Case Study: Management Of 58-Year-Old

Female With Burst Fracture Of T6 Vertebra

A 58-year-old female patient, who was involved with a fall where she slipped and landed on her back on some stairs.  She was seen at another hospital where an incomplete workup was done and she was sent home. Unfortunately, her pain became worse and she was unable to carry out her activities of daily living despite aggressive medical management. 

She presented to the emergency room at the Hospital in excruciating amounts of pain.  An imaging workup revealed a burst fracture of the T6 vertebral body with more than 50% loss of height and acute angulation at that level, which worsened with flexion and extension.

The pain was described as sharp pain with a severe intensity (10/10). The pain was non-radiating and located in the upper mid-back. The pain was worse with movements. There was a paraspinal tenderness.

She had no power sensory deficit in the bilateral upper limbs and the lower limbs. There was no bowel or bladder dysfunction. The deep tendon reflexes were present and symmetrical bilaterally. Babinski reflex was indeterminate and Hoffman’s reflex was absent.

Preoperative X-ray of the Thoracolumbar Spine in Lateral View

Preoperative X-ray of the Thoracolumbar Spine in Lateral View.

CT revealed moderate acute wedge compression fracture associated with the T6 vertebral body.  The posterior cortex of the T6 vertebral body mildly impresses upon the anterior margin of the thoracic dural sac.  Minimal hematoma is situated between the T6 vertebral body and the surrounding pleura.

There was a normal configuration of the remaining thoracic vertebral bodies. The thoracic disc spaces are not narrowed. Posterior disc bulges or herniations are not demonstrated. The narrowing is not associated with the thoracic neural foramina.

Preoperative CT Scan of the Thoracolumbar Spine in Axial Section at T6

Preoperative CT Scan of the Thoracolumbar Spine in Axial Section at T6

CT Sagittal and coronal Sections CT Sagittal and coronal Sections 2

CT Sagittal and coronal Sections.

Given the acute fracture with biomechanical instability and unremitting back pain with a burst fracture compromising the spinal canal, we considered this a neurosurgical emergency and we offered the patient stabilization.  She understood all the risks, benefits, and alternatives to surgery and she agreed to give informed consent for spine surgery.

PREOPERATIVE DIAGNOSIS:  T6 burst fracture with acute kyphosis after a fall.

POSTOPERATIVE DIAGNOSIS:  T6 burst fracture with acute kyphosis after a fall.

OPERATION:

  1. T6 kyphoplasty.
  2. T5 to T7 segmental instrumentation.
  3. T5 to T7 posterior arthrodesis and fusion with the use of morselized autograft and allograft.
  4. Use of intraoperative fluoroscopy.
  5. Use of intraoperative neuromonitoring.
  6. Bilateral transpedicular biopsies.

ANESTHESIA:  General endotracheal anesthesia.

ESTIMATED BLOOD LOSS:  50 mL.

PROCEDURE IN DETAIL:  The patient was identified in the preoperative holding area and then brought back to the operating room where he was induced under general anesthesia and intubated.  A foley catheter was inserted and the patient was turned prone after neuromonitoring electrodes were attached. 

He was secured onto an open bottom Jackson table and all of his pressure points were padded appropriately.  The patient’s thoracic region was prepped and draped in the usual sterile fashion after using fluoroscopy to identify the level of operation.  A time-out was called and preoperative antibiotics were dosed.

Intraoperative fluoroscopy images Intraoperative fluoroscopy images 2

Intraoperative fluoroscopy images.

We marked a midline incision with an indelible marker and then used a #10 blade to incise the skin down to the level of the subcutaneous fat. 

At this point, we used Bovie cautery to complete our dissection exposing the T5 through T7 lamina and we kept all the posterior elements intact.  Using the NuVasive Maxcess retractor system, we held the muscle and skin edges apart.

Intraoperative fluoroscopic images 3 Intraoperative fluoroscopic images 4

Intraoperative fluoroscopic images.

We employed fluoroscopy once again to check our level of operation and extended our incision slightly in the cephalad direction.  At this point, we confirmed the level of the T6 vertebral body and started our open kyphoplasty. 

First we inserted the Jamshidi needles under fluoroscopy through the pedicles to the vertebral body.  We then inserted the cannulas for the kyphoplasty system bilaterally and obtained transpedicular biopsies, which were sent for histopathology.

At this point, we inserted the balloon on the patient’s right side and inflated it with contrast up to approximately 380 mmHg and this was checked constantly under both AP and lateral fluoroscopy simultaneously. We inflated the balloon to approximately 2 mL maintaining the pressure and to ensure that we remained within the confines of the vertebral body with the balloon inflation. 

