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Dae Jeon Hurisarang Hospital, Dae Jeon Department of Neurosurgery, Mokpo Hankook Hospital, Mokpo

Screw reinforcing Percutaneous Short Segment Transpedicular Screwing for Unstable Thoracolumbar Burst Fractures. Hyeun Sung Kim Sung Keun Park, Hoon Joy, In Ho Park, Jae Kwang Ryu Changil Ju , Seok Won Kim, Seung Myung Lee, Ho Shin. Dae Jeon Hurisarang Hospital, Dae Jeon

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Dae Jeon Hurisarang Hospital, Dae Jeon Department of Neurosurgery, Mokpo Hankook Hospital, Mokpo

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  1. Screw reinforcing Percutaneous Short Segment Transpedicular Screwing for Unstable Thoracolumbar Burst Fractures Hyeun Sung Kim Sung Keun Park, Hoon Joy, In Ho Park, Jae KwangRyu ChangilJu, Seok Won Kim, SeungMyung Lee, Ho Shin Dae Jeon Hurisarang Hospital, Dae Jeon Department of Neurosurgery, Mokpo Hankook Hospital, Mokpo Department of Neurosurgery, School of Medicine, Chosun University, Gwangju, Korea

  2. Introduction Goals of surgical treatment for unstable thoracolumbar burst fractures • restore stability of the vertebral column • decompress the spinal canal • facilitateearly mobilization of the patients Surgical treatment of burst fractures • an extensive, huge, and very invasive procedure that requires a large opening with a long skin incision • Anterior Approach • significant invasion of the retroperitoneal space or thoracic cavity with wide dissection • prolonged operation and hospitalization time • blood loss, donor site complaints, increased morbidity and even mortality • Posterior Approach • extensive dissection of paraspinal muscles of the back • : may lead to muscular denervation & necrosis • => resulting in prolonged postoperative pain and disability • resection of posterior elements of the spine Kim Hyeun Sung (ilovespine.com)

  3. Material and Methods Denis Three-column Concept : Burst fracture : 2 or 3 column injury • anterior height < 50% of posterior height (kyphosis), > 50% canal compromise • angular deformity greater than 20°, progressive kyphosis • multiple contiguous fractures • any neurologic injury • in patients with extensive associated injuries Material • From January 2007 to September 2008: 11 patients Inclusion criteria • > 50% loss of anterior vertebral height, > 50% canal compromise • kyphotic angle more than 20 • Three column injury according to the Denis 3-column injury theory Kim Hyeun Sung (ilovespine.com)

  4. Material and Methods Patients Series Kim Hyeun Sung (ilovespine.com)

  5. Methods : Surgical Methods Two Method for Restoration of Vetebral Height and Kyphotic Angle • Pillow reduction • Intra-operative pressure compression Pillow reduction Pressure Compression Kim Hyeun Sung (ilovespine.com)

  6. Methods : Surgical Methods 1. Fractured vertebral augmentation : PMMA Augmentation with Pressure Compression Screw Insert PMMA Injection Pressure Compression Kim HS, Park SK, Joy H, Ryu JK, Kim SW, Ju CI. Bone Cement Augmentation of Short Segment Fixation for Unstable Burst Fracture in Severe Osteoporosis. J Korean Neurosurg Soc 2008:44;8-14 2. Screw Reinforcement Ha-stick: PENTAX (Japan): INFRAMED KOREA • Non-osteoporotic : Hydroxyapatite • Osteoporotic : Polymethylmethacrylate(PMMA) Stick insert cannula Stick insert Kim Hyeun Sung (ilovespine.com)

  7. Methods : Surgical Methods 3. Percutaneous Screwing : Apollon System (Solco Medical, South Korea) • at one level above and below the fractures site including the fractured level itself • General anesthesia & prone position under the Pressure reduction position • Skin incision under the C-arm guide : Lateral to pedicle Surgical Method – Rod rotation • After remove the extender holder bar • Rotate the rod inserting bar • Bone biopsy needle insert into pedicle using the Ruller guide • Ruler guide remove : Insert pin => Remove bone biopsy needle => Remove guide • Bone biopsy needle or hydroxyapatite insert guide insert • Remove pin guide • Bone cement injection : Average 2.5-3cc /one side : Onelevel : Average5-6cc • Percutaneoustranspedicular screwing • Fracture level : Maintain pressure reduction posture: anterior column restoring • => Minimized the cement leakage : spinal canal, paravertebral space etc. • Percutaneous screwing system(Apollon : Solco medical) insert : Lordotic shape • Rod Rotation using the rod holder • Rod tightening Kim Hyeun Sung (ilovespine.com)

  8. Result Mean Follow-up Period • 10.64 months Mean Operation Time • 76minutes Mean Blood loss • 50.9mL VAS • 8.09 => 2.36 Kyphotic angle • 20.8 °±8.2° => 5.7 °±2.3° Vertebral height • 43.45%±8.05% => 82.00%±5.25% Kim Hyeun Sung (ilovespine.com)

  9. Case: Non-osteoporotic Fracture T10 bursting fracture • 23yrs/F, Fall down, C/C : Severe back pain, N/E : intact • Kyphotic Deformity : 21 • Vertebral Height : 42% • Vertebral Height : 42% => 77% • Kyphotic Deformity : 21 => 5 Kim Hyeun Sung (ilovespine.com)

  10. Case: Non-osteoporotic Fracture L1 bursting fracture • 50yrs/F, Fall down, C/C : Severe back pain • Vertebral Height : 43% => 78% • Kyphotic Deformity : 25 => 9 • Vertebral Height : 43% • Kyphotic Deformity : 25 Kim Hyeun Sung (ilovespine.com)

