Alright, yesterday we talked about cervical trauma, now we're going to talk about thoracolumbar trauma and we're going to start by just going over a few things related to classification and then we'll get into discussion about management. Okay, so who's familiar with the AO classification? Anyone? Who can name all 53 AO subtypes? Eric Woodard can, that's fantastic. Anyone else? Anyone else even willing to try? So the AO classification has been around for 20 years now. Really what you should understand about the AO classification is that it boils down to three injury patterns, which are the compression or type A injuries, the distraction or type B injuries, and the rotational or type C injuries. And you can imagine that as you go from A to B to C, you become more severe in the amount of force that is applied to the spine and the failure of the spine. Can you close that door please? Thanks. And then the subtypes of the A, B, and C as you start getting into the sub-sub-specifications of the AO classification, but basically as you go from A to C you get more severe and as you go from A1 to A3, A3 is more severe than A1. But in general, you can imagine that with the AO classification, the more severe your compression load, the more failure, the higher the degree of failure of the underlying spinal column, then the higher the grade would be in the AO classification. But no one actually knows all 53 injury patterns, no matter what they say, and people have done the studies to show that the inter- and intra-rater reliability is not terribly high. But the principles are of value. And in fact, those same principles of understanding the vector of force that's applied to produce the injury pattern underlies a far more useful classification in terms of surgical decision making, in my opinion, which is the telix. Now, who is familiar with telix? So in many ways, just like if you were on the phone and you describe a 37-year-old male who was in a motor vehicle crash, who's a GCS6, you have in 15 seconds alerted the person on the other end of that phone call that they're probably coming in to do an operation, right? And if you tell someone that you have a 27-year-old who fell off a roof and is a T10 AJA, you probably understand that you're going to be coming in to operate on that person as well. And if you're talking about someone who's neurologically intact with a telix score of 2, that has meaning, right? So there's value in these classification systems that we use, like the GCS, like the ASIA, like the telix, because they communicate information in a very compact manner. The telix score is based on the injury morphology, the PLC status, the posterior ligamentous complex status, and the neurologic status. And you get points depending on whether it's a compression. You get an extra point if it's a burst fracture. You get points as it relates to the integrity or lack thereof of the posterior ligamentous complex. And then, which is also very wise, is that an incomplete injury gets a higher score than a complete injury, which is basically inducing you to do something about the person who has an incomplete injury in the setting of neuroelement compression. And then if your telix score is less than 4, it portends nonoperative management greater than 4, portends operative management, and 4 is the gray zone. And then the last thing is this load-sharing classification, which was born initially out of Gaines' description of this comminution index. The goal of this thing, and you don't really need to know this. I mean, reading McCormick's paper in 1994 is actually a good read. But really the point of this is to make you think to yourself, do I need anterior column support? And the more disrupted, the more kyphotic the anterior column is, the more you should be thinking to yourself, this is a person that needs anterior column support. Alright, so now let's talk about cases and management strategies. And this is all against a backdrop of personal bias, just like yesterday. So, this is what I do. And there are lots of ways to skin a cat, but this is what I do. Alright, compression fractures. I don't brace compression fractures. I don't brace stable burst fractures. I try to avoid the use of braces throughout my practice, whether it is elective deformity corrections. I don't put those people in TLSOs afterwards. I mean, thank God that the—are there still people out there who put their ACVFs in collars afterwards? Does that still happen? Why? Why? Paranoia. You know, we have very strong evidence to demonstrate that a brace really has no role for a single-level compression fracture. And really has a minor role in stable burst fractures. So, do any of you guys train in a place where people discharge patients from the hospital with a stable burst fracture and no brace? Who? Yeah. What are you doing these days, Dom? Are you bracing stable burst fractures? Obviously, the trick is your definition of stable. My attitude of bracing is closer to yours, probably not quite as perconating, but I don't brace any of my ACVFs, you know, 1, 2, 3 levels. You know, the 1, 2, or 4 level, even that I don't brace. Most fractures I don't brace, but, you know, inflection compression fractures, simple fractures like that, I definitely don't brace. But if someone has a burst that I consider, you know, if I consider unstable, I'm definitely going to operate on it. And if I consider it stable, I'll treat it non-surgically. Those I typically will brace. Which ones will you brace? A burst fracture that I consider stable. So, someone comes in with a three-column injury, let's say, in the lumbar spine, 20% canal compromise, you know, less than 5 degrees of kyphosis. But it's three columns, the sets aren't sprung, it looks like the ligaments are okay. They've got an MRI, they've got their own tech. So that's a TLIC score of 2. Yeah, so that guy, and one of the reasons is that I think it helps to ambulate them. I think that when they have a brace, then we'll have to get out of bed, and we'll have to get out of the hospital. I think if you