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Thoracolumbar Burst Fractures
Posted: Jan 2 2020 #(C101350)
A

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.

PE

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
2%
16/753
Operative
91%
686/753
Outside my area of expertise - best if I don't vote
6%
51/753
2. If you choose operative treatment at this time, how would you approach this?
Anterior Only
3%
27/695
Posterior Only
40%
279/695
Anterior-Posterior (L2 corpectomy)
44%
306/695
Outside my area of expertise - best if I don't vote
11%
83/695
3. If you choose an Anterior-Posterior (L2 corpectomy), what anterior approach would you use?
Standard Retroperitoneal - Left Side
20%
126/608
Standard Retroperitoneal - Right Side
7%
46/608
Direct Lateral (e.g., XLIF) - Left Side
13%
82/608
Direct Lateral (e.g., XLIF) - Right Side
4%
25/608
Oblique Lateral (e.g, OLIF) - Left Side
7%
47/608
Oblique Lateral (e.g, OLIF) - Right Side
2%
17/608
I would NOT do a Anterior-Posterior (L2 corpectomy)
19%
118/608
Outside my area of expertise - best if I don't vote
24%
147/608
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%
156/528
Yes - assist approach surgeon - direct lateral (XLIF)
8%
43/528
Yes - assist approach surgeon - oblique lateral (OLIF)
4%
25/528
No - standard retroperitoneal approach Alone
8%
46/528
No - direct lateral (XLIF) Alone
7%
40/528
No - obique lateral (OLIF) Alone
3%
17/528
I would NOT do a Anterior-Posterior (L2 corpectomy)
16%
89/528
Outside my area of expertise - best if I don't vote
21%
112/528
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))
2%
10/473
Decompress from FRONT (remove posterior cortex during corpectomy)
21%
100/473
Decompress from BACK (L2 laminectomy, do not remove posterior cortex during corpectomy)
18%
87/473
Decompress from FRONT & BACK (L2 laminectomy, remove posterior cortex during corpectomy)
27%
130/473
I would NOT do a Anterior-Posterior (L2 corpectomy)
15%
73/473
Outside my area of expertise - best if I don't vote
15%
73/473
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%
144/431
Instrument & Fusion ONE level above and below
23%
102/431
Instrument TWO levels above and below, fuse ONE level above and below (instrument long, fuse short)
19%
82/431
I would NOT do a Anterior-Posterior (L2 corpectomy)
12%
54/431
Outside my area of expertise - best if I don't vote
11%
49/431
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%
189/417
Posterior first - then anterior - same day
12%
54/417
Anterior First - then posterior - different days
6%
26/417
Posterior first - then anterior - different day
6%
29/417
I would NOT do a Anterior-Posterior (L2 corpectomy)
14%
62/417
Outside my area of expertise - best if I don't vote
13%
57/417
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%
115/399
Yes - I would put BMP in the cage
46%
186/399
I would NOT do a Anterior-Posterior (L2 corpectomy)
11%
46/399
Outside my area of expertise - best if I don't vote
13%
52/399
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%
48/393
Distract to pre-fracture vertebral body height
48%
190/393
Over distract by 10% above pre-fx height to get extra lordosis and open foramen
15%
62/393
I would NOT do a Anterior-Posterior (L2 corpectomy)
10%
43/393
Outside my area of expertise - best if I don't vote
12%
50/393
10. If performing posterior instrumentation 2 levels above and below, how would you do it?
Percutaneous Screws - Using Fluoro
16%
69/409
Percutaneous Screws - Using Inraop CT Navigation
8%
34/409
Open Screws - Using Fluoro
35%
145/409
Open Screws - Using Inraop CT Navigation
9%
37/409
Open Screws - Using Anatomic Technique
15%
64/409
I would not instrument posterior 2 levels above and below
4%
18/409
Outside my area of expertise - best if I don't vote
10%
42/409
11. If you did a Posterior Only approach, what would you do?
Posterior Fusion Only (No Decompression with laminectomy)
1%
8/406
Posterior Fusion and L2 Laminectomy only
35%
143/406
Posterior Fusion and Corpectomy with Cage (from back by removing partial pedicle)
31%
127/406
I would not do a Posterior Only approach
21%
87/406
Outside my area of expertise - best if I don't vote
10%
41/406
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%
185/419
Yes - The lamina fracture means he is unstable and needs surgery
48%
205/419
Outside my area of expertise - best if I don't vote
6%
29/419
PROCEDURE #1 DOP: 1/3/2020

Anterior-Posterior Surgery - Direct Lateral L2 Corpectomy and Cage Followed by Percutanous Instrumentation from T12 to L4. L2 laminectomy.

Intra-procedure P1
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