The Effect of Fusion Levels on Clinical Outcomes in Lower Lumbar Vertebral Fractures

The Effect of Fusion Levels on Clinical Outcomes in Lower Lumbar Vertebral Fractures | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Effect of Fusion Levels on Clinical Outcomes in Lower Lumbar Vertebral Fractures Halil Gok, Alim Can Baymurat, Asim Ahmadov, Alpaslan Senkoylu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6486786/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Fractures of the lower lumbar (LL) spine are relatively rare and the surgical management of fractures in this region remains uncertain. The aim of this study was to evaluate the mid- and long-term clinical and radiological outcomes of short segment posterior instrumentation (SSPI) and long segment posterior instrumentation (LSPI) for LL fractures. Methods Methods: A retrospective analysis was performed of patients who underwent posterior instrumentation for thoracolumbar (TL) and LL fractures between 2005 and 2022. Patients with at least 24 months of follow-up were included. The included patient cohort consisted of 49 patients, including 16 LL fractures (8 SSPI, 8 LSPI) and 33 TL fractures. Clinical outcomes were assessed using the Oswestry Disability Index (ODI) and visual analogue scale (VAS) for pain. Radiological outcomes were assessed by measuring the Sagittal Cobb Angle (SCA) preoperatively, postoperatively and at final follow-up. Statistical analyses were performed using non-parametric tests. Results The mean follow-up duration was 84 months. Functional assessments demonstrated significantly lower ODI and VAS scores in the LL SSPI and TL groups compared to the LL LSPI group (ODI: p = 0.019, VAS: p = 0.005). Among LL fractures, SSPI resulted in ODI (p = 0.255) and VAS (p = 0.066) scores comparable to TL fractures, suggesting minimal functional impairment. Radiologically, all groups exhibited significant improvements in SCA (p < 0.001). Conclusion Conclusion: According to the study, SSPI is an effective surgical approach for LL fractures and provides functional results comparable to surgery in the TL region. Lower lumbar fractures short segment fusion long segment fusion posterior instrumentation Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Lower lumbar (LL) spine fractures are relatively uncommon compared to fractures that occur in other regions of the spine [ 1 , 2 ]. The LL region, which includes the L3 to L5 vertebrae, has unique anatomical and biomechanical characteristics, such as larger vertebral bodies, strong paraspinal muscles, sagittally oriented facet joints, and increased lumbar lordosis and segmental mobility. If not properly managed, spine fractures can lead to neurological deficits, chronic pain, and progressive structural deformity. The primary goals of surgical treatment are to achieve fracture reduction, restore spinal stability, and prevent further neurological deterioration [ 3 ]. Therefore, it is essential to consider the distinct anatomical and biomechanical features of the lower lumbar spine when managing fractures in this area. In addition to the limited evidence available in the literature on LL fractures, the optimal management of these injuries remains uncertain. While some authors advocate conservative treatment in neurologically intact patients, others support surgical intervention [ 2 , 4 ]. Due to the limited spinal mobility in the thoracolumbar (TL) region (T10-L2), spinal fusions in this area do not significantly impact patients' quality of life [ 5 – 7 ] When we examine the significance of the lumbar lordosis (LL) region in maintaining spinal balance in the sagittal plane and promoting lumbar mobility, concerns about the surgical treatment of fractures arise. This study aimed to assess the mid- and long-term clinical and radiological outcomes of patients who underwent short- and long-segment posterior fusion for LL vertebral fractures. MATERIALS AND METHODS The study received approval from the institutional review board and was conducted in accordance with established ethical standards. The identities of the participants were kept confidential, and all data collected were used solely for scientific research purposes. Throughout the study, we adhered to the ethical principles outlined in the Helsinki Declaration. In this retrospective study, we reviewed patients who underwent surgical treatment for LL and TL fractures between 2005 and 2022. Inclusion criteria comprised patients aged 18–65 years with fractures in the TL region (T10–L2) or LL region (L3–L5) who underwent posterior instrumentation and had a minimum clinical and radiological follow-up of 24 months. Only patients with unstable fracture patterns classified according to the AO Spine Thoracolumbar Injury Classification System and who underwent surgery within two weeks of injury were included to ensure standardized treatment timing. Patients with complete spinal cord injuries were excluded. Additional exclusion criteria included a history of prior spinal surgery, severe osteoporosis, active infection, and revision procedures. Informed consent was obtained from all participants. LL fractures were classified into two categories based on the extent of posterior instrumentation: short-segment fixation, which involves two levels, and long-segment fixation, which includes three or more levels. The control group comprised patients with TL fractures who underwent only short-segment (two-level) posterior instrumentation (Fig. 1). Surgical Technique All surgical procedures were performed by two experienced spine surgeons. Each patient underwent surgery in the prone position using a standard posterior approach. A prophylactic dose of 1 g of intravenous cefazolin was administered 30 to 60 minutes before the incision. A meticulous posterior approach was used to minimize intraoperative bleeding. The paraspinal muscles were carefully stripped subperiosteally, and the posterior elements at the predetermined instrumentation levels were adequately exposed. During this exposure, special attention was given to preserving the supraspinous and interspinous ligaments, as well as the facet joint capsules at both the upper and lower adjacent levels, to prevent segmental degeneration. Pedicle screws were bilaterally inserted using the freehand technique, with diameters ranging from 6.5 to 7.5 mm in the lumbar region and from 5.5 to 6.5 mm in the thoracic region. After placing the pedicle screws, anteroposterior and lateral radiographs were obtained to confirm proper screw positioning. Rods were then carefully inserted to ensure proper lumbar lordosis in the LL region. In cases of vertebral body collapse, fracture reduction was performed using the ligamentotaxis technique (Figs. 2 and 3). In short-segment instrumentation, posterior fixation was achieved by placing pedicle screws in the vertebra above and below the fracture, as well as in the fractured vertebra itself. Short-segment posterior instrumentation (SSPI) was primarily performed in cases of A2 split fractures, A3 incomplete burst fractures with progressive collapse, or A4 complete burst fractures. In long segment instrumentation (LSPI), the fractured spine is instrumented to include two upper and two lower vertebrae. LSPI is typically performed for type B2 fractures with posterior tension band injuries, type B3 fractures involving hyperextension injuries, and type C fracture-dislocations. When the pedicles of the fractured vertebra are intact, pedicle screws are also inserted at the fracture level. In all patients, the medial facet joints are resected, and the articular cartilage is decorticated to promote fusion. The lamina, pars interarticularis, and transverse processes are also decorticated. Following this, autografts and/or allografts are placed over the decorticated lamina and facet joints. Before wound closure, anteroposterior and lateral radiographs were obtained to assess fracture reduction and spinal alignment in both the coronal and sagittal planes. A Hemovac drain was placed, and standard layered closure was performed. No postoperative bracing was applied in any patient. In-bed exercises were initiated on the same day after the resolution of anesthesia. Patients with stable vital signs were allowed to sit at the bedside on the day of surgery and were mobilized on postoperative day one. Hemovac drains were removed once drainage decreased below 50 mL. Most patients were discharged on the second or third postoperative day. Follow-up visits were scheduled at 3 and 6 weeks, 3, 6, and 12 months postoperatively, and annually thereafter. Data Collection Baseline demographic data, including age, sex, and body mass index (BMI), were recorded. Radiological outcomes were assessed by measuring the sagittal Cobb angle (SCA) at three time points: preoperatively, immediately postoperatively, and at the final follow-up. Improvement in SCA was defined as the difference between preoperative and final follow-up measurements. Functional outcomes were evaluated using the Oswestry Disability Index (ODI) and the Visual Analog Scale (VAS) for pain. Perioperative variables, including operative time, intraoperative blood loss, and complications, were also documented. Statistical Analysis Descriptive statistics were used to summarize baseline characteristics and outcome measures. The Shapiro–Wilk test was applied to assess the normality of continuous variables, which indicated a non-normal distribution. Consequently, non-parametric tests were employed. Continuous variables were expressed as mean ± standard deviation and categorical variables as frequencies and percentages. Pairwise comparisons were conducted based on fracture location (thoracolumbar vs. lumbar) and posterior instrumentation