Minimally Invasive Treatment for Traumatic Thoracolumbar Fractures
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Published:
Feb 11, 2021
Keywords:
Thoracolumbar fracture, percutaneous stabilization, minimally invasive surgery, spinal fusion, thoracolumbar arthrodesis
Main Article Content
Abstract
Introduction: Minimally invasive techniques for the treatment of thoracolumbar fractures have been developed to reduce perioperative morbidity. The primary purpose of this work is to evaluate the clinical and radiological outcomes in a group of patients with traumatic thoracolumbar fracture treated with minimally invasive procedures.
Materials and methods: Taking a group of patients within the inclusion criteria, we retrospectively analyzed demographic data, along with pre and postoperative radiographic measurements and postoperative functional scores, using the Oswestry Disability Index and the Visual Analog Scale for pain. We recorded the complications and the hospital stay.
Results: 15 patients were analyzed (10 of them were male). The average age was 59 years, and the average follow-up was 32.9 months. The patients presented an average postoperative pain score of 2/10 and an average Oswestry Disability Index score of 14/100. The radiographic analysis showed an average preoperative segmental kyphosis value of 16º that was corrected to 10° (p = 0.01). The preoperative average height for compromised vertebrae was 18 mm, with an average height of 21 mm at the last follow-up (p = 0.02). There were 3 complications (20%) in 3 patients. Hospital stay was 9 days long on average. Three patients were rehospitalized within 90 days after surgery.
Conclusion: The treatment of traumatic thoracolumbar fractures by minimally invasive techniques was a safe procedure, with good clinical and radiological results in the medium term of follow-up.
Level of evidence: IV
Materials and methods: Taking a group of patients within the inclusion criteria, we retrospectively analyzed demographic data, along with pre and postoperative radiographic measurements and postoperative functional scores, using the Oswestry Disability Index and the Visual Analog Scale for pain. We recorded the complications and the hospital stay.
Results: 15 patients were analyzed (10 of them were male). The average age was 59 years, and the average follow-up was 32.9 months. The patients presented an average postoperative pain score of 2/10 and an average Oswestry Disability Index score of 14/100. The radiographic analysis showed an average preoperative segmental kyphosis value of 16º that was corrected to 10° (p = 0.01). The preoperative average height for compromised vertebrae was 18 mm, with an average height of 21 mm at the last follow-up (p = 0.02). There were 3 complications (20%) in 3 patients. Hospital stay was 9 days long on average. Three patients were rehospitalized within 90 days after surgery.
Conclusion: The treatment of traumatic thoracolumbar fractures by minimally invasive techniques was a safe procedure, with good clinical and radiological results in the medium term of follow-up.
Level of evidence: IV
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Pereira Duarte, M., Camino Willhuber, G., Estefan, M. M., Kido, G. R., Bassani, J., Petracchi, M. G., Sola, C. A., & Gruenberg, M. (2021). Minimally Invasive Treatment for Traumatic Thoracolumbar Fractures . Revista De La Asociación Argentina De Ortopedia Y Traumatología, 86(1), 44-57. https://doi.org/10.15417/issn.1852-7434.2021.86.1.1026
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Clinical Research
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References
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2. Diaz Jr JJ, Cullinane DC, Altman DT, Bokhari F, Cheng JS, Como J, et al. Practice management guidelines
for the screening of thoracolumbar spine fracture. J Trauma 2007;63(3):709-18. https://doi.org/10.1097/
TA.0b013e318142d2db
3. Esses SI, Botsford DJ, Kostuik JP. Evaluation of surgical treatment for burst fractures. Spine (Phila Pa 1976)
1990;15(7):667-73. https://doi.org/10.1097/00007632-199007000-00010
4. Park Y, Ha JW. Comparison of one-level posterior lumbar interbody fusion performed with a minimally invasive
approach or a traditional open approach. Spine 2007;32(5):537-43. https://doi.org/10.1097/01.brs.0000256473.49791.f4
5. Kim DY, Lee SH, Chung SK, Lee HY. Comparison of multifidus muscle atrophy and trunk extension
muscle strength: percutaneous versus open pedicle screw fixation. Spine (Phila Pa 1976) 2005;30(1):123-9.
