Microsoft PowerPoint - DORSAL_PRES [Read-Only]

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COMBINEDCOMBINEDANTERIOR AND POSTERIOR

DECOMPRESSION AND SHORTSEGMENT FIXATION FOR

UNSTABLE BURST FRACTURES INTHE DORSAL LUMBAR REGION

WITH OR WITHOUT NEUROLOGICAL DEFICIT

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Consultant Neuro & Spinal Surgeon, Consultant Neuro & Spinal Surgeon, Lilavati Hospital & Research Center.Lilavati Hospital & Research Center.

Mumbai, India.Mumbai, India.

M.S. (Bom.) Neuro (Lon.) M.Sc.. Neuro (Eng..) F.A.C.S. & F.I.C.SM.S. (Bom.) Neuro (Lon.) M.Sc.. Neuro (Eng..) F.A.C.S. & F.I.C.S. (USA) F.N.A.M.S., D.Sc... (USA) F.N.A.M.S., D.Sc..

Dr. P.S Ramani

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LILAVATI HOSPITAL, LILAVATI HOSPITAL, MUMBAIMUMBAI

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** Unstable zone.Unstable zone.** Jn. of fixed and mobile segments.Jn. of fixed and mobile segments.** Jn. of kyphosis and lordosis.Jn. of kyphosis and lordosis.** Second common site for injury of spine.Second common site for injury of spine.

DORSO LUMBAR SPINE DORSO LUMBAR SPINE (D10 TO L2)(D10 TO L2)

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∗∗ High morbidity.High morbidity.∗∗ Mortality 0.5 to 1%.Mortality 0.5 to 1%.∗∗ 75% have some degree of 75% have some degree of

neurological deficit.neurological deficit.

S. Rangachari - 1996

INJURY TO DL SPINE

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TREATMENT OF DL TREATMENT OF DL FRACTURESFRACTURES

without Neurological deficitwithout Neurological deficit

Controversial Controversial

Strong proponents of conservative treatmentStrong proponents of conservative treatment

Strong proponents of surgical treatmentStrong proponents of surgical treatment

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** Complete bed restComplete bed rest -- -- -- -- -- -- 4 weeks 4 weeks

** Brace Brace -- -- -- -- -- -- 12 weeks12 weeks

STD. CONSERVATIVE STD. CONSERVATIVE TREATMENTTREATMENT

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DL BURST FRACTURESDL BURST FRACTURES

•• Stable or unstable.Stable or unstable.•• Very difficult to define.Very difficult to define.•• 15% of all DL injuries are burst 15% of all DL injuries are burst

fractures.fractures.

* Esses ; Spine ; 1990

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STABLE BURST FRACTURESSTABLE BURST FRACTURES

** Caused by vertical load.Caused by vertical load.** Anterior and posterior parts of the Anterior and posterior parts of the

body are fractured.body are fractured.** Post. column not involved.Post. column not involved.

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UNSTABLE BURST UNSTABLE BURST FRACTURESFRACTURES

** Rotational force is involved.Rotational force is involved.** May have injury to posterior column.May have injury to posterior column.** Integrity of PLL is an important Integrity of PLL is an important

determining factor.determining factor.** Non functioning middle column is prime Non functioning middle column is prime

determinant.determinant.

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THREE COLUMN THREE COLUMN CLASSIFICATION OF DENISCLASSIFICATION OF DENIS

** Ant.Column:Ant.Column: Ant.vertebral Ant.vertebral body, ant.annulus fibrosus, body, ant.annulus fibrosus, ALL.ALL.

** Middle column:Middle column:Post.vertebral body, Post.vertebral body, post.annulus, PLLpost.annulus, PLL..

** Post.Column:Post.Column: All All post.elements: facets, post.elements: facets, laminae, spinous processes, laminae, spinous processes, interlaminar, inter and interlaminar, inter and supraspinous ligaments.supraspinous ligaments.

