Posted: Jan 2 2020 #(C101350) 2019 Orthopaedic Summit Evolving Techniques

L2 Burst with Urinary Retention 18 months after Injury in 41M

HPI

5/6/2018 Patient fell from ladder in May of 2018. At that time he presented to the ER with back pain only. He denied subjective weakness in lower extremity or bowel or bladder symptoms. Physical exam shows he is neurologically intact. After a discussion regarding treatment options, he elected to proceed with nonoperative treatment in a TLSO. 7/1/18 He was watched radiographically and clinical over first 8 weeks and there was no progression of his kyphosis or clinical symptoms. His exam remained intact. 7/6/2019 The patient presents with persistent back pain, and some feeling of weakness to hip flexion and pain in anterior thighs. He denies any bowel or bladder symptoms. Physical exam shows some trace weakness to b/l hip flexion only, full strength in all other motor groups. Transforaminal selective nerve root injections a L2/3 improved his pain in the anterior thighs. 12/15/19 The patient presents to the emergency room with bladder symptoms, and reports he is told he has urinary retention due to his fracture.

PMH

Obese. Diabetes. Recent bariatric surgery.

Current Exam 4/4 bilateral hip flexion 5-/5 bilateral Knee Extension 5/5 APF/ADF bilaterally Normal reflexes

Poll

1 of 12

1. Now that it is 18 months years after his initial fracture, and he has progressive back pain, some hip flexion weakness, and reports of urinary retention, how would you treat this patient at this time?

Nonoperative

16/747

Operative

91%

680/747

Outside my area of expertise - best if I don't vote

51/747

2. If you choose operative treatment at this time, how would you approach this?

Anterior Only

27/689

Posterior Only

40%

278/689

Anterior-Posterior (L2 corpectomy)

43%

301/689

Outside my area of expertise - best if I don't vote

12%

83/689

3. If you choose an Anterior-Posterior (L2 corpectomy), what anterior approach would you use?

Standard Retroperitoneal - Left Side

20%

125/603

Standard Retroperitoneal - Right Side

45/603

Direct Lateral (e.g., XLIF) - Left Side

13%

80/603

Direct Lateral (e.g., XLIF) - Right Side

25/603

Oblique Lateral (e.g, OLIF) - Left Side

47/603

Oblique Lateral (e.g, OLIF) - Right Side

17/603

I would NOT do a Anterior-Posterior (L2 corpectomy)

19%

117/603

Outside my area of expertise - best if I don't vote

24%

147/603

4. If you choose an Anterior-Posterior (L2 corpectomy), would you have an approach surgeon (e.g., vascular surgeon) assist you during the anterior part?

Yes - assist approach surgeon - retroperitoneal

29%

154/523

Yes - assist approach surgeon - direct lateral (XLIF)

42/523

Yes - assist approach surgeon - oblique lateral (OLIF)

25/523

No - standard retroperitoneal approach Alone

46/523

No - direct lateral (XLIF) Alone

39/523

No - obique lateral (OLIF) Alone

17/523

I would NOT do a Anterior-Posterior (L2 corpectomy)

16%

88/523

Outside my area of expertise - best if I don't vote

21%

112/523

5. If you choose an Anterior-Posterior (L2 corpectomy), how would you do your decompression for stenosis at L2?

None (no laminectomy, leave posterior cortex of L2, rely on resortation of alignement))

10/468

Decompress from FRONT (remove posterior cortex during corpectomy)

21%

99/468

Decompress from BACK (L2 laminectomy, do not remove posterior cortex during corpectomy)

18%

87/468

Decompress from FRONT & BACK (L2 laminectomy, remove posterior cortex during corpectomy)

26%

126/468

I would NOT do a Anterior-Posterior (L2 corpectomy)

15%

73/468

Outside my area of expertise - best if I don't vote

15%

73/468

6. If you choose an Anterior-Posterior (L2 corpectomy), how would you instrument and fuse from the back?

Instrument & Fusion TWO levels above and below

33%

142/426

Instrument & Fusion ONE level above and below

23%

101/426

Instrument TWO levels above and below, fuse ONE level above and below (instrument long, fuse short)

18%

80/426

I would NOT do a Anterior-Posterior (L2 corpectomy)

12%

54/426

Outside my area of expertise - best if I don't vote

11%

49/426

7. If you choose an Anterior-Posterior (L2 corpectomy), would you do the anterior or posterior first, and would you do it all in the same day?

Anterior First - then posterior - same day

45%

186/412

Posterior first - then anterior - same day

12%

53/412

Anterior First - then posterior - different days

26/412

Posterior first - then anterior - different day

28/412

I would NOT do a Anterior-Posterior (L2 corpectomy)

15%

62/412

Outside my area of expertise - best if I don't vote

13%

57/412

8. If you performed an Anterior-Posterior (L2 corpectomy + cage), would you put BMP in the cage?

No - I would not use BMP in the cage

28%

114/394

Yes - I would put BMP in the cage

46%

182/394

I would NOT do a Anterior-Posterior (L2 corpectomy)

11%

46/394

Outside my area of expertise - best if I don't vote

13%

52/394

9. If you performed an Anterior-Posterior (L2 corpectomy + cage), how much would you distract/expand your cage (assuming expandable cage)?

Leave at existing height - do not distract

12%

48/388

Distract to pre-fracture vertebral body height

48%

187/388

Over distract by 10% above pre-fx height to get extra lordosis and open foramen

15%

60/388

I would NOT do a Anterior-Posterior (L2 corpectomy)

11%

43/388

Outside my area of expertise - best if I don't vote

12%

50/388

10. If performing posterior instrumentation 2 levels above and below, how would you do it?

Percutaneous Screws - Using Fluoro

16%

68/405

Percutaneous Screws - Using Inraop CT Navigation

33/405

Open Screws - Using Fluoro

35%

144/405

Open Screws - Using Inraop CT Navigation

37/405

Open Screws - Using Anatomic Technique

15%

63/405

I would not instrument posterior 2 levels above and below

18/405

Outside my area of expertise - best if I don't vote

10%

42/405

11. If you did a Posterior Only approach, what would you do?

Posterior Fusion Only (No Decompression with laminectomy)

7/402

Posterior Fusion and L2 Laminectomy only

35%

142/402

Posterior Fusion and Corpectomy with Cage (from back by removing partial pedicle)

31%

127/402

I would not do a Posterior Only approach

21%

85/402

Outside my area of expertise - best if I don't vote

10%

41/402

12. At his initial presentation in 7/2018, despite the fact that he was neurologically intact, would you have operated due to the presence of his lamina fracture alone?

No - Nonoperative for Neuro Intact Burst Fx

44%

183/414

Yes - The lamina fracture means he is unstable and needs surgery

49%

203/414

Outside my area of expertise - best if I don't vote

28/414

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