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Thoracolumbar Burst Fractures
Posted: May 25 2021 #(C101759)
A

L2 Burst Fracture with Neurologic Deficits in 45F

HPI

The patient is a 45-year-old female that fell off her horse yesterday while doing a recreational ride. Immediately after the fall, she had severe pain in her back, making it almost impossible for her to move. She was brought to the ER by EMT. Upon seeing the patient, she complained of pain in her neck, pain in her back, and numbness and tingling primarily in her right leg and bilateral buttocks, and a sensation of "heaviness" in her bilateral lower extremities. She denied abnormal sensations in her perineum.

PMH

Factor V deficiency

PE

Inspection and palpation of the back shows TTP of TL region. No abrasions or lacerations. She has decreased sensation in the region of the buttocks bilaterally. She has normal sensation in the perineum. Rectal exam deferred. LUE: Normal RUE: 4 of 5 deltoid 4 of biceps 5 of 5 BR 5 of 5 Triceps Neg Hoff Examination of her RIGHT lower extremity shows: ~3-4 HF 4 of 5 KE 4 of 5 ADF 4- of 5 APF Normal Patellar Reflexes Neg Bab Examination of her LEFT lower extremity shows: ~3-4 HF 4 of 5 KE 4 of 5 ADF 4+ of 5 APF Normal Patellar Reflexes Neg Bab.