type (short vs. long segment). The Mann–Whitney U test was used for continuous variables, while the chi-square or Fisher’s exact test was applied for categorical data. To control for potential Type I error due to multiple comparisons, the Benjamini–Hochberg procedure was used to adjust p-values. Changes in SCA over time were analyzed using the Friedman test, with post hoc Wilcoxon signed-rank tests for pairwise comparisons. Kendall’s W was calculated to determine the degree of concordance across time points. For significant comparisons, effect sizes were reported using a Cohen’s d equivalent for the Mann–Whitney U test. Statistical significance was set at p < .05. All analyses were performed using SPSS (version 27, macOS) and Python (version 3.10) RESULTS A total of 49 patients were included in the study, comprising 33 cases of TL fractures and 16 cases of LL fractures. The median age of the participants was 39 years (range, 18–63 years), with no statistically significant difference between the TL and LL groups (p = 0.773). The median follow-up duration was 84 months (range, 60–232 months), with no significant differences observed among the groups (p = 0.481 overall; p = 0.682 for short-segment instrumentation; p = 0.710 for long-segment instrumentation). TL fractures most commonly involved the L1 and T12 vertebral levels, whereas LL fractures were predominantly located at L3 and L4 (Table 1). For short-segment PI, ODI scores were lower in TL fractures compared to LL fractures; however, this difference did not reach statistical significance (p = 0.255). VAS scores were also comparable between TL and LL fractures treated with short-segment fusion (p = 0.066). In contrast, among patients who underwent long-segment PI, ODI scores were significantly higher in LL fractures compared to TL fractures (p = 0.040, effect size = 0.33). Similarly, VAS scores were also significantly higher in the LL group (p = 0.038) (Table 2). Significant improvements in SCA were observed across all time points (preoperative, postoperative, and final follow-up) in both TL and LL fracture groups. Preoperative SCA was significantly greater in the TL group (25.5 ± 6.4°) compared to the LL group (12.0 ± 2.3°; p < 0.001). Postoperative and final follow-up SCA measurements demonstrated substantial correction in both groups, with statistically significant differences between TL and LL fractures maintained at both time points (postoperative SCA: p < 0.001; final follow-up SCA: p < 0.001). The Friedman test indicated significant changes in SCA across time points within each group, with Kendall’s W confirming strong concordance (Table 3). SSPI fusion resulted in significant improvements in the sagittal Cobb angle (SCA) in both TL and LL fractures, as well as in long-segment LL fractures. The mean improvements in SCA were 17.1 ± 3.8° for TL fractures, 13.0 ± 3.6° for short-segment LL fractures (p < 0.05, effect size = 0.32), and 13.25 ± 3.06° for long-segment LL fractures (p = 0.003, effect size = 0.49) (Table 2). The Friedman test confirmed statistically significant differences in SCA across preoperative, postoperative, and final follow-up measurements in all groups (p < 0.001 for all). Kendall’s W values demonstrated strong agreement across time points, ranging from 0.904 to 0.945 in thoracolumbar (TL) fractures and from 0.939 to 0.945 in lower lumbar (LL) fractures (Table 4). These results highlight the effectiveness of both short- and long-segment posterior instrumentation in improving sagittal alignment, regardless of fracture location and instrumentation length. DISCUSSION The current study evaluated the impact of instrumentation length on clinical outcomes for LL spine fractures. It was observed that the ODI and VAS scores of patients who underwent short-segment fusion for LL fractures were comparable to those observed in TL fractures. Considering that lumbar mobility is greater in the LL region [ 8 ] and that there are distinct biomechanical differences compared to the TL region, the finding that ODI and VAS scores in LL fractures were similar to those in TL fractures represents a clinically relevant outcome. This indicates that the functional status of LL patients treated with SSPI is not significantly compromised. Long-segment fusion in the LL region has been associated with reduced quality of life, primarily due to its potential impact on spinal mobility and the risk of adjacent segment degeneration [ 9 , 10 ]. In our study, patients with LL fractures treated with short-segment fusion demonstrated functional outcomes comparable to those of patients with TL fractures (ODI: p = 0.255). This finding suggests that short-segment fusion in LL fractures does not compromise functional recovery and supports its potential as a viable treatment strategy, even in a region that plays a critical role in lumbar motion. In contrast, LSPI in LL fractures was associated with significantly higher ODI scores compared to LL fractures undergoing TL and SSPI (p = 0.040, Cohen's d = 0.33), indicating greater functional impairment. This finding is consistent with existing literature suggesting that LSPI in LL fractures may lead to worse functional outcomes due to increased stiffness and higher risk of adjacent segment pathology [ 9 , 10 ]. There are a limited number of studies on the management of LL fractures, and some studies advocate conservative treatment of LL fractures [ 11 , 12 ], while others argue that short segment fusion results are better [ 4 , 13 ]. Kaminski et al. (2003) [ 12 ] reported that transpedicular bone grafting combined with a posterior fixation for LL fractures neither adequately corrected local kyphosis nor restored lumbar lordosis. They also suggested that conservative treatment may be a reasonable approach due to its high complication rate. In our study, radiologic evaluation showed significant improvement in postoperative SCA. Preoperative SCA values were similar between SSPI and LSPI in LL fractures. Postoperative SCA and final control demonstrated significant improvements in SCA and the restoration of sagittal alignment, highlighting the effectiveness of posterior instrumentation. The improvement in SCA in the LL region was more pronounced in the LSPI group. Nonetheless, no statistically significant difference was observed when compared to the short-segment posterior instrumentation (SSPI) group. There was a significant improvement between preoperative and postoperative values. Previous studies have demonstrated that pedicle screw placement at the fracture level can effectively correct local kyphosis and realign the fracture through the ligamentotaxis technique in SSPI [ 14 , 15 ]. In our study, pedicle screws were inserted at the fracture level in all patients who underwent SSPI. In terms of functional outcomes, Erkan et al. (2015) reported that scores on the ODI and VAS improved significantly at the final follow-up for patients who were managed conservatively [ 11 ]. Similarly, our findings showed that ODI and VAS scores were notably better at the final follow-up for the lower lumbar SSPI group. In our study, however, none of the patients experienced any neurological deficits, and those who underwent spinal surgery for lumbar (LL) fractures achieved favorable functional outcomes. Additionally, one of the main advantages of surgical treatment is the restoration of lumbar lordosis through appropriate surgical techniques. We believe that obtaining adequate lordotic alignment using conservative methods remains challenging in cases of LL fractures. Niu et al. reported that lumbar lordosis and sacral inclination were significantly reduced in conservatively managed LL fractures, leading to sagittal lumbosacral imbalance [ 16 ]. They also reported a mean lordosis restoration of 6.29° ± 4.80° in patients treated with kyphoplasty. In comparison, our study demonstrated a mean lordosis correction of 13° in patients treated with LL SSPI. Numerous studies have reported no difference in clinical and radiological outcomes between short and long posterior instrumentation, but it has been emphasised that short posterior instrumentation has significantly shorter incision lengths, shorter operative times and less intraoperative blood loss [ 7 , 17 – 19 ]. These findings align with the results of the present study, which demonstrates that SSPI is clinically effective while minimizing surgical invasiveness. Limitations The retrospective design introduces inherent limitations, including potential selection and reporting biases, which may affect the generalizability of the findings. In addition, the relatively small sample size may limit the statistical power of the study. Another limitation is that functional outcomes, including ODI and VAS scores, were assessed only at the final follow-up visit, with no interim evaluations. Finally, as a single-center study, the results may not be representative of broader patient populations or institutional practices, warranting caution when extrapolating the findings to other settings. Larger, prospective, randomized controlled trials with more diverse patient cohorts are required to confirm and expand upon these results. CONCLUSION This study underscores the effectiveness of short-segment posterior instrumentation fusion in managing low lumbar fractures, achieving significant functional and radiological improvements with reduced surgical invasiveness. The findings highlight the potential of short-segment fusion as a viable and efficient approach, particularly for patients with less severe fracture patterns. With its advantages in operative parameters and comparable outcomes to long-segment fusion, short-segment fusion holds promise as a standard technique for appropriately selected