Injury, Int. J.

Care Injured 47 (2016) 13371344

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Surgical outcomes of temporary short-segment instrumentation

without augmentation for thoracolumbar burst fractures
Hiroyuki Aono a,*, Hidekazu Tobimatsu a, Kenta Ariga b, Masayuki Kuroda c,
Yukitaka Nagamoto a, Shota Takenaka a, Masayuki Furuya d, Motoki Iwasaki e
a

Department of Orthopedic Surgery, Osaka National Hospital, Osaka, Japan

Department of Orthopedic Surgery, Osaka Police Hospital, Osaka, Japan
Department of Orthopedic Surgery, Yao Municipal Hospital, Osaka, Japan
d
Department of Orthopedic Surgery, Osaka University Graduate School of Medicine
e
Department of Orthopedic Surgery, Osaka Rosai Hospital, Osaka, Japan
b
c

A R T I C L E I N F O

A B S T R A C T

Article history:
Accepted 4 March 2016

Background: Short-segment posterior spinal instrumentation for thoracolumbar burst fracture provides
superior correction of kyphosis by an indirect reduction technique, but it has a high failure rate. We
investigated the clinical and radiological results of temporary short-segment pedicle screw xation
without augmentation performed for thoracolumbar burst fractures with the goal of avoiding treatment
failure by waiting to see if anterior reconstruction was necessary.
Methods: We studied 27 consecutive patients with thoracolumbar burst fracture who underwent shortsegment posterior instrumentation using ligamentotaxis with Schanz screws and without augmentation. Implants were removed approximately 1 year after surgery. Neurological function, kyphotic
deformity, canal compromise, fracture severity, and back pain were evaluated prospectively.
Results: After surgery, all patients with neurological decit had improvement equivalent to at least
1 grade on the American Spinal Injury Association impairment scale and had fracture union. Kyphotic
deformity was reduced signicantly, and maintenance of the reduced vertebra was successful even
without vertebroplasty, regardless of load-sharing classication. Therefore, no patients required
additional anterior reconstruction. Postoperative correction loss occurred because of disc degeneration,
especially after implant removal. Ten patients had increasing back pain, and there are some correlations
between the progression of kyphosis and back pain aggravation.
Conclusion: Temporary short-segment xation without augmentation yielded satisfactory results in
reduction and maintenance of fractured vertebrae, and maintenance was independent of load-sharing
classication. Kyphotic change was caused by loss of disc height mostly after implant removal. Such
change might have been inevitable because adjacent endplates can be injured during the original spinal
trauma. Kyphotic change after implant removal may thus be a limitation of this surgical procedure.
2016 Elsevier Ltd. All rights reserved.

Keyword:
Thoracolumbar burst fracture
Short-segment instrumentation
No augmentation
Back pain

Introduction
Thoracolumbar burst fractures are the most common spine
fracture of those that are treated surgically. These fractures are
classied as anterior and midcolumn injuries according to the
three-column classication proposed by Denis [1]. Proper management of these fractures remains controversial and includes

* Corresponding author at: Department of Orthopedic Surgery, Osaka National

Hospital, 2-1-14 Hoenzaka, Chuo-ku, Osaka 540-0006, Japan. Tel.: +81 6 6942 1331;
fax: +81 6 6943 3555.
E-mail address: h-aono@umin.ac.jp (H. Aono).
http://dx.doi.org/10.1016/j.injury.2016.03.003
00201383/ 2016 Elsevier Ltd. All rights reserved.

nonoperative treatment, anterior surgery, posterior surgery, and a

combination of anterior and posterior surgery.
Short-segment posterior spinal instrumentation (pedicle
screw instrumentation one level cephalad and caudad to the
fractured vertebra) without fusion has merit because it preserves
segment motion, provides superior correction of kyphosis using
an indirect reduction technique, and is less invasive than other
procedures. However, there have been frequent reports that
this procedure has failed, with or without instrumentation
failure [24]. Recent reports suggest that additional vertebroplasty provides supplemental load-sharing through anterior
reconstruction and support and that it reduces loss of kyphosis
correction [5,6].

