When to Operate on a Neurologically Intact Burst Fracture Gregory - PowerPoint PPT Presentation

When to Operate on a Neurologically Intact Burst Fracture Gregory D. Schroeder, MD Assistant Professor, Orthopaedic Surgery The Rothman Institute at Thomas Jefferson University

Disclosures – Consult for Advance Medical and Zimmer Biomet – Grants from OREF, Medtronic – Research support and travel payment from AOSpine – Executive editor CSS

A3/A4 Fracutres • Compression type fractures account for 60% of thoracolumbar fractures • No universally accepted classification  disagreement about the ideal treatment Vaccaro. 2013. Spine; Denis. 1983. Spine; Gertzbein. Spine. 1992; Magerl. ESJ. 1994

Classifications • Denis. Spine. 1983 • Divided the spine into an anterior, middle 3 and posterior column 1 2 • Anterior- ALL , anterior 2/3 body • Middle - post 1/3 body, PLL • Posterior- all structures posterior to PLL • Any fracture involving the middle column is unstable • All burst fractures unstable

Classifications • Magerl. ESJ. 1994 • Did not change the treatment of burst fractures • Did not alter the perceived importance of the middle column of the spine for stability • 53 Subtypes • Comprehensive, but its complexity has limited its routine use in clinical practice • Kappa = 0.31 (slight agreement) with CT Oner. ESJ. 2002

Classifications • TLICS. Vaccaro. Spine 2005 • 1 st major classification to repudiate the assertion by Denis that all burst fractures are unstable • Only stable if PLC intact • Surgeons unable to agree if PLC intact • Schroeder. Global Spine Journal. 2015 • Kappa = 0.11 (slight agreement) for compression type fractures

AOSpine Thoracolumbar Injury Classification System • Vaccaro. Spine 2013 • AOSpine thoracolumbar spine injury classification system: fracture description, neurological status, and key modifiers.

AOSpine Thoracolumbar Injury Classification System AOSpine Thoracolumbar Injury Classification System Morphology A--Com pression I njuries A0 No injury/ process fracture A1 Wedge / Impaction fracture A2 Split / Pincer Injury A3 Incomplete burst A4 Complete burst fracture B--Tension band injuries B1 Transosseous disruption (Bony Chance Fx) B2 Posterior ligamentous disruption B3 Anterior ligamentous disruption C--Translational injury Vaccaro. 2013. Spine

AOSpine Thoracolumbar Injury Classification System

AOSpine Thoracolumbar Injury Classification System

AOSpine Thoracolumbar Injury Classification System

AOTL Surgical Algorithm • Vaccaro and Schroeder. ESJ. 2016 • Survey of all AOSpine members on the treatment of fractures with a controversial treatment – A2N0M0 – Every controversial iteration of A3 & A4 – Every controversial iteration of B1 & B2 • Fractures that were not controversial, such as all C type fractures or fractures with an incomplete spinal cord injury were excluded

AOTL Surgical Algorithm South Middle North Europe Asia America East America Africa Global TL (% ) (% ) (% ) (% ) (% ) (% ) (% ) P Value AOSI S 24 20 56 A2N0 (13.8) 7 (7.5) (17.2) 4 (8.9) 0 (0.0) 1 (6.3) (11.6) 0.02† 2 22 14 17 57 A3N0M0 (12.6) (15.1) (14.7) 3 (6.7) 0 (0.0) 1 (6.3) (11.8) 0.07 3 117 57 77 31 16 11 309 A3N0M1 (67.2) (61.3) (66.4) (68.9) (41.0) (68.8) (64.0) 0.06 4 74 27 59 14 180 A3N1M0 (42.5) (29.0) (50.9) (31.1) 2 (5.1) 4 (25.0) (37.3) 0.0001† 4 146 78 99 35 21 12 391 A3N1M1 (83.9) (83.9) (85.3) (77.8) (53.8) (75.0) (81.0) 0.002† 5 130 54 95 27 10 12 328 A3N2M0 (74.7) (58.1) (81.9) (60.0) (25.6) (75.0) (67.9) 0.0001† 5 154 79 113 40 31 14 431 A3N2M1 (88.5) (84.9) (97.4) (88.9) (79.5) (87.5) (89.2) 0.005† 6

AOTL Surgical Algorithm South Middle North Europe Asia America East America Africa Global TL (% ) (% ) (% ) (% ) (% ) (% ) (% ) P Value AOSI S 80 26 60 18 190 0.0001* A4N0M0 (46.0) (28.0) (51.7) (40.0) 0 (0.0) 6 (37.5) † 5 (39.3) 142 60 95 36 19 359 0.0001* A4N0M1 (81.6) (64.5) (81.9) (80.0) (48.7) 7 (43.8) † 6 (74.3) 108 56 81 27 289 0.0001* A4N1M0 (62.1) (60.2) (69.8) (60.0) 7 (17.9) 10 (62.5) (59.8) † 6 144 72 104 37 23 394 A4N1M1 (82.8) (77.4) (89.7) (82.2) (59.0) 14 (87.5) (81.6) 0.002† 7 137 61 98 (84.5 33 14 357 A4N2M0 (78.7) (65.6) ) (73.3) (35.9) 14 (87.5) (73.9) 0.0001† 7 163 81 111 42 35 447 A4N2M1 (93.7) (87.1) (95.7) (93.3) (89.7) 15 (93.8) (92.5) 0.25 8

• What does the scientific literature say?

