SpineNews 12

SpineNews
N U M B E R 12 - NOVE M B E R 2005
News from the world of spinal surgery and biomechanics
Focus on
Thoracolumbar fractures
6
THORACOLUMBAR FRACTURES
TREATMENT
Robert P. Melcher, MD
ISSN 1774-6701
8
THORACOLUMBAR MALUNION
SURGICAL APPROACH
Jean-Paul Steib, PhD
16
EVALUATION
Clinical case comments
23
DECISION TREE FOR
OSTEOPOROSIS TREATMENT
Michel Philippe, MD
33
SPINAL IMPLANT INDUSTRY
OUTLOOK FOR 2006
Robin R. Young, CFA
The official Argos publication / www.argos-europe.com
SpineNews
EDITORIAL
EDITORIAL HEADQUARTERS
Argos
64, rue Tiquetonne 75002 Paris France
PH +33 (0)1 42 33 03 87
FX +33 (0)1 42 33 06 62
EDITORIAL STAFF
Editor in chief :
Anca Mitulescu, PhD
Production/Art director :
Karim Boukarabila
Editorial advisory board :
The Argos committees
Associate editors :
William Blake Rodgers, MD
Robin R. Young, CFA
ARGOS ASSOCIATION :
President :
Pr Christian Mazel, MD
General secretary :
Pr Pierre Kehr, MD
Treasurer : Alain Graftiaux, MD
Communication committee :
Anca Mitulescu, PhD, President
Moreno D’Amico, PhD
Raphaël Dumas, PhD
Pr Tamas Illes, MD, PhD
PR PIERRE KEHR GENERAL SECRETARY
All roads lead to… Paris !
In January 2006 Argos will celebrate its 10th anniversary. For the last ten
years the Board officers (among whom I am privileged to sit), as well as
many other friends too numerous to name here, have supported Christian
Mazel in creating the Argos fraternity and organizing a day and a half
meeting dedicated to spine surgery in Paris each year.
Denis Kaech, MD
Pr Pierre Kehr, MD
Panagiotis Korovessis, MD, PhD
Junichi Kunogi, MD
William Blake Rodgers, MD
Karen E. Warden, PhDc
Training committee :
Pr Jean-Paul Steib, MD, President
Laurent Balabaud, MD
Pr Denis Cordonnier, MD
Pierre-Jacques Finiels, MD
Samo Fokter, MD
Pr Tamas Illes, MD, PhD
Pr Mihai Jianu, MD
Venugopal Menon, MD
Olivier Ricart, MD
Pr Jean-Marc Vital, MD
Evaluation committee :
Pr Wafa Skalli, PhD, President
Pr Jacques De Guise, PhD
Pr Jean Dubousset, MD
Sabri El Banna, MD
Charles-Marc Laager, MD
Mongi Miladi, MD
Joël Sorbier, MD
Constantin Schizas, MD
Pr Jean-Paul Steib, MD
W
hen we began, there were already
several working task forces in spine
surgery, such as the Lumbar Spine
Society, the Cervical Spine Research
Society (with both its international and its
European sections), the young European
Spine Society, the GIEDA group, the GICD
— all of them very well organized and active.
In addition, several medical schools in
France organized days of information and
training. Among those organizers, we
should mention René Louis in Marseille,
Raymond Roy-Camille and later on Gerard
Saillant, at the Pitié Salpêtrière Hospital in
Paris, Alain Deburge at the Beaujon
Hospital in Paris, as well as Arsène Grosse,
Jean-Claude Dosch and myself serving in
the Spine section of the International
Association on Dynamic Osteosynthesis
(AIOD) in Strasbourg.
David A. Wiles, MD
ADVERTISING SALES,
PLEASE CONTACT :
Anca Mitulescu
Fx +33 (0)1 42 33 06 62
[email protected]
Argos SpineNews is published twice a year by
SurgiView SAS. Printed by ICL Lens France. It is
sent for free to physicians, surgeons,
researchers and industrial companies on an
In creating Argos, we intended to provide
an opportunity for specialists of all medical
and biomedical disciplines the world over,
to gather in Paris once a year and share
their experience on topics in spine surgery.
We adopted the rules of classical drama :
unity in place, time and action. The Argos
symposium is held in the same place at the
same time each year, and concentrates on
a single topic. Concentration
exploration were our by-words.
and
Argos has grown beyond our fondest
hopes : from less than 100 attendees at the
beginning, the meeting grew to more than
200 within five years and now upwards of
300 friends strain the capacity of our
meeting room. By including all of those
sworn to care for patients with spinal
maladies — orthopaedists, neurosurgeons,
radiologists,
biomedical
engineers,
physiatrists, rheumatologists, and anyone
else I have forgotten to list — we forged a
multi-disciplinary partnership to a better
understanding of the great controversial
topics in spine surgery.
Perhaps unintentionally, we borrowed our
format from television. We begin with our
guests arguing face-to-face before the
audience of their peers. The discussion
then opens to include the audience and
expands to include a level of interaction
unparalleled in any other meeting. In truth,
a level of interpersonal interaction that
could only be facilitated by the technical
prowess of our logistics team and
collegiality of our participants. We also
wanted this fraternity to cross national
international scale. Single copy price is 7€.
Copyright© 2001 by SurgiView, all rights
reserved. Reproduction in any forms is
forbidden without express permission of
copyright owner.
Argos SpineNews
N°12 November 2005
3
and cultural divides. Therefore, we felt
that providing simultaneous discussion
in English and French was essential.
Bilingual meetings are quite expensive,
but the generosity of our industrial
partner allowed us to offer high quality
real time translation, which made it
possible for the speakers and the
audience to express their opinions in
either English or in French.
From the beginning we have been
honoured by the attendance of worldrenowned specialists ; their feedback
has been uniformly positive and we
certainly are very proud of what the
symposium has become.
I would be remiss however if I failed to
acknowledge our great gratitude for the
generous support we have received
from industry. We have been fortunate from
the beginning to find partners who not only
allowed, but expected the full scientific
independence of Argos, leaving the choice
of topics and guest speakers to the Argos
Board.
The French Spine Society (Société
Française du Rachis) has been recently
created under the aegis of the French
Society of Orthopaedic Surgery and Trauma
(Société
Française
de
Chirurgie
Orthopédique et Traumatologique SOFCOT). What role then remains for
Argos and GIEDA and other very
specialized groups ? In my opinion, they are
perfectly
compatible
since
their
methodologies are different. The French
Spine Society is the spine section of a large
national orthopaedic society that needed a
dedicated spine sub-group, while the
others are the results of individual initiatives
gathering surgeons, engineers, and
medical doctors of various specialties with
an interest in spine who have deliberately
chosen a multidisciplinary approach and an
international forum for the exchange of
opinions.
Argos is proud to be such a group. As says
the ancient adagio “All roads lead to Rome”,
I sincerely hope that these two groups
(Argos and GIEDA) continue to lead the
progress in therapies for the benefit of
patients with spinal disorders.
EDITO BY PIERRE KEHR, MD FOUNDING MEMBER AND
GENERAL SECRETARY OF ARGOS
Argos SpineNews summary
SPECIAL ISSUE ON
THORACOLUMBAR
FRACTURES
INTRODUCING SOME
OF OUR GUEST
SPEAKERS AT THE 10TH
INTERNATIONAL
ARGOS SYMPOSIUM
COMMUNICATION
19
29
32
33
EVALUATION
8
9
29
TRAINING
6
14
16
23
4
Argos SpineNews
N°12 November 2005
Literature update
Agenda
Web review
Spinal implant industry outlook for 2006
Thoracolumbar malunions
JEAN-PAUL STEIB
Thoughts on thoracolumbar fractures
Thoracolumbar fractures
ROBERT P. MELCHER
Thoracolumbar fracture treatment
Osteroporosis treatment
CLAES OLERUD
JEAN-PAUL STEIB
Malunion/surgical strategy
Clinical case discussion
ROBIN R. YOUNG
ROBERT P. MELCHER
WILLIAM BLAKE RODGERS, GUY MATGÉ
MICHEL PHILIPPE
Commercial advertising offer 2005
ADVERTISER INFORMATION :
Diffusion : direct mailing
Frequency : 2 times a year
Print run : 10.000 samples
Addressed to : orthopedic surgeons,
neurosurgeons, biomedical staff, spine
specialists.
Print mode : offset CTP (digital)
Required elements : digital only, all
fonts included (bitmap and postscript™ in
Apple Macintosh font format).
Data formats :
- QuarkXpress™/RTF (Rich Text
Format)/Word compatible formats/Adobe
Acrobat® (high resolution PDF with no
printing restriction) for text files
- Adobe Illustrator® (EPS, AI)
for vector graphics (all fonts
must be vectorized)
- Adobe Photoshop® (PSD, TIFF, EPSF,
BMP in CMYK or RGB mode with 300
dots per inch at least) for bitmap
illustrations
Size : A4 (210x297mm) for a single page
Delay : digital files required 4 weeks
before printing.
10.000 biannual issues of Argos SpineNews are distributed for free by direct
mailing to surgeons and spine professionals all over the world. We regularly include in
our journal commercial advertisings for clinical devices and accessories manufacturers.
Would you be interested in putting an ad or more in the Argos SpineNews journal, we
would be glad to provide you with a complete information on our offer.
Double page
Single page
Half page (vertical)
Half page (horizontal)
420x297mm
210x297mm
105x297mm
210x150mm
Estimate :
Double page ad (double A4, 4 colors)
Single page ad (A4, 4 colors)
Double page illustrated article (describing a product)
Single page illustrated article (describing a product)
Half page ad (vertical or horizontal)
Extra journal sample (10 issues are delivered by default to your address)
€
€
€
€
€
4.500,3.000,4.500,3.000,1.500,€ 7,-
Discounts on the overall estimate per issue :
5%
10 %
15 %
2 ads/issue :
3 ads/issue :
4 (or more) ads/issue :
Discounts per number of issues :
For more information,
please contact :
Anca Mitulescu
[email protected]
FX +33 (0)1 42 33 06 62
5%
10 %
15 %
2 issues :
3 issues :
4 (or more) issues :
The discounts per number of ads and per number of issues may be cumulated. E.g. :
Discount for 4 (or more) ads in 4 consecutive or non consecutive issues : 30%. Our
industrial partners are also provided with a complete feedback on the readers interest
in their products and/or services. This particular service is offered for free to all our
partners.
Argos SpineNews
N°12 November 2005
5
TRAINING / MALUNION
without posterior stabilization will leave the patient with an
unstable spine.
Malunion / surgical
strategy : single, double,
multiple approaches
BY ROBERT P. MELCHER KARLSBAD-LANGENSTEINBACH, GERMANY
The correct classification of thoracolumbar fractures requires a
complete radiological evaluation. Not all injuries of the posterior
elements can be detected in the Xray or CT. MRI is mandatory to
visualize potential spinal cord compression but, just as
importantly, to evaluate the competency of the posterior spinal
ligaments.
When approaching a thoracolumbar malunion,
the surgeon must assess each fracture with a
case by case evaluation that asks the following
questions :
Does the spinal canal need to be
decompressed ?
First of all, it is important to clarify the definition
of the term “malunion” in this context. Most posttraumatic spinal deformities result from absent or
delayed bony healing. Therefore the term
malunion is not only used to describe the osseous
nonunion (pseudarthrosis), but at the
thoracolumbar junction the term encompasses
the resultant deformity and unsatisfactory sagittal
alignment.
How much correction of the sagittal
alignment is required ?
What is the condition of the anterior
column ?
• Is the complete or partial resection of the vertebral body required ?
• What is the condition of the adjacent intervertebral discs ?
• How much anterior support is required ?
Are the posterior elements intact ?
A
fter a fracture has gone on to malunion, the assigning of
blame begins. It is always easiest to deflect blame from
the physician to the patient (“noncompliant”) or the
situations (“poor bone quality”). Clearly, hardware failures occurs
– screws pull out of osteoporotic bone and cages subside but,
what is the main reason for failure in younger patients ? All too
often it is the surgeon who bears the major responsibility for these
poor results. Misinterpretation and misclassification of a
thoracolumbar fracture yields an incorrect treatment program
which inexorably leads to malalignment, malunion, and disability.
For example : in Magerl type B and C fractures with injury to the
posterior elements, anterior decompression and instrumentation
6
Argos SpineNews
N°12 November 2005
• Are the osseous elements (e.g. pedicle, lamina or facet joints)
fractured ?
• Are the ligamentous structures competent ?
If the fracture was treated operatively
before, to what extent do the old implants
need to be removed and replaced ?
Is a posterior release necessary because of
osseous bridging or prior fusion ?
TRAINING / MALUNION
posterior implants. The reason is the injury
of one or more intervetebral discs which
leads to segmental collapse. This
phenomenon was described by Lindsey
and Dick in 1991. Disc resection followed
by anterior fusion is the treatment of choice
for these patients. We advocate
augmenting the anterior reconstruction
with posterior instrumentation loaded in
compression.
It is not possible to cover all possible
treatment options for the wide variety of
malunions which can present. However,
addressing these questions can provide a
useful guideline for the planned revision
procedure.
