In thoracolumbar spine trauma, the biomechanical goals in minimally invasive fracture treatment include decompression of the spinal canal, reduction of spinal deformities, and maintenance of stable fixation of the spine to permit early mobilization. This was a teaching lecture given by Prof. Mohamed Mohi Eldin, professor of neurosurgery, in the Multi- Institutional Neurosurgical Meeting, Kasr El Aini Hospital, Cairo University, April 2nd, 2009.

1. Minimally Invasive Approaches
in Thoracolumbar Trauma
DDrr.. MMoohhaammeedd MMoohhii EEllddiinn ,, MB-BCH
, M.Sc., MD
Prof. of Neurosurgery,
Faculty of Medicine,
Cairo University
Consultant Neurosurgeon
The Multi- Institutional Neurosurgical Meeting, Kasr El Aini Hospital, April 2nd, 2009

2. Biomechanical Requirements in
MIS Fracture Treatment
The surgical goals are
 decompression of the spinal canal,
 reduction of spinal deformities, and
 maintenance of stable fixation of the spine
to permit early mobilization.

3. Thoracolumbar Spine Trauma
General Techniques
1. Microsurgical Anterior Approach
2. Thoracoscopically Assisted Anterior Approach
3. Minimally Invasive Open Approach for
Reconstruction of the Anterior Column
4. Minimally Invasive Lateral Access Spine Surgery
5. Percutaneous Screw Fixations
6. Microsurgical Open Vertebroplasty and
Kyphoplasty
7. Percutaneous Vertebroplasty in Osteoporotic
Vertebral Fractures
8. Percutaneous Kyphoplasty in Traumatic Fractures

4. Microsurgical Anterior Approach
to the Thoracolumbar Junction
 AA mmooddiiffiieedd “Mini-TTA” ( transthoracic
approach)

5. Surgical Principle
The anterior spine is approached from the right side
 a limited thoracotomy
 4- to 6-cm skin incision depending
on the number of levels to be
treated.
 The thoracic cavity can be opened
either by
– resection of a small part of the rib
(“window” technique),
– by a rib flap (“open-door”
technique),
– by a single osteotomy of one rib
(“sliding” technique), or by
– An intercostal approach.

6. AApppprrooaacchh
 soft tissue spreader is used to retract the ribs, the
ipsilateral lung, and, if necessary, the diaphragm
 With microscope or an endoscopy, a mono- or
bisegmental anterior exposure of the thoracic spine.

7. Minimally Invasive Anterior
Techniques
 To reduce recovery time, reduce morbidity
 Can create potential spaces, such as the
retroperitoneum, by diaphragm splitting to maintain
or improve visualization and minimize the
approach-related trauma,
 Prove efficacious and safe with at least equivalent
results compared with their open surgical
counterpart

8. Thoracoscopically Assisted
Anterior Approach to
Thoracolumbar Fractures
video-assisted thoracoscopic surgery
(VATS)
or thoracoscopic spine surgery

9. This is usually
achieved in a two-step procedure
 Posterior reduction and stabilization with a pedicle
screw system.
 Anterior decompression of the spinal canal,
 Reconstruction of the fractured vertebra, as well as
augmented (anterior plate system) interbody fusion
with autogenous bone graft or with a vertebral body
replacement

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Contraindications
 Significant previous cardiopulmonary
disease with
 restricted cardiopulmonary function
 Acute posttraumatic lung failure
 Significant disturbances of hemostasis

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A Minimally Invasive Open Approach for
Reconstruction of the Anterior Thoracic and
Lumbar Spine
 blends elements from both endoscopic and
conventional open spine surgery.

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Minimally Invasive Lateral Access
Spine Surgery

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Percutaneous
Screw
Fixations

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Percutaneous Vertebroplasty in
Osteoporotic Vertebral Fractures
Internal augmentation of a fractured
vertebra through the direct intraosseous
injection of bone cement into the
vertebral body in order to reduce pain
and provide stability

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Surgical Principle
 General anesthesia or sedation and local anesthesia
 Trocar needle percutaneously into the vertebral body
(transpedicular or extrapedicular) under fluoroscopy.
 Bone cement injected slowly with continuous
monitoring of the vital parameters
 Reduction of a kyphotic deformity before the injection
by manual traction and hyperlordotic positioning of the
patient.