PMID: 15626992
6. Rampersaud YR, Annand N, Dekutoski MB. Use of minimally invasive surgical techniques in the management of thoracolumbar trauma: current concepts. Spine 2006;31:S96-S102. https://doi.org/10.1097/01.brs.0000218250.51148.5b
7. Weber BR, Grod D, Dvorak J, Müntener M. Posterior surgical approach to the lumbar spine and its effect on the
multifidus muscle. Spine (Phila Pa 1976) 1997;22:1765-72. https://doi.org/10.1097/00007632-199708010-00017
8. Ntilikina Y, Bahlau D, Garnon J, Schuller S, Walter A, Schaeffer M, et al. Open versus percutaneous instrumentation in thoracolumbar fractures: magnetic resonance imaging comparison of paravertebral muscles after implant removal. J Neurosurg Spine 2017;27(2):235-41. https://doi.org/10.3171/2017.1.SPINE16886
9. Phan K, Rao JP, Mobbs RJ. Percutaneous versus open pedicle screw fixation for treatment of thoracolumbar
fractures: Systematic review and meta-analysis of comparative studies. Clin Neurol Neurosurg 2015;135:85-92.
https://doi.org/10.1016/j.clineuro.2015.05.016
10. Foley KT, Gupta SK, Justis JR, Sherman MC. Percutaneous pedicle screw fixation of the lumbar spine. Neurosurg Focus 2001;10(4):E10. https://doi.org/10.3171/foc.2001.10.4.11
11. Mobbs RJ, Sivabalan P, Li J. Minimally invasive surgery compared to open spinal fusion for the treatment of
degenerative lumbar spine pathologies. J Clin Neurosci 2012;19(6):829-35. https://doi.org/10.1016/j.jocn.2011.10.004
12. Song HP, Lu JW, Liu H, Zhang C. [Case-control studies between two methods of minimally invasive surgery
and traditional open operation for thoracolumbar fractures]. Zhongguo Gu Shang 2012;25(4):313-6. [En chino]
PMID: 22812097
13. Court C, Vincent C. Percutaneous fixation of thoracolumbar fractures: current concepts. Orthop Traumatol Surg Res 2012;98(8):900-9. https://doi.org/10.1016/j.otsr.2012.09.014
14. Schmidt OI, Strasser S, Kaufmann V, Strasser E, Gahr RH. Role of early minimal-invasive spine fixation in acute
thoracic and lumbar spine trauma. Indian J Orthop 2007;41(4):374-80. https://doi.org/10.4103/0019-5413.37003
15. Gruenberg MG, Solá CA, Petracchi MG, Ortolán EG. Fracturas por estallido en la columna dorsolumbar
instrumentadas con tornillos pediculares. Rev Asoc Arg Ortop Traumatol 2003;68(4):273-83. https://www.aaot.org.ar/revista/2003/n4_vol68/art4.pdf
16. Nicolino TI, Petracchi M, Sola C, Valacco M, Gruenberg M. Evaluación clínica y radiológica de la instrumentación y artrodesis corta por vía posterior en fracturas toracolumbares. Rev Asoc Arg Ortop Traumatol 2015;80(1):20-29. https://doi.org/10.15417/267
17. Payares K, Lugo LH, Morales V, Londoño A. Validation in Colombia of the Oswestry disability questionnaire in
patients with low back pain. Spine (Phila Pa 1976) 2011;36(26):E1730-5. https://doi.org/10.1097/BRS.0b013e318219d184
18. Frankel HL, Hancock PO, Hyslop G, Melzak J, Michaelis LS, Ungar GH, et al. The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. Part I. Paraplegia 1969;7:179-92. https://doi.org/10.1038/sc.1969.30
19. Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S. A comprehensive classification of thoracic and lumbar
injuries. Eur Spine J 1994;3(4):184-201. https://doi.org/10.1007/BF02221591
20. Vaccaro AR, Lim MR, Hurlbert RJ, Lehman RA Jr, Harrop J, Fisher DC, et al. Surgical decision making for
