addition, patients who were
always herald a clinical failure, but patients who have
kyphosis more than 10 degrees even if it is progressively managed with a delay of 10 days or more were also excluded
of this study. The most common level of injury was L1 (n =
increased, feel substantially more pain that those who have
25) and T12 (n = 18) as seen in Table 1.
little or no loss of correction of the fractured vertebral body
[3]. Significant correction loss and failure was also found in The mean patients’ age was 32 years old (13-55 years
long-segment (LS) instrumentation [2]. old) and the leading cause of the fracture was motor vehicle
accidents followed by occupational injuries (Table 1). The
pre-operative evaluation included computed tomography
*Address correspondence to this author at the D' Department of (CT) scanning of the spine. Twenty-five patients were
Orthopaedics, "KAT" General Hospital 2, Nikis Str, 14561 Kifissia, Greece; evaluated additionally with magnetic resonance imaging
Tel: +30 6944 297086; Fax: +30 210 61 37 145; (MRI). All fractures were classified as AO “A3.3” which
E-mail: [email protected]

1874-3250/10 2010 Bentham Open

8 The Open Orthopaedics Journal, 2010, Volume 4 Sapkas et al.

characterized by at least partial comminution of the vertebral the fractured vertebra. Autologous graft or frozen femoral
body with centrifugal extrusion of the fragments [4]. heads was the most used grafts. All patients were managed
postoperatively with immobilization in a custom-molded
Patients were divided into two groups. The first group
thoraco-lumbo-sacral brace for three months.
included 20 patients (12 males and 8 females) who had been
managed with SS pedicle instrumentation constructs Radiographic and clinical outcome of 50 patients who
spanning two vertebrae, one cephalad and one caudal to the was operated due to a thoracolumbar burst fracture was
fracture (Fig. 1a, b). The mean follow up for this group was evaluated. The Low Back Outcome Score (LBOS) was used
34 months (range, 25-70 months). for the clinical evaluation of the patients [3]. According to
Table 1. Causes and Location of the Spinal Fractures
LBOS, overall scores can vary from 0 (very disabled) to 75
Treated Operatively – Additional Lesions (not at all disabled). The patients were placed in one of four
outcome categories depending on their overall pure scores:
65 or higher (excellent), 50-64 (good), 30-49 (fair), 29 or
Cause of Accident
lower (poor). Neurological recovery or functional result,
Automobile 28 were not objectives of this study.
Occupational 11 Radiographic Measurements
Motorcycle 8 Patients were followed up with physical examination and
Horse 3 X-Ray imaging using a lateral radiograph cantered on the
fracture level. Progressive deformity was considered as the
Location of the Fracture
change of the sagittal alignment of the spine comparing the
T11 6 initial post-operative weight-bearing radiograph to the most
recent radiograph of the follow up. This progression was
Two pts also presented with a L3
T12 16
vertebral body burst fracture considered to be absent, minor, or major. A 5 to 10 degrees
increase of the kyphosis was defined as minor progression;
L1 23 an increase of more than 10 degrees was defined as major
L2 5 progression. Successful instrumentation was considered
when solid fusion without progressive deformity or failure of
Additional Lesions
the implant was achieved. Failure or bending of the implant,
Long Bone Fracture 9 or development of major kyphosis before fusion was
occurred, were considered as failure of the fixation
Other Fractures 6
regardless of the duration of the follow-up.
Rib Fractures 5
All the radiographic measurements were taken
Concussion 4 preoperatively (pre-op), postoperatively (post-op) and at the
Heart Contusion 2 time of latest follow up, except for the intervertebral motion,
which was measured only at the follow-up. Local kyphosis
Lung Contusion 2 angle of the vertebral body (Cobb angle) was measured as
Without Other Lesions 23 the angle between the superior and the inferior vertebral
endplate. Segmental kyphosis was measured as the angle
between the inferior endplate of the superior adjacent
The second group included 30 patients (20 males and 10 vertebral endplate and the superior endplate of the inferior
females) who had been managed with LS pedicle adjacent vertebra. This method of measurements
instrumentation constructs (Fig. 2a, b). In this group the incorporates both discs in the instrumented spine section.
instrumentation spanned four vertebrae, two cephalad and Overall disc height was defined as the average of anterior
two caudal to the fracture. The mean follow up of this group and posterior disc height (Beck index). Follow-up
was 36 months (range, 24-72 months). In two cases a long measurements were expressed in relation to disk height
instrumentation construct was applied to stabilize both a immediately after the operation.
thoracic (T12) fracture and a lumbar L3 fracture.
Statistical Analysis
Screws which were used were forty or forty-five
millimeters long depending on the level and size of the All analyses were conducted using the SPSS, version
vertebra. Screws with diameter five and a half millimeters 11.00 (SPSS Inc., Chicago, IL, USA). Two-factor mixed
were used caudally to the eleventh thoracic vertebrae level. factorial ANOVA was used to examine the interaction
The instrumentation was applied bilaterally and cross-links between the type of stabilization factor and time factor. One
(transverse traction devices) were placed cephalad and factor Repeated Measures ANOVA model was used for the
caudal to the fracture in order to augment the torsional comparison of different time measurement of radiological
rigidity. Laminectomies were performed in 10 patients with parameters for each group. Pair wise multiple comparisons
SS screw constructs and in 15 patients with LS screw were performed using the method of Tukey critical
constructs. Laminectomy performed in cases with severe difference. The percentage change of some parameters
neurological deficit (Frankel A, B, C), in order either to comparing them with the preoperative values was analysed
excise the retropulsed bone fragments or the disc remnants using the Mann-Whitney test. The mean absolute change
from the spinal canal or to push them back into the vertebral observed between preoperative, postoperative and the latest
body. Grafts have been used one level above and one below follow up values was statistically analysed by means of
Short vs Long Segment Stabilization The Open Orthopaedics Journal, 2010, Volume 4 9

