ICAC | Especialistas cirugía reconstructiva para fracturas.

What is the reconstructive surgery for fractures?

For the treatment of fractures of the thoracic and lumbar spine there are different alternatives.. It fundamentally depends on the type of fracture that has occurred, the clinical impact it produces and other personal factors such as age or pathological factors such as contributing diseases.

There is a wide variation of descriptive classifications on the type of vertebral fracture that can occur. There are no universally accepted algorithms to decide what should be the most appropriate treatment for a vertebral fracture.

In general, the treatment to be applied will depend on the stability or instability of the morphological type of fracture and the existence of neurological deficit due to spinal cord or nerve root compression.

Cutting-edge alternative at the Spine Surgery Institute in Madrid

In our service, For the treatment of thoracic and lumbar vertebral fractures, we opt for surgical treatment with minimally invasive systems. as the therapeutic alternative that implies a better and faster recovery.

As a general algorithm, in Stable compressive vertebral fractures in young patients without osteoporosis or osteopenia (<55 years), we performed the re-expansion of the sunken fragments of the vertebral body using a hydraulic-type lifting system and stabilization with bone cement as support. In osteoporotic stable compression fractures (> 55 years), more common in women, we perform re-expansion and cementation using kyphoplasty with an inflatable balloon. In unstable fractures Temporary fixation with screws and bars is necessary until the fracture heals and the bone hardens. We use fixation with percutaneous implantation with incisions smaller than 1 cm at the vertebral levels where fixation is required.

All information about vertebral fractures

The most common cases of vertebral fractures originate due to strong impact trauma. However, there are factors that can increase the possibility of suffering from this trauma, such as osteoporosis, which leads to a vertebral fracture with a mild impact or when performing exercises with high load.

The pathologies that we treat using minimally invasive systems include fractures of the lumbar vertebrae, fractures of the dorsal or thoracic vertebrae, as well as pathological fractures due to osteoporosis, tumors or bone metabolism diseases. A common example is the L1 fracture.

In the case of young patients with stable fractures, the Spine Jack ® (Vexim) re-expansion and cementation system is used.

Typically, the anesthesia used during this procedure is sedation and local anesthesia.. The patient's position on the operating room table is prone (face down). After locating the fracture using X-rays, two very small incisions are made in the back, about 5 mm. The pedicles of the fractured vertebra are located and a transpedicular access route is created to insert 2 implants that re-expand the fracture using a system similar to the jack-type lift in a car. Under X-ray control, the implants are elevated and, once the initial shape and height of the fractured vertebra is restored, it is stabilized using bone cement that hardens in a few minutes. To finish the surgery, the instruments are removed and a stitch is made in each incision.

In the case of patients with stable osteoporotic or osteopenic vertebral fractures, balloon kyphoplasty (Kyphon® Medtronic) and cementation for restoration of the vertebra.

This intervention is performed under local anesthesia and sedation, in a prone position (face down). The approach is similar to the previous procedure, minimally invasive, with 5 mm incisions in the back, at the affected level.. In this case, instead of an elevation implant, a reexpandable balloon is used inside the body of the vertebra to restore the subsidence. The entire procedure is performed under X-ray control and the fracture repair is completed by providing support with bone cement. To finish the surgery, the two incisions are closed with a stitch.

These techniques allow obtaining a bone sample for anatomopathological studies in the case of suspected pathological fractures due to tumors or bone metabolism diseases.

For patients with unstable fractures at risk of neurological involvement compressing the spinal cord or nerve roots, with great involvement of the vertebra and its ligaments, a more rigid fixation system with screws and bars is required.

A percutaneous system is used during surgery (Horizon Longitude® Medtronic CD), minimally invasive, which reduces muscle damage and only requires small incisions at the vertebral levels that need to be treated to form a stable system.

This procedure is performed under general anesthesia in the prone (face down) position. Vertebral levels that require fixation with screws and bars are located using X-rays and are approached with small skin incisions of approximately 1 cm. With constant x-ray vision in two planes, the exact place where a 1 mm needle will be introduced into the vertebral body through the pedicles of the vertebrae is identified. These will serve as a guide for the introduction of the cannulated screws.

On the other hand, the bar is also inserted into the screws percutaneously through two small incisions. Using a distraction system, the fracture is reduced and the small skin incisions are closed with 2 stitches each.

The duration of this procedure varies from 30 to 45 minutes per fractured vertebra. The procedure can be performed on an outpatient basis without the need for the patient to be admitted.

