Executive Editor: Luiz Vialle General Editor: German Ochoa (in memoriam)

Authors: Alex Vaccaro, Frank Kandziora, Michael Fehlings, Rajasekaran Shanmughanathan

Thoracic and lumbar trauma - B2

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Glossary

General considerations

53-B2

Type B2 injuries are posterior bone or ligament disruptions, creating a potential instability. Surgical treatment is recommended with fusion.

Anterior stabilization
Main indication Skill Equipment
Neurological damage Highly experienced and skilled surgeon Full specialized surgical and imaging resources

When a fracture needs to be treated surgically, the choice to perform anterior or posterior stabilization or combined MIS or open depends on surgeon's preference.

Indications:

  • Neurological damage
  • Symptomatic anterior spinal cord compression from retropulsed bone
  • Symptomatic traumatic disc herniation
  • Unstable burst fracture in the absence of neurologic compromise
  • Compromised bone quality
  • Residual instability following posterior stabilization
  • Residual compression following posterior stabilization
  • Evidence of increasing kyphosis while treated nonoperatively
  • Pincer fracture

Contraindications:

  • Previous anterior surgery placing viscus and vascular structures at risk due to scarring/adhesions
  • Lung, vascular, and abdominal diseases, which make anterior approaches difficult or dangerous
  • Patient not fit for surgery

Advantages:

  • Ability to perform short segment fixation
  • Direct visualization of compromised anterior neurologic structures
  • Excellent biomechanical anterior column support

Disadvantages:

  • Complex surgical approach
  • Complications of an anterior approach including potential for vascular and organ injuries
  • Anterior standalone procedures may not be as sound biomechanically as multisegmental posterior stabilization procedures
  • Transthoracic procedures may be challenging in patients with concomitant chest injuries
Posterior short segment fixation with pedicle screws
Main indication Skill Equipment
A3, A4, B1, B2 fractures without severe anterior column damage Some specialized surgical experience Simple surgical and imaging resources

When a fracture needs to be treated surgically, the choice to perform anterior or posterior stabilization or combined MIS or open depends on surgeon's preference.

Indication:

  • A3, A4, B1, B2 fractures without severe anterior column damage

Contraindications:

  • Severe anterior column damage
  • C type fractures
  • Patients not fit for surgery

Advantages:

  • Common procedure
  • Fast surgery

Disadvantages:

  • Less stability
  • In patients with significant vertebral body comminution, additional anterior reconstruction may be needed to prevent implant failures
Posterior short segment fixation with Schanz pins
Main indication Skill Equipment
All A2, A3, A4, B1, B2 fractures Some specialized surgical experience Simple surgical and imaging resources

When a fracture needs to be treated surgically, the choice to perform anterior or posterior stabilization or combined MIS or open depends on surgeon's preference.

Indication:

  • All A2, A3, A4, B1, B2 fractures

Contraindications:

  • C type fractures
  • Patients not fit for surgery

Advantages:

  • This system provides strong lordosing and distraction forces to enable fracture reduction and kyphosis correction
  • Schanz pins stronger than pedicle screws
  • Independent correction of kyphosis and shortening
  • Divergent pin application increase the stress shielding resistance 

Disadvantage:

  • In patients with significant vertebral body comminution, additional anterior reconstruction may be needed to prevent implant failures
Posterior short segment fixation with intermediate screws
Main indication Skill Equipment
All A3, A4, B2 fractures with intact pedicles at the level of fracture Some specialized surgical experience Simple surgical and imaging resources

When a fracture needs to be treated surgically, the choice to perform anterior or posterior stabilization or combined MIS or open depends on surgeon's preference.