analysis of covariance using as dependent variable the Table 3. Summary of Radiographic Data
absolute change of preoperative radiological parameters and
follow up measurements as covariates. In addition, 95%  Subgroup 1 - Short-segment Pedicle Instrumentation
confidence intervals for pair wise differences between types
of stabilization means were calculated. Comparison of Index Checkpoint Mean Min Max
categorical data between groups was performed using chi-
square test. The level of statistical significance was set at p < Pre-op 17 8 29
0.05. Cobb angle Post-op 5 0 9
RESULTS Follow-up 8.5 1 22
Patient demographic data is summarized in Table 2. Pre-op 4 1 13
There is no significant difference between the two groups Kyphotic deformation
concerning age and gender (p = N.S). The average operative Post-op -9 -20 +5
of the vertebral body
time was 170min (Range, 140-220min) and the average Follow-up 4.5 -3.5 24
blood loss was 1050ml (Range, 350-1800ml) for the SS
Pre-op 0.60 0.38 0.70
pedicle instrumentation and 220min (Range, 190-300min)
and 1200ml (Range, 550-2100ml) for the LS pedicle Vertebral height (Beck Index) Post-op 0.92 0.60 1.00
instrumentation respectively. There is a statistically Follow-up 0.90 0.55 1.00
significant difference between the two groups as far as the
duration of operation and the blood loss are concerned (p <
0.005). On the opposite, comparing the LBOS between the
 Subgroup 2 - Long-Segment Pedicle Instrumentation
two groups no significant difference is found (p = N.S).
There is homogeneity between the SS pedicle Index Checkpoint Mean Min Max
instrumentation versus LS pedicle instrumentation of LBOS
four categories: Poor, (5% vs 0%); Fair, (30% vs 30%); Pre-op 17.5 9 30
Good, (45% vs 53.3%); Excellent, (20% vs 16.7%). Cobb angle Post-op 3 0 8

Table 2. Demographic Data of the Patients Follow-up 6 0 10

Pre-op 9.5 -3 21
Kyphotic deformation
Group 1 SS Group 2 LS of the vertebral body Post-op -8 -18 +2
Follow-up 40 -10 190
Number of patients 20 30
Pre-op 0.60 0.40 0.82
Median age (years) 33 (13-52) 35 (17-55)
Vertebral height (Beck Index) Post-op 0.94 0.65 1.00
Male/Female 12/8 20/10
Follow-up 0.92 0.70 1.00

