1 Introduction top
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Preliminary remarks
Type A2 injuries are vertebral body fractures in which the fracture involves both endplates.
These can be called split- or pincer-type fractures.
Minimally invasive surgery
MIS reduces the surgical trauma for the patient, potentially resulting in a quicker recovery while providing similar clinical mid to long term results.
Repair of dural laceration
More details on repair of dural laceration can be found here.
2 Patient preparation and approach top
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Percutaneous posterior approach for pedicle screw placement is used together with the appropriate patient preparation.
3 Closed reduction top
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Primary reduction is performed by positioning of the patient onto a frame to create lordosis.
4 Reduction with Schanz pins top
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Preliminary remarks
Due to the fact that bilateral instrumentation is necessary in all cases, all steps described below are repeated on the opposite side, unless described otherwise.
Pitfall: Multisegmental fixation
In the thoracic spine, multisegmental stabilization is necessary in general.
If this is the case, pedicle screws have to be used instead of Schanz pins.
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Schanz pin insertion
In patients with significant kyphosis, PSSF-SS can be used to achieve better fracture reduction and lordosis.
Schanz pins are inserted into the vertebrae cephalad and caudal to the fracture level on both sides, using the starting point and trajectory as described in pedicle screws. ( Schanz pin insertion)
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The fracture clamps are placed on the proximal and distal Schanz pins.
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Rod insertion
The rod is inserted through both the clamps and the whole construct is pushed towards the spine.
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The distance between the two Schanz pins is secured by tightening the rod to the fracture clamps.
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Lordosis
The kyphosis is corrected using the Schanz pins restoring the normal lordosis.
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The lordotic correction may be applied immediately when there is no posterior wall fragment.
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The angle of the Schanz pins is fixed by tightening the Schanz pins to the fracture clamps.
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Distraction
The rod fixation is released from the fracture clamp and distraction of the Schanz pins is performed using a distraction device or the C-washer. This restores the height of the vertebral body, especially in the posterior part.
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The distance between the two Schanz pins is secured by tightening the rod to the fracture clamps.
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When reduction is achieved, the Schanz pins are cut.
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The final construct is shown from a lateral view.
5 Fusion top
Decision
Although fusion was routinely performed for all spinal fractures, its indications are now being restricted to fractures that are highly unstable.
Nonfusion fixations can be performed for A3, A4, and B1 type injuries.
Fusion is routinely performed for A2, B2, B3, and all C injuries as they are unstable injuries with extensive soft tissue and ligamentous disruption.
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Fusion
If the surgeon plans for a fusion, the facet capsule is excised and the joint cartilage surfaces are denuded/ curetted.
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Pieces of bone graft (autograft, allograft) are inserted into the decorticated facet joint for fusion.