Indication:

  • All A3, A4, B2 fractures with intact pedicles at the level of fracture

Contraindications:

  • C type fractures
  • Patients not fit for surgery

Advantage:

  • Provides additional biomechanical stability

Disadvantage:

  • In patients with significant vertebral body comminution, additional anterior reconstruction may be needed to prevent implant failures
Posterior long segment fixation
Main indication Skill Equipment
All unstable injuries Some specialized surgical experience Simple surgical and imaging resources

Indication:

  • All unstable injuries

Contraindication:

  • Patient not fit for surgery

Advantages:

  • Highest stability
  • Fast rehabilitation

Disadvantages:

  • Demanding surgery
  • Invasive
MIS Anterior Stabilization
Main indication Skill Equipment
Neurological damage Highly experienced and skilled surgeon Full specialized surgical and imaging resources

When a fracture needs to be treated surgically, the choice to perform anterior or posterior stabilization or combined MIS or open depends on surgeon's preference.

Indications:

  • Symptomatic anterior spinal cord compression from retropulsed bone
  • Symptomatic traumatic disc herniation
  • Unstable burst fracture in the absence of neurologic compromise
  • Compromised bone quality
  • Residual instability following posterior stabilization
  • Residual compression following posterior stabilization
  • Evidence of increasing kyphosis while treated nonoperatively
  • Pincer fracture

Contraindications:

  • Previous anterior surgery placing viscus and vascular structures at risk due to scarring/adhesions
  • Lung, vascular, and abdominal diseases, which make anterior approaches difficult or dangerous
  • Patient not fit for surgery
  • C type fractures

Advantages:

  • Ability to perform short segment fixation
  • Direct visualization of compromised anterior neurologic structures
  • Excellent biomechanical anterior column support
  • Less soft-tissue trauma
  • Less skin incision
  • Less blood loss
  • Earlier rehabilitation
  • Shorter hospital stay
  • Less pain
  • Better function
  • Reduced OR time

Disadvantages:

  • Complex surgical approach
  • Complications of an anterior approach including potential for vascular and organ injuries
  • Anterior standalone procedures may not be as sound biomechanically as multisegmental posterior stabilization procedures
  • Transthoracic procedures may be challenging in patients with concomitant chest injuries
  • Technically demanding, special instruments required
  • Initially high costs
  • Technical drawbacks : Less reduction options, no cross connectors, less visualization, less tactile feedback
  • High radiation exposure
MIS posterior short segment fixation with pedicle screws
Main indication Skill Equipment
A3, A4, B1, B2 fractures without severe anterior column damage Highly experienced and skilled surgeon Full specialized surgical and imaging resources

When a fracture needs to be treated surgically, the choice to perform anterior or posterior stabilization or combined MIS or open depends on surgeon's preference.

Indication:

  • A3, A4, B1, B2 fractures without severe anterior column damage

Contraindications:

  • Severe anterior column damage
  • C type fractures
  • Patients not fit for surgery

Advantages:

  • Common procedure
  • Fast surgery
  • Less soft-tissue trauma
  • Less skin incision
  • Less blood loss
  • Earlier rehabilitation
  • Shorter hospital stay
  • Less pain

Disadvantages:

  • Less stability
  • In patients with significant vertebral body comminution, additional anterior reconstruction may be needed to prevent implant failures
  • Technically demanding
  • High radiation exposure
MIS posterior short segment fixation with Schanz pins
Main indication Skill Equipment
All A2, A3, A4, B1, B2 fractures Highly experienced and skilled surgeon Full specialized surgical and imaging resources

When a fracture needs to be treated surgically, the choice to perform anterior or posterior stabilization or combined MIS or open depends on surgeon's preference.

Indication:

  • All A2, A3, A4, B1, B2 fractures

Contraindications:

  • C type fractures
  • Patients not fit for surgery

Advantages:

  • This system provides strong lordosing and distraction forces to enable fracture reduction and kyphosis correction
  • Schanz pins stronger than pedicle screws
  • Independent correction of kyphosis and shortening
  • Divergent pin application increase the stress shielding resistance
  • Less soft-tissue trauma
  • Less skin incision
  • Less blood loss
  • Earlier rehabilitation
  • Shorter hospital stay
  • Less pain

Disadvantages:

  • In patients with significant vertebral body comminution, additional anterior reconstruction may be needed to prevent implant failures
  • High radiation exposure
*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

v1.0 2014-12-99