Due to its unique biomechanical properties, the thoracolumbar junction (T10-L2) is especially vulnerable to severe injury. It is a transitional region with particular vulnerabilities situated between the more flexible lumbar spine below and the stiffer and less mobile thoracic spine, which contains the ribs and sternum (1). Thoracolumbar spine injuries are common and frequently result from high-energy accidents, which make up a significant percentage of cases (40–80%). These kinds of events include accidents involving motor vehicles, falls from great heights, mishaps during leisure activities, and injuries sustained at work (2). Additionally, the force of impact causes injury to two or more different organ systems in around 25% of patients with such fractures, or they may have additional spine fractures elsewhere. Pneumothorax, hemothorax, rib fractures, bronchial disruption, myocardial or pulmonary contusion, damage to major blood arteries, hemopericardium, cardiac tamponade, and diaphragmatic rupture are among the commonly associated injuries (3).

According to the literature, around 27% of individuals who sustain injuries to the thoracolumbar junction suffer from severe neurological impairments, deformities, and disability (3). As a result, continuous efforts have been focused on creating efficient treatment plans. The goal of treating these fractures is to repair the spinal deformity over the long term and either restore or maintain neurological function (4-6). It is true that there have been major developments in the surgical treatment of spinal disorders in recent decades. The anterior approach and posterior approach are among the methods used to treat thoracolumbar fractures. Nevertheless, every one of these methods and surgical procedures has unique benefits and drawbacks (7, 8).

The treatment of thoracolumbar fractures has been the subject of several research, but few have thoroughly assessed and contrasted the results of various surgical techniques. Verlaan et al. recently conducted a systematic literature review that brought to light the paucity and insufficiency of research on surgical techniques for thoracolumbar injuries. Additionally, debates about the best method and kind of surgery continue (7). In their comprehensive assessment, Oprel et al. only examined posterior approach in contrast to combined anterior-posterior procedures; they did not examine comparisons with the anterior approach (8). As a result, there is still a large gap in the literature comparing the three different methods. There is an urgent need to fill this research empty space since there is no agreement on how to treat these fractures. Thus, the goal of the current study is to objectively assess and compare the various surgical techniques used to treat thoracolumbar spine fractures.

Search strategy: This systemic review was carried out in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) standards. We conducted a thorough analysis of several published research articles. We looked for published articles using the terms "Thoracolumbar junction fractures," "Approaches," "Decompression," "Surgical management," "Systematic review," and "Meta-analysis," among others, in online databases such as PubMed, NCBI, Google Scholar, and ResearchGate (Figure 1).

Selection of relevant studies: Articles were chosen for inclusion based on their scientific merit. Primary relevance with the review topic was established using the names of the articles that were searched. To keep the list accurate and relevant, we further reviewed the abstract and made necessary revisions before included it in the review. This study excluded articles lacking a full text and those published in languages other than English. Each author independently assessed and selected the reference papers to be included in this review. Any disputes amongst the authors were thoughtfully discussed and resolved. In the end, full-text publications were obtained to finish the task and enhance quality assessment. Total 95 relevant articles were screened. Out of which duplicates were removed leading to 72 articles. Out of them, the article published before year 2000 were excluded leading to final number of 55 article. After eligibility assessment, 12 articles were selected. In final analysis 9 articles were included whose full texts were available (Figure 2).

Statistical analysis: Data is represented in number and percentage for categorical variables and was represented as mean and standard deviation for continuous variables. Appropriate tables were made to depict the data. The data was extracted for age, gender, follow up period, operative time, blood loss and hospital stay in subjects treated with anterolateral and posterior approach surgical approaches for managing thoracolumbar spine fractures.

The nature of the study was range from simple observational study to the randomized control trials (RCTs). Out of nine studies, there were three RCT studies, four were retrospective studies, and two were prospective observational studies. The mean sample size of nine studies was 53.89 ± 36.22. An increase in the sample size was observed in recent studies, moreover, RCT tends to have lower sample size as compared to the retrospective and observational studies. The mean age patients among all studies were 42.01 ± 4.012 years indicating a high prevalence of spine fracture in the 4^th decade of life. In eight studies, male predominance was observed whereas in only single study, the female proportion in study population is high. This indicates high prevalence of spinal fractures in male population (Table 1).

Table 1: Study nature, age and gender distribution.

The mean follows up period among all studies was 26.30 ± 15.70 months with highest follow up to 47.5 months and lowest follow up to 12 months. The mean operative time in anterolateral approach was 233.7 ± 39.64 min which is higher as compared to the operative time in posterior approach in which mean time was 169.0 ± 51.92 min. Operative time showed a consistent high value in anterolateral approach as compared to the posterior approach in all studies. The mean blood in anterolateral approach was 836.8 ± 458.3 ml which is higher as compared to the blood loss in posterior approach in which mean blood loss was 451.1 ± 303.4 ml. Blood loss showed a consistent high value in anterolateral approach as compared to the posterior approach in all studies (Table 2).

