Transfascial Paraspinal Versus Conventional Open Posterior Pedicle Screw Fixation for Thoracolumbar Fractures: A Randomized Controlled Trial.

introductionPosterior pedicle screw fixation is the standard treatment for unstable thoracolumbar fractures requiring surgery. The conventional open posterior approach, however, requires extensive subperiosteal stripping of the paraspinal muscles, causing ischemia, denervation, greater intraoperative blood loss, more postoperative pain, and delayed recovery. The Wiltse paraspinal, or transfascial, approach exploits the natural intermuscular plane between the multifidus and longissimus muscles to limit this soft-tissue disruption while preserving adequate exposure. Still, robust randomized evidence comparing the two techniques remains limited. Our objective was to compare the perioperative, clinical, and radiological outcomes of pedicle screw fixation performed through the transfascial paraspinal approach versus the conventional open posterior approach in patients with AO Spine Type A thoracolumbar fractures.

methodsFifty patients aged 18-60 years with a single-level AO Spine Type A thoracolumbar fracture were randomized 1:1 using a computer-generated sequence with allocation concealment to transfascial paraspinal (n=25) or conventional open posterior (n=25) fixation and followed for 12 months. Outcomes included operative time, blood loss, postoperative drain output, mobilization time, hospital stay, Visual Analog Scale pain scores at two weeks and three, six, and 12 months, fluoroscopy time, sagittal Cobb angle correction, and surgical site infection. Continuous variables were compared using the independent-samples t-test or Mann-Whitney U test, and categorical variables using the chi-square or Fisher's exact test, with p<0.05 considered statistically significant.

resultsThe transfascial group had significantly shorter operative time (96.16±13.77 vs. 106.64±17.70 min, p=0.047), less intraoperative blood loss (173.76±37.94 vs. 294.00±89.35 mL, p<0.001), lower drain output (37.60±18.94 vs. 93.20±43.48 mL, p<0.001), earlier mobilisation (2.44±1.04 vs. 4.08±2.77 days, p=0.033) and shorter hospital stay (3.08±1.82 vs. 5.48±4.30 days, p=0.012) than the conventional group. VAS pain scores were significantly lower in the transfascial group at two weeks, three, six, and 12 months (all p≤0.004), despite similar baseline pain (p=0.533). Postoperative Cobb angle correction (4.40±1.15° vs. 4.60±1.19°, p=0.549) and fluoroscopy time (7.04±1.35 vs. 7.68±1.65 sec, p=0.140) did not differ significantly between groups. Surgical site infection distribution was also similar (Fisher-Freeman-Halton test, p=0.349), though deep infection occurred only in the conventional group (8.0% vs. 0%).

conclusionThe transfascial paraspinal approach achieves radiological correction equivalent to that of the conventional open posterior approach while significantly reducing operative time, blood loss, wound drainage, hospital stay, and postoperative pain. In appropriately selected patients with AO Spine Type A thoracolumbar fractures, it represents an effective, reproducible, and safe muscle-sparing alternative to conventional open fixation, supporting wider adoption pending confirmation in larger multicenter randomized trials with longer follow-up.