SpineNews 12
Transcription
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. 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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. 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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.