Table 2: Follow up period, operative time and blood loss in anterolateral and posterior approach.

The mean hospital stay in the anterolateral approach was 13.63 ± 3.063 days whereas in the posterior approach was 14.68 ± 8.132 days. Two studies indicated a high hospital stay duration in anterolateral approach whereas one study indicated a high hospital stay duration in posterior approach. Other studies did not compile or compared the hospital stay data among anterolateral and posterior approach (Table 3).

Table 3: Hospital stay duration in anterolateral and posterior approach.

The best surgical strategy for treating thoracolumbar fractures is still up for dispute among medical professionals. Instead of thoroughly considering the precise indications, benefits, and downsides of each strategy, surgeons usually base their decision on their own experience. An evidence-based method to methodically list and assess the many surgical techniques that are available is desperately needed. Standardizing treatment procedures and guaranteeing the best possible patient outcomes for thoracolumbar spine fractures need the establishment of a strategy for the selection of surgical techniques. We may create recommendations that help surgeons make well-informed judgments based on the needs of each patient and the features of fractures by carrying out in-depth study and combining the available data (17).

The methodological variations among the included studies should be acknowledged in our present analysis as they may have a substantial influence on the findings. Three RCTs, four retrospective studies, and two prospective observational studies made up the nine investigations in total. Furthermore, a few of the studies were notable for being multicenter and having a sizable sample size, which might improve the findings generalizability and robustness. Our study findings showed that different surgical techniques had notably varying results. In particular, the anterolateral technique was observed to result in considerably greater mean operating duration and volume blood loss. In contrast, both anterior and posterior approaches showed comparable postoperative hospital stays.

In some circumstances, the anterior approach to spinal surgery might be advantageous because it reduces spinal canal compression and restores anterior column stability (5). But because it involves major blood arteries, organs in the chest and abdomen, and other essential tissues, it is complicated and requires a skillful surgeon. Furthermore, this kind of vertebral excision may cause greater damage, which might result in further complications (6, 7). According to studies like the one by Wu et al., the anterior method typically results in more blood loss, longer surgical times, and larger incision lengths than the posterior approach (15). When choosing the best surgical strategy, these differences should be taken into account.

The safety profile of the posterior approach to spine surgery, the avoidance of important visceral and vascular systems, and the typically positive clinical results are some of its benefits. In addition to neurological state, this method is appropriate for a number of purposes, such as distraction injuries without neural compression, isolated nerve root deficits with intact posterior ligaments, and numerous situations involving intact or damaged posterior ligaments. According to the current study findings, the posterior technique usually leads to more blood loss and longer surgical times. On the other hand, a number of studies suggest that using the posterior technique has resulted in reduced blood loss and less operating time for uncomplicated junctional fractures. This may be explained by avoiding important vascular and visceral structures (16, 18, 19).

The current study findings demonstrate that every strategy has advantages and disadvantages of its own. Before choosing a technique, the surgeon should take the patient health and trauma state, fracture type, and economy into account. The current study highlights the absence of clear protocols or insufficient criteria for thoracolumbar approach decision-making. Additionally, there aren't many randomized control studies that address the specific topic; therefore, the current study findings should be interpreted cautiously. The population's heterogeneity, which includes differences in comorbidities, fracture kinds, follow-up periods, intervention scheduling, surgeon skill, and surgical methods among the included studies, is one of the study shortcomings. There is also variation in follow-up times, ages, genders, and sample sizes. Furthermore, it is more difficult to draw firm conclusions because different clinical measures were used in the various research. Notwithstanding these difficulties, this study is the first thorough evaluation of different methods for treating thoracolumbar spine fractures. Despite the relatively minimal risk of bias in individual research, problems such confounding biases and randomization are observed. Notwithstanding its shortcomings, this evaluation offers the most up-to-date and relevant data, making it a useful tool for both academics and physicians.

Numerous research looking at various surgical techniques for thoracolumbar fractures were examined in the current systematic review. According to the current study findings, patients who had the posterior approach often had longer recovery times and more blood loss than those who underwent the anterior or anterior-posterior combined techniques. The current study highlights the lack of a clear methodology or insufficient criteria for thoracolumbar approach decision-making. These findings highlight how crucial it is to raise surgeons and physicians understanding of the various results and possible risks connected to various surgical techniques. To create clear guidelines for choosing the best course of action for managing thoracolumbar fractures, we advise carrying out more research using rigorous study designs.

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