Traumatismes du rachis thoraco-lombaire

Prof Marc-Antoine Rousseau

Hocircpital Avicenne

Faut-il opeacuterer

bull Un problegraveme neurologique CLINIQUE ndash Preacuteciser lrsquoatteinte neurologique

bull Intensiteacute siegravege

bull Un problegraveme meacutecanique IMAGERIE ndash Deacutemarche diagnostique

ndash Bilan drsquoimagerie

ndash Limites des classifications

bull Traitement

Classification de Frankel

American Spinal Injury Association

Score ASIA

Phreacutenique

Coeur

Sphincter anal

Faut-il opeacuterer

bull Deacuteplacement Stable

bull Deacuteplacement toleacuterable

Stabiliteacute

bull Radiologie

description des traits

bull Biomeacutecanique

Interpreacutetation des traits

ne

Denis

Denis F Spinal instability as defined by

the three-column spine concept in acute

spinal trauma Clin Orthop Relat Res

198418965--76

bull Biomeacutecanique

bull Instabiliteacute gt 2

bull Meacutecanisme

Classification de Magerl

AO Magerl F Harms J Gertzbein SD A new classification of spinal

fractures Presented at the Societe Internationale Orthopaedie et

Traumatologie Meetings Montreal Canada 1990

Magerl F Aebi M Gertzbein S Harms J Nazarian S A

comprehensive classification of thoracic and lumbar injuries Eur

Spine J (1994) 3 184-201

bull A compression

bull B distraction

bull C rotation

radios

A

B

C

Magerl A

bull Tassement

bull Seacuteparation

bull Eclatement

bull A 31

bull A 32

bull A 33 laquo burst raquo

Magerl B

bull Distraction

ndash Posteacuterieure

bull Ligamentaire

bull Osseuse

laquo Chance raquo

ndash Anteacuterieure

Magerl C

bull Rotation

Deacutemarche diagnostic

Rotation

Distraction

Compression

C

B

A

A ou B

Compression

Distraction

Bilan imagerie

Deacuteformation ART

(Angulation Reacutegionale Traumatique)

Cyphose reacutegionale laquo normale raquo

T11 9 deg

T12 7 deg

L1 1 deg

L2 - 8deg

L3 - 18 deg

L4 - 33 deg

L5 - 36 deg

bull Exple

ndash L2

ndash CR = 15deg

ndash ART = 15 ndash (-8) = 23 deg

Limites bull Classifications

ndash Reproductibiliteacute (A ou B ) asymp 05 laquo modeacutereacute raquo Woods 2005 JBJS

ndash Ligaments posteacuterieur bull Aspect IRM Augmente le Oner 2002 Eur Spine J

ndash Seuil de cyphose toleacuterable

ndash Que faire des A31 et 32

bull Autres facteurs de

deacutecision theacuterapeutique ndash Statut neurologique

ndash Poids

ndash Niveaux Charniegravere (TL)

Drsquoautres classifications hellip

Parker JW Lane JR Karaikovic EE et al

Successful short-segment instrumentation

and fusion for thoracolumbar spine fractures

a consecutive 4 12-year series Spine

2000251157ndash70

lt 7 posteacuterieur

gt 6 anteacuterieur

Load sharing TLISS

Vaccaro AR Zeiller SC Hulbert RJ et al The

thoracolumbar injury severity score A proposed

treatment algorithm J Spinal Disord Tech

200518209 ndash15

Principes techniques

bull Deacutecompression urgence = posteacuterieure ndash laminectomie

bull Stabilisation voie posteacuterieure

ndash Fixation interverteacutebrale

bull Symeacutetrique (1+1) ou (2+2) bull Avec ou sans greffe Percutaneacute AMO secondaire

ndash Chirurgie endoverteacutebrale

bull +- deacutecompression arthrodegravese anteacuterieure

compleacutementaire circonfeacuterentiel

Voie posteacuterieure installation

bull Deacutecubitus ventral

ndash Installation sur 4 billots

ndash Installation genu pectorale

ndash Installation sur la table orthopeacutedique

bull Attention particuliegravere

ndash Compression oculaire

ndash Compression abdominale (retour veineux)

Le plus souvent reacuteduction agrave lrsquoinstallation

Tile B2 Magerl B2

bull Leacutesions associeacutees

5

6

Fractures multieacutetageacutees

Vertebral Compression Fracture

15 agrave 30 1000 par an entre75 et 79 ans

J Orthop Surg Res 2011 Aug 19643 doi 1011861749-799X-6-43 Kyphoplasty in osteoporotic vertebral compression fractures--guidelines and technical considerations Robinson Y Heyde CE Foumlrsth P Olerud C

Tassements en cascade

Cyphose

Faut-il opeacuterer

bull Un problegraveme neurologique CLINIQUE ndash Preacuteciser lrsquoatteinte neurologique

bull Intensiteacute siegravege

bull Un problegraveme meacutecanique IMAGERIE ndash Deacutemarche diagnostique

ndash Bilan drsquoimagerie

ndash Limites des classifications

bull Traitement

Classification de Frankel

American Spinal Injury Association

Score ASIA

Phreacutenique

Coeur

Sphincter anal

Faut-il opeacuterer

bull Deacuteplacement Stable

bull Deacuteplacement toleacuterable

Stabiliteacute

bull Radiologie

description des traits

bull Biomeacutecanique

Interpreacutetation des traits

ne

Denis

Denis F Spinal instability as defined by

the three-column spine concept in acute

spinal trauma Clin Orthop Relat Res

198418965--76

bull Biomeacutecanique

bull Instabiliteacute gt 2

bull Meacutecanisme

Classification de Magerl

AO Magerl F Harms J Gertzbein SD A new classification of spinal

fractures Presented at the Societe Internationale Orthopaedie et

Traumatologie Meetings Montreal Canada 1990

Magerl F Aebi M Gertzbein S Harms J Nazarian S A

comprehensive classification of thoracic and lumbar injuries Eur

Spine J (1994) 3 184-201

bull A compression

bull B distraction

bull C rotation

radios

A

B

C

Magerl A

bull Tassement

bull Seacuteparation

bull Eclatement

bull A 31

bull A 32

bull A 33 laquo burst raquo

Magerl B

bull Distraction

ndash Posteacuterieure

bull Ligamentaire

bull Osseuse

laquo Chance raquo

ndash Anteacuterieure

Magerl C

bull Rotation

Deacutemarche diagnostic

Rotation

Distraction

Compression

C

B

A

A ou B

Compression

Distraction

Bilan imagerie

Deacuteformation ART

(Angulation Reacutegionale Traumatique)

Cyphose reacutegionale laquo normale raquo

T11 9 deg

T12 7 deg

L1 1 deg

L2 - 8deg

L3 - 18 deg

L4 - 33 deg

L5 - 36 deg

bull Exple

ndash L2

ndash CR = 15deg

ndash ART = 15 ndash (-8) = 23 deg

Limites bull Classifications

ndash Reproductibiliteacute (A ou B ) asymp 05 laquo modeacutereacute raquo Woods 2005 JBJS

ndash Ligaments posteacuterieur bull Aspect IRM Augmente le Oner 2002 Eur Spine J

ndash Seuil de cyphose toleacuterable

ndash Que faire des A31 et 32

bull Autres facteurs de

deacutecision theacuterapeutique ndash Statut neurologique

ndash Poids

ndash Niveaux Charniegravere (TL)

Drsquoautres classifications hellip

Parker JW Lane JR Karaikovic EE et al

Successful short-segment instrumentation

and fusion for thoracolumbar spine fractures

a consecutive 4 12-year series Spine

2000251157ndash70

lt 7 posteacuterieur

gt 6 anteacuterieur

Load sharing TLISS

Vaccaro AR Zeiller SC Hulbert RJ et al The

thoracolumbar injury severity score A proposed

treatment algorithm J Spinal Disord Tech

200518209 ndash15

Principes techniques

bull Deacutecompression urgence = posteacuterieure ndash laminectomie

bull Stabilisation voie posteacuterieure

ndash Fixation interverteacutebrale

bull Symeacutetrique (1+1) ou (2+2) bull Avec ou sans greffe Percutaneacute AMO secondaire

ndash Chirurgie endoverteacutebrale

bull +- deacutecompression arthrodegravese anteacuterieure

compleacutementaire circonfeacuterentiel

Voie posteacuterieure installation

bull Deacutecubitus ventral

ndash Installation sur 4 billots

ndash Installation genu pectorale

ndash Installation sur la table orthopeacutedique

bull Attention particuliegravere

ndash Compression oculaire

ndash Compression abdominale (retour veineux)

Le plus souvent reacuteduction agrave lrsquoinstallation

Tile B2 Magerl B2

bull Leacutesions associeacutees

5

6

Fractures multieacutetageacutees

Vertebral Compression Fracture

15 agrave 30 1000 par an entre75 et 79 ans

J Orthop Surg Res 2011 Aug 19643 doi 1011861749-799X-6-43 Kyphoplasty in osteoporotic vertebral compression fractures--guidelines and technical considerations Robinson Y Heyde CE Foumlrsth P Olerud C

