When to Operate on a Neurologically Intact Burst Fracture Gregory - - PowerPoint PPT Presentation

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When to Operate on a Neurologically Intact Burst Fracture Gregory - - PowerPoint PPT Presentation

Oct 03, 2023 586 likes •1.01k views

When to Operate on a Neurologically Intact Burst Fracture Gregory D. Schroeder, MD Assistant Professor, Orthopaedic Surgery The Rothman Institute at Thomas Jefferson University Disclosures Consult for Advance Medical and Zimmer Biomet

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SLIDE 1

Gregory D. Schroeder, MD Assistant Professor, Orthopaedic Surgery The Rothman Institute at Thomas Jefferson University

When to Operate on a Neurologically Intact Burst Fracture

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SLIDE 2

Disclosures

– Consult for Advance Medical and Zimmer Biomet – Grants from OREF, Medtronic – Research support and travel payment from AOSpine – Executive editor CSS

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SLIDE 3

A3/A4 Fracutres

  • Compression type fractures account for 60% of

thoracolumbar fractures

  • No universally accepted classification  disagreement

about the ideal treatment

  • Vaccaro. 2013. Spine; Denis. 1983. Spine; Gertzbein. Spine. 1992; Magerl. ESJ. 1994
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SLIDE 4

Classifications

  • Denis. Spine. 1983
  • Divided the spine into an anterior, middle

and posterior column

  • Anterior- ALL , anterior 2/3 body
  • Middle - post 1/3 body, PLL
  • Posterior- all structures posterior to

PLL

  • Any fracture involving the middle column

is unstable

  • All burst fractures unstable

1 2 3

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SLIDE 5

Classifications

  • Magerl. ESJ. 1994
  • Did not change the treatment of burst fractures
  • Did not alter the perceived importance of the

middle column of the spine for stability

  • 53 Subtypes
  • Comprehensive, but its complexity has limited

its routine use in clinical practice

  • Kappa = 0.31 (slight agreement) with CT
  • Oner. ESJ. 2002
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SLIDE 6

Classifications

  • TLICS. Vaccaro. Spine 2005
  • 1st major classification to repudiate the assertion by

Denis that all burst fractures are unstable

  • Only stable if PLC intact
  • Surgeons unable to agree if PLC intact
  • Schroeder. Global Spine Journal. 2015
  • Kappa = 0.11 (slight agreement) for

compression type fractures

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SLIDE 7

AOSpine Thoracolumbar Injury Classification System

  • Vaccaro. Spine 2013
  • AOSpine thoracolumbar spine injury classification

system: fracture description, neurological status, and key modifiers.

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SLIDE 8

AOSpine Thoracolumbar Injury Classification System

AOSpine Thoracolumbar Injury Classification System Morphology

A--Com pression I njuries A0 No injury/ process fracture A1 Wedge / Impaction fracture A2 Split / Pincer Injury A3 Incomplete burst A4 Complete burst fracture B--Tension band injuries B1 Transosseous disruption (Bony Chance Fx) B2 Posterior ligamentous disruption B3 Anterior ligamentous disruption C--Translational injury

  • Vaccaro. 2013. Spine
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SLIDE 9

AOSpine Thoracolumbar Injury Classification System

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SLIDE 10

AOSpine Thoracolumbar Injury Classification System

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SLIDE 11

AOSpine Thoracolumbar Injury Classification System

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AOTL Surgical Algorithm

  • Vaccaro and Schroeder. ESJ. 2016
  • Survey of all AOSpine members on the treatment of

fractures with a controversial treatment

– A2N0M0 – Every controversial iteration of A3 & A4 – Every controversial iteration of B1 & B2

  • Fractures that were not controversial, such as all C

type fractures or fractures with an incomplete spinal cord injury were excluded

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SLIDE 13

AOTL Surgical Algorithm

Europe (% ) Asia (% ) South America (% ) Middle East (% ) North America (% ) Africa (% ) Global (% ) P Value TL AOSI S A2N0 24 (13.8) 7 (7.5) 20 (17.2) 4 (8.9) 0 (0.0) 1 (6.3) 56 (11.6) 0.02† 2 A3N0M0 22 (12.6) 14 (15.1) 17 (14.7) 3 (6.7) 0 (0.0) 1 (6.3) 57 (11.8) 0.07 3 A3N0M1 117 (67.2) 57 (61.3) 77 (66.4) 31 (68.9) 16 (41.0) 11 (68.8) 309 (64.0) 0.06 4 A3N1M0 74 (42.5) 27 (29.0) 59 (50.9) 14 (31.1) 2 (5.1) 4 (25.0) 180 (37.3) 0.0001† 4 A3N1M1 146 (83.9) 78 (83.9) 99 (85.3) 35 (77.8) 21 (53.8) 12 (75.0) 391 (81.0) 0.002† 5 A3N2M0 130 (74.7) 54 (58.1) 95 (81.9) 27 (60.0) 10 (25.6) 12 (75.0) 328 (67.9) 0.0001† 5 A3N2M1 154 (88.5) 79 (84.9) 113 (97.4) 40 (88.9) 31 (79.5) 14 (87.5) 431 (89.2) 0.005† 6

