- Email: [email protected]
Saturday, November 2, 2001 1:30–2:13 pm Concurrent Session 5B: Trauma
Proceedings of the NASS 17th Annual Meeting / The Spine Journal 2 (2002) 47S–128S Disclosures: No disclosures. Conflict of interest: No conflicts. PII: S1529-9430(02)00341-8
Saturday, November 2, 2001 1:30–2:13 pm Concurrent Session 5B: Trauma 1:30 Short-segment pedicle instrumentation for thoracolumbar fractures with pedicle screws in the injured vertebra Hani Mhaidli, MD1, Arturo Montesdeoca, MD1, Jose Agusto Lorenzo, MD1; 1 Hospital Universitario Gran Canaria, Las Palmas, Spain Purpose of study: To evaluate effectiveness of the short-segment pedicle fixation construct for the treatment of burst thoracolumbar fractures with a pedicle screw inserted in the fractured vertebra. The relationship between the pedicle screw and the bone fragments in the canal are analyzed both before and after pedicle screw insertion in the fractured vertebra with computed tomography (CT) scan. Methods used: Subjects were 34 patients with burst thoracolumbar fractures: 24 men and 10 women. The average age was 34 years. The most common level of fracture was L1. The average spinal canal occupation was 50%. There was no neurological deficit. The surgical procedure was a posterior approach using two pedicle screws in the fractured vertebra; two pedicle screws in the cephalad and two with pedicle-laminar claw one level caudad to the fracture. The instrumentation used is CD titanium CT scans before surgery and immediately after surgery and 6 months after surgery. Minimum follow-up was 36 months. Summary of findings: The vertebra height was corrected and maintained in the last follow-up in all cases. The occupation of the spinal canal remained the same or improved in all cases, and there were no neurological or vascular injuries resulting from the placement of pedicle screws. There was no hardware failure and no reoperations. Bone fusion occurred in all cases. Relationship between findings and existing knowledge: The major concern is the early and late failures described in all short-segment pedicle screw instrumentation studies. However, all avoided pedicle screws in the fractured vertebra. This construct overcomes the hardware failure and loss of correction. Overall significance of findings: Our results suggest that short-segment pedicle screw instrumentation with pedicle screws in the injured vertebra is safe and effective for the treatment of burst thoracolumbar fractures without neurological deficit. Using the intermediate screw and distal pedicle-laminar claw overcomes hardware failure of the instrumentation. Disclosures: Device or drug: CD. Status: approved. Conflict of interest: No conflicts. PII: S1529-9430(02)00342-X
1:36 Thoracoscopic treatment of 371 thoracic and lumbar fractures Larry Khoo, MD1, Rudolf Beisse, MD2, Potulski Michael, MD2, Richard Fessler, MD,PhD3; 1University of Southern California, Pasadena, CA, USA; 2Berufsgenossenschaftliche Unfallklinik Murnau, Murnau, Bavaria, Germany; 3Chicago Institute of Neurosurgery and Neuroresearch, Chicago, IL, USA Purpose of study: Conventional approaches for the treatment of thoracic and thoracolumbar fractures require extensive surgical exposure, often leading to significant postoperative pain and morbidity. Thoracoscopic spinal surgery was introduced to reduce the morbidity of these approaches while still achieving the primary goals of spinal decompression, reconstruction and
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stabilization. The purpose of this study was to summarize our experience with the thoracoscopic treatment of 371 consecutive cases of thoracic and lumbar fractures. Methods used: Between May 1996 and May 2001, 371 patients with fractures of the thoracic and thoracolumbar spine (T3–L3) were treated with a thoracoscopically assisted procedure. Case records and radiographs were reviewed. All phases of the procedure, including discectomy, vertebrectomy, grafting and instrumentation, were accomplished through this minimally invasive technique. Summary of findings: Seventy-three percent of the fractures were located at the thoracolumbar junction. In 49% of cases, mobilization of the diaphragm was performed to expose the fracture with subsequent repair. Both radiographic canal compromise with neural deficit was present in 15% of patients. In 35% of cases, a stand-alone anterior thoracoscopic reconstruction was performed. For cases of greater instability, this was supplemented with a posterior pedicle-screw construct in 65% of patients. A steep learning curve was present with an average operating room time of 300 minutes in the first 50% of cases and a recent average of 180 minutes with use of the MACS-TL system. The severe complication rate was low (1.3%) with one case each of aortic injury, splenic contusion, neurological deterioration, cerebrospinal fluid leak and severe wound infection. Compared with a group of 30 patients treated with open thoracotomy, thoracoscopically