Comparison Of The Clinical Efficacy Of Three Surgical Methods In Treatment Of Thoracolumbar Fractures:a Meta-Analysis

Section OneComparison of the Clinical Efficacy of Pedicular Screw Fixation on or across the Fractured Vertebrae in Treatment of Thoracolumbar Fractures:a Meta-AnalysisBACKGROUNDThe thoracolumbar region often refers from the eleventh thoracic vertebra to the second lumbar vertebra. Most spinal injury often resulted from a high energy trauma, such as vigorous accidental traumatic injury. Recently, there were enormous increment of the modern operative techniques for spine fractures, from the previous conservative treatment as bed rest to currently developed new surgical operative procedures, including anterior decompression and internal fixation, posterior internal fixation across the fractured bertebrae, posterior long-segment internal fixation, and minimally invasive percutaneous internal fixation operation, and so on.At present, the most common treatment of thoracolumbar fracture by posterior operation is pedicular screw fixation across the fractured vertebrae, through placing the pedicle screw in the injured vertebra, adjacent upper and lower vertebral body to achieve the reduction and fixation of the fracture. The advantage of the procedure is simple, less traumatic to the surrounding tissues, fast recovery, and still retaining the mobility of the operative part. But, some results pointed out that this kind of operation will prone to have failure of internal fixation, causing some complications, such as effect of parallel quadrilateral or suspension. Furthermore, pedicular screw fixation on the fractured vertebrae can further strengthen the internal fixation, and obtain more spinal stability.OBJECTIVETo evaluate the clinical efficacy of pedicular screw fixation on or across the fractured vertebrae in treatment of thoracolumbar fractures.METHODElectronic search was performed from Pubmed, OVID, Embase (Holland medical literature database), CENTRAL (Cochrane Central Register of Controlled Trails,Cochrane trials database), and domestic Wanfang database, China National Knowledge infrastructure. The last search was performed up to December 2014.Meanwhile, search was also performed from the domestic and international conference literature, China spinal Department of orthopaedics clinical trials registry. Manual search was performed from Chinese Journal of Spine and Spinal Cord Trauma.Randomized controlled trials that met the inclusion criteria were brought into the analysis. Meta-analysis was performed with measures including age, operation time, intraoperative bleeding volume, ratio of anterior and posterior margin of vertebral height, kyphosis Cobb angle, VAS pain score, rate of canal compromise. We used Jadad score to evaluate the RCTs.RESULTSIn this meta-analysis,16 trials that met the inclusion criteria were included. All trials were randomized controlled trials,2 were written in English and the remaining were in Chinese. We enrolled a total of 1183 patients, of which,627 patients were receiving pedicular screw fixation on the fractured vertebrae and 556 patients for pedicular screw fixation across the fractured vertebrae. All these 16 literatures belong to the level one evidence and the method way improved version Jadad scoring criteria is seen on the table.Our pooled results comparing pedicular screw fixation on or across the fractured vertebrae showed that the time of operation (MD:-3.78,95%CI[-11.38,3.82], P=0.33,I2=55%), the amount of haemorrhage (MD=-2.61,95%CI[-22.46,17.24], P=0.80,I2=0%), occupying ratio (preoperative:MD=0.34,95%CI[-0.99,1.67], P=0.62; after the operation:MD=0.33,95%CI[-0.72,0.06], P=0.10), preoperative ratio of anterior and posterior margin of vertebral height (MD=-0.32,95%CI[-0.95,0.31], P=0.32,I2=0%), preoperative kyphosis Cobb angle (MD=0.02,95%CI[-0.34,0.38], P=0.92,I2=0%) and operation before the pain VAS score (MD=-0.03,95%CI[-0.33,0.27], P=0.85,I2=0%) and there was no significant difference between two groups. However, the anterior height of injured vertebra after operation for one week (MD=5.41,95%CI[2.80,8.02], P<0.0001,I2=88%),12 months late(MD=-2.27,95%CI[-3.47,-1.07], P=0.0002,I2=98%),six months late(MD=-2.67,95%CI[-4.33,-1.02], P=0.002,I2=91%),12 months late (MD=-3.93,95%CI[-6.57,-1.29], P=0.004,I2=98%); postoperative pain VAS score for one week(MD=-0.29, 95%CI[-0.50,-0.07], P=0.008,I2=23%),12 months late (MD=-1.00, 95%CI[-1.38,-0.62], P<0.0001,12=0%) showing the comparison of the two groups was statistically significant. Therefore, the way with pedicular screw fixation in the fractured vertebrae has better than without fixation in the fractured vertebrae. Additional, fixation in the fractured vertebrae