Among the most common treatment
failures that we see is collapse across the
operative segment in thoracolumbar
fractures treated with posterior short
segment transpedicular instrumentation
alone. These failures can be classified into
two types : failures occurring with the
instrumentation in place and progressive
deformity after hardware removal. In the
first scenario, the extent of anterior
instability was underestimated and the
posterior implant was not capable of
providing sufficient stability, resulting in an
increasing kyphosis. Anterior support must
be provided through an anterior approach
with complete or partial vertebrectomy and
reconstruction with an adequate spacer
and additional bone graft. To achieve
sufficient correction of the deformity,
intraoperative intervertebral distraction
must be performed. This cannot be
accomplished thoracoscopically; it must be
done through an open procedure. In cases
of severe deformity, it is always necessary
to remove the posterior hardware.
Laminectomy (at least of the cephalad
vertebra) is also important. In cases of mild
deformity, anterior distraction may be
possible “against” the posterior hardware.
Restoration of the posterior tension band
by an adequate posterior implant locked in
compression is mandatory.
In the second scenario, the fracture
appears to be fully healed and yet the
deformity progress after removal of the
AP and lateral view of an L3 fracture
in a 37 year-old lady treated by fixateur
externe. Loss of correction and
displacement of the hardware results in
adjacent disc injury.
In all cases with fixed deformity, multiple
approaches must be considered : first to
release the posterior instrumentation. If the
system allows loosening and can serve as a
sliding rod stabilization, it can be left in situ,
otherwise it should be replaced by an
adequate construct. The neural elements
must then be decompressed posteriorly in
anticipation of impingement during the
reduction maneuver. The dorsal wound is
temporarily closed and the patient is
brought into the lateral decubitus position.
The anterior spine can be most efficiently
reached by taking down the diaphragm.
Anterior construction is then performed.
The patient is returned to the prone position
and the procedure is completed by the
application of posterior compression forces.
In patients with poor bone quality,
additional strength can be obtained by
augmenting the vertebra with cement either
through cannulated pedicle screws or
directly.
Conclusion ::
The thoracolumbar junction is exposed to
high rotational stresses, thus complete
restoration of stability and strong
instrumentation constructs are mandated.
Surgical strategies must address both the
deformity and the instability and thus, in
situations where the initial treatment has
failed, salvage procedures required
extensive combined reconstructions.
Same patient 7 years after
reconstruction. Correction of the
kyphotic and scoliotic deformity was
performed by a combined posterioranterior-posterior approach.
Note : the Th12/L1 level had to be
included into the construct to correct
the deformity in the coronal plane.
Argos SpineNews
N°12 November 2005
7
EVALUATION / THORACOLUMBAR MALUNION
vertebral endplates and intercalary grafting
(usually rib inlaid in a trench cut into the
vertebral body). The intercalary graft is
augmented with local autogenous bone
and/or synthetic bone substitutes. If the
bone is of poor quality, we perform a
vertebrectomy and cage reconstruction of
the anterior column.
Thoracolumbar malunions
Surgical approach strategy : single,
double or combined approach
BY JEAN-PAUL STEIB, S. MEZGHANI HÔPITAUX UNIVERSITAIRES DE STRASBOURG,
The posterior procedure took 157 min
(80-360 min). The instrumentation pattern
has been described previously for fracture
stabilization : two screws protected by
hooks at the level above (normally a
pediculo-transverse claw at D10 and the
level below (using offset laminar hooks).
Posterior osteostomies are performed if
necessary, as is common after failed prior
surgical treatment. Reduction is
DEPT OF ORTHOPAEDIC SURGERY, FRANCE
ABOUT
Treatment must correct the deformity and
achieve a stable, balanced spinal column.
Based on our series of 20 malunions (7
surgical treatment failures, 13 brace
treatment failures) treated surgically with a
follow up over one year, we have developed
the following protocol.
The spine is approached dorsally and
ventrally, instrumented and grafted (360° in
every case).
The deformity is corrected by in situ
contouring. The spine must be flexible to
allow the correction. The reducibility of the
deformation can be appreciated on dynamic
Xrays (flexion-extension Xrays, billot test).
T
he most frequent site of spinal
fractures is the thoraco-lumbar
junction
(T11-L2).
This
frequency would logically beget a host
of malunited fractures – either from
failures of understanding, or biology, or
technique. These malunions fall into
kyphosis yielding a sagittal imbalance.
The spine attempts to correct itself by
decreasing the thoracic kyphosis above
or increasing the lumbar lordosis below.
This may lead to local pain at the
malunion but more commonly to pain
above or below the injured level. As the
neural elements are stretched across
this angular kyphosis radicular or
myelopathic symptoms may appear.
8
Argos SpineNews
N°12 November 2005
In our series we found that if angular
mobility was less than 6°, it was necessary
to perform an anterior release with waiting
graft, and then a posterior correction. If
mobility was greater than 6°, the spine is
approached from a posterior approach and
an anterior grafting is performed
afterwards.
In our series we have preferred to perform
both procedures during the same
anesthesia. The anterior approach is
performed by video-assisted techniques.
The operative time averaged 125 min
(60-270 min). Anterior release was
performed by removing the disc above and
below the fracture with decortication of the
Jean-Paul Steib
HÔPITAL CIVIL DE STRASBOURG, PAVILLON CHIRURGICAL B
BP 426, 67091 STRASBOURG FRANCE
PH +33 3 88 11 68 27 - FX +33 3 88 11 67 75
Professor JP. Steib completed his internship
at Colmar and Strasbourg Hospitals in 1978
and became a Hospital practitioner at
Stéphanie Hospital under Pr Lang and Pr
Kehr in June 1988. He then served in the
Spinal and Sports Injuries Orthopaedic
Surgery Unit, under Pr H. Jaeger at the
Hopitaux Universitaires de Strasbourg. He is
currently full Professor in spine surgery at
the Hopitaux Universitaires de Strasbourg.
He is an active member of numerous
specialized societies and associations and
the author and co-author of over 75 papers
published in national and international
peer-reviewed journals and over 35 didactic
papers and book chapters, 100
communications in international meetings,
100 in national meetings and 160 lectures
as a guest speaker. Pr Steib is the President
of the Training Committee of Argos and the
President elect of the French Scoliosis
Society (GES) starting from March 2006,
founding member of the French Spine
Surgery Society (SFCR) and served as a
general secretary for GICD from 1989 to
1999. Pr Steib has a strong experience in
spine surgery with over 400 surgeries
performed each year (degenerative
diseases, deformities, tumour and
trauma).
EVALUATION / THORACOLUMBAR FRACTURES
performed by bilateral and symmetrical
contouring along both rods with implants
closed but not locked.
In our series, 12 procedures began posteriorly
and finished anteriorly while 8 started anteriorly
and concluded with a posterior approach.
Farcy’s sagittal index was 22° pre-operatively
(6-36) and 2.5° post-operatively (-10-8.7).
There was no significant loss of correction at
final follow-up. The correction of the thoracolumbar kyphosis was not accompanied by
pelvic decompensation. Blood loss was
averaged 1022 ml (370-2320 ml). The analog
visual pain score was 7.7 (3.5-10) preoperatively and 4.1 (0-6.5) post-operatively.
The comparison of the techniques and their
results with literature is difficult. The
thoraco-lumbar junction can indeed extend
from T6 to L3 and there is no established
relative measurement. Farcy performs the
simultaneous double approach in lateral
position associated to a corporectomy. This
surgery is a little longer with more blood
loss with similar results.
Conclusion ::
We routinely treat malunions of the
thoraco-lumbar junction with systematic
combined
dorsal
and
ventral
approaches. The sequence of
approaches is determined by the preoperative angular mobility. Reduction is
performed by in situ contouring with
posterior instrumentation.
Thoughts on thoracolumbar spine
fractures and correction of
post-traumatic kyphosis
BY CLAES OLERUD, MD PHD ASSOCIATE PROFESSOR, DEPARTMENT OF ORTHOPEDICS, UPPSALA UNIVERSITY HOSPITAL,
UPPSALA, SWEDEN
The choice of construct for treating a thoracolumbar spine fracture is based
on a number of factors that balance between the stability and durability of
the construct on one hand and spinal mobility on the other.
O
bviously, the biomechanical
properties of the spine and how
they are affected by the fracture
remain primary. When standing, the
vertebral column is located posterior to
the resultant gravitational force vector
(RGV) of the torso, resulting in a flexion
moment throughout the entire length of
the spine. This flexion moment is
counteracted dorsally by the tension in
the posterior ligaments and muscles and
ventrally by compression of the anterior
column of the spine, i.e. the vertebral
bodies and disks. The larger the distance
between the vertebral column and RGV
the longer the lever arm for the load, and
the larger the moment for the same
applied load. Due to the normal thoracic
kyphosis the moment acting on the spinal
column is larger in the mid thoracic than in
the thoracolumbar or lumbar spine, but
the presence of an intact rib cage aids in
balancing the thoracic kyphogenic
moment.
Any loss of mechanical integrity of the
spinal column will result in kyphosis,
whether this is compression of the anterior
column as in a burst fracture, or rupture of
the posterior structures as in a chance
fracture (figure 1, 2). Such a failure
increases the kyphosis, which will increase
the distance between the spine and the
RGV (i.e. the lever arm for the flexion
moment). Thus, the kyphogenic moment
will increase as the deformity progresses.
As the lever arm is largest in the mid
thoracic spine, and the load increases
distally, this effect is most pronounced in
the middle to lower thoracic spine,
especially if the chest cage is unstable due
to rib and sternal fractures.
1
2
(figure 1, 2) CT reconstruction of a burst
fracture and a chance fracture of L1. Due to the
biomechanincal principles insufficiency of the
anterior and posterior columns will result in similar
deformity
Argos SpineNews
N°12 November 2005
9
EVALUATION / THORACOLUMBAR FRACTURES
ABOUT
Claes Olerud
UPPSALA UNIVERSITY HOSPITAL
DEPT OF ORTHOPAEDICS, 751 85 UPPSALA SWEDEN
PH +46 18 66 44 83 - FX +46 18 50 94 27
Dr Olerud graduated
the College in
Uppsala
(Celsiusskolan) and
he was a foreign
exchange student in
USA from 1972 to
1973. He then graduated the Medical
school at Karolinska Institute,
Stockholm, in 1981. He subsequently
completed his Internship in Eksjö with
Dr. Bengt Hagstedt and a Specialist
training in Uppsala with Professor
Sven Olerud and in Nottingham with
Mr JK Webb. He is currently
Consultant/Head of section for Spine
Surgery at the Department of
Orthopedics, Uppsala University
Hospital, Uppsala, Sweden under
Professor Olle Nilsson. The section
constitutes 1/5 of the Department of
Orthopedics and approximately 400
spine procedures are performed every
year. All aspects of spine surgery are
covered including deformity, cervical
spine surgery, degenerative, and
tumors. Claes Olerud also serves as a
member of the Editorial Board for J
Bone Joint Surg — Br, Secretary for
Cervical Spine Research Society —
European Section and President Elect
for Swedish Spine Surgery Society, to
become President in 2006.
10
Argos SpineNews
N°12 November 2005
Local fracture factors will also affect
the stability and durability of a construct.
In a burst fracture (type A fracture,
Magerl 1994) the tension band
properties of the posterior column are,
by definition, intact. The anterior column
is fractured, but still capable of bearing
some loads through compression
between fracture fragments. Burst
fractures usually occur at the
thoracolumbar junction where the
distance between the spinal column and
the RGV is small. Thus, an unreduced
burst fracture with a limited degree of
kyphosis is relatively stable but the
stability decreases significantly once the
fracture is reduced due to the absence of
the anterior column structural integrity.
Posterior instrumentation thus shares the
loads with the bone if a burst fracture is
stabilized in situ, but will be load bearing
(the worst situation for durability) if the
fracture is reduced.
Predictably, the clinical experience with
such constructs is disappointing (Knop et
al. 1997). This has led to recommendations
for alternative techniques — long posterior
constructs with hooks above and below,
attempts to reconstruct the anterior column
with transpedicular grafts, anterior
reconstruction alone, or even combined
ventral and dorsal procedures (“360°
surgery”)
with
anterior
column
reconstruction with bone graft or cages.
However, most burst fractures can be
treated conservatively with excellent result
compared to operative treatment, which
has been shown in several good studies
including a prospective controlled study by
Shen et al. (2001) and a prospective
randomised study by Wood et al. (2003).
3
Not all burst fractures do well with
conservative treatment. If the kyphosis
exceeds 20-30° the incidence of late back
pain increases (Soreff 1977) thus surgery
should probably be the primary treatment in
those cases. What type of procedure to
choose is not clear, but an attempt to
reconstruct the anterior column should be
strongly considered. We, like others, have
tried, and failed, with transpedicular bone
grafting (Knop et al 1997). Another
alternative is anterior surgery, but in the
acute patient this is associated with a high
blood loss. Combined ventral and dorsal
procedures are cumbersome and require
significant resources. Recently I have
treated selected cases with severe
comminution with primary posterior closing
wedge resection and a short posterior
fixation (Reyes-Sanchez et al. 2002)
(figure 3).
