surgical treatment of fractures and dislocations of the thoracic and lumbar spine
DESCRIPTION
Surgical Treatment of Fractures and Dislocations of the Thoracic and Lumbar Spine. Christopher M. Bono, MD and Mitchel B. Harris, MD Original Authors: Jim A. Youssef, MD & Mitch Harris; March 2004 New Authors: Christopher M. Bono, MD & Mitch Harris, MD; Revised August 2005 and May 2011. - PowerPoint PPT PresentationTRANSCRIPT
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Surgical Treatment of Fractures and Dislocations of the Thoracic and Lumbar
Spine
Christopher M. Bono, MD and Mitchel B. Harris, MD
Original Authors: Jim A. Youssef, MD & Mitch Harris; March 2004New Authors: Christopher M. Bono, MD & Mitch Harris, MD;
Revised August 2005 and May 2011
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Spinal Stability
Mechanical stability: maintain alignment under physiologic loads without significant onset of pain or
deformity
Neurologic stability: prevent neural signs or symptoms under anticipated loads
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Mechanical Stability
3-column theory (Denis ‘83)– middle middle = posterior ½ VB, posterior disc,
post longitudinal lig
2-column theory (Holdsworth,’53) – anterior= VB, disc, ALL, PLL
– posterior= neural arch, Post lig complexPost lig complex
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Denis: MIDDLE COLUMN is key to stability
– No anatomic basis– Stable burst fracture defies definition
Holdsworth : PLC is key to stability !!!
– James, et al ‘94
– Posterior lig complex more important to in vitro resistance versus kyphosis
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How Can We Detect Instability?
Dynamic: deformity worsens under physiologic loads– acute kyphosis with standing
– progressive kyphosis over time
Static: Inferred from x-rays– Plain films- widened spinous processes, biplanar
deformity– CT - facet complex disruption
– MRI- disrupted PLC
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Deformity (Kyphosis)
Initial radiographs usually supine
Alignment can appear acceptable without load
Upright loading can increase deformity
If unstable, deformity will progress or neurological signs will occur
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Instability(“textbook” definition)
Relies on ‘accepted’ standards>50 % loss of height implies PLC injury>30 º Cobb kyphosis implies PLC injury
Direct MRI visualization of a disrupted PLC
However, little clinical data to support these values.
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Neurologic Stability
Defined by the neurological findings at time of presentation …and
Reflects the (remaining) intrinsic ability of the spinal column to protect the neural elements from (further) damage under
anticipated loadsRelated to mechanical stability
Crucial for intact and incomplete SCI
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Goals of Surgical Treatment
•To “stabilize” the unstable spine
•To restore/ improve sagittal balance
•To decompress a progressive neural deficit
•To protect intact or incompletely injured neural elements
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How Do We Achieve These Goals?
Decompression
Fixation for acute correction and stability
Fusion with bone graft for long-term maintenance of reduction/ stability
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Canal Decompression
Complete SCI – Complete SCI (after spinal shock resolves): regardless of treatment method,
shows little functional improvement
Intact neurological status– Intact neuro status: regardless of x-ray
appearance, neuro status can’t get better !!!
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Canal Decompression
Indicated for incomplete neurological deficits with canal compromise….
Does surgical decompression improve
neurological recovery? *Current literature lacks stats to support*
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Decision to Decompress
Location of SCI – Little functional benefit seen with 1 or 2 level
improvement in upper thoracic (>T9) cord injuries– Conus (T10-L1) lesions are critical: bowel/bladder– Low lumbar--roots more accommodating to canal
compromise, and more apt to recover
Completeness of SCI
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Methods of DecompressionAnterior Decompression = “Gold Standard”“Gold Standard”
– Most common in thoracic and thoracolumbar regions– Direct visualization of cord with removal of fractured body
– Readily combined with reconstruction and fusion– Treatment of choice for burst fractures with incomplete SCI– In presence of posterior ligamentous injuries may require
A/P surgery
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Methods of Decompression• Laminectomy alone is Contraindicated !!!
– Further destabilizes an unstable spine, may lead to post-traumatic kyphosis
– Provides access to allow visualization and repair of dural tears.
– Be aware of the clinical triad of neurological injury and concomitant lamina fracture with burst pattern (Cammisa, 1989)---trapped roots!!
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• Indirect Reduction (ligamentotaxis)– Canal cleared by spinal realignment– Relies primarily on posterior annulus
reducing retro-pulsed fragment – Optimal time: within 72 hrs.
Methods of DecompressionPosterolateral decompression
– Transpedicular or costo-transversectomy
– Useful when anterior approach not a viable option
– Useful in lumbar spine w/dural mobilization
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Timing of Decompression?
Early1. Most animal SCI
studies support early decompression
2. Intuitively, remove pressure early for improved recovery
Delayed1. Clinically, early intervention has less support, its less convenient.
2. Fear of complications related to early surgery
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Indication for Early/Emergent Decompression
Progressive neurological deficit associated with canal compromise from
retro-pulsed fragments or spinal mal-alignment (fracture-dislocations).
