Open versus Percutaneous Stabilization of Thoracolumbar Fractures: An Analysis of Safety, Facility Utilization, and Rates of Revision Surgery

Introduction: Management of thoracolumbar fractures (TLF) has been the focus of surgeons for decades. While unstable fractures warrant surgical intervention, the debate between open and minimally invasive approaches to instrumentation has long divided surgeons. Currently, there is no conclusive evidence demonstrating the superiority of percutaneous screws over open fixation for TLF. Herein, we present the largest retrospective comparison of perioperative safety and rates of revision surgery between open and percutaneous stabilization of short-segment TLF.

Methods: Patients who underwent spinal fixation for short-segment TLF at our institute from 2008-2021 were reviewed. Patient demographics, number of screws used, intraoperative adjunct procedures, imaging, facility utilization, and rates of revision surgery were compared between open and percutaneous approaches.

Results: 713 patients (n=393 open, n=320 percutaneous) were available for review. Patients in the percutaneous cohort were more frequently males (65.3% vs. 53.4%; p< 0.001), required fewer total screws (6.8 vs. 8.1; p< 0.001), did not frequently need decompression (8.1% vs. 72.0%; p< 0.001) or fusion grafting (19.1% vs. 96.2%; p< 0.001), required significantly lesser fluoroscopy (59.7% vs. 69.0%; p< 0.010), and sustained lower estimated blood loss (71 vs 342 ml; p< 0.001) and shorter length of surgery (114 vs. 155 minutes; p< 0.001). No significant difference was seen in the rates of reoperation between the two cohorts. However, greater frequency of elective, asymptomatic hardware removal was seen with the percutaneous cohort, while revision surgery due to significantly greater incidence of hardware failure, pseudoarthrosis, and wound complications was seen in the open group (p < 0.001).

Conclusion : Percutaneous screw fixation for TLF was associated with shorter operative time, shorter segment fusion, and a greater safety profile without any difference in the reoperation rate. However, reoperation in the percutaneous group was most often elective. Further longitudinal studies investigating costs and outcomes are warranted as we move towards an era of value-based healthcare.