Meta-analysis of the long-term efficacy of unilateral <i>versus</i> bilateral screw fixation on thoracolumbar single vertebral fracture_West China Medical Journal

Authors：

GE Wenli ¹ ,  XIAO Jie ² , HU Lu ³

1. College of Acupuncture and Trauma, Guizhou University of Traditional Chinese Medicine, Guiyang, Guizhou 550002, P. R. China;
2. Department of Spinal Surgery, Guiyang Fourth People's Hospital, Guiyang, Guizhou 550002, P. R. China;
3. Nursing School of Nanchang University, Nanchang, Jiangxi 330000, P. R. China;

Corresponding author：

XIAO Jie, Email: jx4363@sina.com

Keywords：

Thoracolumbar fracture; Screw placement of injured vertebra; Unilateral; Bilateral; Meta-analysis

DOI：

10.7507/1002-0179.201908097

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Objective To evaluate the long-term effect of unilateral versus bilateral screw placement on thoracolumbar single vertebral fracture by means of meta-analysis.Methods The data of China National Knowledge Infrastructure, Wangfang Database, SinoMed, VIP Database for Chinese Technical Periodicals, PubMed, Elsevier Science Direct, EBSCO, Web of Science, and Springer Link were searched by computer, and the literatures related to effect comparison between unilateral and bilateral pedicle screw fixation in thoracolumbar single vertebral fracture were collected, including domestic and foreign published journal literatures and grey literatures such as academic conference reports and dissertations. The retrieval time was from their inception to August 17, 2019. After literature screening, quality evaluation, and data extraction, Stata 12.0 and RevMan 5.0 softwares were used for data analysis.Results A total of 12 articles were included, including 7 in English and 5 in Chinese, with a total of 848 patients (424 in the unilateral pediclescrew fixation group and 424 in the bilateral pedicle screw fixation group). The results of meta-analysis showed that: there was no significant difference in any of the main outcome indicators between the two groups, including the ratio of anterior height of fractured vertebra [mean difference (MD)= −0.16%, 95% confidence interval (CI) (−1.20%, 0.88%), P=0.76], postoperative follow-up Cobb angle [MD=−0.17°, 95%CI (−0.50, 0.15)°, P=0.29], postoperative follow-up Visual Analogue Scale score [MD=−0.06, 95%CI (−0.16, 0.04), P=0.24], postoperative follow-up Oswestry Disability Index score [MD=−0.28, 95%CI (−0.66, 0.11), P=0.15], and incidence of complications [relative risk=0.81, 95%CI (0.57, 1.15), P=0.23], but two secondary outcome indicators namely operation time [MD=−33.26 minutes, 95%CI (−51.72, −14.80) minutes, P=0.000 4] in the unilateral pedicle screw fixation group were smaller than those in the bilateral pedicle screw fixation group, whlie there were no statistically significant difference in postoperative length of hospital stay [MD=−1.59 days, 95%CI (−4.53, 1.36) days, P=0.29] and intraoperative blood loss [MD=−74.09 mL, 95%CI (−155.96, 7.77) mL, P=0.08] between the two groups.Conclusion Unilateral and bilateral screw placement of thoracolumbar single vertebral fracture has the same long-term effect, and unilateral screw placement can reduce the number of screw implantation, and shorter operation time, which is more in line with the actual clinical needs.

Citation： GE Wenli, XIAO Jie, HU Lu. Meta-analysis of the long-term efficacy of unilateral versus bilateral screw fixation on thoracolumbar single vertebral fracture. West China Medical Journal, 2020, 35(1): 51-59. doi: 10.7507/1002-0179.201908097 Copy

