Short-same segment fixation utilizing differential screw application with sequential reduction for thoracolumbar burst fractures without neurological deficit via Wiltse approach: a technical strategy to enhance reduction and radiological outcomes.

Posterior distraction reduction (DR) technique with polyaxial screw fixation may fail to achieve sufficient central endplate reduction, potentially resulting in residual cavities, postoperative vertebral collapse and hardware failure. The biomechanical benefits of mixed screw types remain insufficiently explored. This study aims to evaluate clinical and radiographic outcomes of a novel transpedicular prying reduction (TPR) technique after axial distraction performed via the Wiltse approach using a sequential monoaxial-monoaxial-polyaxial screw configuration in patients with thoracolumbar burst fractures without neurological deficits, with emphasis on vertebral healing morphology and implant-related complications. We retrospectively analyzed 106 patients with single-level thoracolumbar burst fractures treated between 2014 and 2023, divided into TPR (n = 50) and conventional distraction-reduction (DR; n = 56) groups. Pain assessment and radiographic parameters, including vertebral height, local kyphotic angle, and canal compromise, were measured preoperatively, postoperatively, and at final follow-up. Vertebral healing patterns were classified using three-dimensional CT reconstructions; implant failures were also documented. Both groups achieved significant pain relief and postoperative improvement in all radiographic parameters (P < 0.05). The TPR group demonstrated superior restoration and maintenance of correction, with no screw breakage versus 2.1% in the DR group (P = 0.03). Favorable healing patterns (Type I and Type II) were more prevalent in the TPR cohort. Logistic regression analysis identified loss of regional kyphotic angle (l-RKA) as an independent predictor of screw breakage (P < 0.05), while immediately postoperative restoration of middle vertebral height (r-MVH) correlated significantly with healing morphology (P < 0.05). TPR with a sequential monoaxial-monoaxial-polyaxial screw construct provides enhanced radiographic outcomes and reduced hardware failure compared with conventional DR. l-RKA is a critical risk factor for screw breakage, whereas r-MVH may serve as an early imaging indicator of favorable vertebral healing.