vertebral fracture

Re: vertebral fracture

Evelyn Barbour-Hill — Sun, 06 Nov 2011 19:00:13 GMT

I admit that the two-dimensional nature of a radiograph can be very misleading, but this seems to illustrate to me (not a spinal expert) that even a structure which is mechanically unsound can be good enough.

Re: vertebral fracture

Rob Loxley — Sun, 06 Nov 2011 18:50:02 GMT

How's the patient doing?

Re: vertebral fracture

jose targa — Sun, 06 Nov 2011 11:26:04 GMT

After and before surgery:

The bigger pins ar 2mm positive threated ones, the smaller are 1,5 mm (not threated). After removing the T-12/T-13 arthicular surface, stability still present, i think that dorsal compartment is very strong in this case, good idea not to touch!!!. The cement was aplied in T-11/ T-13 traction, as you can see in the picture, general spinal alignement is correct...and the most important: There´s no pain!!!!!!!!!!!!!! since the same postoperative moment there´s no pain, that´s the most important advantage of this fixation for me.

What do you think about?

Thanks for your interest.

Warm regards

Re: vertebral fracture

jose targa — Sat, 05 Nov 2011 15:18:59 GMT

Dear Malcolm and Mark

Finally i performed a right hemilaminectomy, and for my surprise, the bone fragments were causing serious damage to the medula, finally i had to put pins and cement (promis to send pictures of the final result to get your expert opinions).

The gross aspect of the medula wasn´t nice...i saw a big subdural hematoma...what do you think about?? Which medical treatment would you chose????.

In advance many thanks for your interest!!!!!

Warm regards

Re: vertebral fracture

Judith Joyce — Fri, 04 Nov 2011 20:33:44 GMT

I agree completely with the prognosis in genuinely deep pain negative cases - very, very few, if any such dogs improve at all and fewer still will make a useful functional recovery.

The 3 compartment scheme is an elegant lift from human medicine but I have not seen it convincingly validated in our patients and my current opinion is that is a useful way of "justifying" exciting surgery in cases that might not truly benefit from that approach. This kind of compression/impaction fracture is inherently stable - that is biomechanics and this fracture still seems to be exactly where it got to when the car hit it - and when you add in the stability that comes from muscle tone etc, I am very nervous about cutting these cases as the one absolutely unavoidable fact is that to get down far enough to place implants, you have to do an awful lot of damage to the (currently stabilising) soft tissues. Furthermore, any surgical stabilisation will involve the adjacent vertebrae, thereby extending the morbidity further than it already exists.

As Mark indicates, there are lots of different surgical techniques described and that is proof positive that none is ideal (otherwise there wouldn't be a debate). I will look for the info about back casts but my personal dislike of the pins and cement technique stems first from my background researching mechanics and biomechanics and more specifically from a pilot study I did to compare pins and cement with a locking plate system using sheep lumbar spines. Even with the luxury of a flesh-less spine and the freedom to use more cement than would be practical in a clinical case, the constructs performed surprisingly poorly. The size/number of pins you will get into the TL vertebrae of a 20kg dog are limited and the volume of bone cement will be worryingly small.

Regrettably, there is very little of any use in the vet literature about this subject - lots of "I saw 20 fractures and treated them like this" accounts but nothing of any quality and no reliable comparative stuff or anything approaching a controlled study.

The trouble with spinal fractures is that they are treated either by orthopaedic surgeons who know bugger all about the neurology, or neurologists who know similarly little about the biomechanics and how to fix a fracture!!

Malcolm N

Re: vertebral fracture

Evelyn Barbour-Hill — Fri, 04 Nov 2011 13:47:23 GMT

[quote user="Judith Joyce"]The pin and cement technique you propose is mechanically poor and a well made back splint is likely to be very much better.[/quote]

That's extremely interesting. Malcolm, could you point me to any useful articles upon back splints, the use and construction thereof?