unstable thoracolumbar spine injuries: results of a consensus panel review by the Spine Trauma Study Group. J
Spinal Disord Tech 2006;19:1-10. https://doi.org/10.1097/01.bsd.0000180080.59559.45
21. Zdichavsky M, Blauth M, Knop C, Graessner M, Herrmann H, Krettek C, et al. Accuracy of pedicle screw
placement in thoracic spine fractures. Part I: inter- and intra-observer reliability of the scoring system. Eur J Trauma 2004;30:234-240. https://doi.org/10.1007/s00068-004-1422-9
22. Zdichavsky M, Blauth M, Knop C, Lotz J, Krettek C, Bastian L. Accuracy of pedicle screw placement in thoracic
spine fractures. Part II: a retrospective analysis of 278 pedicle screws using computed tomographic scans. Eur J
Trauma 2004;30:241-7. https://doi.org/10.1007/s00068-004-1423-8
23. Pereira Duarte M, Petracchi MG, Mereles ME, Gruenberg M, Solá CA, Girardi FP. Artrodesis intersomática lateral de columna lumbar. Técnica quirúrgica y conceptos actuales. Rev Asoc Argent Ortop Traumatol 2018;83(4):303-316. https://doi.org/10.15417/issn.1852-7434.2018.83.4.754
24. Alanay A, Pekmezci M, Karaemigogullari O, Acaroglu E, Yazici M, Cil A, et al. Radiographic measurement of
the sagittal plane deformity in patients with osteoporotic spinal fractures evaluation of intrinsic error. Eur Spine J
2007;16(12):2126-32. https://doi.org/10.1007/s00586-007-0474-z
25. Assaker R. Minimal access spinal technologies: state-of-the-art, indications, and techniques. Joint Bone
Spine 2004;71(6):459-69. https://doi.org/10.1016/j.jbspin.2004.08.006
26. Wild MH, Glees M, Plieschnegger C, Wenda K. Five-year follow-up examination after purely minimally invasive
posterior stabilization of thoracolumbar fractures: a comparison of minimally invasive percutaneously and
conventionally open treated patients. Arch Orthop Trauma Surg 2007;127(5):335-43. https://doi.org/10.1007/s00402-006-0264-9
27. Pehlivanoglu T, Akgul T, Bayram S, Meric E, Ozdemir M, Korkmaz M, et al. Conservative versus operative
treatment of stable thoracolumbar burst fractures in neurologically intact patients: is there any difference regarding the clinical and radiographic outcomes? Spine (Phila Pa 1976) 2020;45(7):452-8.
https://doi.org/10.1097/BRS.0000000000003295
28. Koosha M, Nayeb Aghaei H, Khayat Kashani HR, Paybast S. Functional outcome of surgical versus conservative therapy in patients with traumatic thoracolumbar fractures and thoracolumbar injury classification and severity score of 4; A non-randomized clinical rrial. Bull Emerg Trauma 2020;8(2):89-97. https://doi.org/10.30476/BEAT.2020.46448
29. McCormack T, Karaikovic E, Gaines RW. The load sharing classification of spine fractures. Spine (Phila Pa 1976) 1994;19(15):1741-4. https://doi.org/10.1097/00007632-199408000-00014
30. Ni WF, Huang YX, Chi YL, Xu HZ, Lin Y, Wang XY, et al. Percutaneous pedicle screw fixation for neurologic intact thoracolumbar burst fractures. J Spinal Disord Tech 2010;23:530-7. https://doi.org/10.1097/BSD.0b013e3181c72d4c
31. Merom L, Raz N, Hamud C, Weisz I, Hanani A. Minimally invasive burst fracture fixation in the thoracolumbar
region. Orthopedics 2009;32(4): orthosupersite.com/view.asp?rID=38353. https://doi.org/10.3928/01477447-20090401-03
32. Palmisani M, Gasbarrini A, Brodano GB, De Iure F, Cappuccio M, Boriani L, et al. Minimally invasive percutaneous fixation in the treatment of thoracic and lumbar spine fractures. Eur Spine J 2009;18:71-4.
