Classification? Classification system should be: Comprehensive Usable Accurate Predictable Able to guide intervention

Transcription

1 Moderator: Dr. P.S. Chandra Dr. Dr Deepak Gupta

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5 Classification? Classification system should be: Comprehensive Usable Accurate Predictable Able to guide intervention

6 A precise, comprehensive, ideal and informative classification system has eluded spine surgeons since Boehler first proposed his injury categories in 1929.

7 classification? Holdsworth ods ot (JBJS, JS, 1970) Denis (Spine, 1983) McAfee Classification(JBJS J 65 A; 1983) Load sharing Classification(McCormack et.al. Spine 19; 1994) Comprehensive Classification(Magerl Eur J Spine 3; 199Gertzbein Spine 19; 1994) Thoracolumbar Injury Severity Score (TLISS)(Spine 2007 Feb 1;32(3).)

8 Denis (Spine, 1983) 1 st classification after introduction of CT Modified the column concept of Holdsworth Spinal stability is based on 3 column Middle column: important of structural stability. Degree of instability: included the neurological status of patient. t

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10 McCormack and Gaines (Spine 19; 1994) Load sharing classification Degree of vertebral body comminution, apposition of fracture fragments, and the amount of sagittal plane deformity. Sought to predict the risk of implant failure.

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12 AO(Arbeitsgemeinschaft fur Osteosynthesenfragen)/ Magerl (Eur J Spine 3; 1994) Based on Pathomorphological criteria. And review of 1445 consecutive TL cases. Advantage Comprehensive Disadvantage Complex Does not define stability Moderate reliability. Eur Spine J Jun;11(3): Epub 2002 Jan 29 Does not include neurological deficit

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14 Type A : vertebral body compression A1: impaction fracture A2: split fracture A3: burst fracture Type B : distraction ( all 3 columns) B1: posterior injury ligamentous B2: posterior injury osseous B3: anterior injury through disc Type c : rotational (all 3 columns) C1: type A with rotation C2: type B with rotation C3: rotational shear

15 TLISS (Spine 2007 Feb 1;32(3).) To assist in clinical decision making for operative versus non operative care Mechanism of injury, integrity of the PLC, and neurologic status. <3 : non operative, > 5 : operative, stabilization with or without decompression. Advantage Comprehensive Define stability Moderate reliability J Spinal Disord Tech Aug;22(6): Disadvantage Validity and ability to prove outcome remain unproven Validation studies performed by spine trauma study group. Spine J Sep;9(9):780 8.

16 Injury morphology Compression 1 Burst +1 Translational/rotational 3 Distraction 4 Neurological status PLC Intact 1 Nerve root 2 Cord, Conus medullaris Incomplete 3 Complete 2 Cauda Equina 3 Intact 0 Injury Suspected/indeterminate 2 Injured 3

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21 Imaging X ray Inexpensive and quick Demonstrate loss of vertebral height. Kyphotic angle Interspinous distance in AP and Lateral view with alignment of spinous process for rotation of vertebra. Assess posterior vertebral body on lateral l view.

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23 CT scan Excellent visualization of bony anatomy, particularly middle spinal column, spinal canal shape and patency. Reverse cortical sign contraindication for ligamentotaxis in posterior approach.

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25 MRI scan Excellent visualization of soft tissue i.e. ligament (post ligament), disc, spinal cord. Poor prognostic factor : edema extending two vertebral level and presence of hematoma within spinal cord.

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27 Defining instability Why is it important to look for instability? Instability is the key to therapeutic indications because it equates, in many cases, with a need for internal stabilization. Francis Denis, M.D. Spinal stability as defined by the three column spine concept in acute spinal trauma. CORR. 189: 65 76

28 Definition of stability as formulated by Whitesides,Magrel and Denis A stable spine is one which can withstand axial forces anteriorly, tensile forces posteriorly and rotational forces, so as to hold the body erect, protecting the contents of the canal and preventing progressive kyphosis Whitesides TE Jr (1977) Traumatic kyphosis of the thoracolumbar spine. Clin Orthoped 128: Francis Denis. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine Vol 8; No 8:

29 If neurology is intact whether h to operate or not No superiority of conservative therapy over operative therapy Surg Neurol Mar;67(3):221 31; discussion 231. A review of the management of thoracolumbar burst fractures. Dai LY J Bone Joint Surg Am May;85 A(5): Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit. A prospective, randomized study. Wood K, Cochrane Database Syst Rev Oct 18;(4):CD Operative versus non operative treatment for thoracolumbar burst fractures without neurological ldeficit. Yi L

30 Stable thoracolumbar burst without neurology (vertebral compression or canal encroachment < 40% or kyphosis <15 degrees with a stable posterior column) Medically unfit J Neurosurg Jan;86(1):48 55

31 Whether cast bracing can be used in stable/unstable burst fracture J Neurosurg Spine 2009 Christopher S. Bailey A thoracolumbar burst fracture, in exclusion of an associated posterior ligamentous complex injury, is inherently a very stable injury and may not require a brace.

32 Spine Sep 1996 Chow, Gregory H. Functional Outcome of Thoracolumbar Burst Fractures Managed With Hyperextension Casting or Bracing and Early Mobilization Non operative management of thoracolumbar burst fractures with hyperextension casting or bracing was proven to be a safe and effective method of treatment in selected patients. Clinical results were favorable. No neurologic deterioration was observed. Hospitalization i times were minimized. i i Patient satisfaction was high. The authors do not believe that ligamentous injury of the posterior column is a contraindication to nonoperative management of thoracolumbar burst fractures.

33 What is the ideal time for surgery Spine (Phila Pa 1976) Apr 20;35(9 Suppl):S Does early fracture fixation of thoracolumbar spine fractures decrease morbidity or mortality? Bellabarba C These studies demonstrated that early stabilization of fractures reduced the mean number of days on a ventilator, the number of days in intensive care unit and in hospital Ideally, patients with unstable thoracic fractures y,p should undergo early (<72 hours) stabilization of their injury to reduce morbidity and, possibly, mortality.

34 J Spinal Cord Med. 2005;28(1):11 9. Timing of surgery following spinal cord injury. Kishan S Early surgical treatment ( within 24 hrs ) is beneficial in terms of reducing complications length of stay, and hospital costs. Further studies are needed d to clearly l demonstrate t the impact of operative timing on neurological outcome. Those patients in whom operations were performed within first 24 hour had a lower rate of complications. Willberger JE (1991)

35 Early surgery ( <5 days) : Ligamentotaxis /Annulotaxis useful in burst fractures. Anterior approach : Wait 3 4 days for hyperemeia to subside, less bleeding. Severely injured : early surgery: Few c/c, shorter hospital stay, reduced ventilatory requirement. A retrospective analysis of treatment outcomes. Olumide A Danisa. Spine surgery, Virginia, JNS 1995.

36 Approach? Journal of Spinal Disorders & Techniques. February 2006 Surgical Decision Making for Unstable Thoracolumbar Spine Injuries: Results of a Consensus Panel Review by the Spine Trauma Study Group. Vaccaro, Alexander R Decision making for the surgical treatment of thoracolumbar injuries is largely dependent on three patient characteristics: Injury morphology Neurologic status Posterior ligament integrity. A logical and practical decision making process based on these characteristics may guide treatment even for the most complicated fracture patterns.

37 Suggested Surgical Approach

38 Anterior approach Advantage: Predictable canal decompression, improvement neurology, no increased morbidity Posterior approach Advantage : Spinal stability, deformity correction, low morbidity Disadvantage Disadvantage Stiffness : 15% + than normal spine Stiffness of normal spine : 76% Instrument failure :4 11% Instrument failure rate : 9 54% Loss of correction : 1 4 degrees Loss of correction 3 12 degrees Less time, Less blood loss, less expensive ( JNS 1995,Virginia)

39 Is decompression indicated for complete spinal cord injury Journal Bone Joint Surg Br Jul;82(5): () Does 'canal clearance' affect neurological outcome after thoracolumbar burst fractures? Boerger TO The paralysis occurs at the moment of injury and is not related to the position of the fragments of the fracture on subsequent imaging. Alteration of the canal by 'surgical clearance' does not affect the neurological outcome. There is no established advantage of surgical over non surgical treatment as regards neurological improvement. Surgical treatment for burst fracture in the belief that neurological improvement can be achieved is not justified, although surgery may still occasionally be indicated for structural reasons.

40 Length of fusion : short versus long segment Short segment fusion : fracture without translation (LSC 6 or <6). Long segment fusion : fracture with translation ( LSC 7,8,9). Better but loses spinal mobility.