Tassements en cascade

Cyphose

Classification de Frankel

American Spinal Injury Association

Score ASIA

Phreacutenique

Coeur

Sphincter anal

Faut-il opeacuterer

bull Deacuteplacement Stable

bull Deacuteplacement toleacuterable

Stabiliteacute

bull Radiologie

description des traits

bull Biomeacutecanique

Interpreacutetation des traits

ne

Denis

Denis F Spinal instability as defined by

the three-column spine concept in acute

spinal trauma Clin Orthop Relat Res

198418965--76

bull Biomeacutecanique

bull Instabiliteacute gt 2

bull Meacutecanisme

Classification de Magerl

AO Magerl F Harms J Gertzbein SD A new classification of spinal

fractures Presented at the Societe Internationale Orthopaedie et

Traumatologie Meetings Montreal Canada 1990

Magerl F Aebi M Gertzbein S Harms J Nazarian S A

comprehensive classification of thoracic and lumbar injuries Eur

Spine J (1994) 3 184-201

bull A compression

bull B distraction

bull C rotation

radios

A

B

C

Magerl A

bull Tassement

bull Seacuteparation

bull Eclatement

bull A 31

bull A 32

bull A 33 laquo burst raquo

Magerl B

bull Distraction

ndash Posteacuterieure

bull Ligamentaire

bull Osseuse

laquo Chance raquo

ndash Anteacuterieure

Magerl C

bull Rotation

Deacutemarche diagnostic

Rotation

Distraction

Compression

C

B

A

A ou B

Compression

Distraction

Bilan imagerie

Deacuteformation ART

(Angulation Reacutegionale Traumatique)

Cyphose reacutegionale laquo normale raquo

T11 9 deg

T12 7 deg

L1 1 deg

L2 - 8deg

L3 - 18 deg

L4 - 33 deg

L5 - 36 deg

bull Exple

ndash L2

ndash CR = 15deg

ndash ART = 15 ndash (-8) = 23 deg

Limites bull Classifications

ndash Reproductibiliteacute (A ou B ) asymp 05 laquo modeacutereacute raquo Woods 2005 JBJS

ndash Ligaments posteacuterieur bull Aspect IRM Augmente le Oner 2002 Eur Spine J

ndash Seuil de cyphose toleacuterable

ndash Que faire des A31 et 32

bull Autres facteurs de

deacutecision theacuterapeutique ndash Statut neurologique

ndash Poids

ndash Niveaux Charniegravere (TL)

Drsquoautres classifications hellip

Parker JW Lane JR Karaikovic EE et al

Successful short-segment instrumentation

and fusion for thoracolumbar spine fractures

a consecutive 4 12-year series Spine

2000251157ndash70

lt 7 posteacuterieur

gt 6 anteacuterieur

Load sharing TLISS

Vaccaro AR Zeiller SC Hulbert RJ et al The

thoracolumbar injury severity score A proposed

treatment algorithm J Spinal Disord Tech

200518209 ndash15

Principes techniques

bull Deacutecompression urgence = posteacuterieure ndash laminectomie

bull Stabilisation voie posteacuterieure

ndash Fixation interverteacutebrale

bull Symeacutetrique (1+1) ou (2+2) bull Avec ou sans greffe Percutaneacute AMO secondaire

ndash Chirurgie endoverteacutebrale

bull +- deacutecompression arthrodegravese anteacuterieure

compleacutementaire circonfeacuterentiel

Voie posteacuterieure installation

bull Deacutecubitus ventral

ndash Installation sur 4 billots

ndash Installation genu pectorale

ndash Installation sur la table orthopeacutedique

bull Attention particuliegravere

ndash Compression oculaire

ndash Compression abdominale (retour veineux)

Le plus souvent reacuteduction agrave lrsquoinstallation

Tile B2 Magerl B2

bull Leacutesions associeacutees

5

6

Fractures multieacutetageacutees

Vertebral Compression Fracture

15 agrave 30 1000 par an entre75 et 79 ans

J Orthop Surg Res 2011 Aug 19643 doi 1011861749-799X-6-43 Kyphoplasty in osteoporotic vertebral compression fractures--guidelines and technical considerations Robinson Y Heyde CE Foumlrsth P Olerud C

Tassements en cascade

Cyphose

American Spinal Injury Association

Score ASIA

Phreacutenique

Coeur

Sphincter anal

Faut-il opeacuterer

bull Deacuteplacement Stable

bull Deacuteplacement toleacuterable

Stabiliteacute

bull Radiologie

description des traits

bull Biomeacutecanique

Interpreacutetation des traits

ne

Denis

Denis F Spinal instability as defined by

the three-column spine concept in acute

spinal trauma Clin Orthop Relat Res

198418965--76

bull Biomeacutecanique

bull Instabiliteacute gt 2

bull Meacutecanisme

Classification de Magerl

AO Magerl F Harms J Gertzbein SD A new classification of spinal

fractures Presented at the Societe Internationale Orthopaedie et

Traumatologie Meetings Montreal Canada 1990

Magerl F Aebi M Gertzbein S Harms J Nazarian S A

comprehensive classification of thoracic and lumbar injuries Eur

Spine J (1994) 3 184-201

bull A compression

bull B distraction

bull C rotation

radios

A

B

C

Magerl A

bull Tassement

bull Seacuteparation

bull Eclatement

bull A 31

bull A 32

bull A 33 laquo burst raquo

Magerl B

bull Distraction

ndash Posteacuterieure

bull Ligamentaire

bull Osseuse

laquo Chance raquo

ndash Anteacuterieure

Magerl C

bull Rotation

Deacutemarche diagnostic

Rotation

Distraction

Compression

C

B

A

A ou B

Compression

Distraction

Bilan imagerie

Deacuteformation ART

(Angulation Reacutegionale Traumatique)

Cyphose reacutegionale laquo normale raquo

T11 9 deg

T12 7 deg

L1 1 deg

L2 - 8deg

L3 - 18 deg

L4 - 33 deg

L5 - 36 deg

bull Exple

ndash L2

ndash CR = 15deg

ndash ART = 15 ndash (-8) = 23 deg

Limites bull Classifications

ndash Reproductibiliteacute (A ou B ) asymp 05 laquo modeacutereacute raquo Woods 2005 JBJS

ndash Ligaments posteacuterieur bull Aspect IRM Augmente le Oner 2002 Eur Spine J

ndash Seuil de cyphose toleacuterable

ndash Que faire des A31 et 32

bull Autres facteurs de

deacutecision theacuterapeutique ndash Statut neurologique

ndash Poids

ndash Niveaux Charniegravere (TL)

Drsquoautres classifications hellip

Parker JW Lane JR Karaikovic EE et al

Successful short-segment instrumentation

and fusion for thoracolumbar spine fractures

a consecutive 4 12-year series Spine

2000251157ndash70

lt 7 posteacuterieur

gt 6 anteacuterieur

Load sharing TLISS

Vaccaro AR Zeiller SC Hulbert RJ et al The

thoracolumbar injury severity score A proposed

treatment algorithm J Spinal Disord Tech

200518209 ndash15

Principes techniques

bull Deacutecompression urgence = posteacuterieure ndash laminectomie

bull Stabilisation voie posteacuterieure

ndash Fixation interverteacutebrale

bull Symeacutetrique (1+1) ou (2+2) bull Avec ou sans greffe Percutaneacute AMO secondaire

ndash Chirurgie endoverteacutebrale

bull +- deacutecompression arthrodegravese anteacuterieure

compleacutementaire circonfeacuterentiel

Voie posteacuterieure installation

bull Deacutecubitus ventral

ndash Installation sur 4 billots

ndash Installation genu pectorale

ndash Installation sur la table orthopeacutedique

bull Attention particuliegravere

ndash Compression oculaire

ndash Compression abdominale (retour veineux)

Le plus souvent reacuteduction agrave lrsquoinstallation

Tile B2 Magerl B2

bull Leacutesions associeacutees

5

6

Fractures multieacutetageacutees

Vertebral Compression Fracture

15 agrave 30 1000 par an entre75 et 79 ans

J Orthop Surg Res 2011 Aug 19643 doi 1011861749-799X-6-43 Kyphoplasty in osteoporotic vertebral compression fractures--guidelines and technical considerations Robinson Y Heyde CE Foumlrsth P Olerud C

Tassements en cascade

Cyphose

Faut-il opeacuterer

bull Deacuteplacement Stable

bull Deacuteplacement toleacuterable

Stabiliteacute

bull Radiologie

description des traits

bull Biomeacutecanique

Interpreacutetation des traits

ne

Denis

Denis F Spinal instability as defined by

the three-column spine concept in acute

spinal trauma Clin Orthop Relat Res

198418965--76

bull Biomeacutecanique

bull Instabiliteacute gt 2

bull Meacutecanisme

Classification de Magerl

AO Magerl F Harms J Gertzbein SD A new classification of spinal

fractures Presented at the Societe Internationale Orthopaedie et

Traumatologie Meetings Montreal Canada 1990

Magerl F Aebi M Gertzbein S Harms J Nazarian S A

comprehensive classification of thoracic and lumbar injuries Eur

Spine J (1994) 3 184-201

bull A compression

bull B distraction

bull C rotation

radios

A

B

C

Magerl A

bull Tassement

bull Seacuteparation

bull Eclatement

bull A 31

bull A 32

bull A 33 laquo burst raquo

Magerl B

bull Distraction

ndash Posteacuterieure

bull Ligamentaire

bull Osseuse

laquo Chance raquo

ndash Anteacuterieure

Magerl C

bull Rotation

Deacutemarche diagnostic

Rotation

Distraction

Compression

C

B

A

A ou B

Compression

Distraction

Bilan imagerie

Deacuteformation ART

(Angulation Reacutegionale Traumatique)