fracture types. Declarations All authors made substantial contributions to the study. The authors confrm that the manuscript, including related data, fgures and tables has not been previously published and is not under consideration elsewhere. There has been no fnancial remuneration. All authors state that the manuscript represents honest work. Ethics Approval Ethics committee approval was obtained from the ethics commission of our institution for the study (Number: E-77082166-604.01-1176128). Author Contribution HG contributed significantly to hypothesis formulation and study design and he drafted the work and revised it critically for important intellectual content. He approved the version of the manuscript to be published. ACB made significant contributions to the review of recent papers and the drafting of the manuscript. He approved the version of the manuscript to be published. AA contributed significantly to the conception, design and data collection of the study. He approved the version of the manuscript to be published. AS supervised and was responsible for the organisation and progress of the manuscript. He also revised and approved the version of the manuscript to be published. References Lehman RA Jr, Paik H, Eckel TT, Helgeson MD, Cooper PB, Bellabarba C. Low lumbar burst fractures: a unique fracture mechanism sustained in our current overseas conflicts. Spine J. 2012 Sep;12(9):784-90. https://doi.org/10.1016/j.spinee.2011.09.005. Sansur CH, Shaffrey CI. Diagnosis and management of low lumbar burst fractures. Seminars in Spine Surgery. 2010; 22(1):33-7 https://doi.org/10.1053/j.semss.2009.10.002 Suer O, Aydemir S, Kilicli B, Akcali O, Ozturk AM. Should the level of the posterior instrumentation combined with the intermediate screw be a short segment or a long segment in thoracolumbar fractures with fusion to the fractured segment? Eur J Trauma Emerg Surg. 2024 Aug;50(4):1753-1763. https://doi.org/10.1007/s00068-024-02518-7. Moawad CM, Arzi H, Naik A, Bashir R, Arnold PM. 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Surg Neurol Int. 2022 Jun 3;13:233. https://doi.org/10.25259/SNI_238_2022. Tables Table 1. Descriptive Characteristics of Patients with Thoracolumbar and Lumbar Fractures TL Fractures (n = 33) LL Fractures (n = 16) Total P value a Age (mean±SD) 40.5 ± 14.1 39.1 ± 11.4 40.1 ± 13.2 0.773 Follow up period (months) (mean±SD) 91.1 ± 35.3 95.1 ± 32.8 92.4 ± 34.2 0.481 Sex (F/M) 11 (33.3%) / 22 (66.7%) 4 (25.0%) / 12 (75.0%) 15 (30.6%) / 34 (69.4%) 0.743 b Level of fracture L1: 7 (21.2%), L2: 7 (21.2%), T10: 5 (15.2%), T11: 6 (18.2%), T12: 8 (24.2%) L3: 7 (43.8%), L4: 8 (50.0%), L5: 1 (6.3%) L1: 7 (14.3%), L2: 7 (14.3%), L3: 7 (14.3%), L4: 8 (16.3%), L5: 1 (2.0%), T10: 5 (10.2%), T11: 6 (12.2%), T12: 8 (16.3%) - PI length (Short =3) 33 (100%) 8 (50.0%) / 8 (50.0%) 33 (67.3%) / 16 (32.7%) 0.761 b PI length (mean±SD) 2.9 ± 0.9 3.1 ± 1.3 3.0 ± 1.0 0.757 BMI (mean±SD) 25.6 ± 4.1 27.8 ± 5.0 26.3 ± 4.5 0.196 ODI (mean±SD) 22.9 ± 10.6 33.0 ± 14.0 26.2 ± 12.6 0.019 VAS (mean±SD) 1.6 ± 1.1 2.2 ± 2.0 2.1 ± 1.6 0.065 TL: thoracolumbar; LL: lower lumbar; SD: standard deviation; ODI: Oswestry Disability index; VAS: visual analog scale; BMI: body mass index; Values are presented as mean ± standard deviation for continuous variables and frequencies (percentages) for categorical variables. P-values for continuous variables are derived from a Mann-Whitney U tests. For categorical variables, b Chi-square or Fisher's exact test was used. Significant differences (p < .05) are observed for the Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) scores. Table 2. Comparative Analysis of Thoracolumbar and Lower Lumbar Fractures Variable TL SSPI (n = 33) (mean±SD) LL SSPI (n = 8) (mean±SD) LL LSPI (n = 8) (mean±SD) P value (LL) P value (S) P value (L) Age 45.21 ± 14.33 40.25 ± 12.10 38.00 ± 11.39 0.938 0.46125 0.71 Follow up period (months) 84.86 ± 18.24 87.50 ± 16.51 102.75 ± 43.59 0.917 0.682 0.71 Sex (F/M) 33%/67% (11/22) 37.5%:62.5% (3/5) 12.5%:87.5% (1/7) 0.675 1 ODI 20.36 ± 10.26 25.38 ± 7.17 40.63 ± 15.42 0.459 0.255 0.040 (0.33)* VAS 1.96 ± 1.08 2.18 ± 2.39 3.00 ± 1.69 1 0.0666 0.038 BMI 24.64 ± 3.39 26.75 ± 4.53 28.75 ± 5.63 1 0.46125 0.258 Preop SCA 21.14 ± 3.66 11.50 ± 2.14 12.50 ± 2.56 1 <0.001 (0.55)* <0.001 (0.55)* Postop SCA 3.57 ± 1.83 -2.75 ± 1.49 -3.00 ± 1.51 0.938 <0.001 (0.54)* <0.001 (0.54)* Last control SCA 4.07 ± 2.46 -1.50 ± 2.27 -0.75 ± 1.39 1 0.003 (0.49)* 0.005 (0.44)* Improvement in SCA 17.1 ± 3.83 13.00 ± 3.6 13.25 ± 3.06 0.915 0.050 (0.32)* 0.003 (0.49)* TL: thoracolumbar; LL: lower lumbar; SD: standard deviation; SSPI: short-segment posterior instrumentation; LSPI: long-segment posterior instrumentation; SCA: sagittal Cobb angle; Preop: preoperative; Postop: postoperative; ODI: Oswestry Disability index; VAS: visual analog scale; BMI: body mass index; P value (S) represents the Mann-Whitney U test comparing short posterior instrumentation (PI) fusions between thoracolumbar (TL) and lumbar (LL) fractures. P value (L) represents the Mann-Whitney U test comparing long PI fusions between TL and LL fractures. P value (TL) represents the Mann-Whitney U test comparing short and long PI fusions within TL fractures. P value (LL) represents the Mann-Whitney U test comparing short and long PI fusions within LL fractures. All p values were adjusted for Type I error using the Benjamini-Hochberg procedure. Effect sizes (Cohen's d equivalent) are indicated in parentheses for significant p values, marked with an asterisk (*). Improvement in SCA (sagittal Cobb angle) was calculated as the difference between the LastControlSCA and PreopSCA. Statistical significance was set at p < .05. Table 3. Sagittal Cobb Angles at Preoperative, Postoperative, and Late Follow-Up for Thoracolumbar and Lumbar Fractures TL Fractures (n = 33) LL Fractures (n = 16) Total P value a Preop SCA (mean±SD) 25.5 ± 6.4 12.0 ± 2.3 21.1 ± 8.4 <0.001 Postop SCA (mean±SD) 2.6 ± 2.0 -2.9 ± 1.5 0.8 ± 3.2 <0.001 Last control SCA (mean±SD) 3.5 ± 2.6 -1.1 ± 1.9 2.0 ± 3.2 <0.001 P value (Friedman) b <0.001 <0.001 <0.001 P value (Preop-Postop) c <0.001 <0.001 <0.001 P value (Preop-Late Postop) c <0.001 <0.001 <0.001 P value (Postop-Late Postop) c <0.001 0.003 <0.001 TL: thoracolumbar; LL: lower lumbar; SD: standard deviation; SSPI: short-segment posterior instrumentation; LSPI: long-segment posterior instrumentation; SCA: sagittal Cobb angle; Preop: preoperative; Postop: postoperative; b Comparisons of preoperative, postoperative, and late follow-up SCA were conducted using the Friedman test with post-hoc pairwise comparisons via c Wilcoxon signed-rank tests. a The differences between thoracolumbar and lumbar fracture groups at each time point were assessed using the Mann-Whitney U test. All p-values less than .05 are considered statistically significant . Table 4. Friedman Test and Kendall’s W for Sagittal Cobb Angle (SCA) Changes Across Preoperative, Postoperative, and Last Control Time Points in Lower Lumbar and Thoracolumbar Fractures. Variable TL SSPI (n = 33) LL SSPI (n = 8) LL LSPI (n = 8) Mean Rank (Preop SCA) 3 3 3 Mean Rank (Postop SCA) 1.39 1.19 1.13 Mean Rank (Last control SCA) 1.61 1.81 1.88 Chi-Square 39.795 16.909 13.231 df 2 2 2 p-value p < .001 p < .001 p = .001 Kendall's W W = .907 W = .935 W = .950 TL: thoracolumbar; LL: lower lumbar; SD: standard deviation; SSPI: short-segment posterior instrumentation; LSPI: long-segment posterior instrumentation; SCA: sagittal Cobb angle; Preop: preoperative; Postop: postoperative; Chi-square values and Kendall’s W statistics reflect the degree of change across time points within each group. Kendall's W (ranging from 0 to 1) indicates a high level of concordance, with values close to 1 suggesting a strong effect. Significance is considered at p < .05. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6486786","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":455553845,"identity":"071eabbc-c2ab-4fed-9cca-acc41ff59e24","order_by":0,"name":"Halil Gok","email":"","orcid":"","institution":"Ankara Etlik City Hospital, Department of Orthopaedics and Traumatology","correspondingAuthor":false,"prefix":"","firstName":"Halil","middleName":"","lastName":"Gok","suffix":""},{"id":455553846,"identity":"b3cc8eaa-221e-4265-a700-b432bb45dbe9","order_by":1,"name":"Alim Can Baymurat","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABA0lEQVRIiWNgGAWjYDACdsYGEJUA48sxMPAQ0MKMqsXAmAgtEAquJbGBkBb+ZubWDT9q7uTxz8hOk66o+ZO+4fjZgw8+MNjJ6TZg1yJxmLHtZs+xZ8USN3K3SZ45ZpC74UxesuEMhmRjswM4rAFquc3AdjixAaSlgQ2o5UCOmTQPw4HEbTi0yIO1/DucOB+s5Z9BusH5N/i1GIC0MLYdTtwA0tLYZpBgcIOALYYgv/T2HS42PPN2s2Vjn7HhzBtvjA1nGOD2i9zx9mc3fnw7nCd3PHfjzYZvcvJ853MMH3yosJPD6X04EEiA0ApglQaElIMAP9RQ+QZiVI+CUTAKRsFIAgC2cWec8WjRLQAAAABJRU5ErkJggg==","orcid":"","institution":"Gazi University Medical Faculty, Department of Orthopaedics and Traumatology","correspondingAuthor":true,"prefix":"","firstName":"Alim","middleName":"Can","lastName":"Baymurat","suffix":""},{"id":455553847,"identity":"b6fea5c2-490b-48a1-9c0f-59f048a84d28","order_by":2,"name":"Asim Ahmadov","email":"","orcid":"","institution":"Gazi University Medical Faculty, Department of Orthopaedics and Traumatology","correspondingAuthor":false,"prefix":"","firstName":"Asim","middleName":"","lastName":"Ahmadov","suffix":""},{"id":455553848,"identity":"2e9bb218-297c-453a-ac33-2bc0ca8b03f0","order_by":3,"name":"Alpaslan Senkoylu","email":"","orcid":"","institution":"Gazi University Medical Faculty, Department of Orthopaedics and Traumatology","correspondingAuthor":false,"prefix":"","firstName":"Alpaslan","middleName":"","lastName":"Senkoylu","suffix":""}],"badges":[],"createdAt":"2025-04-19 23:08:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6486786/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6486786/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82897608,"identity":"37fc137b-dc96-4f90-8d41-cfcdd25a01a2","added_by":"auto","created_at":"2025-05-16 13:07:33","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":41781,"visible":true,"origin":"","legend":"\u003cp\u003ePatient selection flowchart\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6486786/v1/3f2874d06cc362bf4f4fdebb.jpg"},{"id":82897610,"identity":"eefe5dc6-514d-4558-a09d-57c36f05c42b","added_by":"auto","created_at":"2025-05-16 13:07:34","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":59098,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative (a, b) and postoperative (c, d) plain radiographs of a patient who underwent short segment posterior instrumentation for L 3 vertebral fracture.