In contrast to a burst fracture, the
unreduced chance fracture is severely
unstable, but becomes stable by reduction
with the application of a tension band
posteriorly. Because the anterior column is
competent the fixation device is loadsharing and, thus, durable (figure 4, 5). In
more complicated situations, Magerl Type C
fractures, long fixation constructs are
required to provide rotational stability
(figure 6).
Neurological compromise is usually
considered an indication for surgical
treatment in hopes that this would improve
chances for recovery. Several studies have
been performed to evaluate this, but very
little convincing evidence is presented in
the literature. Perhaps more relevant
reasons for surgical treatment in patients
A Burst fracture treated with primary
wedge resection in order to recreate a
competent anterior column
EVALUATION / THORACOLUMBAR FRACTURES
with spinal cord injuries would be the
facilitation of nursing care and earlier
functional rehabilitation. In Magerl type B
and C fractures reduction alone will
effectively decompress the spinal canal
whereas in burst fractures the ability to
reduce
intraspinal
fragments
via
“ligamentotaxis” (Benson et al. 1992,
Sjöström et al. 1996) is more unreliable. It
has been shown that intraspinal fragments
will resorb spontaneously to a great extent
(Sjöström et al. 1994). However, if
decompression is required this is most
effectively achieved through an anterior
approach.
The quality of the bone will have a bearing
on fixation. It is obvious that screw
purchase decreases in osteoporotic bone
and thus more fixation points are needed.
Spinal stiffness affects construct stability as
well. In ankylosing spondylitis or advanced
DISH large areas of the spine can be
ossified. A fracture within such an area may
be the only place where motion can occur.
The stiff adjacent parts of the spine will act
as long lever arms for the forces generated
by normal activities and put unreasonable
demands on any fixation device. In this
situation more points of fixation on the
skeleton are beneficial (Olerud et al. 1996).
The drawbacks of long fixation constructs
are obvious. Fusing more levels leaves less
of the spine capable of moving and
compensating for any residual deformity.
with more natural movement. Thus, fusing
several levels in the thoracic spine will result
in less disability than fusing the same
number of levels in the lumbar spine.
• Burst fractures (type A fractures) with
greater deformity after reconstruction
of the anterior column
• Fractures in the lumbar spine
The issue of fusion itself is controversial. In
burst fractures, commonly the cephalad
disk is damaged and the motion segment
will not regain normal function after fracture
healing. Thus, fusion of the instrumented
segments is logical in order to minimize the
risk for progressive deformity and
subsequent pain. In Magerl Type B
fractures the torn dorsal ligaments will
usually not heal and a fusion across the
injured segments should be performed.
Also in Magerl Type C fractures the motion
segments are so disrupted that normal
function can never be achieved and thus
fusion is recommended.
Long instrumentation and
fusion
• Fractures in the thoracic spine
• Burst fractures (type A fractures) with
greater deformity ; after reduction,
but where the anterior column is left
untreated.
• Fractures in ankylosing spondylitis or
DISH
• Osteoporosis
• Greatly unstable rotation injuries (type
C fractures)
• Multiple fractures
Attempts have been made to “instrument
long – fuse short,” with a planned early
removal of the fixation device in order to
preserve some motion segments. However,
no large series has been published and
there is animal model evidence of facet joint
deterioration within the fixed segments
(Kahanovitz et al. 1984a and b).
With this background in mind, we have
developed an algorithm for the treatment of
thoracolumbar fractures :
This is not equally true across all sections of
the spine, however.
Non-operative management
• Compression fractures and burst
fractures (type A fractures) without
neurological deficit and with limited
deformity
Clearly fusing sections with less natural
mobility is less disabling than fusing those
Short instrumentation and fusion
• Chance fractures (type B fractures)
4
5
(figure 4, 5) a chance fracture becomes stable after reduction and posterior “tension band”
instrumentation
With this algorithm hopefully few
malunions will occur. However
post-traumatic kyphosis is still seen as
sequelae after thoracolumbar fractures.
The clinical presentation is usually pain
but may also be neurological symptoms
of varying degree. Sometimes the
deformity causes the patient to seek
help. In case of myelopathy a persistent
canal fragment may be present, but the
kyphosis in itself may also contribute to
anterior pressure on the cord. The
fracture may be healed or there may be
a non-union causing “instability” across
an injured segment. The abnormal
kyphosis may contribute to imbalance in
the sagittal plane with compensatory
hyperlordosis below and secondary
lumbar pain.
From a therapeutical point of view there
are several considerations. The kyphosis
is caused by a lack of anterior column
6
A C-fracture with multidirectional
instability requires a long fixation to ensure
stability
Argos SpineNews
N°12 November 2005
11
EVALUATION / THORACOLUMBAR FRACTURES
support, which must be reconstructed
after reduction of the kyphosis. There
may be an intraspinal fragment that
needs removal to allow effective
decompression. The deformity may be
fixed both anteriorly and posteriorly,
requiring release to allow reduction. The
stability of the spine must be
reconstructed as does the alignment.
This calls for a thorough preoperative
analysis.
In the author’s opinion, the spine is
best stabilised from dorsally with
transpedicular screw instrumentation
and the best deformity control in the
frontal plane is also achieved from
behind. On the other hand an anterior
approach is better for spinal canal
decompression. If healing has
occurred of both anterior and
posterior columns, both these will
have to be released to allow deformity
correction. The various available surgical
techniques all have their merits and
drawbacks. “Anterior only” may be useful
for decompression and anterior column
reconstruction, but if healing has occurred
posteriorly reduction may be blocked. The
frontal plane deformity is difficult to
correct and control via an anterior
approach and an anterior instrumentation
has its obvious shortcomings in
osteoporotic bone. Nevertheless the
results with this technique are quite good
(Been et al. 2004).
Combined front and back surgery (360°
procedures) integrates the benefit of
posterior instrumentation with an effective
anterior decompression and anterior
column reconstruction, but care must be
taken to achieve deformity correction. This
technique also exhausts more resources
KNOP C, BLAUT M, BASTIAN L, LANGE U, KESTING
References
BEEN HD, POOLMAN RW, UBAGS LH.
than the “anterior only” technique since two
consecutive operations are performed.
Front-back-front surgery or simultaneous
posterior and anterior approach will
overcome the problems of reduction, but
also further strains limited resources.
Posterior closing wedge osteotomy,
probably first described by Thomasen
(1985) for kyphosis correction in
ankylosing spondylitis, is a technically
demanding technique, however, one with
many advantages (Gertzbein and Harris
1992). In spite of being a “one side only”
procedure
it
allows
satisfactory
decompression, good kyphosis correction,
good frontal plane deformity control, and
optimal fixation with transpedicular
instrumentation. The technique is becoming
increasingly popular and I have used it as
routinely for several years with good
results.
SPINAL CANAL REMODELLING AFTER STABILIZATION OF
J, TSCHERNE H.
THORACOLUMBAR BURST FRACTURES. EUR SPINE J. 1994/
FRACTURES OF THE THORACOLUMBAR SPINE. LATE
3(6) : 312-7.
SJÖSTRÖM L, KARLSTRÖM G, PECH P, RAUSCHNING
RESULTS OF DORSAL INSTRUMENTATION AND ITS
CLINICAL OUTCOME AND RADIOGRAPHIC RESULTS AFTER
CONSEQUENCES. UNFALLCHIRURG 1997 AUG/ 100(8) :
W.
SURGICAL TREATMENT OF POST-TRAUMATIC
630-9.
INDIRECT SPINAL CANAL DECOMPRESSION IN BURST
FRACTURES TREATED WITH PEDICLE SCREW
THORACOLUMBAR KYPHOSIS FOLLOWING SIMPLE TYPE A
MAGERL F, AEBI M, GERTZBEIN J ET AL.
FRACTURES. EUR SPINE J. 2004 MAR/13(2) : 101-7. EPUB
INSTRUMENTATION. SPINE. 1996 JAN 1/ 21(1) : 113-23.
A COMPREHENSIVE CLASSIFICATION OF THORACIC AND
2003 NOV 13.
LUMBAR FRACTURES. EUR SPINE J, 1994/ 3 : 184-201.
BENSON DR, BURKUS JK, MONTESANO PX ET AL.
SOREFF J.
ASSESSMENT OF THE LATE RESULTS OF TRAUMATIC
UNSTABLE THORACOLUMBAR AND LUMBAR FRACTURE
OLERUD C, FROST A, BRING J.
COMPRESSION FRACTURES OF THE THORACO-LUMBAR
TREATED WITH THE AO FIXATEUR INTERNE, J SPINAL DIS
SPINAL FRACTURES IN PATIENTS WITH ANKYLOSING
VERTEBRAL BODIES : A CLINICAL, RADIOLOGICAL AND
1992/5 : 335-343.
SPONDYLITIS. EUR SPINE J. 1996/ 5(1) : 51-5.
MEDICO-SOCIAL, COMPUTER CONDUCTED STUDY. DISS.
KAROL. INST. STOCKHOLM 1977 ISSN/ISBN 91-7222-183-6.
GERTZBEIN SD, HARRIS MB.
REYES-SANCHEZ A, ROSALES LM, MIRAMONTES
WEDGE OSTEOTOMY FOR THE CORRECTION OF POST-
VP, GARIN DE.
TRAUMATIC KYPHOSIS. A NEW TECHNIQUE AND A REPORT
TREATMENT OF THORACOLUMBAR BURST FRACTURES BY
VERTEBRAL OSTEOTOMY FOR CORRECTION OF KYPHOSIS
THOMASEN E.
OF THREE CASES. SPINE. 1992 MAR/17(3) : 374-9.
VERTEBRAL SHORTENING. EUR SPINE J. 2002 FEB/ 11(1) : 8-
IN ANKYLOSING SPONDYLITIS. CLIN ORTHOP RELAT RES.
12.
1985 APR/(194) : 142-52.
KAHANOVITZ N, ARNOCZKY SP, LEVINE DP ET AL.
THE EFFECTS OF INTERNAL FIXATION ON THE ARTICULAR
SHEN WJ, LIU TJ, SHEN YS.
NONOPERATIVE TREATMENT VERSUS POSTERIOR FIXATION
JHANJEE R, SECHRIEST V, BUTTERMAN G.
SPINE 1984/ 9 : 268-272.
FOR THORACOLUMBAR JUNCTION BURST FRACTURES
OPERATIVE COMPARED WITH NONOPERATIVE TREATMENT
WITHOUT NEUROLOGIC DEFICIT. SPINE. 2001 MAY 1/ 26(9) :
OF A THORACOLUMBAR BURST FRACTURE WITHOUT
1038-45.
NEUROLOGICAL DEFICIT. A PROSPECTIVE, RANDOMIZED
KAHANOVITZ N, BULLOUGH P, JACOSS RR
THE EFFECT OF INTERNAL FIXATION WITHOUT
ARTHRODESIS ON HUMAN FACET JOINT CARTILAGE. CLIN
ORHOP 1984/ 189 : 204-208.
12
WOOD K, BUTTERMANN G, MEHBOD A, GARVEY T,
CARTILAGE OF UNFUSED CANINE FACET JOINT CARTILAGE.
Argos SpineNews
N°12 November 2005
STUDY. J BONE JOINT SURG AM. 2003 MAY/ 85-A(5) : 773SJÖSTRÖM L, JACOBSSON O, KARLSTRÖM G,
PECH P, RAUSCHNING W.
81. ERRATUM IN : J BONE JOINT SURG AM. 2004 JUN/86A(6) : 1283.
TRAINING / FRACTURE TREATMENT
How long to instrument ?
No question could be simpler to answer.
“As short as possible and as long as necessary.”
But what is necessary ? And what is possible ?:
Thoracolumbar (T11-L2) fracture treatment
Decision criteria : type of construct,
long or short instrumentation
BY ROBERT P. MELCHER KARLSBAD-LANGENSTEINBACH, GERMANY
A
pplying traumatic, extraphysiologic
flexion, compressive, or rotational
forces on the spine concentrates
stress mainly at the junctional zones.
“Thoracolumbar fracture” only describes
the location of the fracture, the transition
zone between the rigid thoracic and the
more flexible lumbar spine. The individual
elasticity and/or stability modules of the
tissues in the thoracolumbar spine and the
kinds of forces determine whether the
injury affects the bones, ligaments and/or
the intervertebral discs.
Another important issue is the immediate or
the anticipated local kyphotic deformity.
This may significantly alter the global
sagittal profile.
Above and beyond the injury to the
vertebral column, spinal canal compromise
can lead to varying degrees of neurological
impairment.
Too often we hear surgeons remark : “the
patient has an unstable thoracolumbar
fracture requiring stabilization” or simply
refer to a burst fracture as “stable or
unstable” and, in so doing, neglect the
complexity of the problem and provide
inadequate treatment. No fracture can be
appropriately treated until it is evaluated
References :
[1] MAGERL F, AEBI M, GERTZBEIN SD, HARMS J, NAZARIAN S.
