From the Guidelines
For unstable thoracolumbar burst fractures, long segment constructs are generally recommended over short segment constructs due to their superior biomechanical stability and better maintenance of kyphosis correction, as evidenced by recent studies 1. When considering the treatment of unstable thoracolumbar burst fractures, the primary goal is to achieve stability, prevent further neurological deterioration, and maintain spinal alignment. The choice between long and short segment constructs depends on various factors, including fracture characteristics, patient factors, and the surgeon's expertise.
- Key considerations include:
- Fracture morphology: Highly comminuted fractures or those with significant load-sharing classification scores may benefit from long segment constructs.
- Bone quality: Poor bone quality may necessitate longer constructs to achieve adequate fixation.
- Neurological status: Patients with significant neurological deficits may require more extensive stabilization.
- Patient factors: Age, activity level, and overall health status can influence the decision between long and short segment constructs. While short segment constructs offer advantages in terms of preserving motion segments and reducing operative time, they are associated with higher rates of instrumentation failure and kyphosis progression, as noted in studies on spine trauma 1.
- Recent evidence suggests that adding screws at the fracture level (short segment with intermediate screws) can improve biomechanical stability and outcomes, but this may not be sufficient for highly unstable fractures. In contrast, long segment constructs provide superior biomechanical stability and better maintenance of kyphosis correction, making them a more reliable option for unstable thoracolumbar burst fractures, as supported by the American College of Radiology's guidelines on suspected spine trauma 1.
- However, long segment constructs also involve longer surgeries, greater blood loss, and the potential for adjacent segment degeneration. Ultimately, the decision between long and short segment constructs should be individualized based on a thorough evaluation of the patient's condition and fracture characteristics, with a focus on achieving the best possible outcomes in terms of morbidity, mortality, and quality of life.
From the Research
Evidence For Long Segment Constructs
- A study published in 2006 2 compared anterior-only fixation with short-segment posterior-only construct for unstable thoracolumbar burst fractures, and found that the anterior-only group had better maintenance of sagittal plane alignment, with an average increase in sagittal plane kyphosis of only 1.8 degrees, compared to 8.1 degrees in the posterior-only group.
- Another study published in 2009 3 found that fracture level screw combination provided better intraoperative correction and maintenance in the treatment of unstable thoracolumbar burst fractures, which was more prevalent in long-segment fixation groups.
Evidence For Short Segment Constructs
- A study published in 2010 4 found that short-segment posterior instrumentation supplemented with balloon-assisted vertebroplasty and calcium phosphate reconstruction can provide excellent reduction of unstable thoracolumbar burst fractures with minimal loss of correction and low rate of instrumentation failure.
- The same study 4 also found that the use of short-segment instrumentation with transpedicular balloon-assisted reduction and anterior column reconstruction with calcium phosphate bone cement can maintain or improve neurologic function in patients with neurologic deficits.
Evidence Against Short Segment Constructs
- A study published in 2006 2 found that short-segment posterior-only constructs had a higher loss of sagittal plane correction, with an average loss of 8.1 degrees, compared to anterior-only constructs.
- Another study published in 2009 3 found that short-segment posterior instrumentation without fracture level screw combination had poorer intraoperative correction and maintenance in the treatment of unstable thoracolumbar burst fractures.
General Considerations
- A review article published in 2007 5 found that there is no generally accepted criteria for the treatment of thoracolumbar burst fractures, and that the choice of management depends on various factors such as the severity of kyphotic deformity, canal compromise, vertebral height loss, and neurologic status.
- A systematic review published in 2010 6 found that the management of thoracolumbar burst fractures remains challenging, and that the ideal treatment should effectively correct the deformity, induce neurological recovery, allow early mobilization and return to work, and be associated with minimal risk of complication.