1. Dae Jeon Hurisarang Hospital, Dae Jeon Department of Neurosurgery, Mokpo Hankook Hospital, Mokpo Department of Neurosurgery, School of Medicine, Chosun University, Gwangju, Korea

2. Kim Hyeun Sung (ilovespine.com) Introduction Goals of surgical treatment for unstable thoracolumbar burst fractures restore stability of the vertebral column decompress the spinal canal facilitate early mobilization of the patients restore stability of the vertebral column decompress the spinal canal facilitate early mobilization of the patients Surgical treatment of burst fractures an extensive, huge, and very invasive procedure that requires a large opening with a long skin incision Anterior Approach significant invasion of the retroperitoneal space or thoracic cavity with wide dissection prolonged operation and hospitalization time blood loss, donor site complaints, increased morbidity and even mortality Anterior Approach significant invasion of the retroperitoneal space or thoracic cavity with wide dissection prolonged operation and hospitalization time blood loss, donor site complaints, increased morbidity and even mortality Posterior Approach extensive dissection of paraspinal muscles of the back : may lead to muscular denervation & necrosis => resulting in prolonged postoperative pain and disability resection of posterior elements of the spine Posterior Approach extensive dissection of paraspinal muscles of the back : may lead to muscular denervation & necrosis => resulting in prolonged postoperative pain and disability resection of posterior elements of the spine 2013-12-31 2

3. Kim Hyeun Sung (ilovespine.com) Inclusion criteria > 50% loss of anterior vertebral height, > 50% canal compromise kyphotic angle more than 20 Three column injury according to the Denis 3-column injury theory > 50% loss of anterior vertebral height, > 50% canal compromise kyphotic angle more than 20 Three column injury according to the Denis 3-column injury theory Denis Three-column Concept : Burst fracture : 2 or 3 column injury anterior height 50% canal compromise angular deformity greater than 20°, progressive kyphosis multiple contiguous fractures any neurologic injury in patients with extensive associated injuries anterior height 50% canal compromise angular deformity greater than 20°, progressive kyphosis multiple contiguous fractures any neurologic injury in patients with extensive associated injuries Material From January 2007 to September 2008: 11 patients Material and Methods 2013-12-31 3

4. Kim Hyeun Sung (ilovespine.com) Patients Series Material and Methods NO.NO. AGEAGE SEXSEX LevelBMDOP. time (min.) Intraop. Bleeding (cc) Kyphotic angleVertebral Height (%) AnesthesiaAugmentationF/U (Mns) Complic ations Preop.Postop.Preop.Postop. 159FL1-2.5390502233487GeneralPMMA17Cement leakage 260ML2-3.17100652674580GeneralPMMA16- 373ML1-3.2885951564364GeneralPMMA15- 454FT11-2.8680451874484GeneralPMMA11Cement leakage 550FT12-0.3280502594378GeneralHydroxyapatite10- 665FL1-3.0870601954896GeneralPMMA9- 749ML3-2.6770451984776SpinalPMMA9- 823FT10+1.2860402154277GeneralHydroxyapatite8- 956ML1-3.4965501784483SpinalPMMA8- 1047MT12+0.2370302734086GeneralHydroxyapatite7 1147MT12+0.1265302024887GeneralHydroxyapatite7 2013-12-31 4

5. Kim Hyeun Sung (ilovespine.com) Two Method for Restoration of Vetebral Height and Kyphotic Angle Pillow reduction Intra-operative pressure compression Pillow reduction Intra-operative pressure compression Methods : Surgical Methods Pillow reduction Pressure Compression 2013-12-31 5

6. Kim Hyeun Sung (ilovespine.com) 1. Fractured vertebral augmentation : PMMA Augmentation with Pressure Compression Kim HS, Park SK, Joy H, Ryu JK, Kim SW, Ju CI. Bone Cement Augmentation of Short Segment Fixation for Unstable Burst Fracture in Severe Osteoporosis. J Korean Neurosurg Soc 2008:44;8-14 Methods : Surgical Methods 2. Screw Reinforcement Non-osteoporotic : Hydroxyapatite Osteoporotic : Polymethylmethacrylate(PMMA) Non-osteoporotic : Hydroxyapatite Osteoporotic : Polymethylmethacrylate(PMMA) Ha-stick : PENTAX (Japan) : INFRAMED KOREA Stick insert cannula Stick insert Pressure Compression PMMA Injection Screw Insert 2013-12-31 6