https://doi.org/10.1007/s00586-009-0989-6
33. Rechtine GR, Bono PL, Cahill D, Bolesta MJ, Chrin AM. Postoperative wound infection after instrumentation of
thoracic and lumbar fractures. J Orthop Trauma 2001;15(8):566-9. https://doi.org/10.1097/00005131-200111000-00006
34. Korovessis P, Hadjipavlou A, Repantis T. Minimal invasive short posterior instrumentation plus balloon kyphoplasty with calcium phosphate for burst and severe compression lumbar fractures. Spine (Phila Pa 1976) 2008;33(6):658-67. https://doi.org/10.1097/BRS.0b013e318166e0bb
35. Pelegri C, Benchikh El Fegoun A, Winter M, Brassart N, Bronsard N, Hovorka I, et al. Percutaneous fixation of
lumbar and thoracolumbar fractures without neurological involvement: surgical technique and preliminary results. Rev Chir Orthop Reparatrice Appar Mot 2008;94(5):456-63. https://doi.org/10.1016/j.rco.2008.03.035
36. Rampersaud YR, Foley KT, Shen AC, Williams S, Solomito M. Radiation exposure to the spine surgeon during
fluoroscopically assisted pedicle screw insertion. Spine (Phila Pa 1976) 2000;25(20):2637-45. https://doi.org/10.1097/00007632-200010150-00016
37. Knox JB, Dai JM III, Orchowski JR. Superior segment facet joint violation and cortical violation after minimally
invasive pedicle screw placement. Spine J 2011;11(3):213-7. https://doi.org/10.1016/j.spinee.2011.01.024
38. Patel RD, Graziano GP, Vanderhave KL, Patel AA, Gerling MC. Facet violation with the placement of percutaneous pedicle screws. Spine (Phila Pa 1976) 2011;36(26):E1749-E1752. https://doi.org/10.1097/BRS.0b013e318221a800
39. Park Y, Ha JW, Lee YT, Sung NY. Cranial facet joint violations by percutaneously placed pedicle screws adjacent to a minimally invasive lumbar spinal fusion. Spine J 2011;11(4):295-302. https://doi.org/10.1016/j.spinee.2011.02.007
1996;21(4):492-9. https://doi.org/ 10.1097/00007632-199602150-00016
2. Diaz Jr JJ, Cullinane DC, Altman DT, Bokhari F, Cheng JS, Como J, et al. Practice management guidelines
for the screening of thoracolumbar spine fracture. J Trauma 2007;63(3):709-18. https://doi.org/10.1097/
TA.0b013e318142d2db
3. Esses SI, Botsford DJ, Kostuik JP. Evaluation of surgical treatment for burst fractures. Spine (Phila Pa 1976)
1990;15(7):667-73. https://doi.org/10.1097/00007632-199007000-00010
4. Park Y, Ha JW. Comparison of one-level posterior lumbar interbody fusion performed with a minimally invasive
approach or a traditional open approach. Spine 2007;32(5):537-43. https://doi.org/10.1097/01.brs.0000256473.49791.f4
5. Kim DY, Lee SH, Chung SK, Lee HY. Comparison of multifidus muscle atrophy and trunk extension
muscle strength: percutaneous versus open pedicle screw fixation. Spine (Phila Pa 1976) 2005;30(1):123-9.
PMID: 15626992
6. Rampersaud YR, Annand N, Dekutoski MB. Use of minimally invasive surgical techniques in the management of thoracolumbar trauma: current concepts. Spine 2006;31:S96-S102. https://doi.org/10.1097/01.brs.0000218250.51148.5b
7. Weber BR, Grod D, Dvorak J, Müntener M. Posterior surgical approach to the lumbar spine and its effect on the
multifidus muscle. Spine (Phila Pa 1976) 1997;22:1765-72. https://doi.org/10.1097/00007632-199708010-00017
8. Ntilikina Y, Bahlau D, Garnon J, Schuller S, Walter A, Schaeffer M, et al. Open versus percutaneous instrumentation in thoracolumbar fractures: magnetic resonance imaging comparison of paravertebral muscles after implant removal. J Neurosurg Spine 2017;27(2):235-41. https://doi.org/10.3171/2017.1.SPINE16886
9. Phan K, Rao JP, Mobbs RJ. Percutaneous versus open pedicle screw fixation for treatment of thoracolumbar
fractures: Systematic review and meta-analysis of comparative studies. Clin Neurol Neurosurg 2015;135:85-92.
