Thoracolumbar burst fractures still are a great challenge to surgeons, especially in elderly patients with osteoporotic bones. In old and very old patients, early mobilization has to be the primary goal in order to reduce the time of the hospital stay and to decrease the morbidity and the mortality respectively. The short-segment posterior pedicle screw instrumentation is a well-accepted technique for the reduction and stabilization of vertebral burst fractures [4, 11, 19]. According to the long-term follow-up results that have been gathered over the last decades, the exclusive stabilization with this technique seems to be insufficient. The reported failure rate varies from 20 to 50% in the case of pedicle screw failure and a consecutive increase of spinal kyphosis [8, 20]. Therefore, additional anterior procedures are recommended. The anterior approach allows a full visualization of the fracture. The use of plates, cages or iliac cortical grafts facilitates the direct vertebral restoration, the decompression and a solid fusion. Although the anterior approach leads to an extended operation time, the more traumatic ventral approach, on the contrary, leads to a higher blood loss and an elevated postoperative morbidity.
During the last decade, the dorsal instrumentation in combination with absorbable cement augmentation techniques has become increasingly popular for younger patients [13, 14, 19]. Marco and Kushwaha  treated 39 patients with a mean age of 38 years, with or without a neurological deficit, with a short-segment instrumentation in combination with a calcium phosphate cement reconstruction. They claimed that an excellent lasting reduction of unstable burst fractures had been achieved during a 2-year-follow-up with the use of this combined technique. Nevertheless, some complications were observed: Screw breakage was recorded in two patients, wound dehiscence was observed in one patient and finally a pseudarthrosis of the dorsolateral fusion in another. Cement leakage was not observed at all though. However, patients with senile osteoporosis were excluded. Cho et al . reported on a group of 70 patients (mean age 45 years) 50 of whom were treated by short-segment pedicle-screw instrumentation alone while the remaining 20 were treated by combined reinforced PMMA vertebroplasty. In the first group, implant failure was observed in 22% of the patients and after a two-year follow-up, an increase of the kyphotic deformity of 6.2 degrees was recorded. No implant failure was observed in the second group, where the increase of the kyphotic deformity was amounted to only 0.3 degrees. In 1998, Mermelstein et al . already conducted a biomechanical study in which the reinforcement of the thoracolumbar burst fractures with calcium phosphate cement in a cadaver model of an L1 burst fracture was observed. A decrease of the pedicle-screw bending moments of 59% in flexion and of 38% in extension was observed. Therefore, it was concluded that this combined technique may improve the patient’s outcome without a secondary anterior procedure. In a study of Verlaan et al [13, 14]. the height of the fractured vertebral body could be restored at up to 91% of the estimated intact height in 20 patients with transpedicular balloon vertebroplasty in combination with posterior instrumentation. Korovessis et al . included 23 patients with a mean age of 48 years in a prospective study with balloon kyphoplasty using calcium phosphate and stabilization with pedicle screw instrumentation and fusion. After a follow-up of 24 months, an improvement of the kyphosis deformity as well as of the vertebral body weight ratio was reported.
Only a few cases of dorsal internal fixation in combination with cement augmentation techniques for older patients with osteoporotic bones, have been reported in the current literature [22–24]. The case of a 97-year-old male with a lumbar burst fracture that is presented here, illustrates the use of a dorsal pedicle screw instrumentation not only in combination with a balloon-assisted kyphoplasty but also with additional cement-augmented pedicle screws. To our knowledge, this technique has not yet been reported for a patient of this age. For this one-step-procedure with a non-absorbable bone cement augmentation, we decided to provide more stability in a severe osteoporotic bone in order to prevent secondary cutting-out or screw loosening. Our patient recovered quickly and could be remobilized without any pain. Because of the use of this technique, no additional anterior approach was necessary. Therefore, this technique lead to a reduction of the operative trauma and the risk of postoperative wound complications as well as of the morbidity and the length of the stay in hospital. Wound infection or necrosis did not occur at all. At this high age, multiple complications can result in a prolonged wound healing. Local infection rates after dorsoventral approach ranged between 7% and 14% [25–27]. The next problem consists in the osteoporotic vertebrae themselves: We were able to observe fractures of the vertebrae in the next segment that was located caudal or cephalad to the fixateur interne. These fractures were manly located cephalad, because of the increased stress and forces that were caused the stabilisation. It should always be discussed how many segments have to be addressed in order to provide enough stability to prevent the next fracture. The use of cement to augment the screws provides more stability for the osteoporotic bone, but the removal of the screws is very problematic and associated with a high incidence of collateral damage.
Especially in older patients, the presented technique of PMMA-augmented pedicle screw instrumentation combined with balloon-assisted kyphoplasty could be an option to address unstable vertebral fractures in “a minor-invasive way”. In order to minimize the surgical morbidity and to increase the quality of life, the standard procedure of a two-step dorsoventral approach has to be reduced to a one-step procedure.