1.	Gamanagatti S, Rathinam D, Rangarajan K, et al. Imaging evaluation of traumatic thoracolumbar spine injuries: radiological review. World J Radiol, 2015, 7(9): 253-265.
2.	Wood KB, Buttermann GR, Phukan R, et al. Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit: a prospective randomized study with follow-up at sixteen to twenty-two years. J Bone Joint Surg Am, 2015, 97(1): 3-9.
3.	Liao JC, Chen WP, Wang H. Treatment of thoracolumbar burst fractures by short-segment pedicle screw fixation using a combination of two additional pedicle screws and vertebroplasty at the level of the fracture: a finite element analysis. BMC Musculoskelet Disord, 2017, 18(1): 262.
4.	McLain RF. The biomechanics of long versus short fixation for thoracolumbar spine fractures. Spine (Phila Pa 1976), 2006, 31(Suppl 11): S70-S79.
5.	Ökten Aİ, Gezercan Y, Özsoy KM, et al. Results of treatment of unstable thoracolumbar burst fractures using pedicle instrumentation with and without fracture-level screws. Acta Neurochir (Wien), 2015, 157(5): 831-836.
6.	陈艺, 白波, 孙辉, 等. 短节段椎弓根钉固定术的生物力学研究. 中华创伤杂志, 2010, 26(1): 39-43.
7.	Goel VK, Lim TH, Gwon J, et al. Effects of rigidity of an internal fixation device. A comprehensive biomechanical investigation. Spine (Phila Pa 1976), 1991, 16(Suppl 3): S155-S161.
8.	Kasai Y, Inaba T, Kato T, et al. Biomechanical study of the lumbar spine using a unilateral pedicle screw fixation system. J Clin Neurosci, 2010, 17(3): 364-367.
9.	郝申申, 赵如元, 刘志斌, 等. 有限元分析胸腰段脊柱骨折经伤椎置钉的固定. 中国组织工程研究, 2017, 21(31): 5060-5065.
10.	Higgins JP, Altman DG, Gotzsche PC, et al. The cochrane collaboration’s tool for assessing risk of bias in randomised trials. BMJ, 2011, 343: d5928.
11.	Yang X, Wang H, Zhao Q, et al. A comparison of unilateral and bilateral pedicle screw fixation combined with transforaminal lumbar interbody fusion for lumbar degenerative diseases. Chin Med J (Engl), 2014, 127(20): 3592-3596.
12.	Liu F, Feng Z, Zhou X, et al. Unilateral versus bilateral pedicle screw fixation in transforaminal lumbar interbody fusion:a monocentric study of 215 patients with a minimum of 4-year follow-up. Clin Spine Surg, 2017, 30(6): E776-E783.
13.	Işik HS, Okutan Ö, Yildirim T, et al. Comparison of unilateral versus bilateral pedicle screw fixation in transforaminal lumbar interbody fusion for single level lumbar degenerative diseases and review of literature. Turk Neurosurg, 2018, 28(5): 731-739.
14.	Sun C, Liu X, Tian J, et al. Comparison of unilateral versus bilateral pedicle screw fixation at the level of fracture using posterior short-segment pedicle instrumentation in the treatment of severe thoracolumbar burst fractures. Int J Surg, 2017, 41: 50-55.
15.	Xue H, Tu Y, Cai M. Comparison of unilateral versus bilateral instrumented transforaminal lumbar interbody fusion in degenerative lumbar diseases. Spine J, 2012, 12(3): 209-215.
16.	Chen DJ, Yao C, Song Q, et al. Unilateral versus bilateral pedicle screw fixation combined with transforaminal lumbar interbody fusion for the treatment of low lumbar degenerative disc diseases: analysis of clinical and radiographic results. World Neurosurg, 2018, 115: e516-e522.
17.	曾至立, 程黎明, 李山珠, 等. 伤椎置钉结合短节段椎弓根螺钉固定治疗胸腰椎骨折. 中华医学杂志, 2013, 93(27): 2117-2121.
18.	李连华, 刘智, 王浩, 等. 单侧和双侧伤椎固定胸腰椎爆裂骨折的疗效比较. 中华创伤杂志, 2017, 33(1): 33-37.
19.	何伟, 钱宇, 金聪, 等. 单侧与双侧经伤椎短节段固定治疗伴单侧椎弓根骨折胸腰椎骨折的疗效比较. 中华创伤杂志, 2018, 34(10): 911-918.
20.	杨恺, 刘书茂, 管波青, 等. 伤椎单侧与双侧置钉治疗胸腰段椎体骨折的比较研究. 中华临床医师杂志(电子版), 2017, 11(10): 1681-1685.
21.	王长志. 跨伤椎固定与经伤椎单侧、双侧置钉治疗胸腰段单椎体骨折的疗效对比. 福州: 福建医科大学, 2017.