Cyphose reacutegionale laquo normale raquo

T11 9 deg

T12 7 deg

L1 1 deg

L2 - 8deg

L3 - 18 deg

L4 - 33 deg

L5 - 36 deg

bull Exple

ndash L2

ndash CR = 15deg

ndash ART = 15 ndash (-8) = 23 deg

Limites bull Classifications

ndash Reproductibiliteacute (A ou B ) asymp 05 laquo modeacutereacute raquo Woods 2005 JBJS

ndash Ligaments posteacuterieur bull Aspect IRM Augmente le Oner 2002 Eur Spine J

ndash Seuil de cyphose toleacuterable

ndash Que faire des A31 et 32

bull Autres facteurs de

deacutecision theacuterapeutique ndash Statut neurologique

ndash Poids

ndash Niveaux Charniegravere (TL)

Drsquoautres classifications hellip

Parker JW Lane JR Karaikovic EE et al

Successful short-segment instrumentation

and fusion for thoracolumbar spine fractures

a consecutive 4 12-year series Spine

2000251157ndash70

lt 7 posteacuterieur

gt 6 anteacuterieur

Load sharing TLISS

Vaccaro AR Zeiller SC Hulbert RJ et al The

thoracolumbar injury severity score A proposed

treatment algorithm J Spinal Disord Tech

200518209 ndash15

Principes techniques

bull Deacutecompression urgence = posteacuterieure ndash laminectomie

bull Stabilisation voie posteacuterieure

ndash Fixation interverteacutebrale

bull Symeacutetrique (1+1) ou (2+2) bull Avec ou sans greffe Percutaneacute AMO secondaire

ndash Chirurgie endoverteacutebrale

bull +- deacutecompression arthrodegravese anteacuterieure

compleacutementaire circonfeacuterentiel

Voie posteacuterieure installation

bull Deacutecubitus ventral

ndash Installation sur 4 billots

ndash Installation genu pectorale

ndash Installation sur la table orthopeacutedique

bull Attention particuliegravere

ndash Compression oculaire

ndash Compression abdominale (retour veineux)

Le plus souvent reacuteduction agrave lrsquoinstallation

Tile B2 Magerl B2

bull Leacutesions associeacutees

5

6

Fractures multieacutetageacutees

Vertebral Compression Fracture

15 agrave 30 1000 par an entre75 et 79 ans

J Orthop Surg Res 2011 Aug 19643 doi 1011861749-799X-6-43 Kyphoplasty in osteoporotic vertebral compression fractures--guidelines and technical considerations Robinson Y Heyde CE Foumlrsth P Olerud C

Tassements en cascade

Cyphose

Stabiliteacute

bull Radiologie

description des traits

bull Biomeacutecanique

Interpreacutetation des traits

ne

Denis

Denis F Spinal instability as defined by

the three-column spine concept in acute

spinal trauma Clin Orthop Relat Res

198418965--76

bull Biomeacutecanique

bull Instabiliteacute gt 2

bull Meacutecanisme

Classification de Magerl

AO Magerl F Harms J Gertzbein SD A new classification of spinal

fractures Presented at the Societe Internationale Orthopaedie et

Traumatologie Meetings Montreal Canada 1990

Magerl F Aebi M Gertzbein S Harms J Nazarian S A

comprehensive classification of thoracic and lumbar injuries Eur

Spine J (1994) 3 184-201

bull A compression

bull B distraction

bull C rotation

radios

A

B

C

Magerl A

bull Tassement

bull Seacuteparation

bull Eclatement

bull A 31

bull A 32

bull A 33 laquo burst raquo

Magerl B

bull Distraction

ndash Posteacuterieure

bull Ligamentaire

bull Osseuse

laquo Chance raquo

ndash Anteacuterieure

Magerl C

bull Rotation

Deacutemarche diagnostic

Rotation

Distraction

Compression

C

B

A

A ou B

Compression

Distraction

Bilan imagerie

Deacuteformation ART

(Angulation Reacutegionale Traumatique)

Cyphose reacutegionale laquo normale raquo

T11 9 deg

T12 7 deg

L1 1 deg

L2 - 8deg

L3 - 18 deg

L4 - 33 deg

L5 - 36 deg

bull Exple

ndash L2

ndash CR = 15deg

ndash ART = 15 ndash (-8) = 23 deg

Limites bull Classifications

ndash Reproductibiliteacute (A ou B ) asymp 05 laquo modeacutereacute raquo Woods 2005 JBJS

ndash Ligaments posteacuterieur bull Aspect IRM Augmente le Oner 2002 Eur Spine J

ndash Seuil de cyphose toleacuterable

ndash Que faire des A31 et 32

bull Autres facteurs de

deacutecision theacuterapeutique ndash Statut neurologique

ndash Poids

ndash Niveaux Charniegravere (TL)

Drsquoautres classifications hellip

Parker JW Lane JR Karaikovic EE et al

Successful short-segment instrumentation

and fusion for thoracolumbar spine fractures

a consecutive 4 12-year series Spine

2000251157ndash70

lt 7 posteacuterieur

gt 6 anteacuterieur

Load sharing TLISS

Vaccaro AR Zeiller SC Hulbert RJ et al The

thoracolumbar injury severity score A proposed

treatment algorithm J Spinal Disord Tech

200518209 ndash15

Principes techniques

bull Deacutecompression urgence = posteacuterieure ndash laminectomie

bull Stabilisation voie posteacuterieure

ndash Fixation interverteacutebrale

bull Symeacutetrique (1+1) ou (2+2) bull Avec ou sans greffe Percutaneacute AMO secondaire

ndash Chirurgie endoverteacutebrale

bull +- deacutecompression arthrodegravese anteacuterieure

compleacutementaire circonfeacuterentiel

Voie posteacuterieure installation

bull Deacutecubitus ventral

ndash Installation sur 4 billots

ndash Installation genu pectorale

ndash Installation sur la table orthopeacutedique

bull Attention particuliegravere

ndash Compression oculaire

ndash Compression abdominale (retour veineux)

Le plus souvent reacuteduction agrave lrsquoinstallation

Tile B2 Magerl B2

bull Leacutesions associeacutees

5

6

Fractures multieacutetageacutees

Vertebral Compression Fracture

15 agrave 30 1000 par an entre75 et 79 ans

J Orthop Surg Res 2011 Aug 19643 doi 1011861749-799X-6-43 Kyphoplasty in osteoporotic vertebral compression fractures--guidelines and technical considerations Robinson Y Heyde CE Foumlrsth P Olerud C

Tassements en cascade

Cyphose

Denis

Denis F Spinal instability as defined by

the three-column spine concept in acute

spinal trauma Clin Orthop Relat Res

198418965--76

bull Biomeacutecanique

bull Instabiliteacute gt 2

bull Meacutecanisme

Classification de Magerl

AO Magerl F Harms J Gertzbein SD A new classification of spinal

fractures Presented at the Societe Internationale Orthopaedie et

Traumatologie Meetings Montreal Canada 1990

Magerl F Aebi M Gertzbein S Harms J Nazarian S A

comprehensive classification of thoracic and lumbar injuries Eur

Spine J (1994) 3 184-201

bull A compression

bull B distraction

bull C rotation

radios

A

B

C

Magerl A

bull Tassement

bull Seacuteparation

bull Eclatement

bull A 31

bull A 32

bull A 33 laquo burst raquo

Magerl B

bull Distraction

ndash Posteacuterieure

bull Ligamentaire

bull Osseuse

laquo Chance raquo

ndash Anteacuterieure

Magerl C

bull Rotation

Deacutemarche diagnostic

Rotation

Distraction

Compression

C

B

A

A ou B

Compression

Distraction

Bilan imagerie

Deacuteformation ART

(Angulation Reacutegionale Traumatique)

Cyphose reacutegionale laquo normale raquo

T11 9 deg

T12 7 deg

L1 1 deg

L2 - 8deg

L3 - 18 deg

L4 - 33 deg

L5 - 36 deg

bull Exple

ndash L2

ndash CR = 15deg

ndash ART = 15 ndash (-8) = 23 deg

Limites bull Classifications

ndash Reproductibiliteacute (A ou B ) asymp 05 laquo modeacutereacute raquo Woods 2005 JBJS

ndash Ligaments posteacuterieur bull Aspect IRM Augmente le Oner 2002 Eur Spine J

ndash Seuil de cyphose toleacuterable

ndash Que faire des A31 et 32

bull Autres facteurs de

deacutecision theacuterapeutique ndash Statut neurologique

ndash Poids

ndash Niveaux Charniegravere (TL)

Drsquoautres classifications hellip

Parker JW Lane JR Karaikovic EE et al

Successful short-segment instrumentation

and fusion for thoracolumbar spine fractures

a consecutive 4 12-year series Spine

2000251157ndash70

lt 7 posteacuterieur

gt 6 anteacuterieur

Load sharing TLISS

Vaccaro AR Zeiller SC Hulbert RJ et al The

thoracolumbar injury severity score A proposed

treatment algorithm J Spinal Disord Tech

200518209 ndash15

Principes techniques

bull Deacutecompression urgence = posteacuterieure ndash laminectomie

bull Stabilisation voie posteacuterieure

ndash Fixation interverteacutebrale

bull Symeacutetrique (1+1) ou (2+2) bull Avec ou sans greffe Percutaneacute AMO secondaire

ndash Chirurgie endoverteacutebrale

bull +- deacutecompression arthrodegravese anteacuterieure

compleacutementaire circonfeacuterentiel

Voie posteacuterieure installation

bull Deacutecubitus ventral

ndash Installation sur 4 billots

ndash Installation genu pectorale

ndash Installation sur la table orthopeacutedique

bull Attention particuliegravere

ndash Compression oculaire

ndash Compression abdominale (retour veineux)

