dae jeon hurisarang hospital, dae jeon department of neurosurgery, mokpo hankook hospital, mokpo...

Dae Jeon Hurisarang Hospital, Dae JeonDepartment of Neurosurgery, Mokpo Hankook Hospital, Mokpo

Department of Neurosurgery, School of Medicine, Chosun University, Gwangju, Korea

Kim Hyeun Sung (ilovespine.com)

Introduction

Goals of surgical treatment for unstable thoracolumbar burst fractures restore stability of the vertebral column decompress the spinal canal facilitate early mobilization of the patients

Surgical treatment of burst fractures

an extensive, huge, and very invasive procedure that requires a large opening with a long skin incision Anterior Approach

significant invasion of the retroperitoneal space or thoracic cavity with wide dissection prolonged operation and hospitalization time blood loss, donor site complaints, increased morbidity and even mortality

Posterior Approach extensive dissection of paraspinal muscles of the back

: may lead to muscular denervation & necrosis => resulting in prolonged postoperative pain and disability

resection of posterior elements of the spine

23年 4月 10日 2


Inclusion criteria

> 50% loss of anterior vertebral height, > 50% canal compromise kyphotic angle more than 20 Three column injury according to the Denis 3-column injury theory

Denis Three-column Concept : Burst fracture : 2 or 3 column injury anterior height < 50% of posterior height (kyphosis), > 50% canal compromise angular deformity greater than 20°, progressive kyphosis multiple contiguous fractures any neurologic injury in patients with extensive associated injuriesMaterial

From January 2007 to September 2008: 11 patients

Material and Methods

23年 4月 10日 3


Patients Series

Material and Methods

NO.

AGE

SEX

Level BMD OP. time(min.

)

Intraop.Bleeding

(cc)

Kyphotic angle Vertebral Height(%)

Anesthesia Augmentation F/U(Mn’s)

Complications

Preop. Postop. Preop. Postop.

1 59 F L1 -2.53 90 50 22 3 34 87 General PMMA 17 Cement

leakage

2 60 M L2 -3.17 100 65 26 7 45 80 General PMMA 16 -

3 73 M L1 -3.28 85 95 15 6 43 64 General PMMA 15 -

4 54 F T11 -2.86 80 45 18 7 44 84 General PMMA 11 Cement

leakage

5 50 F T12 -0.32 80 50 25 9 43 78 General Hydroxyapatite

10 -

6 65 F L1 -3.08 70 60 19 5 48 96 General PMMA 9 -

7 49 M L3 -2.67 70 45 19 8 47 76 Spinal PMMA 9 -

8 23 F T10 +1.28

60 40 21 5 42 77 General Hydroxyapatite

8 -

9 56 M L1 -3.49 65 50 17 8 44 83 Spinal PMMA 8 -

10 47 M T12 +0.23


7

11 47 M T12 +0.12


7

23年 4月 10日 4


Two Method for Restoration of Vetebral Height and Kyphotic Angle Pillow reduction

Intra-operative pressure compression

Methods : Surgical Methods

Pillow reductionPillow reduction Pressure CompressionPressure Compression

23年 4月 10日 5


1. Fractured vertebral augmentation : PMMA Augmentation with Pressure Compression

Kim HS, Park SK, Joy H, Ryu JK, Kim SW, Ju CI. Bone Cement Augmentation of Short Segment Fixation for Unstable Burst Fracture in Severe Osteoporosis. J Korean Neurosurg Soc 2008:44;8-14


2. Screw ReinforcementNon-osteoporotic : HydroxyapatiteOsteoporotic : Polymethylmethacrylate(PMMA)

Ha-stick : PENTAX (Japan) : INFRAMED KOREA

Ha-stick : PENTAX (Japan) : INFRAMED KOREA

Stick insert cannulaStick insert cannula Stick insertStick insert

Pressure CompressionPressure Compression PMMA InjectionPMMA Injection Screw InsertScrew Insert

23年 4月 10日 6


Rod Rotation using the rod holderRod tightening

General anesthesia & prone position under the Pressure reduction position Skin incision under the C-arm guide : Lateral to pedicleBone biopsy needle insert into pedicle using the Ruller guide

Ruler guide remove : Insert pin => Remove bone biopsy needle => Remove guideBone biopsy needle or hydroxyapatite insert guide insert Remove pin guide

Bone cement injection : Average 2.5-3cc /one side : One level : Average 5-6ccPercutaneous transpedicular screwingFracture level : Maintain pressure reduction posture : anterior column restoring => Minimized the cement leakage : spinal canal, paravertebral space etc.Percutaneous screwing system(Apollon : Solco medical) insert : Lordotic shape


at one level above and below the fractures site including the fractured level itself

