Combined anteroposterior fixation using a titanium cage versus solely posterior fixation for traumatic thoracolumbar fractures: A systematic review and meta-analysis

STUDY DESIGN: Systematic review with meta-analysis. OBJECTIVE: Additional anterior stabilization might prevent posterior implant failure, but over time, the disadvantageous of bone grafts have become evident. The objective of this systematic review was to compare risks and advantages of additional anterior stabilization with a titanium cage to solely posterior fixation for traumatic thoracolumbar fractures. METHODS: An electronic search was performed in the literature from 1980 to March 2016. Studies comparing only posterior with anteroposterior fixation by means of a titanium cage were included in this study. Data extraction and Cochrane risk of bias assessment were done by two independent authors. In addition, the PRISMA statement was followed, and the GRADE approach was used to present results. RESULTS: Of the 1584 studies, two randomized controlled trials (RCTs) and one retrospective cohort study were included in the meta-analysis. The RCTs reported evidence of high quality that anteroposterior stabilization maintained better kyphosis correction than posterior stabilization alone. However, these results were neutralized in the meta-analysis by the cohort study. Implant failure was reported by one study, in the posterior group. No differences in follow-up visual analog scale scores, neurologic improvement, and complications were found. Operation time, blood loss, and hospital stay all increased in the anteroposterior group. CONCLUSIONS: Patients with a highly comminuted or unstable fracture could benefit from combined anteroposterior stabilization with a titanium cage, for some evidence suggests this prevents loss of correction. However, large randomized studies still lack. There is a risk of cage subsidence, and increased perioperative risks have to be considered when choosing the optimal treatment.