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CC BY 4.0 · Indian Journal of Neurotrauma
DOI: 10.1055/s-0045-1810107
Original Article

Safety and Feasibility of Including the Fracture Level in the Fixation Construct for Traumatic Vertebral Fractures

Hany Elkholy 
1   Department of Neurosurgery, Faculty of Medicine, Menoufia University, Shibin Elkom, Menoufia Governorate, Egypt
,
Mohamed Ahmed El Nagar 
1   Department of Neurosurgery, Faculty of Medicine, Menoufia University, Shibin Elkom, Menoufia Governorate, Egypt
,
Nour Elnoamany
1   Department of Neurosurgery, Faculty of Medicine, Menoufia University, Shibin Elkom, Menoufia Governorate, Egypt
,
Alaa Elsisi
2   Department of General Surgery, Faculty of Medicine, Menoufia University, Shibin Elkom, Menoufia Governorate, Egypt
,
Hisham Aborahma
1   Department of Neurosurgery, Faculty of Medicine, Menoufia University, Shibin Elkom, Menoufia Governorate, Egypt
› Author Affiliations

Funding None.
› Further Information
Also available ateRefMedOne
 
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Abstract

Background

Management of spinal injuries is continuously evolving and the main surgical aim is to restore the spine integrity. Performing short-segment fixation (SSF) or long-segment fixation (LSF) is still under debate and there is limited data concerning the safety and value of including the fracture segment in the fixation construct.

Materials and Methods

A retrospective observational series included 69 patients ≥ 18 years who suffered unstable thoracic, lumbar, or thoracolumbar vertebral fractures that were treated with pedicle screws fixation from January 2021 to January 2024. The aim was to evaluate the safety and value of including the fracture level in the fixation construct; preoperative clinical and radiographic parameters (visual analog scale [VAS], Oswestry Disability Index [ODI], anterior vertebral body [AVB] height) were compared with the postoperative ones at discharge and after 12 months.

Results

The mean age was 32.61 ± 9.11 years. Males constituted 55.1%. Back pain was the predominant clinical presentation followed by lower limb weakness, 24.6%. L1 was the most commonly affected level (34.8%) followed by D12 (33.3%). SSF was done in 65.2% and 34.8% were operated with LSF. Patients operated with SSF showed less intraoperative blood loss and shorter operative duration. After 12 months, there was significant improvement in regards to VAS score, Cobb angle, ODI score, and AVB height (p < 0.001).

Conclusion

While treating vertebral fractures, provided that the pedicle walls are intact, incorporation of the fractured vertebra in the fixation construct can offer a safe, feasible, and effective method for intraoperative fracture reduction and correction of sagittal deformity, in addition to good stiffness, strong pullout strength, and maintained correction over time.


 

Keywords

vertebral fractures - short-segment fixation - long-segment fixation - transpedicular screws - fracture level

Introduction

Vertebral column fractures involving the thoracic, lumbar, or thoracolumbar (TL) regions constitute a wide range of spinal injuries extending from simple fractures to complex fracture dislocations. Vertebral fractures (VFs) may result in significant disability, spinal deformity, and can lead to variable neurological deficits.[1] [2]

Management of VFs is continuously evolving with the main surgical aim is to restore the integrity of the vertebral column. Different surgical techniques are available for treating VFs including: posterior, anterior, open, minimally invasive, and combined posterior-anterior approaches.[3] [4] [5]

Pedicle screws have become a well-established surgical technique for the management of VFs. Attempting to achieve successful clinical recovery, the relevant point to decide for is the number of levels that should be instrumented.[6] Performing long-segment fixation (LSF) including two or more levels above and below the fractured vertebra carry the benefits of low failure rate and better stabilization; however, it can be associated with significant reduction of vertebral mobility, back pain, and implant failure as the main postoperative drawbacks.[7] On the other hand, short-segment fixation (SSF) including one segment above and below the fracture level can preserve the range of mobility but it may be associated with the disadvantages of inadequate stability, loss of kyphosis correction, and risk of implant failure.[8]

Literature demonstrated that inclusion of the fractured vertebra in the fixation construct may improve stability and reduce the rate of implant failure.[7] However, still there is controversy and limited data concerning the safety and feasibility of including the fracture segment in the fixation construct where, the decision is always based on the surgeon preference and previous expertise. Hence, in the current series the main objective was to evaluate the safety and value of including the fracture segment in the fixation construct among cases suffering from VFs.


