We present a series of patients with acute thoraco-lumbar fractures in whom we performed balloon vertebroplasty kyphoplasty , either alone percutaneous or combined to posterior transpedicular fusion open kyphoplasty. We emphasize the possibility of extending the use of kyphoplasty to non-osteoporotic vertebral fractures, and combining this method with traditional posterior fusion procedures.. Between and , patients suffering from thoraco-lumbar acute fractures, were treated in our Department. The latter group was not included in the present study.. Mean hospitalization rate was 29 days in CTG..
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To demonstrate that the extrapedicular unilateral percutaneous treatment in multiple thoracolumbar fractures is effective, minimally invasive and can treat several vertebrae at the same time in the same surgery. From January to January patients with multiple vertebral fractures in the thoracolumbar junction of various etiologies were treated, of which were women and 60 men.
The extrapedicular unilateral treatment shows good clinical results that are maintained over time, is performed on an outpatient basis with minimal complications, and enables rapid incorporation of patients to their daily activities.
Our study shows that unilateral extrapedicular percutaneous kyphoplasty is an effective treatment for multiple thoracolumbar vertebral fractures. This method makes the procedure less invasive, allowing multiple levels are treated in the same surgical intervention, resulting in relief of pain and stability of the spine, minimal complications and immediate return of the patient to daily activities.
Spinal fractures are a big health problem, with approximately , new cases each year in the United States, , of which cause intense pain and , of which require hospitalization. Worldwide, a new spinal fracture occurs every 22 seconds. The thoracolumbar junction is characterized as being biomechanically vulnerable, i.
Many of these patients become dependent and can be relegated to a wheelchair or a bed in the not too distant future. The planning of surgical treatment of this location should have these objectives: pain relief, prevention of neurological deficit, restoration of spinal stability, and improvement of the quality of life. The role of surgery in the treatment of spinal fractures is controversial. While techniques based on postural reduction and rest have remained virtually unchanged, surgical treatment has experienced constant renovation.
This has been the result of three basic elements. One: better knowledge of the biomechanics and kinetics of the spine that has allowed the adoption of different solutions to the classic problems of instability.
Two: increasingly sophisticated advances in diagnostic tools. Three: major advances in instrumentation devices, materials, and spine support techniques that have made fantastic methods of lesion repair available to us, as is the case with balloon kyphoplasty.
The objective of our study is to demonstrate that, differently from many authors who perform bilateral transpedicular kyphoplasty, the unilateral extrapedicular approach is a less invasive method that permits treating multiple levels in the same surgical procedure with few complications and that provides continued pain relief and improved quality of life to patients over time.
The study sample was made up of patients diagnosed with multiple spine fractures of the thoracolumbar junction of various etiologies, treated at the International Institute of Larkin Hospital in Miami, Florida, during the period from January to January Two hundred and forty-six of them were women between 45 and 93 years of age.
Informed consent was obtained from all patients and the protocol to be followed was explained to them. The diagnosis was based on a thorough physical exam supported by simple AP and lateral view x-rays, computed axial tomography with three-dimensional image reconstruction, especially in the STIR sequence that clearly shows edema that appears as hyper intense in an acute fracture with compression.
A decision for surgical treatment was always preceded by failed conservative management where the primary clinical symptom was difficult-to-control pain of long evolution and progressive intensity, exacerbated when in a standing position and hindering the patient's ability to walk, forcing bed rest. An evaluation of pain was conducted in all cases using the Visual Analog Scale VAS and of functional quality using the Oswestry scale 11 prior to surgery, immediately following surgery, after one month, six months, and then yearly with support by telephone or in-home visits.
To perform the kyphoplasty, we used the Kyphon system from Medtronic Figure 1 , Kyphon System Figure 2 with fluoroscopy. The patient was placed in a prone position on the operating table to achieve the extension of the thoracic and lumbar spines, and the planning of the approach was conducted by fluoroscopy. Figure 3 In most patients, local anesthesia and sedation were sufficient, although in some cases, due to their health condition, we preferred to use general anesthesia.
Once the entry points were defined, the skin was numbed with lidocaine and a 2mm incision was made for the introduction of the cannulated needle, Figure 4 though which we introduced a drill with which we created a space in the vertebral body. At this time, a sample was taken to perform a biopsy.
The drill was removed and balloons that have radiopaque markers were introduced in order to achieve precise placement. The balloon was inflated using a contrast injection system with a volume of 4 to 5 ml and a maximum pressure of psi. The balloon remained inflated for between 4 and 5 minutes, after which time it was deflated and removed.