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Patient selection is the key to a successful
outcome for most surgical interventions.
The indication for percutaneous vertebroplasty in
osteoporotic VCFs is usually based on:
 VCF, not old or healed, “chronic fresh”
osteoporotic fractures
 Pain corresponding to the level of the fracture,
refractory to medical therapy.

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Contraindications
 Absolute contraindications as any other surgical intervention:
– systemic or local infections, bleeding disorders
– (e.g., oral anticoagulation), and anesthetic obstacles,
 Specific contraindications are
– unstable fractures,
– compromise of the spinal canal or nerve roots,
– severe compression fractures (>70% of vertebral height),
– An allergy to bone cement.
 Technical aspects
– Severe deformities,
– previous surgeries, or
– obesity

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Microsurgical Open Vertebroplasty
and Kyphoplasty
 For selected indications
 Enables a less invasive treatment of severe
osteoporotic and neoplastic fracture types
with neural compromise

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Considerations for
Microsurgical Augmentation
Four conditions needs microsurgical VP or KP:
1. Osteoporotic vertebral fractures with compression of neural
structures
2. Osteolytic vertebral tumours with compression of neural
structures
3. Osteoporotic vertebral fractures or osteolytic tumours with severe
compromise of the posterior vertebral wall
4. Osteoporotic vertebral fractures with symptomatic spinal stenosis
requiring decompression

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Surgical Technique
Microsurgical Interlaminar Vertebroplasty
and Kyphoplasty

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Single kyphoplasty balloon placed
convergently into the vertebral body
through the interlaminar approach

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BBaalllloooonn KKyypphhooppllaassttyy
 EExxiissttss ssiinnccee 11999988
 CCaann bbee ddoonnee uunnddeerr ggeenneerraall oorr llooccaall aanneesstthheettiicc
 44 ssiimmppllee sstteeppss

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SStteepp 11
IInnsseerrttiioonn ooff ttwwoo bbaalllloooonnss iinnttoo tthhee
ffrraaccttuurreedd vveerrtteebbrraall bbooddyy..

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SStteepp 22
IInnffllaattiioonn ooff tthhee bbaalllloooonnss ttoo ccrreeaattee aa ccaavviittyy aanndd
ppeerrffoorrmm ffrraaccttuurree rreedduuccttiioonn..
AAfftteerrwwaarrddss tthhee bbaalllloooonnss aarree rreemmoovveedd..

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SStteepp 33
FFiilllliinngg tthhee ccaavviittyy,, ccrreeaatteedd bbyy tthhee bbaalllloooonnss,, wwiitthh
bboonnee cceemmeenntt ttoo oobbttaaiinn ffrraaccttuurree ffiixxaattiioonn..

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SStteepp 44
TThhee ffrraaccttuurree iiss ssttaabbiilliisseedd wwhhiicchh ffaacciilliittaatteess ppaattiieenntt
mmoobbiilliittyy aanndd ggiivveess ffaasstt ppaaiinn rreelliieeff

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IInnddiiccaattiioonnss
PPaattiieennttss wwiitthh VVeerrtteebbrraall CCoommpprreessssiioonn
FFrraaccttuurreess ccaauusseedd bbyy::
•• PPrriimmaarryy OOsstteeooppoorroossiiss
•• SSeeccoonnddaarryy OOsstteeooppoorroossiiss
•• MMuullttiippllee MMyyeelloommaa
•• BBoonnee MMeettaassttaassiiss

