Double-level noncontiguous thoracic Chance fractures treated with percutaneous stabilization: illustrative case

BACKGROUND Chance fractures are unstable due to horizontal extension of the injury, disrupting all three columns of the vertebra. Since being first described in 1948, Chance fractures have been commonly found at a single level near the thoracolumbar junction. Noncontiguous double-level Chance fractures that result from a single traumatic event are rarely reported in the literature. OBSERVATIONS The authors report a case of an 18-year-old male who presented to the emergency department after a rollover motor vehicle accident. The patient complained of severe back pain when at rest and had no neurological deficits. Computed tomography revealed two unstable Chance fractures of bony subtype located at T6 and T11. The patient underwent percutaneous stabilization from T4 to T12. The postoperative assessment revealed continued 5/5 power bilaterally in all extremities, back pain, and the ability to ambulate with a walker. At 3 months after the operation, clinical assessment revealed no significant back pain and the ability to walk independently. Imaging confirmed stable fixation of the spine with no acute osseous or hardware complications. LESSONS This report complements previous studies demonstrating support for more extensive stabilization for such unique fractures. Additionally, rapid radiological imaging is needed to identify the full injury and lead patients to appropriate treatment.

Use of a circular fixator construct to facilitate closed reduction and percutaneous stabilization of a distal femoral physeal fracture in a dog

Background: Fractures of the distal femoral physis are the most common physeal fracture sustained by skeletally immature dogs. Reduction and stabilization of these fractures can sometimes be achieved through closed reduction, primarily in fractures that are nominally displaced. Circular external fixator constructs have been used to assist in indirect, closed reduction of fractures at other anatomic locations in dogs and this report describes application of this method to reduce a displaced Salter-Harris type II fracture of the distal femur in a 1-year-old dog. Case Description: A 1-year-old female spayed Akita was referred for treatment of a Salter-Harris type II fracture of the right distal femur. The epiphyseal segment was laterally and slightly caudally displaced. Multiple attempts to manually reduce the fracture during surgery were unsuccessful, so a two-ring circular external fixator construct was applied to facilitate distraction and reduction. The construct was applied by placing a medial-to-lateral Kirschner wire in both the mid-femoral diaphysis and in the distal femoral epiphysis. Distraction of the construct provided sufficient separation of the fracture segments to facilitate near anatomic reduction. The fracture was stabilized with two percutaneously placed Steinmann pins placed in Rush fashion. Radiographic union was confirmed 5 weeks after surgery. The dog was not lame and was bearing more weight on the right pelvic limb, as assessed using force plate analysis, 9 months following surgery. Goniometric measurements of stifle range of motion and thigh muscle circumference were similar between the pelvic limbs. Conclusion: Application of a two-ring circular construct would appear to be useful to facilitate closed reduction and percutaneous stabilization of distal femoral physeal fractures.

The Role of Minimal Access Surgery in the Treatment of Spinal Metastatic Tumors

Study Design: Literature review. Objective: To provide an overview of the recent advances in minimal access surgery (MAS) for spinal metastases. Methods: Literature review. Results: Experience gained from MAS in the trauma, degenerative and deformity settings has paved the road for MAS techniques for spinal cancer. Current MAS techniques for the treatment of spinal metastases include percutaneous instrumentation, mini-open approaches for decompression and tumor resection with or without tubular/expandable retractors and thoracoscopy/endoscopy. Cancer care requires a multidisciplinary effort and adherence to treatment algorithms facilitates decision making, ultimately improving patient outcomes. Specific algorithms exist to help guide decisions for MAS for extradural spinal metastases. One major paradigm shift has been the implementation of percutaneous stabilization for treatment of neoplastic spinal instability. Percutaneous stabilization can be enhanced with cement augmentation for increased durability and pain palliation. Unlike osteoporotic fractures, kyphoplasty and vertebroplasty are known to be effective therapies for symptomatic pathologic compression fractures as supported by high level evidence. The integration of systemic body radiation therapy for spinal metastases has eliminated the need for aggressive tumor resection allowing implementation of MAS epidural tumor decompression via tubular or expandable retractors and preliminary data exist regarding laser interstitial thermal therapy and radiofrequency ablation for tumor control. Neuronavigation and robotic systems offer increased precision, facilitating the role of MAS for spinal metastases. Conclusions: MAS has a significant role in the treatment of spinal metastases. This review highlights the current utilization of minimally invasive surgical strategies for treatment of spinal metastases.