All right. Our next talk is Paul Park. Thoracolumbar burst fracture without neuro deficit. Percutaneous fixation is superior. Yeah, no, I appreciate the opportunity to give this presentation. You know, I found it a little bit surprising that they were, Mike and Juan were so balanced. Usually you take one side and you go with it. You know, they both started off a little bit equivocating. I won't equivocate. I really believe percutaneous fixation is superior for this problem. You know, Sanjay and I have talked about this before. So I'm definitely on the pro side. Here are my disclosures. So I just want to start with a brief intro. This is pretty much common knowledge, but I think it sets a background, right? So a thoracolumbar burst fracture is a common injury due to a compressive load. Fifty-four to ninety percent of all spinal injuries involve a T.L. fracture. And forty-five percent of T.L. fractures are burst fractures. I think we've all seen this. And the majority, I would say well more than fifty percent, are neurologically intact. Pretty standard. There's a lot of classification systems. One of the most popular is the A.O. classification. It's otherwise known as the Magro classification. And the burst fracture would be a type A fracture. And most of the ones that tend to be operative are A3 fractures. And you can see here's a little bit of a diagram here for a typical A3. And this is a clinical example of that. So a question, you know, before we get on to surgery is, is surgery even needed? There's an argument that with these fractures, they're stable fractures, and maybe you should just brace them. In fact, people have gone one step further and said, do we even need a brace? And so this is a randomized study that was published back in 2014. And they looked at these specific T.L. fractures, these type A3 fractures, and they did have a specific inclusion criteria. So it wasn't all comers. So neurologically intact, a certain amount of kyphosis, a certain age range. But when this was done, with these criteria, and they looked at various metrics, and the primary endpoint from a clinical, you know, a metric was a Roland Morris Disability Questionnaire at three months. They also followed the patients for two years, but not clinically, just radiographically. They showed equivalence, actually, whether you braced or not for these fractures. So 110 patients were randomized. If you looked, they had about 50 in each category. They were very well matched, very similar patient population. And they did about the same when you looked at the RMDQ and the SF36s, very equivalent. So no difference, no difference in patient satisfaction. And when they followed it out for two years, radiographically, there was not much change either. So what this study showed was it really even questioned the use of a brace. So when is surgery needed? Unstable burst fractures, but the definition of an unstable burst fracture is actually fairly controversial. Some people would argue with significant vertebral height, body height loss, and a significant amount of convolution that's unstable. Significant fracture of the posterior elements, if you have a facet fracture or lateral mass fractures. But when it comes to my patient population, it's refractory pain. So you can argue that these patients need a brace or not, but even with bracing, people sometimes can't get out of bed. They're not functional. So this would be a relative indication for surgery, but I do think surgery can help in this situation. And that would be probably the most common relative indication. Another one is healing in a kyphotic position. I think we all know that sagittal alignment is an important factor in terms of disability. So will these kyphotic fractures, because often these TL fractures heal in kyphosis, result in long-term problems? So this is another argument that you'd consider surgery for. So if you do consider surgery, what sort of surgery is needed here? Well, I think spine surgeons are like carpenters. That analogy is made quite frequently, particularly with orthopedic spine surgeons. And we have a variety of tools in our kit, whether it's techniques, approaches, instrumentation. We just, we can do whatever we want. It could be anterior, posterior, lateral. But for these fractures, I think we're imposed on a couple of different tools. You could do a traditional open instrument fusion or percutaneous pedicle suffixation without fusion. And I'm going to argue a perk screw is the way to go. So you just want to choose the right tool for the job. And, you know, Sanjay's going to give the con argument here. And so I got this website, and I go, God, Sanjay's a good-looking guy. This great, great picture here. He's the director of spinal neurotrauma at UCSF. So, you know, prominent guy, well-known in the area. And, you know, he and I have talked about this on a number of occasions. Sanjay's always taking the, no, it needs an open operation. You want to do the definitive job. And a perk screw just adds garbage, is what he says. So, you know, what I've come to realize is Sanjay's a one-tool man. Everything is fusion. In fact, his motto is fusion cures all. And I, he really adheres to that. But, you know, fusion can work, but it's like a hammer on a screw. I think you just want to take the right tool. You want to be the most efficient person. Right? So I, you know, I could go on and on about this, but I just want to back this up with some literature. And there's tons of advantages of perk screws. And I just, I had a swath of literature, and I'm not even sure what Sanjay's argument is going to be, but the literature is pretty clear here. That, you know, that perk screws are better. So this is a perspective comparative study, 37 patients, equally divided. So short segment, open instrument fusion versus perk screws, no fusion. Okay? Very equivalent groups here, so no difference. And no difference in fracture type, the types of A3 fractures, the type of mechanism of injury, all very similar groups, right? Perspective comparative study. This is just an example of publishing an article showing what you can achieve with perk screws. So you get fracture reduction, height restoration, looks a lot better. Just perk screws, no trauma. And you can look at the outcomes of vertebral body index, which is just a measure of the height, vertebral body angle, the cob angle. It's all very similar between the groups. You can see the error bars, they're all overlapped. The only difference is in pain. The perk screw group did much better in pain relief, and that's not unexpected. When you're looking at overall satisfaction, it's very similar. But what they noted was decreased blood loss, decreased OR time, which is an important factor, particularly in these polytraumas where they may have other injuries and less post-operative pain, with the similar clinical results at long term. And in fact, there was a trend toward the MIS group returning to work quicker. So much better in every category for the most part, either clinical equivalents or better. And this is another perspective comparative study, and I will summarize. It shows you the same thing. Fifty-nine patients enrolled. Again, perspective comparative. Two equal groups, long-term follow-up. Very similar groups. You can see no change in the demographic, demographics or the vertebral body fracture type. Within each group, everybody did fine. So within each group, they had improvement in the cob angles and the degree of correction. So no difference between groups, but significant difference within the groups. But what about other factors like pain? The percutaneous group did much better short-term, which is not unexpected. So you don't have the exposure-related morbidity, so there's less pain. At long-term, it's equivalent, but in the short-term, patients did better. Same thing with the low back outcome score. The PERC group was much better clinically. So we have yet another article showing improvement. And what about OR time? You can see here, statistically significantly improved in the PERC group versus the open group, with same clinical outcomes, a faster recovery. I could just go on, and this is another study that essentially shows you the same thing. So I don't want to dwell on the numbers, and I keep rehashing it, but I'm driving the point home that all these studies show that PERC groups are better in many ways. Here's a meta-analysis that was recently published with Paul Anderson, who's a well-known trauma surgeon, and even he acknowledges, and he's an open surgeon, that there's clinical equivalence, and there's a statistically significant, within this meta-analysis, positive finding for blood loss and OR time. So in conclusion, I think PERC screws are similar in long-term clinical and radiographic outcomes, with the benefit of decreased blood loss, OR time, and pain, which to me is the right thing to do for our patients. Thank you. Thank you. APPLAUSE

thoracolumbar burst fracturing

percutaneous fixation

superiority of percutaneous fixation

outcomes of bracing vs. non-bracing for fractures

criteria for surgery in thoracolumbar burst fractures