A COMPREHENSIVE CLASSIFICATION OF THORACIC AND LUMBAR INJURIES EUR SPINE J. 1994/3(4) : 184-201
[2] CHANCE GQ
NOTE ON A TYPE OF FLEXION FRACTURE OF THE SPINE. BRIT J. RADIOL. 1948/21 : 442
14
Argos SpineNews
N°12 November 2005
and classified. A widely accepted
classification is the Magerl, Aebi, Gertzbein,
Harms, Nazarian[1] classification.
Compression fractures
(type A fracture)
Type A Fractures involve vertebral body
compression. The A1 type fracture is
crumpling of the body next to the endplate.
Type A2 is a split fracture of the vertebral
body. The type A3.1 is the incomplete and
A3.2 the complete burst fracture. By
definition, in all type A fractures, the
posterior elements remain intact.
Nevertheless, spinal canal narrowing with
neurological compromise may be seen,
especially in A3.2 fractures. The
development of a segmental kyphosis
depends on the impaction of the anterior
column and the capacity of the posterior
elements to compensate for the lost
anterior support.
Treatment of type A fractures focuses on
restoring and maintaining the sagittal
profile. If spinal canal decompression is
required, few surgeons would hesitate to
operate. If the patient is neurologically
intact non-operative treatment may seem to
be the easier option. However, it is
important to know that residual kyphotic
deformities have an adverse influence on
the long term outcome. In my opinion,
compression of the anterior column with
significant segmental kyphosis requires
restoration of the anterior column with
additional posterior stabilization.
This can be accomplished by one-level
fusion in A2 and some A3.1 fractures
TRAINING / FRACTURE TREATMENT
whenever more than half of the vertebral
body remain intact. Although type A1
fractures should be treated non operatively,
in some patients a one-level interbody
fusion may become necessary due to
persistent pain from severe disc injury.
Complete burst fractures or split fractures,
especially where both adjacent discs are
damaged should be treated by corpectomy
followed by restoration of the anterior
column with a cage construct and a
posterior pedicle screw-rod construct.
Stand alone anterior cage constructs have
proven to be unstable.
Distraction fractures
(type B fracture)
When considering the surgical treatment
options in type B fractures, the severity of
posterior element injury determines the
length of fusion.
Intra-articular flexion-distraction (B1)
fractures can be treated by one-level fusion
if the anterior column injury is to the disc
alone. The classic B2 fracture is the osseous
disruption of the interarticular portion of the
lamina and the pedicles propagating into
the vertebral body. This type of fracture is
also known as Chance fracture[2]. It is a very
rare fracture and requires only temporarily
posterior internal fixation until bony healing
occurs.
The force in B3 fractures causes
hyperextension of the thoraco-lumbar
junction resulting in the disruption of the
anterior column and injury of the posterior
elements in one or more adjacent levels.
These fractures may require more than a
two segment instrumentation. However, a
longer posterior construct may be used as
temporary internal fixation.
Although the B3 fracture (also called the
hyperextension-shear fracture) is rarely
seen in normal individuals, it is the typical
type of fracture seen in patients with
ankylosing spondylitis. Due to the nature of
the disease and the poor bone quality, a
more extensive posterior instrumentation is
always
recommended.
Anterior
reconstruction is not always necessary. A
similar situation may occur in elderly
patients with severe multisegmental
spondylosis resulting in a more or less
ankylosed thoracolumbar spine.
Rotational fractures
(type C fracture)
The most unstable fractures are the
rotational fractures, the type C fractures.
It is sometimes possible to diagnosis the
exact type of a C fracture by a careful
reading of the AP Xray. Fractures to the
lateral elements, such as transverse process
or even the rib heads, a lateral offset of the
fractured vertebra are strong indicators of a
rotational fracture. The reduced distance of
the spinous process indicates a
compression fracture (type C1), whereas
an increase in the distance between the
spinous process of the fractured vertebra
and the cephalad vertebra indicate a
rotational fracture with a distraction
component, a type C2 fracture.
A lateral view Xray is required to
characterize the type C3 fracture by its
shear component.
spine surgeon to accomplish these
goals. Surgical procedures which do not
fulfil these requirements should not be
performed ! Long instrumentation is
only required in multilevel rotational
fractures.
ABOUT
Robert P. Melcher
SRH-GRUPPE
KLINIKUM KARLSBAD-LANGENSTEINBACH
GUTTMANNSTRASSE 1, 76307 KARLSBAD GERMANY
PH +49 720 261 33 46 - FX +49 720 261 61 66
Doctor Melcher graduated from the
Medical School in Heidelberg and
completed his Orthopaedic Residency
at the Klinikum KarlsbadLangensteinbach. He was a research
fellow at the University of California,
San Francisco (UCSF), Dept. of
Orthopaedic Surgery, San Francisco
from 2000 to 2001 and at the Weil
Medical College of Cornell University ;
New York from 2003 to 2004.
He is currently serving as Oberarzt
Type C fractures almost always require
fusion of at least two segments. It is also
recommended to begin by stabilizing the
spine with posterior instrumentation. In the
face of severe disruption of the posterior
elements, a corpectomy will increase
instability and predispose the spine to
increased intraoperative translation.
(senior surgeon) with Professor Harms
in his department of spine surgery at
the Klinikum KarlsbadLangensteinbach, Germany.
Poor bone quality, as seen in elderly,
adversely effects construct stability.
Additional support can be obtained by
cement augmentation through canulated
screws and/or extension of the posterior
instrumentation.
Conclusion ::
The key objectives in the surgical treatment
of thoracolumbar fractures must be :
• immediate stability
• restoration and maintenance of the
sagittal alignment
• decompression of the spinal canal, where
required
• limitation of the instrumentation construct
to the injured segments
Today’s surgical techniques and modern
spinal instrumentation should allow the
Argos SpineNews
N°12 November 2005
15
TRAINING / CLINICAL CASE DISCUSSION
Comments on Argos SpineNews clinical case
presentation April 2005
CLINICAL CASE BY FRANCK GANEM, MD NEUROSURGEON, CAEN FRANCE
Reminder : 72 year old woman comes with a S1 right sciatica, complaining of medication resistant pain for over one year. She has
already undergone 3 infiltrations, but she experienced no pain relief. Two months ago the sciatica increased and was associated to
paresis sensation during walk, combined with ascendant rachialgia up to the cervical spine as well as unsystemic pain in the upper
limbs. Clinical examination shows neither sensitive nor motor deficit. The right leg Achilles reflex is absent and the other reflexes seem
a little too sharp. The spine is rather rigid with moderate low lumbar contraction. One year old medical images show a right side L5-S1
disc hernia and canal stenosis. What would you do in this case ?
Further investigation (please specify)
Discectomy only
Discectomy + recalibration only
Discectomy + recalibration + instrumented fusion
Other
Comment 1
Comment 2
R
egarding this 72-yearold woman with right
S1 sciatica, an absent
Achilles
reflex
and
hyperreflexia of her other
reflexes, I would favor further investigation.
Specifically I would want to have MRI scans
of her cervical, thoracic, and lumbar spine
to obtain a better analysis of the neural axis
and to investigate the hyperreflexia
mentioned in the clinical presentation.
1
CT-scan L4-L5
2
If we assume that the MRI scanning is
unremarkable except for the disk
degeneration and stenosis that is
evidenced on the studies presented in the
April issue then I would also want flexion
and extension radiographs to see if there is
any latent instability at the L5-S1 level.
In a 72-year-old woman complaining
predominantly of leg pain — assuming that
the only pathology is what has been
presented so far — I would favor a simple
decompression with diskectomy and
foraminotomy on the right to treat the
sciatica. I would not be in favor of fusion
unless absolutely necessary.
Such a
necessity would be documented by instability
on dynamic radiographs or potentially by an
extremely extensive decompression if that
were necessary at the time of surgery.
CT-scan L5-S1
COMMENT BY WILLIAM BLAKE RODGERS, MD SPINE
3
MIDWEST, JEFFERSON CITY, MO USA
Lumbar Xray
16
Argos SpineNews
N°12 November 2005
F
rom a clinical point of
view, this patient may
have a hidden cervical
myelopathy (cervical and
upper limbs involvement with
unsystemic pain, little too sharp reflexes),
needing further investigation with cervical
MRI. The danger is to operate on lumbar
spine with neck rotation in prone position.
Concerning the lumbar problem (clinically
S1 radiculopathy), there is a rather common
L5-S1 disc herniation which may require
secondarly a simple (non-destabilising)
micro-discectomy. The L4-L5 right lateral
recess stenosis does not seem to be
involved in the clinical presentation of this
72 year old women. The message seems to
be “don’t treat pictures but patient’s
symptoms”.
COMMENT BY GUY MATGÉ, MD NATIONAL NEUROSURGICAL
DEPARTMENT CH LUXEMBOURG
TRAINING / CLINICAL CASE DISCUSSION
Final comment
G
iven the medical images available (ancient Xrays, figures
1, 2, 3), we asked for a second CT scan exam. However,
the CT scan showed no significant changes with regard
to the previous one. Therefore we studied the patient’s clinical
records again. The gait deficit associated with diffused pain in the
upper limbs and the tendinous hyperreflexia that made us
recommend an Xray examination of the cervical spine. The Xrays
showed a high volume meningioma that we operated by posterior
approach.
After the surgery, the patient quickly recovered with no residual
pain in the upper limbs nor gait deficit.
However, persistent S1 sciatica had to be treated. Thereby we
operated the disc herniation by unilateral approach. At present, the
patient has some slight residual intermittent pain in the right leg.
It sometimes happens that, when consulting for disc herniation,
patients also complain about associated cervicalgia and even
1
numbness in the upper limbs. It is also frequent that we hardly
pay attention to this complain as we focus on the lumbar
pathology only.
This case is an incentive to stay vigilant and not consider such
“secondary” clinical signs as functional or accessory. The recent
modifications in the clinical records (gait deficit, upper limbs
paresthesis) and the tendinous hyperreflexia led us to the cervical
tumor that we operated by posterolateral approach, which, in our
opinion, is better an option then the corpectomy by anterior
approach, in a female patient over 70.
As for the disc herniation, we operated it by unilateral approach
only. The results, with no residual gait deficit, justify the absence
of laminectomy, particularly because it was not the lumbar
stenosis but the cervical meningioma that was responsible for the
lower limbs paresis.
FINAL COMMENT BY FRANCK GANEM, MD NEUROSURGEON, CAEN FRANCE
2
CT-scan L4-L5
CT-scan L5-S1
3
4
Cervical MRI
5
Cervical MRI
Cervical MRI
6
Cervical MRI
Argos SpineNews
N°12 November 2005
17
COMMUNICATION / NEW MEMBERS
2005 new members
ABDELHAFID TALHA, MD
HOSPITALIER PRACTITIONER
ORTHOPAEDIC SURGERY AND TRAUMA
DPT, UNIVERSITY HOSPITAL
49033 ANGERS CEDEX FRANCE
593 surgical procedures out of which 135
surgical procedures on the spine. He wrote
66 scientific articles published in
international and italian Orthopedics
journals.
[email protected]
After having graduated the School of
Medicine in Angers, Abdelhafid Talha did
his training in general gurgery and later on
specialized in orthopaedic surgery and
neurosurgery. He began his training in
spine surgery at the University Hospital in
Nantes and he continued at Pitié Salpetrière
in Paris, then in Nice, Marseille, Besançon,
Berck, Strasbourg, Hambourg, Rennes. For
the last 15 years, Dr Talha’s main activity
has focussed on spinal trauma and
metastases.
ABDELILAH EZZAHOUI, MD
CENTRE HOSPITALIER DE MACON
BOULEVARD L. ESCANDE
71018 MACON FRANCE
[email protected]
Doctor Ezzahoui attended the University of
Rabat School of Medicine in Rabat,
Marocco, where he obtained his doctorate
degree in medicine in 1993. He undertook
his residency training in orthopedics in Paris,
France. In 1999 he was appointed assistant
surgeon then, one year later, full staff
surgeon in the Department of Orthopedics
at the Centre Hospitalier d’Argenteuil on the
outskirts of Paris. In 2004 he was appointed
tenured staff surgeon in the Department of
Orthopedics at the Centre Hospitalier in
Macon in France.
FRANCO GUIDA, MD
DPT OF NEUROSURGERY
VIA CIRCONVALLAZIONE N° 50
30170 MESTRE VENICE ITALY
PH + 39 041 2607101 / FX + 39 041 2607115
[email protected]
STEFANO BORIANI, MD
PRIMARIO UNITÀ OPERATIVA DI
ORTOPEDIA E TRAUMATOLOGIA,
OSPEDALE MAGGIORE, LARGO B.
NIGRISOLI, 2 - 40133 BOLOGNA ITALY
Stefano Boriani graduated the School of
Medicine, University of Bologna, in 1976,
and got the “Diploma di Specialista in
Ortopedia e Traumatologia” (post-graduate
School) at the University of Bologna in 1979.
