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- Anterior = ALL + Anterior 2/3 VB
- Middle = Posterior 1/3 + PLL
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- 10-20% risk of contiguous injuries
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- Yes
- epidural hematoma
- 10% non-contiguous cervical spine fracture (Katsura et al. J. Ortho 2016)
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- Looking at 3 components - morphology, neurology, PLC involvement; total is 10
- Neurology - note that complete cord lower score
- Morphology - distraction worse than translation
- < 4 non op; 4 indeterminate; > 4 surgical
- Chance fracture at least 4 + 3 = 7 even without neurology
- Burst fracture with PLC involvement 2 + 3 = 5 even without neurology
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- A = compression and burst
- B = tension band (chance)
- C = Translational
OSTEOPOROTIC COMPRESSION FRACTURES
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- Need TRO pathological causes before labelling as osteoporotic
- FBC, ESR, CRP
- KIV urine and serum electrophoresis for multiple myeloma
- MRI usually not necessary unless TRO tumor
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- No consensus on optimal management. Multiple RCT on Lancet and NEJM shows conflicting results on the efficacy of cementoplasty.
- UK NICE Guidelines 2013 simply recommends cementoplasty for patients who meets 3 criteria
- “severe pain” after
- “recent” unhealed VB fracture AND
- pain confirmed at the level with imaging.
- No mention of duration
- Thus, I will guide my treatment based on review by Sahota et al. in Injury
- I will trial non op for 6 weeks
- If improving ➔ continue non op
- If not ➔ MRI ➔ if presence of unhealed feature with bone edema ➔ consider Cementoplasty
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- Very Heterogenous results
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- Rachelle buchbinder NEJM AUSTRALIAN RCT 2009. Pain < 12 months MRI bone edema. VP no difference from placebo.
- David Kallmes et al. NEJM INVEST RCT 2009. Pain < 12 months. VP no difference from placebo
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- William Clark et al. The Lancet VAPOUR RCT Trial - painful < 6 weeks. VP superior to placebo
- Caroline Klazen et al. The Lancet VERTOS RCT Trial - pain < 6 weeks. VP superior to placebo
- VERTOS 4 trial BMJ 2018 - most recent trial
- No difference vertebroplasty vs Sham
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- Aware of the heterogenous results in literature
- Based on UK nice guidelines in 2013, 3 criteria can be used to decide to treat with cementoplasty
- “severe pain” after
- “recent” unhealed VB fracture AND
- pain confirmed at the level with imaging.
- However, no guidelines on duration is given
- Aware of the highly heterogenous results published in NEJM and Lancet recently
- Most recent VERTOS 4 trial published in BMJ. RCT of 180 patients with median 6 weeks of back pain
- Vertebroplasty vs sham with subcutaneous lidocaine
- No difference at 1 month vs 12 months
- In my hands, I will treat with analgesia, PT, kIV bracing for comfort. if after 6 weeks persistent pain will consider vertebroplasty as per UK NICE guidelines
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- Sudden progression of compression to burst fracture in setting of severe osteoporosis [senile burst fracture]
- Mx = Transpedicular decompression with posterior stabilization by a screw-rod construct offers a good chance for neurological improvement, simultaneously correcting the kyphotic deformity at the affected spinal level fairly well.
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- 2 proposed MOI:
- improved biomechanics with cement;
- exothermic effects can kill nerve endings, reducing pain
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- KP = + balloon first to create void and thus potential for reduction
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- Location: Inject cement not too far posterior
- Volume = 13-16% VB volume. As most VB is 30mls, that will be about 4mls.
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- Cement leakage
- Adjacent segment fracture
- Pneumothorax
BURST FRACTURES
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- Widening of pedlcles, retropulsion, kyphotic deformity
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- Deficit is related to initial injury
- Neurology is proportionate to the maximum canal occlusion and neural compression at the moment of impact
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- Dural injury
- Predictors of dural injury are the presence of laminar fractures, extent of burst (interpedicular distance) and size of retropulsed segment
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- Can be treated non operatively
- Several studies show 75% to 100% neurological recovery for radicular symptoms based on review by So Kato et al. 2017 JOT.
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- Controversial. Theoretically can prevent deformity and kyphosis
- Wallace et al. JBJS meta-analysis of RCTS 2019. Similar clinical and radiological outcomes with or without bracing at long term f/u of 5 years for STABLE burst fractures without neurology.
Burse Fracture bracing.pdf1442.5KB
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- T8-L4 = TLSO
- T10-L2 (junctional) = Jewett Brace with 3 point fixation
- T1-T7 = TLSO + Cervical spine extension
- L5-S1 = TLSO + leg extension
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- Decompression can be direct or indirect
- Direct = removal of fragments
- Indirect = by ligamentotaxis by restoring VB height
- Fixation or Fusion with Modern pedicle screws allow 2 level above 2 level below under distraction to restore vertebral height
- Naresh does 1 level up and 1 level down
- Plan for ROI in 1-2 years
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- Classifx by comminution = McCormack-Gaines LOAD SHARING Classifx (LSC) - 1994
- 3 components - Extent of comminution, Apposition of fragments, Reducibility
- Principle is that in high score, no load sharing ➔ high cantilever bending loads on posterior fixation
- > 7 points may require anterior approach with vertebrectomy + strut grafting
- < 7 posterior approach w screw and rods sufficient
- However, many recent studies show that with new pedicle screws, Short-segment posterior instrumentation is sufficient to treat burst fracture REGARDLESS of LSC
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- No difference
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- Controversial.
- Traditionally, long segment fusion advocated to reduce risk of kyphosis.
- However, recent studies find short segment fusion with modern pedicle screws and rods to be equally effective
- Meta-analysis by Tarek et al. Asian Spine Journal 2017.
- 9 trials, 365 patients
- No difference in radiological outcome, functional outcome, neurologic improvement or implant failure rate.
- In my hands I will do long segment fusion
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- Traditionally, arthrodesis is done to promote final biological stabilization, and to theoretically reduce the incidence of reccurrent kyphosis
- But Require bone grafting ➔ longer op, higher morbidity
- Jindal et al. JBJS August 2012 - RCT of 50 patients. Fusion vs non fusion. Fusion was via decortication of posterior elements and bone grafting for ICBG. Not interbody fusion.
- Blood transfusion requirements, Duration of surgery higher in fusion
- No clinical or radiological difference in outcomes between groups
- On the other hand, fixation and subsequently implant removal hopes to maintain mobility of the spine to prevent adjacent segment disease in the future
Jindal\.pdf812.0KB
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- Controversial; not necessary but risk of screw breakage
- Chou et al. JBJS retrospective analysis of 69 patients; follow up of 5 years.
- Radiological and functional outcomes of both implant removal and retention is similar.
- 1/3 of patients had screw breakage
Unnamed
CHANCE FRACTURE
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- It is a 3 column injury with FULCRUM AT Anterior Longitudinal ligament
- It can be bony chance which have better healing OR ligamentous chance
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- GIT injury in 50%
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- Short (single level up and down) vs long segment (2 levels up and down) remains controversial. Most authors recommend Long segment fixation
- However, some advocate single level fixation to preserve spinal motion even in type B, CHANCE fractures.
- Modifications to short segment fixation has also been described such as screws through the level of the fracture.
- Opn vs MIS?
- No difference in kyphotic deformity
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- Some surgeons treat bony chance fractures conservatively with immobilisation in a thoracolumbosacral orthosis in an extension position with 2-week follow-up for non-union and degree of kyphosis deformity.
- However, I will base my treatment on the TLICS score, and it is considered and unstable injury