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INSTABILITY AT DL Jn.INSTABILITY AT DL Jn.(After Punjabi)(After Punjabi)

** Ant. elements destroyed/unable to function Ant. elements destroyed/unable to function 2 points.2 points.** Post. elements destroyed/unable to function Post. elements destroyed/unable to function 2 points.2 points.** Rel. Sag. plane translation, 2.5mm Rel. Sag. plane translation, 2.5mm 2 points.2 points.** Sagital plane angulation of 5 degree Sagital plane angulation of 5 degree 2 points.2 points.** Neurological deficitNeurological deficit 2 points.2 points.** Disturbed costo vertebral area Disturbed costo vertebral area 1 point.1 point.** Dangerous anticipated loadingDangerous anticipated loading 1 point.1 point.

More than 5 points = unstable burst.

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CLINICAL CRITERIA USED IN CLINICAL CRITERIA USED IN OUR SERIESOUR SERIES

(for instability)(for instability)

** Severe and persistent pain.Severe and persistent pain.** Kyphosis more than 20 degrees.Kyphosis more than 20 degrees.** Ant.Vertebral body compr. more than Ant.Vertebral body compr. more than

50%.50%.** Canal compromise 40%.Canal compromise 40%.** Asso. post. column injury.Asso. post. column injury.** Asso. neurological deficitAsso. neurological deficit..

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BONY CANAL COMPROMISEBONY CANAL COMPROMISE

** Difficult to decide threshold for surgery.Difficult to decide threshold for surgery.** 50% canal compromise = surgery.50% canal compromise = surgery.** 20 degrees kyphosis = surgery.20 degrees kyphosis = surgery.** No relationship between canal No relationship between canal

compromise and neurological damage.compromise and neurological damage.

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SURGICAL MANAGEMENTSURGICAL MANAGEMENT

Present PhilosophyPresent Philosophy

** Long struggle of errors & trials since Long struggle of errors & trials since 1978.1978.

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LONG POSTERIOR RODDINGLONG POSTERIOR RODDING

•• Involves : Involves : •• 1 : Intermediate points of fixation.1 : Intermediate points of fixation.•• 2 : Use of three point bending construct.2 : Use of three point bending construct.

•• Can cause fatigue of hook or sublaminar wire.Can cause fatigue of hook or sublaminar wire.

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POSTERIOR STABILISATION POSTERIOR STABILISATION ALONEALONE

Either withEither with

••Harrington rodsHarrington rods••Luque rectangle orLuque rectangle or••Pedicle screwsPedicle screws••failed to maintain sagittal correction at 12 monthsfailed to maintain sagittal correction at 12 months

••Sasso; Spine; 1993.Sasso; Spine; 1993.

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POSTERIOR STABILISATION POSTERIOR STABILISATION ALONEALONE

** High rate of failure with short segment CD High rate of failure with short segment CD instrumentation.instrumentation.

McLain et.al. J.Bone Jt.Surg; 1993.McLain et.al. J.Bone Jt.Surg; 1993.

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KANEDA DEVICEKANEDA DEVICE

•• Beginning of modern era of Ant. Beginning of modern era of Ant. stabilization (short segment)stabilization (short segment)

** 1 : Plates hooked to vertebral bodies.1 : Plates hooked to vertebral bodies.

** 2 : Two rods for stabilisation.2 : Two rods for stabilisation.

** 3 : Two bicortical screws in each vertebral body 3 : Two bicortical screws in each vertebral body resists all axial loads.resists all axial loads.

•• Post. stabilisation not necessary.Post. stabilisation not necessary.

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LATE NEUROLOGICAL LATE NEUROLOGICAL DEFICITDEFICIT

(Conservative management)(Conservative management)

••Definite possibility.Definite possibility.••Denis reported 17% late neurological deficit.Denis reported 17% late neurological deficit.

••Denis: Clin Orthop; 1984.Denis: Clin Orthop; 1984.

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Conservative Treatment 1st DayConservative Treatment 1st Day

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Conservative Treatment Conservative Treatment -- 8 mths.8 mths.