H. Aono et al. / Injury, Int. J. Care Injured 47 (2016) 13371344

1338

McCormack et al. [3] proposed the load-sharing classication

system in 1994 in which the parameters of comminution, fragment
apposition, and reproducibility of sagittal deformation are each
given 1 point (low score) to 3 points (high score), and the total of
those points serves as the load-sharing score, which can range from
3 to 9. They recommend anterior reconstruction for patients with a
score of 7, because patients with scores of 6 had no screw
fractures; all fractures that showed evidence of screw fracture had
scores of 7.
In our institution, we perform posterior reduction and xation
rst to establish spinal stability and reduce surgical stress. Then if
anterior reconstruction is considered to be necessary, we plan
anterior reconstruction as a second procedure. Thus, we conducted
a study to investigate the surgical results of temporary shortsegment pedicle screw xation without augmentation for the
surgical treatment of thoracolumbar burst fractures.

Patients and methods

Our study group consisted of 27 consecutive patients in whom a
single thoracolumbar burst fracture, with or without neurological
impairment, was diagnosed between September 2006 and July
2012 at Osaka National Hospital. This study has been approved by
institutional review board of our hospital and informed consent
was obtained from all patients. There were 19 men and 8 women,
with an average age of 43 years (range, 2066 years). The injuries
were caused by trafc accidents (6 patients), falls from a signicant
height (20 patients), and being hit by falling object (1 patients).
Thus, all patients suffered high-energy injuries. Twenty-two
patients had associated injuries: extremity fracture in 14 patients,
stable pelvic fractures in 7, lung injury in 4, abdominal injury in 2,
cerebral contusion in 2. The level of spinal involvement was T11 in
1 patient, T12 in 5 patients, L1 in 8, L2 in 10, and L3 in 3.
The neurological status of the patients was assessed using the
American Spinal Injury Association (ASIA) impairment scale. We
also evaluated (low) back pain before injury and at the nal followup examination using the Denis pain scale [7] (Table 1).
Radiographic assessment was performed using supine anteroposterior and lateral roentgenograms, computed tomography
(CT) scans (GE Discovery CT750 HD; slice thickness 0.625 mm), and
magnetic resonance imaging ([MRI] Philips 1.5T NT- Intera) before
surgery. All patients were monitored radiographically after surgery
using standing anteroposterior and lateral roentgenograms and CT
scans just after surgery, 6 months later, 1 year later (around the
time of implant removal), and 2 years later (approximately 1 year
after removal). MRI was performed 1 year after surgery and 1 year
after implant removal.
Three independent observers evaluated all radiographs and CT
scans. The sagittal plane contour was assessed by measuring (1)
the vertebral body angle (VBA), which was measured between the
superior and inferior endplates of the injured vertebra, and (2) the
superoinferior endplate angle (SIEA), which was measured
between the superior endplate of the intact vertebra cephalad
to the fracture and the inferior endplate of the vertebra caudad to
the fracture with using the Cobb method (Fig. 1).

Table 1
Denis pain scale.
Pain

P1: no pain
P2: occasional minimal pain; no need for medication
P3: moderate pain, occasionally medications; no interruption of work
or activities of daily living
P4: moderate to severe pain, occasionally absent from work;
signicant changes in activities of daily living
P5: constant, severe pain; chronic pain medications

Fig. 1. Radiographic measurement of the sagittal plane contour. The vertebral body
angle is the angle between B and C. The superoinferior endplate angle in the angle
between A and D.

Canal compromise was determined using CT scanning by

directly measuring the anteroposterior canal dimension at the
maximum area of the retropulsed osseous fragment or fragments
and was recorded in millimetres. This value was then compared
with the average of similar dimensions measured at the levels
above and below the injury. The result of this comparison was
recorded as the percentage of anteroposterior canal compromise at
the injured vertebra.
The extent of intervertebral disc degeneration was evaluated on
midsagittal T2-weighted MRI according to the criteria of Borenstein et al. [8] as follows: normal (score = 0); mild, with slight
dehydration of the disc on T2-weighted images (score = 1);
moderate, with disc dehydration and mild loss of disc height
(score = 2); and severe, with total disc dehydration and nearly
complete loss of disc height (score = 3). Discs above and below the
fractured vertebra were graded.
Fracture severity was calculated using the load-sharing
classication [3], the AO classication [9], and the Denis
classication [1].
Patients were allowed to sit up as soon after surgery as a
custom-moulded thoracolumbosacral brace was fabricated. Nine
patients had delay to sitting up because of an associated injury.
However, they could sit up by 1 week, and no patient was required
to remain lying in bed for a long period. The brace was used for at
least 3 months after surgery. During this period, physical activity
was restricted, and if kyphotic deformity due to vertebral collapse
was observed, we planned to perform anterior reconstruction.
Sports activities and strenuous labour were prohibited for
6 months after surgery. Removal of implants was performed
approximately 1 year after initial surgery after conrming union of
the fracture by CT scan and MRI, because of the preservation of
segment motion and the possibility of implant failure, which was
explained before initial surgery. Therefore, the pedicle screw
implants were only temporary. All patients were monitored