22.	Dong J, Rong L, Feng F, et al. Unilateral pedicle screw fixation through a tubular retractor via the Wiltse approach compared with conventional bilateral pedicle screw fixation for single-segment degenerative lumbar instability: a prospective randomized study. J Neurosurg Spine, 2014, 20(1): 53-59.
23.	Wang HW, Li CQ, Zhou Y, et al. Percutaneous pedicle screw fixation through the pedicle of fractured vertebra in the treatment of type A thoracolumbar fractures using sextant system: an analysis of 38 cases. Chin J Traumatol, 2010, 13(3): 137-145.
24.	Wood KB, Bohn D, Mehbod A. Anterior versus posterior treatment of stable thoracolumbar burst fractures without neurologic deficit: a prospective, randomized study. J Spinal Disord Tech, 2005, 18(Suppl): S15-S23.
25.	Kim BG, Dan JM, Shin DE. Treatment of thoracolumbar fracture. Asian Spine J, 2015, 9(1): 133-146.
26.	Sun C, Guan G, Liu X, et al. Comparison of short-segment pedicle fixation with versus without inclusion of the fracture level in the treatment of mild thoracolumbar burst fractures. Int J Surg, 2016, 36(Pt A): 352-357.
27.	Pellisé F, Barastegui D, Hernandez-Fernandez A, et al. Viability and long-term survival of short-segment posterior fixation in thoracolumbar burst fractures. Spine J, 2015, 15(8): 1796-1803.
28.	Deng Z, Zou H, Cai L, et al. The retrospective analysis of posterior short-segment pedicle instrumentation without fusion for thoracolumbar burst fracture with neurological deficit. Scientific World J, 2014, 2014: 457634.
29.	Vu TT, Morishita Y, Yugue I, et al. Radiological outcome of short segment posterior instrumentation and fusion for thoracolumbar burst fractures. Asian Spine J, 2015, 9(3): 427-432.
30.	Mahar A, Kim C, Wedemeyer M, et al. Short-segment fixation of lumbar burst fractures using pedicle fixation at the level of the fracture. Spine (Phila Pa 1976), 2007, 32(14): 1503-1507.
31.	Xu BS, Tang TS, Yang HL. Long-term results of thoracolumbar and lumbar burst fractures after short-segment pedicle instrumentation, with special reference to implant failure and correction loss. Orthop Surg, 2009, 1(2): 85-93.
32.	Takami M, Yamada H, Nohda K, et al. A minimally invasive surgery combining temporary percutaneous pedicle screw fixation without fusion and vertebroplasty with transpedicular intracorporeal hydroxyapatite blocks grafting for fresh thoracolumbar burst fractures: prospective study. Eur J Orthop Surg Traumatol, 2014, 24(Suppl 1): S159-S165.
33.	Tong MJ, Tang Q, Wang CG, et al. Efficacy of using intermediate screws in short-segment fixation for thoracolumbar fractures: a meta-analysis of randomized controlled trials. World Neurosurg, 2018, 110: e271-e280.
34.	Dobran M, Nasi D, Brunozzi D, et al. Treatment of unstable thoracolumbar junction fractures: short-segment pedicle fixation with inclusion of the fracture level versus long-segment instrumentation. Acta Neurochir (Wien), 2016, 158(10): 1883-1889.
35.	Anekstein Y, Brosh T, Mirovsky Y. Intermediate screws in short segment pedicular fixation for thoracic and lumbar fractures: a biomechanical study. J Spinal Disord Tech, 2007, 20(1): 72-77.
36.	Luo J, Gong M, Gao M, et al. Both unilateral and bilateral pedicle screw fixation are effective for lumbar spinal fusion-a meta-analysis-based systematic review. J Orthop Translat, 2014, 2(2): 66-74.
37.	Li C, Zhou Y, Wang H, et al. Treatment of unstable thoracolumbar fractures through short segment pedicle screw fixation techniques using pedicle fixation at the level of the fracture: a finite element analysis. PloS One, 2014, 9(6): e99156.
38.	Chen HH, Cheung HH, Wang WK, et al. Biomechanical analysis of unilateral fixation with interbody cages. Spine (Phila Pa 1976), 2005, 30(4): E92-E96.