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6486786/v1/c7893c2ba128ee819e5c5aee.jpg"},{"id":82897611,"identity":"a165bf51-f495-4598-97fe-b9ce4a38e484","added_by":"auto","created_at":"2025-05-16 13:07:34","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":48329,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative (a, b) and postoperative (c, d) plain radiographs of a patient who underwent long segment posterior instrumentation for L 3 vertebral fracture.\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6486786/v1/b84920e339e8ce43ad4f2c27.jpg"},{"id":87141989,"identity":"ebd77e53-0ad1-4f1b-aa31-56a6d281768a","added_by":"auto","created_at":"2025-07-20 16:46:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":802980,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6486786/v1/20f4f6f7-c6d7-4e47-af4b-04fd8a56453d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eThe Effect of Fusion Levels on Clinical Outcomes in Lower Lumbar Vertebral Fractures\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eLower lumbar (LL) spine fractures are relatively uncommon compared to fractures that occur in other regions of the spine [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The LL region, which includes the L3 to L5 vertebrae, has unique anatomical and biomechanical characteristics, such as larger vertebral bodies, strong paraspinal muscles, sagittally oriented facet joints, and increased lumbar lordosis and segmental mobility. If not properly managed, spine fractures can lead to neurological deficits, chronic pain, and progressive structural deformity. The primary goals of surgical treatment are to achieve fracture reduction, restore spinal stability, and prevent further neurological deterioration [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Therefore, it is essential to consider the distinct anatomical and biomechanical features of the lower lumbar spine when managing fractures in this area.\u003c/p\u003e \u003cp\u003eIn addition to the limited evidence available in the literature on LL fractures, the optimal management of these injuries remains uncertain. While some authors advocate conservative treatment in neurologically intact patients, others support surgical intervention [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDue to the limited spinal mobility in the thoracolumbar (TL) region (T10-L2), spinal fusions in this area do not significantly impact patients' quality of life [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eWhen we examine the significance of the lumbar lordosis (LL) region in maintaining spinal balance in the sagittal plane and promoting lumbar mobility, concerns about the surgical treatment of fractures arise.\u003c/p\u003e \u003cp\u003eThis study aimed to assess the mid- and long-term clinical and radiological outcomes of patients who underwent short- and long-segment posterior fusion for LL vertebral fractures.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003e The study received approval from the institutional review board and was conducted in accordance with established ethical standards. The identities of the participants were kept confidential, and all data collected were used solely for scientific research purposes. Throughout the study, we adhered to the ethical principles outlined in the Helsinki Declaration.\u003c/p\u003e \u003cp\u003e In this retrospective study, we reviewed patients who underwent surgical treatment for LL and TL fractures between 2005 and 2022. Inclusion criteria comprised patients aged 18\u0026ndash;65 years with fractures in the TL region (T10\u0026ndash;L2) or LL region (L3\u0026ndash;L5) who underwent posterior instrumentation and had a minimum clinical and radiological follow-up of 24 months. Only patients with unstable fracture patterns classified according to the AO Spine Thoracolumbar Injury Classification System and who underwent surgery within two weeks of injury were included to ensure standardized treatment timing. Patients with complete spinal cord injuries were excluded. Additional exclusion criteria included a history of prior spinal surgery, severe osteoporosis, active infection, and revision procedures. Informed consent was obtained from all participants.\u003c/p\u003e \u003cp\u003eLL fractures were classified into two categories based on the extent of posterior instrumentation: short-segment fixation, which involves two levels, and long-segment fixation, which includes three or more levels. The control group comprised patients with TL fractures who underwent only short-segment (two-level) posterior instrumentation (Fig.\u0026nbsp;1).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSurgical Technique\u003c/h2\u003e \u003cp\u003eAll surgical procedures were performed by two experienced spine surgeons. Each patient underwent surgery in the prone position using a standard posterior approach. A prophylactic dose of 1 g of intravenous cefazolin was administered 30 to 60 minutes before the incision. A meticulous posterior approach was used to minimize intraoperative bleeding. The paraspinal muscles were carefully stripped subperiosteally, and the posterior elements at the predetermined instrumentation levels were adequately exposed. During this exposure, special attention was given to preserving the supraspinous and interspinous ligaments, as well as the facet joint capsules at both the upper and lower adjacent levels, to prevent segmental degeneration.\u003c/p\u003e \u003cp\u003ePedicle screws were bilaterally inserted using the freehand technique, with diameters ranging from 6.5 to 7.5 mm in the lumbar region and from 5.5 to 6.5 mm in the thoracic region. After placing the pedicle screws, anteroposterior and lateral radiographs were obtained to confirm proper screw positioning. Rods were then carefully inserted to ensure proper lumbar lordosis in the LL region. In cases of vertebral body collapse, fracture reduction was performed using the ligamentotaxis technique (Figs.\u0026nbsp;2 and 3).\u003c/p\u003e \u003cp\u003eIn short-segment instrumentation, posterior fixation was achieved by placing pedicle screws in the vertebra above and below the fracture, as well as in the fractured vertebra itself. Short-segment posterior instrumentation (SSPI) was primarily performed in cases of A2 split fractures, A3 incomplete burst fractures with progressive collapse, or A4 complete burst fractures.\u003c/p\u003e \u003cp\u003eIn long segment instrumentation (LSPI), the fractured spine is instrumented to include two upper and two lower vertebrae. LSPI is typically performed for type B2 fractures with posterior tension band injuries, type B3 fractures involving hyperextension injuries, and type C fracture-dislocations. When the pedicles of the fractured vertebra are intact, pedicle screws are also inserted at the fracture level. In all patients, the medial facet joints are resected, and the articular cartilage is decorticated to promote fusion. The lamina, pars interarticularis, and transverse processes are also decorticated. Following this, autografts and/or allografts are placed over the decorticated lamina and facet joints.\u003c/p\u003e \u003cp\u003eBefore wound closure, anteroposterior and lateral radiographs were obtained to assess fracture reduction and spinal alignment in both the coronal and sagittal planes. A Hemovac drain was placed, and standard layered closure was performed. No postoperative bracing was applied in any patient. In-bed exercises were initiated on the same day after the resolution of anesthesia. Patients with stable vital signs were allowed to sit at the bedside on the day of surgery and were mobilized on postoperative day one. Hemovac drains were removed once drainage decreased below 50 mL. Most patients were discharged on the second or third postoperative day.\u003c/p\u003e \u003cp\u003eFollow-up visits were scheduled at 3 and 6 weeks, 3, 6, and 12 months postoperatively, and annually thereafter.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eBaseline demographic data, including age, sex, and body mass index (BMI), were recorded. Radiological outcomes were assessed by measuring the sagittal Cobb angle (SCA) at three time points: preoperatively, immediately postoperatively, and at the final follow-up. Improvement in SCA was defined as the difference between preoperative and final follow-up measurements. Functional outcomes were evaluated using the Oswestry Disability Index (ODI) and the Visual Analog Scale (VAS) for pain. Perioperative variables, including operative time, intraoperative blood loss, and complications, were also documented.