When it comes to the percutaneous system CD Horizon Longitude® Medtronic, 15 minutes are usually spent for each level in which screws are required to be placed. The most common surgery requires 4-level fixation when there is an unstable fractured vertebra. The surgery usually lasts about 90 minutes.

Generally, the Consolidation time of a vertebral fracture leads to hospital discharge 24-48 hours after performing the vertebral fracture surgery, the recovery time for a dorsal or lumbar vertebra fracture being very short.

Spine microsurgery offers a fundamental advantage by rapidly relieving pain and preventing serious potential complications such as post-traumatic deformities.

Our surgical approach is based on percutaneous minimally invasive systems, providing multiple benefits:

  • Precise and short-term surgical procedure: We carry out short interventions with few risks due to continuous control with X-rays and the use of local anesthesia with sedation.
  • Minimal blood loss and muscle damage: The technique used minimizes injuries to the muscles next to the vertebrae, reducing the postoperative pain and shortening hospital stay.
  • Discharge from hospital on the same day of surgery: Patients are usually discharged on the same day or within 24 – 48 hours in the case of screws and bars.
  • Very small scars: Thanks to minimally invasive techniques with small approaches to the skin of 0.5 mm to 1 cm, large scars and tissue injuries from open surgeries are avoided.
  • Early pain relief and prompt return to activity: Early treatment allows early pain relief returning to activities of daily living and a normal social life quickly.
  • Restoration of anatomical deformity and the biomechanics of the spine: post-traumatic kyphosis that involves chronic back pain is avoided. In the case of osteoporotic fractures, new fractures are prevented by restoring the height of the vertebra, avoiding the progressive anterior tilt of the back and the increase in the weight that the vertebrae have to support in the anterior part of the vertebral body, which implies new fractures.
  • Prevention of short-term complications: Surgery prevents vertebral collapse, neurological compressions and instability, improving clinical outcomes and reducing the risk of complications.
  • Improved quality of life in older people: In older people, lung vital capacity is improved by correcting kyphotic posture.
  • Corsets and long periods of bed rest are avoided: Their use implies a prolonged intake of analgesics and a greater possibility of complications.

These benefits help in faster recovery, reduce the need for prolonged pain medication, and minimize the chances of associated complications.

Accurate diagnosis and comprehensive evaluation of the affected areas are essential to determine the most appropriate treatment in cases of vertebral fractures. The tests used for this purpose are key:

  • Spinal x-rays: Provide a quick initial assessment of the presence of a vertebral fracture and its severity. It allows us to distinguish compression fractures, translation-rotation fractures or distraction fractures.
  • Computed Axial Tomography (CAT): Identifies the involvement of the vertebral bone and possible bone displacements, especially those that can invade the spinal canal. It provides a definition of the bone involvement through millimeter cuts in all axes and the possibility of a three-dimensional reconstruction.
  • Magnetic Resonance: offers a detailed view of the involvement of the vertebral disc and soft tissues: ligaments, capsules and muscles. It is crucial to detect if there is involvement of the structures of the posterior ligament complex of the vertebrae since its involvement indicates instability of the vertebral segment, conditioning the use of a more rigid type of fixation in the surgical treatment.

In addition, Magnetic Resonance provides valuable information about the evolution time of the fracture, being especially important in people over 55-60 years of age. It allows us to distinguish between recent (acute) and old fractures, detecting bone edema in MRI sequences for recent fractures. It also informs us about involvement in the disc and adjacent soft tissues that could indicate a pathological fracture due to tumors or metabolic bone diseases.

Upon discharge from the hospital, it is essential to have the medical report that specifies the types of fractures treated and the system used during the intervention.

As post-surgical medication, we use anti-inflammatories – analgesics the first days as required. An analgesic drug is generally sufficient., although we recommend having two alternatives in case they are required. In cases of lumbar contracture, muscle relaxants are used as necessary.

The surgical incision is about 0.5 – 1 in the back of the back in the lumbar or thoracic region, depending on the fracture. A stitch or staple is usually given. Wound washings usually begin on the fifth day, keeping it clean and dry with povidone-iodine or chlorhexidine dressings. Their small size generally minimizes potential complications such as infections or wound openings.

A corset is not usually required and after the first 15 days physical activity can be increased.. From the first day, it is advisable to carry out movements of the thoracolumbar spine without vigorous movements: flexion-extension, lateralizations and rotations. We recommend avoiding bad posture or handling heavy loads.

If there is any lumbar discomfort due to muscle contracture, we can apply local heat for 20 minutes 3-4 times a day and perform progressive stretching exercises.

