Adobe Systems TREATMENT OF SPINAL TRAUMA FN Brno_modra_ctverec Department of Othopeadic Surgery at Faculty of Medicine, Masaryk University and University Hospital Brno Head : prof. MUDr. Martin Repko, Ph.D. MUDr. D. Matejička, MUDr. J. Sklenský, MUDr. M. Prýmek Adobe Systems I.Revision of Anatomy II.Biomechanics of spine Mechanisms of trauma, III.AO classification IV.Spinal cord injury + examination V.Treatment -----→ VI.Instrumentation of the spine - trauma vs. degenerative goals & treatment CONTENT: A.CONSERVATIVE B.SURGICAL Adobe Systems I. Revision of Anatomy - SPINE 10014 tab_142 - count of vertebrae (variability!) - spine curvatures - neuro-vascular structures! single%20vertebrae%20coronal.jpg Adobe Systems part+functions 2.jpg Facet joints angle joint angle.gif Adobe Systems FSU_ligments.png -Synarthrosis „joints“ (conection by cartilage/ligament/bone) - -Diarthrosis (synovial) joints (articular surfaces, joint capsule, cavity, synovial fliud …) peicles + PLL.jpg Th-vert.jpg Adobe Systems atlantoax.png atlantoaxial.jpg sacrum2.jpg Adobe Systems FSU.jpg II. Biomechanics - Functional Spinal Unit (FSU) = smallest mobile segment of the spine -Composed of: 2 adjacent vertebrae, intervertebral disc, ligamnets 2 facet joints and capsules, surrounding soft tissues FSU.bmp Adobe Systems II. Incidence of spinal trauma •3-6 % of all injuries •70 % thoracic and lumbar •30 % cervical • •20 % presence of neurological deficit Obsah obrázku snímek obrazovky Popis byl vytvořen automaticky Leucht et al. 2009 Adobe Systems Obsah obrázku snímek obrazovky Popis byl vytvořen automaticky Adobe Systems Etiology of spinal trauma Obsah obrázku snímek obrazovky Popis byl vytvořen automaticky o oHigh energy trauma – youth oLow energy trauma – over 60 yo (osteoporotic fx.) oFalls oTraffic accidents - whiplash injury oSport oCombinations o o 10019 3029 Leucht et al. 2009 Adobe Systems SCI.jpg Spinal trauma- mechanisms golf_movements.jpg [USEMAP] Adobe Systems Types of injuries ØAxial load forces ØFlexion-Extention forces ØRotation formces ØCombination 3032a mech.SCI.jpg axial load.jpg [USEMAP] Adobe Systems Image result for double collum spine classification III. SPINE TRAUMA CLASSIFICATION [USEMAP] Adobe Systems [USEMAP] Adobe Systems komprese distrakce AO classification (Magerl 1994) https://image.winudf.com/v2/image/YWYub3JnLmFvZm91bmRhdGlvbi5BT1NSX3NjcmVlbl8wX3Zxb3JkNjZ2/screen-0 .jpg?fakeurl=1&type=.jpg [USEMAP] Adobe Systems 04d 04b 04a COMPRESSION FLECTION+ DISTRACTION EXTENSION ROTATION/ TRANSLATION [USEMAP] Adobe Systems [USEMAP] Adobe Systems [USEMAP] Adobe Systems https://prod-images-static.radiopaedia.org/images/42752970/06629130783c633a43638879c83501_jumbo.jpe g https://prod-images-static.radiopaedia.org/images/37436129/c9bafd56ecd2b7da2b10c7cb53907f_jumbo.jpe g [USEMAP] Adobe Systems Spine INSTABILITY BONY HEALING FUSION ACUTE LIGAMENTOUS CHRONIC INSTABILITY [USEMAP] Adobe Systems LIGAMENTOUS INSTABILITY • conservative treatment cannot lead to healing • • result is chronic progressive instability • • pseudoathrosis or kyphotic deformity may occur • • can only be repaired by fusion of affected segment Image result for kyfotic deformity spine x ray [USEMAP] Adobe Systems IV. Spinal Cord Injuries (SCI) Spinal cord impairment causing temporary or permanent changes in motor, sensory, or autonomous spinal cord functions. 