Comparison of anterior and posterior approaches for thoracolumbar burst fracture: a meta-analysis on Cobb angle loss, Frankel grading improvement and vertebral height loss

doi:10.3969/j.issn.2095-4344.2015.04.025

Abstract

Abstract:

BACKGROUND: Although there are many studies comparing different surgical approaches for the patients with thoracolumbar burst fracture who need a surgical treatment, there are no multi-center large-scale randomized controlled studies to reach a conclusion with high evidence level. This makes it necessary to do a meta-analysis with the existing studies to compare anterior and posterior approaches in treatment of thoracolumbar burst fracture.

OBJECTIVE: To analyze the differences of anterior and posterior approaches for thoracolumbar burst fracture and provide guidance for the further operative treatments through a literature retrieval.

METHODS: An online retrieval of PubMed, Medline, Elsevier, Wanfang and CNKI databases was performed for articles about the anterior and posterior approaches for thoracolumbar burst fracture, with the key words of “thoracolumbar fracture, randomized controlled trial, spinal fracture, RCT, anterior and posterior” in English, and “thoracolumbar fracture, anterior, posterior, spine” in Chinese. We compared the operative time, total blood loss, loss of Cobb angle, improvement in Frankel grading, and loss of the vertebral height between the anterior and posterior surgical approaches.

RESULTS AND CONCLUSION: Finally 18 randomized controlled trials with a total of 925 patients were included. There were 459 cases in anterior approach group and 466 cases in posterior approach group. The anterior approach cost 36.47 minutes longer than posterior approach and the blood loss in the anterior approach group was 432.58 mL more than the posterior approach group. Compared with the posterior approach group, the loss of Cobb angle was 3.41° lower, the improvement of Frankel grading was 0.33° higher, and the loss of vertebral height was 1.76 mm lower in the anterior approach group. There were significant differences in the operative time, total blood loss, loss of Cobb angle, improvement in Frankel grading and loss of vertebral height between the anterior and posterior surgical approaches (P < 0.01). Although the anterior approach has disadvantages such as long operative time, more intraoperative blood loss, and high technical requirement, the good short-term and long-term results make it worthwhile to apply for the treatment of thoracolumbar burst fractures.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

全文链接：

Key words: Spine Fracture, Lumbar Vertebrae, Thoracic Vertebrae, Meta-Analysis

CLC Number:

R318

Aikeremujiang•Muheremu, Sun Yu-qing, Wu Zhong-yan, Tian Wei. Comparison of anterior and posterior approaches for thoracolumbar burst fracture: a meta-analysis on Cobb angle loss, Frankel grading improvement and vertebral height loss[J]. Chinese Journal of Tissue Engineering Research, 2015, 19(4): 634-641.

Figures/Tables 4

Results of literature retrieval Among the 2 324 papers screened, 18 papers were chosen for the final analysis[3-20] (Figure 1), including 4 English language papers and 14 Chinese language papers. The meta-analysis included a total number of 925 patients, 459 of whom were treated by anterior approach and 466 were treated with posterior approach (Table 1). Most studies were proved to be of relatively high quality assessing according the Dephli list of Cochrane Back Review Group[20] (Table 2). Meta-analysis on the operation time Fourteen studies[3, 5-11, 13-17, 19] including 736 patients (347 patients underwent anterior approach and 389 patients underwent posterior approach) have reported the time spent on the surgery. The standard mean difference and 95%CI between two groups is 1.23 (0.60, 1.85). Patients underwent anterior approach spent significantly more time than those with posterior approach (P < 0.01; Figure 2). Meta-analysis of the total intraoperative blood loss Fourteen studies[3, 5-11, 13-17, 19] including 707 patients (336 patients underwent anterior approach and 371 patients underwent posterior approach) have reported the total intraoperative hemorrhage. The standard mean difference and 95%CI between two groups is 2.2 (1.29, 3.11). Patients with anterior approach had more loss of blood than the posterior approach group (P < 0.01; Figure 3). Meta-analysis of the loss of Cobb angle at the last follow-up Fifteen studies[3-4, 6-12, 15-20] including 770 patients (384 patients applied anterior approach and 386 patients applied posterior approach) have reported the loss of Cobb angle at the last follow-up. The standard mean difference and 95%CI between two groups is 2.32 (1.30, 3.34). Patients with anterior approach had significantly less loss of Cobb angle than that of posterior approach group (P < 0.01; Figure 4). Meta-analysis of the improvement of Frankel grading Nine studies[3, 8, 10-11, 13-14, 16-17, 20] including 444 patients (221 patients applied anterior approach and 223 patients applied posterior approach) have reported the improvement of Frankel grading after the surgery. The standard mean difference and 95%CI between two groups is 0.96 (0.60, 1.31). Patients with anterior approach had significantly better improvement of Frankel grading than that of posterior approach group (P < 0.01; Figure 5). Meta-analysis of the loss of vertebral height at the last follow-up Four studies[6, 8, 10, 16] including 225 patients (101 patients applied anterior approach and 114 patients applied posterior approach) have reported the loss of spinal body height at the last follow-up. The standard mean difference and 95%CI between two groups is 2.68 (1.39, 3.96). Patients with anterior approach had significantly less loss of vertebral height at the last follow-up than that of posterior approach group (P < 0.01; Figure 6). In addition, three papers mentioned the changes in ASIA score after the surgery[2, 5, 15], all indicating that improvement of ASIA score after the surgery was significantly better in the anterior approach than the posterior approach; another study has reported significantly less loss of spinal canal volume at long-term follow visits in patients underwent anterior approach than those with posterior approach[5]. "

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