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eDescriptive statistics were used to summarize baseline characteristics and outcome measures. The Shapiro\u0026ndash;Wilk test was applied to assess the normality of continuous variables, which indicated a non-normal distribution. Consequently, non-parametric tests were employed. Continuous variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation and categorical variables as frequencies and percentages. Pairwise comparisons were conducted based on fracture location (thoracolumbar vs. lumbar) and posterior instrumentation type (short vs. long segment). The Mann\u0026ndash;Whitney U test was used for continuous variables, while the chi-square or Fisher\u0026rsquo;s exact test was applied for categorical data. To control for potential Type I error due to multiple comparisons, the Benjamini\u0026ndash;Hochberg procedure was used to adjust p-values. Changes in SCA over time were analyzed using the Friedman test, with post hoc Wilcoxon signed-rank tests for pairwise comparisons. Kendall\u0026rsquo;s W was calculated to determine the degree of concordance across time points. For significant comparisons, effect sizes were reported using a Cohen\u0026rsquo;s \u003cem\u003ed\u003c/em\u003e equivalent for the Mann\u0026ndash;Whitney U test. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;.05. All analyses were performed using SPSS (version 27, macOS) and Python (version 3.10)\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 49 patients were included in the study, comprising 33 cases of TL fractures and 16 cases of LL fractures. The median age of the participants was 39 years (range, 18\u0026ndash;63 years), with no statistically significant difference between the TL and LL groups (p\u0026thinsp;=\u0026thinsp;0.773). The median follow-up duration was 84 months (range, 60\u0026ndash;232 months), with no significant differences observed among the groups (p\u0026thinsp;=\u0026thinsp;0.481 overall; p\u0026thinsp;=\u0026thinsp;0.682 for short-segment instrumentation; p\u0026thinsp;=\u0026thinsp;0.710 for long-segment instrumentation). TL fractures most commonly involved the L1 and T12 vertebral levels, whereas LL fractures were predominantly located at L3 and L4 (Table\u0026nbsp;1).\u003c/p\u003e \u003cp\u003eFor short-segment PI, ODI scores were lower in TL fractures compared to LL fractures; however, this difference did not reach statistical significance (p\u0026thinsp;=\u0026thinsp;0.255). VAS scores were also comparable between TL and LL fractures treated with short-segment fusion (p\u0026thinsp;=\u0026thinsp;0.066). In contrast, among patients who underwent long-segment PI, ODI scores were significantly higher in LL fractures compared to TL fractures (p\u0026thinsp;=\u0026thinsp;0.040, effect size\u0026thinsp;=\u0026thinsp;0.33). Similarly, VAS scores were also significantly higher in the LL group (p\u0026thinsp;=\u0026thinsp;0.038) (Table\u0026nbsp;2).\u003c/p\u003e \u003cp\u003eSignificant improvements in SCA were observed across all time points (preoperative, postoperative, and final follow-up) in both TL and LL fracture groups. Preoperative SCA was significantly greater in the TL group (25.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6.4\u0026deg;) compared to the LL group (12.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u0026deg;; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Postoperative and final follow-up SCA measurements demonstrated substantial correction in both groups, with statistically significant differences between TL and LL fractures maintained at both time points (postoperative SCA: p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; final follow-up SCA: p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The Friedman test indicated significant changes in SCA across time points within each group, with Kendall\u0026rsquo;s W confirming strong concordance (Table\u0026nbsp;3).\u003c/p\u003e \u003cp\u003eSSPI fusion resulted in significant improvements in the sagittal Cobb angle (SCA) in both TL and LL fractures, as well as in long-segment LL fractures. The mean improvements in SCA were 17.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u0026deg; for TL fractures, 13.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u0026deg; for short-segment LL fractures (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, effect size\u0026thinsp;=\u0026thinsp;0.32), and 13.25\u0026thinsp;\u0026plusmn;\u0026thinsp;3.06\u0026deg; for long-segment LL fractures (p\u0026thinsp;=\u0026thinsp;0.003, effect size\u0026thinsp;=\u0026thinsp;0.49) (Table\u0026nbsp;2).\u003c/p\u003e \u003cp\u003eThe Friedman test confirmed statistically significant differences in SCA across preoperative, postoperative, and final follow-up measurements in all groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for all). Kendall\u0026rsquo;s W values demonstrated strong agreement across time points, ranging from 0.904 to 0.945 in thoracolumbar (TL) fractures and from 0.939 to 0.945 in lower lumbar (LL) fractures (Table\u0026nbsp;4). These results highlight the effectiveness of both short- and long-segment posterior instrumentation in improving sagittal alignment, regardless of fracture location and instrumentation length.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe current study evaluated the impact of instrumentation length on clinical outcomes for LL spine fractures. It was observed that the ODI and VAS scores of patients who underwent short-segment fusion for LL fractures were comparable to those observed in TL fractures. Considering that lumbar mobility is greater in the LL region [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and that there are distinct biomechanical differences compared to the TL region, the finding that ODI and VAS scores in LL fractures were similar to those in TL fractures represents a clinically relevant outcome. This indicates that the functional status of LL patients treated with SSPI is not significantly compromised.\u003c/p\u003e \u003cp\u003eLong-segment fusion in the LL region has been associated with reduced quality of life, primarily due to its potential impact on spinal mobility and the risk of adjacent segment degeneration [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In our study, patients with LL fractures treated with short-segment fusion demonstrated functional outcomes comparable to those of patients with TL fractures (ODI: p\u0026thinsp;=\u0026thinsp;0.255). This finding suggests that short-segment fusion in LL fractures does not compromise functional recovery and supports its potential as a viable treatment strategy, even in a region that plays a critical role in lumbar motion.\u003c/p\u003e \u003cp\u003eIn contrast, LSPI in LL fractures was associated with significantly higher ODI scores compared to LL fractures undergoing TL and SSPI (p\u0026thinsp;=\u0026thinsp;0.040, Cohen's d\u0026thinsp;=\u0026thinsp;0.33), indicating greater functional impairment. This finding is consistent with existing literature suggesting that LSPI in LL fractures may lead to worse functional outcomes due to increased stiffness and higher risk of adjacent segment pathology [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere are a limited number of studies on the management of LL fractures, and some studies advocate conservative treatment of LL fractures [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], while others argue that short segment fusion results are better [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eKaminski et al. (2003) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] reported that transpedicular bone grafting combined with a posterior fixation for LL fractures neither adequately corrected local kyphosis nor restored lumbar lordosis. They also suggested that conservative treatment may be a reasonable approach due to its high complication rate. In our study, radiologic evaluation showed significant improvement in postoperative SCA. Preoperative SCA values were similar between SSPI and LSPI in LL fractures. Postoperative SCA and final control demonstrated significant improvements in SCA and the restoration of sagittal alignment, highlighting the effectiveness of posterior instrumentation. The improvement in SCA in the LL region was more pronounced in the LSPI group. Nonetheless, no statistically significant difference was observed when compared to the short-segment posterior instrumentation (SSPI) group.\u003c/p\u003e \u003cp\u003eThere was a significant improvement between preoperative and postoperative values. Previous studies have demonstrated that pedicle screw placement at the fracture level can effectively correct local kyphosis and realign the fracture through the ligamentotaxis technique in SSPI [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In our study, pedicle screws were inserted at the fracture level in all patients who underwent SSPI.\u003c/p\u003e \u003cp\u003eIn terms of functional outcomes, Erkan et al. (2015) reported that scores on the ODI and VAS improved significantly at the final follow-up for patients who were managed conservatively [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Similarly, our findings showed that ODI and VAS scores were notably better at the final follow-up for the lower lumbar SSPI group.\u003c/p\u003e \u003cp\u003eIn our study, however, none of the patients experienced any neurological deficits, and those who underwent spinal surgery for lumbar (LL) fractures achieved favorable functional outcomes. Additionally, one of the main advantages of surgical treatment is the restoration of lumbar lordosis through appropriate surgical techniques. We believe that obtaining adequate lordotic alignment using conservative methods remains challenging in cases of LL fractures.