COMPLEX THORACIC INJURIES Avelino Parajón Servicio de Neurocirugía Hospital Universitario Puerta...

COMPLEX THORACIC INJURIES

Avelino ParajónServicio de Neurocirugía

Hospital Universitario Puerta de Hierro Majadahonda, Madrid

• THORACIC SPINE

– T1-T10

• THORACOLUMBAR SPINE

– T11-L2

• LUMBAR SPINE

– L3-L5

THORACOLUMBAR FRACTURES

– MEN: WOMEN 2/3:1/3

– 20-40 YEARS OLD

– 15-20% OF FRACTURES

– 2/3 OF SPINE FRACTURES

THORACIC COMPLEX INJURIES

• TRAUMA / ATLS

• ABC / GCS

• SPINE EXAM

– RED FLAGS

– INSPECT AND PALPATE ENTIRE SPINE

• THOROUGH RX EXAM

SPINAL CORD INJURY ASSESMENT

• MANY GRADING SYSTEMS

– IMPAIRMENT BASED

• FRANKEL

• ASIA

• YALE

• MOTOR INDEX

– FUNCTION BASED

• MODIFIED BARTHEL INDEX

SPINAL CORD INJURY ASSESMENT

• COMPLETE

– NO FUNCTION BELOW LEVEL OF INJURY

– ABSENCE OF SENSATION AND VOLUNTARY MOVEMENT IN S4/5 DISTRIBUTION

• INCOMPLETE

– PRESERVATION OF SENSATION IN S4/5 DISTRIBUTION AND VOLUNTARY CONTROL OF ANAL SPHINCTER

• BÖHLER, 1929• WATSON-JONES, 1931• NICOLL, 1949

• HOLDSWORTH, 1963, 2 COLUMNS• LOUIS-GOUTALLIER, 1977

• DENIS, 1983, 3 COLUMNS• FERGUSON-ALLEN, 1984

• MAGERL, 1994, AO• McCORMACK, 1994, LOAD SHARING• VACCARO, 2005, TLISS

• VACCARO, 2006, TLICS

HOLDSWORTH

• STABLE– COMPRESSION – BURST

• UNSTABLE– ROTATION– DISLOCATION

DENIS CLASSIFICATION-compression fractures

• 50%• COMPRESSION• ANTERIOR

COLUMN• STABLE• NO NEURO DEFICIT• NON SURGICAL /SURGICAL

DENIS CLASSIFICATION- compression fractures

• WITH ANTERIOR WEDGING

• WITH LATERAL WEDGING

DENIS CLASSIFICATION-burst fractures

• 20% • COMPRESSION• ANTERIOR AND

MIDDLE COLUMN• UNSTABLE• MAY HAVE NEURO

DEFICIT• SURGERY

DENIS CLASSIFICATION-burst fractures

• FRACTURE OF BOTH ENDPLATES

• FRACTURE OF THE SUPERIOR ENDPLATE

• FRACTURE OF THE INFERIOR ENDPLATE

• BURST + ROTATION

• BURST + LATERAL FLEXION

DENIS CLASSIFICATION-flexion distraction fx

• UNCOMMON• FLEXION +

DISTRACTION• MIDDLE AND

POSTERIOR COLUMNS• UNSTABLE• USUALLY NO NEURO

DEFICIT• FX. CHANCE

DENIS CLASSIFICATION- flexion distraction fx

• PURE OSSEOUS DISCONTINUITY, 1 LEVEL (CHANCE)

• OSSEOUS- LIGAMENTOUS DISCONTINUITY, 1 LEVEL

• OSSEOUS DISCONTINUITY, 2 LEVELS

• OSSEOUS-LIGAMENTOUS DISCONTINUITY, 2 LEVELS

DENIS CLASSIFICATION- chance fracture

DENIS CLASSIFICATION-fracture dislocation

• 25%• FLEXION-ROTATION

FLEXION DISTRACTION• THREE COLUMNS• UNSTABLE• NEURO DEFICIT• SURGERY

DENIS CLASSIFICATION-fracture dislocation

AO CLASSIFICATION

• A- COMPRESSION

• B- DISTRACTION

• C- ROTATION

AO CLASSIFICATION- A

• A.1 IMPACTATIONN– A.1.1 of superior endplate– A.1.2 wedge – A.1.3 vertebral body colapse

• A.2 SECTION– A.2.1 sagital section– A.2.2 coronal section– A.2.3 Pincer fracture