Le plus souvent reacuteduction agrave lrsquoinstallation

Tile B2 Magerl B2

bull Leacutesions associeacutees

5

6

Fractures multieacutetageacutees

Vertebral Compression Fracture

15 agrave 30 1000 par an entre75 et 79 ans

J Orthop Surg Res 2011 Aug 19643 doi 1011861749-799X-6-43 Kyphoplasty in osteoporotic vertebral compression fractures--guidelines and technical considerations Robinson Y Heyde CE Foumlrsth P Olerud C

Tassements en cascade

Cyphose

Classification de Magerl

AO Magerl F Harms J Gertzbein SD A new classification of spinal

fractures Presented at the Societe Internationale Orthopaedie et

Traumatologie Meetings Montreal Canada 1990

Magerl F Aebi M Gertzbein S Harms J Nazarian S A

comprehensive classification of thoracic and lumbar injuries Eur

Spine J (1994) 3 184-201

bull A compression

bull B distraction

bull C rotation

radios

A

B

C

Magerl A

bull Tassement

bull Seacuteparation

bull Eclatement

bull A 31

bull A 32

bull A 33 laquo burst raquo

Magerl B

bull Distraction

ndash Posteacuterieure

bull Ligamentaire

bull Osseuse

laquo Chance raquo

ndash Anteacuterieure

Magerl C

bull Rotation

Deacutemarche diagnostic

Rotation

Distraction

Compression

C

B

A

A ou B

Compression

Distraction

Bilan imagerie

Deacuteformation ART

(Angulation Reacutegionale Traumatique)

Cyphose reacutegionale laquo normale raquo

T11 9 deg

T12 7 deg

L1 1 deg

L2 - 8deg

L3 - 18 deg

L4 - 33 deg

L5 - 36 deg

bull Exple

ndash L2

ndash CR = 15deg

ndash ART = 15 ndash (-8) = 23 deg

Limites bull Classifications

ndash Reproductibiliteacute (A ou B ) asymp 05 laquo modeacutereacute raquo Woods 2005 JBJS

ndash Ligaments posteacuterieur bull Aspect IRM Augmente le Oner 2002 Eur Spine J

ndash Seuil de cyphose toleacuterable

ndash Que faire des A31 et 32

bull Autres facteurs de

deacutecision theacuterapeutique ndash Statut neurologique

ndash Poids

ndash Niveaux Charniegravere (TL)

Drsquoautres classifications hellip

Parker JW Lane JR Karaikovic EE et al

Successful short-segment instrumentation

and fusion for thoracolumbar spine fractures

a consecutive 4 12-year series Spine

2000251157ndash70

lt 7 posteacuterieur

gt 6 anteacuterieur

Load sharing TLISS

Vaccaro AR Zeiller SC Hulbert RJ et al The

thoracolumbar injury severity score A proposed

treatment algorithm J Spinal Disord Tech

200518209 ndash15

Principes techniques

bull Deacutecompression urgence = posteacuterieure ndash laminectomie

bull Stabilisation voie posteacuterieure

ndash Fixation interverteacutebrale

bull Symeacutetrique (1+1) ou (2+2) bull Avec ou sans greffe Percutaneacute AMO secondaire

ndash Chirurgie endoverteacutebrale

bull +- deacutecompression arthrodegravese anteacuterieure

compleacutementaire circonfeacuterentiel

Voie posteacuterieure installation

bull Deacutecubitus ventral

ndash Installation sur 4 billots

ndash Installation genu pectorale

ndash Installation sur la table orthopeacutedique

bull Attention particuliegravere

ndash Compression oculaire

ndash Compression abdominale (retour veineux)

Le plus souvent reacuteduction agrave lrsquoinstallation

Tile B2 Magerl B2

bull Leacutesions associeacutees

5

6

Fractures multieacutetageacutees

Vertebral Compression Fracture

15 agrave 30 1000 par an entre75 et 79 ans

J Orthop Surg Res 2011 Aug 19643 doi 1011861749-799X-6-43 Kyphoplasty in osteoporotic vertebral compression fractures--guidelines and technical considerations Robinson Y Heyde CE Foumlrsth P Olerud C

Tassements en cascade

Cyphose

A

B

C

Magerl A

bull Tassement

bull Seacuteparation

bull Eclatement

bull A 31

bull A 32

bull A 33 laquo burst raquo

Magerl B

bull Distraction

ndash Posteacuterieure

bull Ligamentaire

bull Osseuse

laquo Chance raquo

ndash Anteacuterieure

Magerl C

bull Rotation

Deacutemarche diagnostic

Rotation

Distraction

Compression

C

B

A

A ou B

Compression

Distraction

Bilan imagerie

Deacuteformation ART

(Angulation Reacutegionale Traumatique)

Cyphose reacutegionale laquo normale raquo

T11 9 deg

T12 7 deg

L1 1 deg

L2 - 8deg

L3 - 18 deg

L4 - 33 deg

L5 - 36 deg

bull Exple

ndash L2

ndash CR = 15deg

ndash ART = 15 ndash (-8) = 23 deg

Limites bull Classifications

ndash Reproductibiliteacute (A ou B ) asymp 05 laquo modeacutereacute raquo Woods 2005 JBJS

ndash Ligaments posteacuterieur bull Aspect IRM Augmente le Oner 2002 Eur Spine J

ndash Seuil de cyphose toleacuterable

ndash Que faire des A31 et 32

bull Autres facteurs de

deacutecision theacuterapeutique ndash Statut neurologique

ndash Poids

ndash Niveaux Charniegravere (TL)

Drsquoautres classifications hellip

Parker JW Lane JR Karaikovic EE et al

Successful short-segment instrumentation

and fusion for thoracolumbar spine fractures

a consecutive 4 12-year series Spine

2000251157ndash70

lt 7 posteacuterieur

gt 6 anteacuterieur

Load sharing TLISS

Vaccaro AR Zeiller SC Hulbert RJ et al The

thoracolumbar injury severity score A proposed

treatment algorithm J Spinal Disord Tech

200518209 ndash15

Principes techniques

bull Deacutecompression urgence = posteacuterieure ndash laminectomie

bull Stabilisation voie posteacuterieure

ndash Fixation interverteacutebrale

bull Symeacutetrique (1+1) ou (2+2) bull Avec ou sans greffe Percutaneacute AMO secondaire

ndash Chirurgie endoverteacutebrale

bull +- deacutecompression arthrodegravese anteacuterieure

compleacutementaire circonfeacuterentiel

Voie posteacuterieure installation

bull Deacutecubitus ventral

ndash Installation sur 4 billots

ndash Installation genu pectorale

ndash Installation sur la table orthopeacutedique

bull Attention particuliegravere

ndash Compression oculaire

ndash Compression abdominale (retour veineux)

Le plus souvent reacuteduction agrave lrsquoinstallation

Tile B2 Magerl B2

bull Leacutesions associeacutees

5

6

Fractures multieacutetageacutees

Vertebral Compression Fracture

15 agrave 30 1000 par an entre75 et 79 ans

J Orthop Surg Res 2011 Aug 19643 doi 1011861749-799X-6-43 Kyphoplasty in osteoporotic vertebral compression fractures--guidelines and technical considerations Robinson Y Heyde CE Foumlrsth P Olerud C

Tassements en cascade

Cyphose

C

Magerl A

bull Tassement

bull Seacuteparation

bull Eclatement

bull A 31

bull A 32

bull A 33 laquo burst raquo

Magerl B

bull Distraction

ndash Posteacuterieure

bull Ligamentaire

bull Osseuse

laquo Chance raquo

ndash Anteacuterieure

Magerl C

bull Rotation

Deacutemarche diagnostic

Rotation

Distraction

Compression

C

B

A

A ou B

Compression

Distraction

Bilan imagerie

Deacuteformation ART

(Angulation Reacutegionale Traumatique)

Cyphose reacutegionale laquo normale raquo

T11 9 deg

T12 7 deg

L1 1 deg

L2 - 8deg

L3 - 18 deg

L4 - 33 deg

L5 - 36 deg

bull Exple

ndash L2

ndash CR = 15deg

ndash ART = 15 ndash (-8) = 23 deg

Limites bull Classifications

ndash Reproductibiliteacute (A ou B ) asymp 05 laquo modeacutereacute raquo Woods 2005 JBJS

ndash Ligaments posteacuterieur bull Aspect IRM Augmente le Oner 2002 Eur Spine J

ndash Seuil de cyphose toleacuterable

ndash Que faire des A31 et 32

bull Autres facteurs de

deacutecision theacuterapeutique ndash Statut neurologique

ndash Poids

ndash Niveaux Charniegravere (TL)

Drsquoautres classifications hellip

Parker JW Lane JR Karaikovic EE et al

Successful short-segment instrumentation

and fusion for thoracolumbar spine fractures

a consecutive 4 12-year series Spine

2000251157ndash70

lt 7 posteacuterieur

gt 6 anteacuterieur

Load sharing TLISS

Vaccaro AR Zeiller SC Hulbert RJ et al The

thoracolumbar injury severity score A proposed

treatment algorithm J Spinal Disord Tech

200518209 ndash15

Principes techniques

bull Deacutecompression urgence = posteacuterieure ndash laminectomie

bull Stabilisation voie posteacuterieure

ndash Fixation interverteacutebrale

bull Symeacutetrique (1+1) ou (2+2) bull Avec ou sans greffe Percutaneacute AMO secondaire

ndash Chirurgie endoverteacutebrale

bull +- deacutecompression arthrodegravese anteacuterieure

compleacutementaire circonfeacuterentiel

Voie posteacuterieure installation

bull Deacutecubitus ventral

ndash Installation sur 4 billots

ndash Installation genu pectorale

ndash Installation sur la table orthopeacutedique

bull Attention particuliegravere

ndash Compression oculaire

ndash Compression abdominale (retour veineux)

