COMPLEX THORACIC INJURIES Avelino Parajn Servicio de Neurociruga

COMPLEX THORACIC INJURIES Avelino Parajón Servicio de Neurocirugía Hospital Universitario Puerta de Hierro Majadahonda, Madrid

• THORACIC SPINE – T 1 -T 10 • THORACOLUMBAR SPINE – T 11 -L 2 • LUMBAR SPINE – L 3 -L 5

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 S 4/5 DISTRIBUTION • INCOMPLETE – PRESERVATION OF SENSATION IN S 4/5 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 • Mc. CORMACK, 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+ A 1 (wedge) – C. 1. 2 ROTATIO+ A 2 (section) – C. 1. 3. ROTATION+ A 3 (burst) • C. 2 ROTATION + B – C. 2. 1 ROTATION+ B 1 – C. 2. 2 ROTATION + B 2 – C. 2. 3 A ROTATION+ B 3 • C. 3. ROTATION + SHEARING – C. 3. 1. slice shearing – C. 3. 2. oblique shearing

Mc. CORMACK “LOAD SHARING CLASSIFICATION” • COMMINUTION • APPOSITION OF FRAGMENTS • KYPHOTIC DEFORMITY

Mc. CORMACK “LOAD SHARING CLASSIFICATION”

Mc. CORMACK “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

THORACOLUMBAR FRACTURES 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

ANTERIOR APPROACH INDICATIONS • 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 FLEXIONDISTRACTION

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 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 SF 36 NO DIF RETURN TO WORK 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 (T 10 -L 4) AO A TYPE (EXCLUDED A 1. 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 • A 3 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 T 12 -L 3 RIGHT SIDE T 6 -T 11

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 T 12 AO A 3

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 70

5. Outcome • 3 mos. : – – No pain No neuro deficit Return to normal life Return to work 71