He was an attending surgeon at Instituto
Rizzoli, Bologna, as an assistant from 1978 to
1988, then as an “Aiuto Corresponsabile
Ortopedico” until 1996. Since 1994 he was
the head of the Spine Surgery sub-unit
(Modulo Funzionale) in the department
directed by M. Campanacci (Instituto Rizzoli,
Bologna). Since September 1996, Stefano
Boriani is the Head of the department of
Orthopedics and Traumatology at Ospedale
Maggiore in Bologna. From 1986 to 2002, Dr
Boriani performed more that 1800 surgeries
among which more than 500 spine surgeries
(about 300 spine tumors) and more than
800 bone tumors. He is a member of the
Editorial Boards and Advisory Boards of
numerous national and international journals
and the author and co-author of five books,
of more than 200 papers published in
national and international journals and of
almost
400
lectures
and
oral
communications presented worldwide.
Born in Caracas, may 29th, 1954, Franco
Guida graduated in Medicine at the
University of Naples. He did his
specialization in Neurosurgery at the
University of Padua. He is currently the Head
of Neurotraumatology, Department of
Neurosurgery, “Umberto I “ Hospital, Venice.
ROBERT P. MELCHER, MD
KLINIKUM KARLSBADLANGENSTEINBACH
GUTTMANSTRASSE 1
76307 KARLSBAD GERMANY
PH + 49 720 261 33 46
Doctor Melcher graduated from the Medical
School of Heidelberg and completed his
Orthopaedic Residency at the Klinikum
Karlsbad-Langensteinbach. He was a
research fellow at the University of California,
San Francisco (UCSF), Dept. of Orthopaedic
Surgery, San Francisco and at the Weil
Medical College of Cornell University, New
York. He is currently working as a senior
surgeon with Prof. Harms in his department
of spine surgery at the Klinikum KarlsbadLangensteinbach, Germany.
GILLES PERRIN, MD
HÔPITAL PIERRE WERTHEIMER
CHU DE LYON, 59 BOULEVARD PINEL
69394 LYON CEDEX 03 FRANCE
[email protected]
STEFANO BANDIERA, MD
KARIM GHYAMPHY, MD
DPT OF ORTHOPAEDIC AND
CENTRE HOSPITALIER DU MANS
TRAUMATOLOGY
ORHOPEDICS UNIT
OSPEDALE MAGGIORE
194, AVENUE RUBILLARD
40100 BOLOGNA ITALY
72037 LE MANS CEDEX FRANCE
PH +39 051 647 8286
PH +33 243 434 343/ +33 243 432 490
[email protected]
Stefano Bandiera, MD was born in
Bologna, Italy. In August 2000 he was
appointed orthopaedic surgeon in the
department
of
orthopaedics
and
traumatology in ospedale Maggiore of
Bologna, Italy and has been practicing there
ever since. From February 2000 he
performed, as chief of the surgical team,
18
Argos SpineNews
N°12 November 2005
Karim Ghyamphy graduated the School of
Medicine in Angers, France, and completed
his internship and clinical residency in the
University Hospitals in Strasbourg. He is
curently Hospital Practitioner in the
University Hospital of Mans and a member
of the GIEDA and SOFCOT.
Gilles Perrin, MD, is currently Professor of
Neurosurgery at the University Claude
Bernard in Lyon, France and Head of the
Neurosurgical Department at the Neurological
Hospital Pierre Wertheimer. Professor Perrin
has been a full-time senior Neurosurgeon
since 1978 and his centres of research include
pituitary pathologies, cerebral blood flow and
spinal disorders. He is one of the co-founder of
the French Speaking Society of Spinal
Neurosurgery that he has presided over from
1995 to 1999. He is currently President of the
Inspiration Scientific Committee. His
experimental research focuses on spine
COMMUNICATION /LITERATURE UPDATE
biomechanics, spinal navigation systems and
spinal robotics. His main topics of interest for
clinical research are: spinal tumors, vertebral
traumatic lesions, lumbar degenerative lesions
and mainly lumbar spondylolisthesis. He is also
very active in the development of non-fusion
techniques.
Literature update
PIERRE PRIES, MD
DEPARTMENT OF ORTHOPAEDIC AND
TRAUMA SURGERY JEAN BERNARD
H2A LA MILÉTRIE 86021 POITIERS FRANCE
PH +33 054 944 4395 / FX +33 054 944 4112
[email protected]
Pierre Pries, MD, graduated the medical
school in Poitiers and Paris, France, in 1978.
He did his residency in Poitiers and was a
fellow at the Boston Children’s Hospital and
at Mayo Clinic, Rochester Minnesota USA.
He is currently Professor in Orhopaedic
Surgery at the Faculty of Medecine of
Poitiers and Chief of the Spine and
Orthopaedic Unit. He has a great experience
in Spine traumatology, deformities, tumors
and degenerative diseases with over 120
spine surgeries per year.
Source : PubMed (www.ncbi.nlm.nih.gov) Keywords : Thoracolumbar fractures
CATALAY B, CANER H, GOKCE C, ALTINORS N.
KYPHOPLASTY: 2 YEARS OF EXPERIENCE IN A NEUROSURGERY DEPARTMENT. SURG NEUROL. 2005 NOV/64 SUPPL 2 : S72-6.
SINGH K, HELLER JG, SAMARTZIS D, PRICE JS, AN HS, YOON ST, RHEE J, LEDLIE, JT, PHILLIPS FM.
OPEN VERTEBRAL CEMENT AUGMENTATION COMBINED WITH LUMBAR DECOMPRESSION FOR THE OPERATIVE
MEHMET ZILELI, MD
MANAGEMENT OF THORACOLUMBAR STENOSIS SECONDARY TO OSTEOPOROTIC BURST
DEPARTMENT OF NEUROSURGERY
FRACTURES. J SPINAL DISORD TECH. 2005 OCT/18(5) : 413-419.
EGE UNIVERSITY FACULTY OF MEDICINE
BORNOVA, IZMIR 35100 TURKEY
PH +90 232 421 9323 / FX +90 232 463 7751
[email protected]
Doctor Mehmet Zileli is Professor of
Neurosurgery and Head of the Spine Section of
Neurosurgery Dept in Ege University, Izmir,
Turkey. He is a faculty member since 1989.
Between 1987-1988 he has worked as a
Research Fellow in the Dept of Neurosurgery,
University of Erlangen-Nürnberg, Germany,
(Prof J. Schramm). He is the founder and first
president of the Spine Section of Turkish
Neurosurgical Association, (1995-1999), ExCommittee Member of the World Spine Society
(2003-Present), and a member of the Spine
Society of Europe (1993-Present). He has
important contributions to education and
training in spine surgery in Turkey. Since 1997 he
organizes hands-on practical courses on spine
surgery and has organized a cadaver course in
2003 in colloboration with Cleveland Clinic, USA.
He has also been the host of “Travelling
Fellowship of SSE” between 2002 and 2004. He
is married, and father of two children.
AL-KHALIFA FK, ADJEI N, YEE AJ, FINKELSTEIN JA.
PATTERNS OF COLLAPSE IN THORACOLUMBAR BURST FRACTURES.
J SPINAL DISORD TECH. 2005 OCT/18(5) : 410-412.
PERRY A, MAHAR A, MASSIE J, ARRIETA N, GARFIN S, KIM C.
BIOMECHANICAL EVALUATION OF KYPHOPLASTY WITH CALCIUM SULFATE CEMENT IN A CADAVERIC OSTEOPOROTIC
VERTEBRAL COMPRESSION FRACTURE MODEL. SPINE J. 2005 SEP-OCT/5(5) : 489-93.
KNOP C, LANGE U, REINHOLD M, BLAUTH M.
[VERTEBRAL BODY REPLACEMENT WITH SYNEX® IN COMBINED POSTEROANTERIOR SURGERY FOR TREATMENT OF
THORACOLUMBAR INJURIES.] OPER ORTHOP TRAUMATOL. 2005 AUG/17(3) : 249-280. GERMAN.
VERLAAN JJ, VAN DE KRAATS EB, ONER FC, VAN WALSUM T, NIESSEN WJ, DHERT WJ.
THE REDUCTION OF ENDPLATE FRACTURES DURING BALLOON VERTEBROPLASTY : A DETAILED RADIOLOGICAL
ANALYSIS OF THE TREATMENT OF BURST FRACTURES USING PEDICLE SCREWS, BALLOON VERTEBROPLASTY, AND
CALCIUM PHOSPHATE CEMENT. SPINE. 2005 AUG 15/30(16) : 1840-5.
VERLAAN JJ, VAN DE KRAATS EB, ONER FC, VAN WALSUM T, NIESSEN WJ, DHERT WJ.
BONE DISPLACEMENT AND THE ROLE OF LONGITUDINAL LIGAMENTS DURING BALLOON VERTEBROPLASTY IN
TRAUMATIC THORACOLUMBAR FRACTURES. SPINE. 2005 AUG 15/30(16) : 1832-9.
FAROOQ N, PARK JC, POLLINTINE P, ANNESLEY-WILLIAMS DJ, DOLAN P.
CAN VERTEBROPLASTY RESTORE NORMAL LOAD-BEARING TO FRACTURED VERTEBRAE ? SPINE. 2005 AUG 1/30(15) :
1723-30.
To be continued page 22
Argos SpineNews
N°12 November 2005
19
Preliminary program :
Thoracolumbar fractures T11-L2
Thoracolumbar post-traumatic deformities : treatment strategy
Thoracolumbar, post-traumatic deformities : surgical strategy
Fractures in the elderly
➔
➔ Guest Speakers :
Jacques CHIRAS, MDFRANCE
Robert MELCHER, MD
GERMANY
Michel PHILIPPE, MDFRANCE
Claes OLERUD, MD SWEDEN
Jean-Paul STEIB, MD FRANCE
Mark WEIDENBAUM, MD USA
➔ Organizing committee :
Pierre ANTONIETTI, MD
Laurent BALABAUD, MD
Philippe BEDAT, MD
Jean-Paul FORTHOMME, MD
Frank GANEM, MD
Alain GRAFTIAUX, MD
Mihai JIANU, MD
Pierre KEHR, MD
Christian MAZEL, MD
Pr Wafa SKALLI, PhD
Jean-Paul STEIB, MD
Anca MITULESCU, PhD
Alexandre TEMPLIER, PhD
10th International A
JANUARY 26-27, 2006 / MAISON DES ARTS ET MÉ
The Argos president message
Dear friends, regular attendees and new comers, it is my great pleasure to announce the 10th
International Argos Symposium, to be held, as usual, in Paris, in January 2006
irst of all, let me thank you all who attended this meeting over the past
ten years, for having made this symposium a tremendously successful
event, by the high quality of your input. Indeed, Argos symposia are now
renowned as an occasion for fruitful exchange of points of view and for personal
experience sharing.
F
As most of you know, Argos has no borders, as spine specialists, whatever their main
specialty may be, from all over the world, are most welcome to our meetings since it is
our belief that it is only through this multidisciplinary approach that spine surgery can
progress. To celebrate its 10th anniversary, Argos went a step further by deciding to
appoint a President of the Congress each year from now on. We are honored to
introduce Robert Melcher, MD, from Karlsbad-Langensteinbach clinic, Germany, who
kindly accepted this difficult task this year. And as this year’s symposium is the
occasion of a special celebration for our association, the farewell dinner will be held in
a unique place – Bel Canto Restaurant – in Neuilly sur Seine, where young opera
singers accompanied by a pianist will serve you while performing great airs of opera
(Verdi, Mozart, Bizet, Rossini, Puccini…). We hope you will enjoy this magic moment.
As for this year’s scientific program, we hope it will be of high interest for all of you
as it deals with a particularly hot topic – “Thoracolumbar fractures”. Indeed, their
Thoracolumbar Fractures
Acute, post-traumatic deformities, fractures in the elderly, vertebroplasty
Argos Symposium
ÉTIERS / 9BIS AVENUE D’IÉNA PARIS XVI FRANCE
A R G O S / I N S P I R AT I O N N E T W O R K
management is still highly controversial. This is why we will try together to better
understand their mechanisms and define therapeutic patterns.
To begin the first session on Thursday, Professor Jean-Paul Steib and Doctor Mark
Weidenbaum will discuss on the “Choice of approach - Posterior, anterior, double
approach – decision criteria”. The lecturers will give their pros and cons for the
treatment of thoracolumbar lesions by posterior approach versus anterior approach.
The second conference on “Type of construct, long or short fixation – decision criteria”
will be presented successively by Doctor Claes Olerud and Doctor Robert Melcher.
They will define the decision criteria for the surgical approach and state their indications.
The second session, fully dedicated to post-traumatic deformities, will start with a
conference on the “Treatment indication : when to decide surgery, when to
postpone surgery”. Doctor Mark Weidenbaum and Doctor Claes Olerud will
discuss the decision to treat a thoracolumbar malunion and clearly describe all
factors to be taken into account before deciding to operate.
Next day’s first session will bring Professor Jean-Paul Steib and Doctor Robert
Melcher face to face, to exchange on the attitude to adopt when malunion is
diagnosed. Several options will be defended by the speakers.