Then, using a device also introduced through the cannula, the PMMA was injected under low pressure. In our experience, we used Kyphx r HV-R bone cement. After waiting for five minutes, the cannula was removed and the small wound closed with Dermabond. As regards data processing and analysis, we input the data into a percentage system where they were converted to statistical tables. In our study sample, there was predominance of female patients It should be noted that 11 of the patients treated were older than 90 years of age.
Figures 5 and 6. In terms of the causes treated, most cases were from osteoporosis Figure 7. In terms of the location of the fractures, the thoracolumbar junction was the most affected at It is significant that 17 patients 5. Figures 8 and 9. Most of the procedures were performed as outpatient Figures 10 and Regarding functional capacity, we achieved a reduction from We used the Oswestry scale Figure 12 to measure this indicator.
In terms of the behavior of pain, there was no relief in only 5 cases, which represents 1. Figure 13 We also measured the VAS, which decreased from Figure Surgery for vertebral fractures of the thoracolumbar spine has undergone a significant evolution mostly due to the enormous developments in radiology techniques, the intense research conducted about the biomechanics and kinetics of the spine, as well as to the new spine restoration materials, where balloon kyphoplasty plays a very important role.
Regardless of the location of the fracture, we propose using the unilateral extrapedicular technique, in which the point of entry is immediately superior and lateral to the pedicle, medial to the head of the rib and sometimes through the head of the rib in the dorsal location. If the entry point is very lateral, the lung cavity may be perforated, and if it is very low, the segmental artery may be affected. The explanation for the predominance of women above 60 years of age could be due to the fact that the most frequent causes of idiopathic osteoporosis are advanced age and menopause.
It is also known that the tumor that most often metastasizes to the vertebrae is primary breast cancer, 17 that largely justifies our results. In agreement with reports by other authors, the most affected region in our study was the thoracolumbar spine. At first, it was thought that the ideal patient to undergo this type of procedure was that who suffered pain secondary to a fracture that persisted for more than 4 to 6 weeks.
Although a rule cannot be established, better recovery at this level of the spine is achieved the earlier the treatment is performed. According to reports from other researchers, the procedure can be performed as outpatient, 21 which was fully confirmed by our study.
With the help of telephone calls and home visits, we provided follow-up for more than two years with most of our patients. Kyphoplasty is an optimal technique for the treatment of pathological fractures.
The rapid improvement of pain maintained over time, as well as the functional recovery of the patients, make it a perfectly valid technique. Our study showed that according to what has been mentioned above, we could provide pain relief and a return to normal work, in addition to good spine stability, results that have all been maintained over time. In a multicenter report of patients with fractures treated through kyphoplasty, the percentage of serious complications reached 0.
Our study shows that percutaneous unilateral extrapedicular kyphoplasty is an effective treatment for multiple thoracolumbar fractures from pathological causes. It proved to be a safe method for patient pain relief and improved functional capacity maintained over time, with few complications. This much less invasive procedure reduces surgery time per level and permits multilevel treatment in the same surgical intervention. Minimally invasive treatment of osteoporotic vertebral body compression fractures.
Spine J. Myers ME. Vertebroplasty and kyphoplasty: is one of these procedures the best choice for all patients?
Current medical, rehabilitation, and surgical management of vertebral compression fractures. J Womens Health Larchmt. Siegal T, Siegal T. Surgical decompression of anterior and posterior malignant epidural tumors compressing the spinal cord: a prospective study. An ex vivo biomechanical evaluation of an inflatable bone tamp used in the treatment of compression fracture. Spine Phila Pa Joint Bone Spine. A study of complaints and their relation to vertebral destruction in patients with osteoporosis.
Bone Miner. Percutaneous vertebral augmentation: vertebroplasty and kyphoplasty: operative technique. Neurocirugia Astur. Benign versus pathologic compression fractures of vertebral bodies: assessment with conventional spin-echo, chemical-shift, and STIR MR imaging.
Blumenkopf B. Radiology and anatomy of lumbar and lumbosacral fractures. In: Rea G, Miller C, editors. Spinal trauma: current evaluation and management. Neusosurgical topics. Roland M, Fairbank J. The roland-morris disability questionnaire and the oswestry disability questionnaire. Phillips FM. Minimally invasive treatments of osteoporotic vertebral compression fractures. Kyphosis correction and height restoration effects of percutaneous vertebroplasty.
J Bone Miner Res. Occurrence of new vertebral body fracture after percutaneous vertebroplasty in patients with osteoporosis. Surgical management of primary and metastatic tumors of the spine. In: Schmideck HH, editors. Philadelphia: Saunders; Holdsworth F.
Tratamiento de Las Fracturas Dorsolumbares
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