don't brace them, I think they're less apt to be on the mound, they're less apt to tolerate getting up. I mean, those fractures are painful. So, I get what you're saying from a stability perspective, but from a functional perspective in terms of, I don't want you to go home and start riding your motorcycle right away, or I want you to get up and be able to get out of the hospital, I typically will brace them. What I'm looking forward to is when the Apple Watch comes out, and we start getting better health apps for our mobile devices, and then we can actually start tracking things like whether people are getting up and around with these health conditions, and secondly, whether they actually ever put on the brace that you just spent $1,000 on. I'm looking forward to that being a part of the kind of apps that get developed around what's coming through the pipeline with the Apple Watch. But I agree with you, and we'll talk in a moment about a patient... Just to finish the thought, David, I think that I see my bracing go down even more. Like I said, my philosophy is really not to brace. I don't brace after I get my lumbar fusion or anything like that. Some people get their scoliosis cases, their thoracic spine down, their pelvis down. I'll consider bracing those, especially if they're osteoporotic. My attitude is a lot more like yours, but I've seen it move even more now that we can deal with these birth fractures in a minimally invasive fashion. In other words, just putting in medical screw fixation, you can get one at the level, one above, one below. There are patients I will not brace, and not that I push patients to go one way or another. I tell them what you can do is brace for a couple, three months, and you may or may not heal. You may or may not be thoracic, but we can do this one-hour operation, and you might be able to go home tomorrow kind of thing. So I think that's cut into the bracing situation as well. What do you do, Paul? I mean, I'm not a doctor, but I follow your job. Lately, we've been putting in screw fixation. And it's interesting, because in the thoracic spine, I'm not even sure these things move. People argue that not even having to do two operations, one for them, you're not using it. You're making sure you're not moving it somewhere on the spine. I think it depends on the situation. I think I'm not maybe uniform in what I do with the patient. There are some patients, you know, I want to do 90% of my patients that I've braced when I've seen them fall off. They're not willing to brace. Where do you brace? Well, it depends on what you're looking at. Equivalence in pain and one-year x-ray outcomes. There were three failures in the TLSO group, one failure in the no-brace group. And then Moeller has published these two fantastic papers. So as it turns out, in Finland, they've had a common medical record in a socialized health system for 40 years, dating back to the 1960s. And so this is an opportunity for data mining in retrospective fashion. And went back through, and 23 to 41-year follow-up rates, 23 to 41 years, absolutely no difference between bracing and no bracing. And same thing in late adolescence, 27 to 47-year follow-up, absolutely no difference whether there was a brace or not involved in the management. What about unstable burst fractures? And so what I do is, and this is really below T6, because above T6 it's hard to factor in an anterior approach. You're just less likely to do an anterior approach above T6. So below T6, what I do is, when the patients are incomplete, or they have one of those high gains comminution indices, I'll do an anterior corpectomy, structural grafting, and then either an anterior plate or plus-minus a posterior instrumentation. And then I'll do posterior only for the intact patients without much destruction of the anterior column, or for complete injuries where you can still get a decompression through a posterior approach. And actually, what I've started doing recently is taking those, from the PSO tray, those vertebral body breakers, those little paddles that we use to break the posterior vertebral body at the end of a PSO, and I'll slip that underneath the dura for burst fractures and actually bang the retropulse fragments back forward with that little device, is what I'll do if I'm doing a posterior approach for that. So that's what it looks like when we're going from the front. And, you know, so these are posterior constructs versus anterior constructs. When you do an anterior approach, it opens the door to shorter posterior constructs. And then with Adam Cantor in Pittsburgh, we've started doing, we've been doing this for, I think the first one was in about 2009, so gosh, we've been doing this for five years now. For well-selected patients, we'll do this minimally invasively. So you can, you know, make a 5-centimeter incision, and we can get a corpectomy cage and anterior plating all through a 5-centimeter incision. And, you know, that's what the incision looks like, and that was her x-ray, which is, so that's a nifty little thing, and I think Juan talked about that a little bit earlier. So it's nice to see some of these minimally invasive approaches having their indications expanded. All right, what about flexion-distraction injuries? This is mostly posterior, 360-degree for severe canal compromise or incomplete injuries where you're going to get an insufficient decompression from the back. And fracture dislocations, I pretty much do most of these posteriorly, but if it's an incomplete injury, and again, I'm concerned about maximizing decompression, I'll consider a front-back in those patients. And what you want to do is you want to think of the goals. So the goals are realignment, decompression, and stabilization ultimately, right? This is a nifty little trick that I first learned from Mike Steinmetz in Cleveland, and if you can see here, so this is a patient who has a fracture dislocation of the thoracolumbar junction. You can put in your pedicle screws and then put two rods horizontally, so not vertically, but