Prospective Randomized Studies Shen et al Wood et al Siebenga et al Non-Operative Operative Non-Operative Operative Non-Operative Operative Final Focal Kyphosis 24° 12° 13.8° 13° 19.5°* 8.4°* Final VAS 1.5 1.8 1.9 3.3 2.8* 1.3* Return to Work 86% 90% 74% 42% 38%* 85%* Complications 0% 12% 9%* 79%* 20% 29% 4x more expensive than 1/4 the cost of conservative Cost surgery* care* $11,264* $49,063* Not Recorded Not Recorded Functional Outcomes Greenough low 2 back score 65 61 - - - - SF-36 Phys 2 Function - - 86* 63* - - RMDQ-24 disability score 1 for LBP - - - - 8 9* 3 1*

Prospective Randomized Studies • Wood. JBJS. 2015 • 47 consecutive patients • Long-term follow up • Average of eighteen years (range, sixteen to twenty-two years) • Kyphosis • 13 ° —operative treatment; 19 ° —nonoperative (p > 0.05) • VAS Back • 4.0—operative treatment; 1.5—nonoperative (p < 0.001) • ODI • 20—operative treatment; 2—nonoperative (p < 0.001)

Prospective Randomized Studies • Abudou. Cochrane Database Syst Rev. 2013 • Uses only prospective randomized trials • There is not enough data to determine if operative or nonoperative treatment leads to superior clinical outcomes

A3/A4 • Avilés. Medwave. 2016 (Spain) • Meta-analysis. • Operative treatment may decrease the risk of neurologic impairment, but in turn, could increase the risk of general complications. • Unclear • Differences in pain reduction, • Improvement in function and quality of life, • Need for subsequent surgery • Radiographic progression of kyphosis in both groups.

The Use of a Brace • Bailey. The Spine Journal. 2013 (CANADA) • 110 patients with a thoracolumbar burst fracture who were treated non-operatively either with or without a brace • No difference in Roland Morris Disability Questionnaire score three months after the fracture regardless of treatment • Urquhart. JNS Spine. 2017 • Long term follow up (average 7.9 years) on 36 patients from above study • 16 TLSO, 20 no TLSO • No difference in HRQOL or kyphosis

Operative Treatment • Reinhold. ESJ. 2010 (GERMANY) • Operative treatment of 424 compression type fractures • All operative. Not even a nonoperative cohort • Posterior only procedure  improved functional and subjective outcomes • A combined anterior/posterior approach  best radiographic results

Operative Treatment • Schnake. JNS Spine. 2014 (GERMANY) • 5 year follow up of 45 patients with a combined AP surgery • Average loss of lordosis of only 2.4 ° • 96% of patients were ambulatory • 71% required no pain medications • 67% were back at work

Operative Treatment • Spiegl. Eur J Trauma Emerg Surg. 2017 (GERMANY) • Review article that concludes • “A 360 ° -stabilization in osteoporotic vertebral fractures of the thoracolumbar spine is indicated in patients with acute or subacute fracture situation and relevant lesion of the posterior cortex, and in patients with severe kyphotic malalignment (>20 ° )”

MIS • What about MIS???

Operative Treatment • Li. International Journal of Surgery. 2016 • Retrospective review of 37 patients with MIS stabilization and vertebroplasty for a burst fracture • Average follow up of 27.54 ± 2.47 months • VAS 9  2 • No hardware failure or complications • Alignment • Kyphosis 22.58 ± 1.70 ° before surgery • 4.11 ± 1.41 ° immediately after surgery • 5.06 ± 1.11 ° at 2-year follow-up.

Operative Treatment • Proietti. Orthopaedics & Traumatology: Surgery & Research. 2014 • Retrospective review of 63 patients with MIS stabilization for a burst fracture • Average operative blood loss was 82 mL • Mean pre-operative segmental kyphosis was was 13.3 • Postoperateive Kyphosis 5.0 • Not statistically significant correction loss was registered at 1-year minimum follow-up.

Operative Treatment • Proietti. Orthopaedics & Traumatology: Surgery & Research. 2014

Operative Treatment • Proietti. Orthopaedics & Traumatology: Surgery & Research. 2014

Operative Treatment • Takami. Eur J Orthop Surg Traumatol. 2014 • Retrospective review of 21 patients with MIS stabilization and cement augmentation for a burst fracture • OR time was 95.7 min • Average blood loss was 38.6 mL • Average correction angle was 9.6. • No surgical complications

Operative Treatment • Landi. ESJ. 2014 • Retrospective review of 50 patients treated non- operatively or with MIS stabilization • Magerl type A.3 (Burst fracture) • Single level • McCormack score had to be 6 or less • Spinal canal invasion had to be 25 %