• A.3. BURST– A.3.1. incomplete– A.3.2. with section– A.3.3 complete

AO CLASSIFICATION- B

• B.1 predominantly ligamentous lessions

– B.1.1 transverse disruption of disc

– B.1.2 tipo A (compression)+ disrupture post ligam

• B.2 predominantly bone lessions

– B.2.1 transverse fractures of 2 columns+lig

– B.2.2 flexión con espondilolysis

– B.2.3 A (anterior compression)+ flexion distraction posterior

• B.3. lessions by hyperextension-shearing trhough the disc

– B.3.1. hyperextension and lubluxation

– B.3.2. Hiperextensión and spondylolisis

– B.3.3 posterior dislocation

Tipo C: ROTATION• C.1 ROTATION + A

– C.1.1 ROTATIONN+ A1 (wedge)

– C.1.2 ROTATIO+ A2 (section)

– C.1.3. ROTATION+ A3 (burst)

• C.2 ROTATION + B

– C.2.1 ROTATION+ B1

– C.2.2 ROTATION + B2

– C.2.3 A ROTATION+ B3

• C.3. ROTATION + SHEARING

– C.3.1. slice shearing

– C.3.2. oblique shearing

McCORMACK“LOAD SHARING CLASSIFICATION”

• COMMINUTION

• APPOSITION OF FRAGMENTS

• KYPHOTIC DEFORMITY

McCORMACK“LOAD SHARING CLASSIFICATION”

McCORMACK“LOAD SHARING CLASSIFICATION”

• LESSIONS WITH SURGICAL INDICATION AND < 7 POINTS

– POSTERIOR APPROACH

• LESSIONS > 7 POINTS

– ANTERIOR APPROACH

VACCARO- TLISS

• MECHANISM OF INJURY

• LESSION OF POST. LIGAMENT COMPLEX

• NEUROLOGICAL DEFICIT

VACCARO- TLISS

• MECHANISM OF INJURY

– COMPRESSION 1 POINT

– TRASLATION/ROTATION 3 POINTS

– DISTRACTION 4 POINTS

VACCARO- TLISS

• LESSION OF POSTERIOR LIGAMENT COMPLEX

– INTACT 0 POINTS

– SUSPECTED 2 POINTS

– KNOWN 3 POINTS

VACCARO- TLISS

• NEUROLOGICAL DEFICIT

– RADICULAR 2 POINTS

– INCOMPLETE CONUS/SPINAL CORD 2 POINTS

– COMPLETE CONUS/ S. CORD 2 POINTS

– CAUDA EQUINA 3 POINTS

VACCARO- TLISS

• TLISS <4 NON SURGICAL TREATMENT

• TLISS 4 NON SURGICAL / SURGICAL

• TLISS >4 SURGICAL TREATMENT

VACCARO- TLICS

• LESSIONAL MORPHOMETRY

– COMPRESSION 1 POINT

– BURST 1 POINT

– TRASLATION / ROTATION 3 POINT

– DISTRACTION 4 POINT

SURGICAL INDICATIONS:>20º KYFOSIS

>10º CORONAL PLANE DEFORMITY

LIGAMENTOUS INSTABILITY (TYPE B)

LESIONES ROTACIONALES ( TYPE C)

CANAL STENOSIS 35-55%

HIGH LOSS >50%

MOBILITY IN POLITRAUMA PATIENTS

WORSENING NEUROLOGICAL DEFICIT

THORACOLUMBAR FRACTURES

• BURST FRACTURE + INCOMPLETE PARAPLEGIA

• LOW PROBABILITY OF REDUCTION BY POST APPROACH

– RETROPULSION WITH STENOSIS > 67%

– ANTERIOR COMMINUTION WITH ANGULATION > 30º

– > 4 DAYS SINCE TRAUMA

• INSUFFICIENT NEUROLOGICAL IMPROVEMENT AFTER POST DECOMPRRESION

• ANTERIOR COLUMN RECONSTRUCTION AFTER POSTERIOR STABILIZATION

• TRAUMATIC DISC HERNIATION WITH LESSION BY FLEXION- DISTRACTION

ANTERIOR APPROACH INDICATIONS

ANT+ POST VS SHORT POST FUSION

• RANDOMIZED PROSPECTIVE STUDY: SHORT FUSION ENDS UP IN LOST OF CORRECTION

• BUT THIS DON´T CORRELATE TO CLINICAL WORSENING

Korovessis et al. Spine 2006, 31: 859-868

SURGERY VS CONSERVATIVE IN AO A FX

2 PROSPECTIVE RANDOMIZED STUDIES

• Wood: J Bone Joint Surg Am 85: 773-81, 2003

• Siebenga: Spine 31(25): 2881-2890, 2006

SURGERY VS CONSERVATIVE IN AO A FX

• RANDOMIZED, PROSPECTIVE, UNICENTRIC

• HIPOTHESIS:

SURGERY IS BETTER THAN CONSERVATIVE IN

– THORACOLUMBAR FRACTURES

– BURST

– STABLES

– AND WITHOUT NEURO DEFICIT

SURGERY VS CONSERVATIVE IN AO A FX

• SURGERY

– SHORT POSTERIOR FIXATION AND FUSION

– ANTERIOR STABILIZATION AND FUSION

• CONSERVATIVE TREATMENT

– BRACE

SURGERY VS CONSERVATIVE IN AO A FX

• EVALUATION

– SF 36

– ROLAND AND MORRIS DISABILITY QUESTIONNAIRE

– OSWESTRY

– INITIAL AND FINAL KYPHOTIC DEFORMITY

– RETURN TO WORK

SURGERY CONSERVATIVE

INITIAL KYPHOTIC DEF 10º 11.3º

FINAL KYPHOTIC DEF 13º 13.8º

INITIAL CANAL STENOSIS 39 % 34 %

FINAL CANAL STENOSIS 22 % 19 %

OWESTRY NO DIF NO DIF

SF 36 NO DIF NO DIF

RETURN TO WORK NO DIF NO DIF

SURGERY VS CONSERVATIVE IN AO A FX

– LEVEL 2-2 STUDY(POOR QUALITY RANDOMIZED)

– FOLLOW UP < 80 %

– BAD SELECTION OF GROUPS

– HETEROGENOUS SURGICAL GROUP

• STABILIZATION 2 TO 5 LEVELS

• ANTERIOR APPROACH

SURGERY VS CONSERVATIVE IN AO A FX

HYPOTHESIS:

SURGICALLY TREATEDD FRACTURES HAVE BETTER RX AND CLINICAL OUTCOMES COMPARED TO THOSE MANAGED NON SURGICALLY

THORACOLUMBAR FRACTURES (T10-L4)

AO A TYPE (EXCLUDED A1.1.)

NO NEURO DEFICIT(FRANKEL E)

SURGERY VS CONSERVATIVE IN AO A FX

FOLLOW UP

RX EVALUATION

LOCAL SAGITAL ANGLE

REGIONAL SAGITAL ANGLE

RMDQ-24

VAS SPINE SCORE

VAS DEL DOLOR

SURGERY VS CONSERVATIVE IN AO A FX

• A3 FRACTURES (BURST): BETTER FUNCTIONAL RESULTS WITH SURGERY

• BETTER KYPHOTIC CORRECTION WITH SURGERY

• NO CLINICAL- RADIOLOGICAL CORRELATION

SURGERY VS CONSERVATIVE IN AO A FX

• RANDOMIZED, PROSPECTIVE, MULTICENTRIC

• FX CLASSIFICATION ACCORDING TO AO AND LSC

• NO SURGERY

– REST 5 DAYS

– FISIOTHERAPY

– JEWETT ORTHESIS 3 MONTHS

• SURGERY

– BISEGMENTAL POSTERIOR FIXATION USS SYNTHES

ANTERIOR APPROACH TO THORACIC FRACTURES

– BETTER DECOMPRESSION

– BETTER KYPHOTIC CORRECTION

– LESS PAIN

ANTERIOR APPROACH TO THORACIC FRACTURES

TECHNIQUE

THORACOTOMY

THORACOPHRENOLAPAROTHOMY

LEFT SIDE T12-L3

RIGHT SIDE T6-T11

1. Patient History

• MALE 59 YEARS OLD• HIPERCHL• MOTORCICLE ACCIDENT 12/10/09 IN MOROCCO• REFERRED TO OUR HOSPITAL 15/10/09

• INTENSE BACK PAIN• NORMAL NEURO EXPLOR.• FRANKEL E• T12 AO A3

2. Diagnosis

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4. Postoperative Management

• 24 h MOVILIZATION• TERMOPLASTIC ORTHESIS• 3 DAYS POSTOP IN-HOSPITAL STAY• NO SIGNIFICANT BLOOD LOSS• NO OPIOID POSTOP

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5. Outcome

• 3 mos.:

– No pain– No neuro deficit– Return to normal life– Return to work