 

Materials and Methods

Study Design and Patients Population

This is a retrospective observational study that was performed on adult patients aged ≥ 18 years suffering from unstable posttraumatic thoracic, lumbar, or TL (T11-L2) spine fractures that were admitted to our neurosurgery department and were surgically treated with pedicle screws fixation from January 2021 to January 2024. This study was approved by the local ethical scientific committee of our institution (IRB approval number: 12/2024.SURG. 23).


 

Eligibility Criteria

We included patients aged 18 years or older, had single level or two contiguous level posttraumatic thoracic, lumbar, or TL spine fractures, presented with no or incomplete neurological deficit, and treated either with SSF or LSF including the fracture level in the fixation construct. We excluded patients younger than 18 years, with osteopenia or osteoporosis, with previous spine surgery, with multiple noncontiguous VFs, in whom the fractured level was not incorporated in the fixation construct, or presented with complete paraplegia.

During our study period, a total of 102 cases were diagnosed with traumatic VFs. Based on our eligibility criteria 33 cases were excluded (6 cases were younger than 18 years, 11 cases were managed conservatively with bed rest and lumbar support, and 16 cases were operated without inclusion of the fracture level in the fixation construct). So, 69 cases were included in our series. [Fig. 1] demonstrates the distribution of included and excluded cases.

Zoom
Fig. 1 A flowchart demonstrating included and excluded cases.

 

Data Collection

Patients' data were collected from the medical records of our department. Preoperative clinical and radiological data included: age, sex, previous spine surgery, mode of trauma, symptoms and signs, radiological criteria included (fracture level, integrity of the pedicles of the fractured segment, Cobb angle, anterior vertebral height [AVH], and associated conditions). Operative data included (operation time, blood loss, side, length, diameter, reported difficulty, and complications regarding pedicle screws in the fractured vertebra). Postoperative data included: pain improvement, Cobb angle, and anterior vertebral body (AVB) height compared with the preoperative values.


 

Surgical Technique

All cases were operated upon under general anesthesia in prone position. Standard posterior spinal approach was performed. Transpedicular screws were used in all cases and the number of instrumented levels was preoperatively determined by the operating neurosurgeon. The fractured level was instrumented either on one or both sides based on the pedicle integrity. Spinal canal decompression was performed at the fracture level and collected bone graft was placed laterally on both sides.


 

Outcome Measures

General, clinical, and radiological parameters included: (1) the Oswestry Disability Index (ODI) score in the pre- and postoperative period; (2) pre- and postoperative back pain using the visual analog scale (VAS) score; (3) operation time and intraoperative blood loss; (4) length of hospital stay; (5) operative-related complications; (6) the American Spinal Injury Association Impairment (ASIA) scale; (7) pre- and postoperative Cobb angles (the angle between the two tangents of the upper and lower endplates of the upper and lower end vertebra of the structural curvature respectively); (8) pre- and postoperative AVH of the fractured level; and (9) implant failure.


 

Statistical Analysis

SPSS V.25 (IBM Corporation, Armonk, New York, United States) was used to statistically analyze the results and Microsoft Excel 2013 (Microsoft Corporation, Redmond, Washington, United States) was used to tabulate it. Count data were expressed as the rate and were statistically analyzed using the chi-square test. Different pre- and postoperative means were compared using the standard Student's t-test (t) for paired samples. The two fixation techniques (SSF vs. LSF) were compared using the standard Student's t-test (t), for independent samples. A p-value of less than or equal to 0.05 was considered as statistical significance.


 

 

Results

Demographic, Clinical, and Radiological Data among Studied Patients

Our study included 69 adult patients between 19 and 54 years, the mean age was 32.61 ± 9.11 years. Males constituted 55.1% and females 44.9%. Fall from height (FFH) was the most common mode of trauma (59.4%). All cases were admitted within the first 24 hours after trauma with the mean time between trauma and admission was 12.22 ± 4.572 hours. Back pain was the predominant clinical presentation in 100% of cases followed by lower limb weakness (24.6%). In regards to the ASIA scale, 52 cases (75.4%) were grade E, 12 cases (17.4%) were grade D, and 5 cases (7.2%) were grade C. [Table 1] demonstrates the preoperative clinical data among studied cases.

