Eur Spine J (2015) 24 (Suppl 8):S955–S956 DOI 10.1007/s00586-015-4330-2
OPEN OPERATING THEATRE (OOT)
Correction of a mobile posttraumatic kyphosis in the thoracolumbar spine with a combined posterior-anterior approach Robert Morrison1 • K. J. Schnake1
Ó Springer-Verlag Berlin Heidelberg 2015
Keywords Posttraumatic kyphosis Minimal-invasive surgery Posterior fixation Anterior corporectomy Vertebral fracture
Introduction Posttraumatic kyphosis can cause persisting pain in patients. When a pseudarthrosis is present, the patients often complain of instability pain [1]. It is localized at the area of the fracture and often worsens during movement or in hyperextension, as when laying on the back. When the radiological diagnostics show any ‘‘flexibility’’ in the kyphosis a posterior fixation and reduction using a pediclescrew based system can be performed. In cases where an extensive anterior defect is present, an additional anterior support using an expandable cage or an autologous bone graft should be carried out. The video demonstrates the percutaneous pedicle-screw placement and closed reduction, and in the second step an anterior, transthoracic reconstruction using an expandable cage.
Electronic supplementary material The online version of this article (doi:10.1007/s00586-015-4330-2) contains supplementary material, which is available to authorized users.
Case description The 70 year old woman had sustained a T12 fracture 4 months ago, which was treated conservatively. She presented herself in our clinic with a kyphotic deformity of about 55° Cobb angle in standing X-rays due to a vertebra plana T12 and a consecutive fracture of L1. The supine fulcrum X-ray showed a reduction of the deformity down to 25°. The CT-scans showed a void with non-union in L1. Patient had no neurological deficit. Preoperative planning revealed a required correction of approximately 30°.
Surgical procedure Due to the patient age and comorbidities we planned a staged surgery. In the first part we performed a percutaneous pedicle screw placement in prone position, as described in the open operating theatre before [2]. The 5.5 mm polyaxial screws were placed via fluoroscopic guidance in T10 and 11 as well as L2 and 3. To achieve precise screw placement, every vertebra has to be configured in a true anterior-posterior view. Each screw in the thoracic spine was augmented with 1.5 cc of PMMA under fluoroscopic guidance in a lateral view. The screws in the lumbar spine were augmented with 2 cc each. Due to the partial reduction in the supine position, the rest of the reduction could be accomplished over the rod, leaving a residual local kyphosis of about 15°. Watch surgery online
& Robert Morrison [email protected] 1
Scho¨n Klinik Nu¨rnberg, Fu¨rth, Germany
123
S956
After 2 days of recovery we returned to the OR to perform an anterior reconstruction of T12 via a left-lateral transthoracic approach. The surgery was performed as a thoracoscopically assisted mini-open procedure. First a 7 cm long incision was placed over the rib, laying directly over the fractured vertebra. After dissection of the intercostal musculature, the thorax is opened and the left lung is deflated through a double-lumen tube. The disc spaces adjoining the fractured vertebra are marked with K-wires and controlled via fluoroscopy. Then the segmental arteries are coagulated and the vertebra along with the discs are partially removed with a chisel. The correct size of implant is measured and the cage is implanted and expanded to fit the void. The largest possible endplates are used to minimize the chance of subsidence. To further stabilize the situation, the adjoining endplates are augmented with PMMA using a vertebroplasty needle. The cage is covered with bone substitutes and local bone. Via the portal of the thoracoscope, a thoracic drain is placed. The left lung is inflated again, and after it is completely inflated the thorax is closed. Wound closure is completed by suturing of the fascia, subcutaneous tissue, and the skin itself.
