Evidence-Based Recommendations for Spine Surgery

Alexander R. Vaccaro, MD, PhD, MBA; Charles G. Fisher, MD; Srinivas K. Prasad, MD; Alpesh A. Patel, MD, FACS; John Chi, MD, MPH; Kishore Mulpuri, MBBS, MHSc; Kenneth C. Thomas, MD, MHSc; Peter G. Whang, MD, FACS


Spine. 2020;45(21):E1441-E1448. 

In This Article

Recommendation Regarding Impact on Clinical Practice

Although this is a reasonably well-designed trial assessing an important clinical question, unfortunately the description of the methodology is severely lacking and there does not appear to be any in-depth analyses to determine the robustness of the results. In addition, there are myriad mistakes and inconsistencies within the manuscript which is indicative of a considerable degree of carelessness and may even reflect a strong bias toward operative management. Given these inherent flaws, this study does not support the superiority of operative intervention for thoracolumbar fractures with a TLICS score of 4 and these injuries may be treated with or without surgery depending upon surgeon experience and patient preference. Thus, we do not recommend implementing any changes to clinical practice.

Lee GW, Ahn MW. Comparative study of cortical bone trajectory-pedicle screw (cortical screw) versus conventional pedicle screw in single-level posterior lumbar interbody fusion: a 2-year post hoc analysis from prospectively randomized data. World Neurosurg 2018; 109:e194–e202.

While posterior transpedicular instrumentation may still be the "gold standard" technique for stabilizing the lumbar spine, so-called "cortical screws" (CS) have more recently been advocated as an alternative method for providing segmental fixation as part of a fusion construct. By traversing the posterior elements obliquely from medial-to-lateral and caudal-to-cranial, these implants capture dense cortical bone at the entry and exit sites such that that they may exhibit superior biomechanical properties in terms of insertional torque and pull-out strength relative to conventional screws. Furthermore, the placement of CS may be performed using the same more limited exposure required of laminectomy and may therefore be less invasive than open pedicle screws (PS) which purportedly may give rise to less postoperative pain and facilitate a more rapid recovery. Because the starting point for CS is more caudal than that for PS along the pars interarticularis, there may be less disruption of the cephalad facet joint with potentially a lower incidence of adjacent level degeneration. Despite these ostensible benefits, at this point there is little high-quality data regarding arthrodesis rates and other outcomes associated with CS; to address this issue, Lee and Ahn previously reported the initial results of a prospective, randomized, noninferiority investigation comparing the use of either CS or PS for posterior lumbar interbody fusion (PLIF)[19] and more recently they published the 2-year follow-up of these same cohorts.