Fractures and Reconstructive Surgery

The most common causes from which vertebral fractures originate are trauma with a strong impact. There are factors that can increase the possibility of suffering from this trauma, such as osteoporosis, which leads to a vertebral fracture with a slight impact or when exercising with a high load.

The pathologies that we treat with these minimally invasive systems are lumbar vertebrae fractures, dorsal or thoracic vertebrae fractures, as well as pathological fractures due to osteoporosis, tumors, or bone metabolism diseases. A specific example is an L1 fracture.

For young patients with stable fractures, we use the Spine Jack ® (Vexim) reexpansion and cementation system.

Generally, the anesthesia we perform is sedation and local anesthesia. The patient's position on the operating table is prone (face down). After locating the fracture using X-rays, we made two very small incisions on the back, about 5 mm. We locate the pedicles of the fractured vertebra and create a transpedicular access route to insert 2 implants that re-expand the fracture through a system similar to a carjacking. Under X-ray control, we raise the implants and, once the initial shape and height of the fractured vertebra are restored, it is stabilized using bone cement that hardens in a few minutes. To finish, we remove the instruments and put a stitch in each incision.

In the case of patients with stable osteoporotic or osteopenic vertebral fractures, we use balloon kyphoplasty (Kyphon® Medtronic) and cementation for the restoration of the vertebra.

We perform this operation with local anesthesia and sedation in the prone position (face down). The approach is similar to the previous procedure, minimally invasive, with 5mm incisions in the back, at the affected level. In this case, instead of an elevation implant, we use a re-expandable balloon inside the body of the vertebra to restore the subsidence. The entire procedure is performed under X-ray control, and we finish the fracture repair by supporting it with bone cement. Finally, we close both incisions with a stitch.

These techniques make it possible to take a bone sample for its anatomopathological study in the case of suspected pathological fractures due to tumors or bone metabolism diseases.

For unstable fractures with a risk of neurological involvement compressing the spinal cord or nerve roots, with great involvement of the vertebra and its ligaments, a more rigid fixation system is required to stabilize the fracture until it heals, requiring screw fixation and bars.

We use a minimally invasive percutaneous system (CD Horizon Longitude® Medtronic), which reduces muscle damage and only requires small incisions at the vertebral levels that need to be treated to form a stable system.

It is performed under general anesthesia in the prone position (face down). We locate the vertebral levels that require fixation with screws and rods using X-rays and approach with small skin incisions of approximately 1 cm. With constant X-ray vision in two planes, we identify the exact place through which a 1-mm needle is going to be inserted inside the vertebral body through the pedicles of the vertebrae. These will serve as a guide for inserting the cannulated screws.

On the other hand, we introduce the bar into the screws also percutaneously through two small incisions. Using a distraction system, we reduce the fracture and close the small skin incisions with 2 stitches each.

The duration of this procedure varies from 30 to 45 minutes for each fractured vertebra. The procedure can be performed on an outpatient basis without the need for patient admission.

When it comes to the Medtronic Horizon Longitude® CD Percutaneous System, it typically takes 15 minutes for each level that requires screw placement. The most common surgery requires a 4-level fixation when there is an unstable-fractured vertebra. The surgery usually lasts about 90 minutes.

Generally, the consolidation time of a vertebral fracture leads to hospital discharge 24-48 hours after performing the vertebral fracture surgery, with the recovery time of the fracture of the dorsal or lumbar vertebra being very short.

The fundamental advantage of this spinal microsurgery is to relieve pain as soon as possible, avoiding complications with potentially serious post-traumatic deformities.

We use surgical treatment with minimally invasive percutaneous systems with the following advantages:

• We carry out short surgical procedures with a little risk due to continuous X-ray control and the use of local anesthesia with sedation.
• Low blood loss and minimal muscle injuries to the muscles above the vertebrae, mean less postoperative pain and shorter hospital stay.
• Hospital discharge on the same day of surgery, or within 24-48 hours in the case of using screws and bars.
• Very small scars with small skin approach from 0.5 mm to 1 cm. Large scars and tissue injuries from open surgeries are avoided.
• Early treatment allows early relief of pain, quickly returning to activities of daily living and normal social life.
• Restoration of the anatomical deformity and normal biomechanics of the spine prevents post-traumatic kyphosis which leads to chronic back pain. In the case of osteoporotic fractures, new fractures are prevented by restoring the height of the vertebra, avoiding the progressive anterior tilt of the back and the increased weight that the vertebrae have to support in the anterior part of the vertebral body, which implies new fractures.
• With surgical treatment we prevent the progression of sinking and collapse of the vertebra, avoiding neurological compressions and instabilities of the affected vertebral segment, which leads to worse clinical results and a higher risk of short-term complications.
• In older people, the vital pulmonary capacity is improved by correcting the kyphotic posture.
• Corsets and long periods of bed rest are avoided, which implies a longer intake of analgesics and a greater possibility of complications.