The last session will give us a large overview on “Fractures in the elderly”. Professor
Jacques Chiras will share with us his experience on the “Assessment of a porotic
fracture : how to differentiate from other aetiologies”. Then Doctor Michel Philippe
will highlight the importance of osteoporosis management when an accident
occurs as well as before the accident through his lecture on “Decision making
histogram for the management of osteoporosis”.
Last but not least, the role of the vertebroplasty will be discussed by Doctor
Jacques Chiras who will give a lecture on “Vertebroplasty in osteoporotic fractures
- indications and limits, future developments”.
As usual, the interactive clinical cases discussions are the perfect confrontation
with routine clinical practice and will be the best occasion for all of us to give our
point of view on the management of thoracolumbar fractures.
We are looking forward to welcoming you at this very special International Argos
Symposium and we hope that the scientific program as well as the social one will
be as rich as ever thanks to the quality of your input.
PROFESSOR CHRISTIAN MAZEL ARGOS PRESIDENT
COMMUNICATION / LITERATURE UPDATE
Literature update (Continued from page 19)
MIROVSKY Y, ANEKSTEIN Y, SHALMON E, PEER A.
APR 15/30(8) : 964-8.
KIM CW, PERRY A, GARFIN SR.
VACUUM CLEFTS OF THE VERTEBRAL BODIES. AJNR AM J NEURORADIOL. 2005 AUG/26(7) :
SPINAL INSTABILITY : THE ORTHOPEDIC APPROACH. SEMIN MUSCULOSKELET RADIOL. 2005
1634-40.
MAR/9(1) : 77-87. REVIEW.
TEZER M, OZTURK C, AYDOGAN M, MIRZANLI C, TALU U, HAMZAOGLU A.
MEVES R, AVANZI O.
SURGICAL OUTCOME OF THORACOLUMBAR BURST FRACTURES WITH FLEXION-
CORRELATION BETWEEN NEUROLOGICAL DEFICIT AND SPINAL CANAL COMPROMISE IN
DISTRACTION INJURY OF THE POSTERIOR ELEMENTS. INT ORTHOP. 2005 AUG/2 : 1-4 [EPUB
198 PATIENTS WITH THORACOLUMBAR AND LUMBAR FRACTURES. SPINE. 2005 APR
AHEAD OF PRINT]
1/30(7) : 787-91.
KARAIKOVIC EE, PACHECO HO.
WAGNER S, WECKBACH A, MULLER-GERBL M.
TREATMENT OPTIONS FOR THORACOLUMBAR SPINE FRACTURES. BOSN J BASIC MED SCI.
THE INFLUENCE OF POSTERIOR INSTRUMENTATION ON ADJACENT AND TRANSFIXED FACET
2005 MAY/5(2) : 20-6.
JOINTS IN PATIENTS WITH THORACOLUMBAR SPINAL INJURIES : A MORPHOLOGICAL IN
VIVO STUDY USING COMPUTERIZED TOMOGRAPHY OSTEOABSORPTIOMETRY. SPINE. 2005
HU J, LIAO Q, LONG W.
APR 1/30(7) : E169-78.
[DIAGNOSIS AND TREATMENT OF MULTIPLE-LEVEL NONCONTIGUOUS SPINAL FRACTURES]
ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI. 2005 JUN/19(6) : 424-6. CHINESE.
ACOSTA FL JR, ARYAN HE, TAYLOR WR, AMES CP.
KYPHOPLASTY-AUGMENTED SHORT-SEGMENT PEDICLE SCREW FIXATION OF TRAUMATIC
PONGCHAIYAKUL C, NGUYEN ND, JONES G, CENTER JR, EISMAN JA, NGUYEN TV.
ASYMPTOMATIC VERTEBRAL DEFORMITY AS A MAJOR RISK FACTOR FOR SUBSEQUENT
LUMBAR BURST FRACTURES : INITIAL CLINICAL EXPERIENCE AND LITERATURE REVIEW.
NEUROSURG FOCUS. 2005 MAR 15/18(3) : E9.
FRACTURES AND MORTALITY : A LONG-TERM PROSPECTIVE STUDY. J BONE MINER RES.
2005 AUG/20(8) : 1349-55. EPUB 2005 MAR 21.
TEZER M, ERTURER RE, OZTURK C, OZTURK I, KUZGUN U.
CONSERVATIVE TREATMENT OF FRACTURES OF THE THORACOLUMBAR SPINE. INT ORTHOP.
LI KC, HSIEH CH, LEE CY, CHEN TH.
2005 APR/29(2) : 78-82. EPUB 2005 FEB 16.
TRANSPEDICLE BODY AUGMENTER : A FURTHER STEP IN TREATING BURST FRACTURES.
CLIN ORTHOP RELAT RES. 2005 JUL/(436) : 119-25.
CHANG CH, HOLMES JF, MOWER WR, PANACEK EA.
DISTRACTING INJURIES IN PATIENTS WITH VERTEBRAL INJURIES. J EMERG MED. 2005
WOOD KB, KHANNA G, VACCARO AR, ARNOLD PM, HARRIS MB, MEHBOD AA.
FEB/28(2) : 147-52.
ASSESSMENT OF TWO THORACOLUMBAR FRACTURE CLASSIFICATION SYSTEMS AS USED
BY MULTIPLE SURGEONS. J BONE JOINT SURG AM. 2005 JUL/87(7) : 1423-9.
SASSO RC, BEST NM, REILLY TM, MCGUIRE RA JR.
ANTERIOR-ONLY STABILIZATION OF THREE-COLUMN THORACOLUMBAR INJURIES. J
GROVES CJ, CASSAR-PULLICINO VN, TINS BJ, TYRRELL PN, MCCALL IW.
SPINAL DISORD TECH. 2005 FEB/18 SUPPL : S7-14.
CHANCE-TYPE FLEXION-DISTRACTION INJURIES IN THE THORACOLUMBAR SPINE : MR
IMAGING CHARACTERISTICS. RADIOLOGY. 2005 AUG/236(2) : 601-8. EPUB 2005 JUL 1.
WOOD KB, BOHN D, MEHBOD A.
ANTERIOR VERSUS POSTERIOR TREATMENT OF STABLE THORACOLUMBAR BURST
DEFINO HL, SCARPARO P.
FRACTURES OF THORACOLUMBAR SPINE : MONOSEGMENTAL FIXATION. INJURY. 2005
FRACTURES WITHOUT NEUROLOGIC DEFICIT : A PROSPECTIVE, RANDOMIZED STUDY. J
SPINAL DISORD TECH. 2005 FEB/18 SUPPL : S15-23.
JUL/36 SUPPL 2 : B90-7.
VAN GOETHEM JW, MAES M, OZSARLAK O, VAN DEN HAUWE L, PARIZEL PM.
ONER FC, DHERT WJ, VERLAAN JJ.
IMAGING IN SPINAL TRAUMA. EUR RADIOL. 2005 MAR/15(3) : 582-90. EPUB 2005 FEB 5.
LESS INVASIVE ANTERIOR COLUMN RECONSTRUCTION IN THORACOLUMBAR FRACTURES.
INJURY. 2005 JUL/36 SUPPL 2 : B82-9.
VAN DER ROER N, DE LANGE ES, BAKKER FC, DE VET HC, VAN TULDER MW.
MANAGEMENT OF TRAUMATIC THORACOLUMBAR FRACTURES : A SYSTEMATIC REVIEW OF
VIALLE LR, VIALLE E.
THE LITERATURE. EUR SPINE J. 2005 AUG/14(6) : 527-34. EPUB 2005 FEB 3.
THORACIC SPINE FRACTURES. INJURY. 2005 JUL/36 SUPPL 2 : B65-72.
SENGUPTA DK.
ZHAO K, HUANG Y, ZHANG J, FANG XQ, YANG Q.
NEGLECTED SPINAL INJURIES. CLIN ORTHOP RELAT RES. 2005 FEB/(431) : 93-103. REVIEW.
[THORACOSCOPIC ANTERIOR APPROACH DECOMPRESSION AND RECONSTRUCTION FOR
THORACOLUMBAR SPINE DISEASES] ZHONGHUA WAI KE ZA ZHI. 2005 APR 15/43(8) : 491-4.
CHINESE.
KANESAKI K.
VERTEBRAL DEFORMITIES IN FEMALE PATIENTS WITH OSTEOPOROSIS : INFLUENCE OF
TRAUMA AND BONE MINERAL DENSITY. KURUME MED J. 2004/51(3-4) : 203-13.
SEEL EH, VERRILL CL, MEHTA RL, DAVIES EM.
MEASUREMENT OF FRACTURE KYPHOSIS WITH THE OXFORD COBBOMETER : INTRA- AND
INTEROBSERVER RELIABILITIES AND COMPARISON WITH OTHER TECHNIQUES. SPINE. 2005
22
Argos SpineNews
N°12 November 2005
TRAINING / OSTEOPOROSIS TREATMENT
Decision tree
for the treatment of osteroporosis
BY MICHEL P. PHILIPPE, MD HEAD OF DEPARTMENT OF SURGERY, CAVAILLON HOSPITAL, FRANCE
Osteoporosis is an international public health problem as evidenced by
European strategies to make patients and people working in the health care
industry aware of this pathology so that treatment can be improved. The
problems of Brussels are also encountered in France as the 2003 Public
Health law addressing this pathology attests.
Osteoporosis : facts
The vertebral fractures are the most common osteoporotic fractures. Because
about one third of these fractures present no symptoms, they are rarely diagnosed
COOPER C. ET AL. INCIDENCE OF CLINICALLY DIAGNOSED VERTEBRAL FRACTURES : A POPULATION-BASED STUDY IN
ROCHESTER, MINNESOTA, 1985-1989. JBMR 1992/7(2) : 221-227.
Every thirty seconds, one person in the European Union suffers from a hip fracture
resulting from osteoporosis
COMPSTON J ET AL. FAST FACTS – OSTEOPOROSIS 2ND EDITION. HEALTH PRESS LIMITED, OXFORD 1999.
Among post-menopausal women who suffered from a vertebral fracture, one out
of five will suffer from a second vertebral fracture the following year. Long
considered as a slow disease, the evolution of osteoporosis is much faster after
the first fracture
LINDSAY R, ET AL. RISK OF NEW VERTEBRAL FRACTURE IN THE YEAR FOLLOWING A FRACTURE. JAMA 2001/285 : 320-323.
The precursory symptoms of osteoporosis are often invisible, but several vertebral
fractures can lead to height loss, spinal diformities chronic back pain and loss of
autonomy
GOLD DT. THE CLINICAL IMPACT OF VERTEBRAL FRACTURES : QUALITY OF LIFE IN WOMEN WITH OSTEOPOROSIS.
BONE 1996/18 (SUPPL 3) : 185S-189S.
ETTINGER B. ET AL. CONTRIBUTION OF VERTEBRAL DEFORMITIES TO CHRONIC BACK PAIN AND DISABILITY. JBMR
1992/7(4) : 449-456.
SMAIL AA. ET AL. NUMBER AND TYPE OF VERTEBRAL DEFORMITIES : EPIDEMIOLOGICAL CHARACTERISTICS AND
RELATION TO BACK PAIN AND HEIGHT LOSS. OSTEOPOROSIS INT. 1999/9 : 206-213.
Hip fractures are particularly incapacitating. Six months after a hip fracture, only 1
patient out of 7 is able to walk all alone and only 1 patient out of 10 could climb
stairs
US CONGRESS, OFFICE OF TECHNOLOGY ASSESSMENT : HIP FRACTURE OUTCOMES IN PEOPLE AGED FIFTY
How important is the problem in
France ?
Every year, 400.000 women reach the
menopause age, 160.000 of them will
suffer from a fracture.
AND OVER — BACKGROUND PAPER OTA-BP-H-120 WASHINGTON DC : US GOVERNMENT PRINTING OFFICE, JULY 1994.
Following medical complications, a hip fracture in women over 50 leads to the
death of about 1 woman out of 5, during the year following the fracture
56.000 hip fractures were diagnosed in
2001, 110.000 are expected in 2025
(source : Pr Meunier)
NIH CONSENSUS DEVELOPMENT PANEL ON OSTEOPOROSIS PREVENTION, DIAGNOSIS AND THERAPY.
OSTEOPOROSIS PREVENTION, DIAGNOSIS AND THERAPY. JAMA 2001/285 : 785-795.
Osteoporosis is costing a lot to the European Union national treasuries (health
insurances included) : over 4.8 billion euros every year just for hospital care
OSTEOPOROSIS IN THE EUROPEAN COMMUNITY : A CALL TO ACTION. AN AUDIT OF POLICY DEVELOPMENTS
SINCE 1998. PREPARED BY THE INTERNATIONAL OSTEOPOROSIS FOUNDATION, NOVEMBER 2001. WWW.OSTEOFOUND.ORG
“Women suffering from a fracture
resulting from a common fall during
menopause, whatever the fracture,
must be considered as presenting with
osteoporosis, unless evidence of the
opposite is proven “ (source : INSERM
1996)
Argos SpineNews
N°12 November 2005
23
TRAINING / OSTEOPOROSIS TREATMENT
DMO
Assesment of fracture risk (BMD alone : Bone Mineral Density)
T score**
-4
-3
-2
-1
-0
+1
50 years old
69%
48%
29%
16%
8%
4%
60 years old
62%
40%
21%
11%
5%
2%
Out of 100 post-menopausal women
over 50, 50 will suffer from an
osteoporotic fracture : this risk breaks
down into 16 wrist fractures (45.000
new fractures per year), 18 femur
fractures (52.000 new fractures per
year), and 16 vertebral fractures
(60.000 new fractures per year).