Re: vertebral fracture

Mark Lowrie — Fri, 04 Nov 2011 11:35:31 GMT

I agree with Malcolm that the prognosis is set by the initial neurological examination and presence or absence of deep pain sensation. If deep pain sensation is absent I would not do anything more for this dog as the prognosis is hopeless (the literature states <5% but personal experience would suggest closer to 0%). However, if deep pain is present then the prognosis is better. I also defer to Malcolm for the comments on the forelimb injury – I agree that spinal surgery when faced with concurrent orthopaedic disease should be undertaken cautiously.

However, I would be concerned that this fracture is unstable. We always talk about the 3 compartments:

1) Dorsal compartment contains articular processes, laminae, pedicles, spinous processes + supporting soft-tissue structures

2) Middle compartment contains dorsal longitudinal ligament, dorsal aspect of annulus fibrosus of IVD + dorsal part of vertebral body

3) Ventral compartment contains rest of vertebral body, lateral + ventral annulus fibrosus, nucleus pulposus + ventral longitudinal ligament

If 2 or more of these compartments are affected then the fracture is considered unstable. The CT appears to show a complete vertebral body fracture/collapse and so I would suggest this lesion involves the middle and ventral compartments. Therefore I would consider stabilisation for this patient.

I don’t tend to decompress the spinal cord in these cases so I would not perform a hemilaminectomy/dorsal laminectomy or any other approach to the spinal cord. Regarding stabilisation, there are now so many available methods that I simply would advise that you chose the one you are most comfortable with – and perhaps therefore your method of wires and cement is the best option in this case.

Hope all goes well.

Re: vertebral fracture

jose targa — Fri, 04 Nov 2011 10:43:05 GMT

Thank you very much for your opinion Malcolm!!!! your experience and your explanation is very important for me.

Mss. Richards: I´m asking for opinions, different points of view of colleagues with more experience, and more cases than me. Fortunately we solve lots of spinal injury cases every year (keep calm, that´s not my first surgery ), despite of this, i´m not shamed to ask for different points of view...and i hope to still asking for advice the rest of my life, because it means i´ll learn for the rest of my life too. I´m glad to say that i learn something new every day, even the students can teach us something !!!!! Sometimes, different views can open our mind, don´t you think so?.

There´s not a spinal (exclusive) referral center in Spain if you´re intrested in.

Re: vertebral fracture

Hannah Wynne Richards — Fri, 04 Nov 2011 10:20:43 GMT

I would move heaven and earth to twist the owners arms to refer If I have to ask for advice,the animal is better off with someone else-problem is, I don't know what the referral situation is like in Spain

Wynne

Re: vertebral fracture

Judith Joyce — Fri, 04 Nov 2011 10:02:25 GMT

As with any spinal cord injury, the prognosis is set by the day 0 neurological status and its subsequent progression. I would like more detail of your neuro exam. The low panniculus cut-off is a bit of a concern. If there is evidence of pain perception (not just withdrawal which is a reflex, and easily over-interpreted in painful cases) then the prognosis is reasonable; if there is genuine evidence of motor control, then the prognosis is better. I would look closely at the forelimb neuro function - the non-fractured leg should be confirmed as unequivocally normal and you must be confident that you can restore excellent function to the fractured limb - ?? pancarpal arthrodesis.

There is remarkably little evidence that an aggressive surgical approach to these cases is beneficial. This looks like a hyper-flexion fracture and appears to be inherrently stable. I operate on very few of the spinal fractures I see, most are managed conservatively. The pin and cement technique you propose is mechanically poor and a well made back splint is likely to be very much better. I am not convinced of the need to decompress this case and any spinal surgery involves removal of/damage to spinal muscle and bone and inevitable weakening of the spine and core that are essential to a good clinical outcome. In any case, the best time to have been doing the surgery was yesterday!

The concomitant carpal fracture is a massive complicating factor - the spinal convalescence will depend on the dog being able to weight bear and ambulate without compromise on the thoracic limbs. I would caution you to think very carefully before you reach for the scalpel.

Malcolm N