Table 1

Clinical data of included patients

Variable

Frequency

%

Age groups

 18–30 y

28

40.5

 31–50 y

36

52.2

 > 50 y

5

7.3

Sex

 Male

38

55.1

 Female

31

44.9

Mode of trauma

 FFH

41

59.4

 RTA

28

40.6

Clinical presentation

 Back pain

72

100

 Lower limbs weakness

17

24.6

 Autonomic deficit

3

4.3

 Sensory deficit

5

7.2

Preoperative VAS score

 Mean ± SD

7.99 ± 1.35

 Range

4–10

Preoperative ODI (mean ± SD)

54.45 ± 8.83

Abbreviations: FFH, fall from height; ODI, Oswestry Disability Index; RTA, road traffic accidents; SD, standard deviation; VAS, visual analog scale score.


L1 was the most common vertebral level affected (34.8%) followed by D12 (33.3%). [Fig. 2] illustrates the frequency of fracture level among studied cases. The mean preoperative Cobb angle was 22.68 ± 2.86 degrees. The mean AVB height was 16.75 ± 2.27 mm.

Zoom
Fig. 2 Distribution of fracture level among included cases.

 

Intraoperative Data among Studied Cases

[Table 2] represents the intraoperative data among included cases. Forty-five cases (65.2%) were operated with SSF and 24 cases (34.8%) were operated with LSF. [Figs. 3] and [4] illustrate the pre- and postoperative images of two cases.

Table 2

Operative data among included patients

Variable

Frequency

%

Mode of fixation

 SSF

45

65.2

 LSF

24

34.8

Blood loss in mL (mean ± SD)

272.75 ± 41.17

Operative time in minutes (mean ± SD)

151.70 ± 19.22

Screws in fracture segment

 Unilateral

48

69.5

 Bilateral

21

30.5

Abbreviations: LSF, long-segment fixation; SD, standard deviation; SSF, short-segment fixation.


Zoom
Fig. 3 Male patient, 40 years old, with history of fall from height (FFH). Patient has bilateral lower limbs weakness (grade 1 distal, grade 3 at the knee, and grade 2 at the hip) with sensory level up to mid-calf muscles; stool and urine retention and catheter inserted in emergency room (ER). (A) The preoperative computed tomography (CT) scan showing fracture of L1 vertebra with retro-pulsed fragment. (B) Preoperative magnetic resonance imaging (MRI) of the dorsolumbar spine. (C) Postoperative X-ray showing transpedicular screws in D12, L1, and L2. (D) Follow-up X-ray lateral view after 12 months.
Zoom
Fig. 4 Male patient, 38 years old, with history of fall from height (FFH). Patient has bilateral lower limbs weakness (grade 2) (A). (B) Preoperative computed tomography (CT) scans showing L1 and L2 vertebral fracture with retro-pulsed fragment. (C) Preoperative magnetic resonance imaging (MRI) of the dorsolumbar spine. (D) Postoperative X-ray (anterior-posterior [A-P] and lateral views) showing transpedicular screws in D12, L1, L2, and L3. (E) Follow-up X- ray lateral view after 12 months.

 

Postoperative Data among Studied Cases at Discharge

Hospital stay ranged from 2 to 6 days with the mean duration being 3.72 ± 1.05 days. At discharge, the VAS score was improved among all cases and the mean score reached 3.22 ± 1.04. Blood transfusion was indicated in five cases (7.2%). Postoperative complications were reported in four cases (5.8%), where two cases (2.9%) developed wound infection and the other two cases (2.9%) had misdirected screws.


 

Follow-Up Data among Studied Cases (After 12 Months)

As shown in [Table 3], all cases showed postoperative significant improvement (p < 0.001) in regards to VAS score, Cobb angle, ODI score, and AVB height. [Table 4] demonstrates the pre- and postoperative clinical evaluation of patients according to the different grades of the ASIA scale.

Table 3

Clinical and radiological data after 12 months

Variable

Preoperative

After 12 months

p-Value

VAS score (mean ± SD)

7.99 ± 1.35

1.12 ± 0.60

< 0.001[a]

Cobb angle (mean ± SD)

22.68 ± 2.86

13.05 ± 1.81

< 0.001[a]

ODI (mean ± SD)

54.45 ± 8.83

21.96 ± 4.13

< 0.001[a]

AVB height (mean ± SD)

16.75 ± 2.27

17.82 ± 2.25

< 0.001[a]

Abbreviations: AVB, anterior vertebral body; ODI, Oswestry Disability Index; SD, standard deviation; VAS score, visual analog scale score.


a Statistically significant.