horizontally, and actually get a really nice reduction by just taking two rod holders and grabbing onto those rods, and then you can reduce the fracture with pretty good control, pretty nice control. So you can see there's the dislocated facets, basically, you know, jumped thoracic facets, and in just a moment here, he'll nicely reduce this. Pretty sweet little trick, putting the rods horizontally. Gunshots. So non-operative treatment of gunshot wounds is the standard. We know that steroids are not applicable to this patient population, irrespective of what you think about it for the non-penetrating population. Antibiotics are not indicated for gunshot wounds to the spine, even if they traverse the canal and have CSF. They're not indicated unless there's colonic perforation. So that's the only indication for antibiotics. And then we're all tempted to go in and deprive these things and that's really not a very good idea either because you're opening the door to trouble. So decompression is rarely of benefit except for, and this is data from the Spinal Cord Injury Model Systems database, an intracanal bullet between T12 and L5. The removal of bullet fragments that are inside the canal between T12 and L5 was associated with better motor function at one year, but just between T12 and L5. And these fractures are usually stable despite a three-column injury. So again, operating on gunshot wounds to the spine should be a rare event. They rarely produce instability and there really isn't much of a role for surgical intervention unless there's a bullet inside the canal between T12 and L5 or you have something else random like a persistent CSF leak, which I just can't remember ever, ever having actually seen that. And the outcomes are most dependent on the spinal cord injury itself and the associated injuries. There is a high incidence of CSF leaks with unnecessary decompressions. There's an extremely low incidence of CSF leaks when you just leave these people alone. And bullet migration is rare but does occur. And Jeff Manley actually had a case of a cervical bullet that migrated up to the foramen magnum and caused a new neurologic deficit in a patient of his. All right, so a couple cases. 52-year-old male, motorcycle crash, thrown from the motorcycle, landed on his rear. He's neuro-intact, okay? So let's talk about this because this is how we're going to finish this up. We've got five minutes. Nathan Rowland. Yes. Where are you, Nathan? Oh, hey, what's going on? So this is a statural CT scan showing a two-column wrist fracture at T12, T12. There's a little bit of wrist repulsion. I would say that there is a number 10 to 20% canal violation. I don't see a lot of high performance here. And there's about maybe 50% that the person was running high pulse. Is there anything else you want to know? Well, let's see, so his exam is intact. How long ago is this? An hour. Okay. Is he in Asia sport? He is intact. He's in Asia E. Are there any other studies you want? So from an AO perspective, what would this be? A, B, or C? Just A, B, or C? I think it would be an A. Correct. And the T-LIX score? Well, let's see, so the T-LIX would be, so it's a 2 because of the convertible morphology would be a 2. Posterior limb complex, and I think this would be either a 2 or 3. It's either indeterminate or it's injured. I can't tell that from MRI. What if I tell you we went ahead and got an MRI? Okay. So this is now that same sagittal CT on the left, an axial cut of the CT on the middle, and a T2 MRI sagittal cut on the right. On the right I see what looks like an intact PLL at that level. And I don't have a spare sequence to see if there would be more intensity in there. But I think this means it's intact, so that would be a 0. Right. So his T-LIX score would be what? It would just be a 2. Alright, nice job. What do you want to do? So for him, one, he's intact. Two, his T-LIX score is a 2. And based on our discussion of bracing, I think I would just keep watching him. Have him come back to the clinic in 3 or 4 weeks. Maybe just get plenty of films and make sure his state will actually get better. And just continue to follow him. Have him come back to the clinic if he has any problems. Totally reasonable. Turns out this guy couldn't stand up without an intolerable amount of pain. So then we did the oldest treatment of all, which was rest. And we just said, okay, bed rest for a few days. And gave him a couple days of bed rest, tried, still couldn't do it. It's now 5 days later, he's still unable to get up and around. So we gave him a brace, hoping, like Dom was pointing out, hoping that the brace would help this guy. Turns out that didn't help either. So now it's 5 days. We've tried multiple times to get this guy up. Brace, no brace. And it's still untenable. We got a standing x-ray, right there. Which was quite painful for him. But he managed to stay up long enough to get an x-ray. Pain management, medical pain management. We tried it all. And this was his only injury? Yes. Well, I think the principle here is that he isn't in a lot of pain. But he's neuro-infected and his injury seems stable. I still would not operate, just based on him having intolerable pain. I would try whatever I could to try to help. What are your options? To manage his pain? No, no. What are your options at this point? One option is pain management. So we observed, we could try non-operative measures, such as which you guys tried breast, bracing, etc. Surgical options would be to provide a few, he doesn't really need any compression per se, but we could fuse him two levels above and two below and try a little bit of a lanky preventing model and see if that helps his pain. I don't think that's likely, but I would still try to just manage this non-surgical way. Okay. We did percutaneous instrumentation and then he immediately got out of bed the next day. So we did PERC screws. And then this goes back to what Paul brought up earlier. So he did great. And then the question is, do you take this out a year later? So is there anybody who's still