41 Surgical approaches: anterior, posterior or anteroposterior Posterior fixation i : LSC 6 or <6. Anterior fixation : LSC >7 LSC >7 with translational l injury : anterior followed by posterior fixation.

42 Can anterior reconstruction be avoided by long segment posterior fixation in unstable Thoraco Lumbar burst fracture? J Spinal Disord Tech Dec;18(6): Posterior fixation of thoracolumbar burst fracture: short segment segment pedicle fixation versus long segment instrumentation. Tezeren G LS instrumentation is a more effective management of thoracolumbar burst fractures. Anterior column support would negate the need for LS fixation Nevertheless, clinical outcome is same between the two groups.

43 Compression fracture in osteoporotic bones Balloon kyphoplasty versus vertebroplasty for treatment of osteoporotic vertebral compression fracture: a prospective, comparative, and randomized clinical study Higher cost of the kyphotic balloon procedure, we recommend vertebroplasty over kyphoplasty for the treatment of osteoporotic VCFs. Osteoporos Int Feb;21(2): Epub 2009 Jun 10.

44 Vertebral body stenting VBS is an innovative technique which allows for the possibly complete reduction of vertebral compression fractures and helps maintain the restored height by means of a stent. The height loss after balloon deflation is significantly decreased by using VBS compared to kyphoplasty, thus offering a new promising i option for vertebral augmentation. Eur Spine J (2010) 19:

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46 Comparison of anterolateral and posterior approaches in the management of thoracolumbar burst fractures. Angular deformity is more successfully corrected and maintained i when the anterior approach is used. Retrospective study, T12 L2 fracture, 63 patient. J Neurosurg Spine 5: , 2006

47 Unstable Thoracolumbar Burst Fractures Anterior Only Versus Short Segment Posterior Fixation This study compares anterior only fixation utilizing a corpectomy strut graft and a modern thoracolumbar plating system with a posterior only construct using pedicle screws and load sharing hooks for the treatment of unstable burst fractures. Anterior only group continued to demonstrate statistically significant ifi improvement in sagittal alignment at follow up compared to preoperative measurements. J Spinal Disord Tech 2006;19:

48 PLIF in thoracolumbar trauma: technique and radiological results This technique can be an alternative procedure to combined operations regarding the presented radiological i l results of successful fusion and loss of correction. Eur Spine J (2010) 19:

49 Is Methylprednisolone really useful. Uncertain Various studies have shown contradicting results Three multi Centre NASCIS studies in US inconclusive

50 Recommendations within 3 hrs : for 24 hrs 3 8 hrs : for 48 hrs However it should be mentioned that there is no dfii definite conclusive evidence of a beneficial fiil effect and that there could be some complications related to its use. Dose Bolus IV 30 mg/kg body weight over 15 minutes Constant infusion 5.4 mg/kg/hour for 23 hours

51 Take Home Message Classification? No ideal system TLICS, AO, Denis suitable available options Defining instability A stable spine is one which can withstand axial forces anteriorly, tensile forces posteriorly and rotational forces, so as to hold the body erect, protecting the contents of the canal and preventing progressive kyphosis. Injury to PLC is a main indicator of instability. Role of cast bracing in stable/unstable burst fracture Proven to be a safe and effective method of treatment in selected patients.

52 Ideal time for surgery As soon as the general condition is stable. Role of Surgery in neurologically intact pts There is no superiority of conservative therapy over operative therapy except in poly trauma patients t in whom the surgery has better results. Approach? Determined by incompleteness and PLC involvement.

53 Is decompression indicated for complete SCI. Surgical decompression is not vital to the neurological recovery but may obviate later complications of syrinx and may provide a patent canal for any future successful regenerative therapy. Role of pedicle screws in the fracture vertebra? Helps to provide better kyphosis correction and biomechanical stability. Does anterior reconstruction avoid long segment posterior fixation in unstable thoraco Lumbar burst fracture?r Particularly useful in preserving rotation in SCI.

54 Role of augumentation of the fractured vertebrae with kyphoplasty Provides excellent immediate reduction of post traumatic segmental kyphosis. Is methylprednisolone really useful Uncertain For all patients reporting within 8 hours of injury the option of using methylprednisolone could be given to the patients.

55 Thank You