did not increase risk of operational time, the amount of haemorrhage and occupying ratio. According to results of the amount of haemorrhage (MD=-2.61,95%CI[-22.46,17.24], P=0.80,I2=0%), preoperative ratio of anterior and posterior margin of vertebral height (MD=-0.32,95%CI[-0.95, 0.31], P=0.32,I2=0%), preoperative kyphosis Cobb angle (MD=0.02, 95%CI[-0.34,0.38], P=0.92,I2=0%) and operation before the pain VAS score (MD=-0.03,95%CI[-0.33,0.27], P=0.85,I2=0%), the heterogeneity between in these trails was low. So, the conclusions were reliable and the baseline in two groups was similar. However, the heterogeneity of the the time of operation (MD:-3.78,95%CI[-11.38,3.82], P=0.33,I2=55%), the anterior height of injured vertebra after operation for one week (MD=5.41,95%CI[2.80,8.02], P＜0.0001,I2=88%),12 months late(MD=-2.27,95%CI[-3.47,-1.07], P=0.0002,I2=98%),six months late(MD=-2.67,95%CI[-4.33,-1.02], P=0.002,I2=91%),12 months late (MD=-3.93,95%CI[-6.57,-1.29], P=0.004,I2=98%); postoperative pain VAS score for one week(MD=-0.29, 95%CI[-0.50,-0.07], P=0.008,I2=23%),12 months late(MD=-1.00, 95%CI[-1.38,-0.62], P＜0.0001,I2=0%) was high even after process of statistics. After sensitive analysis, the results of the operational time, the amount of haemorrhage, the anterior height of injured vertebra, kyphosis Cobb angle, preoperative pain VAS score were stable and the conclusion was still reliable. The reliability of postoperative pain VAS score is low.ConclusionAccording to the final results of the meta-analysis, the group with pedicular screw fixation on the fractured vertebrae has better postoperative ratio of anterior and posterior margin of vertebral height, kyphosis Cobb angle, VAS pain score. However, there is no significant difference in bleeding, preoperative ratio of anterior and posterior margin of vertebral height, and the operation time between two groups. P=0.002,I2=91%),12 months late (MD=-3.93,95%CI[-6.57,-1.29], P=0.004,I2=98%); postoperative pain VAS score for one week(MD=-0.29, 95%CI[-0.50,-0.07], P=0.008,I2=23%),12 months late(MD=-1.00, 95%CI[-1.38,-0.62], P＜0.0001,I2=0%) was high even after process of statistics. After sensitive analysis, the results of the operational time, the amount of haemorrhage, the anterior height of injured vertebra, kyphosis Cobb angle, preoperative pain VAS score were stable and the conclusion was still reliable. The reliability of postoperative pain VAS score is low.ConclusionAccording to the final results of the meta-analysis, the group with pedicular screw fixation on the fractured vertebrae has better postoperative ratio of anterior and posterior margin of vertebral height, kyphosis Cobb angle, VAS pain score. However, there is no significant difference in bleeding, preoperative ratio of anterior and posterior margin of vertebral height, and the operation time between two groups.Section TwoComparison of the Clinical Efficacy of pedicular screw fixation with bone grafting on or across the fractured vertebrae in treatment of thoracolumbar fractures:a Meta-AnalysisBACKGROUNDAlong with the development of imaging and biomechanics, there were better understandings of the mechanism and diagnosis of spine fracture, and advanced treatments have been developed recently. Although pedicular screw fixation on the fractured vertebrae was a simple procedure for treating the thoracolumbar fracture, we have found that there was an increased incidence of secondary fracture, kyphosis and deformity after taking out the fixation, leading to chronic pain on the back. Some researchers showed that patients receiving both vertebral bone graft and internal fixation in the fractured vertebrae have better spinal stability and much reduction in the secondary fracture. However, some articles concluded that this treatment with negative results. The results were in controversy. Therefore, we conduct a meta-analysis to know whether this kind of treatment has better outcomes.OBJECTIVESTo evaluate the clinical efficacy of pedicular screw fixation with bone grafting on or across the fractured vertebrae in treatment of thoracolumbar fracturesMethodsElectronic search was performed from Pubmed, OVID, Embase (Holland medical literature database), CENTRAL (Cochrane Central Register of Controlled Trails,Cochrane trials database), and domestic Wanfang database, China National Knowledge infrastructure. The last search was performed up to January 2015.Meanwhile, search was also performed from the domestic and international conference literature, China spinal Department of orthopaedics clinical trials registry. Manual search was performed from Chinese Journal of Spine and Spinal Cord Trauma.Randomized controlled trials that met the inclusion criteria were