Role of Including the Index level in Short Segment Pedicular Fixation in Traumatic Thoraco-Lumbar Fractures
Authors: EL-Shazly Ayman Abd-El-Ra’ouf , Hamada Salah Mostafa , Nagaty Ahmed Maged , Nabih Ahmed Adel 
Published: October 2021

Abstract

Background
It is generally acknowledged that short-segment pedicle screw instrumentation is the preferred surgical method for thoracolumbar fractures. However, the use of short-segment instrumentation with or without intermediate screws at the fracture level remains controversial. This review will evaluate the evidence available to date regarding the efficacy of including the fracture level in trans-pedicular screw short segment fixation, to assess clinical and radiological outcome.

Objectives
Our primary objective is evaluating the efficacy and outcome of including the fractured level vertebra in short segment fixation. And concerns regarding the use of pedicle screws into the fractured vertebra as to whether it is safe to insert a screw through a broken bone. Our secondary objective analyzing the importance of posterior pedicle screw fixation in unstable thoracolumbar fractures.

Methods
The following electronic databases will be searched from 1992 to 2018: PubMed, Google scholar search engine. Cochrane database of systematic reviews, EMBASE and science Direct, using the keywords “TLICS”, "index screw", “short segment fixation”, "Thoracolumbar spine trauma", "traumatic spine injury", "spinal cord injury", "spine trauma", "role", “reliability”.Studies will be eligible if they contain the target keywords in title or abstract, addressing our age group. Afterwards the full text of the articles will be reviewed to exclude full texts not fulfilling the criteria or deviating from the initial impression taken from the title/abstract reviewing. References/bibliography of the selected articles will be examined to evaluate potential for further research and possible inclusion in the analysis. Any differences will be sorted by discussion between study team (student, director, and co-directors).

Results
A total of 3010 studies were screened for eligibility , 8 studies were included in our systematic review for comparing the short segment fixation “including” the fracture level with “conventional” methods whether short or long segment fixation. Overall study population reached 512 patients. Analysis showed comparable results regarding clinical picture and radiography, showing highly statistically significant difference in favor of “including” index level in fixation in post operative kyphosis angle correction, loss of correction of kyphosis angle through follow up until 2 years and loss of correction of AVH, also statistically significant difference in rate of implant failure in favor for “including” group, and with no significant difference in operative time , blood loss and VAS for post-operative pain.

Conclusion
We conclude that Short segment fixation including the fracture level is a promising surgical option when it comes to thoraco-lumbar unstable fractures. In conclusion, inclusion of the fracture level into the construct offers a better kyphosis correction, in addition to fewer instrument failures, without additional complications, and with a comparable-if not better-clinical outcome, the radiologic correction achieved is maintained even at the end of 2 years and reflected in good functional outcomes. We recommend insertion of screws into pedicles of the fractured thoracolumbar vertebra when considering a short segment posterior fixation, especially in Magerl type C fractures. Large population prospective randomized controlled studies and clinical trials are recommended for more high level evidence data.