7. Kim Hyeun Sung (ilovespine.com) Rod Rotation using the rod holder Rod tightening Rod Rotation using the rod holder Rod tightening General anesthesia & prone position under the Pressure reduction position Skin incision under the C-arm guide : Lateral to pedicle General anesthesia & prone position under the Pressure reduction position Skin incision under the C-arm guide : Lateral to pedicle Bone biopsy needle insert into pedicle using the Ruller guide Ruler guide remove : Insert pin => Remove bone biopsy needle => Remove guide Bone biopsy needle or hydroxyapatite insert guide insert Remove pin guide Bone biopsy needle or hydroxyapatite insert guide insert Remove pin guide Bone cement injection : Average 2.5-3cc /one side : One level : Average 5-6cc Percutaneous transpedicular screwing Bone cement injection : Average 2.5-3cc /one side : One level : Average 5-6cc Percutaneous transpedicular screwing Fracture level : Maintain pressure reduction posture : anterior column restoring => Minimized the cement leakage : spinal canal, paravertebral space etc. Fracture level : Maintain pressure reduction posture : anterior column restoring => Minimized the cement leakage : spinal canal, paravertebral space etc. Percutaneous screwing system(Apollon : Solco medical) insert : Lordotic shape Methods : Surgical Methods at one level above and below the fractures site including the fractured level itself 3. Percutaneous Screwing : Apollon System (Solco Medical, South Korea) Surgical Method – Rod rotation After remove the extender holder bar Rotate the rod inserting bar After remove the extender holder bar Rotate the rod inserting bar 2013-12-31 7

8. Kim Hyeun Sung (ilovespine.com) Mean Operation Time 76minutes Mean Blood loss 50.9mL VAS 8.09 => 2.36 Kyphotic angle 20.8 °±8.2° => 5.7 °±2.3° Vertebral height 43.45%±8.05% => 82.00%±5.25% Result 10.64 months Mean Follow-up Period 2013-12-31 8

9. Kim Hyeun Sung (ilovespine.com) 23yrs/F, Fall down, C/C : Severe back pain, N/E : intact Kyphotic Deformity : 21 => 5 Kyphotic Deformity : 21 Vertebral Height : 42% Vertebral Height : 42% => 77% T10 bursting fracture Case: Non-osteoporotic Fracture 2013-12-31 9

10. Kim Hyeun Sung (ilovespine.com) Vertebral Height : 43% Kyphotic Deformity : 25 Vertebral Height : 43% Kyphotic Deformity : 25 50yrs/F, Fall down, C/C : Severe back pain L1 bursting fracture Case: Non-osteoporotic Fracture Vertebral Height : 43% => 78% Kyphotic Deformity : 25 => 9 Vertebral Height : 43% => 78% Kyphotic Deformity : 25 => 9 2013-12-31 10

11. Kim Hyeun Sung (ilovespine.com) After Postural Reduction 1day after operation Paresthesia improved completely Kyphotic Deformity : 27 => 3 Kyphotic Deformity : 27 Vertebral Height : 40% Vertebral Height : 40% => 86% 47yrs/M, Fall down, C/C : Severe back pain with bilateral leg paresthesia T12 bursting fracture Case: Non-osteoporotic Fracture 2013-12-31 11

12. Kim Hyeun Sung (ilovespine.com) After Postural Reduction : Cord contusion detected 4day after operation Motor improved G4+/G4+ 1 week after operation Motor improved completely Kyphotic Deformity : 20 => 2 Kyphotic Deformity : 20 Vertebral Height : 48% Vertebral Height : 48% => 87% Initial Motor : G2/G2 47yrs/M, Fall down, C/C : Severe back pain with bilateral leg weakness(G2/G2) T12 bursting fracture Case: Non-osteoporotic Fracture 2013-12-31 12

13. Kim Hyeun Sung (ilovespine.com) 59yrs/F Fall down C/C : Severe back pain N/E : intact 59yrs/F Fall down C/C : Severe back pain N/E : intact Kyphotic Deformity : 22 Vertebral Height : 11/32(34%) Kyphotic Deformity : 22 => 3 Vertebral Height : 11/32(34%) => 29/32(90%), Canal Encrochment : 7/13(54%) => 3/13(23%) L1 bursting fracture Case: Osteoporotic Fracture 17 months later : Sclerotic Change 2013-12-31 13

14. Kim Hyeun Sung (ilovespine.com) 60yrs/M, Fall down, C/C : Severe back pain L2 bursting fracture Case: Osteoporotic Fracture Vertebral Height : 45% Kyphotic Deformity : 26 Vertebral Height : 45% Kyphotic Deformity : 26 Vertebral Height : 45% => 80% Kyphotic Deformity : 26 => 7 Vertebral Height : 45% => 80% Kyphotic Deformity : 26 => 7 2013-12-31 14

15. Kim Hyeun Sung (ilovespine.com) Kyphotic Deformity : 19 => 5 Kyphotic Deformity : 19 Vertebral Height : 48% Vertebral Height : 48% => 96% 65yrs/F, Fall down, C/C : Severe back pain L1 bursting fracture Case: Osteoporotic Fracture 3 days after operation 2013-12-31 15

16. Kim Hyeun Sung (ilovespine.com) Cement leakage 54yrs/F, Fall down, C/C : Severe back pain, N/E : intact Complication : cement leakage into paravertebral space flank dullness and pain : not significant Complication : cement leakage into paravertebral space flank dullness and pain : not significant T11 bursting fracture Case: Complication Cement Leakage 2013-12-31 16