Le plus souvent reacuteduction agrave lrsquoinstallation

Tile B2 Magerl B2

bull Leacutesions associeacutees

5

6

Fractures multieacutetageacutees

Vertebral Compression Fracture

15 agrave 30 1000 par an entre75 et 79 ans

J Orthop Surg Res 2011 Aug 19643 doi 1011861749-799X-6-43 Kyphoplasty in osteoporotic vertebral compression fractures--guidelines and technical considerations Robinson Y Heyde CE Foumlrsth P Olerud C

Tassements en cascade

Cyphose

Magerl A

bull Tassement

bull Seacuteparation

bull Eclatement

bull A 31

bull A 32

bull A 33 laquo burst raquo

Magerl B

bull Distraction

ndash Posteacuterieure

bull Ligamentaire

bull Osseuse

laquo Chance raquo

ndash Anteacuterieure

Magerl C

bull Rotation

Deacutemarche diagnostic

Rotation

Distraction

Compression

C

B

A

A ou B

Compression

Distraction

Bilan imagerie

Deacuteformation ART

(Angulation Reacutegionale Traumatique)

Cyphose reacutegionale laquo normale raquo

T11 9 deg

T12 7 deg

L1 1 deg

L2 - 8deg

L3 - 18 deg

L4 - 33 deg

L5 - 36 deg

bull Exple

ndash L2

ndash CR = 15deg

ndash ART = 15 ndash (-8) = 23 deg

Limites bull Classifications

ndash Reproductibiliteacute (A ou B ) asymp 05 laquo modeacutereacute raquo Woods 2005 JBJS

ndash Ligaments posteacuterieur bull Aspect IRM Augmente le Oner 2002 Eur Spine J

ndash Seuil de cyphose toleacuterable

ndash Que faire des A31 et 32

bull Autres facteurs de

deacutecision theacuterapeutique ndash Statut neurologique

ndash Poids

ndash Niveaux Charniegravere (TL)

Drsquoautres classifications hellip

Parker JW Lane JR Karaikovic EE et al

Successful short-segment instrumentation

and fusion for thoracolumbar spine fractures

a consecutive 4 12-year series Spine

2000251157ndash70

lt 7 posteacuterieur

gt 6 anteacuterieur

Load sharing TLISS

Vaccaro AR Zeiller SC Hulbert RJ et al The

thoracolumbar injury severity score A proposed

treatment algorithm J Spinal Disord Tech

200518209 ndash15

Principes techniques

bull Deacutecompression urgence = posteacuterieure ndash laminectomie

bull Stabilisation voie posteacuterieure

ndash Fixation interverteacutebrale

bull Symeacutetrique (1+1) ou (2+2) bull Avec ou sans greffe Percutaneacute AMO secondaire

ndash Chirurgie endoverteacutebrale

bull +- deacutecompression arthrodegravese anteacuterieure

compleacutementaire circonfeacuterentiel

Voie posteacuterieure installation

bull Deacutecubitus ventral

ndash Installation sur 4 billots

ndash Installation genu pectorale

ndash Installation sur la table orthopeacutedique

bull Attention particuliegravere

ndash Compression oculaire

ndash Compression abdominale (retour veineux)

Le plus souvent reacuteduction agrave lrsquoinstallation

Tile B2 Magerl B2

bull Leacutesions associeacutees

5

6

Fractures multieacutetageacutees

Vertebral Compression Fracture

15 agrave 30 1000 par an entre75 et 79 ans

J Orthop Surg Res 2011 Aug 19643 doi 1011861749-799X-6-43 Kyphoplasty in osteoporotic vertebral compression fractures--guidelines and technical considerations Robinson Y Heyde CE Foumlrsth P Olerud C

Tassements en cascade

Cyphose

Magerl B

bull Distraction

ndash Posteacuterieure

bull Ligamentaire

bull Osseuse

laquo Chance raquo

ndash Anteacuterieure

Magerl C

bull Rotation

Deacutemarche diagnostic

Rotation

Distraction

Compression

C

B

A

A ou B

Compression

Distraction

Bilan imagerie

Deacuteformation ART

(Angulation Reacutegionale Traumatique)

Cyphose reacutegionale laquo normale raquo

T11 9 deg

T12 7 deg

L1 1 deg

L2 - 8deg

L3 - 18 deg

L4 - 33 deg

L5 - 36 deg

bull Exple

ndash L2

ndash CR = 15deg

ndash ART = 15 ndash (-8) = 23 deg

Limites bull Classifications

ndash Reproductibiliteacute (A ou B ) asymp 05 laquo modeacutereacute raquo Woods 2005 JBJS

ndash Ligaments posteacuterieur bull Aspect IRM Augmente le Oner 2002 Eur Spine J

ndash Seuil de cyphose toleacuterable

ndash Que faire des A31 et 32

bull Autres facteurs de

deacutecision theacuterapeutique ndash Statut neurologique

ndash Poids

ndash Niveaux Charniegravere (TL)

Drsquoautres classifications hellip

Parker JW Lane JR Karaikovic EE et al

Successful short-segment instrumentation

and fusion for thoracolumbar spine fractures

a consecutive 4 12-year series Spine

2000251157ndash70

lt 7 posteacuterieur

gt 6 anteacuterieur

Load sharing TLISS

Vaccaro AR Zeiller SC Hulbert RJ et al The

thoracolumbar injury severity score A proposed

treatment algorithm J Spinal Disord Tech

200518209 ndash15

Principes techniques

bull Deacutecompression urgence = posteacuterieure ndash laminectomie

bull Stabilisation voie posteacuterieure

ndash Fixation interverteacutebrale

bull Symeacutetrique (1+1) ou (2+2) bull Avec ou sans greffe Percutaneacute AMO secondaire

ndash Chirurgie endoverteacutebrale

bull +- deacutecompression arthrodegravese anteacuterieure

compleacutementaire circonfeacuterentiel

Voie posteacuterieure installation

bull Deacutecubitus ventral

ndash Installation sur 4 billots

ndash Installation genu pectorale

ndash Installation sur la table orthopeacutedique

bull Attention particuliegravere

ndash Compression oculaire

ndash Compression abdominale (retour veineux)

Le plus souvent reacuteduction agrave lrsquoinstallation

Tile B2 Magerl B2

bull Leacutesions associeacutees

5

6

Fractures multieacutetageacutees

Vertebral Compression Fracture

15 agrave 30 1000 par an entre75 et 79 ans

J Orthop Surg Res 2011 Aug 19643 doi 1011861749-799X-6-43 Kyphoplasty in osteoporotic vertebral compression fractures--guidelines and technical considerations Robinson Y Heyde CE Foumlrsth P Olerud C

Tassements en cascade

Cyphose

Magerl C

bull Rotation

Deacutemarche diagnostic

Rotation

Distraction

Compression

C

B

A

A ou B

Compression

Distraction

Bilan imagerie

Deacuteformation ART

(Angulation Reacutegionale Traumatique)

Cyphose reacutegionale laquo normale raquo

T11 9 deg

T12 7 deg

L1 1 deg

L2 - 8deg

L3 - 18 deg

L4 - 33 deg

L5 - 36 deg

bull Exple

ndash L2

ndash CR = 15deg

ndash ART = 15 ndash (-8) = 23 deg

Limites bull Classifications

ndash Reproductibiliteacute (A ou B ) asymp 05 laquo modeacutereacute raquo Woods 2005 JBJS

ndash Ligaments posteacuterieur bull Aspect IRM Augmente le Oner 2002 Eur Spine J

ndash Seuil de cyphose toleacuterable

ndash Que faire des A31 et 32

bull Autres facteurs de

deacutecision theacuterapeutique ndash Statut neurologique

ndash Poids

ndash Niveaux Charniegravere (TL)

Drsquoautres classifications hellip

Parker JW Lane JR Karaikovic EE et al

Successful short-segment instrumentation

and fusion for thoracolumbar spine fractures

a consecutive 4 12-year series Spine

2000251157ndash70

lt 7 posteacuterieur

gt 6 anteacuterieur

Load sharing TLISS

Vaccaro AR Zeiller SC Hulbert RJ et al The

thoracolumbar injury severity score A proposed

treatment algorithm J Spinal Disord Tech

200518209 ndash15

Principes techniques

bull Deacutecompression urgence = posteacuterieure ndash laminectomie

bull Stabilisation voie posteacuterieure

ndash Fixation interverteacutebrale

bull Symeacutetrique (1+1) ou (2+2) bull Avec ou sans greffe Percutaneacute AMO secondaire

ndash Chirurgie endoverteacutebrale

bull +- deacutecompression arthrodegravese anteacuterieure

compleacutementaire circonfeacuterentiel

Voie posteacuterieure installation

bull Deacutecubitus ventral

ndash Installation sur 4 billots

ndash Installation genu pectorale

ndash Installation sur la table orthopeacutedique

bull Attention particuliegravere

ndash Compression oculaire

ndash Compression abdominale (retour veineux)

Le plus souvent reacuteduction agrave lrsquoinstallation

Tile B2 Magerl B2

bull Leacutesions associeacutees

5

6

Fractures multieacutetageacutees

Vertebral Compression Fracture

15 agrave 30 1000 par an entre75 et 79 ans

J Orthop Surg Res 2011 Aug 19643 doi 1011861749-799X-6-43 Kyphoplasty in osteoporotic vertebral compression fractures--guidelines and technical considerations Robinson Y Heyde CE Foumlrsth P Olerud C

