THORACOLUMBAR FRACTURES - Update

KHALED ABDEEN MD ASSISTANT PROFESSOR SPINE & NEUROSURGERY _

ALEXANDRIA UNIVERSITY FELLOW OF FUJITA UNIVERSITY _JAPAN

Vertebral fracturesVertebral fractures

• TraumaTrauma

• Metastatic tumors . Metastatic tumors .

• Osteoporosis: Osteoporosis:

- Primary. - Primary.

- Secondary : steroid, cushing , - Secondary : steroid, cushing , hypogonadism , dialysis cases , etc. hypogonadism , dialysis cases , etc.

Specific Thoracolumbar InjuriesSpecific Thoracolumbar Injuries

• Compression fracturesCompression fractures

• Burst fracturesBurst fractures

• Flexion-distraction/Chance Flexion-distraction/Chance injuryinjury

• Fracture-dislocationsFracture-dislocations

• Gunshot wounds to the spineGunshot wounds to the spine

Spinal StabilitySpinal Stability

• Mechanical stabilityMechanical stability: maintain alignment : maintain alignment

under physiologic loads without significant under physiologic loads without significant onset of pain or deformityonset of pain or deformity

• Neurologic stabilityNeurologic stability: prevent neural signs or : prevent neural signs or symptoms under anticipated loadssymptoms under anticipated loads

Thoracolumbar fractures

•Posterior short segment

•Posterior long segment .

•Anterior approach .

•Combined .

Short segment fixation

•Makes more sense .

•More physiologic .

•One level above and one below .

•Only one level fusion /////////

Indirect decompression : Ligamentotaxis

Why should we callange the concept of long fixation ?

•Posterior surgery easier, faster, bleeds less.

•Range of motion of lumbar spine 15 degree per level .

•Why fusing normal motion segment ? •Shorter instrumentation preserves

function . •Shorter instrumentation may prevent

late degeneration.

Front or back ?Front or back ?

• Anterior approachAnterior approach

• Anterior Anterior decompression . decompression .

• Anterior column Anterior column recnostruction . recnostruction .

• Shorter segment . Shorter segment .

• Posterior approach Posterior approach

• Reconstruct the Reconstruct the tension band . tension band .

• Midnight surgery . Midnight surgery .

• Long segment Long segment

Load.Sharing.classificationLoad.Sharing.classification• Scoring system : Scoring system :

Recommendation Recommendation

• Total Six or less : Total Six or less : short segment short segment posterior posterior instrumentation instrumentation indicated . indicated .

• Total 7 or more: Total 7 or more: anterior surgery anterior surgery indicated indicated

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M pt 33 ys old, operated for L1 traumatic burst fracture

F pt 25 ys old, operated for L1 traumatic burst fracture

Anterior approach : indications

• Anterior column reconstruction .

• Incomplete neurological deficit .

• Fracture with poor reduction potential .

- large fragment - more than 67% canal

compromise .

• Inadequate canal reduction following posterior procedure with suboptimal neuro recovery

Anterior column Anterior column reconstruction using reconstruction using

titanium mesh cages after titanium mesh cages after thoracolumbar corpectomy : thoracolumbar corpectomy :

Clinical and Radiological Clinical and Radiological Outcome Outcome

– Khaled abdeen MD , Hesham Yousri Khaled abdeen MD , Hesham Yousri *MD ,Ahmed Azab * MD , Ihab Zidan MD . *MD ,Ahmed Azab * MD , Ihab Zidan MD .

– Alexandria university , Almenoufia university * Alexandria university , Almenoufia university * – Department of Neurosurgery Department of Neurosurgery

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•On the basis of clinical and biomechanical investigations, many authors now advocate nowadays to reconstruct the axial load-bearing ability of the anterior spine using different materials for vertebral body replacement

Indications for surgical treatment of the traumatic cases : • the instability of the spine according

to the Load Sharing classification.

• Neurologic deficit .

•Sagittal angulation > 25°.

• axial compression > 50% of vertebral height .

• The optimal treatment of unstable The optimal treatment of unstable thoracolumbar spine remains thoracolumbar spine remains controversial .controversial .

• Treatment goals areTreatment goals are::• to prevent neurological deterioration to prevent neurological deterioration • enhance neurolgical recovery enhance neurolgical recovery • stabilization stabilization • prevent late pain and late kyphotic prevent late pain and late kyphotic

deformity .deformity .

• The recent development of rigid The recent development of rigid corpectomy reconstruction cages has corpectomy reconstruction cages has made the anterior approaches to the made the anterior approaches to the lumbar and thoracolumbar (TL) spine more lumbar and thoracolumbar (TL) spine more attractive by improving the biomechanical attractive by improving the biomechanical strength of the anterior column support.strength of the anterior column support.

