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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
69
70
4. Postoperative Management
• 24 h MOVILIZATION• TERMOPLASTIC ORTHESIS• 3 DAYS POSTOP IN-HOSPITAL STAY• NO SIGNIFICANT BLOOD LOSS• NO OPIOID POSTOP
71
5. Outcome
• 3 mos.:
– No pain– No neuro deficit– Return to normal life– Return to work