We did this then on the left side as well. The balloons were then deflated and removed and cement was introduced in a semi-liquid state, first on the right side, and then on the left side. Approximately 4 mL of cement was introduced from the right side and approximately 1.5 mL of cement was introduced from the left side. 

There was an alarming amount of fracture at this level and the cement was maintained posterior to the anterior border of the vertebral body and anterior to the posterior border of the vertebral body. There was a small amount of extravasation of cement into the superior and inferior endplates.

At this point, given the location of the fracture and the severity, we then moved to finish our instrumented fusion from T5 to T7. The pedicles of T6 were cannulated by using the high-speed drill to create a starting point and then we used the pedicle gearshift under fluoroscopy to enter the pedicles. 

Using anatomic trajectories, we then tapped these pedicles to start and inserted 4.5 x 30 mm pedicle screws on both sides. We confirmed our trajectories using fluoroscopy and triggered EMG. We did the same thing for both the T5 and T7 pedicles probing them using Lenke gearshifts and under fluoroscopy after creating our pilot hole with normal anatomical starting points with the high-speed drill. We inserted 5.5 x 40 mm screws under direct fluoroscopy at the T5 and T7 levels and then applied 5.5 x 65 mm rods, which were secured with caps screws and locked into position. 

All six screws were stimulated using trigger EMGs and found to be in a safe position. We then obtained both the final AP and lateral x-rays to ensure the proper positioning of the screws. The wound was washed out copiously with bacitracin irrigation and then the high-speed drill was used to decorticate the bone and the bone chips obtained were then gathered, morselized, and used for autograft. 

We also applied cancellous chips and DBX mix to create the posterior fusion mass from T5 to T7.  We applied a small amount of vancomycin powder and then closed the wound in layers using #0 Vicryl sutures in the muscle. We created fascial advancement flaps over this region as it was the apex of the curve and to decrease tension on the wound. 

The fascia was closed tightly with #0 Vicryl sutures and 2-0 Vicryl sutures were then used in the subcutaneous tissue followed by Monocryl at the level of the skin in a subcuticular fashion.  The incision measured approximately 8.5 cm and it was dressed with Steri-Strips and an island dressing.  No drains were applied.  The patient was turned supine on to his stretcher and extubated without any issues.  Neuromonitoring signals stayed stable throughout the case and all counts were correct at this end of the case.

Disclaimer – Patient’s name, age, sex, dates, events have been changed or modified to protect patient privacy.

