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

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

Thoracic and lumbar trauma - A4

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Glossary

1 Introduction top

Thoracic and Lumbar fractures: MIS posterior short segment fixation with pedicle screws enlarge

Preliminary remarks

MIS reduces the surgical trauma for the patient, potentially resulting in a quicker recovery while providing similar clinical mid to long term results.


Decompression

In cases where neurological deficit is observed and compression of the spinal canal is assumed, decompression has to be performed. It should be understood that this is a step that can also result in deterioration of neurology unless very meticulously performed.

Decompression can be performed anteriorly or posteriorly. Posteriorly decompression can be indirect or direct.
Indirect decompression may be tried before performing direct decompression. 

Please refer to Decompression techniques for a detailed discussion of indications for the posterior decompression techniques. ( Posterior decompression)

2 Closed reduction top

Thoracic and Lumbar fractures: MIS posterior short segment fixation with pedicle screws enlarge

Primary reduction is performed by positioning of the patient onto a frame to create lordosis or kyphosis as needed by the fracture type and the level of the injury.

3 Reduction with pedicle screws (MIS) top

Thoracic and Lumbar fractures: MIS posterior short segment fixation with pedicle screws 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 differently.


Thoracic and Lumbar fractures: MIS posterior short segment fixation with pedicle screws enlarge

Pitfall: Multisegmental stabilization

In the thoracic spine, multisegmental stabilization is recommended, because reduction is more complicated and loss of mobility is less critical due to the relative rigidity of the thoracic spine.

If multisegmental stabilization is necessary, add screws in the adjacent caudal and cranial vertebrae.


Thoracic and Lumbar fractures: MIS posterior short segment fixation with pedicle screws enlarge

Pedicle screw insertion

Pedicle screws are inserted into the vertebrae cephalad and caudal to the fracture level on both sides. Mono- or polyaxial top or side loading screws can be used in any combination. ( Pedicle screw insertion)


Thoracic and Lumbar fractures: MIS posterior short segment fixation with pedicle screws enlarge

Rod contouring

The amount of lordotic/kyphotic reduction is defined by the pre-bending of the rod. This restores the height of the vertebral body, especially in the anterior part.

Multiple attempts to bend the rod correctly might be necessary.


Thoracic and Lumbar fractures: MIS posterior short segment fixation with pedicle screws enlarge

Rod insertion

The rods are introduced to the distal screw heads on both sides and tightened.


Thoracic and Lumbar fractures: MIS posterior short segment fixation with pedicle screws enlarge

The rod is then inserted into the proximal screw heads without tightening.


Decompression

If it is decided to perform an indirect decompression, this is done at this stage. If indirect decompression proves to be insufficient, a direct decompression eg, posterior or transpedicular decompressions are undertaken. Refer to the Posterior Decompression techniques for detailed instructions. ( Posterior decompression)

4 Distraction top

Thoracic and Lumbar fractures: MIS posterior short segment fixation with pedicle screws enlarge

Monoaxial toploading screws

Distraction of the monoaxial screws is performed using a distraction device. This restores the height of the vertebral body, especially in the posterior part.


Thoracic and Lumbar fractures: MIS posterior short segment fixation with pedicle screws enlarge

Polyaxial toploading screws

Polyaxial toploading fixation should only be used if adequate closed reduction could be achieved.

Lordotic/kyphotic reduction is not possible with polyaxial toploading screws.


Thoracic and Lumbar fractures: MIS posterior short segment fixation with pedicle screws enlarge

Distraction of the fractured vertebra using polyaxial screws is performed using a distraction device.


Thoracic and Lumbar fractures: MIS posterior short segment fixation with pedicle screws enlarge

The screw heads are tightened with the inner nuts to secure the reduction achieved.


Thoracic and Lumbar fractures: MIS posterior short segment fixation with pedicle screws enlarge

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.


Thoracic and lumbar fractures: MIS posterior short segment fixation with pedicle screws enlarge

Nonfusion

For nonfusion surgeries, the facet joint capsule is preserved during the entire procedure.

The screws can be removed after 9 months once the fracture has healed.

6 Intraoperative imaging top

Thoracic and lumbar fractures: MIS posterior short segment fixation with pedicle screws enlarge

Prior to wound closure, intra-operative imaging is performed to check the adequacy of reduction, position and length of screws and the overall coronal and sagittal spinal alignment.

v1.0 2014-12-99