The summary of radiographic data preoperatively,

postoperatively, and at the latest follow-up for the group 1 The same method was used in order to study the kyphotic
(Short-segment pedicle instrumentation) and the group 2 deformation. Thus, using the two-way mixed ANOVA
(Long-segment pedicle instrumentation) are presented in model and comparing this variable for the two types of
Table 3. stabilization at each time point, a statistically significant
difference (p < 0.0005) is found for the LS instrumentation
Table 4 shows the three under comparison variances group at the latest follow-up. Mann-Whitney test used in
(Cobb angle, kyphotic deformation and Beck index) order to compare the median percentage change of the
preoperatively, postoperatively and at the latest follow-up for kyphotic deformation between the two different types of
each group separately and their fluctuation from stabilization from preoperatively to postoperatively and from
preoperatively to postoperatively and preoperatively to the preoperatively to the latest follow-up. A statistically
latest follow-up. Table 4 also shows the comparison of these significant difference is observed for the LS group only from
variances between the groups. preoperative to the latest follow-up (p < 0.0005).
The two types of stabilization are compared in relation to The third variable studied is the Beck index. Thereby, the
the Cobb angle at each time point using the two-way mixed two types of stabilization are compared using the two-way
ANOVA model. There is a statistically significant difference mixed ANOVA model at each time point, but there is no
for the Cobb angle between the two types of stabilization statistically significant difference of this index at any point
postoperatively (p = 0.051). The percentage change of the studied (preoperatively, postoperatively and at the latest
Cobb angle between these types of stabilization from follow-up). Moreover, there is no statistically significant
preoperatively to postoperatively and from preoperatively to difference when the percentage change of the Beck index for
the latest follow-up was examined using the Mann-Whitney each type of stabilization is compared, using the Mann-
test. As far as this percentage change is concerned, there is a Whitney test, neither from preoperatively to postoperatively
statistically significant difference between these two types of nor from preoperatively to the latest follow-up.
stabilization from preoperatively to the latest follow-up (p =
0.03), but there is no statistically significant difference from Eventually, the absolute change for each variable is
preoperatively to postoperatively. presented in Table 5. The change of each index from
10 The Open Orthopaedics Journal, 2010, Volume 4 Sapkas et al.

Table 4. Cobb Angle, Kyphotic Deformation and Beck Index Preoperatively, Postoperatively and at the Latest Follow-Up, for
Short-Segment and Long-Segment Instrumentation Group. The Change of the Variables is Compared Between the Two
Groups of Patients

Cobb Angle Kyphotic Deformation Beck Index

Mean SD p-Value Mean SD p-Value Mean SD p-Value

PRE-OP

Short-segment 17.0 7.0 4 9 0.6 0.1

N.S N.S N.S
Long-segment 17.5 6.8 4.5 8 0.6 0.1
POST-OP
Short-segment 5.0 3.5 -9 4 0.92 0.2
0,051 N.S N.S
Long-segment 3.0 2.0 -8 4 0.94 0.2
FOLLOW-UP
Short-segment 8.5 6.0 4.5 4 0.90 0.2
.S < 0.0005 N.S
Long-segment 6.0 4.0 40 15 0.92 0.2

Cobb angle Kyphotic deformation Beck index

Median (%) p-Value Median (%) p-Value Median (%) p-Value

Comparison between pre-op and post-op

Short-segment -70,6% -330% -53%
.S .S .S
Long-segment -82,9% -277% -56%
Comparison between pre-op and follow-up
Short-segment -50% 11% -50%
0.03 < 0.0005 .S
Long-segment -65,7% 788% -49%

preoperatively to postoperatively and from preoperatively to comparing the absolute change of the kyphotic deformation
the latest follow-up is compared for each type of between the two under study groups, a statistically
stabilization, considering the preoperative measurement as significant difference for the LS group from preoperatively
covariate and using the analysis of covariance model. As far to the latest follow-up (p < 0.0005) is ascertained, but no
as the Cobb angle is concerned, a statistically significant statistically significant difference from preoperatively to
difference exists between the two groups, from postoperatively be noted. Likewise, there is also no
preoperatively to the latest follow-up (p = 0.04) but there is statistically significant difference between the two groups
no respective difference between the preoperative value to comparing the absolute change of the Beck index with the
the postoperative one. Using the same analysis model and analysis model mentioned above.