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AOTL Surgical Algorithm

Europe (% ) Asia (% ) South America (% ) Middle East (% ) North America (% ) Africa (% ) Global (% ) P Value TL AOSI S A4N0M0 80 (46.0) 26 (28.0) 60 (51.7) 18 (40.0) 0 (0.0) 6 (37.5) 190 (39.3) 0.0001* † 5 A4N0M1 142 (81.6) 60 (64.5) 95 (81.9) 36 (80.0) 19 (48.7) 7 (43.8) 359 (74.3) 0.0001* † 6 A4N1M0 108 (62.1) 56 (60.2) 81 (69.8) 27 (60.0) 7 (17.9) 10 (62.5) 289 (59.8) 0.0001* † 6 A4N1M1 144 (82.8) 72 (77.4) 104 (89.7) 37 (82.2) 23 (59.0) 14 (87.5) 394 (81.6) 0.002† 7 A4N2M0 137 (78.7) 61 (65.6) 98 (84.5 ) 33 (73.3) 14 (35.9) 14 (87.5) 357 (73.9) 0.0001† 7 A4N2M1 163 (93.7) 81 (87.1) 111 (95.7) 42 (93.3) 35 (89.7) 15 (93.8) 447 (92.5) 0.25 8

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SLIDE 15
  • What does the scientific literature say?
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Prospective Randomized Studies

Shen et al Wood et al Siebenga et al Non-Operative Operative Non-Operative Operative Non-Operative Operative Final Focal Kyphosis 24° 12° 13.8° 13° 19.5°* 8.4°* Final VAS 1.5 1.8 1.9 3.3 2.8* 1.3* Return to Work 86% 90% 74% 42% 38%* 85%* Complications 0% 12% 9%* 79%* 20% 29% Cost 1/4 the cost of surgery* 4x more expensive than conservative care* $11,264* $49,063* Not Recorded Not Recorded Functional Outcomes Greenough low back score

2

65 61

  • SF-36 Phys

Function

2

  • 86*

63*

  • RMDQ-24

disability score for LBP

1

  • 8 9*

3 1*

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Prospective Randomized Studies

  • Wood. JBJS. 2015
  • 47 consecutive patients
  • Long-term follow up
  • Average of eighteen years (range, sixteen to twenty-two

years)

  • Kyphosis
  • 13°—operative treatment; 19°—nonoperative (p >

0.05)

  • VAS Back
  • 4.0—operative treatment; 1.5—nonoperative (p < 0.001)
  • ODI
  • 20—operative treatment; 2—nonoperative (p < 0.001)
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SLIDE 18

Prospective Randomized Studies

  • Abudou. Cochrane Database Syst Rev. 2013
  • Uses only prospective randomized trials
  • There is not enough data to determine if operative or

nonoperative treatment leads to superior clinical outcomes

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A3/A4

  • Avilés. Medwave. 2016 (Spain)
  • Meta-analysis.
  • Operative treatment may decrease the risk of neurologic

impairment, but in turn, could increase the risk of general complications.

  • Unclear
  • Differences in pain reduction,
  • Improvement in function and quality of life,
  • Need for subsequent surgery
  • Radiographic progression of kyphosis in both groups.
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SLIDE 20

The Use of a Brace

  • Bailey. The Spine Journal. 2013 (CANADA)
  • 110 patients with a thoracolumbar burst fracture who were

treated non-operatively either with or without a brace

  • No difference in Roland Morris Disability Questionnaire

score three months after the fracture regardless of treatment

  • Urquhart. JNS Spine. 2017
  • Long term follow up (average 7.9 years) on 36 patients from

above study

  • 16 TLSO, 20 no TLSO
  • No difference in HRQOL or kyphosis
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Operative Treatment

  • Reinhold. ESJ. 2010 (GERMANY)
  • Operative treatment of 424 compression type fractures
  • All operative. Not even a nonoperative cohort
  • Posterior only procedure  improved functional and

subjective outcomes

  • A combined anterior/posterior approach  best

radiographic results

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Operative Treatment

  • Schnake. JNS Spine. 2014

(GERMANY)