1. Gamanagatti S, Rathinam D, Rangarajan K, et al. Imaging evaluation of traumatic thoracolumbar spine injuries: radiological review. World J Radiol, 2015, 7(9): 253-265.
2. Wood KB, Buttermann GR, Phukan R, et al. Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit: a prospective randomized study with follow-up at sixteen to twenty-two years. J Bone Joint Surg Am, 2015, 97(1): 3-9.
3. Liao JC, Chen WP, Wang H. Treatment of thoracolumbar burst fractures by short-segment pedicle screw fixation using a combination of two additional pedicle screws and vertebroplasty at the level of the fracture: a finite element analysis. BMC Musculoskelet Disord, 2017, 18(1): 262.
4. McLain RF. The biomechanics of long versus short fixation for thoracolumbar spine fractures. Spine (Phila Pa 1976), 2006, 31(Suppl 11): S70-S79.
5. Ökten Aİ, Gezercan Y, Özsoy KM, et al. Results of treatment of unstable thoracolumbar burst fractures using pedicle instrumentation with and without fracture-level screws. Acta Neurochir (Wien), 2015, 157(5): 831-836.
6. 陈艺, 白波, 孙辉, 等. 短节段椎弓根钉固定术的生物力学研究. 中华创伤杂志, 2010, 26(1): 39-43.
7. Goel VK, Lim TH, Gwon J, et al. Effects of rigidity of an internal fixation device. A comprehensive biomechanical investigation. Spine (Phila Pa 1976), 1991, 16(Suppl 3): S155-S161.
8. Kasai Y, Inaba T, Kato T, et al. Biomechanical study of the lumbar spine using a unilateral pedicle screw fixation system. J Clin Neurosci, 2010, 17(3): 364-367.
9. 郝申申, 赵如元, 刘志斌, 等. 有限元分析胸腰段脊柱骨折经伤椎置钉的固定. 中国组织工程研究, 2017, 21(31): 5060-5065.
10. Higgins JP, Altman DG, Gotzsche PC, et al. The cochrane collaboration’s tool for assessing risk of bias in randomised trials. BMJ, 2011, 343: d5928.
11. Yang X, Wang H, Zhao Q, et al. A comparison of unilateral and bilateral pedicle screw fixation combined with transforaminal lumbar interbody fusion for lumbar degenerative diseases. Chin Med J (Engl), 2014, 127(20): 3592-3596.
12. Liu F, Feng Z, Zhou X, et al. Unilateral versus bilateral pedicle screw fixation in transforaminal lumbar interbody fusion:a monocentric study of 215 patients with a minimum of 4-year follow-up. Clin Spine Surg, 2017, 30(6): E776-E783.
13. Işik HS, Okutan Ö, Yildirim T, et al. Comparison of unilateral versus bilateral pedicle screw fixation in transforaminal lumbar interbody fusion for single level lumbar degenerative diseases and review of literature. Turk Neurosurg, 2018, 28(5): 731-739.
14. Sun C, Liu X, Tian J, et al. Comparison of unilateral versus bilateral pedicle screw fixation at the level of fracture using posterior short-segment pedicle instrumentation in the treatment of severe thoracolumbar burst fractures. Int J Surg, 2017, 41: 50-55.
15. Xue H, Tu Y, Cai M. Comparison of unilateral versus bilateral instrumented transforaminal lumbar interbody fusion in degenerative lumbar diseases. Spine J, 2012, 12(3): 209-215.
16. Chen DJ, Yao C, Song Q, et al. Unilateral versus bilateral pedicle screw fixation combined with transforaminal lumbar interbody fusion for the treatment of low lumbar degenerative disc diseases: analysis of clinical and radiographic results. World Neurosurg, 2018, 115: e516-e522.
17. 曾至立, 程黎明, 李山珠, 等. 伤椎置钉结合短节段椎弓根螺钉固定治疗胸腰椎骨折. 中华医学杂志, 2013, 93(27): 2117-2121.
18. 李连华, 刘智, 王浩, 等. 单侧和双侧伤椎固定胸腰椎爆裂骨折的疗效比较. 中华创伤杂志, 2017, 33(1): 33-37.
19. 何伟, 钱宇, 金聪, 等. 单侧与双侧经伤椎短节段固定治疗伴单侧椎弓根骨折胸腰椎骨折的疗效比较. 中华创伤杂志, 2018, 34(10): 911-918.
20. 杨恺, 刘书茂, 管波青, 等. 伤椎单侧与双侧置钉治疗胸腰段椎体骨折的比较研究. 中华临床医师杂志(电子版), 2017, 11(10): 1681-1685.
21. 王长志. 跨伤椎固定与经伤椎单侧、双侧置钉治疗胸腰段单椎体骨折的疗效对比. 福州: 福建医科大学, 2017.
22. Dong J, Rong L, Feng F, et al. Unilateral pedicle screw fixation through a tubular retractor via the Wiltse approach compared with conventional bilateral pedicle screw fixation for single-segment degenerative lumbar instability: a prospective randomized study. J Neurosurg Spine, 2014, 20(1): 53-59.