1) type : A) primary B) secondary 2) degree: A) complete B) incomplete [USEMAP] vsetko je podobne kraniocerebralnym poraneniam - t.j. primarne a sekundarne poranenia, preventabilne je to sekundarne - koli tomuz su terapeuticke intervencie Adobe Systems 1A) Primary SCI It is caused directly during the injury process. Therefore it CAN NOT BE influenced! L Spinal cord compression by bone fragments, hematoma, herniated intervertebral disc. Torsion, distraction, (shear forces = unfavorable prognosis) Ischemia Penetrating injury Obsah obrázku mapa, text Popis byl vytvořen automaticky Obsah obrázku mapa, text Popis byl vytvořen automaticky [USEMAP] Adobe Systems •Vascular changes : - reduced flow - thrombosis - vasospasm - hemorrhagia •electrolyte changes •free O2 radicals •Inflammatory reaction => the result is neuronal necrosis !! 1B) Secondary SCI [USEMAP] vsetko je podobne kraniocerebralnym poraneniam - t.j. primarne a sekundarne poranenia, preventabilne je to sekundarne - koli tomuz su terapeuticke intervencie Adobe Systems Související obrázek 1B) Secondary SCI It occurs as a result of primary impairment. COULD BE partially influenced, and that is the goal of treatment. Possibilities of its influence : - oxygenation, optimal BP - pharmacotherapy (anti-oedematous treatment -corticoids ?) - surgical treatment (decompression of neural structures + insturmentation of the spine for its stabilization) Image result for dexoamed www.medicalexpo.com/prod/rti-surgical/product-103597-820814.html [USEMAP] Adobe Systems 2) Degrees of SCI complete lesion /according to the height of the injury/ cervical quadriplegia thoracic paraplegia incomplete lesion /specific syndromes/ anterior cord sy. central cord sy. posterior cord sy. Brown-Sequard sy. cauda equina sy. tetraplegia Související obrázek Související obrázek [USEMAP] Adobe Systems Cauda Equina Syndrome | Cauda Equina Syndrome (CES) Red Flag Signals Cauda Equina Syndrome Gray662.png H.Gray-Anatomy of the Human Body (1918) [USEMAP] Adobe Systems MMHE_06_093_01_eps Evaluation of spinal cord injury 3 functions: - motoric - sensoric - spinal reflexes The purpose of the evaluation is to determine the height and type of lesion. [USEMAP] Adobe Systems Evaluation of spinal cord injury [USEMAP] Adobe Systems [USEMAP] Adobe Systems CLINICAL EXAMINATION ̶ Aspection (defiguration, hematoma …) ̶ Palpation (rate and spreading of pain) ̶ Basic neurological assessment (Frankel scale, ASIA score) ̶ [USEMAP] Adobe Systems EXAMINATION - imaging methods Anamnesis Clinical examination Neurological status X-ray CT MRI [USEMAP] Adobe Systems Ortopedická klinika LF MU a FNB X- ray [USEMAP] Adobe Systems Fracture of the body and preventrtebral hematoma ! c spine fx + prevert prevertebral haematoma !!! X- ray [USEMAP] Adobe Systems 3D CT [USEMAP] Adobe Systems MRI [USEMAP] Adobe Systems OBJECTIVES OF THERAPY PAINLESSNESS FUNCTIONALITY (movement) STABILITY [USEMAP] Adobe Systems V. THERAPY conservative orthoses, corsets bed rest surgical Decompression of spinal cord and nerve structures + stabilization of the fracture by specific instrumentation Dorsal procedure Ventral procedure Combined Nucleus Medical Media (2020). Posterior spinal fusion [Digital image]. Retrieved from https://ebsco.smartimagebase.com/posterior-spinal-fusion/view-item?ItemID=68987 [USEMAP] A) B) Adobe Systems FIRST AID 1)FIXATION OF THE CERVICAL SPINE 2)EXCLUDE MOVEMENT OF T & L SPINE DURING MANIPULATION 3)TRANSPORT TO SPINAL CARE DEPARTMENT [USEMAP] priklady fixacie C chrbtice - faktom je ze obycajny schantz golier neimobilizuje dostatocne, podstatne lepsou fixacou su stranove opory kt. lepsie imobilizuju hlavu voci trupu Adobe Systems head immob2 head immob head immob3 C collar 1) Fixation of C-spine [USEMAP] dalsou fazou v reťazci je imobilizacia chrbtice - golier + back board a nasledny transport - setrny poranrenie miechy je jasnou indikaciou k co najsetrnejsiemu transporu - zvazit letecky transpor Adobe Systems 2) Imobilization of T & L spine during transport „in line position“ – minimalize patient handling ! Head fixation Body and limbs fixation Surface for transport - „back board“ risk of pressure ulcers - vacuum mattresses - suitable for longer transport log roll [USEMAP] tzv log roll manever - ako pacienta tocit a pri tom zachovat iun line poziciu, nutne zdorazn it, ze je tam potreba aspon 3 ludi Adobe Systems 2)„Log-roll“ manuever Log_Roll_2_small Log_Roll_3_small 1000+ Log Roll Stock Images, Photos & Vectors | Shutterstock [USEMAP] Adobe Systems 3) Transport spine immobilisation - heli picture P1100477 1 zm [USEMAP] Adobe Systems THERAPY conservative vs. surgical v TYPE of fracture v v grade of INSTABILITY v v NEUROLOGICAL find v [USEMAP] Adobe Systems V.A) CONSERVATIVE TREATMENT INDICATIONS: A0-B1.jpg üflection-compression fr. w/o instability (A0, A1, rarely A2) üno injuries to important ligaments or discs (stable ¨burst¨ fr. - A3, w/o kyfotisation) üonly instability in the bone part (Chance's fr.- B1) üOthers (contraindications of surgery) [USEMAP] Adobe Systems V.A) CONSERVATIVE TREATMENT ! unstable ¨burst¨ fr. (A3 + A4) ! flection-distraction fr. (B- group according to AO) ! translation injury (C- group according to AO) ! NEUROLOGICAL deficit (Surgery is necessary within 6 hours !!) CONTRAINDICATIONS: => SURGICAL TREATMENT !! Obsah obrázku text, mapa Popis byl vytvořen automaticky Obsah obrázku mapa, text Popis byl vytvořen automaticky [USEMAP] Adobe Systems Rest regime Collars - foam - Philladelphia P6154039 obr05 obr04 V.A) CONSERVATIVE TREATMENT [USEMAP] kvantifikacia ako jednotlive prostriedky imobilizuju C chrbticu- je vidno ze schantz stale ponechava cca 4ˇ% rozsahu hybnosti, ostavaju najma rotacie, preto je vhodne aj so Schantz golierom hlavu fixovat voci trupu, idealne su stranove opory Adobe Systems 60313_d philladelphia 214 t_1973 100 % 40-45 % 30-35 % 5-10 % [USEMAP] Adobe Systems V.A) CONSERVATIVE TREATMENT 04 CERVICAL spine •halo-cast, halo-vest •Minerva [USEMAP] Adobe Systems exh73701a.jpg Nucleus Medical Media (2020). Cervical spine fracture with application of halo ring stabilization [Digital image]. Retrieved from https://ebsco.smartimagebase.com/cervical-spine-fracture-with-application-of-halo-ring-stabilizatio n/view-item?ItemID=73352 [USEMAP] Adobe Systems Fitting the HALO traction 03080415 03080412 [USEMAP] Adobe Systems Související obrázek CONSERVATIVE TREATMENT THORACO – LUMBAR spine •Jewett (hyperextension) brace - featuring 3 support points: suprapubic, dorsolumbar and sternal - it consists of mass-produced parts, but MUST BE individually adapted to the patient's needs and dimensions! [USEMAP] Adobe Systems Související obrázek foto01 FOTO10 CONSERVATIVE TREATMENT Modifications of THORACO – LUMBAR fixation – according to the height of the injury : •From Th 6 ABOVE • •Th6 – L3 • •from L3 BELOW Jewett brace with cervical extension classic Jewett brace TLSO (Thoracic Lumbar Sacral Orthosis)- individual/ mass-produced 3211-boston_flexaform_2.jpg [USEMAP] Adobe Systems Cotrelův stůl Böhler‘s method of corection in hyperextension Cotrel‘s EDF frame (Elongation, Derotatin, Flection) [USEMAP] Adobe Systems plaster corsets 42317 CONSERVATIVE TREATMENT – history: [USEMAP] Adobe Systems sa01 sa07 Indications of corsets (except taumatic): - m. Scheurmann - Scoliosis (infantile e.g.) Others: - incompliance of pts (luxation of THA e.g.) [USEMAP] Adobe Systems [USEMAP] Adobe Systems V.A) CONSERVATIVE TREATMENT – results: [USEMAP] Adobe Systems 10006 •CORRECTION OF DEFORMIY - restore sagital balance of segment •STABILIZATION - anatomical shape of vertebra - anterior support if it's necessary •INTERVERTEBRAL FUSION - if it's necessary •DECOMPRESSION OF NEURAL STRUCTURES - direct or indirect (ligamentotaxis) • V.B) goals of SURGICAL TREATMENT : [USEMAP] Adobe Systems V. SURGICAL TREATMENT – posterior approach – principles of REPOSITION: C:\Users\Doma\Desktop\AO spine\obr.62.jpg 1) Dorsal (trans-pedicular) fixation (B) 2) 2)Lordotisation (C) 3)Distraction (D) 4)Stabilization - tightening the heads of screws [USEMAP] Adobe Systems V. SURGICAL TREATMENT – posterior approach – principles of DECOMPRESSION of spinal canal: DIRECT = LAMINECTOMY (B) HEMI-LAMINECTOMY with (C) or without facetectomy (E) ANTERIOR DECOMPRESSION (D) INDIRECT = LIGAMENTOTAXIS obr.12.jpg obr.14.jpg 1-s2.0-S0967586817309815-gr2.jpg Schematic view after unilateral hemilaminectomy for exposure of ... E [USEMAP] Adobe Systems V. SURGICAL TREATMENT – posterior approach – principles of TRANSPEDICULAR fixation: → targeting the screws oTranspedicular screws oRods oCross-link conector Související obrázek www.medicalexpo.com/prod/rti-surgical/product-103597-820814.html [USEMAP] Inserting the TP screws Adobe Systems Související obrázek 016 [USEMAP] Adobe Systems TRANSPEDICULAR SCREWS: CT scan of correctly inserted screws in situ. [USEMAP] Adobe Systems V. SURGICAL TREATMENT – posterior approach – principles of TRANSPEDICULAR fixation: ̶DIVERGENT instrumentation 09 10 Ouellet JA, Richards C, Sardar ZM, Giannitsios D, Noiseux N, Strydom WS, Reindl R, Jarzem P, Arlet V, Steffen T. Finite Element Analysis and Biomechanical Comparison of Short Posterior Spinal Instrumentation with Divergent Bridge Construct versus Parallel Tension Band Construct for Thoracolumbar Spine Fractures. Global Spine J. 2013 Jun;3(2):85-94. Divergent instrumentation is up to 30% stronger than parallel ! [USEMAP] Adobe Systems 14 Intersomatic fusion V. SURGICAL TREATMENT T-L SPINE – posterior approach – dorsal instrumentation + spongiolplasty: bokpo1 spongioplasty [USEMAP] Adobe Systems https://journals.plos.org/plosone/article/figure/image?size=medium&id=info:doi/10.1371/journal.pone .0223106.g001 SPONGIO plasty (Daniaux technic) Kanno H, Aizawa T, Hashimoto K, Itoi E. Enhancing percutaneous pedicle screw fixation with hydroxyapatite granules: A biomechanical study using an osteoporotic bone model. PLoS One. 2019 Sep 26;14(9):e0223106. doi: 10.1371/journal.pone.0223106. eCollection 2019. PubMed PMID: 31557234 Milled bone-gaft [USEMAP] Adobe Systems exh5316b.jpg V. SURGICAL TREATMENT T-L SPINE – combined approach – dorsal instrumentation + ventral spongiolplasty with bone strutgraft: Nucleus Medical Media (2020). Surgical decompression and stabilization of the spine [Digital image]. Retrieved from https://ebsco.smartimagebase.com/surgical-decompression-and-stabilization-of-the-spine/view-item?It emID=76291 [USEMAP] Adobe Systems V. SURGICAL TREATMENT T-L SPINE – anterior approach – ventral instrumentation + augmentation of ventral column (Harm's cage vs. Implant): 10012 Nucleus Medical Media (2020). Lumbar spine fracture with surgical repair [Digital image]. Retrieved from https://ebsco.smartimagebase.com/lumbar-spine-fracture-with-surgical-repair/view-item?ItemID=11652 [USEMAP] Adobe Systems V. SURGICAL TREATMENT T-L SPINE – anterior approach – ventral instrumentation + augmentation of ventral column (Harm's cage vs. Implant): 10008 10009 [USEMAP] Adobe Systems V. SURGICAL TREATMENT T-L SPINE – combined approach – dorsal + ventral instrumentation + ventral column augmentation: 21 [USEMAP] Adobe Systems 36 [USEMAP] Adobe Systems 24 Harm‘s cage ventral instrumentation dorsal