Table 5. Change of the Absolute Value of Cobb Angle, Kyphotic Deformation and Beck Index a) from Preoperatively to
Postoperatively and b) from Preoperatively to the Latest Follow-Up, Considering the Preoperative Measurement as
Covariate and Using the Analysis of Covariance Model

Pre-Op vs Post-Op Pre-Op vs Follow-Up

Adjusted Mean Change-95%CI p-value Adjusted Mean Change-95%CI p-Value

Cobb angle
Short-segment -11.88 (-15.6/-7.3 ) -8.3 (-5.1/-11.6)
N.S 0.04
Long-segment -14.1 (-10.1/-18.2) -11 (-7.4/-14.6)
Kyphotic deformation
Short-segment -13,2 (-18.2 /-8.2) 0,5 (-2 /+3)
N.S <0.0005
Long-segment -12,7 (-18.5/-6.3) 35 (-5 /+75)
Beck index
Short-segment 0,31 (0,2/0,4) 0,30 (0,2/0,4)
N.S N.S
Long-segment 0,32 (0,2/0,4) 0,31 (0,2/0,4)
Short vs Long Segment Stabilization The Open Orthopaedics Journal, 2010, Volume 4 11

(a) (a)

(b) (b)

Fig. (1). (a, b) Anteroposterior and lateral radiographs showing a Fig. (2). (a, b). Anteroposterior and lateral radiographs showing a
Short-segment instrumentation system. Long-segment instrumentation system.
12 The Open Orthopaedics Journal, 2010, Volume 4 Sapkas et al.