  11. Case: Non-osteoporotic Fracture T12 bursting fracture • 47yrs/M, Fall down, C/C : Severe back pain with bilateral leg paresthesia • Kyphotic Deformity : 27 • Vertebral Height : 40% After Postural Reduction • Vertebral Height : 40% => 86% • Kyphotic Deformity : 27 => 3 1day after operation Paresthesia improved completely Kim Hyeun Sung (ilovespine.com)

  12. Case: Non-osteoporotic Fracture T12 bursting fracture • 47yrs/M, Fall down, C/C : Severe back pain with bilateral leg weakness(G2/G2) • Kyphotic Deformity : 20 • Vertebral Height : 48% After Postural Reduction : Cord contusion detected • Vertebral Height : 48% => 87% • Kyphotic Deformity : 20 => 2 Initial Motor : G2/G2 4day after operation Motor improved G4+/G4+ 1 week after operation Motor improved completely Kim Hyeun Sung (ilovespine.com)

  13. Case: Osteoporotic Fracture L1 bursting fracture • 59yrs/F • Fall down • C/C : Severe back pain N/E : intact • Kyphotic Deformity : 22 • Vertebral Height: 11/32(34%) • Kyphotic Deformity : 22 => 3 • Vertebral Height : 11/32(34%) => 29/32(90%), Canal Encrochment : 7/13(54%) => 3/13(23%) 17 months later : Sclerotic Change Kim Hyeun Sung (ilovespine.com)

  14. Case: Osteoporotic Fracture L2 bursting fracture • 60yrs/M, Fall down, C/C : Severe back pain • Vertebral Height : 45% => 80% • Kyphotic Deformity : 26 => 7 • Vertebral Height : 45% • Kyphotic Deformity : 26 Kim Hyeun Sung (ilovespine.com)

  15. Case: Osteoporotic Fracture L1 bursting fracture • 65yrs/F, Fall down, C/C : Severe back pain • Vertebral Height : 48% • Kyphotic Deformity : 19 3 days after operation • Vertebral Height : 48% => 96% • Kyphotic Deformity : 19 => 5 Kim Hyeun Sung (ilovespine.com)

  16. Case: Complication Cement leakage T11 bursting fracture • 54yrs/F, Fall down, C/C : Severe back pain, N/E : intact • Complication : cement leakage into paravertebral space • flank dullness and pain : not significant Cement Leakage Kim Hyeun Sung (ilovespine.com)

  17. Discussion Thoracolumbar burst fracture • Treatment : Stabilization and decompression • If does not need decompression of the neural element : posterior approach Short segment posterior fixation • Main advantage : to preserve the motion segment compared to long level fixation • Disadvantage : difficulty in restoring the anterior column • : doesnot lead to satisfactory decompression • Lead to secondary kyphosis • Drawbacks & Sequela • Persistent low back pain • iatrogenic muscle denervation • atrophy & decreased trunk extensor strength • Need a less invasive techniques Limitation of percutaneous pedicle screwing inthoracolumbar junction • Systems for percutaneous pedicle screws : developed for lordotic lumbar spine • More difficult to apply in the thoracolumbar region : kyphoticangulation Kim Hyeun Sung (ilovespine.com)

  18. Discussion Short segment posterior fixation • Parker JW, Lane JR, Karaikovic EE, Gaines RW : Successful short-segment instrumentation and fusion for thoracolumbar spine fractures: a consecutive 41/2-year series. Spine 25 : 1157-1170, 2000 Instrumentation without fusion • Advantages • Elimination of donor site complications • Saving more motion segments • Reducing blood loss and operation time. • Sanderson et al.(1999) : Short segment fixation of thoracolumbar burst fractures without fusion. Eur Spine J • Wang et al.(2006) : Is fusion necessary for surgically treated burst fractures of the thoracolumbar and lumbar spine? Spine Cement augmentation screwing • Tan et al.(2007) : Cement augmentation of vertebral screws enhances the interface strength between interbody device and vertebral body. Spine • kimHS, et al.(2007) : Bone cement augmentation of pedicular screwing in severe osteoporotic spondylolisthetic patients. JKNS • Kim HS, et al(2008) : Bone cement augmentation of short segment fixation for unstable burst fracture in severe osteoporosis. JKNS Kim Hyeun Sung (ilovespine.com)

  19. Discussion Initial After Operation 1 years later Rationale of Screw reinforcing Percutaneous short Segment Screwing • Postural reduction :anterior column restoration,spinal alignment correction,no need decompression • Bone cement augmentation : Maintain spinal stability, Maintain restored anterior column • PercutaneousTranspedicular screwing : No open surgery • Bone fusion : Fracture site itself Thoracolumbar junction kyphosis in Percutaneous screwing system • Percutanoues screwing system : lordosis setting • Rod rotation : under the C-guide using the firm rod holder • Rod fixation : kyphotic setting Advantages of the screw reinforced percutaneous stabilization Reduce the dissections of the paraspinal muscles and posterior spinal elements. Reduce the intraoperative bleeding, the operation time, the anesthesia time, infection, dural tear, etc. Early ambulation Reduce the hospital day Reduce the postoperative pain Kim Hyeun Sung (ilovespine.com)

  20. Discussion In the management of unstable thoracolumbar burst fractures, percutaneous short segment pedicle screw fixation with hydroxyapatite or bone cement augmentation following postural reduction can be used to reduce the total levels of pedicle screw fixation and to correct kyphotic deformities, also, to reduce the several complications in open surgery. Kim Hyeun Sung (ilovespine.com)

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