Eur Spine J (2015) 24 (Suppl 8):S955–S956
Discussion and conclusion In cases of flexible deformities, correction can be reached with posterior osteotomies but the procedures are typically accompanied with a high rate of complications [3]. Especially in the thoracolumbar region a combined posterioranterior procedure can be a possible alternative. In the presented case the instability within the L1 fracture due to a void was obvious in the CT scans. Thus, we could achieve a stable situation and a good restoration of the sagittal profile with posterior fixation followed by an anterior corpectomy and cage implantation. Due to the poor bone quality not only the screws were augmented, but additionally the endplates adjoining to the expandable cage. The endplate augmentation can help to prevent cage subsidence. In cases with poor bone quality at least 4 screws on each side (cranial ? caudal) of the kyphosis are mandatory. Performing a minimal-invasive, staged surgery keeps the surgical burden for the elderly patient low. The complication rate of anterior thoracoscopic surgeries is rather low [4]. Compliance with ethical standards Conflict of interest
None.
Postoperative course References The patient could be mobilized into a sitting position the day after the surgery. The thoracic drain was under suction with 15 mmHg and could be removed the following day after radiological control. The patient needed no orthosis. Upright standing radiographs were performed as soon as the patient could stand freely. A good local correction to about 8° kyphosis was reached. The patient was discharged 10 days after the surgery and was seen for follow-up after 6 and 12 weeks. At this time radiological examinations were routinely performed. The wounds were dry, with no signs of an infection.
123
1. Gertzbein SD (1992) Scoliosis Research Society. Multicenter spine fracture study. Spine (Phila Pa 1976) 17:528–540 2. Hansen-Algenstaedt N, Scha¨fer C, Beyerlein J, Wiesner L, Knight R (2012) Percutaneous multilevel reconstruction in revision surgery. Eur Spine J 21:1220–1222 3. Bianco K, Norton R, Schwab F et al (2014) Complications and intercenter variability of three-column osteotomies for spinal deformity surgery: a retrospective review of 423 patients. Neurosurg Focus 36:E18 4. Khoo LT, Beisse R, Potulski M (2002) Thoracoscopic-assisted treatment of thoracic and lumbar fractures: a series of 371 consecutive cases. Neurosurgery 51(5 Suppl):S104–S117
OPEN OPERATING THEATRE (OOT)
Correction of a mobile posttraumatic kyphosis in the thoracolumbar spine with a combined posterior-anterior approach Robert Morrison1 • K. J. Schnake1
Ó Springer-Verlag Berlin Heidelberg 2015
Keywords Posttraumatic kyphosis Minimal-invasive surgery Posterior fixation Anterior corporectomy Vertebral fracture
Introduction Posttraumatic kyphosis can cause persisting pain in patients. When a pseudarthrosis is present, the patients often complain of instability pain [1]. It is localized at the area of the fracture and often worsens during movement or in hyperextension, as when laying on the back. When the radiological diagnostics show any ‘‘flexibility’’ in the kyphosis a posterior fixation and reduction using a pediclescrew based system can be performed. In cases where an extensive anterior defect is present, an additional anterior support using an expandable cage or an autologous bone graft should be carried out. The video demonstrates the percutaneous pedicle-screw placement and closed reduction, and in the second step an anterior, transthoracic reconstruction using an expandable cage.
Electronic supplementary material The online version of this article (doi:10.1007/s00586-015-4330-2) contains supplementary material, which is available to authorized users.
Case description The 70 year old woman had sustained a T12 fracture 4 months ago, which was treated conservatively. She presented herself in our clinic with a kyphotic deformity of about 55° Cobb angle in standing X-rays due to a vertebra plana T12 and a consecutive fracture of L1. The supine fulcrum X-ray showed a reduction of the deformity down to 25°. The CT-scans showed a void with non-union in L1. Patient had no neurological deficit. Preoperative planning revealed a required correction of approximately 30°.