The fracture risks of the “golden
years”
A 50 year old woman can live up to
88 with 15.6% chance of sustaining a
vertebral fracture, 17.5% chance of
sustaining a hip fracture and 16%
chance of sustaining a wrist fracture.
70 years old
54%
21%
15%
7%
3%
3%
80 years old
36%
18%
8%
3%
1%
< 1%
billion dollars, which means
$20.000 per fracture.
BENDICH A. CLIN THER DIRECT COST OF FEMUR
FRACTURES, 21,1058-72,1999
0,6 to 0,9 billion euros are
spent yearly for the 48.000 new
fractures (cost of medical expenses
only : 13.000 to 18.000 ? per
fracture).
BAUDOIN M. PRESSE MÉDICALE, 30,1451-1456, 1997
In consideration of such costs,
potential savings amount to
$35.000 per fracture avoided if we
reduce the incidence of new femur
fractures
JONSSON OSTEOPOROSIS INT, 5, 136-142).
The appearance of one fracture is a
predicative factor for other fractures :
with a wrist fracture or hip fracture,
the relative risk of a new fracture is
quadrupled and tripled after a
vertebral fracture.
Economic stakes
The overall cost grows with
the increase in incidence due to
the growth of life expectancy.
The overall cost increases with
the medico-technical
development and the
importance of social
interventions. This is a true
epidemic issue about the
optimal use of the resources of
care distribution systems.
M. CHATAIN (HIP 99, TOULOUSE) “THE ECONOMIC
In the first year, the yearly
direct cost of 290 000 fractures
in the USA amounts to 5,6
24
Argos SpineNews
N°12 November 2005
Michel Philippe
LE GARDY, 2081 CHEMIN DE MALEMORT
84200 CARPENTRAS FRANCE
PH +33 4 90 63 23 63
Dr Philippe earned his Certificate in
Physics, Chemistry and Biology, in 1960,
from the Faculty of Science, Lyon and
graduated the Faculty of Medicine in Lyon
in 1970, where he also served as a
Specialist Registrar. Later on he earned
his Certificate of Specialist Training in
General Surgery from the University of
Lyon and his Diploma in Medical Studies
relating to the Repair of Physical Injury
from the Faculty of Medicine in
Montpellier. He is currently the Head of
Department of Surgery at Cavaillon
Hospital. Dr Philippe is also the recipient
of numerous awards for his medical
activity and research and he serves as an
active member of several associations
such as the Study Group in Bone Surgery,
FUTURA 2000, Association for Research
and Study of Knee Surgery, French
Association of Orthopaedic and Trauma
Surgery, FRACTOSUD (Association for the
Study of Osteoporosis). For more than 30
Obviously, we know and understand the
pathology behind the most frequent cause
of suffering in post-menopausal women.
years Dr Philippe has been both in
hospital and in private practice and has
acquired experience both in prosthetic
However, because the risk factors for the
disease cut across the boundaries of
medical specialities, the totality of the
problem is often neglected.
surgery and in traumatology. This was
how he acquired wide experience both in
fundamentals and also in clinical practice.
Clinical evaluation of medical devices is
one of his major interests today.
As the disease evolves, it is fraught with
complications — among which fracture is
the most important — leading to morbidity
and an increase in mortality.
For all these reasons, surgeons must accept
their role in the management of this disease
since we know that, even if the fracture is
handled with skill, the underlying
osteoporosis will continue to progress and
the risk of fracture will increase.
CONSEQUENCES OF FRACTURES OF THE PROXIMAL
FEMUR”.
ABOUT
We reviewed our experience in a mid-size
community hospital and sought to create a
simple decision tree. We began with the
assumption that, in women admitted to the
surgical unit for treatment of a fracture, we
could determine if osteoporosis was a
proximate cause. We then asked the
question, if osteoporosis was present, were
any signs or symptoms present that could
have led to the diagnosis before the fracture
occurred ? Thus we created a Functional
Unit for the Management of Osteoporotic
Fractures. The unit combined the skills of
surgeons, nurses, physical therapists, social
workers, and dieteticians.
On admission, a patient who has sustained a
fracture is evaluated to determine where the
fracture is due to osteoporosis by history and
accident pattern (i.e., a “low energy” injury). If the
answer is positive, the management begins :
Investigational device exemption protocol
(blood collection, life style)
TRAINING / OSTEOPOROSIS TREATMENT
Fracture risk
THE SURGEON
OSTEOPOROSIS ?
HE DOES NOT KNOW !
HE KNOWS
THE PROBLEM REMAINS
UNRESOLVED
HE CANNOT OR HE DOES NOT
WANT TO TAKE CARE OF IT
HE CAN AND HE WANTS
TO TAKE CARE OF IT
RHEUMATOLOGIST
OSTEOPOROSIS HAS BEEN
DIAGNOSED
PATIENT IS SENT TO THE
PRIMARY CARE PHYSICIAN
• Dietetitian protocol (eating habits)
• Physical therapy protocol (life style,
activities by Devanne and Parker scores)
• Surgical protocol (previous surgery,
gynaecologic history, decision of
BMD…)
• Social service protocol (living
arrangements)
• Specialized opinions (Geriatrician,
Gynecologist, Rheumatologist) as needed
Once the data is collected and interpreted
by specially designed computer software, a
treatment plan is outlined and presented to
the patients and their treating physician. We
then reviewed our data to determine
whether the patients treated for fracture
could have benefited from earlier diagnosis
of their osteoporosis. In other words, we
wanted to find patients who had no
identified risk of osteoporosis.
Out of 138 files, 89 met the inclusion criteria
(live in the Vaucluse area, low impact injury)
recorded between March 28th, 2003 and
July 28th, 2003.
After a simple examination and
questionnaire we determined that, out of
those 89 patients, 8 had no identified risk of
osteoporosis.
Thus, 81 patients had signs of at least one
risk factor which, if diagnosed, could have
prompted screening and treatment. Based
on the literature, only half of the patients
properly treated can avoid fracture but,
even in this small study, 40 people would
have been saved their pain. This failure to
diagnose and manage such an insidious
disease is ingrained within us as physicians.
We consider it outside the boundaries of
our expertise — whether we are general
practitioners, emergency physicians,
surgeons, rheumatologists, or even,
gynaecologists and geriatricians.
The benefits of the team approach are
obvious : data collection and interpretation,
protocol development, ease of clinical
decision making and, finally, improvement in
therapy. This team approach is not unique
and local practice patterns must, of
necessity, lead to local solutions. Other
systems have been developed in other
areas and work well to achieve the
same results. It is vitally important that
surgeons remain aware that there are
considerations beyond the fracture to
be treated. Beneath the surface lies the
cause of the fracture. If this cause can
be recognized and treated, the risk of
additional fractures can be markedly
diminished.
Problematics of osteoporosis
fracture management
Conclusion ::
700 patients with hypercholesterolemia
must be treated to avoid one
cerebrovascular accident, 500 patients
must be treated with prophylaxis to
avoid one post-operative phlebitis, but
only 20 women must be treated to avoid
a fracture, and after a fracture, only 7
women must be treated to avoid a new
fracture.
Argos SpineNews
N°12 November 2005
25
EVALUATION / SURGICAL DECISION CRITERIA
Thoracolumbar fractures
surgical decision criteria : posterior,
anterior or combined approach
BY JEAN-PAUL STEIB, M. AOUI HÔPITAUX UNIVERSITAIRES DE STRASBOURG,
DEPT OF ORTHOPAEDIC SURGERY, FRANCE
T
he (T11)T12-L1(L2) thoracolumbar junction is the most
frequent zone of spinal fracture.
This spinal area acts as a joint between
the thoracic kyphosis and the lumbar
lordosis. There is no intrinsic curvature
but the natural trend of this area is to
evolve towards kyphosis. To evaluate
the deformity accurately, it is important
to localise the fracture : above T12, the
spine is in kyphosis, below L1, the spine
is in lordosis. Therefore, the only criteria
to evaluate the deformity are relative
criteria. We use Farcy’s sagittal index
which incorporates a vertebra and a
disc, the lower endplate of the fractured
vertebra, and the lower endplate of the
overlying vertebra. At T12-L1, the
normal sagittal index is 0. At T11-T12,
the index is 5 and at L1-L2,-10.
Let us assume that the decision to
operate has been made already for any
of the usual reasons : established or
impending neurological compromise
and/or deformity (Farcy’s sagittal
index). The realities of modern medicine
require that surgical techniques allow
patients to avoid long hospitalizations
and body casts.
We must keep in mind that the
spinal fracture was (and still is)
the most poorly treated among
fractures, with indications and
treatments which are highly
controversial.
The treatment of a spinal fracture, as any
other fracture, consists of reduction and
stable, solid fixation. This means a complete
reduction with a sagittal index near
approaching normal and instrumentation
that facilitate quickly mobilizing the patient
without plaster or corset.
28
Argos SpineNews
N°12 November 2005
In our hospital, reduction is performed by in
situ contouring. Therefore we always
perform the posterior approach first. From a
technical point of view, the in-situ
contouring aims at first making the rod take
the shape of the spine and then to make
the spine take the shape of the rod that has
been previously contoured. This supposes
that the spine follow the movements of the
rod (and explains why polyaxial screws
cannot be used, always keeping in mind the
principle of perpendicularity). The patient is
first treated by posterior approach
emergently or as soon as possible. A
standard fixation with 2 screws in the under
and overlying vertebrae is carried out.
Screws are protected by hooks, generally a
pediculo-transverse claw above in T10 and
offset sublaminar hooks on the vertebra
underlying the fracture. The rod is inserted
and the contouring is performed bilaterally
and simultaneously. Implants must not be
locked on the rod. The fracture site will
open progressively without any excessive
stress. The correction can be evaluated
under image intensifier or on the angle
made by the screws framing the fractured
vertebra. The surgery ends with a posterior
bone grafting which can prevent a future
hardware removal. The patient can be up as
soon as possible without any brace.
We have recently reviewed a series of 70
thoraco-lumbar fractures, treated using this
approach. In this series, the operative time
averaged 100’ (80-240), blood loss
averaged 813 ml (64-2975), and the
average hospitalisation was 16 days (5-21
days). The length of hospital stay was often
due to other injuries. 71% of the patients
who underwent surgery resumed their
previous employment within 7 months.
Farcy’s sagittal index was 16.98 preoperatively and decreased to 1.62 postoperatively.
When the fracture was treated, reduction
was studied on Xrays. An additional
anterior approach was employed if the
correction sagittal correction through the
disc accounted for more than 50%
compared of the total correction. Such a
“defect” is unstable and must be filled
addressed. If the fracture is at L2, we
normally perform an anterior procedure to
insert a graft in the L1-L2 disc and to
release the L2-L3 disc.
In this series, 38 of the 70 patients (54%)
had an anterior procedure, usually videoassisted and with a scar measuring less than
5 cm. The anterior approach is performed
some time after the posterior approach.
After more than one year, final results
showed an average loss of 5.21° in the
simple posterior approaches and of only
1.18° in the double approaches (p =
0.002). Such loss is less avoided if the
anterior graft is performed before the 6th
week (0.23° against 1.98°, p = 0.001).
Discussion ::
In our hands, the posterior approach seems
easier, feasible at any time of day or night,
and does not lead to heavy bleeding. Such
approach can be performed by a young
surgeon when he is on duty at the hospital.
The standard fixation and the contouring
allow a real reduction and is solid enough to
avoid bracing. It has not been proved that
the same quality of reduction could be
obtained by a single anterior approach or
that the fixation was solid enough to avoid
the brace. For us hypercorrection seems
indicated so that after the slight loss the
final result is not too far from normal values.
In summary, in our opinion the posterior
approach allows reduction and stabilization
of the fracture; the anterior approach is
reserved for the intercalary graft.