brought into the analysis. Meta-analysis was performed with measures including age, operation time, intraoperative bleeding volume, the anterior height of injured vertebra after operation, kyphosis Cobb angle, VAS pain score, ratio of canal compromise. We used Jadad score to evaluate the RCTs.RESULTSIn this meta-analysis, we included 10 trials that met the inclusion criteria. All trials were randomized controlled trials. We enrolled a total of 603 patients, of which,299 patients were receiving transpedicular surgery and 304 patients, intervertebral fixation surgery. We conduct a meta-analysis including following parameters as age, operation time, intraoperative bleeding volume, ratio of anterior and posterior margin of vertebral height, kyphosis Cobb angle, VAS pain score, ratio of canal compromise, effectiveness of the treatment and NEER scores. Our pooled results comparing pedicular screw fixation with bone grafting on or across the fractured vertebrae showed that Operation time (MD:-8.83,95%CI[-21.19,3.52], P=0.16,I2=70%), preoperative vertebral body height ratio (MD:1.09,95%CI[-0.17,2.35], P=0.09,I2=0%), preoperative kyphosis Cobb angle (MD:-0.06,95%CI[-1.04,0.91], P=0.90,I2=18% ), preoperative occupying ratio (MD:0.59,95%CI[-0.50,1.68], P=0.33,I2=24%), postoperative occupying ratio (MD:-0.06,95% CI[-1.04,0.91], P=0.90,I2=18%) and there was no significant difference between two groups. However, amount of bleeding in operation (MD:-29.89,95%CI[-56.81,-2.98], P=0.03,I2=71%), postoperative vertebral body height ratio for one week (MD:5.33, 95%CI[1.32,9.35], P=0.009,I2=96%),12 months late(MD:5.15, 95%CI[2.25,8.05], P=0.0005,I2=78%), postoperative kyphosis Cobb angle for one week (MD:-2.20,95%CI[-4.35,-0.06], P=0.04,I2=99%),12 months late(MD:-3.49,95%CI[-。6.30,-0.68],P=0.01,I2=97%), the total effective rate (P<0.05) and the NEER score (OR:8.97,95%CI[1.96,41.06], P=0.005,I2=0%) showing the comparison of the two groups was statistically significant. Furthermore, the patients with pedicular screw fixation with bone grafting on the fractured vertebrae have better outcomes in ratio of anterior vertebral height, kyphosis Cobb angle after operation and in lowing the risk of blooding in operation and increasing the NEER scores.In this meta-analysis, results also pointed out that there was not too much difference in the heterogeneous of the anterior heigh of injured verterae (MD: 1.09,95%CI[-0.17,2.35], P=0.09,I2=0% )、preopertive kyphosis Cobb angle (MD:-0.06,95%CI[-1.04,0.91], P=0.90,I2=18%)、preopertive ratio of canal compromise (MD:0.59, 95%CI[-0.50,1.68], P=0.33,I2=24%) and NEER scores (OR:8.97, 95%CI[1.96,41.06], P=0.005,I2=0%), so these conclusion has high on reliability.It also showed that preoperative ratio of anterior and posterior margin of vertebral height, kyphosis Cobb angle and ration of canal compromise has good similarity on the baselines in the two groups and the postoperative data after combining but the difference in two groups before operation. There was high heterogeneous after statistical combining in operative time (MD:-8.83, 95%CI[-21.19,3.52], P=0.16,I2=70%), blood in the operation (MD:-29.89, 95%CI[-56.81,-2.98], P=0.03,I2=71%), postoperative the anterior heigh of injured verterae for one week (MD:5.33,95%CI[1.32,9.35], P=0.009,I2=96%), 12 months late(MD:5.15,95%CI[2.25,8.05],P=0.005,I2=78%), kyphosis Cobb angle for one week (MD:-2.20,95%CI[-4.35,-0.06], P=0.04,I2=99%),12 months late(MD:-3.49,95%CI[-。6.30,-0.68], P=0.01,I2=97%) and postoperative ratio of canal compromise (MD:-2.57, 95%CI[-5.37,0.24], P=0.07,I2=91%).After these datas were sensitivity analyses, they still had good reliability but postoperative ratio of canal compromise had been changed(from P=0.07>0.05to P=0.002<0.05). It implied that the stability of the result is poor. But it may be better after more high quality RCTS were concluded and statistical analysis.ConclusionWith the development of new operative procedures in the treatment of thoracolumbar fracture, ranging from traditional transpedicular screw operation mode to transpedicular fixation with vertebral graft, spine surgeons are now applying transpedicular fixation procedure in daily practice. Although there were a large number of articles targeting the prognosis of complications, published yearly, their results were controversial. Therefore, we conduct a meta-analysis to get a better comprehensive answer. Until now, pedicular screw fixation with bone grafting on the fractured vertebrae has become a safer standard procedure in treating the thoracolumbar fracture. Although the including RCTs overall quality was not high, our result will be more reliable and we hope this conclusion would be a guide in clinical practice.