- The document discusses surgical treatment options for thoracolumbar fractures, with a focus on anterior reconstruction techniques. It presents the case of a patient who underwent an anterior corpectomy and reconstruction using a titanium mesh cage. - The procedure provided immediate stabilization and allowed for early mobilization. It corrected deformity and restored sagittal alignment. Solid fusion was achieved with no hardware failure or pseudarthrosis. The technique allows for safe decompression and maximal neurological recovery.

2. THORACOLUMBAR
FRACTURES - Update
KHALED ABDEEN MD
ASSISTANT PROFESSOR SPINE & NEUROSURGERY _
ALEXANDRIA UNIVERSITY
FELLOW OF FUJITA UNIVERSITY _JAPAN

3. Vertebral fractures
• Trauma
• Metastatic tumors .
• Osteoporosis:
- Primary.
- Secondary : steroid, cushing ,
hypogonadism , dialysis cases , etc.

4. Specific Thoracolumbar Injuries
• Compression fractures
• Burst fractures
• Flexion-distraction/Chance injury
• Fracture-dislocations
• Gunshot wounds to the spine

5. Spinal Stability
• Mechanical stability: maintain alignment
under physiologic loads without significant
onset of pain or deformity
• Neurologic stability: prevent neural signs or
symptoms under anticipated loads

6. Thoracolumbar fractures
• Posterior short segment
• Posterior long segment .
• Anterior approach .
• Combined .

7. Short segment fixation
• Makes more sense .
• More physiologic .
• One level above and one
below .
• Only one level
fusion /////////

8. Indirect decompression :
Ligamentotaxis

10. Why should we callange the
concept of long fixation ?
• Posterior surgery easier, faster, bleeds
less.
• Range of motion of lumbar spine 15
degree per level .
• Why fusing normal motion segment ?
• Shorter instrumentation preserves function
.
• Shorter instrumentation may prevent late
degeneration.

13. Front or back ?
• Anterior approach • Posterior approach
• Anterior • Reconstruct the
decompression . tension band .
• Anterior column
recnostruction . • Midnight surgery .
• Shorter segment . • Long segment

14. Load.Sharing.classification
• Scoring system :
Recommendation
• Total Six or less : short
segment posterior
instrumentation
indicated .
• Total 7 or more: anterior
surgery indicated
January 4, 2013 14

16. M pt 33 ys old, operated for L1 traumatic burst fracture

17. F pt 25 ys old, operated for L1 traumatic burst
fracture

18. Anterior approach : indications
• Anterior column reconstruction .
• Incomplete neurological deficit .
• Fracture with poor reduction
potential .
- large fragment
- more than 67% canal
compromise .
• Inadequate canal reduction
following posterior procedure with
suboptimal neuro recovery

21. Anterior column reconstruction
using titanium mesh cages after
thoracolumbar corpectomy :
Clinical and Radiological
Insert Your
Outcome
Photograph Here
– Khaled abdeen MD , Hesham Yousri *MD ,Ahmed
Azab * MD , Ihab Zidan MD .
– Alexandria university , Almenoufia university *
– Department of Neurosurgery
January 4, 2013 21

25. • On the basis of clinical and
biomechanical investigations,
many authors now advocate
nowadays to reconstruct the
axial load-bearing ability of the
anterior spine using different
materials for vertebral body
replacement

26. Indications for surgical treatment of
the traumatic cases :
• the instability of the spine according to the
Load Sharing classification.
• Neurologic deficit .
• Sagittal angulation > 25°.
• axial compression > 50% of vertebral
height .

27. • The optimal treatment of unstable
thoracolumbar spine remains controversial .
• Treatment goals are:
• to prevent neurological deterioration
• enhance neurolgical recovery
• stabilization
• prevent late pain and late kyphotic deformity .

28. • The recent development of rigid corpectomy
reconstruction cages has made the anterior
approaches to the lumbar and thoracolumbar
(TL) spine more attractive by improving the
biomechanical strength of the anterior column
support.

29. Anterior approach
• a more direct and complete decompression of the
spinal canal .
• potentially allowing a better neurological outcome
.
• biomechanical restoration of the
compromised anterior load bearing
column can be achieved.
January 4, 2013 29

30. Disadvantages
• the more extensive
approach required .
• lack of familiarity to many
spinal surgeons .
• the potential for thoracic
pain .
• the potential for
pulmonary complications

31. • The degree of kyphosis, construct height
and the subsidence of the cage in relation
to the vertebral endplates were measured
preoperatively , early post operative , and
at the latest follow up .
• the surgical approach was
thoracoabdominal in 14 cases and
retroperitoneal in 10 cases
January 4, 2013 31

35. January 4, 2013 35

36. • Postoperative x ray after retroperitoneal
approach for L2 fracture

37. Society for Progress & Innovation for
January 4, 2013 37
the Near East

38. Intraoperative photos of the cage placed at the
corpectomy site. Bolts for the lateral stabilizing plate
.The canal and dura are covered with hemostatic patch
and plate
38

40. January 4, 2013 40

41. January 4, 2013 41

43. Results :
• Operation time : mean 150 minutes [ 120-
330 minutes] .
• Estimated blood loss 800-1400 ml
[average 1100 ml ]
• No case had obvious pseudoarthrosis or
implant loosening or complication related
to the anterior reconstruction .
January 4, 2013 43

44. Results :
• Neurological recovery : in our study ;
6 patients were neurologically
intact , Frankel grade E on
admission , and all of them remains
intact postoperatively . Of the 12
patients with Frankel D on
admission , all had recoverd full
motor and sensory function . Of the
6 patients with Frankel C on
admission . three improved one
grade , the other three improved two
grades ..
January 4, 2013 44

45. • The mean construct height of the involved
vertebrae before surgery was 41.6 mm and the
mean construct height immediate after surgery
and at follow up were 47.9 and 42.5 mm
respectively . Solid fusion was observed in all
patients , there were no hardware failure . The
sagittal alignment of the fractured segment was
satisfactorily restored immediately after surgery
as a significant decrease in the local kyphotic
angle .

46. COMPLICATIONS
NO. PERCENTAGE
Peritoneal tear 2 8.3 %
Pulmonary 2 8.3 %
infection
Intercostal 6 25 %
neuralgia
Sympathatic 6 25 %
affection

47. Society for Progress & Innovation for
January 4, 2013 47
the Near East

49. Advantages of this technique
• [a] allows better safe decompression of
neural structures to promotes maximal
neurological recovery .
• [b] provides immediate stablization and
allows for early mobilization .
• [c] corrects deformity and restores sagittal
alignement .
January 4, 2013 49

51. Conclusions
• Titanium mesh cages with cancellous
autograft bone after corpectomy of the
thoracolumbar spine provides immediate
structural support to the anterior column .
the present study has shown that anterior
instrumentation is an effective and safe
treatment for thoracolumbar instability by
demonstaring satisafctory clinical and
radiological outcomes .
January 4, 2013 51

53. Augmented fixation