3. Percutaneous Screwing : Apollon System (Solco Medical, South Korea)

Surgical Method – Rod rotation

After remove the extender holder bar

Rotate the rod inserting bar

23年 4月 10日 7


Mean Operation Time

76minutes

Mean Blood loss 50.9mL

VAS 8.09 => 2.36

Kyphotic angle 20.8 °±8.2° => 5.7 °±2.3°

Vertebral height 43.45%±8.05% => 82.00%±5.25%

Result10.64 monthsMean Follow-up

Period

23年 4月 10日 8


23yrs/F, Fall down, C/C : Severe back pain, N/E : intact

Kyphotic Deformity : 21 => 5

Kyphotic Deformity : 21

Vertebral Height : 42%

Vertebral Height : 42% => 77%

T10 bursting fracture

Case: Non-osteoporotic Fracture

23年 4月 10日 9


Vertebral Height : 43%Kyphotic Deformity : 25

50yrs/F, Fall down, C/C : Severe back painL1 bursting fracture


Vertebral Height : 43% => 78%Kyphotic Deformity : 25 => 9

23年 4月 10日 10


After Postural Reduction

1day after operationParesthesia improved

completely





47yrs/M, Fall down, C/C : Severe back pain with bilateral leg paresthesia



23年 4月 10日 11


After Postural Reduction

: Cord contusion detected

4day after operationMotor improved

G4+/G4+

1 week after operationMotor improved completely





InitialMotor : G2/G2

47yrs/M, Fall down, C/C : Severe back pain with bilateral leg weakness(G2/G2)



23年 4月 10日 12


59yrs/F Fall down C/C : Severe back pain N/E : intact


Vertebral Height : 11/32(34%)


Vertebral Height : 11/32(34%) => 29/32(90%), Canal Encrochment : 7/13(54%) => 3/13(23%)

L1 bursting fracture

Case: Osteoporotic Fracture

17 months later : Sclerotic Change

23年 4月 10日 13


60yrs/M, Fall down, C/C : Severe back painL2 bursting fracture


Vertebral Height : 45%Kyphotic Deformity : 26

Vertebral Height : 45% => 80%Kyphotic Deformity : 26 => 7

23年 4月 10日 14






65yrs/F, Fall down, C/C : Severe back painL1 bursting fracture


3 days after operation3 days after operation

23年 4月 10日 15


Cement leakage

54yrs/F, Fall down, C/C : Severe back pain, N/E : intact

Complication : cement leakage into paravertebral space flank dullness and pain : not significant


Case: Complication

Cement LeakageCement Leakage

23年 4月 10日 16


Thoracolumbar burst fracture Treatment : Stabilization and decompression If does not need decompression of the neural element : posterior approach

Main advantage : to preserve the motion segment compared to long level fixation Disadvantage : difficulty in restoring the anterior column : does not lead to satisfactory decompression

Lead to secondary kyphosis Drawbacks & Sequela

Persistent low back painiatrogenic muscle denervationatrophy & decreased trunk extensor strengthNeed a less invasive techniques

Short segment posterior fixation

Discussion

Limitation of percutaneous pedicle screwing in thoracolumbar junction Systems for percutaneous pedicle screws : developed for lordotic lumbar spine More difficult to apply in the thoracolumbar region : kyphotic angulation

23年 4月 10日 17


Tan et al.(2007) : Cement augmentation of vertebral screws enhances the interface strength between interbody device and vertebral body. Spine kim HS, et al.(2007) : Bone cement augmentation of pedicular screwing in severe osteoporotic spondylolisthetic patients. JKNS Kim HS, et al(2008) : Bone cement augmentation of short segment fixation for unstable burst fracture in severe osteoporosis. JKNS

Advantages Elimination of donor site complications Saving more motion segments Reducing blood loss and operation time.

Instrumentation without fusion

Cement augmentation screwing

Discussion

Sanderson et al.(1999) : Short segment fixation of thoracolumbar burst fractures without fusion. Eur Spine JWang et al.(2006) : Is fusion necessary for surgically treated burst fractures of the thoracolumbar and lumbar spine? Spine

Parker JW, Lane JR, Karaikovic EE, Gaines RW : Successful short-segment instrumentation and fusion for thoracolumbar spine fractures: a consecutive 41/2-year series. Spine 25 : 1157-1170, 2000

Short segment posterior fixation

23年 4月 10日 18


Rationale of Screw reinforcing Percutaneous short Segment Screwing Postural reduction : anterior column restoration, spinal alignment correction, no need decompression Bone cement augmentation : Maintain spinal stability, Maintain restored anterior column Percutaneous Transpedicular screwing : No open surgery Bone fusion : Fracture site itselfThoracolumbar junction kyphosis in Percutaneous screwing system Percutanoues screwing system : lordosis setting Rod rotation : under the C-guide using the firm rod holder Rod fixation : kyphotic setting

1) Reduce the dissections of the paraspinal muscles and posterior spinal elements.2) Reduce the intraoperative bleeding, the operation time, the anesthesia time, infection,

dural tear, etc.3) Early ambulation4) Reduce the hospital day5) Reduce the postoperative pain

Advantages of the screw reinforced percutaneous stabilization

DiscussionInitialInitial After OperationAfter Operation 1 years later1 years later

23年 4月 10日 19


Discussion

23年 4月 10日 20

dae jeon hurisarang hospital, dae jeon department of neurosurgery, mokpo hankook hospital, mokpo...

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