Anterior spine surgery in recent thoracolumbar fractures: An update

Surgical treatment of thoracolumbar spine fractures aims to achieve bony union and restore spinal anatomy. It may associate, as needed, decompression, reduction, graft and/or internal fixation, using a posterior, anterior or combined approach. Indications for an anterior approach weigh the pros and cons as well as the type of osteo-ligamentous lesion, degree of instability and patient's neurological status. The main interest of an anterior approach is to enable medullary decompression by corporectomy while allowing reconstruction of the anterior spine. The technique was less frequently used mainly due to its associated morbidity risk; but the development of videoscopy tools now allows less invasive surgery, compared to conventional thoracophrenolombotomy. Given also the mechanical drawbacks of posterior assembly in certain types of fracture, a video-assisted anterior approach is becoming more common. A conjunction of a staged anterior followed by a posterior approach has progressively developed, to address the needs of spinal trauma: this encompasses posterior surgical reduction-internal fixation, sometimes performed in emergency, with or without laminectomy followed by corporectomy, then anterior spinal reconstruction by graft with or without osteosynthesis to improve medullary decompression and avoid secondary correction loss and non-union. Adapting vertebroplasty techniques to spinal traumatology should gradually limit indications for an anterior approach for purely mechanical purposes; this later will, however, logically remain indicated when anterior spinal cord compression is present with associated neurological deficit, whether or not persisting after posterior reduction-osteosynthesis.