Thoracolumbar fractures constitute the bulk of spine fractures caused by the failure of both the anterior and middle columns of the vertebral body, with or without flexion force. Surgical fixation of thoracolumbar fractures can effectively decrease complications related to prolonged recumbency. The goals of surgical fixation include stabilization of the spine, fracture reduction, and, as appropriate, decompression of neurological structures. Pedicle screw systems, which were first introduced by Boucher, have been widely utilized in the instrumentation of the lumbar spine. Open operations, like operations using the normal midline approach or a paraspinal approach, have proven to be safe an

Thoracolumbar fractures constitute the bulk of spine fractures caused by the failure of both the anterior and middle columns of the vertebral body, with or without flexion force. Surgical fixation of thoracolumbar fractures can effectively decrease complications related to prolonged recumbency. The goals of surgical fixation include stabilization of the spine, fracture reduction, and, as appropriate, decompression of neurological structures. Pedicle screw systems, which were first introduced by Boucher, have been widely utilized in the instrumentation of the lumbar spine. Open operations, like operations using the normal midline approach or a paraspinal approach, have proven to be safe and became standard methods for lumbar fusion surgery. Magerl reported the primary use of percutaneous pedicle screw instrumentation in 1977.

However, open procedures are associated with significant perioperative morbidities, such as blood loss or complications. Therefore, minimally invasive techniques for spinal surgery have increased in popularity. Compared to the open approach, the minimal approach has many advantages for the treatment of thoracolumbar fractures, like small incision, no paraspinous muscle dissection and fewer blood loss. Decreased control of the reduction, the upkeep of lordosis and longer fluoroscopy time are limitations of the percutaneous approach.

Search Strategy and Inclusion

Criteria

To obtain relevant literature, a survey of articles published by May 2017 within the MEDLINE, EMBASE and Cochrane databases was conducted. All fields were screened using the key terms “Minimally invasive”, “Percutaneous pedicle screw” or “Open pedicle screw” and “thoracolumbar fracture” or “lumbar fracture”. Pertinent articles in reference lists were also examined. All eligible publications written in English or Chinese that addressed the association between percutaneous and open pedicle screw fixation were searched group included at least 10 patients. Case reports, reviews, biomechanical studies, cadaveric studies, and duplicate studies were excluded from this meta-analysis.

Data Extraction and Quality

Assessment The following information was extracted from each publication:

1) The primary author’s surname, study year, country and study design;

2) Basic study characteristics, including the amount and ages of enrolled patients and therefore the gender ratio for these patients;

3) Perioperative results, such as operative duration, blood loss, and hospitalization;

4) Rates of complications (e.g., infection or screw misplacement);

5) Data regarding both intraoperative and postoperative complications were extracted.

The quality of the included studies was evaluated using the Cowley criteria. A Cowley score of a minimum of 9 out of a possible 17 was considered indicative of high methodological quality.

Statistical Analysis

This analysis was conducted using the statistical software Review Manager, version 5.3 (Cochrane Collaboration). Because the included studies reported similar findings, only results produced by a random effects model were presented. Continuous outcomes were assessed by calculating weighted mean differences (WMDs) and 95% confidence intervals (CIs). Funnel plots were utilized to assess the possibility of publication bias.

Literature Survey and Study

Characteristics

Eleven comparative studies were identified. The essential search strategy yielded 144 records. Eighty-two articles were screened by title and abstract. Thirty-one case reports, reviews, biomechanical studies, and cadaveric studies were excluded. One duplicate study was found.

Finally, studies that reported outcomes for a complete of 575 patients were included within the

Meta-analysis. All of those patients had been diagnosed with thoracolumbar fracture without neurological compromise via X-rays, computerized tomography (CT) scans and resonance imaging (MRI)

Clinical Outcomes

One study provided means and p-values22, whereas the other seven studies reported adequate mean and standard deviation data11-13,18,19,21,23. The WMD for VAS score was 1.06 lower for the minimal group than the open group (95% CI: -1.32 to -0.8, p.

Complications

Eight studies reported complications related to surgery. Infection, thrombus, screw misplacement and breakage of the pedicle screw were observed. the general complication rates within the minimal and open groups didn't significantly differ (OR 0.78, 95% CI: 0.39 to 1.55, p=0.48). There was no evidence of serious heterogeneity among studies (I2= 0%, p=0.54;). No significant difference in complication rates between the 2 sorts of procedures was found either in studies originating in China (OR 1.12, 95% CI: 0.47 to 2.66, p=0.8) (OR 0.4, 95% CI: 0.12 to

1.36, p=0.14).

Sensitivity Analysis

Sensitivity analysis was conducted by reanalyzing the info after the sequential omission of individual studies. Significant funnel plot asymmetry was observed for blood loss, operative time, and postoperative VAS outcomes. This finding indicated that there was significant publication bias among the studies included during this meta-analysis.

The question of whether percutaneous screw fixation or open screw fixation may be a better treatment for thoracolumbar fracture without neurological deficits remains controversial. Evidence from this updated meta-analysis, which was supported epidemiological studies of high methodological quality, indicated that relative to the open approach, the minimal approach resulted during a lower VAS score, less correction loss, shorter operative time and fewer blood

loss. However, high heterogeneity existed among the included studies. a big difference was observed between Chinese studies and other studies with reference to blood loss. Complication rates for the 2 sorts of procedures didn't significantly differ.

Due to its particular anatomical features, the thoracolumbar region has the very best incidence of spinal fractures. Although open posterior instrumented spinal procedures cause extensive damage to soft tissue that inevitably leads to a high incidence of syndromes related to failed back surgery, such procedures are widely accepted approaches for managing various sorts of thoracolumbar fractures25. In recent decades, there has been a clear trend toward minimizing soft tissue injury during spinal surgery. Percutaneous screw fixation has been wont to treat thoracolumbar fractures.

However, percutaneous screw fixation and open screw fixation treatments for thoracolumbar fractures, particularly those without neurologic deficits, remain controversial. The results of our research address previously reported advantages of percutaneous pedicle fixation compared to the open approach. Reductions in blood loss due to the utilization of a minimal approach are demonstrated in many domains of surgery. Although high heterogeneity among studies was detected, our findings are consistent with these observations. This phenomenon could also be

associated with damage to paraspinal muscles in the open approach.