Tassements en cascade

Cyphose

Deacutemarche diagnostic

Rotation

Distraction

Compression

C

B

A

A ou B

Compression

Distraction

Bilan imagerie

Deacuteformation ART

(Angulation Reacutegionale Traumatique)

Cyphose reacutegionale laquo normale raquo

T11 9 deg

T12 7 deg

L1 1 deg

L2 - 8deg

L3 - 18 deg

L4 - 33 deg

L5 - 36 deg

bull Exple

ndash L2

ndash CR = 15deg

ndash ART = 15 ndash (-8) = 23 deg

Limites bull Classifications

ndash Reproductibiliteacute (A ou B ) asymp 05 laquo modeacutereacute raquo Woods 2005 JBJS

ndash Ligaments posteacuterieur bull Aspect IRM Augmente le Oner 2002 Eur Spine J

ndash Seuil de cyphose toleacuterable

ndash Que faire des A31 et 32

bull Autres facteurs de

deacutecision theacuterapeutique ndash Statut neurologique

ndash Poids

ndash Niveaux Charniegravere (TL)

Drsquoautres classifications hellip

Parker JW Lane JR Karaikovic EE et al

Successful short-segment instrumentation

and fusion for thoracolumbar spine fractures

a consecutive 4 12-year series Spine

2000251157ndash70

lt 7 posteacuterieur

gt 6 anteacuterieur

Load sharing TLISS

Vaccaro AR Zeiller SC Hulbert RJ et al The

thoracolumbar injury severity score A proposed

treatment algorithm J Spinal Disord Tech

200518209 ndash15

Principes techniques

bull Deacutecompression urgence = posteacuterieure ndash laminectomie

bull Stabilisation voie posteacuterieure

ndash Fixation interverteacutebrale

bull Symeacutetrique (1+1) ou (2+2) bull Avec ou sans greffe Percutaneacute AMO secondaire

ndash Chirurgie endoverteacutebrale

bull +- deacutecompression arthrodegravese anteacuterieure

compleacutementaire circonfeacuterentiel

Voie posteacuterieure installation

bull Deacutecubitus ventral

ndash Installation sur 4 billots

ndash Installation genu pectorale

ndash Installation sur la table orthopeacutedique

bull Attention particuliegravere

ndash Compression oculaire

ndash Compression abdominale (retour veineux)

Le plus souvent reacuteduction agrave lrsquoinstallation

Tile B2 Magerl B2

bull Leacutesions associeacutees

5

6

Fractures multieacutetageacutees

Vertebral Compression Fracture

15 agrave 30 1000 par an entre75 et 79 ans

J Orthop Surg Res 2011 Aug 19643 doi 1011861749-799X-6-43 Kyphoplasty in osteoporotic vertebral compression fractures--guidelines and technical considerations Robinson Y Heyde CE Foumlrsth P Olerud C

Tassements en cascade

Cyphose

A ou B

Compression

Distraction

Bilan imagerie

Deacuteformation ART

(Angulation Reacutegionale Traumatique)

Cyphose reacutegionale laquo normale raquo

T11 9 deg

T12 7 deg

L1 1 deg

L2 - 8deg

L3 - 18 deg

L4 - 33 deg

L5 - 36 deg

bull Exple

ndash L2

ndash CR = 15deg

ndash ART = 15 ndash (-8) = 23 deg

Limites bull Classifications

ndash Reproductibiliteacute (A ou B ) asymp 05 laquo modeacutereacute raquo Woods 2005 JBJS

ndash Ligaments posteacuterieur bull Aspect IRM Augmente le Oner 2002 Eur Spine J

ndash Seuil de cyphose toleacuterable

ndash Que faire des A31 et 32

bull Autres facteurs de

deacutecision theacuterapeutique ndash Statut neurologique

ndash Poids

ndash Niveaux Charniegravere (TL)

Drsquoautres classifications hellip

Parker JW Lane JR Karaikovic EE et al

Successful short-segment instrumentation

and fusion for thoracolumbar spine fractures

a consecutive 4 12-year series Spine

2000251157ndash70

lt 7 posteacuterieur

gt 6 anteacuterieur

Load sharing TLISS

Vaccaro AR Zeiller SC Hulbert RJ et al The

thoracolumbar injury severity score A proposed

treatment algorithm J Spinal Disord Tech

200518209 ndash15

Principes techniques

bull Deacutecompression urgence = posteacuterieure ndash laminectomie

bull Stabilisation voie posteacuterieure

ndash Fixation interverteacutebrale

bull Symeacutetrique (1+1) ou (2+2) bull Avec ou sans greffe Percutaneacute AMO secondaire

ndash Chirurgie endoverteacutebrale

bull +- deacutecompression arthrodegravese anteacuterieure

compleacutementaire circonfeacuterentiel

Voie posteacuterieure installation

bull Deacutecubitus ventral

ndash Installation sur 4 billots

ndash Installation genu pectorale

ndash Installation sur la table orthopeacutedique

bull Attention particuliegravere

ndash Compression oculaire

ndash Compression abdominale (retour veineux)

Le plus souvent reacuteduction agrave lrsquoinstallation

Tile B2 Magerl B2

bull Leacutesions associeacutees

5

6

Fractures multieacutetageacutees

Vertebral Compression Fracture

15 agrave 30 1000 par an entre75 et 79 ans

J Orthop Surg Res 2011 Aug 19643 doi 1011861749-799X-6-43 Kyphoplasty in osteoporotic vertebral compression fractures--guidelines and technical considerations Robinson Y Heyde CE Foumlrsth P Olerud C

Tassements en cascade

Cyphose

Compression

Distraction

Bilan imagerie

Deacuteformation ART

(Angulation Reacutegionale Traumatique)

Cyphose reacutegionale laquo normale raquo

T11 9 deg

T12 7 deg

L1 1 deg

L2 - 8deg

L3 - 18 deg

L4 - 33 deg

L5 - 36 deg

bull Exple

ndash L2

ndash CR = 15deg

ndash ART = 15 ndash (-8) = 23 deg

Limites bull Classifications

ndash Reproductibiliteacute (A ou B ) asymp 05 laquo modeacutereacute raquo Woods 2005 JBJS

ndash Ligaments posteacuterieur bull Aspect IRM Augmente le Oner 2002 Eur Spine J

ndash Seuil de cyphose toleacuterable

ndash Que faire des A31 et 32

bull Autres facteurs de

deacutecision theacuterapeutique ndash Statut neurologique

ndash Poids

ndash Niveaux Charniegravere (TL)

Drsquoautres classifications hellip

Parker JW Lane JR Karaikovic EE et al

Successful short-segment instrumentation

and fusion for thoracolumbar spine fractures

a consecutive 4 12-year series Spine

2000251157ndash70

lt 7 posteacuterieur

gt 6 anteacuterieur

Load sharing TLISS

Vaccaro AR Zeiller SC Hulbert RJ et al The

thoracolumbar injury severity score A proposed

treatment algorithm J Spinal Disord Tech

200518209 ndash15

Principes techniques

bull Deacutecompression urgence = posteacuterieure ndash laminectomie

bull Stabilisation voie posteacuterieure

ndash Fixation interverteacutebrale

bull Symeacutetrique (1+1) ou (2+2) bull Avec ou sans greffe Percutaneacute AMO secondaire

ndash Chirurgie endoverteacutebrale

bull +- deacutecompression arthrodegravese anteacuterieure

compleacutementaire circonfeacuterentiel

Voie posteacuterieure installation

bull Deacutecubitus ventral

ndash Installation sur 4 billots

ndash Installation genu pectorale

ndash Installation sur la table orthopeacutedique

bull Attention particuliegravere

ndash Compression oculaire

ndash Compression abdominale (retour veineux)

Le plus souvent reacuteduction agrave lrsquoinstallation

Tile B2 Magerl B2

bull Leacutesions associeacutees

5

6

Fractures multieacutetageacutees

Vertebral Compression Fracture

15 agrave 30 1000 par an entre75 et 79 ans

J Orthop Surg Res 2011 Aug 19643 doi 1011861749-799X-6-43 Kyphoplasty in osteoporotic vertebral compression fractures--guidelines and technical considerations Robinson Y Heyde CE Foumlrsth P Olerud C

Tassements en cascade

Cyphose

Distraction

Bilan imagerie

Deacuteformation ART

(Angulation Reacutegionale Traumatique)

Cyphose reacutegionale laquo normale raquo

T11 9 deg

T12 7 deg

L1 1 deg

L2 - 8deg

L3 - 18 deg

L4 - 33 deg

L5 - 36 deg

bull Exple

ndash L2

ndash CR = 15deg

ndash ART = 15 ndash (-8) = 23 deg

Limites bull Classifications

ndash Reproductibiliteacute (A ou B ) asymp 05 laquo modeacutereacute raquo Woods 2005 JBJS

ndash Ligaments posteacuterieur bull Aspect IRM Augmente le Oner 2002 Eur Spine J

ndash Seuil de cyphose toleacuterable

ndash Que faire des A31 et 32

bull Autres facteurs de

deacutecision theacuterapeutique ndash Statut neurologique

ndash Poids

ndash Niveaux Charniegravere (TL)