If residual low back pain persists, the exercises can be complemented with a physical rehabilitation session, preferably in a specialized center.

Driving the car can be done immediately in the first 15 days. In low cars we recommend using a cushion for the first few days to avoid postural malposition.

In case of any complication or incident, you should consult the emergency service of the hospital where the intervention was performed.

Hospital discharge after procedures such as bone re-expansion and cementation, both with the Spine Jack system and Balloon Kyphoplasty, is an outpatient procedure and is performed on the same day as the surgery.

By reducing the initial shape of the fractured vertebra and cementing it, giving stabilization and support to the vertebra, a restoration of the anatomy is achieved, causing immediate pain relief.

The use of a corset or crutches is not required, allowing patients to leave the hospital on foot. We prescribe some mild analgesic for approximately 5-7 days. Daily activities can be progressively resumed immediately. In most cases, rehabilitation is not usually necessary and return to work and sport usually occurs a month after surgery.

Generally, the first postoperative check-up is carried out after 10 days, to assess the surgical wounds, which, being so small, rarely present complications, allowing the stitches to be removed at that time. The next check-up is usually a month later and includes a control x-ray.

Subsequently, further revisions are not usually necessary, but, individually, depending on the type of work activity carried out by the patient, especially in tasks that involve large manipulations of loads, some more revisions may be required if it is necessary to strengthen the muscles with physical rehabilitation.

For unstable fractures treated with the Medtronic® Horizon Longitude CD System It is also through a percutaneous approach, but as more levels are performed and the incisions are a little wider, it may require 24-hour intravenous analgesics for better pain tolerance. Recovery is usually a little slower, and progressive activity can be resumed from the first postoperative day.. In this case, the use of corsets is not necessary either. Painkillers are usually required for 7-10 days and return to daily activities should be gradual over the first month. Rehabilitation treatment is usually necessary to strengthen the back muscles. Return to work is usually between the sixth and eighth postoperative week, depending on the activity to be carried out. If it involves handling large loads, it is usually necessary to extend muscle strengthening for up to 8-12 weeks.

The extraction of the screws and bars is carried out one year after their implantation., since several levels are fixed to provide structural support so that the fractured vertebra hardens without being subjected to weight support, but once complete consolidation is achieved without bone edema, it is removed to maintain correct mobility of all vertebral levels of the back.

Surgical treatment of thoracic and lumbar fractures has long-term advantages, preventing chronic back pain and avoiding the need for open surgeries due to complications.

In the case of the use of screws and bars, their removal is necessary one year after surgery to improve the harmony and biomechanics of back mobility.

Postoperative follow-up is essential; control consultations are carried out within the first 15 days and one month after surgery with our specialists in spinal traumatology. In some cases, physical rehabilitation is necessary, especially when multiple spinal levels are involved or to strengthen muscles and facilitate the patient's return to work or daily activities.

Vertebral fractures can vary in their origin, presenting different characteristics and causes. Some of the most common fractures include:

  • Compression fractures– These fractures occur when a vertebra is crushed due to a compressive force. This type of injury is usually caused with osteoporosis due to other pathologies such as bone cancer.
  • Burst fractures: It involves the rupture of the anterior part of the vertebra, usually caused by a fall from a height.
  • Flexion fractures: This type of injury occurs when the vertebra bends, but does not break completely, such as in car accidents.

Although it is a surgery that does not usually have complications thanks to our minimally invasive approach, there are some complications that can occur:

  • Infections: If the wound is not cared for, an infection may occur at the incision site.
  • Healing problemsn: the surgical wound may present difficulties in the healing process.
  • Specific complications: Depending on the specific conditions of some patients, complications such as blood clots, breathing problems or adverse reactions to anesthesia may occur.
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Important announcement

The ICAC, now at Teknon in Barcelona

This month of June, We have begun our collaboration with the prestigious Barcelona clinic TMEH to offer spine services at the famous Teknon Medical Center, one of the leading healthcare hospitals in Europe. Thanks to this alliance, we provide a comprehensive and specialized approach with the best solutions for those suffering from back problems.

The ICAC human team, known for being at the vanguard of innovation in traumatology, now brings his talent and advanced ultra-minimally invasive surgery techniques to Barcelona.

This collaboration with TMEH at Teknon Medical Center not only allows us to treat more patients more effectively, but also reinforces our commitment to innovation and excellence in healthcare.

We are excited to be able to offer these services in one of the most important cities in Europe and continue leading the field of traumatology and, in this specific case, in the treatment of the spine.