Our next speaker is Sanjay Dahl from UCSF. Thanks to everybody for showing up for this late session. I'm probably not as funny as Juan or Mike or Paul, but I'm going to try. There are my disclosures. So a little bit more of the background data, and again, I think most of the people in the room already know this. Not only do I agree with Paul about percutaneous fixation, but I actually disagree with him about how to classify these injuries. The AO classification is pretty unwieldy. I mean, I think I do my fair share of spine trauma, and I find it hard to remember all these A6 or whatever it is, all these letters and numbers and stuff. I think Telex is a very elegant, simple way of looking at these patients. Again, it takes into account the fracture pattern, the status of the ligaments, and the neurologic status of the patient. That's huge. Because I think most of us have always, even before this came out, most of us were already doing that. You have somebody with a spinal cord injury, you're going to operate on them for the most part. So at least at one point there was a Telex app. I don't know if it still exists or not, but I had it on my phone a while back, which is great for our millennial residents. So the other cool thing about it is it tells you, you know, when do you operate, right? So if somebody has a Telex of four, it's considered indeterminate. Less than four is nonoperative, and then greater than four is surgical. And I think that's an important take-home point when you look at these percutaneous fusion, or sorry, non-fusion, percutaneous screw fixation papers, right? Really what they're operating on is they're operating on nonoperative injuries, but I'll get to that in a minute. So, you know, minimally invasive surgery is totally all the rage, right? It's super hot. It's awesome. It's like the iPhone 10 or wherever we're at, right? So it's super sweet, like these constructs, right? All percutaneous. And Paul has certainly really pushed the envelope on this, right? He's doing that sweet band-aid surgery on the lady in the bikini, and, you know, and they're out on the beach, you know, the next day. And so, you know, and it's great, right? Because you get this really beautiful cosmetic result. You only stab the patient eight to ten times and shove a bunch of tubes in their back, which is far prettier. I mean, I would, I mean, wouldn't you agree, right? Like, you know, these are far better cosmetic results than a simple midline skin incision. So you definitely get that, right? So, but, you know, Paul really, you know, harped on one very good study, but it's just one study of, you know, some total 37 patients, which, you know, in the scheme of spine literature, having been somebody who's struggled through a lot of spine trauma papers, that's teeny tiny, you know, that's a super tiny sample of patients with spinal injuries. You know, so if you go back and you look at all the studies on percutaneous fixation for spine trauma, you know, it's very, very limited, right? Because, again, going back to what I was saying before, this is only for Asia E patients. Patients who are totally neurologically intact, right? These are retrospective case series. Almost every single one of these papers, with the exception of the one that Paul mentioned, have variable follow-up. It's less than a year. Lots and lots of their patients are lost to follow-up. It's very poor quality, unfortunately. You know, a lot of times these papers don't even mention how many patients are lost to follow-up. So you really got to take that into account. You know, I think if we were to write a guideline on this, we, you know, there would be a very, you know, it would be like a grade I, you know, insufficient on making a recommendation. You know, so here are some examples, and again, you know, I don't want to, I don't want to spend all this time, you know, going through all the different numbers, right? But, you know, if you look at, you know, some of the studies on this, you know, Grossback et al had 11 patients. They compared them to a historical cohort. And no doubt, right, every day of the week, Paul's right. If you do percutaneous screws, you're going to lose less blood than if you do an open surgery. If you're losing more blood doing a per screw case than an open case, there's something wrong with the way you're doing it, right? So you're stabbing the wrong thing. You know, it's, you know, they found that it's equivalent operative time, and certainly, you know, somebody who does a lot of percutaneous fixation is going to be, is going to be quick with it, or quicker. You know, equivalent hardware misplacement, you know, again, you know, this is, this is a tool, right? And, you know, the surgeon that's doing this, and I think all the people in this room have seen mishaps with percutaneous screw fixation, right? There's a learning curve to it, and you've got to be comfortable with it before you do it, especially in the thoracolumbar trauma case where there's a lot of other complexities added to it. You know, this study had, you know, 12 months of follow-up, but we don't actually know how many patients followed up. So probably all the patients who had failures, you know, went to see Dan Ho in Florida or something like that to get a fix. You know, you know, another, another study, you know, that's had great long-term follow-up, you know, over five years of follow-up, but they were taking out the hardware in all these patients. That's the other thing that Paul didn't mention to you, right? You know, very often, you're not doing a fusion. You're crossing a junction, right? A junction where there's motion, and you're putting hardware in, and you're not doing a fusion. So what's going to happen, right? If I did a thoracolumbar fusion and I had a pseudoarthrosis, that hardware's going to come loose. The rod's going to break. Something's going to happen, right? So how is it that you can intentionally do that and you're not going to have a failure, right? So what a lot of these studies have done is they pull the hardware out, right? So why commit your patient to two operations where they get the, you know, get the scars that look like a band of rats attack their back, you know, and then reopen it again to pull all that stuff out, right? So there's some questionable logic there. You know, so, you know, I talked a lot about percutaneous screws, you know, but there's other minimally invasive ways to treat these patients. You know, Dean Chow wrote a great study about mini-open corpectomies, right? So where you're actually doing a fusion operation and then combine that with percutaneous screws makes a lot more sense. Another study looking at lateral mini-open corpectomies, you know, again, much more reasonable option. So, you know, we actually, back in 2014, published a neurosurgery focus, sort of a proposed algorithm on how to manage these traumatic thoracolumbar injuries and when to apply minimally invasive surgery. And, you know, so again, you know, patients who are telix less than four, at the time we wrote apply a brace, I actually completely agree with what Paul said. I've completely stopped bracing those patients. I don't use them at all anymore. Patients who have a telix that is equal to four or greater than four, you know, you have another flow chart, so they're equal to four, you know, you can do external bracing or no bracing. You can do open surgery or you can do minimally invasive surgery of certain kinds, right? So the patients where percutaneous screw fixation makes sense, at least for this algorithm, were the patients who were already prone to fusing, right? So if you have somebody with ankylosing spinalitis and they have a fracture and they don't have a spinal cord injury, you can think about doing a percutaneous screw fixation on that patient. Because that patient, if they're stabilized, they'll grow bone back together. And I think we actually saw some interesting examples of that this morning in our other session. You know, you can, very rarely these people need just a decompression. And again, we talked about minimally invasive corpectomies. You know, for the patients that are greater than the telix of four, we recommended doing an open posterior fusion or again, you know, some combination thereof, right? Doing an anterior or lateral corpectomy combined with percutaneous fixation, right? So you're doing an actual fusion on these patients. You know, I think I'm close to being out of time, but you know, here's a case, right? This is somebody who has a telix of four. This is somebody who failed conservative management. And so this is a patient who ended up undergoing a minimally invasive lateral corpectomy and then posterior percutaneous fixation. So the one instance where percutaneous screw fixation would make sense. So, you know, basically the conclusion here is, you know, when I first started as an attending, I got some advice from one of my mentors and he said, you know, in spine trauma, don't be cute, right? Because you'll regret it. And I tried to be cute anyways and I really regretted it. So, you know, when it comes to thoracolumbar injuries, just get the job done. Get them fused. Get them stabilized. You know, bear in mind that these studies on percutaneous fixation are basically studies on people who never needed surgery in the first place. So you're going to get really great results, you know, in people who didn't actually need it in the first place. You've really got to apply the principles of arthrodesis just like you would to any other patient. So I still think the role of percutaneous non-fusion techniques is very much unclear. Thank you.

spine trauma

Telex system

minimally invasive surgery

fusion

thoracolumbar injuries