Drsquoautres classifications hellip

Parker JW Lane JR Karaikovic EE et al

Successful short-segment instrumentation

and fusion for thoracolumbar spine fractures

a consecutive 4 12-year series Spine

2000251157ndash70

lt 7 posteacuterieur

gt 6 anteacuterieur

Load sharing TLISS

Vaccaro AR Zeiller SC Hulbert RJ et al The

thoracolumbar injury severity score A proposed

treatment algorithm J Spinal Disord Tech

200518209 ndash15

Principes techniques

bull Deacutecompression urgence = posteacuterieure ndash laminectomie

bull Stabilisation voie posteacuterieure

ndash Fixation interverteacutebrale

bull Symeacutetrique (1+1) ou (2+2) bull Avec ou sans greffe Percutaneacute AMO secondaire

ndash Chirurgie endoverteacutebrale

bull +- deacutecompression arthrodegravese anteacuterieure

compleacutementaire circonfeacuterentiel

Voie posteacuterieure installation

bull Deacutecubitus ventral

ndash Installation sur 4 billots

ndash Installation genu pectorale

ndash Installation sur la table orthopeacutedique

bull Attention particuliegravere

ndash Compression oculaire

ndash Compression abdominale (retour veineux)

Le plus souvent reacuteduction agrave lrsquoinstallation

Tile B2 Magerl B2

bull Leacutesions associeacutees

5

6

Fractures multieacutetageacutees

Vertebral Compression Fracture

15 agrave 30 1000 par an entre75 et 79 ans

J Orthop Surg Res 2011 Aug 19643 doi 1011861749-799X-6-43 Kyphoplasty in osteoporotic vertebral compression fractures--guidelines and technical considerations Robinson Y Heyde CE Foumlrsth P Olerud C

Tassements en cascade

Cyphose

Bilan imagerie

Deacuteformation ART

(Angulation Reacutegionale Traumatique)

Cyphose reacutegionale laquo normale raquo

T11 9 deg

T12 7 deg

L1 1 deg

L2 - 8deg

L3 - 18 deg

L4 - 33 deg

L5 - 36 deg

bull Exple

ndash L2

ndash CR = 15deg

ndash ART = 15 ndash (-8) = 23 deg

Limites bull Classifications

ndash Reproductibiliteacute (A ou B ) asymp 05 laquo modeacutereacute raquo Woods 2005 JBJS

ndash Ligaments posteacuterieur bull Aspect IRM Augmente le Oner 2002 Eur Spine J

ndash Seuil de cyphose toleacuterable

ndash Que faire des A31 et 32

bull Autres facteurs de

deacutecision theacuterapeutique ndash Statut neurologique

ndash Poids

ndash Niveaux Charniegravere (TL)

Drsquoautres classifications hellip

Parker JW Lane JR Karaikovic EE et al

Successful short-segment instrumentation

and fusion for thoracolumbar spine fractures

a consecutive 4 12-year series Spine

2000251157ndash70

lt 7 posteacuterieur

gt 6 anteacuterieur

Load sharing TLISS

Vaccaro AR Zeiller SC Hulbert RJ et al The

thoracolumbar injury severity score A proposed

treatment algorithm J Spinal Disord Tech

200518209 ndash15

Principes techniques

bull Deacutecompression urgence = posteacuterieure ndash laminectomie

bull Stabilisation voie posteacuterieure

ndash Fixation interverteacutebrale

bull Symeacutetrique (1+1) ou (2+2) bull Avec ou sans greffe Percutaneacute AMO secondaire

ndash Chirurgie endoverteacutebrale

bull +- deacutecompression arthrodegravese anteacuterieure

compleacutementaire circonfeacuterentiel

Voie posteacuterieure installation

bull Deacutecubitus ventral

ndash Installation sur 4 billots

ndash Installation genu pectorale

ndash Installation sur la table orthopeacutedique

bull Attention particuliegravere

ndash Compression oculaire

ndash Compression abdominale (retour veineux)

Le plus souvent reacuteduction agrave lrsquoinstallation

Tile B2 Magerl B2

bull Leacutesions associeacutees

5

6

Fractures multieacutetageacutees

Vertebral Compression Fracture

15 agrave 30 1000 par an entre75 et 79 ans

J Orthop Surg Res 2011 Aug 19643 doi 1011861749-799X-6-43 Kyphoplasty in osteoporotic vertebral compression fractures--guidelines and technical considerations Robinson Y Heyde CE Foumlrsth P Olerud C

Tassements en cascade

Cyphose

Deacuteformation ART

(Angulation Reacutegionale Traumatique)

Cyphose reacutegionale laquo normale raquo

T11 9 deg

T12 7 deg

L1 1 deg

L2 - 8deg

L3 - 18 deg

L4 - 33 deg

L5 - 36 deg

bull Exple

ndash L2

ndash CR = 15deg

ndash ART = 15 ndash (-8) = 23 deg

Limites bull Classifications

ndash Reproductibiliteacute (A ou B ) asymp 05 laquo modeacutereacute raquo Woods 2005 JBJS

ndash Ligaments posteacuterieur bull Aspect IRM Augmente le Oner 2002 Eur Spine J

ndash Seuil de cyphose toleacuterable

ndash Que faire des A31 et 32

bull Autres facteurs de

deacutecision theacuterapeutique ndash Statut neurologique

ndash Poids

ndash Niveaux Charniegravere (TL)

Drsquoautres classifications hellip

Parker JW Lane JR Karaikovic EE et al

Successful short-segment instrumentation

and fusion for thoracolumbar spine fractures

a consecutive 4 12-year series Spine

2000251157ndash70

lt 7 posteacuterieur

gt 6 anteacuterieur

Load sharing TLISS

Vaccaro AR Zeiller SC Hulbert RJ et al The

thoracolumbar injury severity score A proposed

treatment algorithm J Spinal Disord Tech

200518209 ndash15

Principes techniques

bull Deacutecompression urgence = posteacuterieure ndash laminectomie

bull Stabilisation voie posteacuterieure

ndash Fixation interverteacutebrale

bull Symeacutetrique (1+1) ou (2+2) bull Avec ou sans greffe Percutaneacute AMO secondaire

ndash Chirurgie endoverteacutebrale

bull +- deacutecompression arthrodegravese anteacuterieure

compleacutementaire circonfeacuterentiel

Voie posteacuterieure installation

bull Deacutecubitus ventral

ndash Installation sur 4 billots

ndash Installation genu pectorale

ndash Installation sur la table orthopeacutedique

bull Attention particuliegravere

ndash Compression oculaire

ndash Compression abdominale (retour veineux)

Le plus souvent reacuteduction agrave lrsquoinstallation

Tile B2 Magerl B2

bull Leacutesions associeacutees

5

6

Fractures multieacutetageacutees

Vertebral Compression Fracture

15 agrave 30 1000 par an entre75 et 79 ans

J Orthop Surg Res 2011 Aug 19643 doi 1011861749-799X-6-43 Kyphoplasty in osteoporotic vertebral compression fractures--guidelines and technical considerations Robinson Y Heyde CE Foumlrsth P Olerud C

Tassements en cascade

Cyphose

Cyphose reacutegionale laquo normale raquo

T11 9 deg

T12 7 deg

L1 1 deg

L2 - 8deg

L3 - 18 deg

L4 - 33 deg

L5 - 36 deg

bull Exple

ndash L2

ndash CR = 15deg

ndash ART = 15 ndash (-8) = 23 deg

Limites bull Classifications

ndash Reproductibiliteacute (A ou B ) asymp 05 laquo modeacutereacute raquo Woods 2005 JBJS

ndash Ligaments posteacuterieur bull Aspect IRM Augmente le Oner 2002 Eur Spine J

ndash Seuil de cyphose toleacuterable

ndash Que faire des A31 et 32

bull Autres facteurs de

deacutecision theacuterapeutique ndash Statut neurologique

ndash Poids

ndash Niveaux Charniegravere (TL)

Drsquoautres classifications hellip

Parker JW Lane JR Karaikovic EE et al

Successful short-segment instrumentation

and fusion for thoracolumbar spine fractures

a consecutive 4 12-year series Spine

2000251157ndash70

lt 7 posteacuterieur

gt 6 anteacuterieur

Load sharing TLISS

Vaccaro AR Zeiller SC Hulbert RJ et al The

thoracolumbar injury severity score A proposed

treatment algorithm J Spinal Disord Tech

200518209 ndash15

Principes techniques

bull Deacutecompression urgence = posteacuterieure ndash laminectomie

bull Stabilisation voie posteacuterieure

ndash Fixation interverteacutebrale

bull Symeacutetrique (1+1) ou (2+2) bull Avec ou sans greffe Percutaneacute AMO secondaire

ndash Chirurgie endoverteacutebrale

bull +- deacutecompression arthrodegravese anteacuterieure

compleacutementaire circonfeacuterentiel

Voie posteacuterieure installation

bull Deacutecubitus ventral

ndash Installation sur 4 billots

ndash Installation genu pectorale

ndash Installation sur la table orthopeacutedique

bull Attention particuliegravere

ndash Compression oculaire

ndash Compression abdominale (retour veineux)

Le plus souvent reacuteduction agrave lrsquoinstallation

Tile B2 Magerl B2

bull Leacutesions associeacutees

5

6

Fractures multieacutetageacutees

Vertebral Compression Fracture

15 agrave 30 1000 par an entre75 et 79 ans

J Orthop Surg Res 2011 Aug 19643 doi 1011861749-799X-6-43 Kyphoplasty in osteoporotic vertebral compression fractures--guidelines and technical considerations Robinson Y Heyde CE Foumlrsth P Olerud C

