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

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Presentation on theme: "COMPLEX THORACIC INJURIES Avelino Parajón Servicio de Neurocirugía Hospital Universitario Puerta de Hierro Majadahonda, Madrid."— Presentation transcript:

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

2 THORACIC SPINE –T1-T10 THORACOLUMBAR SPINE –T11-L2 LUMBAR SPINE –L3-L5

3 THORACOLUMBAR FRACTURES –MEN: WOMEN 2/3:1/3 –20-40 YEARS OLD –15-20% OF FRACTURES –2/3 OF SPINE FRACTURES

4 THORACIC COMPLEX INJURIES TRAUMA / ATLS ABC / GCS SPINE EXAM –RED FLAGS –INSPECT AND PALPATE ENTIRE SPINE THOROUGH RX EXAM

5 SPINAL CORD INJURY ASSESMENT MANY GRADING SYSTEMS –IMPAIRMENT BASED FRANKEL ASIA YALE MOTOR INDEX –FUNCTION BASED MODIFIED BARTHEL INDEX

6 SPINAL CORD INJURY ASSESMENT COMPLETE –NO FUNCTION BELOW LEVEL OF INJURY –ABSENCE OF SENSATION AND VOLUNTARY MOVEMENT IN S4/5 DISTRIBUTION INCOMPLETE –PRESERVATION OF SENSATION IN S4/5 DISTRIBUTION AND VOLUNTARY CONTROL OF ANAL SPHINCTER

7 BÖHLER, 1929 WATSON-JONES, 1931 NICOLL, 1949 HOLDSWORTH, 1963, 2 COLUMNS LOUIS-GOUTALLIER, 1977 DENIS, 1983, 3 COLUMNS FERGUSON-ALLEN, 1984 MAGERL, 1994, AO McCORMACK, 1994, LOAD SHARING VACCARO, 2005, TLISS VACCARO, 2006, TLICS

8 HOLDSWORTH STABLE –COMPRESSION –BURST UNSTABLE –ROTATION –DISLOCATION

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11 DENIS CLASSIFICATION-compression fractures 50% COMPRESSION ANTERIOR COLUMN STABLE NO NEURO DEFICIT NON SURGICAL /SURGICAL

12 DENIS CLASSIFICATION- compression fractures WITH ANTERIOR WEDGING WITH LATERAL WEDGING

13 DENIS CLASSIFICATION-burst fractures 20% COMPRESSION ANTERIOR AND MIDDLE COLUMN UNSTABLE MAY HAVE NEURO DEFICIT SURGERY

14 DENIS CLASSIFICATION-burst fractures FRACTURE OF BOTH ENDPLATES FRACTURE OF THE SUPERIOR ENDPLATE FRACTURE OF THE INFERIOR ENDPLATE BURST + ROTATION BURST + LATERAL FLEXION

15 DENIS CLASSIFICATION-flexion distraction fx UNCOMMON FLEXION + DISTRACTION MIDDLE AND POSTERIOR COLUMNS UNSTABLE USUALLY NO NEURO DEFICIT FX. CHANCE

16 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

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18 DENIS CLASSIFICATION- chance fracture

19 DENIS CLASSIFICATION-fracture dislocation 25% FLEXION-ROTATION FLEXION DISTRACTION THREE COLUMNS UNSTABLE NEURO DEFICIT SURGERY

20 DENIS CLASSIFICATION-fracture dislocation

21 AO CLASSIFICATION A- COMPRESSION B- DISTRACTION C- ROTATION

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23 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

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25 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

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27 Tipo C: ROTATION C.1 ROTATION + A –C.1.1 ROTATIONN+ A1 (wedge) –C.1.2 ROTATIO+ A2 (section) –C.1.3. ROTATION+ A3 (burst) C.2 ROTATION + B –C.2.1 ROTATION+ B1 –C.2.2 ROTATION + B2 –C.2.3 A ROTATION+ B3 C.3. ROTATION + SHEARING –C.3.1. slice shearing –C.3.2. oblique shearing

