B3 Fracture, most unstable 3 column dissociation

difficulty in management

Dr. Moneer K. Faraj AO Spine Principles Course

M.B.,Ch.B.,FICMS,FACS,FICS,IFAANS,FWFNS
Baghdad, November 2015
Consultant Neurosurgeon
Hospital of Neurosciences
College of Medicine, Baghdad University
Baghdad, Iraq
 Type B
• Failure of posterior or anterior constraints (including the tension band either the

Posterior Ligamentous Complex (PLC) or the anterior longitudinal ligament)

Patient Management:

• The Advanced Trauma Life Support (ATLS) Guidelines.

• Complete Neurological Assessment.
Indications for operative treatment

• Neurological damage
• Symptomatic anterior spinal cord compression
from retro pulsed bone
• Symptomatic traumatic disc herniation
• Unstable burst fracture in the absence of neurologic compromise
• Compromised bone quality
Anterior Approach Indications:

• Symptomatic anterior spinal cord compression

from retropulsed bone
• Evidence of increasing kyphosis while treated non operatively
• Residual instability following posterior stabilization
• Residual compression following posterior stabilization
Anterior Approach C/I:

• Previous anterior surgery placing viscus and vascular structures at risk due to
scarring/adhesions.
• Lung, vascular, and abdominal diseases, which make anterior approaches difficult or
dangerous
• Patient not fit for surgery
Anterior Approach Advantages:
• Ability to perform short segment fixation
• Direct visualization of compromised anterior neurologic structures
• Excellent biomechanical anterior column support

Anterior Approach Disadvantages:

• Complex surgical approach

• Complications of an anterior approach including potential for vascular
and organ injuries .
• Anterior standalone procedures may not be as sound biomechanically as multi
segmental posterior stabilization procedures
• Transthoracic procedures may be challenging in patients with concomitant chest injuries
Posterior Approach: Long Segment Fixation

Indication:
All unstable injuries
Contraindication:
Patient not fit for surgery
Posterior Approach Advantages:

• Highest stability
• Fast rehabilitation

Posterior Approach disadvantages:

• Demanding surgery
• Invasive
Minimally Invasive Spine Surgery (MIS)

Advantages:
• Less soft-tissue trauma
• Less skin incision
• Less blood loss
• Earlier rehabilitation
• Shorter hospital stay
• Less pain
• Reduced OR time

Disadvantages:
• Complex surgical approach
• Complications of an anterior approach including potential for vascular and organ injuries
• Anterior standalone procedures may not be as sound biomechanically as multi segmental posterior
• stabilization procedures
Transthoracic procedures may be challenging in patients with concomitant chest injuries
• Technically demanding, special instruments required
 When a fracture needs to be treated surgically, the choice to
perform anterior or posterior stabilization or combined MIS or
open depends on surgeon's preference.
THANK YOU