instrumentation [USEMAP] Adobe Systems 30 Synex - expandable implant [USEMAP] Adobe Systems 29 [USEMAP] Adobe Systems CERVICAL SPINE INJURY oComminutive fr. of the body o odiscoligamentous lesions disks and ligament o oCombined - tear drop radiopaedia.org/cases/flexion-teardrop-fracture-illustration?lang=us [USEMAP] Adobe Systems INJURY OF THE UPPER C-SPINE Ø fractures of condyles of occipital bone (C0) Ø atlantooccipital dislocations (C0-C1) Ø atlas fractures (C1) Ø atlantoaxial dislocations (C1-C2) Ø fractures of the epistropheum (C2) [USEMAP] Adobe Systems Synthes CerviFix 10028 > kjn-15-55-g001 Korean J Neurotrauma. 2019 Apr;15(1):55-60. https://doi.org/10.13004/kjnt.2019.15.e3 V. SURGICAL TREATMENT – UPPER C- SPINE – atlantooccipital dislocation : Dorsal O-C fusion [USEMAP] Adobe Systems V. SURGICAL TREATMENT UPPER C- SPINE: – atlas fractures (disruption of transvers ligamnet): atlantoaxial screw fixation and fusion (Magerl C1 and C2 transfacet screw technique) Obsah obrázku text Popis byl vfhfhdfytvořen automaticky Gehweiler classification (1980) Schleicher P, Pingel A, Kandziora F. Safe management of acute cervical spine injuries. EFORT Open Rev. 2018 May 21;3(5):347-357. doi: 10.1302/2058-5241.3.170076. eCollection 2018 May. PubMed PMID: 29951274 Jefferson‘s fr. = type 3A (stable), 3B (unstable) !! Types 1,2,4,5 – non-operatively [USEMAP] Adobe Systems ODONTOID FRACTURES OF C2 https://boneandspine.com/dens-odontoid-fractures/ F1.large.jpg Anderson and D’Alonzo Classification of Odontoid Fractures Type II = NECESSITY OF SURGERY especially: -In pts age > 50 (high risk of non-union) -Fracture dispacement ≥ 5mm -Neurological deficit -Comminution - [USEMAP] Adobe Systems CSpineOpenMouth spine-c_1_anatomy Transoral (Sandberg) projection Type III odontoid fractures: A subgroup analysis of complex, high ... [USEMAP] Adobe Systems 10001a https://d3i71xaburhd42.cloudfront.net/7cf234057e4e93f1757fc7837aebf4ce8e8e8a7b/5-Figure5-1.png ODONTOID FRACTURES OF C2 V. SURGICAL TREATMENT UPPER C- SPINE – fractures of the epistropheum : dorsal / ventral appproach Harm‘s C1-C2 construct [USEMAP] Adobe Systems HANGMAN FRACTURE – traumatic olisthesis C2 V. SURGICAL TREATMENT UPPER C- SPINE – fractures of the epistropheum : dorsal / ventral appproach SCI.jpg [USEMAP] Adobe Systems Jeong DH, You NK, Lee CK, Cho KH, Kim SH. Posterior C2-C3 Fixation for Unstable Hangman's Fracture. Korean J Spine. 2013 Sep;10(3):165-9. doi: 10.14245/kjs.2013.10.3.165. Epub 2013 Sep 30. PubMed PMID: 24757480 Dorsal – TP fixation [USEMAP] Adobe Systems Ventral procedures - Plating - Discs / vertebral bodies replacement Dorsal procedures - TP stabilzations Combinations 3036 3038 V. SURGICAL TREATMENT LOWER C- SPINE – ventral / dorsal appproach Obsah obrázku stůl, vsedě, malé, dort Popis byl vytvořen automaticky www.bbraun.com/content/dam/b-braun/global/website/products-and-therapies/degenerative-spinal-disord ers/O85002_Aesculap_XP.pdf.bb-.95195616/O85002_Aesculap_XP.pdf [USEMAP] Adobe Systems exh5843.jpg Nucleus Medical Media (2020). Surgical decompression and stabilization of the spine [Digital image]. Retrieved from https://ebsco.smartimagebase.com/surgical-decompression-and-stabilization-of-the-spine/view-item?It emID=76291 ACDF = Anterior Cervical Decomresion and Fusion [USEMAP] Adobe Systems Ventral - ACDF [USEMAP] Adobe Systems INTERSOMATIC FUSION C6/7 https://www.zimmerbiomet.com/content/dam/zimmer-biomet/medical-professionals/spine/roi-c-cervical-c age/ROI-C%20Product%20Brochure.pdf [USEMAP] Adobe Systems TRABECULAR METAL [USEMAP] Adobe Systems Dorsal – TP fixation [USEMAP] Adobe Systems VERTEBROPLASTY MISS (Mini Invasive