COMMUNICATION / AGENDA
Agenda
Meetings of interest for spine specialists
VII Congreso Iberoamericano de
Columna SILACO-AMCICO
RSNA Radiological Society of North America
91th Scientific Assembly & Annual Meeting
OCTOBER 12-15 - MERIDA MEXICO
NOV 27-DEC 2, 2005 - MCCORMICK PLACE, CHICAGO, USA
www.amcico.org
Scoliosis Research Society 40th Annual
Meeting
OCTOBER 26-30, 2005 - MIAMI, FLORIDA USA
SAS Spine Arthroplasty Society Summit 6
MAY 9-16, 2006 - MONTREAL, QUEBEC CANADA
www.spinearthroplasty.org
www.rsna.org
CSRS 33rd Annual Meeting
CSRS Cervical Spine Research Society European Section : 22nd Annual Meeting
DECEMBER 1-3, 2005 - SAN DIEGO, CALIFORNIA USA
MAY 17-20, 2006 - BERLIN GERMANY
www.csrs.org
www.csrs.de
www.srs.org
Australian Orthopaedic Association
Annual Meeting
First Congress on Computer-Aided Surgery
IMAST International Meeting on Advanced
DECEMBER 9-10, 2005 - LYON FRANCE
Spine Techniques
European and Middle East Meeting
[email protected]
OCTOBER 9-14, 2005 - PERTH AUSTRALIA
www.aoa.org.au
MAY 26-28, 2006 - ISTANBUL TURKEY
10th ARGOS International Symposium
www.srs.org
JANUARY 26-27, 2006 - PARIS FRANCE
Aegean Spine Review 2005
www.argos-europe.com
A WORLD SPINE SOCIETY COURSE
NOVEMBER 6-12, 2005 - IZMIR TURKEY
www.aegean-spine.org
Orthopaedic Research Society 41stAnnual Meeting
MARCH 5-8, 2006 - NEW ORLEANS, LOUISIANA USA
ISSLS International Society for the Study of
the Lumbar Spine Annual Meeting
JUNE 13-17, 2006 - BERGEN NORWAY
www.issls.org
www.ors.org
SOFCOT 2005 - Société Française de
Chirurgie Orthopédique et Traumatologie
NOVEMBER 7-11, 2005 - PARIS FRANCE
www.socot.com.fr
AAOS American Academy of Orthopaedic
Surgeons Annual Meeting
ASIA American Spinal Injury Association and
ISCoS International Spinal Cord Society 32nd
Annual Meeting
MARCH 8-12, 2006 - NEW ORLEANS, LOUISIANA USA
JUNE 25-28, 200 - BOSTON, MASSACHUSETTS USA
www.aaos.org
Spine Surgery : Advanced Applications
and Techniques
NOVEMBER 11-13, 2005 - ROSEMONT, ILLINOIS USA
[email protected]
AANS/CNS Joint Section on Disorders of the
Spine and Peripheral Nerves Annual Meeting
13th IMAST International Meeting on
Advanced Spine Techniques
MARCH 15-18, 2006 - ORLANDO, FLORIDA USA
JULY 12-16, 2006 - ATHENS GREECE
www.spinesection.org
Asian Academy of Minimally Invasive
Spinal Surgery (AAMISS) / Japanese
Society of the Study of Endoscopic and
Minimally Invasive Spine Surgery
(JESMISS)
GES : 37th Annual Meeting
MARCH 16-18, 2006 - PARIS FRANCE
www.ges.asso.fr
SNCLF (French Society of Neurosurgery )
NOVEMBER 21-23, 2005 - PARIS FRANCE
APRIL 22-27, 2006 - SAN FRANCISCO, CALIFORNIA USA
[email protected]
www.snclf.com
www.imastonline.org
NASS North American Spine Society & JSRS
Japan Spine Research Society
Spine Across the Sea 2006
JULY 23-27, 2006, MAUI, HI USA
AANS American Association of Neurological
Surgeons : Annual Meeting / Meeting the
Challenges of Neurosurgery : Expanding
Resources for a Growing Population
NOVEMBER 20, 2005 - JAPAN
www.asia-spinalinjury.org
www.spine.org
www.aans.org
Argos SpineNews
N°12 November 2005
29
COMMUNICATION / WEB REVIEW
Web review
Spine University
People who suffer from back and neck problems sometimes
find it hard to find good answers about what is causing their
problems and what can be done to make it better. Spine
University was designed as a place where patients can get
their questions answered. Spine University work with the a
panel of spine specialists to provide patients with straight
answers about their condition.
www.spineuniversity.com
may be provided by internal eMedicine copy editing staff,
the physician author, or a physician or Pharm D member of
the editorial board associated with each article. Updates
after the initial peer review do not generally go through
subsequent peer review, though select articles may
undergo a level of repeat peer review. eMedicine is proud to
be certified by the Health On the Net Foundation
(HONConduct #256884) verifying compliance with its 8
principles of conduct. In compliance with the guidance
associated with the fourth principle — attribution —
eMedicine posts the date of the last revision of any kind on
each article. The eMedicine Clinical Knowledge Base
contains 30.000 multimedia files and features the largest
online repository of medical education credits for physicians,
nurses, and optometrists. eMedicine.com, Inc. is a privately
held company and has a corporate publishing and business
office in Omaha, Nebraska, and a technology center in
Syracuse, New York. The company also has offices in
Boston, Massachusetts ; Lafayette, New Jersey ; and Saint
Louis, Missouri.
www.emedicine.com
eMedicine
Launched in 1996, www.eMedicine.com comprises the
largest and most current Clinical Knowledge Base available
to physicians and other healthcare professionals.
eMedicine’s subscription site for institutions is
www.iMedicine.com. Nearly 10.000 physician authors and
editors contribute to the eMedicine Clinical Knowledge
Base, which contains articles on 7000 diseases and
disorders. The evidence-based content, updated 24/7,
provides the latest practice guidelines in 59 medical
specialties. eMedicine’s professional content undergoes 4
levels of physician peer review plus an additional review by
a PharmD prior to publication. In May 2003, eMedicine
launched
a
new
consumer
health
site,
www.eMedicineHealth.com. Current medical information is
available in the Health Resource, First Aid and Emergencies,
and Lifestyle and Wellness Centers. With more than 5500
pages of health content, the site contains articles written by
physicians for patients and consumers. Each article is
reviewed by 2 physicians and a PharmD prior to publication.
Subsequent revisions of professional or consumer articles
32
Argos SpineNews
N°12 November 2005
Medicinet
MedicineNet.com is an online, healthcare media publishing
company. It provides easy-to-read, in-depth, authoritative
medical information for consumers via its robust, userfriendly, interactive web site. Since 1996, MedicineNet.com
has had a highly accomplished, uniquely experienced team
of qualified executives in the fields of medicine, healthcare,
Internet technology, and business to bring you the most
comprehensive, sought after healthcare information
anywhere. Nationally recognized, 100% Doctor-Produced
by a network of over 70 US Board Certified Physicians,
MedicineNet.com is the trusted source for online health and
medical information. The Doctors of MedicineNet are also
proud to author Webster’s New World™ Medical Dictionary
First and Second Editions (January, 2003) John Wiley &
Sons, Inc. ; ISBN : 0-7645-2461-5.
www.medicinenet.com
COMMUNICATION / WEB REVIEW
Trauma
Trauma.org exists to promote and disseminate the knowledge
and practice of injury prevention and trauma care throughout
the world. Using the Internet it aims to provide accurate,
current information in the field of trauma, and present an
interactive forum for trauma care providers throughout the
globe. Trauma.org aims to provide a repository for educational
materials, sources of information, details of forthcoming
events and original articles, relating to the field of trauma care.
Bringing together the knowledge and experience of doctors,
nurses, paramedics, researchers and all groups directly and
indirectly related to trauma management, it has established an
on-line, global, trauma community that promotes and furthers
the care of the injured patient. The Trauma.org web site and its
associated mailing list, the trauma-list, was established in
1995. Site accesses have increased exponentially alongside
the growth of the internet. Currently we are transmitting 32
gigabytes of information per month as 1.130.000 pages to
93.000 visitors in 110 countries. The site is linked to by over
3000 sites on the Internet and has been reviewed and
recommended in the British Medical Journal, Archives of
Surgery and a numerous conferences and meetings around
the world.
www.trauma.org
Spinal implant industry
outlook for 2006
BY ROBIN R. YOUNG CFA PRESIDENT ROBIN YOUNG CONSULTING AND PUBLICATIONS
- PENNSYLVANIA USA
For the first nine months of 2005, worldwide spinal
T implant sales rose, we estimate, 22% to $3.9 billion
and appear on track to reach $5.3 billion for the full
year. In terms of major companies, Sofamor Danek remains
both the largest and among the fastest growing in the world
at $2.1 billion in expected sales this year and growing, we
estimate, 21%.
Overall, the spinal implant industry is very healthy with both an
outstanding group of increasingly skillful and knowledgeable
surgeons and a steady stream of new technologies from both
inventors and manufacturers. As usual, the EU is leading the
world with new technology. The US, however, is only this year
beginning to adopt one of the most important new
technologies in spine repair — motion preservation.
Family doctor
This Web site is operated by the American Academy of Family
Physicians (AAFP), a national medical organizations
representing more than 93,700 family physicians, family
practice residents and medical students. All of the information
on this site has been written and reviewed by physicians and
patient education professionals at the AAFP.
familydoctor.org
While expectations were higher earlier in the year for disc
arthroplasty products in the United States, the reality has
proven to be a challenge. Surgeon and patient experience has
been excellent since approval by the FDA of the Charite and,
therefore, interest was (and is) high. But reimbursement has
lagged clinical experience with non-fusion implants. The
Centers for Medicaid and Medicare Services (CMS), the US
government agency responsible for setting reimbursement
rates for medical devices in the US has been slow in
determining the correct reimbursement rate for
Argos SpineNews
N°12 November 2005
33
COMMUNICATION / SPINAL IMPLANT INDUSTRY
disc arthroplasty. As a result, sales of the only FDA approved
TDA, the Charite, have been less than expected. Likewise, FDA
review of Synthes’s ProDisc will not likely occur until 2006. So, in
the United States, surgeons will have only one disc arthroplasty
product to use as the current year ends.
While motion preservation has, in fact, become a treatment option
for US patients with degenerative disc disease — the availability of
TDA remains low. US patients have, however, become aware of
this option and many are choosing to go to the EU for treatment.
We continue to expect industry leader, Sofamor Danek, to expand
its market share in 2005 on the basis of both InFuse and MIS
products like Sextant. Sofamor Danek will, we think, be able to
maintain a 40+% share in 2006. Coming on strong are a new
class of small to medium size spinal implant companies including
NuVasive, Abbott Spine, LDR, Blackstone Medical, Globus
Medical and Scient’x. DePuy Spine remains the second largest
spinal implant manufacturer followed by Synthes Spine and
Zimmer Spine.
Among the more interesting new technologies being introduced
at this year’s NASS are new biomaterials and an increasing
emphasis on spinal instrumentation.
The new biomaterials include a new carbon fiber based polymer
from Signus Spine (Germany) which appears to have a
compressive strength that rivals titanium and two new methods
for introducing stem cells into a spine fusion patient. Blackstone
Medical, in conjunction with Osiris (a stem cell tissue engineering
company) is introducing a new allograft product with viable stem
cells. Harvest Technologies recently received CE mark approval
for a new bone marrow concentrating product that will provide
highly concentrated quantities of autologous stem cells.
The following are our estimates of spine market growth from
2004-2009.
to rise in both the European Union and the United States. In 2004,
we estimate, about 2.6% of the population in the EU with severe
back problems underwent inpatient surgeries of some kind. The
most common being discectomies. Continuously improving
surgeon skill combined with new technologies — principally
motion preserving technologies but also MIS systems and the
use of biologics — will, we think, move the penetration rate in the
EU to over 3.0% by 2009.
In the United States, where spine surgery is a more practiced
therapy, the current penetration rate is about 4.4%. By 2009, for
many of the same reasons that the EU market will expand, the US
percentage of back pain patients choosing to undergo surgery
will, we expect, rise to 5.7%.
Again, the technologies that we think will play an increasingly
important role in the continuum of care for severe back pain will
be the following :
Spinal implant innovations 2004-2008
Traditional fusion instrumentation
New treatment modalities
Lower profile screws
2nd generation disc arthroplasty
Increasing use of MIS access
Facet joint arthroplasty
Motion preserving rods
Annulus repair
Low temperature cements
Disc regeneration
Resorbable load bearing plastics
Drug delivery on implants
High BMP bone void fills
Time release peptides
Stem cell products
anti-adhesion
One final note. The role of instrumentation is rising in both
importance and value. A number of companies have now clearly
demonstrated that strong instrumentation and surgeon training
may well be more valuable than a specific implant. Kyphon, for
example, created significant value and revenues by providing a
unique compression fracture instrument set. Likewise, NuVasive
has captured surgeon attention with instruments that can “sense”
nerves during surgery.
Market penetration rates in spine repair are expected to continue
US data only
Back problems
% inpatient repair
Spinal Repair
Spinal Fusion
Spinal Refusion
Total
Eu data only
Back problems
% Inpatient repair
Spinal repair
Spinal fusion
Spinal refusion
Total
34 Argos SpineNews
2004
2009
27.580.000
4.4%
779.843
433.038
20.205
1.233.086
29.700.000
5.7%
1.075.000
597.000
19.000
1.691.000
2004
2009
99.500.000
2.6%
103.300.000
3.1%
170.600
83.600
3.900
220.000
95.300
4.200
258.100
319.500
N°12 November 2005
In summary, the spinal implant market continues to be
characterized by innovation and creativity all of which will, we
expect, result in better patient outcomes over time.