  • 5 year follow up of 45

patients with a combined AP surgery

  • Average loss of lordosis of
  • nly 2.4°
  • 96% of patients were

ambulatory

  • 71% required no pain

medications

  • 67% were back at work
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SLIDE 23

Operative Treatment

  • Spiegl. Eur J Trauma Emerg Surg. 2017 (GERMANY)
  • Review article that concludes
  • “A 360°-stabilization in osteoporotic vertebral

fractures of the thoracolumbar spine is indicated in patients with acute or subacute fracture situation and relevant lesion of the posterior cortex, and in patients with severe kyphotic malalignment (>20°)”

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SLIDE 24

MIS

  • What about MIS???
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Operative Treatment

  • Li. International Journal of Surgery. 2016
  • Retrospective review of 37 patients with MIS

stabilization and vertebroplasty for a burst fracture

  • Average follow up of 27.54 ± 2.47 months
  • VAS 9  2
  • No hardware failure or complications
  • Alignment
  • Kyphosis 22.58 ± 1.70° before surgery
  • 4.11 ± 1.41° immediately after surgery
  • 5.06 ± 1.11° at 2-year follow-up.
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Operative Treatment

  • Proietti. Orthopaedics & Traumatology: Surgery &
  • Research. 2014
  • Retrospective review of 63 patients with MIS

stabilization for a burst fracture

  • Average operative blood loss was 82 mL
  • Mean pre-operative segmental kyphosis was was

13.3

  • Postoperateive Kyphosis 5.0
  • Not statistically significant correction loss was

registered at 1-year minimum follow-up.

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Operative Treatment

  • Proietti. Orthopaedics & Traumatology: Surgery &
  • Research. 2014
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SLIDE 28

Operative Treatment

  • Proietti. Orthopaedics & Traumatology: Surgery &
  • Research. 2014
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Operative Treatment

  • Takami. Eur J Orthop Surg Traumatol. 2014
  • Retrospective review of 21 patients with MIS stabilization

and cement augmentation for a burst fracture

  • OR time was 95.7 min
  • Average blood loss was 38.6 mL
  • Average correction angle was 9.6.
  • No surgical complications
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Operative Treatment

  • Landi. ESJ. 2014
  • Retrospective review of 50 patients treated non-
  • peratively or with MIS stabilization
  • Magerl type A.3 (Burst fracture)
  • Single level
  • McCormack score had to be 6 or less
  • Spinal canal invasion had to be 25 %
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Operative Treatment

  • Landi. ESJ. 2014
  • Retrospective review of 50 patients treated non-
  • peratively or with MIS stabilization
  • Surgery—80 minutes, 10 cc blood loss
  • No complications
  • No difference in alignment
  • The amount of time necessary for a full return to

normal daily activities

  • 31 days in surgically treated patients
  • 87.1 days in those treated conservatively
  • P ?
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Operative Treatment

  • Landi. ESJ. 2014
  • Retrospective review of 50 patients treated non-
  • peratively or with MIS stabilization
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SLIDE 33

Operative Treatment

  • Landi. ESJ. 2014
  • Retrospective review of 50 patients treated non-
  • peratively or with MIS stabilization
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Operative Treatment

  • Kumar. SpringerPlus. 2015
  • The management of thoracolumbar burst fractures: a

prospective study between conservative management, traditional open spinal surgery and minimally interventional spinal surgery

  • Prospectively study evaluated “single thoracolumbar

fracture with > 20 degrees of kyphosis”

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Operative Treatment

  • Kumar. SpringerPlus. 2015
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Operative Treatment

  • Kumar. SpringerPlus. 2015
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Operative Treatment

  • McAnany. GSJ. 2016
  • Systematic Review of Open vs. MIS treatment of burst

fractures

  • 6 studies included
  • blood loss and operative time were significantly

lower in MIS group (p < 0.05)

  • No differences in vertebral body height,

kyphosis angle, or VAS scores

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SLIDE 38

Compensation

  • Not likely to be able to obtain reliable upright images

immediately after injury

  • At 2 weeks it may be possible to determine if patient is

going to be able to compensate for injury

  • No studies have been designed to look at the ability of a

patient to compensate for changes in lumbar alignment after a fracture

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SLIDE 39

Compensation

  • Many deformity measurements, but simple is better

»SRS Schwab Classification (Schwab. Spine. 2012)

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SLIDE 40

Future Research

  • AOSpine Trauma Knowledge Forum

– Equipoise study

  • Prospective cohort study designed to determine

the best treatment for an A3/4 fracture in a neurologically intact patient

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Conclusion

  • Currently literature to support any treatment decision
  • North American bias towards non-operative care
  • Unclear the effect of newer surgical techniques
  • Unclear the effect of long-term alignment