Percutaneous Screw Distraction vs Open Surgery for Anatomic Restoration After Burst Fracture

Introduction: While the benefits of instrumentation for thoracolumbar burst fractures are clear and numerous, the optimal technique for operative stabilization remains an expert opinion. We sought to compare the radiographic outcomes between percutaneous fixed-angle screw instrumentation versus open pedicle screw fixation for thoracolumbar burst fractures without laminectomy.

Methods: Patients who underwent posterior instrumentation without laminectomy for traumatic thoracolumbar burst fracture were analyzed for sufficient pre-operative and post-operative radiologic imaging for inclusion. Data collected included patient demographics, perioperative characteristics, and radiographic outcomes such as vertebral body index (VBI), canal cross-sectional area (aCSA), and bisegmental Cobb angle (BCA). Statistical comparisons were conducted using t-tests and chi-square tests.

Results: Sixty-seven patients treated between 2018 and 2024 were included for analysis. Twenty-four patients underwent percutaneous fixation with fixed-angle screws, and 43 had open posterior instrumentation. Baseline demographics were comparable between the groups, though concurrent orthopedic and other injuries were more common in the open cohort (33.3% percutaneous vs. 65.1% open, p=0.01; 20.8% vs. 48.8%, p=0.02, respectively). The percutaneous group experienced significantly less intraoperative blood loss (94.4 ± 76.0 mL vs. 256.0 ± 225.8 mL, p< 0.001). Radiographically, the percutaneous group showed greater improvement in canal cross-sectional area (Δ0.5 ± 0.5 cm² vs. Δ0.2 ± 0.5 cm², p=0.02) from predistraction to postdistraction and also had improved vertebral body index from postdistraction to last follow-up (Δ8.3 ± 17.9 vs. Δ-2.3 ± 10.4, p=0.03). The groups were statistically similar in all other radiographic outcomes. Elective hardware removal was more frequent in the percutaneous cohort (41.7% vs. 2.3%, p< 0.001).

Conclusion : Percutaneous instrumentation for thoracolumbar burst fractures is not inferior to open techniques. In some measurements, percutaneous instrumentation yielded superior results, especially for indirect canal decompression and focal kyphosis at long-term follow-up. Long-term patient reported outcomes deserve further investigation. Evidence would be strengthened by multicenter trials to validate generalizability.