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Timing of Surgical Stabilization
Benefits of early surgery :– facilitates aggressive pulmonary toilet
– decreases risk of DVT/PE with mobilization– prevents likelihood of decubitus ulcers
– facilitates earlier rehab
Surgery should be delayed until:
– Hemodynamically/medically stabilized– An experienced surgeon/ team is available
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Specific Thoraco-lumbar Injuries
Compression fracturesBurst fractures
Flexion-distraction/Chance injuryFracture-dislocations
Gunshot wounds to the spine
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Compression Fractures
Anterior column injuryDoes not extend into posterior vertebral
wall on CTWith increasing severity, the likelihood of
posterior lig complex injury increases. If PLC is disrupted -- UNSTABLE
(not a compression fracture)
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Compression Fractures
Compression fractures rarely require surgerySurgery is indicated if PLC disrupted
Relative indications for surgery– single level lumbar VB height loss >50 %– single level thoracic VB height loss >30 %– combined multi-level height loss >50 %
– relative segmental or combined kyphosis >30 º
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Compression Fractures
Non-operative treatment – TLSO or Jewitt extension bracing– Frequent radiographic follow-up
– Deformities can progress
Advantages: avoid surgical complications and muscle injury 20 to surgery
Disadvantages: post-traumatic kyphosis
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Compression FracturesOutcomes and Complications
Most common sequelae is BACK PAIN
– does not correlate with severity of deformity (Young, 1993, Hazel, 1988)– Lumbar worse than thoracic (Day,
1977)
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Specific Thoracolumbar Injuries
Compression fracturesBurst fractures
Flexion-distraction/Chance injuryFracture-dislocations
Gunshot wounds to the spine
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Burst Fractures
Definition: fracture extends into posterior vertebral wall
May be stable or unstable
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Unstable Burst Fractures
Related to PLC integrity>30 º relative kyphosis
Loss of vertebral body height > 50%Biplanar deformity on AP x-rayMRI finding of disrupted PLC
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Stable Burst Fractures
Criteria (burst with intact PLC)– <20-30 º kyphosis(controversial)– <50% lumbar canal compromise– <30% thoracic canal compromise
TLSO/Jewitt brace for comfort
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Stable Burst Fractures
Radiographic follow-up to follow potential deformity
progressionRepeat CT to monitor canal
resorptionSame treatment principles as
compression fracture
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Surgical Approaches Posterior Approach
– Fractures at T6 or above– Posterior ligament complex injury
– Multi-level injury– Associated chest trauma
Anterior Approach– Ideal for T6 and lower
– Decompression via corpectomy– Reconstruction with strut graft and anterior instrumentation
– May combine with post stabilization
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Nerve and Cord Decompression
Anterior corpectomy to visualize neural elements.
– Safest and most predictable form of decompression
Alternative within 48-72 hours: indirect decompression – Lordosis and distraction
– Relies on annulus to reduce retro-pulsed fragment through
ligamentotaxis.
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Burst FracturesOutcomes and Complications
Anterior Approach– Ileus (GI) after anterior approach
– Retrograde ejaculation– Risk of large vessel damage
Improved chances of bladder recovery with anterior decompression (SRS,’92)
Without decompression: fragment resorption decreases canal compromise by 30%
Non-operative results are similar to results of operative treatment.
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Specific Thoracolumbar Injuries
Compression fracturesBurst fractures
Flexion-distraction/Chance injuryFracture-dislocations
Gunshot wounds to the spine
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Chance (Flexion-Distraction) Injury
“Seatbelt” injuryTrans-abdominal ecchymosis
Common in children (seatbelt higher up)0-30% neurologic injury
Most common associated non-spinal injury: perforated viscus (pressure)
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Chance Injury
Injury involves 3-columnsUsually little comminution
Center of rotation: ALLPLC disrupted or posterior
neural arch fractured transversely
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“Chance” Fracture Variants
Purely ligamentous/ trans-discal
• Part bony/part ligamentous
• Purely bone
Best healing No healing
Some healing
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Flexion-Distraction Injuries
Boney Chance: stable in extension (TLSO) brace
– the fracture will heal
Ligamentous injuries do not heal, require stabilization and fusion
– need to restore the disrupted posterior tension band
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Surgical Approach
Posterior approach Relies on intact ALL
If burst component present, optimal treatment with pedicle
screws (maintain anterior column length, don’t over
compress as that may increase retro-pulsion )
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Chance FracturesOutcomes and Complications
10-20% residual pain65% functional recovery35% diminished function
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Specific Thoracolumbar Injuries
Compression fracturesBurst fractures
Flexion-distraction/Chance injuryFracture-dislocations
Gunshot wounds to the spine
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Fracture-Dislocations
High-energy injuriesHighest rate of SCI of all spinal fractures
Thoracic--worst prognosisRare non-operative management
Unstable with multi-planar deformity---little residual stability
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Decompression
Spinal realignment often decompresses the cord.– prone positioning on OR
table– “O.R.I.F.”
– “locked” facets requires open reduction by
resection of articular processes.
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Posterior constructs provide stability after
re-alignment – little chance for neuro
recovery
Rarely require anterior decompression/ reconstruction
Fracture-Dislocations
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Fracture-dislocationsOutcome and Complications
Severity of SCI --main predictor of outcome
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Specific Thoracolumbar Injuries
Compression fracturesBurst fractures
Flexion-distraction/Chance injuryFracture-dislocations
Gunshot wounds to the spine
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Gunshot Wounds
Non-operative treatment the standardSteroids not useful (Heary, 1997)
10-14 days IV antibiotics for colonic perforations (colon before spine) ONLY
No role for debridement
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TreatmentDecompression rarely of
benefit except forINTRA-CANAL BULLET AT
THE T12 TO L5 LEVELS(better motor recovery than
non-operative)
Fractures usually stable, despite “3-column” injury
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GSW to the SpineOutcome and Complications
Most dependent on SCI and associated injuries
High incidence of CSF leaks with unnecessary decompression
Lead toxicity rare, even with bullet in canal
Bullet migration rare: late neurological sequelae
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