Tassements en cascade

Cyphose

Limites bull Classifications

ndash Reproductibiliteacute (A ou B ) asymp 05 laquo modeacutereacute raquo Woods 2005 JBJS

ndash Ligaments posteacuterieur bull Aspect IRM Augmente le Oner 2002 Eur Spine J

ndash Seuil de cyphose toleacuterable

ndash Que faire des A31 et 32

bull Autres facteurs de

deacutecision theacuterapeutique ndash Statut neurologique

ndash Poids

ndash Niveaux Charniegravere (TL)

Drsquoautres classifications hellip

Parker JW Lane JR Karaikovic EE et al

Successful short-segment instrumentation

and fusion for thoracolumbar spine fractures

a consecutive 4 12-year series Spine

2000251157ndash70

lt 7 posteacuterieur

gt 6 anteacuterieur

Load sharing TLISS

Vaccaro AR Zeiller SC Hulbert RJ et al The

thoracolumbar injury severity score A proposed

treatment algorithm J Spinal Disord Tech

200518209 ndash15

Principes techniques

bull Deacutecompression urgence = posteacuterieure ndash laminectomie

bull Stabilisation voie posteacuterieure

ndash Fixation interverteacutebrale

bull Symeacutetrique (1+1) ou (2+2) bull Avec ou sans greffe Percutaneacute AMO secondaire

ndash Chirurgie endoverteacutebrale

bull +- deacutecompression arthrodegravese anteacuterieure

compleacutementaire circonfeacuterentiel

Voie posteacuterieure installation

bull Deacutecubitus ventral

ndash Installation sur 4 billots

ndash Installation genu pectorale

ndash Installation sur la table orthopeacutedique

bull Attention particuliegravere

ndash Compression oculaire

ndash Compression abdominale (retour veineux)

Le plus souvent reacuteduction agrave lrsquoinstallation

Tile B2 Magerl B2

bull Leacutesions associeacutees

5

6

Fractures multieacutetageacutees

Vertebral Compression Fracture

15 agrave 30 1000 par an entre75 et 79 ans

J Orthop Surg Res 2011 Aug 19643 doi 1011861749-799X-6-43 Kyphoplasty in osteoporotic vertebral compression fractures--guidelines and technical considerations Robinson Y Heyde CE Foumlrsth P Olerud C

Tassements en cascade

Cyphose

Drsquoautres classifications hellip

Parker JW Lane JR Karaikovic EE et al

Successful short-segment instrumentation

and fusion for thoracolumbar spine fractures

a consecutive 4 12-year series Spine

2000251157ndash70

lt 7 posteacuterieur

gt 6 anteacuterieur

Load sharing TLISS

Vaccaro AR Zeiller SC Hulbert RJ et al The

thoracolumbar injury severity score A proposed

treatment algorithm J Spinal Disord Tech

200518209 ndash15

Principes techniques

bull Deacutecompression urgence = posteacuterieure ndash laminectomie

bull Stabilisation voie posteacuterieure

ndash Fixation interverteacutebrale

bull Symeacutetrique (1+1) ou (2+2) bull Avec ou sans greffe Percutaneacute AMO secondaire

ndash Chirurgie endoverteacutebrale

bull +- deacutecompression arthrodegravese anteacuterieure

compleacutementaire circonfeacuterentiel

Voie posteacuterieure installation

bull Deacutecubitus ventral

ndash Installation sur 4 billots

ndash Installation genu pectorale

ndash Installation sur la table orthopeacutedique

bull Attention particuliegravere

ndash Compression oculaire

ndash Compression abdominale (retour veineux)

Le plus souvent reacuteduction agrave lrsquoinstallation

Tile B2 Magerl B2

bull Leacutesions associeacutees

5

6

Fractures multieacutetageacutees

Vertebral Compression Fracture

15 agrave 30 1000 par an entre75 et 79 ans

J Orthop Surg Res 2011 Aug 19643 doi 1011861749-799X-6-43 Kyphoplasty in osteoporotic vertebral compression fractures--guidelines and technical considerations Robinson Y Heyde CE Foumlrsth P Olerud C

Tassements en cascade

Cyphose

Principes techniques

bull Deacutecompression urgence = posteacuterieure ndash laminectomie

bull Stabilisation voie posteacuterieure

ndash Fixation interverteacutebrale

bull Symeacutetrique (1+1) ou (2+2) bull Avec ou sans greffe Percutaneacute AMO secondaire

ndash Chirurgie endoverteacutebrale

bull +- deacutecompression arthrodegravese anteacuterieure

compleacutementaire circonfeacuterentiel

Voie posteacuterieure installation

bull Deacutecubitus ventral

ndash Installation sur 4 billots

ndash Installation genu pectorale

ndash Installation sur la table orthopeacutedique

bull Attention particuliegravere

ndash Compression oculaire

ndash Compression abdominale (retour veineux)

Le plus souvent reacuteduction agrave lrsquoinstallation

Tile B2 Magerl B2

bull Leacutesions associeacutees

5

6

Fractures multieacutetageacutees

Vertebral Compression Fracture

15 agrave 30 1000 par an entre75 et 79 ans

J Orthop Surg Res 2011 Aug 19643 doi 1011861749-799X-6-43 Kyphoplasty in osteoporotic vertebral compression fractures--guidelines and technical considerations Robinson Y Heyde CE Foumlrsth P Olerud C

Tassements en cascade

Cyphose

Voie posteacuterieure installation

bull Deacutecubitus ventral

ndash Installation sur 4 billots

ndash Installation genu pectorale

ndash Installation sur la table orthopeacutedique

bull Attention particuliegravere

ndash Compression oculaire

ndash Compression abdominale (retour veineux)

Le plus souvent reacuteduction agrave lrsquoinstallation

Tile B2 Magerl B2

bull Leacutesions associeacutees

5

6

Fractures multieacutetageacutees

Vertebral Compression Fracture

15 agrave 30 1000 par an entre75 et 79 ans

J Orthop Surg Res 2011 Aug 19643 doi 1011861749-799X-6-43 Kyphoplasty in osteoporotic vertebral compression fractures--guidelines and technical considerations Robinson Y Heyde CE Foumlrsth P Olerud C

Tassements en cascade

Cyphose

Le plus souvent reacuteduction agrave lrsquoinstallation

Tile B2 Magerl B2

bull Leacutesions associeacutees

5

6

Fractures multieacutetageacutees

Vertebral Compression Fracture

15 agrave 30 1000 par an entre75 et 79 ans

J Orthop Surg Res 2011 Aug 19643 doi 1011861749-799X-6-43 Kyphoplasty in osteoporotic vertebral compression fractures--guidelines and technical considerations Robinson Y Heyde CE Foumlrsth P Olerud C

Tassements en cascade

Cyphose

Tile B2 Magerl B2

bull Leacutesions associeacutees

5

6

Fractures multieacutetageacutees

Vertebral Compression Fracture

15 agrave 30 1000 par an entre75 et 79 ans

J Orthop Surg Res 2011 Aug 19643 doi 1011861749-799X-6-43 Kyphoplasty in osteoporotic vertebral compression fractures--guidelines and technical considerations Robinson Y Heyde CE Foumlrsth P Olerud C

Tassements en cascade

Cyphose

5

6

Fractures multieacutetageacutees

Vertebral Compression Fracture

15 agrave 30 1000 par an entre75 et 79 ans

J Orthop Surg Res 2011 Aug 19643 doi 1011861749-799X-6-43 Kyphoplasty in osteoporotic vertebral compression fractures--guidelines and technical considerations Robinson Y Heyde CE Foumlrsth P Olerud C

Tassements en cascade

Cyphose

Fractures multieacutetageacutees

Vertebral Compression Fracture

15 agrave 30 1000 par an entre75 et 79 ans

J Orthop Surg Res 2011 Aug 19643 doi 1011861749-799X-6-43 Kyphoplasty in osteoporotic vertebral compression fractures--guidelines and technical considerations Robinson Y Heyde CE Foumlrsth P Olerud C

Tassements en cascade

Cyphose

Vertebral Compression Fracture

15 agrave 30 1000 par an entre75 et 79 ans

J Orthop Surg Res 2011 Aug 19643 doi 1011861749-799X-6-43 Kyphoplasty in osteoporotic vertebral compression fractures--guidelines and technical considerations Robinson Y Heyde CE Foumlrsth P Olerud C

Tassements en cascade

Cyphose

Inteacuterecircts

bull Sortie preacutecoce

bull Sans contention

bull Evitement du glissement

bull Eacutevitement du deacuteconditionnement musculaire

Inconveacutenients

bull Anestheacutesie

bull Ciment ndash Fuite locale

ndash Extravasation voie geacutenerale

Vertebroplastie solidification laquo en place raquo Kyphoplastie restauration de hauteur ballons stent

Fractures plus seacutevegraveres Possibiliteacute drsquoinstrumentation compleacutementaire Possibiliteacute de deacutecompression si fuite de ciment

Proceacutedure peacutediculaire percutaneacutee

Vertebroplastie solidification laquo en place raquo Kyphoplastie restauration de hauteur ballons stent

Fractures plus seacutevegraveres Possibiliteacute drsquoinstrumentation compleacutementaire Possibiliteacute de deacutecompression si fuite de ciment

Proceacutedure peacutediculaire percutaneacutee

Fractures plus seacutevegraveres Possibiliteacute drsquoinstrumentation compleacutementaire Possibiliteacute de deacutecompression si fuite de ciment

Proceacutedure peacutediculaire percutaneacutee

Proceacutedure peacutediculaire percutaneacutee