Percutaneous Pedicle Screw Fixation

In percutaneous pedicle screw fixation, screws are introduced into the pedicles (the strong bony bridges of each vertebra) through small stab incisions, under image guidance, without stripping the muscles off the spine as a traditional open operation does. Rods are then passed beneath the muscle and connected to the screws to bridge and stabilise the injured level. The construct holds the spine in a good position while the fracture heals. Because the muscles are spread rather than cut and stripped, blood loss and tissue trauma tend to be lower.

This technique can be used for a range of unstable thoracolumbar fractures where the main need is to stabilise the spine and maintain alignment, and where the spinal canal does not need to be opened widely for decompression. It is particularly suited to fractures in people who are neurologically intact but mechanically unstable. Where there is significant compression of the neural structures that must be relieved, or where the vertebral body needs direct reconstruction, a different or additional approach may be required. The suitability of a percutaneous approach is judged on the fracture pattern and the imaging.

The appeal of a percutaneous approach in trauma is that it can achieve stable fixation while sparing the muscles and soft tissues. Compared with open surgery, minimally invasive fixation is generally associated with less blood loss, smaller wounds, and potentially lower rates of some complications, while providing comparable stability for suitable fractures. This can be helpful in injured patients, where minimising the additional physiological insult of surgery is valuable. The trade-offs against open surgery are weighed for each individual injury.

The evidence supports percutaneous fixation as an effective option for suitable thoracolumbar fractures. Systematic reviews and meta-analyses comparing percutaneous with open pedicle screw fixation report comparable fracture stabilisation with advantages for the percutaneous approach in terms of blood loss, wound size and some complication rates. Large pooled analyses of cohort studies in fractures without neurological deficit reach similar conclusions. This literature underpins the role of minimally invasive fixation in appropriately selected spinal trauma.

Whether a percutaneous approach is suitable depends on the fracture pattern, the stability of the spine, and whether the neural structures need decompression. Where it is appropriate, it offers stable fixation through small incisions with less soft-tissue disruption; where more is needed, an open or combined approach is chosen. The plan, realistic expectations and risks are discussed individually.

• —Phan K, et al. Percutaneous versus open pedicle screw fixation for thoracolumbar fractures: systematic review and meta-analysis. Eur Spine J 2015. (PMID 26051881)
• —Wang H, et al. Percutaneous pedicle screw fixation for thoracolumbar fractures: systematic review and meta-analysis. Medicine (Baltimore) 2022. (PMID 35144416)
• —Li Y, et al. Percutaneous versus open approaches for thoracolumbar fractures without neurological deficit: meta-analysis. J Orthop Surg Res 2024. (PMID 38263482)
• —Wu MH, et al. Minimally invasive percutaneous versus open surgery for thoracolumbar fractures: a comparative study. Zhongguo Gu Shang 2018. (PMID 29349998)