23. Wang HW, Li CQ, Zhou Y, et al. Percutaneous pedicle screw fixation through the pedicle of fractured vertebra in the treatment of type A thoracolumbar fractures using sextant system: an analysis of 38 cases. Chin J Traumatol, 2010, 13(3): 137-145.
24. Wood KB, Bohn D, Mehbod A. Anterior versus posterior treatment of stable thoracolumbar burst fractures without neurologic deficit: a prospective, randomized study. J Spinal Disord Tech, 2005, 18(Suppl): S15-S23.
25. Kim BG, Dan JM, Shin DE. Treatment of thoracolumbar fracture. Asian Spine J, 2015, 9(1): 133-146.
26. Sun C, Guan G, Liu X, et al. Comparison of short-segment pedicle fixation with versus without inclusion of the fracture level in the treatment of mild thoracolumbar burst fractures. Int J Surg, 2016, 36(Pt A): 352-357.
27. Pellisé F, Barastegui D, Hernandez-Fernandez A, et al. Viability and long-term survival of short-segment posterior fixation in thoracolumbar burst fractures. Spine J, 2015, 15(8): 1796-1803.
28. Deng Z, Zou H, Cai L, et al. The retrospective analysis of posterior short-segment pedicle instrumentation without fusion for thoracolumbar burst fracture with neurological deficit. Scientific World J, 2014, 2014: 457634.
29. Vu TT, Morishita Y, Yugue I, et al. Radiological outcome of short segment posterior instrumentation and fusion for thoracolumbar burst fractures. Asian Spine J, 2015, 9(3): 427-432.
30. Mahar A, Kim C, Wedemeyer M, et al. Short-segment fixation of lumbar burst fractures using pedicle fixation at the level of the fracture. Spine (Phila Pa 1976), 2007, 32(14): 1503-1507.
31. Xu BS, Tang TS, Yang HL. Long-term results of thoracolumbar and lumbar burst fractures after short-segment pedicle instrumentation, with special reference to implant failure and correction loss. Orthop Surg, 2009, 1(2): 85-93.
32. Takami M, Yamada H, Nohda K, et al. A minimally invasive surgery combining temporary percutaneous pedicle screw fixation without fusion and vertebroplasty with transpedicular intracorporeal hydroxyapatite blocks grafting for fresh thoracolumbar burst fractures: prospective study. Eur J Orthop Surg Traumatol, 2014, 24(Suppl 1): S159-S165.
33. Tong MJ, Tang Q, Wang CG, et al. Efficacy of using intermediate screws in short-segment fixation for thoracolumbar fractures: a meta-analysis of randomized controlled trials. World Neurosurg, 2018, 110: e271-e280.
34. Dobran M, Nasi D, Brunozzi D, et al. Treatment of unstable thoracolumbar junction fractures: short-segment pedicle fixation with inclusion of the fracture level versus long-segment instrumentation. Acta Neurochir (Wien), 2016, 158(10): 1883-1889.
35. Anekstein Y, Brosh T, Mirovsky Y. Intermediate screws in short segment pedicular fixation for thoracic and lumbar fractures: a biomechanical study. J Spinal Disord Tech, 2007, 20(1): 72-77.
36. Luo J, Gong M, Gao M, et al. Both unilateral and bilateral pedicle screw fixation are effective for lumbar spinal fusion-a meta-analysis-based systematic review. J Orthop Translat, 2014, 2(2): 66-74.
37. Li C, Zhou Y, Wang H, et al. Treatment of unstable thoracolumbar fractures through short segment pedicle screw fixation techniques using pedicle fixation at the level of the fracture: a finite element analysis. PloS One, 2014, 9(6): e99156.
38. Chen HH, Cheung HH, Wang WK, et al. Biomechanical analysis of unilateral fixation with interbody cages. Spine (Phila Pa 1976), 2005, 30(4): E92-E96.

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Meta-analysis of the long-term efficacy of unilateral versus bilateral screw fixation on thoracolumbar single vertebral fracture

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