| Objective To evaluate the clinical and radiographic results of Wiltse approach and percutaneous approach pedicle screw fixation for the treatment of single level thoracolumbar fracture without neurological deficits.Methods A retrospective analysis was performed on 57 cases of single level thoracolumbar fracture without neurological deficits admitted to our hospital from April 2015 to May 2018.According to the approach of pedicle screw implantation,the patients were divided into Wiltse approach group(27 cases)and percutaneous approach group(30 cases).Incision length,operation time,intraoperative blood loss,X-ray frequency and length of hospital stay were compared between the two groups.Visual analog score(VAS),Oswestry dysfunction index(ODI),vertebral body height and Cobb angle were compared at different time points between the two groups after surgery.The accuracy of pedicle screw implantation was evaluated by 3d CT(mobbs-raley evaluation method,with penetration of the vertebral pedicle as the boundary,grade 4:no penetration,less than 2 mm,greater than 2 mm without complications,and greater than 2 mm with complications).The independent sample t test was used to compare the measurement data between the two groups with normal distribution.The comparison among different time points in the same group was tested by SNK method.Chi-square test was used for the enumeration data(gender,age,AO classification of fractures and fracture segments).P<0.05 was considered statistically significant.Results All patients completed the operation successfully,and all 57 patients were followed up for 12 to 15 months(mean 13.42±2.75).The mean operation time of Wiltse approach group was 63.40±7.83 min,intraoperative blood loss was 110.91±29.28 ml,incision length was 8.64±3.28 cm,intraoperative fluoroscopy times were 10.89±3.02,and hospital stay was 8.94±1.75 d.The mean operation time of the percutaneous approach group was 81.40±9.23 min,intraoperative blood loss was 50.73±15.67 ml,incision length was 6.54±2.32 cm,intraoperative fluoroscopy was 15.72±5.69,and hospital stay was 6.43±1.21 d.Compared with the Wiltse approach group,the percutaneous approach group had smaller incision,less intraoperative bleeding,shorter hospitalization time,longer operative time and more intraoperative X-ray fluoroscopy(P<0.05).VAS scores before operation in Wiltse approach group and percutaneous approach group were 5.16±0.98 and 4.73±0.82.ODI score before operation in Wiltse approach group and percutaneous approach group were 46.78±2.81 and 47.23±2.53.VAS scores in the Wiltse approach group and percutaneous approach group 1 week after surgery were 2.93±0.42 and 1.68±0.43.ODI score in the Wiltse approach group and percutaneous approach group 1 week after surgery were 20.04 ±4.67 and 16.27±2.21.VAS scores and ODI scores in both groups were significantly improved 1 week after surgery(P<0.05).VAS score and ODI score of the percutaneous approach group 1 week after surgery were significantly improved compared with those of the Wiltse approach group(P<0.05).VAS score and ODI score of the Wiltse approach group at 3 and 12 months after surgery were "0.95±0.48" and "0.55±0.49",and "5.87 ±2.0" and"2.48 ±0.98" respectively.VAS score and ODI score of the percutaneous approach group at 3 and 12 months after surgery were "0.63±0.44" and"0.30 ±0.48",and "4.94 ±1.69" and "2.19±0.88" respectively.VAS scores and ODI scores of the Wiltse approach group and the percutaneous approach group at 3 and 12 months after surgery were significantly improved compared with those at 1 week after surgery(P<0.05),but no statistically significant differences were found between the two groups(P>0.05).In the Wiltse approach group,the anterior edge height of the injured vertebral body was "25.67 ±3.53 mm,24.53±2.56 mm,24.41 ±2.38 mm,and 24.23 ±2.08 mm,at one week,3 months,12 months after the operation and 1 month after the internal fixation removed.The anterior edge height of the injured vertebral body in the percutaneous approach group was "26.23 ±3.24 mm,25.28 ±2.37 mm,24.92 ±2.15 mm,and 24.64±2.03 mm".The cobb angles of the Wiltse approach group were "12.64 ±4.84°,13.77 ±3.89°,15.26±4.24° and 15.46 ±4.09°" at one week,3 months,12 months after operation and 1 month after internal fixation removed.The cobb angle of the percutaneous approach group were "13.62±4.87°,14.72±4.75°,14.82±3.16° and 15.23±5.50°".The height of anterior vertebral body and cobb angle in the two groups were significantly improved compared with those before surgery(P<0.05),but there was no statistically significant difference between the two groups(P>0.05).A total of 108 pedicle screws were implanted in the Wiltse approach group,including 10 T10,8 T11,34 T12,20 L1,24 L2 and 12 L3.A total of 120 pedicle screws were implanted in the percutaneous approach group,including 14 T10,10 T11,40 T12,20 L1,26 L2,and 10 L3.In the Wiltse approach group,2 pedicle screws perforated the lateral wall of the pedicle,3 through the medial wall of the pedicle,2 through the upper wall of the pedicle,and 0 through the lower wall of the pedicle through the postoperative 3d CT findings.The total rate of screw setting of defective pedicle screw was 6.48%.In the percutaneous approach group,3 pedicle screws perforated the lateral wall of the pedicle,4 through the medial wall of the pedicle,2 through the upper wall of the pedicle and 1 through the lower wall of the pedicle.The total rate of screw setting of defective pedicle screw was 8.33%.According to Mobbs-Raley classification criteria,101 pieces(93.52%)in the Wiltse approach group were at grade 0,5 pieces(4.62%)of grade 1,2 pieces(1.85%)of grade 2,and 0 pieces(0%)of grade 3.In the percutaneous approach group,there were 110 grade 0(91.67%),7 grade 1(5.83%),3 grade 2(1.67%),and 1 grade 3(0.83%).There was no significant difference between the two groups(P>0.05).Conclusion Both Wiltse approach and percutaneous approach pedicle screw fixation could achieve satisfactory recovery of height and Cobb's angle of the fracture vertebral body in the treatment of single level thoracolumbar fractures without neurological deficits.Although percutaneous pedicle screw internal fixation increases operation time and the number of intraoperative fluoroscopies,it can significantly reduce surgical trauma and the early postoperative pain,shorten the length of hospital stay.The accuracy of pedicle screw implantation is similar to that of the Wiltse approach. |
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