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Pipsa Ylanko, AOSpine Global Education Manager

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

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

Thoracic and lumbar trauma - A2

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Glossary

1 Introduction top

Thoracic and lumbar fractures: Posterior short segment fixation with Schanz pins enlarge

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.

2 Closed reduction top

Thoracic and lumbar fractures: Posterior short segment fixation with Schanz pins enlarge

Primary reduction is performed by positioning of the patient onto a frame to create lordosis.


 

3 Reduction with Schanz pins top

Thoracic and lumbar fractures: Posterior short segment fixation with Schanz pins enlarge

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.


Thoracic and lumbar fractures: Posterior short segment fixation with Schanz pins enlarge

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)


Thoracic and lumbar fractures: Posterior short segment fixation with Schanz pins enlarge

The fracture clamps are placed on the proximal and distal Schanz pins.


Thoracic and lumbar fractures: Posterior short segment fixation with Schanz pins enlarge

Rod insertion

The rod is inserted through both the clamps and the whole construct is pushed towards the spine. 


Thoracic and lumbar fractures: Posterior short segment fixation with Schanz pins enlarge

The distance between the two Schanz pins is secured by tightening the rod to the fracture clamps.


Thoracic and lumbar fractures: Posterior short segment fixation with Schanz pins enlarge

Lordosis

The kyphosis is corrected using the Schanz pins restoring the normal lordosis.


Thoracic and lumbar fractures: Posterior short segment fixation with Schanz pins enlarge

The lordotic correction may be applied immediately when there is no posterior wall fragment. 


Thoracic and lumbar fractures: Posterior short segment fixation with Schanz pins enlarge

The angle of the Schanz pins is fixed by tightening the Schanz pins to the fracture clamps.


Thoracic and lumbar fractures: Posterior short segment fixation with Schanz pins enlarge

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.


Thoracic and lumbar fractures: Posterior short segment fixation with Schanz pins enlarge

The distance between the two Schanz pins is secured by tightening the rod to the fracture clamps.


Thoracic and lumbar fractures: Posterior short segment fixation with Schanz pins enlarge

When reduction is achieved, the Schanz pins are cut.


Thoracic and lumbar fractures: Posterior short segment fixation with Schanz pins enlarge

The final construct is shown from a lateral view.

4 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.


Thoracic and lumbar fractures: Posterior short segment fixation with Schanz pins enlarge

Fusion

If the surgeon plans for a fusion, the facet capsule is excised and the joint cartilage surfaces are denuded/ curetted.


Thoracic and lumbar fractures: Posterior short segment fixation with Schanz pins enlarge

Pieces of bone graft (autograft, allograft) are inserted into the decorticated facet joint for fusion.

5 Intraoperative imaging top

enlarge

Prior to wound closure, intraoperative imaging is performed to check the adequacy of reduction, position, and length of pins and the overall coronal and sagittal spinal alignment.

v1.0 2014-12-99