H. Aono et al. / Injury, Int. J. Care Injured 47 (2016) 13371344

clinically and radiographically for a minimum of 2 years, with the

median follow-up duration being 50 months (range, 2484
months).
Surgical techniques
All surgical procedures were performed under controlled
general anaesthesia. Patients were placed in a prone position;
initial postural reduction was then obtained. Using a standard
posterior midline approach, we exposed the levels above and
below the injured segment. Schanz pedicle screws (AO Universal
Spine System, DePuy Synthes, West Chester, PA) with a diameter of
6.2 or 7.0 mm and a thread length of 3540 mm were placed down
the pedicles of the bilateral vertebrae above and below the
fracture. Pedicle screws with the largest possible diameter were
used. In patients with narrow pedicles, we attempted to place at
least a 6.2-mm pedicle screw, even if this required expansion of
the pedicles. The exception was one of the earlier cases, in which
5.0-mm pedicle screws were used.
Posterior wall decompression by way of indirect reduction via
ligamentotaxis was performed using the following technique,
which is based on a technique described by Aebi et al. [10]. The
lordosing manoeuvre was performed rst, followed by segmental
distraction. Before reduction with Schanz screws, 2 half-rings were
placed on each of the 6-mm rods, at a distance of approximately
5 mm from the clamp of the Schanz screw, to protect the posterior
wall of the vertebral body from compression. We then corrected
the kyphosis by manually approximating the dorsal ends of the
Schanz screws. Furthermore, we applied distraction using spreader
forceps. Cross-links were not routinely used. For all 27 patients,
procedures were checked by lateral-view radiographs.
We did not perform open reduction, decompression, laminectomies, or laminotomies, with one exception: One patient required
laminectomy to treat eruption of the cauda equina caused by
injury to the posterior column. In addition, we did not perform
autologous iliac bone fusion, posterior fusion, posterolateral
fusion, or vertebroplasty.

1339

Table 2
Neurologic function (ASIA Impairment Scale).
Postoperative neurologic status (no. of patients)
A
Preoperative
A
B
C
D
E

1
8
13

pain. At the nal follow-up examination, 10 patients reported

increased back pain; however, no patients had interruptions in
their activities of daily life or work because of pain (Table 3).
Complications
No patients had iatrogenic neurological decits or developed
infections. At implant removal, there were no instances of
instrumentation failure, including breakage, bending, or loosening
of the pedicle screws; the only exception was the breakage of one
5-mm cephalad pedicle screw 8 months after the initial operation.
There have been no additional procedures.
Radiological results
Kyphotic deformity was evaluated and mean values were
calculated. All patients had union of the injured vertebrae, which
was conrmed by MRI and CT scans.
Vertebral body angle

Statistical analyses were performed using the Wilcoxon test.

The level of signicance was set at p < 0.05.

The VBA was corrected from 17.38 (range, 3188) before surgery
to 6.18 (range, 1118) after surgery. Loss of correction was 0.58
before removal, which deteriorated by another 0.38 after removal.
Total loss of correction was 0.88 from the initial surgery. Thus,
fractured vertebrae were corrected and maintained after surgery.
Therefore, none of our patients needed anterior reconstruction.
Statistical analysis revealed that the VBA was signicantly reduced
(p < 0.001) and there was no signicant loss of correction in the
series (Table 4; Figs. 2 and 3).

