Vertebral Fracture/Luxationoldwebsite.anzcvs.org.au/surgery_assets...spinal arch external skeletal...
Transcript of Vertebral Fracture/Luxationoldwebsite.anzcvs.org.au/surgery_assets...spinal arch external skeletal...
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Vertebral Fracture/Luxation! Mark Newman!! University of Sydney!! Melbourne Resident’s Forum 2014
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Anatomy
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Spinal Biomechanics! Vertebral motion unit!
! Osseous and soft tissue contributors to stability!! Fractures tend to occur at junction of immobile/mobile
areas!! Moment of resistance (Zotti et al Res Vet Sci 2011)!
! Resistance of bending forces of vertebral bodies!! Lowest around T9 and rising to L2!! Rising bone mineral density!! Adaptation to bending stress
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Spinal Biomechanics! Forces acting on the spine!
! Dorsoventral bending (disc, vertebral body, dorsal elements)!
! Lateral bending (disc, facets, vertebral body, rib head)!! Torsion (disc, facets, rib head)!! Shear !! Axial compression (disc, vertebral endplates)!
! Relative contribution of each force in normal movement unknown!! Disc most important in bending and rotation (Schulz et al
AJVR 1996, Shires et al Prog Vet Neurol 1991)
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Anatomical Influence! Thoracic spine!
! Inherently stable!! Small articular facets but large dorsal structures!
! Thoracolumbar junction (50% of VFL)!! Highly mobile!! Large facets!! Facets change orientation from ventrodorsal to saggital!
! Lumbar spine (25-30% of VFL)!! Relatively rigid!! Dorsoventral flexion
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3 Column Model (Dennis Spine 1983)
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3 Column Model (Dennis Spine 1983)! Dorsal column!
! Articular facets, laminae, dorsal spinous processes, interspinous ligaments, ligamentum flavum!
! Middle column!! Dorsal longitudinal ligament, dorsal annulus fibrosis,
dorsal vertebral cortex!! Ventral column!
! Ventral longitudinal ligament, remainder of intervertebral disc, ventral vertebral cortex
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3-Column Model – Fracture Configurations! Compression !
! Failure of the ventral column under compression!
! Intact middle column acts as the hinge!
! Flexion injury
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3-Column Model – Fracture Configurations! Burst!
! Failure of vertebral body (ventral and middle columns) under compression!
! Dorsal column is the hinge!! Flexion injury
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3-Column Model – Fracture Configurations! Seat-Belt!
! Failure of dorsal and middle columns under tension!
! Ventral column may also be involved but maintains role as the hinge
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3-Column Model – Fracture Configurations! Fracture-Dislocation!
! Failure of all columns!! A: flexion/rotation!! B: shear (hyperextension)!! C: flexion/distraction
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3 Compartment Model (Sharp & Wheeler)! 3-column model!
! Based on mode of injury (stability inferred)!! Indications for surgery in humans different to quadripeds !
! Assesses ability of vertebral column to resist applied forces!
! Addresses integrity of:!! Intervertebral disc!! Vertebral body!! Articular facets!
! Serves as a guide to the fixation best suited to each fracture
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3 Compartment Model (Sharp & Wheeler)! I – Disc failed, facets and body intact!
! Rotation, lateral bending, extension!! II – Facets failed, disc and body intact!
! Rotation!! III – Body failed, facets and disc intact!
! Bending, compression!! IV – Two or more components fail!
! Generally all forces
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Imaging! Plain radiology (Kinns et al
Vet Rad Ultrasound 2006)!! 72% sensitivity for fractures!! 77.5% sensitivity for luxations!! 58% NPV for canal narrowing!! 52% NPV for fragments in
canal!! Poor for fractures involving
dorsal/middle compartments
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Imaging! Significance of displacement!
! Not associated with outcome (McKee et al Vet Rec 1990) unless 100% (Bagley Vet Clin North Am 2000)!
! Displacement + axis deviation significantly associated with outcome in dogs (Bali et al VCOT 2009)
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Advanced Imaging! CT gives greatest bone detail!
! Safe implant corridors!! MRI!
