Discussion

In this single-center series of 46 neurologically intact patients with thoracolumbar burst fractures, PPSF performed using a single conventional C-arm achieved high pedicle screw placement accuracy (94.0% grade A), low blood loss (mean, 103 mL), a short hospital stay (mean, 2.6 days), and significant immediate correction of both kyphosis and AVBH, with no recorded complications. These findings are broadly consistent with the published PPSF literature.

The mean operative time of 108 minutes was longer than that reported in several PPSF series, for example, 78 minutes in Ni et al. and 81 minutes in Silva et al., most plausibly because a single conventional fluoroscope was used rather than biplanar imaging or navigation [11,16]. Blood loss (103 mL) and length of hospital stay (2.6 days) were nonetheless favorable and within or below the range reported for open short-segment fixation, in which blood loss and hospital stay are typically substantially greater. Because the present study had no internal control group, these comparisons are descriptive only; no statistical comparison between PPSF and open surgery was performed.

Kyphosis correction (10.2°) and AVBH restoration (18.9%) were significant and comparable to those reported by Silva et al., Ni et al., and Yang et al. [11,16,17]. Postoperative pain scores decreased rapidly, consistent with the reduced paraspinal dissection inherent to the percutaneous approach. A screw malposition rate of 6.0% closely accords with reported rates of 5.9%-6.7% using fluoroscopy-guided percutaneous insertion [11,17,18]. None of the malpositioned screws in this series produced clinical sequelae, supporting the safety of the technique even without tactile pedicle feedback.

An unexpected finding was the female predominance (60.9%), which contrasts with most thoracolumbar trauma series, in which male patients predominate [19]. The most likely explanation is selection bias: by excluding patients with neurological deficits, who are more often male and more often injured in high-energy mechanisms such as road traffic accidents, the cohort was enriched for lower-energy mechanisms, with falls from height predominating. This interpretation is plausible but cannot be confirmed from the present data and should be regarded as hypothesis-generating.

The principal trade-offs of PPSF are the absence of formal arthrodesis and canal decompression and increased radiation exposure. The stability of a burst fracture managed without fusion depends on bony healing and remodeling; for more unstable injuries (e.g., type B2/C) or those with neurological compromise, open decompression and fusion remain indicated. The reported screw malposition rate for the open technique using anatomical landmarks is 10%-20% [20,21]. The lower rate observed in the present study is reassuring for image-guided percutaneous placement.

Although the immediate outcomes observed in this study are encouraging, the absence of a comparison group and long-term follow-up limit conclusions regarding the durability of these results and the comparative effectiveness of PPSF.

Limitations

This study has several limitations. It was a single-arm series with no open-surgery comparison group, so relative effectiveness cannot be inferred. The sample size was modest. Critically, radiographic and clinical outcomes were assessed only in the immediate postoperative period; no defined follow-up interval was reported, so maintenance of correction, loss of reduction, fracture union, implant behavior, and functional recovery over time were not evaluated. Outcomes were also limited to a single fracture pattern (A3/A4 fractures with intact neurology), limiting generalizability. The statistical test used for paired comparisons was not specified in the source data and is assumed to be a paired t-test. These constraints should temper interpretation of the efficacy findings, which are best viewed as evidence of safe, accurate fixation with good immediate correction rather than proof of durable clinical benefit. Additional limitations include the lack of blinded radiographic assessment, which may have introduced observer bias, and the absence of validated functional outcome measures, such as the Oswestry Disability Index or Short Form-36 Health Survey (SF-36), precluding a comprehensive evaluation of postoperative functional recovery and health-related quality of life.