Modified Spinous Process–Splitting Approach for Thoracolumbar Burst Fractures With Neurological Deficits: Technical Description and Preliminary Clinical Outcomes

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Abstract

ABSTRACT Background Thoracolumbar burst fractures with neurological deficits require decompression and stabilization. The spinous process‐splitting approach (SPSA) achieves neural decompression while preserving the posterior osteoligamentous complex and minimizing paraspinal muscle injury. Objective Although various posterior surgical techniques are available for thoracolumbar burst fractures with neurological deficits, achieving adequate neural decompression while maximally preserving the posterior osteoligamentous complex remains technically challenging; a standardized approach that balances sufficient decompression with posterior structural preservation is still lacking. Therefore, we aimed to describe a modified SPSA combining the Wiltse interval with spinous process splitting for decompression, and to preliminarily evaluate its feasibility, safety, and early clinical and radiographic outcomes. Methods We retrospectively reviewed seven consecutive male patients who underwent posterior fixation, decompression, and fusion via modified SPSA between January 2020 and December 2024. Outcomes included American Spinal Injury Association (ASIA) grade, Visual Analog Scale (VAS) for pain, Gardner angle, anterior vertebral height ratio, and spinal canal encroachment ratio, assessed preoperatively, at 1 week postoperatively, and at 14 ± 2 months. Repeated‐measures ANOVA was performed (α = 0.05). Results All procedures were completed successfully with mean operative time of 172.1 ± 95.7 min. All patients improved by at least one ASIA grade postoperatively, with no neurological deterioration. VAS scores decreased from 6.86 ± 0.90 preoperatively to 3.29 ± 0.49 at 1 week, and to 1.14 ± 0.38 at final follow‐up ( F  = 350.00, p  < 0.01). Gardner angle improved from 19.63° ± 8.92° to 4.39° ± 4.08° and remained stable at 4.69° ± 4.27° ( F  = 54.65, p  < 0.01). Anterior vertebral height ratio increased from 51.82% ± 1.20% to 91.96% ± 7.93% and was maintained at 91.30% ± 8.13% ( F  = 89.41, p  < 0.01). Spinal canal encroachment decreased from 62.32% ± 14.90% to 16.42% ± 10.78% postoperatively and remained stable at 16.89% ± 11.54% ( F  = 48.49, p  < 0.01). All fractures achieved radiographic union without loss of correction. Conclusions Modified SPSA combining the Wiltse interval and midline spinous process splitting appears feasible for achieving decompression, reduction, and fixation while preserving posterior structures in selected patients with thoracolumbar burst fractures and neurological deficits. Larger prospective comparative studies are required to confirm long‐term efficacy and define optimal patient selection criteria.