Table 4

Clinical evaluation of patients according to the ASIA scale

Grade

Number of patients

Preoperative

At discharge

After 6 months

After 12 months

E

52

52

57

65

D

12

12

9

4

C

5

5

3

0

Abbreviation: ASIA, American Spinal Injury Association Impairment.


Notes: C = Incomplete: Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have a muscle grade of less than 3; D = Incomplete: Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have a muscle grade that is greater than or equal to 3; E = Normal: Sensory and motor functions are normal.



 

SSF versus LSF Techniques ([Table 5])

Table 5

Short-segment versus long-segment fixation

Variable

SSF

LSF

p-Value

Blood loss in mL (mean ± SD)

265.49 ± 45.14

286.38 ± 28.60

0.04[a]

Operative time in minutes (mean ± SD)

145.33 ± 19.56

163.60 ± 11.49

0.000[a]

Need for blood transfusion

1.89 ± 0.31

2.0 ± 0

0.092

Duration of hospital stay (mean ± SD)

3.51 ± 1.058

4.13 ± 0.947

0.02[a]

Postoperative complications

5.73 ± 1.07

5.83 ± 0.56

0.672

VAS score at discharge (mean ± SD)

0.96 ± 0.60

1.42 ± 0.50

0.002[a]

VAS score 12 months (mean ± SD)

0.38 ± 0.49

0.25 ± 0.44

0.290

Kyphotic angle at 12 months (mean ± SD)

12.86 ± 1.90

13.41 ± 1.59

0.227

ODI 12 months (mean ± SD)

21.64 ± 4.38

22.54 ± 3.64

0.395

AVB height 12 months (mean ± SD)

18.19 ± 2.38

18.12 ± 1.83

0.426

Abbreviations: AVB, anterior vertebral body; LSF, long-segment fixation; ODI, Oswestry Disability Index; SD, standard deviation; SSF, short-segment fixation; VAS, visual analog scale score.


a Statistically significant.


There was no significant difference between patients treated with either SSF or LSF in regards to age, sex, mode of trauma, or time to admission. Compared with those operated with LSF, patients operated with SSF showed significantly less intraoperative blood loss, shorter operative duration, shorter hospital stay, and improved VAS score at discharge. After 12 months, there was no significant difference between SSF and LSF.


 

 

Discussion

Because of the stiffer fixation and lower morbidity it offers, posterior pedicle screws fixation is still being considered the most frequent surgical procedure used for stabilization of VFs.[9] [10]

The traditional technique of LSF can provide stabilization enough to enable early mobilization with low risk of kyphosis and screws pull out. However, this method can result in a motionless spine.[6] The SSF technique has achieved increased popularity because of its advocated benefits of saving more segments of motion in addition to reducing the operative time and hospital costs.[11] [12] However, this technique showed some drawbacks such as inadequate long-term reduction and possibility of construct failure with risk of postoperative kyphosis.[13]

Dick et al[14] in 1994 were the first to describe including the fractured level in the short-segment construct. Moreover, others recommended insertion of pedicle screws at the fractured vertebrae aiming for more reinforcement of the construct and trying to avoid postoperative kyphosis.[6] [11]

In the current study, 69 patients with traumatic VFs were operated upon using pedicle screws fixation with inclusion of the fracture level in the fixation construct either in SSF or in LSF. No doubt that early admission, stabilization, and intervention has strong impact on postoperative neurological outcome. The mean time between trauma and admission was 12.22 ± 4.572 hours. The mean age was 32.61 ± 9.11 years (range: 19–54) with the majority of cases (36 cases) were between 30 and 50 years. Our findings are in line with previous studies,[13] [15] where young adults are more susceptible to trauma because of continuous activities and outdoor duties.

In our series, 55.1% were males and 44.9% were females. Literature demonstrated that males are more prone to spine trauma.[15] [16] FFH was the most frequent mode of trauma (59.4%) followed by road traffic accident (RTA) and this result comes in agreement with most of the previous studies.[13] [14] [15] [16] [17] [18] On the other hand, the Altay et al[19] study reported that the most frequent reason for injury was RTA.