\u003c/p\u003e \u003cp\u003eNiu et al. reported that lumbar lordosis and sacral inclination were significantly reduced in conservatively managed LL fractures, leading to sagittal lumbosacral imbalance [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. They also reported a mean lordosis restoration of 6.29\u0026deg; \u0026plusmn; 4.80\u0026deg; in patients treated with kyphoplasty. In comparison, our study demonstrated a mean lordosis correction of 13\u0026deg; in patients treated with LL SSPI.\u003c/p\u003e \u003cp\u003eNumerous studies have reported no difference in clinical and radiological outcomes between short and long posterior instrumentation, but it has been emphasised that short posterior instrumentation has significantly shorter incision lengths, shorter operative times and less intraoperative blood loss [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. These findings align with the results of the present study, which demonstrates that SSPI is clinically effective while minimizing surgical invasiveness.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe retrospective design introduces inherent limitations, including potential selection and reporting biases, which may affect the generalizability of the findings. In addition, the relatively small sample size may limit the statistical power of the study. Another limitation is that functional outcomes, including ODI and VAS scores, were assessed only at the final follow-up visit, with no interim evaluations. Finally, as a single-center study, the results may not be representative of broader patient populations or institutional practices, warranting caution when extrapolating the findings to other settings. Larger, prospective, randomized controlled trials with more diverse patient cohorts are required to confirm and expand upon these results.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis study underscores the effectiveness of short-segment posterior instrumentation fusion in managing low lumbar fractures, achieving significant functional and radiological improvements with reduced surgical invasiveness. The findings highlight the potential of short-segment fusion as a viable and efficient approach, particularly for patients with less severe fracture patterns. With its advantages in operative parameters and comparable outcomes to long-segment fusion, short-segment fusion holds promise as a standard technique for appropriately selected fracture types.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAll authors made substantial contributions to the study. The authors confrm that the manuscript, including related data, fgures and tables has not been previously published and is not under consideration elsewhere. There has been no fnancial remuneration. All authors state that the manuscript represents honest work.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthics Approval\u003c/strong\u003e \u003cp\u003e Ethics committee approval was obtained from the ethics commission of our institution for the study (Number: E-77082166-604.01-1176128).\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eHG contributed significantly to hypothesis formulation and study design and he drafted the work and revised it critically for important intellectual content. He approved the version of the manuscript to be published. ACB made significant contributions to the review of recent papers and the drafting of the manuscript. He approved the version of the manuscript to be published. AA contributed significantly to the conception, design and data collection of the study. He approved the version of the manuscript to be published. AS supervised and was responsible for the organisation and progress of the manuscript. He also revised and approved the version of the manuscript to be published.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLehman RA Jr, Paik H, Eckel TT, Helgeson MD, Cooper PB, Bellabarba C. Low lumbar burst fractures: a unique fracture mechanism sustained in our current overseas conflicts. Spine J. 2012 Sep;12(9):784-90. https://doi.org/10.1016/j.spinee.2011.09.005.\u003c/li\u003e\n\u003cli\u003eSansur CH, Shaffrey CI. Diagnosis and management of low lumbar burst fractures. Seminars in Spine Surgery. 2010; 22(1):33-7 https://doi.org/10.1053/j.semss.2009.10.002\u003c/li\u003e\n\u003cli\u003eSuer O, Aydemir S, Kilicli B, Akcali O, Ozturk AM. Should the level of the posterior instrumentation combined with the intermediate screw be a short segment or a long segment in thoracolumbar fractures with fusion to the fractured segment? Eur J Trauma Emerg Surg. 2024 Aug;50(4):1753-1763. https://doi.org/10.1007/s00068-024-02518-7.\u003c/li\u003e\n\u003cli\u003eMoawad CM, Arzi H, Naik A, Bashir R, Arnold PM. Short-Segment Pedicle Fixation of Traumatic Low Lumbar Fractures (L3-L5): Report of 36 Cases. Clin Spine Surg. 2022 Aug 1;35(7):E590-E595. https://doi.org/10.1097/BSD.0000000000001324.\u003c/li\u003e\n\u003cli\u003eShaheen E, Almuqhim MMS, Alotaibi AA, Bormah AW, Naser FM, FaresHamed A, et al. Surgical Management of Lumbar Spine Fractures and Dislocations. Journal of Advanced Zoology. 2023. 44(S-3):1456-1461. https://doi.org/10.53555/jaz.v44iS3.1774\u003c/li\u003e\n\u003cli\u003eWood KB, Li W, Lebl DR, Ploumis A. Management of thoracolumbar spine fractures. Spine J. 2014 Jan;14(1):145-64. https://doi.org/10.1016/j.spinee.2012.10.041.\u003c/li\u003e\n\u003cli\u003eCabrera JP, Guiroy A, Carazzo CA, Yurac R, Valacco M, Vialle E, Joaquim AF; AO Spine Latin America Trauma Study Group. Unstable Thoracolumbar Injuries: Factors Affecting the Decision for Short-Segment vs Long-Segment Posterior Fixation. Int J Spine Surg. 2022 Aug;16(5):772-778. https://doi.org/10.14444/8337.\u003c/li\u003e\n\u003cli\u003eYao X, Chen F, Dong C, Wang J, Tan Y. Kinetic magnetic resonance imaging analysis of thoracolumbar segmental mobility in patients without significant spondylosis. Medicine (Baltimore). 2020 Jan;99(2):e18202. https://doi.org/10.1097/MD.0000000000018202.\u003c/li\u003e\n\u003cli\u003eLack W, Buchelt M, Kiss H, Katterschafka T. Die Auswirkungen der entz\u0026uuml;ndungsbedingten Blockwirbelbildung im Lumbalbereich auf das Bewegungsverhalten der LWS [Effects of inflammation-induced spinal fusion of the lumbar area on movement of the lumbar spine]. Z Orthop Ihre Grenzgeb. 1993 May-Jun;131(3):248-51. German. https://doi.org/10.1055/s-2008-1040236.\u003c/li\u003e\n\u003cli\u003eH\u0026auml;kkinen A, Ylinen J, Kautiainen H, Airaksinen O, Herno A, Tarvainen U, Kiviranta I. Pain, trunk muscle strength, spine mobility and disability following lumbar disc surgery. J Rehabil Med. 2003 Sep;35(5):236-40. https://doi.org/10.1080/16501970306096.\u003c/li\u003e\n\u003cli\u003eErkan S, Tosyalı K, \u0026Ouml;zalp T, Yercan H, Okcu G. The analysis of functional and radiographic outcomes of conservative treatment in patients with low lumbar burst fractures. Injury. 2015 Jul;46 Suppl 2:S36-40. d https://doi.org/10.1016/j.injury.2015.05.030.\u003c/li\u003e\n\u003cli\u003eKaminski, A., M\u0026uuml;ller, E., Hankemeier, S. et al. Low Lumbar Spine Fracture. Eur J Trauma 29, 23\u0026ndash;30 (2003). https://doi.org/10.1007/s00068-003-1202-y\u003c/li\u003e\n\u003cli\u003eDai LD. Low lumbar spinal fractures: management options. Injury. 2002 Sep;33(7):579-82. https://doi.org/10.1016/s0020-1383(02)00021-9.\u003c/li\u003e\n\u003cli\u003eHu ZC, Li XB, Feng ZH, Wang JQ, Gong LF, Xuan JW, Fu X, Jiang BJ, Wu L, Ni WF. Modified pedicle screw placement at the fracture level for treatment of thoracolumbar burst fractures: a study protocol of a randomised controlled trial. BMJ Open. 2019 Jan 28;9(1):e024110. https://doi.org/10.1136/bmjopen-2018-024110. PMID: 30696677;\u003c/li\u003e\n\u003cli\u003eGuduru AV, Keerthi I, Sujir P, Jain MK, Sodavarapu P. Effect of pedicle screw placement into the fractured vertebra in management of unstable thoracolumbar and lumbar fractures. Int J Burns Trauma. 2022 Aug 15;12(4):139-148.\u003c/li\u003e\n\u003cli\u003eNiu J, Feng T, Huang C, Yan Q, Song D, Gan M, Yang H, Zou J. Characteristics of Osteoporotic Low Lumbar Vertebral Fracture and Related Lumbosacral Sagittal Imbalance. Orthopedics. 2021 Jan 1;44(1):e7-e12. https://doi.org/10.3928/01477447-20201028-05.\u003c/li\u003e\n\u003cli\u003eAl Mamun Choudhury A, Alam MS, Jonayed S, Dastagir O, Jahan MS. Long-Segment Versus Short-Segment Pedicle Screw Fixation Including Fractured Vertebrae for the Management of Unstable Thoracolumbar Burst Fractures. Cureus. 2023 Feb 20;15(2):e35235. https://doi.org/10.7759/cureus.35235.\u003c/li\u003e\n\u003cli\u003e\u0026Ouml;zt\u0026uuml;rk AM, S\u0026uuml;er O, Aydemir S, Kılı\u0026ccedil;lı B, Ak\u0026ccedil;alı \u0026Ouml;. The effect of the size of pedicle screw on the long-term radiological and clinical results of short-segment posterior instrumentation in the management of thoracolumbar vertebral fractures. Acta Orthop Traumatol Turc. 2024 Jan;58(1):20-26. https://doi.org/10.5152/j.aott.2024.23056.\u003c/li\u003e\n\u003cli\u003eAgrawal H, Sharma A, Singh V, Naseem A, Gaddikeri M, Amin A. Long-segment fixation versus short-segment fixation with instrumentation of index vertebra for thoracolumbar fractures. Surg Neurol Int. 2022 Jun 3;13:233. https://doi.org/10.25259/SNI_238_2022.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eDescriptive Characteristics of Patients with Thoracolumbar and Lumbar Fractures\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTL Fractures\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 33)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLL Fractures\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 16)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 150px;\"\u003e\n \u003cp\u003eAge (mean\u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e40.5 \u0026plusmn; 14.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e39.1 \u0026plusmn; 11.