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30 McCORMACK “LOAD SHARING CLASSIFICATION” COMMINUTION APPOSITION OF FRAGMENTS KYPHOTIC DEFORMITY

31 McCORMACK “LOAD SHARING CLASSIFICATION”

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34 LESSIONS WITH SURGICAL INDICATION AND < 7 POINTS –POSTERIOR APPROACH LESSIONS > 7 POINTS – ANTERIOR APPROACH

35 VACCARO- TLISS MECHANISM OF INJURY LESSION OF POST. LIGAMENT COMPLEX NEUROLOGICAL DEFICIT

36 VACCARO- TLISS MECHANISM OF INJURY – COMPRESSION1 POINT –TRASLATION/ROTATION 3 POINTS –DISTRACTION4 POINTS

37 VACCARO- TLISS LESSION OF POSTERIOR LIGAMENT COMPLEX –INTACT 0 POINTS –SUSPECTED2 POINTS –KNOWN3 POINTS

38 VACCARO- TLISS NEUROLOGICAL DEFICIT –RADICULAR2 POINTS –INCOMPLETE CONUS/SPINAL CORD2 POINTS –COMPLETE CONUS/ S. CORD 2 POINTS –CAUDA EQUINA 3 POINTS

39 VACCARO- TLISS TLISS <4NON SURGICAL TREATMENT TLISS 4NON SURGICAL / SURGICAL TLISS >4SURGICAL TREATMENT

40 VACCARO- TLICS LESSIONAL MORPHOMETRY –COMPRESSION1 POINT –BURST1 POINT –TRASLATION / ROTATION3 POINT –DISTRACTION4 POINT

41 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 THORACOLUMBAR FRACTURES

42 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 FLEXION- DISTRACTION ANTERIOR APPROACH INDICATIONS

43 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:

44 SURGERY VS CONSERVATIVE IN AO A FX 2 PROSPECTIVE RANDOMIZED STUDIES Wood: J Bone Joint Surg Am 85: , 2003 Siebenga: Spine 31(25): , 2006

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46 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

47 SURGERY VS CONSERVATIVE IN AO A FX SURGERY –SHORT POSTERIOR FIXATION AND FUSION –ANTERIOR STABILIZATION AND FUSION CONSERVATIVE TREATMENT –BRACE

48 SURGERY VS CONSERVATIVE IN AO A FX EVALUATION –SF 36 –ROLAND AND MORRIS DISABILITY QUESTIONNAIRE –OSWESTRY –INITIAL AND FINAL KYPHOTIC DEFORMITY –RETURN TO WORK

49 SURGERY CONSERVATIVE INITIAL KYPHOTIC DEF 10º11.3º FINAL KYPHOTIC DEF 13º13.8º INITIAL CANAL STENOSIS 39 %34 % FINAL CANAL STENOSIS 22 %19 % OWESTRY NO DIF SF 36 NO DIF RETURN TO WORK NO DIF

50 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

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52 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 (T10-L4) AO A TYPE (EXCLUDED A1.1.) NO NEURO DEFICIT(FRANKEL E)

53 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

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56 SURGERY VS CONSERVATIVE IN AO A FX A3 FRACTURES (BURST): BETTER FUNCTIONAL RESULTS WITH SURGERY BETTER KYPHOTIC CORRECTION WITH SURGERY NO CLINICAL- RADIOLOGICAL CORRELATION

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58 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

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60 ANTERIOR APPROACH TO THORACIC FRACTURES –BETTER DECOMPRESSION –BETTER KYPHOTIC CORRECTION –LESS PAIN

61 ANTERIOR APPROACH TO THORACIC FRACTURES TECHNIQUE THORACOTOMY THORACOPHRENOLAPAROTHOMY LEFT SIDET12-L3 RIGHT SIDE T6-T11

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66 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 T12 AO A3

67 2. Diagnosis

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69 69

70 70 4. Postoperative Management 24 h MOVILIZATION TERMOPLASTIC ORTHESIS 3 DAYS POSTOP IN-HOSPITAL STAY NO SIGNIFICANT BLOOD LOSS NO OPIOID POSTOP

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


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