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Conservative Treatment 18 mths.Conservative Treatment 18 mths.

** Pt. Seeking relief from painPt. Seeking relief from pain

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SPINAL MUSCLE FORCESPINAL MUSCLE FORCE

** The natural The natural muscle forces in muscle forces in the spine pass the spine pass through the through the vertebral bodies in vertebral bodies in the dorso lumbar the dorso lumbar region.region.

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BRIDGE FIXATION BRIDGE FIXATION PRINCIPLEPRINCIPLE

** Bridges the Bridges the ant.construct during ant.construct during healing.healing.

** Helps in load sharing.Helps in load sharing.** No cross bar.Torque No cross bar.Torque

prevented by ant.plate.prevented by ant.plate.** Must survive for 1 year.Must survive for 1 year.

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BRIDGE FIXATION BRIDGE FIXATION PRINCIPLEPRINCIPLE

** Cross links if Cross links if provided bear provided bear tremendous force in tremendous force in flexion.flexion.

** System will fail System will fail without without ant.construct.ant.construct.

** Most stresses are Most stresses are taken away by taken away by ant.constructant.construct.

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BRIDGE FIXATION BRIDGE FIXATION PRINCIPLEPRINCIPLE

** Needs torque Needs torque prevention.prevention.

** Has to bear 100% Has to bear 100% load.load.

** Usually gives way Usually gives way within one year.within one year.

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NEUTRALISATION PRINCIPLENEUTRALISATION PRINCIPLE

** Decompression of Decompression of cord anteriorly.cord anteriorly.

** Restoration of Restoration of height.height.

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NEUTRALISATION PRINCIPLENEUTRALISATION PRINCIPLE

** Prevents stress.Prevents stress.** Minimizes:Minimizes:

TortionTortionShearingShearingExcess axial load.Excess axial load.

** Increases stability.Increases stability.** Early functional Early functional

restoration.restoration.

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NEUTRALISATION NEUTRALISATION PRINCIPLEPRINCIPLE

** Plates act as Plates act as tension band in tension band in extension and extension and buttress in flexion.buttress in flexion.

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PRESENT CONSTRUCTPRESENT CONSTRUCT

** Post.implants bear Post.implants bear one third load.one third load.

** Less chance of Less chance of failure.failure.

** Lasts long.Lasts long.** Lordosis is not Lordosis is not

significant.significant.

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POSTERIOR IMPLANTSPOSTERIOR IMPLANTS

** VSP Plates 4mm VSP Plates 4mm thick.thick.

** Screws Screws 5.5mm. x 36 mm.5.5mm. x 36 mm.

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ANTERIOR IMPLANTSANTERIOR IMPLANTS

** PLATES :PLATES :Reconstruction or Reconstruction or DCP 4 mm Thick.DCP 4 mm Thick.

** SCREWS :SCREWS :Locking or Locking or Unlocking 4.5 mm Unlocking 4.5 mm cortical.cortical.

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SURGICAL MANAGEMENTSURGICAL MANAGEMENT

** Post. pedicle screws, short segment fixation Post. pedicle screws, short segment fixation after decompression.after decompression.

** Anterior excision of body, decompression, Anterior excision of body, decompression, fusion with iliac crest autograft.fusion with iliac crest autograft.

** Metallic implants :Metallic implants : Reconstruction plate with Reconstruction plate with one screw above and one belowone screw above and one below..

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SITE OF INJURYSITE OF INJURY

∗∗ L1 vertebraL1 vertebra 33 cases.33 cases.** D12D12 12 cases.12 cases.** D11D11 7 cases.7 cases.∗∗ D10D10 2 cases.2 cases.∗∗ L2 0 casesL2 0 cases..** L2 involved partly with L1L2 involved partly with L1 3 cases.3 cases.