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RRiisskk ooff ssuubbsseeqquueenntt ffrraaccttuurreess
 IIff aa ppaattiieenntt aallrreeaaddyy hhaass aa ffrraaccttuurree ((66..11 mmoorree ttiimmeess))
 TThhee mmoorree ffrraaccttuurreess aa ppaattiieenntt hhaass,, tthhee hhiigghheerr tthhee rriisskk (( 33
##,, rriisskk iiss 2233 mmoorree ttiimmeess))
 IIff tthhee ffrraaccttuurree iiss ((wweeddggee ttyyppee)) tthhee rriisskk ooff aann aaddddiittiioonnaall
ffrraaccttuurree iinnccrreeaasseess ssiiggnniiffiiccaannttllyy (( 55..99 ))
Lunt M, Characteristics of a prevalent vertebral deformity predict subsequent vertebral
fracture: results from the European Prospective study. Bone 33 (2003) 505-513

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BBaalllloooonn KKyypphhooppllaassttyy
PPrroocceedduurree

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AAssssuurriinngg ssaaffeettyy
 BByy uussiinngg 22 bbaalllloooonnss,, ttrraabbeeccuullaarr bboonnee iiss ccoommppaacctteedd..
TThhiiss ccrreeaatteess aa ““wwaallll”” ttoo pprreevveenntt cceemmeenntt ffrroomm LLeeaakk..
 UUssiinngg vveerryy hhiigghh vviissccoossiittyy cceemmeenntt..
 TThhee cceemmeenntt iiss ppllaacceedd iinn tthhee ccaavviittyy uunnddeerr llooww
mmaannuuaall pprreessssuurree

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KKyypphhooppllaassttyy HHeeiigghhtt RReessttoorraattiioonn
Pre-Op Post-Op
Height
Restoration
Fracture Age, 4 months

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Leakage rate vvss ootthheerr tteecchhnniiqquuee
Rod S Taylor, Rebecca J Taylor, Peter Fritzell, Balloon Kyphoplasty in the Management of Vertebral
Compression Fractures: An Updated Systematic Review and Meta-analysis, report August 2006

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Complications rate vvss ootthheerr TTeecchhnniiqquuee
RReessuullttss ooff aa llaarrggee ssyysstteemmaattiicc rreevviieeww.. MMoorree tthhaann 33665500
vveerrtteebbrraaee
Rod S Taylor, Rebecca J Taylor, Peter Fritzell, Balloon Kyphoplasty in the Management of Vertebral
Compression Fractures: An Updated Systematic Review and Meta-analysis, report August 2006

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NNIICCEE:: IIPPGG 116666
NNIICCEE hhaass
iissssuueedd aa
IInntteerrvveennttiioonnaall
PPrroocceedduurree
GGuuiiddaannccee ffoorr
BBaalllloooonn
KKyypphhooppllaassttyy iinn
AApprriill 22000066..

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BBaalllloooonn KKyypphhooppllaassttyy
CClliinniiccaall OOuuttccoommeess

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1- Fast aanndd ssuussttaaiinneedd ppaaiinn
rreelliieeff
CCoommpplleettee ppaaiinn rreelliieeff iiss rreeppoorrtteedd bbyy 6688%% ooff tthhee ppaattiieennttss aafftteerr oonnee wweeeekk
aanndd bbyy 8866%% bbyy 33--66 mmoonntthhss ppoosstt--ooppeerraattiivveellyy..
RReessuulltt iiss mmaaiinnttaaiinneedd ffoorr 22 yyeeaarrss ((9900%%))..
Ledlie J.T.; Kyphoplasty Treatment of Vertebral Fractures: 2-Year Outcomes show Sustained Benefits

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2- Less usage ooff nnaarrccoottiicc ppaaiinn
mmeeddiiccaattiioonn
PPaattiieennttss rreeqquuiirriinngg nnaarrccoottiicc mmeeddiiccaattiioonn ssiiggnniiffiiccaannttllyy ddeeccrreeaasseedd
aafftteerr BBaalllloooonn KKyypphhooppllaassttyy ttrreeaattmmeenntt ((pp<<00..000011))..
Ledlie J.T.; Kyphoplasty Treatment of Vertebral Fractures: 2-Year Outcomes show Sustained Benefits