In terms of the implant failure, three screws (three instrumentation that used in this study is the immediate
patients) were broken and four screws (four patients) were mobilization of patients with less dependence on bracing, the
bent in the SS segment group. On the opposite, in the LS distribution of corrective forces over multiple levels and the
pedicle instrumentation group, no implant failure was reduction of the likelihood of implant failure, which is a
observed. The vast majority of the patients refused to remove common complication of Harrington rod constructs.
the implants. Six patients had their instrumentation removed
Serin et al. [1], reported that four levels posterior fixation
after an average of 2 years (range 9 to 35 months) after the
is superior to two levels posterior fixation and that this
accident. No other complication was occurred.
fixation is more stable when using an accessory offset hook.
DISCUSSION Tezeren et al. [26] demonstrated that final outcome
regarding sagittal index and anterior body compression is
It is widely accepted that thoracolumbar burst fractures better in the LS instrumentation group than in the SS
should be addressed surgically [6-13]. The goals of the instrumentation group.
treatment of thoracolumbar fractures, regardless of the
selected method, are the restoration of the stability of the The aim of the current study is to compare the SS
vertebral column and the decompression of the spinal canal, fixation to LS fixation as far as the surgical correction is
leading to earlier mobilization of the patient. However, the concerned. These surgical methods were compared using the
treatment of thoracolumbar burst fractures remains a statistical analysis of specific indexes (Cobb angle, kyphotic
controversial issue. Short-segment pedicle fixation is a deformation and Beck Index) in order to investigate which
popular option. Dick et al. [14], have developed the SS technique gives better results according to these indexes.
stabilization for the operative treatment of thoracolumbar Our experience showed that the majority of the problems
and lumbar fractures. However, there is a controversy as far related with fixation and instrumentation failure occurred
as the results of this instrumentation are concerned. There when the injury was located at the first or second lumbar
are studies that report high rate of failure because of vertebra level. This observation is consistent with the higher
proximal screw pullout, screw breakage, and loss of injury prevalence at these levels, but it may also reflect a
correction even if material failure does not always affect the greater degree of instability at these levels.
clinical outcome [6,7,15,16]. Nevertheless, some studies
demonstrate that clinical long-term results are favourable in In seven patients included in the SS pedicle construct
patients who underwent SS pedicle instrumentation [17, 18]. group, the loss of correction was in the range of the initial
In attempt to achieve a stiffer construct, within the limits of a reposition. Broken and bended screws were noted within the
SS fixation, several technical issues have been described, first year and probably were due to long term cyclic loading.
including addition of cross-links and supplemental hooks at Interestingly, implant failure was not related to apparent
the levels of the screws [19-22]. Many authors suggest that pseudarthrosis.
SS transpedicular instrumentation is the best option for Two basic conclusions can be exported from this study.
unstable low lumbar fractures. Their advantage is that the The first is that according to the statistical analysis using the
loss of the lumbar lordosis associated with flat back Mann-Whitney test there is a significant difference for both
syndrome can be avoided [5, 23]. the Cobb angle and the kyphotic deformation, between the
Significant correction loss and failure is also noted in the two different under study groups. In the SS group, the
LS (greater than two segments) instrumentation with two- median value of the Cobb angle at the latest of follow up is
level fixation. Sasso and Cotler used this method, which diminished 50 per cent from the value of this index
failed at 12 months follow-up [12]. Verlaan et al. [24], postoperatively. In the LS group the respective change of the
reviewed 132 papers, published within a 30-year period Cobb angle is 65.7 per cent (p < 0.05). The fluctuation of the
(1970-2001), for studying the surgical outcome of this median value of the kyphotic deformation from
instrumentation in the management of thoracic and preoperatively to the latest follow up is 11 per cent in the SS
thoracolumbar fractures and its complications rates. Most of group and 788 per cent in the LS group respectively (p <
these papers are retrospective studies which examine 0.0005). The second result exported from this study is that as
different types of implants and different surgical techniques. far as the Beck index is concerned, there is no significant
Moreover, there are inequities as far as the severity of the difference according to all the statistical tests used this study,
injury is concerned between the divided groups. Eventually, indicating that this index is not reliable enough for the follow
no difference found between the outcomes of patients treated up of the patients suffered from similar fractures. Finally, no
with long constructs compared to them who treated with significant difference was found for all the indexes between
short constructs. Additionally, pedicle screws fixation needs their preoperative and immediate postoperative values.
more time to perform than hook fixation. Regarding to the The outcomes of the radiographic indexes studied (Cobb
complications, a low rate of complications and a very low angle and kyphotic deformation) are better in the LS pedicle
rate of serious complications was reported. The time needed instrumentation group than in the SS pedicle instrumentation
for returning to work and the pain that these patients suffered group implying that the LS instrumentation is more effective
seemed to be better than the general belief. method for the management of the burst thoracolumbar
McLain [25] studied patients with severe spinal fractures fractures than the SS instrumentation. SS instrumentation
treated with segmental fixation and found that those who had seems to have higher rate of failure. However, this method
treated with long surgical reconstructions had not more has smaller operation time and less blood loss. As far as the
impairment than those who had treated with shorter clinical outcome of the patients according to LBOS is
constructs and less dissection. The advantages of segmental concerned, no statistically significant difference was note
between the SS and LS instrumentation group. These results
Short vs Long Segment Stabilization The Open Orthopaedics Journal, 2010, Volume 4 13

suggest that LS and SS stabilization are equivalently able in [12] Sasso RC, Cotler HB. Posterior instrumentation and fusion for
reducing the segmental kyphosis and the vertebral body unstable fractures and fracture-dislocations of the thoracic and
lumbar spine. A comparative study of three fixation devices in 70
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stabilization was associated with better results concerning [13] Wenger DR, Carollo JJ. The mechanics of thoracolumbar fractures
the radiological parameters and the patients’ satisfaction. stabilized by segmental fixation. Clin Orthop 1984; (189): 89-96.
[14] Dick W, Kluger P, Magerl F, Woersdorfer O, Zach G. A new
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Received: October 25, 2009 Revised: November 10, 2009 Accepted: December 3, 2009

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