Thoracolumbar fractures. Treatment options. A long trip.

Size: px

Start display at page:

Download "Thoracolumbar fractures. Treatment options. A long trip."

Easter Wilkins
5 years ago
Views:

$Thoracolumbar fractures. Treatment options. A long trip. MIS SURGERY. WHY NOT? Murcia. October 5, 2012. Dr.$

1 Thoracolumbar fractures. Treatment options. A long trip. MIS SURGERY. WHY NOT? Murcia. October 5, Dr. Pedro Cortés García. Spinal Unit. Orthopaedic department. Canary Islands University Hospital Tenerife. Spain

2 CLASSIFICATIONS.

3 Classification. Many attemps of classification. Ancient system ( Watson-Jones; Nicoll; Holdsworth). New system ( Denis, Mc Affe; Magerl AO, TLICS)

$In 1983. Three column concept. Four types of fractures. Denis. Classification. Denis F.$

4 In Three column concept. Four types of fractures. Denis. Classification. Denis F. The three-column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine 1983; 8:

5 Mc Affe Classification. Evolution of Denis system. Focus on medial column. This can fail on axial compresion, traction or traslation. Mc Affe PC; Yuan H A;Friedrikson BL. The value of computed tomography in thoracolumbar fractures: an analysis of one hundred consecutive cases and a new clssification.j Bone J Surg Am 1983;65:

6 Mc Affe Classification.

7 Magerl ( AO) Classification. Divided in three groups. Type A ( compresion) Type B ( traction) Type C ( rotation) Is a global classification but reliability inter and intraobserver is a problem. Magerl F, Aebi M, Gertzbein SD. A comprehensive classification of thoracic and lumbar spinal injuries. Europ.spine J.1994;3:

8 TLICSS Classification. Spine Trauma Study Group in Vaccaro A, Lehman R, Hurlbert J, el al. A new classification of thoracolumbar injuries. Spine 2005;20: Attempt to integrate mechanical and morphological aspects with prognosis and treatment.

9 TLICSS Classification. Tlicss use three concepts to define stability: 1. Fracture morphology. 2. Neurologic lesion. 3. Integrity of PLC.

10 TLICSS Classification. Fracture morphology is divided in compresion, traslation, and traction by CT and Xray. Neurologic lesion with MRI. Option to surgical treatment. Integrity of PLC with MRI ( T2 and STIR).

11 TLICSS Classification. Surgery is recomended with 5 > points. Conservative treatment with 3 < points. 3-4 points is debate.

12 TREATMENT.

13 Treatment. CONSERVATIVE. SURGICAL.

14 Conservative treatment. Stable fractures. Compresion fractures. Burst stable. TLICSS < or 3. Bed rest few days, analgesics Orthosis ( TLSO, others).

15 Conservative treatment. Folman Y, Gepstein R : Late outcome of nonoperative management of thoracolumbar vertebral wedge fractures. J Orthop trauma 2003;17: Adecuate clinical and radiographic outcome. Shen W,Liu T,Shen Y: nonoperative tratment versus posterior fixation for thoracolumbar junction fractures without neurologic deficit. Spine 2001;26: No diferences > 6 months in clinical outcome.

16 Surgical treatment. Absolute indication in: Failed conservative treatment. Complete spinal cord lesion with kyphosis and canal compromise. Fracture- dislocation.

17 Surgical treatment. Relative indication in: Compresion or burst fractures with PLC lesion.

18 Surgical treatment. Anterior approach. Posterior approach. Combined. The choice depends of fracture patern, neurologic status and surgeon preference.

19 Surgical treatment. Anterior approach. Absolute indication: incomplete neurologic lesion. Corpectomy with decompresion and stabilization. Fracture patern trated by anterior surgery only is burst fracture without PLC lesion.

20 Surgical treatment. Anterior approach. Kaneda K,Taneichi H,Abumi K,et al: anterior decompression and stabilization with the Kaneda device for thoracolumbar burst fractures associated with neurological deficit. J Bone J Surg Am 1997; 79: patients. Corpectomy,decompression, bone graft and stabilization. 93% fusion. 90% improvement in Frankel scale.

21 Surgical treatment. Posterior approach. The most prefered approach. Used to stabilize the majority of fractures. Pedicular screws have better control for reduction. Short construct and fusion.

22 Surgical treatment. Posterior approach. Alanay A,Acaroglu E, Yazici M,et al. The effect of transpedicular intracorporeal grafting in the tratment of thoracolumbar burst fractures on canal remodeling. Europ Spine J 2001; 10: Progresive kyphosis and or screw breakage in 50% patients. Tezeren G,Kuru I: posterior fixation of thoracolumbar burst fractures: short segment pedicle fixation versus longsegment instrumentation.j Spinal Disord Tech2005;18: Short construct have 55% failed rate and collapse of vertebral body compared with long construct.

