bale wervelfractu ren

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1 bale wervelfractu ren W.M. Bakker Inhoud Incidentie Lichamelijk onderzoek Aanvullend onderzoek Classificaties Behandeling Osteoporose Follow up Incidentie 1

2 Incidentie Geschatte incidentie per miljoen ± 2500 opnames per jaar Man : vrouw verhouding 2:1 Gemiddelde leeftijd 42 ±10 jaar Oorzaken Verkeersongevallen (50%) Val van hoogte (35%) Incidentie Machino et al. Yonsei Med J Jul;54(4): Lichamelijk onderzoek 2

3 Evidence Lichamelijk onderzoek: Factoren die lichamelijk onderzoek negatief beinvloeden: Glasgow coma scale < 15 Alcohol of drugs intoxicatie Distracting injury Vaak fout negatieve test J.M. Hsu et al. / Injury, Int. J. Care Injured 34 (2003) Neurologisch onderzoek Aanvullend onderzoek 3

4 Radiologische metingen Cobb hoek VKA = vertebral kyphotic angle >50% hoogteverlies. AVH/PVH = vertebral Vermoeden height ratio op posterieur letsel >30 graden kyfose Anterieur hoogteverlies O. Keynan et al; Radiographic Measurement Parameters in TLWK Fractures: A Systematic Review and Consensus Statement of the Spine Trauma Study Group, Spine 2006;31:E156 E165 Evidence Aanvullend onderzoek Gevoeligheid van CT neemt toe bij afname coupe d R. Sheridan et al. / J Trauma 2003;55:

5 Termen Burstfractuur Dekplaat/ Sluitplaat Voorste/ middelste/ achterste pijler Achterste complex Inzakking Osteoporose Stabiel/ instabiel Brace/ gipskorset Spondylodese Classificaties Wervelfractuur classificatie Denis classificatie: Spine (Phila Pa 1976) Nov-Dec;8(8): The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Denis F. 5

6 Wervelfractuur classificatie McAfee classificatie: J Bone Joint Surg Am Apr;65(4): The value of computed tomography in thoracolumbar fractures. An analysis of one hundred consecutive cases and a new classification. McAfee PC, Yuan HA, Fredrickson BE, Lubicky JP. Wervelfractuur classificatie Magerl (AO) classificatie: Eur Spine J. 1994;3(4): A comprehensive classification of thoracic and lumbar injuries. Magerl F1, Aebi M, Gertzbein SD, Harms J, Nazarian S. TLICS Thoracolumbar spine trauma classification: the Thoracolumbar Injury Classification and Severity Score system and case examples. Patel AA et al. J Neurosurg Spine Mar;10(3):

7 Nieuwe AO Posterieure Ligamenten & spieren Posterior ligament complex Supraspinous ligament (SSL) Interspinous ligament (ISL) Ligamentum flavum (LF) Facet joint capsules Nieuwe AO classificatie Type-A injuries: failure under axial compression of the anterior elements with intact posterior constraining elements Type-B injuries: failure of the posterior constraining elements Type-C injuries: failure of anterior and posterior elements leading to displacement Eur Spine J Oct;22(10): doi: /s Epub 2013 Mar 19. AO spine injury classification system: a revision proposal for the thoracic and lumbar spine. Reinhold M1, Audigé L, Schnake KJ, Bellabarba C, Dai LY, Oner FC. 7

8 Type A Type B Type C 8

9 Behandeling Evidence Behandeling: Conservatief Operatief Voordelen Geen chirurgische complicaties Herstel van alignement Minder kosten Directe mobilisatie Nadelen Geen reductie fractuur Meer complicaties Risico op progressie deformiteit Hogere kosten Anatomische stand / alignement correleert niet met klinische en functionele uitkomst Nonoperative versus operative treatment for thoracolumbar burst fractures without neurologic deficit: a meta-analysis. Gnanenthiran SR, Adie S, Harris IA. Clin Orthop Relat Res 2011;470(2): Evidence Behandeling: conservatief vs operatief Cochrane review records gescreend 2 geïncludeerd Totaal 87 patiënten met TLWK burst fractures Follow up 2 jaar Resultaten: 2 studies met tegenstrijdige uitkomsten Conclusie: 2 potentially biased RCTs were insufficient to draw conclusions Surgical versus non-surgical treatment for thoracolumbar burst fractures without neurological deficit. Abudou et al; Cochrane Database Syst. Rev. Juni