! Cord compression!! Disc extrusion!! Signal change – T2W hyperintensity!
! Correlation with outcome!! Levine et al JVIM 2009
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Treatment! Prevent ongoing injury!
! Limit instability!! Relieve spinal cord compression!
! Realign spinal canal!! Apposition or near-apposition!
! Intervertebral disc!! Hemilaminectomy?!
! Fragments!! Human studies suggest unneccesary!! Must retropulsed and resorbed
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Conservative Therapy! Non-surgical management!
! Indications poorly defined – ‘stable’ fractures!! Isolated facet fractures or disc extrusions!! Some body fractures!
! Difficult to immobilise thoracolumbar spine!! Patterson & Smith VCOT 1992!
! Selcer et al JAVMA 1991!! Shorter hospitalisation!! Longer recovery!! Surgically treated animals improved more but no
difference in eventual long term outcome
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Surgical Management! Ventral stabilisation!
! Pins or screws/PMMA!! Plates!! ESF!
! Dorsal Stabilisation!! Spinous process plating!! Tension band/modified segmental spinal fixation!! Laminar plating
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Implant Corridors! Watine et al JSAP 2006!
! Thoracic vertebrae!! Insertion angle opens from 22° to 44.5°!! Azygous vein 1mm away!
! Lumbar vertebrae!! Insertion angle 60°!! Vital structures more protected
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Pin Penetration of the Canal! Hettlich et al Vet Surg 2010!! Left/right accuracy 93.1%!! Radiographs !
! Sensitivity 50%!! Specificity 83%!
! CT !! Sensitivity 93.4%!! Specificity 86%
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Pins + PMMA! Versatile!! Strong in flexion, extension, torsion!
! At least that of intact spine (Walker et al Vet Surg 2002)!! Depends on configuration(David Hall, pers comm)!
! Threaded pins preferred!! Less pull-out!! Less migration!! Firm anchorage of cement!
! 3+ implants per vertebra, screws inferior to pins!! Garcia et al Vet Surg 1994
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Vertebral Body Plating! Swaim JAVMA 1971!
! Technical feasibility of small dorsolateral body plates on adjacent vertebrae!
! Recommended sacrificing nerve roots!! Clinical use substantiated!
! Downes et al JSAP 2009!! Conventional plates superseded by
locking plates?!! SOP (McKee & Downes JSAP 2006)!! PAX?
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Internal Fixation Systems! Walter et al Vet Surg 1986!
! Dorsal + vertebral body plate strongest followed by vertebral body plate!
! Waldron et al Prog Vet Neurol 1991!! Pins + PMMA strongest
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External Skeletal Fixation! Blunt tipped pins ideal + arches!! Open!
! Lanz et al Vet Neurology Neurosurgery 2009!
! 3 dogs – good reduction with no complications!
! Poor follow-up!! Closed!
! Wheeler et al Vet Surg 2007!! 5 dogs – good to excellent
function in all !! Fixators in place up to 282 days
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External Skeletal Fixation! Open vs closed!
! Wheeler et al Vet Surg 2002!! Both open and closed application different from the ideal
angle/depth!! Better bone purchase in closed!! Difficult to apply to thoracic especially open!
! Strength -Walker et al Vet Surg 2002!! Eight pin/arch combo stiffer than bilateral type I ESF!! Comparable to Eight pin/PMMA combo
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Modified Segmental Spinal Stabilisation! Longitudinal Steinmann pins held in
place with wire through spinous processes!
! McAnulty et al, Vet Surg 1986!! 4 dogs 10-56 kg, all unstable fractures!! 1 broken pin at 18 months!
! Not recommended?!! Wire pull-out!! No ventral support!! Suited to thoracic fractures
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Tension Band Fixation! Voss & Montavon JAVMA 2004!
! Modification of MSSS!! 38 dogs/cats up to 45kg!! Unstable fractures!
! Vertebral body involvement!! 78% complete or functional!! 11% implant or fixation failure!
! Dogs >16kg
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Laminar Plating! Benefit of dorsal
stabilisation!! Potentially more cortices!! Knell et al AJVR 2011!
! Lower ROM and NZ than vertebral body plating!