Results

Superoinferior endplate angle

Clinical results

The SIEA was corrected from 138 (range, 298 to 168) before
surgery to 18 (range, 248 to 248) after surgery. Correction loss was
2.38 before removal, which deteriorated by another 7.58 after
removal, making the total correction loss 9.88 from the initial
surgery. A mean kyphotic deformity of 10.68 (range, 288 to 188)
remained by the time of the nal follow-up examination. Six
patients (24%) had kyphotic deformity that was >208 (range, 21
288). The SIEA was also signicantly reduced (p < 0.001), and there
was a statistically signicant loss of correction after removal of
instrumentation (p = 0.012; Table 4 and Figs. 2 and 4). Taken
together, these results indicate that postoperative kyphotic change
was related to disc level, not to the fractured vertebrae;
maintenance of reduced vertebral body height was successful
regardless of load-sharing classication.
CT scans revealed a mean spinal canal narrowing of 50.2%
(range, 1488%) before surgery, 26.3% (range, 748%) after surgery,
and 14.8% (range, 5.134%) by the time of nal follow-up
examination, showing further improvement (Fig. 5, Table 4).
The mean fracture severity according to load-sharing classication was 7.1 points. Three patients had a score of 9 points, 8 had a
score of 8, 8 had a score of 7, 6 had a score of 6, and 2 had a score of

Statistical analysis

Nine patients were taken to the operating room for surgical

stabilisation within 24 hours of injury, another 10 patients
underwent surgery within 3 days, and the remaining 8 patients
had surgery within 4 to 9 days. The cause of surgery delay in the
latter group was abdominal injury in 3, head injury in 2, delay of
admission to our hospital in 2, and myocardiac infarction in
1. Thus, the mean time elapsed between injury and surgery was
3.5 days.
The mean duration of all surgical procedures was 101 minutes
(range, 70158 minutes), and the mean estimated blood loss was
142 mL (range, 10420 mL).
Fifty-two percent (14 of 27) of patients had a neurological
decit: 2 patients had an ASIA grade of B, 4 had a grade of C, and
8 had a grade of D. All patients had improved neurologically by at
least 1 ASIA grade by the nal follow-up examination (Table 2). No
patients needed additional anterior reconstruction due to kyphotic
deformity because of vertebral collapse.
As dened by the Denis scale, 3 patients had moderate back
pain, 13 had occasionally minimum back pain, and 11 had no back

H. Aono et al. / Injury, Int. J. Care Injured 47 (2016) 13371344

1340
Table 3
Back pain (Denis pain scale).

Postoperative status (no. of patients)

Pre-injury
P1
P2
P3
P4
P5

P1 (no pain)

P2 (occasionally minimal)

P3 (moderate)

11

8
5

1
1
1

P4 (moderatesevere)

P5 (severe)

Table 4
Radiological ndings: mean values (SD).

Vertebral body angle (VBA)

Superoinferior endplate angle (SIEA)
Canal compromise
a

Pre-op

After reduction

At implant removal

Final follow-up

Total correction loss

17.38 (6.0)
138 (9.6)
50.2% (19.9)

6.18 (3.5)
18 (10.2)
26.3% (13.5)

6.68 (3.4)
3.38 (10.0)

6.98 (3.5)
10.88 (12.5)
14.8% (9.5)a

0.88 (0.7)
9.88 (5.3)

Two-year follow up examination.

5. Nineteen patients (70%) had a score of 7, a score for which

anterior reconstruction is traditionally recommended. However,
statistical analysis revealed that there was no signicant relation
between load-sharing score and correction loss. Using the AO

classication, we found that 21 patients had type A3 fractures,

3 patients had type B1, and another 3 patients had type B2, whereas
under the Denis classication, 7 patients had type A fractures,
19 patients had type B fractures, and 1 patient had a type C fracture.

Fig. 2. Lateral radiographs of a 56-year-old man with an L1 burst fracture, showing changes over time in the superoinferior endplate angle (SIEA) and vertebral body angle
(VBA). a: Before surgery, the VBA was 318 and the SIEA was 248. b: After surgery, the VBA and SIEA were corrected to 88 and 78, respectively. c: By 1 year after surgery, there had
been no change in either angle. d: By 2 years after surgery, the VBA remained unchanged but the SIEA had changed to 148 (correction loss of 78).

H. Aono et al. / Injury, Int. J. Care Injured 47 (2016) 13371344

1341

Fig. 3. Statistical analysis shows that the vertebral body angle was signicantly
corrected after surgery and maintained after implant removal.

Fig. 4. Statistical analysis shows that the superoinferior endplate angle was
signicantly corrected after surgery but that there was signicant correction loss
after implant removal.

At the 2-year follow-up examinations, MRI revealed that disc

degeneration had accelerated at least 1 grade in all 27 patients, at
the level above the injury in 23 patients, and at the level below the
injury in 6 patients (Fig. 6).