treated patients used 42% less narcotics in the postoperative period. Relationship between findings and existing knowledge: Compared with the reported rates of complications and morbidity for open thoracotomy in the literature, our results are on par with, if not lower than, the published data. Overall significance of findings: A complete anterior thoracoscopically assisted reconstruction of thoracic and thoracolumbar fractures can be safely and effectively accomplished, thereby reducing the pain and morbidity associated with conventional thoracotomy and thoracolumbar approaches. Although a steep learning curve is present, the functional and cosmetic benefits to the patient warrant the difficult training process. Disclosures: Device or drug: MACS-TL plating system. Status: approved. Conflict of interest: Larry Khoo, grant research support. PII: S1529-9430(02)00343-1
1:42 Thorascopic transdiaphragmatic decompression and stabilization of thoracolumbar fractures: 220 cases from two institutions Daniel Kim, MD1, Tae-Ahn Jahng, MD2, Michael Potulski, MD3, I-Chun Wang 1, Rudolf Beisse 3; 1Stanford University, Stanford, CA; 2Wonkwang University, Iksan, South Korea; 3Murnau, Germany Purpose of study: Conventional thoracoabdominal surgical approach for thoracolumbar junction fractures requires extensive exposures and diaphragm splitting, which can cause significant associated morbidity. With recent developments in endoscopic instruments (MACS-tl, Aesculap) and technique, minimally invasive stabilization of thoracolumbar junction fractures (T11–L2) using thoracoscopic approach has developed. Methods used: Over past 5 years (1996–2001), 420 patients were managed with thoracoscopic-assisted stabilization with or without decompression. Of those patients with thoracolumbar junction fractures, 220 required thoracoscopic diaphragm detachment to achieve access for decompression and instrumentation. Restrospective analysis was done with clinical chart and radiologic studies of thoracoscopic-assisted stabilization. Clinical presentation, operative detail, complications and postoperative course were analyzed. Summary of findings: Most were type A injury (61%) according to AO classification. Average operative time was 172 minutes for thoracoscopic anterior operation. Sixty-five percent of patients required combined posterior stabilization. Average hospitalization was less than 1 week after operation. Access-related complications occurred in 5.4%, and infection was noted 1.8%. No hernia or relaxation of the diaphragm has been recorded. One transient injury of the L1 root occurred during thoracoscopic detach-
Saturday, November 2, 2001 1:30–2:13 pm Concurrent Session 5B: Trauma 1:30 Short-segment pedicle instrumentation for thoracolumbar fractures with pedicle screws in the injured vertebra Hani Mhaidli, MD1, Arturo Montesdeoca, MD1, Jose Agusto Lorenzo, MD1; 1 Hospital Universitario Gran Canaria, Las Palmas, Spain Purpose of study: To evaluate effectiveness of the short-segment pedicle fixation construct for the treatment of burst thoracolumbar fractures with a pedicle screw inserted in the fractured vertebra. The relationship between the pedicle screw and the bone fragments in the canal are analyzed both before and after pedicle screw insertion in the fractured vertebra with computed tomography (CT) scan. Methods used: Subjects were 34 patients with burst thoracolumbar fractures: 24 men and 10 women. The average age was 34 years. The most common level of fracture was L1. The average spinal canal occupation was 50%. There was no neurological deficit. The surgical procedure was a posterior approach using two pedicle screws in the fractured vertebra; two pedicle screws in the cephalad and two with pedicle-laminar claw one level caudad to the fracture. The instrumentation used is CD titanium CT scans before surgery and immediately after surgery and 6 months after surgery. Minimum follow-up was 36 months. Summary of findings: The vertebra height was corrected and maintained in the last follow-up in all cases. The occupation of the spinal canal remained the same or improved in all cases, and there were no neurological or vascular injuries resulting from the placement of pedicle screws. There was no hardware failure and no reoperations. Bone fusion occurred in all cases. Relationship between findings and existing knowledge: The major concern is the early and late failures described in all short-segment pedicle screw instrumentation studies. However, all avoided pedicle screws in the fractured vertebra. This construct overcomes the hardware failure and loss of correction. Overall significance of findings: Our results suggest that short-segment pedicle screw instrumentation with pedicle screws in the injured vertebra is safe and effective for the treatment of burst thoracolumbar fractures without neurological deficit. Using the intermediate screw and distal pedicle-laminar claw overcomes hardware failure of the instrumentation. Disclosures: Device or drug: CD. Status: approved. Conflict of interest: No conflicts. PII: S1529-9430(02)00342-X