taking out instrumentation a year later? Is Juan still here? We don't. You don't? No. What are you doing, Paul? You and I have had discussions with Juan about this and I think it's great. A lot of these patients, they're going to come back. I don't know exactly what happened, but there's a couple of papers out that would suggest that if the instrumentation is low enough, you might want to consider removing them because there's so much emotion that they'll eventually halo and you should not be using them. But anything above that, you can probably leave them in and that's fine. There's not that much more to it. And I wouldn't say anecdotally. I haven't looked at my series, but I remember I did ER nurse once. He came in after the homicide by accident and did an X-ray. He just did what you just did right there. And he had a lot of learning to do. But I don't know what happened to him. It's part of his system. He came back and I finished him and it's true, there's still a place. I didn't use it or anything. And you're not leaving him. It's anecdotally a good example, but there's so much to consider. What's your opinion on that, Rusty? I don't think we're being screwed with the lies and lying that the county hospital is trying to do it. And I think he does try to take that out of it. I don't know if he specifically designates certain fellows or not. And what are you doing, Don? He's leaving it. They don't have a problem with him, number one. Number two, Paul said they don't fly and they'll come back if they're doing well if they're not doing well, you can hear about it. And so we don't plan on taking him out. I'm not saying we're not against taking him out. I'm not saying we want him out if we're having problems or if they don't need him. It's not unheard of. But we don't need to leave him at home. What's wrong with sending this guy home with a bottle of Romanox and tell him to stay out of school for a couple of weeks? I mean, if you broke your ankle and you had a dislocated hip fracture, the last thing in the world that we would do is tell you why don't you get up on this tomorrow and tell me if you have a pain. Of course you wouldn't. You've been on late for three months anyway. So why do we treat the spawn so differently? I do this, I'm guilty. I break the spawn, yes. But... This is $3.06 at $800 a box. You are an OBAR, general anesthesiologist, blah blah. I'm guessing best case scenario, this is 25 grand. Right? That episode of the show. And long-term outcome in terms of pain and things like that, surgery, no surgery, doesn't matter. Is this really cost-effective? It's faster. Right. Is it more cost-effective? That's a fantastic question that I don't actually know the answer to. But when you start factoring in what would be the number of DVTs or PEs or the number of pneumonias or the number of something else that it would take to actually convert this into a cost-effective intervention. I'm just saying that out loud. I don't know the answer to that question. I think those are very good points. But when we look at it, it's going to be 50 to probably not going to get a pneumo. You're right. I think the 78-year-old who comes in like this, that's a much more difficult problem because you're keeping it on break candidates for tubal augmentation. You're right. The brace is meaningless in those guys which is probably the main generator of the pain. I don't know how a real good treatment for those people would work. Well, I think it needs to be visualized not treated as a 10-day able worker or a four-to-100-hour endocrinologist that just sits in silence and is distracted. And in fact, that's the reason the patient breaks months, couldn't return to work, couldn't get out of bed. Going back to work, I think loss of work has to factor into it. But spending $25,000 to get someone back to a $50,000-a-year job six weeks sooner is a valid question. But then you have to factor in all the other costs because the narcotic use is actually less in people who get this percutaneous instrumentation than in people who are treated non-operatively. If you want to know the answer to the question of is it cost-effective, there's a way to do that and there's a way to calculate that and it starts becoming much broader and more complex than just focusing on the $25,000 episode of care for the surgery, which is not to discount the validity or importance of the question. Rusty? It may play a role in the multi-trauma patient who's going to be going back and forth to the OR with abdominal surgeries, chest surgeries where you basically have an internal brace to make that safer. And it has become crystal clear that in people who have unstable spine fractures that early intervention has a very long list of benefits and is clearly superior to waiting as far as mobilization, hospital length of stay, medical complications, faster transition to rehab, etc. So for unstable fractures early intervention is clearly, clearly superior and cost-effective. This is a stable situation and I've never actually seen the cost analysis. The cost-effectiveness analysis of this particular intervention is probably long overdue for someone in the room who wants to tackle that. Alright, who's next? Can you comment on that right there? Is there any issue you think with having a robotic rod at that level? Right, and so this case is actually from 2009. We took his instrumentation out a year later and we've given up on we don't take the instrumentation out anymore and we also don't use this particular system anymore because this system you're sort of induced to use a lordotic rod and the system we use now we have lots of options and we can bend the rod to whatever we want so it's a good point but we took his instrumentation out a year later anyway. How do you take it out? Can you use the same percutaneous incisions? No, and the irony of it all is that we did a midline open approach to take it out.

thoracolumbar trauma

AO classification

telix score

management strategies

compression fractures

non-operative approaches

cost-effectiveness