Poll
1 of 13
1. In addition to a CT chest/abdomen/pelvis ordered by the trauma team, what additional imaging studies would you obtain to dictate management?
None
15%
177/1176
Additional radiographs (aXR) (ie. Lumbar Flex and Ext)
1%
20/1176
Fine Cut Lumbar CT (LCT)
4%
57/1176
MRI Lumbar
49%
580/1176
aXR + LCT
0%
11/1176
LCT + MRI
12%
144/1176
aXR + MRI
3%
47/1176
aXR + LCT + MRI
5%
62/1176
Outside my area of expertise - best if I don't vote
6%
78/1176
2. Would you use a classification system for this injury to guide management?
No - a classification system would not help me
15%
164/1053
Yes - Dennis
16%
171/1053
Yes - TLCIS
51%
538/1053
Yes - Other
6%
67/1053
Outside my area of expertise - best if I don't vote
10%
113/1053
3. How would you manage this fracture?
Nonoperative
2%
25/1140
Operative
93%
1068/1140
Outside my area of expertise - best if I don't vote
4%
47/1140
4. The accident occurred around 5 pm in the afternoon. The MRI was not completed until 10 pm. If you choose Operative management when would you do the case?
I would not choose Operative management
0%
10/1090
Same night (middle of night)
30%
337/1090
First case following morning - bump other scheduled cases
47%
518/1090
Add case to end of following day schedule (~ 4pm following day)
4%
51/1090
Next open OR slot within 48 hours
11%
125/1090
Outside my area of expertise - best if I dont vote
4%
49/1090
5. If you choose Operative Management, what approach would you use?
I would not choose Operative management
0%
5/1093
Anterior Only (includes direct lateral)
3%
39/1093
Posterior Only
69%
755/1093
Combined Anterior + Posterior
18%
205/1093
Outside my area of expertise - best if I don't vote
8%
89/1093
6. If you choose a Posterior Only Procedure, what would you do?
I would not choose a Posterior Only procedure
2%
27/1033
Instrumented Fusion Only (no decompression)
4%
51/1033
Decompression Only (no fusion)
2%
30/1033
Decompression + Instrumented Fusion
84%
875/1033
Outside my area of expertise - best if I don't vote
4%
50/1033
7. If you choose a Posterior Decompression + Fusion, how would you perform the decompression?
I would not perform a Posterior Decompression + Fusion
2%
29/1018
L2 Laminectomy Only
15%
154/1018
L2 Laminectomy + Retropulsed Fracture Reduction (push anterior)
51%
523/1018
L2 Laminectomy + L2 Corpectomy + Cage Placement from Posterior
22%
228/1018
Outside my area of expertise - best if I don't vote
8%
84/1018
8. If you choose a Posterior Decompression & Fusion with L2 laminectomy +/- fracture reduction, what levels would you instrument to?
I would not perform a Posterior Decompression & Fusion with L2 laminectomy
1%
18/955
One Above/Below (L1-L3 PSF)(Short Segment)
39%
379/955
Two Above/Below (T12-L4 PSF)
50%
484/955
Three Above/Below (T11-L5 PSF)
1%
18/955
Outside my area of expertise - best if I don't vote
5%
56/955
9. If you choose a Posterior Decompression & Fusion and instrumented Two Above/Below (T12-L4 PSF), what levels would you actually fuse (decorticate bone) vs. instrument?
I would not perform Posterior Decompression & Fusion
1%
15/893
No fusion, only instrumentation
13%
121/893
"Fuse Short (Decorticate L1-3) Instrumented Long" (T12-L4)
55%
492/893
"Fuse Long" (Decorticate from T12-L4)
20%
185/893
Outside my area of expertise - best if I don't vote
8%
80/893
10. If you choose to Fuse Short (L1-3) Instrumented Long (T12-L4) with Percutaneous Screws, would you remove your hardware?
I would not Fuse Short (L1-3) Instrumented Long (T12-L4) with Percutaneous Screws
6%
52/805
No - leave all screws in forever unless symptomatic
48%
387/805
Yes - Remove Distal screws Only (T12, L4, cut rods) at 3 months
0%
6/805
Yes - Remove Distal screws Only (T12, L4, cut rods) at 6 months
3%
25/805
Yes - Remove Distal screws Only (T12, L4, cut rods) at 12 months
8%
72/805
Yes - Remove All Screws and Rods at 3 months
0%
3/805
Yes - Remove All Screws and Rods at 6 months
3%
30/805
Yes - Remove All Screws and Rods at 12 months
18%
147/805
Outside my area of expertise - best if I don't vote
10%
83/805
11. If performing Posterior instrumentation 2 levels above and below, what pedicle screw technique would you use?
I would not instrument posterior 2 levels above and below
2%
20/806
Percutaneous Screws - Using Fluoro
16%
133/806
Percutaneous Screws - Using Intraoperative CT Navigation (no robot)
6%
55/806
Percutaneous Screws - Using Navigated Robot
2%
17/806
Open Screws - Using Anatomic Technique
25%
206/806
Open Screws - Using Fluoro
29%
237/806
Open Screws - Using Intraoperative CT Navigation (no robot)
6%
50/806
Open Screws - Using Navigated Robot
1%
10/806
Outside my area of expertise - best if I don't vote
9%
78/806
12. If you choose an Anterior-Posterior Procedure with an Anterior L2 Corpectomy and Cage, what levels would you instrument to posteriorly?
I would not perform an Anterior-Posterior Procedure with an Anterior L2 Corpectomy and Cage
23%
176/756
One Above/Below (L1-L3 PSF)
34%
264/756
Two Above/Below (T12-L4 PSF)
30%
233/756
Three Above/Below (T11-L5 PSF)
2%
17/756
Outside my area of expertise - best if I don't vote
8%
66/756
13. If you performed a Posterior L2 corpectomy and expandable cage, would you be willing to sacrifice the L2 nerve root to get your cage in?
I would not perform a Posterior corpectomy and cage
22%
165/739
No - I would absolutely not sacrifice the L2 nerve root
59%
438/739
Yes - if I had to (try to place cage without taking it first)
8%
61/739
Yes - I would plan on sacrificing to place cage
0%
5/739
Outside my area of expertise - best if I don't vote
9%
70/739
PROCEDURE #1 DOP: 5/8/2021

Posterior Decompression with L2 laminectomy and fracture reduction (push retropulsed bone anterior), T12-L4 Instrumentation with Navigated Percutaneous Screws, Arthrodesis from L1-L3

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