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e40.1 \u0026plusmn; 13.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e0.773\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 150px;\"\u003e\n \u003cp\u003eFollow up period (months) (mean\u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e91.1 \u0026plusmn; 35.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e95.1 \u0026plusmn; 32.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e92.4 \u0026plusmn; 34.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e0.481\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 150px;\"\u003e\n \u003cp\u003eSex (F/M)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e11 (33.3%) /\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e22 (66.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e4 (25.0%) /\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e12 (75.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e15 (30.6%) /\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e34 (69.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e0.743\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 150px;\"\u003e\n \u003cp\u003eLevel of fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eL1: 7 (21.2%),\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eL2: 7 (21.2%),\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eT10: 5 (15.2%),\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eT11: 6 (18.2%),\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eT12: 8 (24.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eL3: 7 (43.8%),\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;L4: 8 (50.0%),\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eL5: 1 (6.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003eL1: 7 (14.3%),\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eL2: 7 (14.3%),\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eL3: 7 (14.3%),\u003c/p\u003e\n \u003cp\u003eL4: 8 (16.3%),\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eL5: 1 (2.0%),\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eT10: 5 (10.2%),\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eT11: 6 (12.2%),\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eT12: 8 (16.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 150px;\"\u003e\n \u003cp\u003ePI length (Short \u0026lt;=2 / Long \u0026gt;=3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e33 (100%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e8 (50.0%) /\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e33 (67.3%) /\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e16 (32.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e0.761\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 150px;\"\u003e\n \u003cp\u003ePI length (mean\u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e2.9 \u0026plusmn; 0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e3.1 \u0026plusmn; 1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e3.0 \u0026plusmn; 1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e0.757\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 150px;\"\u003e\n \u003cp\u003eBMI (mean\u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e25.6 \u0026plusmn; 4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e27.8 \u0026plusmn; 5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e26.3 \u0026plusmn; 4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e0.196\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 150px;\"\u003e\n \u003cp\u003eODI (mean\u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e22.9 \u0026plusmn; 10.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e33.0 \u0026plusmn; 14.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e26.2 \u0026plusmn; 12.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.019\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 150px;\"\u003e\n \u003cp\u003eVAS (mean\u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e1.6 \u0026plusmn; 1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e2.2 \u0026plusmn; 2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 162px;\"\u003e\n \u003cp\u003e2.1 \u0026plusmn; 1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e0.065\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTL: thoracolumbar; LL: lower lumbar; SD: \u0026nbsp;standard deviation; ODI:\u0026nbsp;Oswestry Disability index; VAS: visual analog scale;\u0026nbsp;\u0026nbsp;BMI: body mass index;\u0026nbsp;Values are presented as mean \u0026plusmn; standard deviation for continuous variables and frequencies (percentages) for categorical variables. P-values for continuous variables are derived from \u003csup\u003ea\u0026nbsp;\u003c/sup\u003eMann-Whitney U tests. For categorical variables, \u003csup\u003eb\u0026nbsp;\u003c/sup\u003eChi-square or Fisher\u0026apos;s exact test was used. Significant differences (p \u0026lt; .05) are observed for the Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) scores.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003eComparative Analysis of Thoracolumbar and Lower Lumbar Fractures\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTL SSPI\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 33)\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(mean\u0026plusmn;SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLL SSPI\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 8)\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(mean\u0026plusmn;SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLL LSPI\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 8)\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(mean\u0026plusmn;SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value (LL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value (S)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value (L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003eAge\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e45.21 \u0026plusmn; 14.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e40.25 \u0026plusmn; 12.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e38.00 \u0026plusmn; 11.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e0.938\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e0.46125\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003eFollow up period (months)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e84.86 \u0026plusmn; 18.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e87.50 \u0026plusmn; 16.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e102.75 \u0026plusmn; 43.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e0.917\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e0.682\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003eSex (F/M)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e33%/67% (11/22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e37.5%:62.5% (3/5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e12.5%:87.5% (1/7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e0.675\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003eODI\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e20.36 \u0026plusmn; 10.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e25.38 \u0026plusmn; 7.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e40.63 \u0026plusmn; 15.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e0.459\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e0.255\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.040 (0.33)*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003eVAS\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e1.96 \u0026plusmn; 1.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e2.18 \u0026plusmn; 2.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e3.00 \u0026plusmn; 1.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e0.0666\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.038\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e24.64 \u0026plusmn; 3.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e26.75 \u0026plusmn; 4.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e28.75 \u0026plusmn; 5.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e0.46125\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.258\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003ePreop SCA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e21.14 \u0026plusmn; 3.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e11.50 \u0026plusmn; 2.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e12.50 \u0026plusmn; 2.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001 (0.55)*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001 (0.55)*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003ePostop SCA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e3.57 \u0026plusmn; 1.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e-2.75 \u0026plusmn; 1.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e-3.00 \u0026plusmn; 1.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e0.938\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001 (0.54)*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001 (0.54)*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003eLast control SCA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e4.07 \u0026plusmn; 2.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e-1.50 \u0026plusmn; 2.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e-0.75 \u0026plusmn; 1.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.003 (0.49)*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.005 (0.44)*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003eImprovement in SCA \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e17.1 \u0026plusmn; 3.