Preoperative Clinical and Radiological Data

In our series, all cases (100%) suffered variable degrees of back pain and lower limb weakness was reported in 24.6%. The mean preoperative VAS score was 7.99 ± 1.35 with range from 4 to 10. The mean preoperative ODI was 54.45 ± 8.83. L1 vertebra was the most common vertebral level affected (34.8%) followed by D12 (33.3%). Previous studies[11] [17] [19] also reported that L1 was the most commonly affected vertebra. The mean preoperative Cobb angle was 22.68 ± 2.86 degrees. The mean AVB height was 16.75 ± 2.27 mm.


 

Intraoperative Data

Forty-five patients (65.2%) were operated with SSF and 24 cases (34.8%) were operated with LSF. The fracture level was included in the fixation construct either unilateral or bilateral. The mean intraoperative blood loss was 272.75 ± 41.17 mL. Patients operated with LSF showed significantly (p = 0.04) higher intraoperative blood loss. Close to our results, Al Mamun Choudhury et al[13] reported that the mean blood loss in the short-segment group was 350.38 ± 31.26 mL and was 427.31 ± 49.62 mL in the long-segment group (p < 0.001). In contrary to our result, Raja[15] reported that blood loss was statistically insignificant in cases operated with SSF (p = 0.23). The majority of our patients who required blood transfusion belonged to the LSF technique; however, the difference between the two fixation methods was of no statistical significance (p = 0.092).

The mean operative time was 151.70 ± 19.22 minutes. Operative time was significantly longer (p < 0.001) in patients operated with LSF (163.60 ± 11.49 minutes) in comparison to cases operated with SSF (145.33 ± 19.56 minutes). Hence, the SSF technique provides a time-saving method because of the smaller skin incision, limited muscle splitting, and fewer inserted pedicle screws. Most of the previous studies reported similar results.[11] [17] [20] [21]

Pedicle screws insertion in the fracture level was successful bilaterally in 48 cases (69.5%). In the remaining 21 cases (30.5%), insertion of screws in the fracture level was done unilaterally either due to fracture of the pedicle on the other side or failure of insertion. In all cases, it was reported that the length of screws inserted in the fracture level was shorter than other screws but the screw's diameter was chosen according to the size of the pedicle. The risk of screw breach into the spinal canal is always a concern among neurosurgeons. However, in most patients with vertebral burst fractures, the pedicle walls are usually intact and screw insertion can be similar to pedicle screw insertion in other vertebrae. In our series, there was no reported intraoperative screw breach into the spinal canal when inserting a screw through the broken vertebra. This reflects the safety of inserting screws in the fractured vertebra as long as its pedicle in not fractured. Mohammed et al[22] study reported similar results.


 

Postoperative Functional Recovery and Operative-Related Complications

The mean period of hospitalization was 3.72 ± 1.05 days. Patients operated with SSF had significantly shorter (p = 0.02) hospital stay (3.51 ± 1.058 days) compared with 4.13 ± 0.947 days in those operated with LSF. Postoperatively, VAS score was improved in all cases from 7.99 ± 1.35 preoperatively to 3.22 ± 1.04 at discharge. Improvement in VAS score was reported in those operated with either LSF or LSF; however, it was significantly higher in patients operated with SSF (p = 0.002). Similar to our results, Mohammed et al[22] study reported that back pain score was significantly lower in patients operated with fracture level screw construct (p = 0.025) compared with the nonfracture level group.

In our study, there was no reported postoperative neurological deterioration among included patients. This finding was similar to that reported in Hamdan et al[17] study. Postoperative complications were documented in four cases (5.8%). Two cases (2.9%) developed wound infection that was medically treated without sequelae. Two cases (2.9%) had hardware failure due to maldirected screws (this was in vertebral bodies other than the fractured one) and underwent resurgery for correction. The complication rate was insignificant between the two methods of fixation (SSF or LSF). Previous studies also reported insignificant variations regarding operative-related complications (p = 0.31 and 0.416) in Tezeren and Kuru[23] and Al Mamun Choudhury et al[13] studies, respectively. Also, in Mohammed et al[22] study conducted on 34 patients treated with fracture level screw construct compared with 19 patients who had no pedicle screws at the fractured vertebra, 6 patients required revision surgery, 5 for construct problems and 1 for deep infection. Notably, the two groups showed no significant difference in terms of revision surgery, wound infection, implant failure, or postoperative hospitalization.