Spine Surgery) KYPHOPLASTY - pain reduction 70-90% -fracture stabilization -does NOT adjust vertebral height -HIGH pressure cement application ! -HIGH risk of leaking cement (65%) !! ̶could be outpatient - - pain reduction 90% - fracture stabilization - adjustment of vertebral height especially in acute fractures -creation of cavity reduces the risk of leakage (10%) - general anaesthesia https://thejns.org/spine/view/journals/j-neurosurg-spine/98/1/full-spi_2003_98_1_0021.fig002.jpg Fourney DR, Schomer DF, Nader R, Chlan-Fourney J, Suki D, Ahrar K, Rhines LD, Gokaslan ZL. Percutaneous vertebroplasty and kyphoplasty for painful vertebral body fractures in cancer patients. J Neurosurg. 2003 Jan;98(1 Suppl):21-30. [USEMAP] Adobe Systems http://www.painmanagementexperts.com/vertebroplasty-for-compression-fractures/ VERTEBROPLASTY – potential risks [USEMAP] Adobe Systems Výřez obrazovky Výřez obrazovky Výřez obrazovky Výřez obrazovky VERTEBROPLASTY [USEMAP] Adobe Systems Screen Clipping Screen Clipping KYPHOPLASTY [USEMAP] Adobe Systems PERCUTANE FIXATION & DECOMPRESSION MISS (Mini Invasive Spine Surgery) Intraoperative photographs show simultaneous insertion of two Sextant Fixators. Use of rod templates to determine the length of the rod (A). Inserted via stab incisions. Conventional rod distractors are used for added distraction force to the posterior wall fragment (B) and Rods are attached to the Sextant Introducer (C). Final approachrelated injury is minimal as demonstrated by these < 2 cm long stab incisions for a bisegmental internal fixator (D) Schmidt OI, Strasser S, Kaufmann V, Strasser E, Gahr RH. Role of early minimal-invasive spine fixation in acute thoracic and lumbar spine trauma. Indian J Orthop. 2007 Oct;41(4):374-80. doi: 10.4103/0019-5413.37003. [USEMAP] Adobe Systems PERCUTANE FIXATION & DECOMPRESSION MISS (Mini Invasive Spine Surgery) ̶ MIS TLIF procedure Kim C, Siemionow K, Anderson D, Phillips F: The current state of minimally invasive spine surgery, in Egol K, Tornetta III P, eds: Instr Course Lect, 60. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2011, 353-370. Nucleus Medical Media (2020). Miniminally invasive disc removal [Digital image]. Retrieved from https://ebsco.smartimagebase.com/miniminally-invasive-disc-removal/view-item?ItemID=22128 [USEMAP] 23.jpg 24.jpg Courtesy of prof. Kevin Foley [USEMAP] 26.jpg Courtesy of prof. Kevin Foley [USEMAP] Adobe Systems TRAUMATIC VI. INSTRUMENTATION OF THE SPINE DEGENERATIVE & DEFORMITY ̶Instrumentation should to restore physiological conditions (including mobility) ̶Intervertebral fusion is NOT perfromed (or rarely) ̶The instrumentarium is usually removed after fractures have healed ̶The instrumentation helps to create new anatomical-biomechanical conditions (deformity correction, slip reduction, prevention of iatrogenic instability, etc.) ̶Intervertebral fusion is the MAIN OBJECTIVE OF SURGERY (= immobilization of operated extent!) ̶Instrumentarium stays in the body for rest of life Nucleus Medical Media (2020). Posterior spinal fusion [Digital image]. Retrieved from https://ebsco.smartimagebase.com/posterior-spinal-fusion/view-item?ItemID=69744 [USEMAP] Adobe Systems Understanding the Risks of Spine Surgery Výřez obrazovky Complications of surgical treatment ØIncreased blood loss - epidural venous plexus, open cancellous bone Ø ØWrong placement of transpedicular screws - medial (spinal canal) or caudal (intervertebral foramen) Ø ØInjury of the dural sac - risk of developing a CSF fistula Ø ØInfection - early, late www.pauljeffordsmd.com/understanding-the-risks-of-spine-surgery [USEMAP] Adobe Systems [USEMAP]