! VBP constructs: bone failure at facet joints!
! LP constructs: construct faillure!
! Less screw loosening in LP (1/9) than VBP (5/9)
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Laminar Plating! Knell et al AJVR 2011!! Angles of instertion L1/
L2!! Lamina = approx 20°
ventral, 10° dorsal!! Facet = 24° ventral, 12°
dorsal!! Screw penetration 1/24!
! Screw did not follow drill hole
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Spinous Plating! Krauss et al VCOT 2012!
! Similar function to tension band stabilisation!
! 15 unstable fractures!! 80% complete or functional
outcome !! No implant failure!! Spinous process
demineralisation!! Rischen et al Vet Surg 1987!
! No change in underlying vascularity!
! Demineralisation by 8 weeks!! Foreign body reaction
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Prognosis! Surgical technique!
! Results seem fairly comparable across techniques!! 80-100%!! Complication rates vary!
! Significance of absent nociception!! Very poor recovery rates – avg 5%!! Spinal walking – rim of peripheral surviving tracts?
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References➢ Bali MS, Lang J, Jaggy A, et al: Comparative study of vertebral fractures
and luxations in dogs and cats. Vet Comp Orthop Traumatol 22:47, 2009.!➢ Bruce CW, Brisson BA, Gyselinch K: Spinal fracture and luxation in dogs
and cats: a retrospective evaluation of 95 cases. Vet Comp Orthop Traumatol 21:280, 2008.!
➢ Denis F: The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine 8:817, 1983.!
➢ Downes CJ, Gemmill TJ, Gibbons SE, et al: Hemilaminectomy and vertebral stabilization for the treatment of thoracolumbar disc protrusion in 28 dogs. J Small Anim Pract 50:525, 2009.!
➢ Garcia JNP, Milthorpe BK, Russel D, et al: Biomechanical study of canine spinal fracture fixation using pins or bone screws with polymethylmethacrylate. Vet Surg 23:322, 1994.!
➢ Hettlich BF, Fosgate GT, Levine JM, et al: Accuracy of conventional radiography and computed tomography in predicting implant position in relation to the vertebral canal in dogs. Vet Surg 39(6):680, 2010.!
➢ Kinns J, Mai W, Seiler G, et al: Radiographic sensitivity and negative predictive value for acute canine spinal trauma. Vet Radiol Ultrasound 47:563, 2006.!
➢ Lanz OI, Jones JC, Bergman R: Use of an external skeletal fixator to correct spinal fracture/luxation and instability in three dogs. Vet Neurol NeuroSurg (serial online) 2:1, 2000. Available at: http://www.vin.com/VNNJ/Journal.plx?AID=1471085. Accessed February 2, 2014.!
➢ Levine JM, Fosgate GT, Chen AV, et al: Magnetic resonance imaging in dogs with neurologic impairment due to acute thoracic and lumbar intervertebral disk herniation. J Vet Intern Med 23:1220, 2009.!
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➢ Takeuchi T, Abumi K, Shono Y et al; Biomechanical Role of the Intervertebral Disc and Costovertebral Joint in Stability of the Thoracic Spine: A Canine Model Study. Spine 24(14), 15 July 1999, p 1414!
➢ Voss K, Montavon PM: Tension band stabilization of fractures and luxations of the thoracolumbar vertebrae in dogs and cats: 38 cases (1993–2002). J Am Vet Med Assoc 225:78, 2004. !
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➢ Wheeler JL, Cross AR, Rapoff AJ: A comparison of the accuracy and safety of vertebral body pin placement using a fluoroscopically guided versus an open surgical approach: an in vitro study. Vet Surg 31:468, 2002. !
➢ Wheeler JL, Lewis DD, Cross AR, et al: Closed fluoroscopic-assisted spinal arch external skeletal fixation for the stabilization of vertebral column injuries in five dogs. Vet Surg 36:442, 2007. !
➢ Zotti A, Gianesella M, Gasparinetti N, et al: A preliminary investigation of the between the ‘moment of resistance’ of the canine spine , and the frequency of traumatic vertebral lesions at different spinal levels. Res Vet Sci 90:179, 2011