Anterior approachAnterior approach

• a more a more direct and completedirect and complete decompression decompression of the spinal canal .of the spinal canal .

• potentially allowing a better neurological potentially allowing a better neurological outcome .outcome .

• biomechanical restoration of the biomechanical restoration of the compromised anterior load bearing compromised anterior load bearing column can be achieved. column can be achieved.

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DisadvantagesDisadvantages

• the more the more extensiveextensive approach required .approach required .

• lack of familiarity to lack of familiarity to many spinal surgeons .many spinal surgeons .

• the potential for the potential for thoracic painthoracic pain . .

• the potential for the potential for pulmonarypulmonary complicationscomplications

• The degree of kyphosis, construct The degree of kyphosis, construct height and the subsidence of the cage height and the subsidence of the cage in relation to the vertebral endplates in relation to the vertebral endplates were measured preoperatively , early were measured preoperatively , early post operative , and at the latest follow post operative , and at the latest follow up .up .

• the surgical approach was the surgical approach was thoracoabdominalthoracoabdominal in 14 cases and in 14 cases and retroperitoneal retroperitoneal in 10 casesin 10 cases

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• Postoperative x ray after retroperitoneal Postoperative x ray after retroperitoneal approach for L2 fracture approach for L2 fracture

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Intraoperative photos of the cage placed at the Intraoperative photos of the cage placed at the corpectomy site. Bolts for the lateral stabilizing corpectomy site. Bolts for the lateral stabilizing

plate .The canal and dura are covered with plate .The canal and dura are covered with hemostatic patch and platehemostatic patch and plate

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Results : Results :

• Operation time : mean 150 minutes [ Operation time : mean 150 minutes [ 120-330 minutes] . 120-330 minutes] .

• Estimated blood loss 800-1400 ml Estimated blood loss 800-1400 ml [average 1100 ml ] [average 1100 ml ]

• No case had obvious pseudoarthrosis No case had obvious pseudoarthrosis or implant loosening or complication or implant loosening or complication related to the anterior reconstruction related to the anterior reconstruction . .

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Results : Results :

• Neurological recovery : in our Neurological recovery : in our study ; 6 patients were study ; 6 patients were neurologically intact , Frankel neurologically intact , Frankel grade E on admission , and all of grade E on admission , and all of them remains intact them remains intact postoperatively . Of the 12 postoperatively . Of the 12 patients with Frankel D on patients with Frankel D on admission , all had recoverd full admission , all had recoverd full motor and sensory function . Of motor and sensory function . Of the 6 patients with Frankel C on the 6 patients with Frankel C on admission . three improved one admission . three improved one grade , the other three improved grade , the other three improved two grades .. two grades ..

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• The mean construct height of the involved The mean construct height of the involved vertebrae before surgery was 41.6 mm and vertebrae before surgery was 41.6 mm and the mean construct height immediate after the mean construct height immediate after surgery and at follow up were 47.9 and 42.5 surgery and at follow up were 47.9 and 42.5 mm respectively . Solid fusion was observed mm respectively . Solid fusion was observed in all patients , there were no hardware in all patients , there were no hardware failure . The sagittal alignment of the failure . The sagittal alignment of the fractured segment was satisfactorily fractured segment was satisfactorily restored immediately after surgery as a restored immediately after surgery as a significant decrease in the local kyphotic significant decrease in the local kyphotic angle .angle .

COMPLICATIONS COMPLICATIONS

NO. NO. PERCENTAGEPERCENTAGE

Peritoneal Peritoneal tear tear

22 8.3 %8.3 %

Pulmonary Pulmonary infection infection

22 8.3 %8.3 %

Intercostal Intercostal neuralgianeuralgia

66 25 % 25 %

Sympathatic Sympathatic affection affection

66 25 %25 %

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Advantages of this Advantages of this techniquetechnique

• [a] allows better safe decompression [a] allows better safe decompression of neural structures to promotes of neural structures to promotes maximal neurological recovery . maximal neurological recovery .

• [b] provides immediate stablization [b] provides immediate stablization and allows for early mobilization . and allows for early mobilization .

• [c] corrects deformity and restores [c] corrects deformity and restores sagittal alignement . sagittal alignement .

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ConclusionsConclusions

  • Titanium mesh cages with cancellous Titanium mesh cages with cancellous

autograft bone after corpectomy of autograft bone after corpectomy of the thoracolumbar spine provides the thoracolumbar spine provides immediate structural support to the immediate structural support to the anterior column . the present study anterior column . the present study has shown that anterior has shown that anterior instrumentation is an effective and instrumentation is an effective and safe treatment for thoracolumbar safe treatment for thoracolumbar instability by demonstaring instability by demonstaring satisafctory clinical and radiological satisafctory clinical and radiological outcomes . outcomes .

  

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Augmented fixation Augmented fixation