 

Follow-Up Data (After 12 Months)

The mean VAS score was significantly improved (p < 0.001) from 7.99 ± 1.35 preoperatively to 1.12 ± 0.60 after 12 months. This finding was supported by multiple previous studies.[11] [13] [17]

ODI was significantly improved (p < 0.001) from 54.45 ± 8.83 preoperatively to 21.96 ± 4.13 after 12 months. In Hamdan et al[17] study, the mean ODI was 19.87% and patients reported minimal to moderate postoperative disability.

Cobb angle was significantly improved (p < 0.001) from 22.68 ± 2.86 preoperatively to 13.05 ± 1.81 after 12 months. El Behairy et al[24] concluded in their series that SSF with inclusion of the fractured vertebra was associated with good correction of segmental kyphosis that was maintained for 2 years. In Hamdan et al[17] study, the kyphotic angle showed significant postoperative improvement (p ≤ 0.001) as the mean Cobb angle was 19.37 degrees preoperatively versus 11.77 degrees postoperatively.

The AVB height was increased from 16.75 ± 2.27 preoperatively to 17.82 ± 2.25 after 12 months (p < 0.001). Hamdan et al[17] reported significant postfixation AVB height restoration. Also, Kanna et al[11] reported a significantly restored AVB height (13.86 mm preoperatively, 21.6 mm at discharge, and 21.1 mm at the end of follow-up). El Behairy et al[24] study also confirmed that including the fractured segment in the short-segment construct showed better restoration of AVB that was maintained for up to 2 years after fixation.

After 1 year of follow-up there was high fusion rate among included cases, where none had hardware failure; there was no reported lucency around the screws in 64 cases (92.75%) and bridging bone formation was reported in 62 cases (89.85%) without screws displacement or breakage.


 

The Value of Inserting Screws in the Fractured Vertebrae

Intraoperatively, including the fractured vertebra in the fixation construct either in SSF or LSF was of great help in fracture reduction and correction of sagittal deformity. Moreover, follow-up computed tomography images demonstrated good containment of screws inserted in the fractured level and revealed that fracture level screws have good stiffness and pullout strength and these cases showed no loss of correction over time. This result confirms safety when inserting a screw through the broken vertebra as long as the walls of the pedicles are intact. Guven et al[6] in their series reported that inserting screws at the fracture level can help in intraoperative fracture reduction and sagittal deformity correction. Results from Mohammed et al[22] series reported that applying fracture level screw had the advantage of sagittal index correction better than without its use. Also, other studies[11] [12] [25] reported that kyphosis correction was significantly better in SSF including the fractured level than in SSF skipping the fractured level. Studies conducted by Guven et al,[6] Mahar et al,[8] and Bolesta et al[26] reported increased biomechanical stability and maintained kyphosis correction with inclusion of the fracture level in the fixation construct.

Among our cases, none had hardware failure at final follow-up. Our results come in accordance with the Hamdan et al[17] study; they reported no lucency around the screws in 96.7% of cases, bridging bone formation in 93.3% of cases without screws displacement or breakage. Hence, they recommend inclusion of the fracture segment within the short-segment construct. Also, at the final follow-up in Kanna et al[11] study, no patient had postoperative implant failure.


 

Short-Segment versus Long-Segment Fixation Methods

Comparing the follow-up (after 12 months) results among patients operated with either SSF or LSF showed no significant difference in regards to VAS score (p > 0.05). For SSF, the mean preoperative Cobb's angle was 22.65 ± 2.86 degrees and the angle of correction was 9.79 ± 3.63 degrees after 12 months. While in LSF, the mean preoperative Cobb's angle was 22.74 ± 2.91 degrees and the angle of correction was 9.32 ± 3.20 degrees after 12 months.