Surgical procedure Due to the patient age and comorbidities we planned a staged surgery. In the first part we performed a percutaneous pedicle screw placement in prone position, as described in the open operating theatre before [2]. The 5.5 mm polyaxial screws were placed via fluoroscopic guidance in T10 and 11 as well as L2 and 3. To achieve precise screw placement, every vertebra has to be configured in a true anterior-posterior view. Each screw in the thoracic spine was augmented with 1.5 cc of PMMA under fluoroscopic guidance in a lateral view. The screws in the lumbar spine were augmented with 2 cc each. Due to the partial reduction in the supine position, the rest of the reduction could be accomplished over the rod, leaving a residual local kyphosis of about 15°. Watch surgery online
& Robert Morrison [email protected] 1
Scho¨n Klinik Nu¨rnberg, Fu¨rth, Germany
123
S956
After 2 days of recovery we returned to the OR to perform an anterior reconstruction of T12 via a left-lateral transthoracic approach. The surgery was performed as a thoracoscopically assisted mini-open procedure. First a 7 cm long incision was placed over the rib, laying directly over the fractured vertebra. After dissection of the intercostal musculature, the thorax is opened and the left lung is deflated through a double-lumen tube. The disc spaces adjoining the fractured vertebra are marked with K-wires and controlled via fluoroscopy. Then the segmental arteries are coagulated and the vertebra along with the discs are partially removed with a chisel. The correct size of implant is measured and the cage is implanted and expanded to fit the void. The largest possible endplates are used to minimize the chance of subsidence. To further stabilize the situation, the adjoining endplates are augmented with PMMA using a vertebroplasty needle. The cage is covered with bone substitutes and local bone. Via the portal of the thoracoscope, a thoracic drain is placed. The left lung is inflated again, and after it is completely inflated the thorax is closed. Wound closure is completed by suturing of the fascia, subcutaneous tissue, and the skin itself.
Eur Spine J (2015) 24 (Suppl 8):S955–S956
Discussion and conclusion In cases of flexible deformities, correction can be reached with posterior osteotomies but the procedures are typically accompanied with a high rate of complications [3]. Especially in the thoracolumbar region a combined posterioranterior procedure can be a possible alternative. In the presented case the instability within the L1 fracture due to a void was obvious in the CT scans. Thus, we could achieve a stable situation and a good restoration of the sagittal profile with posterior fixation followed by an anterior corpectomy and cage implantation. Due to the poor bone quality not only the screws were augmented, but additionally the endplates adjoining to the expandable cage. The endplate augmentation can help to prevent cage subsidence. In cases with poor bone quality at least 4 screws on each side (cranial ? caudal) of the kyphosis are mandatory. Performing a minimal-invasive, staged surgery keeps the surgical burden for the elderly patient low. The complication rate of anterior thoracoscopic surgeries is rather low [4]. Compliance with ethical standards Conflict of interest
None.
Postoperative course References The patient could be mobilized into a sitting position the day after the surgery. The thoracic drain was under suction with 15 mmHg and could be removed the following day after radiological control. The patient needed no orthosis. Upright standing radiographs were performed as soon as the patient could stand freely. A good local correction to about 8° kyphosis was reached. The patient was discharged 10 days after the surgery and was seen for follow-up after 6 and 12 weeks. At this time radiological examinations were routinely performed. The wounds were dry, with no signs of an infection.
123
1. Gertzbein SD (1992) Scoliosis Research Society. Multicenter spine fracture study. Spine (Phila Pa 1976) 17:528–540 2. Hansen-Algenstaedt N, Scha¨fer C, Beyerlein J, Wiesner L, Knight R (2012) Percutaneous multilevel reconstruction in revision surgery. Eur Spine J 21:1220–1222 3. Bianco K, Norton R, Schwab F et al (2014) Complications and intercenter variability of three-column osteotomies for spinal deformity surgery: a retrospective review of 423 patients. Neurosurg Focus 36:E18 4. Khoo LT, Beisse R, Potulski M (2002) Thoracoscopic-assisted treatment of thoracic and lumbar fractures: a series of 371 consecutive cases. Neurosurgery 51(5 Suppl):S104–S117