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3- Improving QQuuaalliittyy OOff LLiiffee
SSttaattiissttiiccaallllyy ssiiggnniiffiiccaanntt iimmpprroovveemmeenntt iinn 77 ooff 88 ddoommaaiinnss ooff tthhee
SSFF--3366 ssccoorreess wwhheenn ccoommppaarriinngg pprree--aanndd ppoosstt--oopp rreessuullttss..
RReessuullttss aarree mmaaiinnttaaiinneedd oovveerr aann 1188 mmoonntthh ffoollllooww--uupp ppeerriioodd..
Coumans et al; Kyphoplasty for Vertebral Compression Fractures: 1-year clinical outcomes from a
prospective study, The Journal of Neurosurgery, Vol. 99, July 2003

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4- Less back pain rreellaatteedd hheeaalltthh
ccaarree vviissiittss
SSiiggnniiffiiccaanntt rreedduuccttiioonn iinn tthhee nnuummbbeerr ooff bbaacckk ppaaiinn rreellaatteedd
hheeaalltthh ccaarree vviissiittss wwhheenn ccoommppaarriinngg tthhee BBaalllloooonn KKyypphhooppllaassttyy
ggrroouupp wwiitthh tthhee ccoonnttrrooll ggrroouupp..
Grafe et al; Reduction of pain and fracture incidence after Kyphoplasty: 1-year outcomes of a prospective
controlled trial with primary osteoporosis, Osteoporosis Int (2005) 16: 2005-2012

43. 5- Correction of the SSppiinnaall DDeeffoorrmmiittyy
43
SSiiggnniiffiiccaannttllyy ((pp<<00..000011)) ccoorrrreecctt vveerrtteebbrraall wweeddggee ffrraaccttuurreess ttoo
mmoorree tthhaann 8800%% ooff iittss oorriiggiinnaall hheeiigghhtt..
Ledlie J.T.; Kyphoplasty Treatment of Vertebral Fractures: 2-Year Outcomes show Sustained Benefits

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6- Correction ooff tthhee SSppiinnaall
DDeeffoorrmmiittyy
Prone positioning of the patient improved the kyphosis angle by 3.7°,
inflating the balloon added another 4.2° to the correction
(Voggenreiter, Spine Vol 30 N° 24, 2005)

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7- Reduced risk for ssuubbsseeqquueenntt
ffrraaccttuurreess
AA ssiiggnniiffiiccaanntt rreedduuccttiioonn iinn tthhee %% ooff ppaattiieennttss wwhhoo hhaavvee aa
nneeww ffrraaccttuurree dduurriinngg 11--yyeeaarr ffoollllooww--uupp wwaass rreeppoorrtteedd iinn tthhee
BBaalllloooonn KKyypphhooppllaassttyy ggrroouupp wwhheenn ccoommppaarreedd ttoo tthhee ccoonnttrrooll ggrroouupp..
Kapserk C. et al; Treatment of Painful vertebral fractures by Kyphoplasty in patients with primary
osteoporosis: a prospective nonrandomized controlled study, J Bone Miner Res 15:721-739

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BBeenneeffiittss
PPaattiieenntt ssaattiissffaaccttiioonn
•• EExxppeerriieenncciinngg ffaasstt aanndd ssuussttaaiinneedd ppaaiinn rreelliieeff
•• PPeerrffoorrmmiinngg aaccttiivviittiieess ooff ddaaiillyy lliivviinngg aaggaaiinn
CCoorrrreeccttiioonn ooff ssppiinnaall ddeeffoorrmmiittyy
•• IImmpprroovviinngg tthhee bbiioommeecchhaanniiccss ooff tthhee ssppiinnee rreedduucciinngg tthhee rriisskk ffoorr nneeww
ffrraaccttuurreess
•• IImmpprroovviinngg yyoouurr ppaattiieennttss’’ vviittaall ccaappaacciittyy bbyy ccoorrrreeccttiinngg tthheeiirr ppoossttuurree

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TTHHAANNKK
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