A Novel Reduction Manoeuver for Highly Unstable Thoraco- Lumbar Fracture Dislocation: Technical Note

Fracture dislocations of thoracic and lumbar vertebrae are commonly encountered and are a result of high velocity trauma (Fig 1) [1] . Surgical treatment poses challenge in terms of safe and effective reduction maneuvers. Various techniques have been diversely described in literature for reducing highly unstable thoracolumbar fractures. We describe a novel reduction maneuver which is slow, steady and graded technique using four parallel rods and vice grips. We believe that this technique is easy to perform and reproducible, tailor made and maintains good sagittal and coronal balance of spine in such unstable situations. These surgeries are done for mainly early mobilization with a stable spine understanding that the neurology will rarely improve. Surgical technique: 1) The patient is positioned prone very carefully taking care to prevent further neurological insult. Maintaining the lumbar lordosis can help in partial vertebral reduction. 2) Standard Posterior midline approach taken and exposure done. Utmost care taken at fractured vertebrae level to prevent neural injury. 3) Pedicles identified and screws are inserted at two levels above and below the level of dislocation bilaterally (Fig 2a). Role of assistant surgeon is very important in view of giving the counter traction and support the completely shattered spine while inserting pedicle screws. We have seen the shortening of the column because of overlapping of two diseased ends. 4) Two small rods are applied: one below the level of injury and other above (Fig 2b). Once the rods are secured, a three step maneuver is performed. Two rods are held securely by two vice grips and gentle, slow and sustained distraction applied across the vertebrae (Fig 2c). With distraction maintained the surgeon gently pushes the anteriorly displaced proximal column and pulls the distal column (commonly encountered situation where proximal column is anteriorly displaced with respect to distal one) leading to unlocking and disimpaction of dislocated vertebrae. Now opposite forces are applied pulling the proximal column and pushing the distal column to achieve reduction of facet joints bilaterally (Fig 2d). The reduction is checked under fluoroscopy. Sham rod is immediately fixed before the check image. 5) Care should be taken to avoid unnecessary jerky and violent movements. Any bony or soft tissue structures obstructing the reduction should be cleared before attempting reduction. 6) The operating surgeon maintains the reduction and the assistant applies rod on the opposite side and temporarily fixes the A Novel Reduction Manoeuver for Highly Unstable ThoracoLumbar Fracture Dislocation: Technical Note