It is worth noting that although the reduction of Cobb angle and the increase in AVH were higher in the SSF group, the difference between the two groups was nonsignificant. Similar to our results, Aly[27] reported that the difference in ODI score between included groups revealed no statistical significance (p = 0.36). Also, Al Mamun Choudhury et al[13] reported that the VAS and ODI scores between the short- and the long segment groups was statistically nonsignificant (p = 0.587 and 0.161, respectively). Dobran et al[16] also showed no significant difference between SSF including fractured level and LSF in regards to kyphosis correction or maintenance. Whereas for the SSF group the mean postoperative kyphotic angle was 14.2 ± 6.50 degrees and it was 17.13 ± 11.63 degrees for the LSF group, with the average correction being 6.73 and 5.46 degrees, respectively. However, this difference had no statistical significance (p = 0.243). Ökten et al[12] reported similar results where the mean Cobb angle at the last follow-up was not statistically significant (p = 0.579). Similarly, in Al Mamun Choudhury et al[13] study, the mean Cobb angle at the last follow-up was 9.13 ± 3.04 and 10.18 ± 3.35 degrees in short- and long-segment groups, respectively, with no significant difference (p = 0.120).

On the other hand, Sapkas et al[28] reported a statistically significant difference where the favorable measures were found in the LSF group. However, there was no incorporation of the fractured level in either fixation technique. Waqar et al[29] concluded that patients operated with LSF had better postoperative kyphotic angle compared with those operated with SSF, however, the difference had no statistical significance (p = 0.068).


 

 

Limitations

The limitations of our study come from its retrospective nature, the fact that it was a single-center experience, and operations were performed by different surgeons. However, we believe that this baseline information can be important and can provide a basis for comparison for future trials.


 

Conclusion

Incorporation of the fractured vertebra in the fixation construct can offer a safe, feasible, and effective surgical step while treating patients with VFs provided that the pedicle walls are intact. Screws in the fractured vertebra usually possess good stiffness and strong pullout strength that can be of great help in intraoperative fracture reduction and correction of sagittal deformity; in addition to the advantage of maintained correction over time.

Doing a SSF technique with inclusion of the fractured level showed a comparable clinical and functional outcome to LSF without additional complications. Moreover, the operative time, intraoperative blood loss, hospital stay, and overall cost of surgery can be significantly lower in the SSF technique. Hence, we recommend considering SSF for VFs (lumbar, thoracic, or TL junction) whenever insertion of screws into the pedicles of the fractured vertebra is feasible.


 

 

Conflict of Interest

None declared.

Note

This study was performed in the Department of Neurosurgery, Faculty of Medicine, Menoufia University Hospital.


Authors' Contributions

All authors made a significant contribution to the work reported, whether that was in the conception; study design; execution; and acquisition, analysis, and interpretation of data. All authors took part in drafting, revising, and final approval of the article. This article has been read and approved by all authors and all agreed to be accountable for all aspects of the work.


Data Availability Statement

All data and materials included in this work are available.


Ethical Approval

This study was approved by the clinical research committee of the faculty of Medicine, Menoufia University (IRB approval number: 12/2024.SURG. 23) and it followed the tenets of the Declaration of Helsinki.



Address for correspondence

Hany Elkholy, MD
Department of Neurosurgery, Faculty of Medicine, Menoufia University
Shibin Elkom, Menofia Governorate 6131567
Egypt   

Publication History

Article published online:
05 August 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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Zoom
Fig. 1 A flowchart demonstrating included and excluded cases.
Zoom
Fig. 2 Distribution of fracture level among included cases.
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Fig. 3 Male patient, 40 years old, with history of fall from height (FFH). Patient has bilateral lower limbs weakness (grade 1 distal, grade 3 at the knee, and grade 2 at the hip) with sensory level up to mid-calf muscles; stool and urine retention and catheter inserted in emergency room (ER). (A) The preoperative computed tomography (CT) scan showing fracture of L1 vertebra with retro-pulsed fragment. (B) Preoperative magnetic resonance imaging (MRI) of the dorsolumbar spine. (C) Postoperative X-ray showing transpedicular screws in D12, L1, and L2. (D) Follow-up X-ray lateral view after 12 months.
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Fig. 4 Male patient, 38 years old, with history of fall from height (FFH). Patient has bilateral lower limbs weakness (grade 2) (A). (B) Preoperative computed tomography (CT) scans showing L1 and L2 vertebral fracture with retro-pulsed fragment. (C) Preoperative magnetic resonance imaging (MRI) of the dorsolumbar spine. (D) Postoperative X-ray (anterior-posterior [A-P] and lateral views) showing transpedicular screws in D12, L1, L2, and L3. (E) Follow-up X- ray lateral view after 12 months.