23 Surgical treatment. Posterior approach. Posterior fixation in short segments is better with reconstruction of anterior support. Also in flexion-distraction patern. Weak anterior column, long instrumentation ( 2 levels above and below). Indirect decompression or ligamentotaxis: if PLL are intact. Wesberg P,Wang Y, Irstam L,et al: The effects of surgery and remodeling on spinal canal measurements after thoracolumbar burst fractures. Europ Spine J :55-63.

24 Surgical treatment. Posterior approach. Patients to be trated by ligamentotaxis are: Compresión fr Burst fr PLL intact. Direct decompresion: several authors propose this strategy to avoid anterior surgery. Problem arise from high seudo rate ( 17.8%). Kaya RA, Aydin Y: Modified transpedicular approach for the surgical treatment of severe thoracolumbar or lumbar burst fractures. Spine J 2004;4:

25 Surgical treatment. Combined approach. The indications are in debate. Disadvantage: morbidity related with two surgeries. Advantage: adress the pathology. Absolute indication: TL fracture with incomplete neurologic lesion and LPC lesion. Been HD, Bouma GJ: Comparison of two types of surgery for thoraco-lumbar burst fractures. Combined anterior and posterior stabilization vs posterior instrumentation only.acta Neurochir 1999;141:

26 Surgical treatment. Nonfusion Methods. Indications: can be used in unstable fracture with PLC injury ( flexion-distraction or burst). < 40 years Absence of neurologic lesion Absence of facet or disc lesion

27 Surgical treatment. Nonfusion Methods. Require surgical intervention to remove instrumentation No indication: >20º kyphosis with severe disc injury, require posterior fusion. >30º kyphosis or >55% loss of anterior vertebral height, anterior fusion is needed. Kim Y, Kim D, Choi E: Nonfusion Method in thoracolumbar and lumbar spinal fractures. Spine 2011;36:

28 MIS TECHNIQUES.

29 MIS techniques. Rationale. In open surgeries: Greater blood loss ( 1000 ml) Infection rate ( %) Approach related morbidity. Verlaan JJ,Dieckerhof C, et al. Surgical treatment of traumatic fractures of the thoracic and lumbar spine: a systenatic review of the literature on techniques, complications, and outcome. Spine 2004;29:

30 MIS techniques. Rationale. Standard midline posterior approach can produce : Iatrogenic muscle denervation Ischemia Revascularization injury Irreversible changes on paraspinal muscles. Clinical effect with pain and functional impairment.

31 MIS techniques. Requirements. Knowledge of anatomy. For anterior surgery: training on endoscopic techniques. For posterior surgery: use of pecutaneus pedicle screws. Intraoperative imaging ( biplanar fluoroscopy) Neurophysiologic monitoring. Rampersaud Y, Foley K, Shen A. Radiation exposure to the spine surgeon during fluoroscopically assisted pedicle screw insertion.spine 2000; 25:

32 MIS techniques. Currently : 1. Anterior techniques ( endoscopic decompresion and stabilization). 2. Posterior techniques ( percutaneous screw fixation) 3. Percutaneous vertebral body ballon-assisted endplate reduction and augmentation. 4. Temporary percutaneous posterior fixation. 5. Combination of previous techniques

33 MIS techniques. Anterior endoscopic decompresion and stabilization. Used in stand alone or with supplemental posterior tension band fixation for TL burst fractures. Verheyden A,Hoelzl A, Lill H. The endoscopically assisted simultaneous posteroanterior reconstruction of the thoracolumbar spine in prone position. Spine J 2004;4: Compared with conventional techniques: diminished blood loss, postop pain and hospital stays. No differences in long term functional outcomes.

34 MIS techniques. Posterior percutaneous tension band fixation. Indication : stand alone fixation in burst and flexiondistraction injuries. With or without fusion. Combination with endoscopic anterior techniques. Assaker R. Minimal access spinal technologies: state of the art,indications and techniques. Joint Bone Spine 2004;71: No differences on long term outcomes.

35 MIS techniques. Percutaneous vertebral body baloon-assisted. Baloon assisted Techniques can be used alone or with posterior fixation. Verlaan JJ,Van Heden H, Oner F.Baloon vertebraplasty with calcium phosphate augmentation for direct restoration of traumatic thoracolumbar vertebral fractures. Spine 2002;27: Good indication in unstable osteoporotic fractures.

36 MIS techniques. Temporary percutaneous posterior fixation. Controversial indication. In polytrauma patients, to stabilize spine fractures. Mc Lain R, Benson D. Urgent surgical stabilization of spinal fractures in polytrauma patients. Spine 1999;24:

Classification of Thoracolumbar Spine Injuries

Classification of Thoracolumbar Spine Injuries Guillem Saló Bru 1 IMAS. Hospitals del Mar i de l Esperança. ICATME. Institut Universitari Dexeus USP. UNIVERSITAT AUTÒNOMA DE BARCELONA Objectives of classification