The mean correction loss in patients with and without back

pain aggravation was 14.68 and 7.58, respectively. Because this
difference was statistically signicant (Fig. 7), back pain aggravation may have some correlation with correction loss. The mean

Fig. 5. Computed tomography (CT) scans of the same 56-year-old man as in Fig. 2 show changes in spinal canal stenosis. a: Preoperative retropulsion of 64%. b: Postoperative
CT showed spinal canal stenosis of 32%. c: Two years after the initial operation, spinal stenosis had decreased to 15%. d: The patients load-sharing classication score was 9
(apposition: (apposition: 3 points; comminution: 3 points; kyphotic correction: 3 points; 238).

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H. Aono et al. / Injury, Int. J. Care Injured 47 (2016) 13371344

Fig. 6. Midsagittal T2-weighted magnetic resonance images of the same 56-year-old man as in Fig. 2 show progressive disc degeneration. a: Before surgery. b: One year after
surgery, there did not appear to be progression of degeneration in either adjacent disc. c: Two years after surgery (1 year after implant removal), progression of degeneration
was apparent in the disc below the fractured vertebra.

range of motion in exion-extension radiographs of the SIEA was

88 at the 2-year follow-up examination.

Discussion
Several studies have shown that short-segment pedicle screw
instrumentation without support of the anterior column for the
treatment of unstable thoracolumbar burst fractures is associated
with a high rate of early instrumentation failure and progression of
kyphotic deformity [24]. In their study, kyphotic deformity was
indicated by the collapse of corrected vertebra, which led to
instrumentation failure. In contrast, in our study the reduced
fractured vertebral body was maintained after surgery and
kyphotic deformity occurred because of a loss of disc height that
developed mainly after implant removal. Furthermore, we
observed no early instrumentation failure, even in patients whose
load-sharing classication score was 7, the point at which
anterior reconstruction is traditionally recommended.
Multiple factors contributed to the success of this surgical
procedure. One factor is the material used in instrumentation.
Ebelke et al. [2] reported that high failure rates may result if
anterior bone augmentation is not performed. McLain et al. [4] also
noted that 10 of 19 patients (53%) whose surgical repair involved
short-segment pedicle instrumentation alone had instrumentation
failure.

McCormack et al. [3] reported that 10 of 28 patients (36%) who

underwent surgery using short-segment pedicle instrumentation
without restoration of the anterior column had subsequent screw
breakage. These previous reports of failure (Ebelke et al., McLaine
et al., and McCormack et al.) were published in the early 1990s, and
the research described in them was carried out between 1986 and
1991. At that time, the material used for surgical implants was
stainless steel. The implant material currently used is titanium; in
our study, the implants were made of titanium plus 10% vanadium.
Because titanium has almost two times the strength and elasticity
of stainless steel [11,12] (Table 5), the screws have the strength to
sustain the implant through fusion of the fracture. Once fracture
fusion has occurred, stress on the pedicle screws decreases, even
without anterior augmentation. Implant failure would thus be
reduced.
A second factor is the diameter of the pedicle screws. If the
diameter of the patients pedicles was large enough, we used 7-mm
pedicle screws. This is the largest diameter of screw available for
this system. In patients with narrow pedicles, we attempted to
place at least a 6.2-mm screw, even if this required pedicle
expansion (Fig. 8). Misenheimer et al. [13] reported that if the
screw diameter exceeds the endosteal diameter of the pedicle, the
pedicle will adapt in one of three ways: pedicle expansion, pedicle
cutout by screw threads, or pedicle fracture. Misenheimer et al.
noted pedicle changes when the screw size exceeded 80% of the
outer cortical diameter. Sjostrom et al. [14] also noted that when
the screw diameter exceeded 65% of the outer cortical pedicle
diameter, 85% of the pedicles expanded. The larger the diameter of
the pedicle screw, the more durable the instrumentation will be.
Taking these reports into consideration, we believe that placing
large pedicle screws into smaller-diameter pedicles is acceptable
and could prevent instrumentation failure.
Another factor contributing to the success of this technique is
the preservation of the posterior column. We did not perform
laminectomy or laminotomy, even in patients with neurological
decits. There is only a minor relationship between decompression
and neurological recovery [4,15,16]. Toyone et al. [6] reported good
neurological improvement in 15 patients with thoracolumbar
Table 5
Strength and elasticity of two materials.