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Post Op.Post Op.RehabilitationRehabilitation

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MATERIALMATERIAL

** Total 54 cases.Total 54 cases.** Period 6Period 61/21/2 yrs. from Jun 94 till Dec. 2000.yrs. from Jun 94 till Dec. 2000.** MalesMales--46: Females46: Females--8.8.** Age ranged from 18 to 51 yrs.(Mean 32.6 yrs.).Age ranged from 18 to 51 yrs.(Mean 32.6 yrs.).** 75% admitted after 72 hours.75% admitted after 72 hours.** Commonest cause: fall from heightsCommonest cause: fall from heights..

* Vehicular accidents: Less common.

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Neurological Deficit

Totally Paraplegic 29

Partial Neuro. Deficit 13

No Deficit 12

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RESULTS : WORK SCALERESULTS : WORK SCALEW1:W1: Regular physical work.Regular physical work. 6 pts.6 pts.W1:W1: Students who have resumed 7 pts.Students who have resumed 7 pts.

their studies.their studies.W2:W2: Restricted physical work.Restricted physical work. 9 pts.9 pts.W3:W3: Not returned to work.Not returned to work. 3 pts.3 pts.W4:W4: Unable to work, does some Unable to work, does some

activity.activity. 18 pts.18 pts.W5:W5: Completely disabled.Completely disabled. 11 pts.11 pts.

W4 and W5 totally paraplegic patients.W4 and W5 totally paraplegic patients.

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RESULTS : RELIEF OF PAINRESULTS : RELIEF OF PAIN

P1:P1: No pain.No pain. 34 pts.34 pts.P2:P2: Occasional pain: no medication.Occasional pain: no medication. 20 pts.20 pts.P3:P3: Moderate pain: medication, normalModerate pain: medication, normal

work.work. 5 pts.5 pts.P4:P4: Moderate pain: medication, change Moderate pain: medication, change

in ADL, activity restricted.in ADL, activity restricted. 4 pts.4 pts.P5:P5: Constant severe pain.Constant severe pain. 1 pt.1 pt.

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RESULTS : NEUROLOGICAL RESULTS : NEUROLOGICAL IMPROVEMENTIMPROVEMENT

••Partial neurological deficit = 13 pts.Partial neurological deficit = 13 pts.••All showed improvement.All showed improvement.••Hip and knee muscles improve quickly.Hip and knee muscles improve quickly.••Residual weakness in ankle.Residual weakness in ankle.

••Maximum recovery at 8 months.Maximum recovery at 8 months.

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COMPLICATIONSCOMPLICATIONS

•• Mortality : 1 pt. died within one month.Mortality : 1 pt. died within one month.•• Lat. cut. nerve injury : Common.Lat. cut. nerve injury : Common.•• Bedsores : Common.Bedsores : Common.•• Infection : 33% contained.Infection : 33% contained.•• Implants not removed.Implants not removed.•• Bladder stones removed : 3 pts.Bladder stones removed : 3 pts.•• Orchitis from self catheter : 1 pt.Orchitis from self catheter : 1 pt.

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CONCLUSIONSCONCLUSIONSShort segment antero/posterior spinal stabilisation.Short segment antero/posterior spinal stabilisation.

Better neurological recovery.Better neurological recovery.Early rehabilitation.Early rehabilitation.Shorter hospital stay.Shorter hospital stay.Early return to work.Early return to work.

Good anatomical arthrodesis along the lines of axial Good anatomical arthrodesis along the lines of axial load.load.

No post op. kyphosis.No post op. kyphosis.

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PRINCIPLES OF MANAGEMENTPRINCIPLES OF MANAGEMENT

••1: Shorter period of hospitalisation.1: Shorter period of hospitalisation.••2: Early and solid spinal fusion.2: Early and solid spinal fusion.••3: Good stability.3: Good stability.••4: Less incidence of progression of kyphosis.4: Less incidence of progression of kyphosis.••5: Good results.5: Good results.

••Short segment surgical stabilization of spineShort segment surgical stabilization of spine..

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RECENT MODIFICATIONS

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Presented byPresented by

Dr. P. S. RamaniDr. P. S. Ramani

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Studio Inc.Studio Inc.

Created byCreated by