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e13.00 \u0026plusmn; 3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e13.25 \u0026plusmn; 3.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e0.915\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.050 (0.32)*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.003 (0.49)*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTL: thoracolumbar; LL: lower lumbar; SD: \u0026nbsp;standard deviation; \u0026nbsp;SSPI: short-segment posterior instrumentation; LSPI: long-segment posterior instrumentation; SCA: sagittal Cobb angle; Preop: preoperative; Postop: postoperative; ODI: Oswestry Disability index; VAS: visual analog scale; BMI: body mass index; \u003cem\u003eP value (S) represents the Mann-Whitney U test comparing short posterior instrumentation (PI) fusions between thoracolumbar (TL) and lumbar (LL) fractures. P value (L) represents the Mann-Whitney U test comparing long PI fusions between TL and LL fractures. P value (TL) represents the Mann-Whitney U test comparing short and long PI fusions within TL fractures. P value (LL) represents the Mann-Whitney U test comparing short and long PI fusions within LL fractures. All p values were adjusted for Type I error using the Benjamini-Hochberg procedure. Effect sizes (Cohen\u0026apos;s d equivalent) are indicated in parentheses for significant p values, marked with an asterisk (*). Improvement in SCA (sagittal Cobb angle) was calculated as the difference between the LastControlSCA and PreopSCA. Statistical significance was set at p \u0026lt; .05.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003eSagittal Cobb Angles at Preoperative, Postoperative, and Late Follow-Up for Thoracolumbar and Lumbar Fractures\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 210px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTL Fractures\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 33)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLL Fractures\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 16)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 210px;\"\u003e\n \u003cp\u003ePreop SCA (mean\u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003e25.5 \u0026plusmn; 6.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e12.0 \u0026plusmn; 2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e21.1 \u0026plusmn; 8.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 210px;\"\u003e\n \u003cp\u003ePostop SCA (mean\u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003e2.6 \u0026plusmn; 2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e-2.9 \u0026plusmn; 1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e0.8 \u0026plusmn; 3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 210px;\"\u003e\n \u003cp\u003eLast control SCA (mean\u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003e3.5 \u0026plusmn; 2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e-1.1 \u0026plusmn; 1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e2.0 \u0026plusmn; 3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 210px;\"\u003e\n \u003cp\u003eP value (Friedman)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 210px;\"\u003e\n \u003cp\u003eP value (Preop-Postop)\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 210px;\"\u003e\n \u003cp\u003eP value (Preop-Late Postop)\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 210px;\"\u003e\n \u003cp\u003eP value (Postop-Late Postop)\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTL: thoracolumbar; LL: lower lumbar; SD: \u0026nbsp;standard deviation; \u0026nbsp;SSPI: short-segment posterior instrumentation; LSPI: long-segment posterior instrumentation;\u0026nbsp;SCA:\u0026nbsp;sagittal Cobb angle; Preop: preoperative; Postop: postoperative;\u0026nbsp;\u0026nbsp; \u003cstrong\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/strong\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003eComparisons of preoperative, postoperative, and late follow-up SCA were conducted using the Friedman test with post-hoc pairwise comparisons via \u003cstrong\u003e\u003csup\u003ec\u003c/sup\u003e\u003c/strong\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003eWilcoxon signed-rank tests. \u003cstrong\u003e\u003csup\u003ea\u0026nbsp;\u003c/sup\u003e\u003c/strong\u003eThe differences between thoracolumbar and lumbar fracture groups at each time point were assessed using the Mann-Whitney U test. All p-values less than .05 are considered statistically significant\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4.\u0026nbsp;\u003c/strong\u003eFriedman Test and Kendall\u0026rsquo;s W for Sagittal Cobb Angle (SCA) Changes Across Preoperative, Postoperative, and Last Control Time Points in Lower Lumbar and Thoracolumbar Fractures.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTL SSPI (n = 33)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLL SSPI (n = 8)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLL LSPI (n = 8)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003eMean Rank (Preop SCA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003eMean Rank (Postop SCA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e1.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e1.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e1.13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003eMean Rank (Last control SCA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e1.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e1.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e1.88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003eChi-Square\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e39.795\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e16.909\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e13.231\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003edf\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003ep \u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003ep \u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003ep = .001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003eKendall\u0026apos;s W\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eW = .907\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eW = .935\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003eW = .950\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTL: thoracolumbar; LL: lower lumbar; SD: \u0026nbsp;standard deviation; \u0026nbsp;SSPI: short-segment posterior instrumentation; LSPI: long-segment posterior instrumentation; SCA: sagittal Cobb angle; Preop: preoperative; Postop: postoperative; Chi-square values and Kendall\u0026rsquo;s W statistics reflect the degree of change across time points within each group. Kendall\u0026apos;s W (ranging from 0 to 1) indicates a high level of concordance, with values close to 1 suggesting a strong effect. Significance is considered at p \u0026lt; .05.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Lower lumbar fractures, short segment fusion, long segment fusion, posterior instrumentation","lastPublishedDoi":"10.21203/rs.3.rs-6486786/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6486786/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eFractures of the lower lumbar (LL) spine are relatively rare and the surgical management of fractures in this region remains uncertain. The aim of this study was to evaluate the mid- and long-term clinical and radiological outcomes of short segment posterior instrumentation (SSPI) and long segment posterior instrumentation (LSPI) for LL fractures.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eMethods: A retrospective analysis was performed of patients who underwent posterior instrumentation for thoracolumbar (TL) and LL fractures between 2005 and 2022. Patients with at least 24 months of follow-up were included. The included patient cohort consisted of 49 patients, including 16 LL fractures (8 SSPI, 8 LSPI) and 33 TL fractures. Clinical outcomes were assessed using the Oswestry Disability Index (ODI) and visual analogue scale (VAS) for pain. Radiological outcomes were assessed by measuring the Sagittal Cobb Angle (SCA) preoperatively, postoperatively and at final follow-up. Statistical analyses were performed using non-parametric tests.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe mean follow-up duration was 84 months. Functional assessments demonstrated significantly lower ODI and VAS scores in the LL SSPI and TL groups compared to the LL LSPI group (ODI: p\u0026thinsp;=\u0026thinsp;0.019, VAS: p\u0026thinsp;=\u0026thinsp;0.005). Among LL fractures, SSPI resulted in ODI (p\u0026thinsp;=\u0026thinsp;0.255) and VAS (p\u0026thinsp;=\u0026thinsp;0.066) scores comparable to TL fractures, suggesting minimal functional impairment. Radiologically, all groups exhibited significant improvements in SCA (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eConclusion: According to the study, SSPI is an effective surgical approach for LL fractures and provides functional results comparable to surgery in the TL region.\u003c/p\u003e","manuscriptTitle":"The Effect of Fusion Levels on Clinical Outcomes in Lower Lumbar Vertebral Fractures","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-16 12:59:28","doi":"10.21203/rs.3.rs-6486786/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"60107ede-d42f-4064-8cf4-82de2861d73b","owner":[],"postedDate":"May 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-20T16:38:35+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-16 12:59:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6486786","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6486786","identity":"rs-6486786","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}