17. Kim Hyeun Sung (ilovespine.com) Thoracolumbar burst fracture Treatment : Stabilization and decompression If does not need decompression of the neural element : posterior approach Treatment : Stabilization and decompression If does not need decompression of the neural element : posterior approach Main advantage : to preserve the motion segment compared to long level fixation Disadvantage : difficulty in restoring the anterior column : does not lead to satisfactory decompression Lead to secondary kyphosis Drawbacks & Sequela Persistent low back pain iatrogenic muscle denervation atrophy & decreased trunk extensor strength Need a less invasive techniques Main advantage : to preserve the motion segment compared to long level fixation Disadvantage : difficulty in restoring the anterior column : does not lead to satisfactory decompression Lead to secondary kyphosis Drawbacks & Sequela Persistent low back pain iatrogenic muscle denervation atrophy & decreased trunk extensor strength Need a less invasive techniques Short segment posterior fixation Discussion Limitation of percutaneous pedicle screwing in thoracolumbar junction Systems for percutaneous pedicle screws : developed for lordotic lumbar spine More difficult to apply in the thoracolumbar region : kyphotic angulation Systems for percutaneous pedicle screws : developed for lordotic lumbar spine More difficult to apply in the thoracolumbar region : kyphotic angulation 2013-12-31 17

18. Kim Hyeun Sung (ilovespine.com) Tan et al.(2007) : Cement augmentation of vertebral screws enhances the interface strength between interbody device and vertebral body. Spine kim HS, et al.(2007) : Bone cement augmentation of pedicular screwing in severe osteoporotic spondylolisthetic patients. JKNS Kim HS, et al(2008) : Bone cement augmentation of short segment fixation for unstable burst fracture in severe osteoporosis. JKNS Tan et al.(2007) : Cement augmentation of vertebral screws enhances the interface strength between interbody device and vertebral body. Spine kim HS, et al.(2007) : Bone cement augmentation of pedicular screwing in severe osteoporotic spondylolisthetic patients. JKNS Kim HS, et al(2008) : Bone cement augmentation of short segment fixation for unstable burst fracture in severe osteoporosis. JKNS Advantages Elimination of donor site complications Saving more motion segments Reducing blood loss and operation time. Advantages Elimination of donor site complications Saving more motion segments Reducing blood loss and operation time. Instrumentation without fusion Cement augmentation screwing Discussion Sanderson et al.(1999) : Short segment fixation of thoracolumbar burst fractures without fusion. Eur Spine J Wang et al.(2006) : Is fusion necessary for surgically treated burst fractures of the thoracolumbar and lumbar spine? Spine Sanderson et al.(1999) : Short segment fixation of thoracolumbar burst fractures without fusion. Eur Spine J Wang et al.(2006) : Is fusion necessary for surgically treated burst fractures of the thoracolumbar and lumbar spine? Spine Parker JW, Lane JR, Karaikovic EE, Gaines RW : Successful short-segment instrumentation and fusion for thoracolumbar spine fractures: a consecutive 41/2-year series. Spine 25 : 1157-1170, 2000 Short segment posterior fixation 2013-12-31 18

19. Kim Hyeun Sung (ilovespine.com) Rationale of Screw reinforcing Percutaneous short Segment Screwing Postural reduction : anterior column restoration, spinal alignment correction, no need decompression Bone cement augmentation : Maintain spinal stability, Maintain restored anterior column Percutaneous Transpedicular screwing : No open surgery Bone fusion : Fracture site itself Postural reduction : anterior column restoration, spinal alignment correction, no need decompression Bone cement augmentation : Maintain spinal stability, Maintain restored anterior column Percutaneous Transpedicular screwing : No open surgery Bone fusion : Fracture site itself Thoracolumbar junction kyphosis in Percutaneous screwing system Percutanoues screwing system : lordosis setting Rod rotation : under the C-guide using the firm rod holder Rod fixation : kyphotic setting Percutanoues screwing system : lordosis setting Rod rotation : under the C-guide using the firm rod holder Rod fixation : kyphotic setting 1)Reduce the dissections of the paraspinal muscles and posterior spinal elements. 2)Reduce the intraoperative bleeding, the operation time, the anesthesia time, infection, dural tear, etc. 3)Early ambulation 4)Reduce the hospital day 5)Reduce the postoperative pain 1)Reduce the dissections of the paraspinal muscles and posterior spinal elements. 2)Reduce the intraoperative bleeding, the operation time, the anesthesia time, infection, dural tear, etc. 3)Early ambulation 4)Reduce the hospital day 5)Reduce the postoperative pain Advantages of the screw reinforced percutaneous stabilization Discussion Initial After Operation 1 years later 2013-12-31 19

20. Kim Hyeun Sung (ilovespine.com) Discussion 2013-12-31 20