https://doi.org/10.1016/j.clineuro.2015.05.016
10. Foley KT, Gupta SK, Justis JR, Sherman MC. Percutaneous pedicle screw fixation of the lumbar spine. Neurosurg Focus 2001;10(4):E10. https://doi.org/10.3171/foc.2001.10.4.11
11. Mobbs RJ, Sivabalan P, Li J. Minimally invasive surgery compared to open spinal fusion for the treatment of
degenerative lumbar spine pathologies. J Clin Neurosci 2012;19(6):829-35. https://doi.org/10.1016/j.jocn.2011.10.004
12. Song HP, Lu JW, Liu H, Zhang C. [Case-control studies between two methods of minimally invasive surgery
and traditional open operation for thoracolumbar fractures]. Zhongguo Gu Shang 2012;25(4):313-6. [En chino]
PMID: 22812097
13. Court C, Vincent C. Percutaneous fixation of thoracolumbar fractures: current concepts. Orthop Traumatol Surg Res 2012;98(8):900-9. https://doi.org/10.1016/j.otsr.2012.09.014
14. Schmidt OI, Strasser S, Kaufmann V, Strasser E, Gahr RH. Role of early minimal-invasive spine fixation in acute
thoracic and lumbar spine trauma. Indian J Orthop 2007;41(4):374-80. https://doi.org/10.4103/0019-5413.37003
15. Gruenberg MG, Solá CA, Petracchi MG, Ortolán EG. Fracturas por estallido en la columna dorsolumbar
instrumentadas con tornillos pediculares. Rev Asoc Arg Ortop Traumatol 2003;68(4):273-83. https://www.aaot.org.ar/revista/2003/n4_vol68/art4.pdf
16. Nicolino TI, Petracchi M, Sola C, Valacco M, Gruenberg M. Evaluación clínica y radiológica de la instrumentación y artrodesis corta por vía posterior en fracturas toracolumbares. Rev Asoc Arg Ortop Traumatol 2015;80(1):20-29. https://doi.org/10.15417/267
17. Payares K, Lugo LH, Morales V, Londoño A. Validation in Colombia of the Oswestry disability questionnaire in
patients with low back pain. Spine (Phila Pa 1976) 2011;36(26):E1730-5. https://doi.org/10.1097/BRS.0b013e318219d184
18. Frankel HL, Hancock PO, Hyslop G, Melzak J, Michaelis LS, Ungar GH, et al. The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. Part I. Paraplegia 1969;7:179-92. https://doi.org/10.1038/sc.1969.30
19. Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S. A comprehensive classification of thoracic and lumbar
injuries. Eur Spine J 1994;3(4):184-201. https://doi.org/10.1007/BF02221591
20. Vaccaro AR, Lim MR, Hurlbert RJ, Lehman RA Jr, Harrop J, Fisher DC, et al. Surgical decision making for
unstable thoracolumbar spine injuries: results of a consensus panel review by the Spine Trauma Study Group. J
Spinal Disord Tech 2006;19:1-10. https://doi.org/10.1097/01.bsd.0000180080.59559.45
21. Zdichavsky M, Blauth M, Knop C, Graessner M, Herrmann H, Krettek C, et al. Accuracy of pedicle screw
placement in thoracic spine fractures. Part I: inter- and intra-observer reliability of the scoring system. Eur J Trauma 2004;30:234-240. https://doi.org/10.1007/s00068-004-1422-9
22. Zdichavsky M, Blauth M, Knop C, Lotz J, Krettek C, Bastian L. Accuracy of pedicle screw placement in thoracic
spine fractures. Part II: a retrospective analysis of 278 pedicle screws using computed tomographic scans. Eur J
Trauma 2004;30:241-7. https://doi.org/10.1007/s00068-004-1423-8
23. Pereira Duarte M, Petracchi MG, Mereles ME, Gruenberg M, Solá CA, Girardi FP. Artrodesis intersomática lateral de columna lumbar. Técnica quirúrgica y conceptos actuales. Rev Asoc Argent Ortop Traumatol 2018;83(4):303-316. https://doi.org/10.15417/issn.1852-7434.2018.83.4.754
24. Alanay A, Pekmezci M, Karaemigogullari O, Acaroglu E, Yazici M, Cil A, et al. Radiographic measurement of
the sagittal plane deformity in patients with osteoporotic spinal fractures evaluation of intrinsic error. Eur Spine J
2007;16(12):2126-32. https://doi.org/10.1007/s00586-007-0474-z
25. Assaker R. Minimal access spinal technologies: state-of-the-art, indications, and techniques. Joint Bone
Spine 2004;71(6):459-69. https://doi.org/10.1016/j.jbspin.2004.08.006
26. Wild MH, Glees M, Plieschnegger C, Wenda K. Five-year follow-up examination after purely minimally invasive
posterior stabilization of thoracolumbar fractures: a comparison of minimally invasive percutaneously and
conventionally open treated patients. Arch Orthop Trauma Surg 2007;127(5):335-43. https://doi.org/10.1007/s00402-006-0264-9
27. Pehlivanoglu T, Akgul T, Bayram S, Meric E, Ozdemir M, Korkmaz M, et al. Conservative versus operative
treatment of stable thoracolumbar burst fractures in neurologically intact patients: is there any difference regarding the clinical and radiographic outcomes? Spine (Phila Pa 1976) 2020;45(7):452-8.
