**1. Introduction**

A new spinal fracture occurs every 22 s worldwide [1]. As a mechanical transition junction between the relatively rigid thoracic and the more flexible lumbar spine, the thoracolumbar region is the most common site of fracture to the spine, and burst fractures of the

**Citation:** Wang, X.; Wu, X.-D.; Zhang, Y.; Zhu, Z.; Jiang, J.; Li, G.; Liu, J.; Shao, J.; Sun, Y. The Necessity of Implant Removal after Fixation of Thoracolumbar Burst Fractures—A Systematic Review. *J. Clin. Med.* **2023**, *12*, 2213. https://doi.org/10.3390/ jcm12062213

Academic Editor: Panagiotis Korovessis

Received: 6 January 2023 Revised: 24 February 2023 Accepted: 27 February 2023 Published: 13 March 2023

**Copyright:** © 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

thoracolumbar spine account for approximately 20–50% of such injuries [2,3]. Though common, the management of thoracolumbar burst fractures presents several clinical challenges, which mainly include surgical indications (surgery vs. non-surgery), surgical approach (anterior vs. posterior; traditional open approach vs. minimally invasive percutaneous approach), and surgical options (e.g., short segment fixation vs. long segment fixation, fusion vs. non-fusion) [4–12]. In any case, pedicle screw fixation has been well established as a standard procedure for the treatment of unstable thoracolumbar burst fractures that aims to establish immediate stability and rapid restoration of spinal alignment, prevent neurologic deterioration, minimize pain, and protect the spinal cord from further neurological injury [13–16].

After fracture consolidation has been achieved, there is another considerable controversy related to the pedicle screw instrument removal. So far, several indications have gained wide acceptance for implant removal after spinal surgery, including infection, pedicle screw misplacement, periprosthetic fracture, implant loosening, implant failure, instrumentation protrusion and local irritation, and growth disturbance [17–19]. However, the indications, potential benefits, and possible risks for implant removal in successful fracture-healing patients remain controversial [18]. Possible concerns of in situ implants are thought to be reduced range of motion, potential back pain due to mechanical irritation, micromotion, implant prominence and irritation, disc degeneration, facet arthrosis, fretting corrosion, allergic reaction, low-grade infection, stress shielding-related osteopenia, and stress concentration at the adjacent segment [17–24]. Pedicle screw removal might be a beneficial and cost-effective procedure because it can alleviate pain and discomfort, improve the segmental motion angle, restore flexibility, and enhance functional outcomes [25,26]. However, pedicle screw implants should not be considered dispensable when fracture consolidation is present, and implant removal should, by no means, be considered a benign and harmless procedure. On the contrary, implant removal requires a second operative procedure, which is accompanied by risks such as surgical site infection, neurovascular injury, significant loss of segmental kyphosis correction, worsened back pain, and re-fracture [25,26].

To date, there remains a paucity of expert consensus or clinical practice guidelines relating to implant removal after thoracolumbar burst fractures [18]. Thus, we undertook a systematic review to investigate the potential benefit-to-risk ratio and provide up-to-date evidence.