Fig. 7. Statistical analysis showed that patients with back pain aggravation had
statistically signicant correction loss.

Material

Ultimate tensile
strength (Mpa)

Youngs (tensile) modulus

of elasticity (GPa)

Stainless steel
Titanium 10% vanadium

580
900

193
105120

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1343

Fig. 8. CT scan of a 19-year-old woman with pedicle expansion. a: Before surgery, pedicles of L2 vertebra was thin (diameter 4.0 mm). b: After surgery, we placed 6.2 mm
pedicle screws to expand her pedicles. c: After removal, the pedicles was expanded.

fracture and incomplete neurological decits whom they treated

using short-segment pedicle screw xation without laminectomy
or laminotomy.
Limb et al. [17] reported that neurological damage occurs at the
time of trauma rather than as a result of pressure from fragments
in the spinal canal. Boerger et al. [18] concluded that the
geometrical parameters of canal compromise do not relate to
initial neurological decits, and that there is no evidence that
operative clearance helps the neurological situation. Therefore,
according to these reports, posterior decompression is not
necessary, even in patients with neurological decit. Because
preservation of the posterior column leads to the reduction of
stress in the injured anterior and middle columns, it may prevent
early instrumentation failure. In one of our earlier cases involving
pedicle screw breakage, 5-mm screws had been used. Eruption of
the cauda equina because of injury to the posterior column was
observed, and laminectomy had to be performed. This result
supports our hypothesis.
In our study, kyphotic deformity was corrected satisfactorily
during surgery. Maintenance of the reduced fractured vertebral
body height was successful regardless of the load-sharing
classication, even without augmentation. Postoperative kyphotic
changes occurred because of loss of disc height, not as a result of
the fracture of the vertebral body itself. However, kyphotic
deformity occurred because of vertebral collapse, not because of
disc degeneration during the early phase before implant removal in
previous failure reports. Our results are different from those of
previous studies.
Concerning the loss of adjacent disc height and disc degeneration after surgery, Wang et al. [19] reported that disc degeneration

usually occurs at the level adjacent to the fractured endplate of

thoracolumbar burst fractures after implant removal in shortsegment pedicle screw xation without augmentation. They also
concluded that endplate fracture is strongly associated with disc
degeneration. Because all patients in our study had endplate
fracture, disc degeneration after implant removal might have been
unavoidable in our patients.
Furthermore, thoracolumbar burst fractures involve not only
injury to the vertebral body but also complex tissue injuries. Such
damage inevitably includes injury to endplates and adjacent discs.
Consequently, it is impossible to prevent disc degeneration. Disc
injury at onset might have been connected with loss of correction
in our series. Thus, correction loss at adjacent discs could be
unavoidable, and this might be a limitation to this surgical
procedure.
Six (22%) of our patients had kyphotic deformity of >208.
Fortunately, none of our patients had back pain severe enough to
interrupt their daily activities or work. We could have performed
short-segment fusion with augmentation, such as posterolateral
fusion without implant removal, for these 6 patients, because
kyphotic change had occurred mostly after implant removal.
However, this would not have allowed preservation of segment
motion. Moreover, it is impossible to predict this major kyphotic
deformity preoperatively, because correction of kyphosis by
vertebral collapse was achieved during the initial operation in
these 6 patients, and progression of kyphosis occurred mostly after
implant removal, just as for other patients without major kyphotic
deformity. Additional surgery such as osteotomy might be needed
later in patients who have severe back pain due to major kyphotic
deformity.

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H. Aono et al. / Injury, Int. J. Care Injured 47 (2016) 13371344

Conclusion
Temporary short-segment xation without augmentation
yielded satisfactory results in the reduction and maintenance of
fractured vertebrae, independent of load-sharing classication.
Kyphotic change occurred because of loss of disc height mostly
after implant removal. Such change might be inevitable because
adjacent discs and endplates can be injured at the onset. Kyphotic
change may thus be a limitation of this surgical procedure. There is
some correlation between back pain aggravation and progression
of kyphosis after implant removal. However, we did not determine
the factor responsible for progression of kyphosis.
Conict of interest statement
All authors report no support and no conict of interest
concerning the materials or methods used in this study or the
ndings specied in this paper.
Acknowledgments
Medical editor Katharine OMoore-Klopf, ELS (East Setauket, NY,
USA) provided professional English-language editing of this article.
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