The tests that must be carried out for the diagnosis of a vertebral fracture and to be able to globally assess all the affected parts in order to decide on the best treatment to be carried out are X-rays of the spine, and computerized axial tomography (CAT) and MRI. Magnetic (MRI). On some occasions, we should also use neurophysiological studies with electroneuromyograms if there is neurological involvement.

• X-rays provide us with a quick assessment of whether there is a vertebral fracture and guidance about its severity. We can distinguish between compression fractures, translation-rotation fractures, or distraction fractures.
• CT is used to identify vertebral bone involvement and possible bone displacement, especially those that can invade the spinal canal. It provides a definition of bone involvement through millimeter cuts in all axes and the possibility of three-dimensional reconstruction.
• Magnetic Resonance better defines the involvement of the vertebral disc and soft tissues: ligaments, capsules, and muscles.

It is very important to define Magnetic Resonance if there is the involvement of the structures of the complex of posterior ligaments of the vertebrae, since its involvement indicates instability of the vertebral segment, determining the use of a more rigid type of fixation in surgical treatment.

Magnetic Resonance Imaging also provides us with information on the time of evolution of the fracture, which is very important, especially in people over 55-60 years of age, who may have had osteoporotic fractures, and with MRI we can define whether it is a recent fracture (acute). Or is old. When it is recent, we can observe edema inside the bone in one of the MR sequences. It also informs us about damage to the disc and adjacent soft tissues that could indicate a pathological fracture (tumors, bone metabolism diseases, etc.).

Upon discharge from the hospital, we must have the medical report specifying the types of fractures treated and the system used.

In relation to post-surgical medication, we use anti-inflammatories - analgesics the first few days as required. Generally, an analgesic drug is usually sufficient, although it is better to complement the report with two alternatives, if necessary. Muscle relaxants will be used in case of lumbar contracture.

The surgical wound is about 0.5 – 1 in the posterior part of the back in the lumbar or thoracic region, depending on the fracture. A stitch or staple is usually given. We can wash the wound from the 5th day, keeping it clean and dry with betadine or chlorhexidine cures. There are usually no complications of infection or wound openings due to its small size.

No corset is required and after the first 15 days, physical activity can be increased. From the first day, it is advisable to carry out movements of the thoracolumbar spine without energetic movements: flexion-extension, lateralization, and rotation. We recommend avoiding bad postures or handling heavy loads.

If there is any lumbar discomfort due to contracture of the muscles, we can apply local heat for 20 minutes 3-4 times a day and perform progressive stretching exercises.

If there is residual lumbar pain, the exercises can be complemented with a physical rehabilitation session, better in a specialized center.

Driving the car can be done immediately in the first 15 days. In low cars, we recommend using a cushion for the first few days to avoid poor posture.

In the event of any complication or incident, consult the emergency department of the hospital where you underwent surgery.

Hospital discharge in cases of bone re-expansion and cementation, both for the Spine Jack system and for Balloon Kyphoplasty, is ambulatory and is performed on the same day as surgery.

By reducing the initial shape of the fractured vertebra and cementing it, giving it stabilization and support, a restoration of the anatomy is achieved, causing immediate pain relief.

No brace or crutches are required, for self-discharge. We prescribe some mild analgesics for about 5-7 days. Daily activities can be performed immediately and progressively. Rehabilitation is not usually necessary, and return to work and sports usually occur a month after surgery.

Generally, the first postoperative check-up is carried out 10 days later, to assess the surgical wounds which, being so small, do not usually have any complications, and at that time the stitches can be removed. The next check-up is usually after a month, with a control X-ray being performed.

Subsequently, no further check-ups are usually necessary but, individually, depending on the type of work activity carried out by the patient, especially in tasks that involve large load manipulations, some more check-ups may be required if it is necessary to enhance the muscles with physical rehabilitation.

In the case of unstable fractures treated with the CD Horizon Longitude Medtronic® system, it is also through a percutaneous approach, but as more levels are performed and the incisions are a little wider, 24-hour intravenous analgesics may be required for better pain tolerance. . Recovery is usually a little slower, and progressive activity can be carried out from the first postoperative day. The use of corsets is also not necessary. Analgesics are usually required for 7-10 days. Return to daily activities is gradual over the course of the first month. Rehabilitation treatment is usually necessary to strengthen the back muscles. Returning to work is usually between the sixth and eighth postoperative week, depending on the activity to be carried out. If it involves the manipulation of large loads, it is usually necessary to prolong muscle strengthening until 8-12 weeks.

The extraction of the screws and bars is done one year after their implantation since several levels are set to provide structural support so that the fractured vertebra hardens without being subjected to weight support, but once complete consolidation is achieved without bone edema, it is removed to maintain correct mobility of all the vertebral levels of the back.

The surgical approach and treatment of thoracic and lumbar fractures imply better results in the medium and long term, avoiding chronic back pain and open surgeries due to complications.

In the case of the use of screws and bars, it is necessary to remove them a year after surgery to improve the harmony and biomechanics of back mobility.

Control is usually done in consultation in the first 15 days and a month after surgery by our spinal traumatologists, physical rehabilitation being necessary in case of approaching several vertebral levels or if a high muscle strengthening is required for the development of their work or everyday activities.