1:36 Thoracoscopic treatment of 371 thoracic and lumbar fractures Larry Khoo, MD1, Rudolf Beisse, MD2, Potulski Michael, MD2, Richard Fessler, MD,PhD3; 1University of Southern California, Pasadena, CA, USA; 2Berufsgenossenschaftliche Unfallklinik Murnau, Murnau, Bavaria, Germany; 3Chicago Institute of Neurosurgery and Neuroresearch, Chicago, IL, USA Purpose of study: Conventional approaches for the treatment of thoracic and thoracolumbar fractures require extensive surgical exposure, often leading to significant postoperative pain and morbidity. Thoracoscopic spinal surgery was introduced to reduce the morbidity of these approaches while still achieving the primary goals of spinal decompression, reconstruction and
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stabilization. The purpose of this study was to summarize our experience with the thoracoscopic treatment of 371 consecutive cases of thoracic and lumbar fractures. Methods used: Between May 1996 and May 2001, 371 patients with fractures of the thoracic and thoracolumbar spine (T3–L3) were treated with a thoracoscopically assisted procedure. Case records and radiographs were reviewed. All phases of the procedure, including discectomy, vertebrectomy, grafting and instrumentation, were accomplished through this minimally invasive technique. Summary of findings: Seventy-three percent of the fractures were located at the thoracolumbar junction. In 49% of cases, mobilization of the diaphragm was performed to expose the fracture with subsequent repair. Both radiographic canal compromise with neural deficit was present in 15% of patients. In 35% of cases, a stand-alone anterior thoracoscopic reconstruction was performed. For cases of greater instability, this was supplemented with a posterior pedicle-screw construct in 65% of patients. A steep learning curve was present with an average operating room time of 300 minutes in the first 50% of cases and a recent average of 180 minutes with use of the MACS-TL system. The severe complication rate was low (1.3%) with one case each of aortic injury, splenic contusion, neurological deterioration, cerebrospinal fluid leak and severe wound infection. Compared with a group of 30 patients treated with open thoracotomy, thoracoscopically treated patients used 42% less narcotics in the postoperative period. Relationship between findings and existing knowledge: Compared with the reported rates of complications and morbidity for open thoracotomy in the literature, our results are on par with, if not lower than, the published data. Overall significance of findings: A complete anterior thoracoscopically assisted reconstruction of thoracic and thoracolumbar fractures can be safely and effectively accomplished, thereby reducing the pain and morbidity associated with conventional thoracotomy and thoracolumbar approaches. Although a steep learning curve is present, the functional and cosmetic benefits to the patient warrant the difficult training process. Disclosures: Device or drug: MACS-TL plating system. Status: approved. Conflict of interest: Larry Khoo, grant research support. PII: S1529-9430(02)00343-1
1:42 Thorascopic transdiaphragmatic decompression and stabilization of thoracolumbar fractures: 220 cases from two institutions Daniel Kim, MD1, Tae-Ahn Jahng, MD2, Michael Potulski, MD3, I-Chun Wang 1, Rudolf Beisse 3; 1Stanford University, Stanford, CA; 2Wonkwang University, Iksan, South Korea; 3Murnau, Germany Purpose of study: Conventional thoracoabdominal surgical approach for thoracolumbar junction fractures requires extensive exposures and diaphragm splitting, which can cause significant associated morbidity. With recent developments in endoscopic instruments (MACS-tl, Aesculap) and technique, minimally invasive stabilization of thoracolumbar junction fractures (T11–L2) using thoracoscopic approach has developed. Methods used: Over past 5 years (1996–2001), 420 patients were managed with thoracoscopic-assisted stabilization with or without decompression. Of those patients with thoracolumbar junction fractures, 220 required thoracoscopic diaphragm detachment to achieve access for decompression and instrumentation. Restrospective analysis was done with clinical chart and radiologic studies of thoracoscopic-assisted stabilization. Clinical presentation, operative detail, complications and postoperative course were analyzed. Summary of findings: Most were type A injury (61%) according to AO classification. Average operative time was 172 minutes for thoracoscopic anterior operation. Sixty-five percent of patients required combined posterior stabilization. Average hospitalization was less than 1 week after operation. Access-related complications occurred in 5.4%, and infection was noted 1.8%. No hernia or relaxation of the diaphragm has been recorded. One transient injury of the L1 root occurred during thoracoscopic detach-