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Thoracolumbar Burst Fractures
Posted: Apr 23 2016 #(C2573)
A

Polytrauma Lumbar Burst Fxs in 61M

HPI

Pt fell from tree about 30 feet while intoxicated. On arrival was moving b/l extremities. Injuries include 1. L1 and L3 burst fx 2. type 1 hangman's fx 3. non-displaced fx of posterior arch of C6 4. R proximal humerus fx 5. left distal radius fx 6. nonoperative subdural hemorrhage. After 2 days in hospital went into DTs and went into respiratory distress. Pt has pneumothrax and chest tube was placed. Pt was intubated to protect airway due to agitated state. Sedation required. Pt developed right lobe pneumonia, possibly from aspiration. Orthopaedic spine consulted after pt intubated and sedated. While very difficult to determine examine, pt appeared to have slowly increasing weakness on bilateral lower extremity. During state of agitation initially would bring knees off bed. This was slowly lost over course of several days. Difficulty to tell if it was due to a systemic process (sedation, mental status changes) or due to stenosis at L3.

PMH

Diabetes, ETOH.

PE

Patient moving toes and knee. Pt was intubated with mental status changes, not following any command, so difficult to access. With agitation pt flexing elbows and moving hands.

Poll
1 of 8
1. Would you perform operative L3 decompression +/- stabilization on this patient at this time (mental status changes, likely progressive weakness but unreliable exam)?
Yes
79%
983/1237
No
20%
254/1237
2. If you choose stabilization +/- decompression, what surgical approach would you use?
Anterior only - corpectomy and plate fixation only
4%
54/1082
Posterior only - PSF only, NO decompression
3%
43/1082
Posterior only - Laminectomy alone with PSF
25%
277/1082
Posterior only - Laminectomy, posterior-corpectomy with reconstruction, PSF
27%
300/1082
Combined Anterior (corpectomy,cage,plate) and Posterior (laminectomy, PSF)
33%
365/1082
Posterior only - L3 Percutaneous augmented instrumentation (kyphoplasty of L3, percutaneous pedicles screws, no decompression)
3%
43/1082
3. If performing posterior stabilization, what levels would you fuse?
L2 to L4 Posterior Spinal Fusion
19%
206/1056
T12 to L4 Posterior Spinal Fusion
37%
394/1056
T11 to L5 Posterior Spinal Fusion
36%
385/1056
T11 to sacrum
6%
71/1056
4. Would you utilize a percutaneous pedicle screw approach if/when performing posterior stabilization?
Yes
31%
307/962
No
68%
655/962
5. What type of bone graft would you use for your posterior spinal fusion
Local bone only
18%
178/962
Local bone and allograft (cortical and cancellous chips)
46%
445/962
Posterior iliac crest bone graft (autograft)
29%
288/962
BMP
5%
51/962
6. What classification system would you use to dictate your treatment?
Watson-Jones
0%
2/761
Denis Three Column
22%
175/761
Ferguson and Allen
0%
5/761
AO thoracolumbar system
17%
133/761
Thoracolumbar Injury Classification and Severity Score (TLICS)
49%
379/761
None apply, this is a lumbar burst fx, not thoracolumbar
8%
67/761
7. According to the TLICS, with the clinical and radiographic information provided, what status would you assign to the Posterior Ligamentous Complex (PLC) Integrity ?
TLICS does not apply, this is a lumbar burst fx
7%
54/699
Intact
14%
102/699
Suspected/Intermediate
32%
230/699
Disrupted
44%
313/699
8. A posterior decompression and stabilization was performed (see post P1 images below). Since then the patient's mental status has improved (alert and appropriate) and his lower extremity exam is improving. He is now 2-3 of 5 motor in LE bilaterallly. Based on the postoperative CT below, would you still proceed with an anterior L3 corpectomy, cage, and plate (L2-L4)
Yes
44%
355/805
No
55%
450/805
PROCEDURE #1 DOP: 5/3/2016

T11 to L5 PSF. L2 and L3 laminectomy, left partial L2/3 facetectomy with best effort to push retropulsed bone anterior via a posterior approach, repair of large traumatic durotomy with extravasation of nerve roots with entrapment in posterior lamina fx at L3.

PROCEDURE #2 DOP: 5/24/2016

L3 corpectomy, expandable cage.

Intra-procedure P2
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OUTCOMES
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3 days after
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