10 Behandeling wereldwijd Conservatieve therapie Evidence-based management of traumatic thoracolumbar burst fractures: a systematic review of nonoperative management. Bakhsheshian J, Dahdaleh NS, Fakurnejad S, Scheer JK, Smith ZA. Neurosurg Focus Jul;37(1). Orthosis for thoracolumbar burst fractures without neurologic deficit: A systematic review of prospective randomized controlled trials Alcalá-Cerra G, Paternina-Caicedo AJ, Díaz-Becerra C, Moscote-Salazar LR, Fernandes-Joaquim A. J Craniovertebr Junction Spine Jan;5(1): The Spine Journal 14 (2014)

11 Bailey et al. July July 2009 Inclusion criteria: yr isolated AO A3 # Th10-L3 kyfosis< 35 neurologically intact 110 assessed for eligibility 14 excluded: 3 resided outside Canada 8 refused to participate 3 ambulated prior to consent 49 assigned NO 47 assigned TLSO 48 received NO 43 received TLSO 1 received surgery 4 received surgery Bailey et al. Geen verschil in Roland Morris Disability Questionnaire Geen verschil in pijn Geen verschil in tevredenheid Geen verschil in toename in kyfose hoek Osteoporose 11

12 Osteoporose Evidence Conservatieve behandeling: Exercise for improving outcomes after osteoporotic vertebral fracture. Giangregorio LM, Macintyre NJ, Thabane L, Skidmore CJ, Papaioannou A Cochrane Database Syst 2013 Jan 31;(1):CD AUTHORS' CONCLUSIONS: No definitive conclusions can be made regarding the benefits of exercise for individuals with vertebral fracture. Although individual trials did report benefits for some pain, physical function and quality of life outcomes, the findings should be interpreted with caution given that findings were inconsistent and the quality of evidence was very low. The small number of trials and variability across trials limited our ability to pool outcomes or make conclusions. Evidence regarding the effects of exercise after vertebral fracture, particularly for men, is scarce. A high-quality randomized trial is needed to inform exercise prescription for individuals with vertebral fractures. Evidence Conservatieve behandeling: Spinal Orthoses for Vertebral Osteoporosis and Osteoporotic Vertebral Fracture: A Systematic Review. Newman M, Minns Lowe C, Barker K. Arch Phys Med Rehabil Jun;97(6): CONCLUSIONS: The limited evidence about orthoses after acute OVF is inconclusive; better evidence of efficacy is needed, particularly when considering complications 12

13 Evidence Fysiotherapie: Physiotherapy Rehabilitation for Osteoporotic Vertebral Fracture (PROVE): study protocol for a randomised controlled trial. Barker KL, Javaid MK, Newman M, Minns Lowe C, Stallard N, Campbell H, Gandhi V, Lamb S. Trials Jan 14;15:22. Build better bones with exercise: protocol for a feasibility study of a multicenter randomized controlled trial of 12 months of home exercise in women with a vertebral fracture. Giangregorio LM, Thabane L, Adachi JD, Ashe MC, Bleakney RR, Braun EA, Cheung AM, Fraser LA, Gibbs JC, Hill KD, Hodsman AB, Kendler DL, Mittmann N, Prasad S, Scherer SC, Wark JD, Papaioannou A. Phys Ther Sep;94(9): Too Fit To Fracture: exercise recommendations for individuals with osteoporosis or osteoporotic vertebral fracture. Giangregorio LM, Papaioannou A, Macintyre NJ, Ashe MC, Heinonen A, Shipp K, Wark J, McGill S, Keller H, Jain R, Laprade J, Cheung AM. Osteoporos Int Mar;25(3): Follow up Follow up 8 maanden na L1 # 13

14 Saggitale balans Deformiteit grote impact op ADL patiënten waarvan 766 met rug deformiteiten Patiënten scoren slechter dan andere chronische ziekten Met name: physical functioning (PF) role-physical (RP) Impact on health related quality of life of adult spinal deformity compared with other chronic conditions. bodily pain (BP) Pellise et al; Eur Spine J 2015;24:3-11 Correctie is grote operatie Smith-Petersen osteotomie Max. 10 gr correctie/niveau Relatief eenvoudig Relatief laag risico Pedikel subtractie osteotomie ± 30 graden correctie Complexe ingreep Hoog complicatie risico (25%) 14

15 Take Home Testen lichamelijk onderzoek vaak fout negatief Cave osteoporose In follow up denk aan de saggitale balans rol voor fysiotherapeut 15

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