https://doi.org/10.1097/BRS.0000000000003295
28. Koosha M, Nayeb Aghaei H, Khayat Kashani HR, Paybast S. Functional outcome of surgical versus conservative therapy in patients with traumatic thoracolumbar fractures and thoracolumbar injury classification and severity score of 4; A non-randomized clinical rrial. Bull Emerg Trauma 2020;8(2):89-97. https://doi.org/10.30476/BEAT.2020.46448
29. McCormack T, Karaikovic E, Gaines RW. The load sharing classification of spine fractures. Spine (Phila Pa 1976) 1994;19(15):1741-4. https://doi.org/10.1097/00007632-199408000-00014
30. Ni WF, Huang YX, Chi YL, Xu HZ, Lin Y, Wang XY, et al. Percutaneous pedicle screw fixation for neurologic intact thoracolumbar burst fractures. J Spinal Disord Tech 2010;23:530-7. https://doi.org/10.1097/BSD.0b013e3181c72d4c
31. Merom L, Raz N, Hamud C, Weisz I, Hanani A. Minimally invasive burst fracture fixation in the thoracolumbar
region. Orthopedics 2009;32(4): orthosupersite.com/view.asp?rID=38353. https://doi.org/10.3928/01477447-20090401-03
32. Palmisani M, Gasbarrini A, Brodano GB, De Iure F, Cappuccio M, Boriani L, et al. Minimally invasive percutaneous fixation in the treatment of thoracic and lumbar spine fractures. Eur Spine J 2009;18:71-4.
https://doi.org/10.1007/s00586-009-0989-6
33. Rechtine GR, Bono PL, Cahill D, Bolesta MJ, Chrin AM. Postoperative wound infection after instrumentation of
thoracic and lumbar fractures. J Orthop Trauma 2001;15(8):566-9. https://doi.org/10.1097/00005131-200111000-00006
34. Korovessis P, Hadjipavlou A, Repantis T. Minimal invasive short posterior instrumentation plus balloon kyphoplasty with calcium phosphate for burst and severe compression lumbar fractures. Spine (Phila Pa 1976) 2008;33(6):658-67. https://doi.org/10.1097/BRS.0b013e318166e0bb
35. Pelegri C, Benchikh El Fegoun A, Winter M, Brassart N, Bronsard N, Hovorka I, et al. Percutaneous fixation of
lumbar and thoracolumbar fractures without neurological involvement: surgical technique and preliminary results. Rev Chir Orthop Reparatrice Appar Mot 2008;94(5):456-63. https://doi.org/10.1016/j.rco.2008.03.035
36. Rampersaud YR, Foley KT, Shen AC, Williams S, Solomito M. Radiation exposure to the spine surgeon during
fluoroscopically assisted pedicle screw insertion. Spine (Phila Pa 1976) 2000;25(20):2637-45. https://doi.org/10.1097/00007632-200010150-00016
37. Knox JB, Dai JM III, Orchowski JR. Superior segment facet joint violation and cortical violation after minimally
invasive pedicle screw placement. Spine J 2011;11(3):213-7. https://doi.org/10.1016/j.spinee.2011.01.024
38. Patel RD, Graziano GP, Vanderhave KL, Patel AA, Gerling MC. Facet violation with the placement of percutaneous pedicle screws. Spine (Phila Pa 1976) 2011;36(26):E1749-E1752. https://doi.org/10.1097/BRS.0b013e318221a800
39. Park Y, Ha JW, Lee YT, Sung NY. Cranial facet joint violations by percutaneously placed pedicle screws adjacent to a minimally invasive lumbar spinal fusion. Spine J 2011;11(4):295-302. https://doi.org/10.1016/j.spinee.2011.02.007