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I had an extremely friendly and personalized medical consult with Dr Karkare. Dr Karkare was very knowledgeable and very professional. His communication skills was extremely good and explained my medical condition in very simple words. The office visit was very helpful in understanding my medical condition. Thank you Dr Karkare
Padmanabhan Nagaraj
20:49 25 Sep 23
Dr. Karlkare and his staff were excellent. Dr. Karkare explained everything clearly and took his time getting to know my Dad.
Anna Acker
22:46 07 Sep 23
Dr Vedant Vaksha had done emergency surgery in 2020 after a traumatic injury.His office at Complete Orthopedics handled the continued care thereafter.Dr V and his staff had been Professional and friendly throughout the process, taking the time to explain all the questions on how to proceed and what to expect.Whenever I needed to speak with Dr V or the office they were a phone call away, without waiting or calling several numbers like in so many other medical offices.The office was accommodating to scheduling to my needs at all times. Dr Vedant Vaksha earned the following5 out of 5 stars, highly recommended.
John Kuey
20:58 05 Sep 23
Dr. Vaksha helped me recover from an injury. I am very thankful that he took the time to explain the best treatment for my injury. Also thankful for the wonderful office staff!
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22:30 02 Aug 23
The office is wonderful!… Dr Paresh was very helpful and attentive and made my sister in laws recovery so much better.. Thank you for everything
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17:48 14 Jul 23
The ladies are very welcoming, the service is great, the doctor is very professional and caring and the building is super clean. I really like to come here, the atmosphere is very friendly... Come and you will love it too.
Joan Carasco
14:41 30 Jun 23
Dr. Nakul Karkare is awesome! And patriotic! Thank you, Dr. Karkare for displaying the American Flag in your waiting room, honoring and mourning our military personnel, this Memorial Day, who died while serving in the United States Armed Forces.
Dave
00:52 30 May 23
Excellent and skilled orthopedic practice specializing in joint replacements. Dr Karkare was trained at the Hospital for Special Surgery and has excellent results, as do his associates!! Would gladly refer family members to the practice!!
Eclectic54
00:24 30 May 23
I had such a wonderful experience with Complete Orthopedics in Stony Brook. Not only did Dr. Kuo fix my broken wrist with such kindness and care, but the office staff, including Billing, Reception and the X-Ray Technician, was always so helpful, going out of their way to ensure that each patient felt welcome, answering any questions with a smile, and ensuring any issues with insurance/billing were handled with the utmost professionalism. I highly recommend their practice!
Victoria DeMatteo
19:49 10 May 23
I'm very happy St. Catherine's sent me to this office for treatment after I broke my collar bone! Unfortunately the break was too severe to repair on its own and I had to have it rebuilt a week after the injury. Dr. Vaksha did a great job fixing it. I'm three months out, and I have full use of the arm and shoulder. The whole office staff is very professional, accommodating, and welcoming. I hope to not need orthopedic services again, but Dr. Vaksha will be my number one choice if I or anyone in family suffers such am injury.
Tina Rivera
20:42 08 May 23
No one likes going to the doctor. But these people make it painless. I go for knees, hips and shoulders. At almost 70 Complete Orthopedics keeps my active life style running smoothly. Whether chasing my Grandson and even surfing again, I highly recommend them!!
Thomas Slavin
15:02 02 Mar 23
Dr. Kuo knowledgeable and competent surgeon- very good experience and more importantly great result.
Joseph McCoy
21:23 25 Feb 23
Dr Vaksha was so kind and helpful. He took extra time with us and explained things so thoroughly. Highly recommend. Office very clean.
Susan Bosinius
20:20 19 Feb 23
Dr Vaksha, is a great doctor very professional knows what he talking about. Treat patient with upmost respect. Thank You
Troy Spencer
16:46 19 Jan 23
Dr. Karkare is an amazing doctor, very caring and attentive, the girl at the front desk is very kind and helpful. .elizabeth .thank you so much .
blanca ventura
21:32 26 Oct 22
Been going to this place before my accident and after I had my knee surgery. So happy how I been treated and how well I am getting. Thank you all and specially Dr. VAKSHA for everything and getting back on track.
Ita Opico
19:01 25 Oct 22
Love this place From the minute I called I was treated kindly. When I arrived The Dr saw me right away he was compassionate and ordered the appropriate tests for me. I came back in for my follow up and had the same great experience.
Christine Rostock
21:28 23 May 22
Dr Vaksha and Dr karkare are 2 of the best orthopedic doctors around my wife Susan had a very serious broken ankle in March of 2019 she didn't think she was going to walk again Dr vaksha did an excellent surgery on her ankle he said it was his toughest he ever did he put a lot of hardware in her ankle and told her she would be alright she made remarkable recovery thanks to his surgery as of now she regained 100 percent use of her ankle she would highly recommend him to anyone. My own experience with Dr karkare has been wonderful he takes his time with you listens to what you have to say and prescribes various treatments and is very caring I would highly recommend him to anyone I would give both doctors a 10 plus rating we are very happy with them the best.
Harry Jones
23:31 19 May 22
Complete orthopedics is a wonderful place to go when you hurt or injured a great staff and wonderful doctors very knowledgeable and helpful I would recommend this place to all of my family and friends that is in me of orthopedic care I give them 10 thumbs up
Wayne Pemberton
17:39 18 May 22
The staff is very professional and helpful. Dr. Vaksha is excellent. He takes time to listen and offer suggestions to help you get better. I’m very thankful and happy to be a patient here at Complete Orthopedics.
Phoenix Rising
19:54 16 May 22
Dr.Karkare is the best. He listens to everything and explains everything I recommend him to everyone. I am so happy he is my doctor.
Myrna James
00:48 13 May 22
Dr.Kuo is amazing very attentive,caring,and passionate and staff is awsome too.Thank you for everything Dr.kuo.
Erick Murillo
23:17 12 May 22
I was in a car accident November 1 I was referred to Dr. Vaksha For shoulder surgery . I he was amazing he made me feel very comfortable and explained everything that was going to happen from surgery all the way through my physical therapy highly recommend Dr. Vaksha
Yolanda Ojeda
19:37 09 May 22
My appointment with Dr. Vaksha was amazing. Dr. Vaksha was very thorough and kind. I would refer this office to anyone who needs a great orthopedic doctor.
John Senechal
19:54 05 May 22
Scheduling my appointment was quick and easy. The staff was super friendly and down to earth. I was seen on time. The appropriate test, “x-rays” were taken before the conversation with doctor, something I really liked, test for analysis and conversation was done upfront. Dr. V had a great personality and was no BS, straight forward diagnosis and a play on next steps. I am happy I found them and would refer them to friends and family.
Sam
00:46 03 May 22
I have seen Dr. Kuo two times already and he's awesome along with his staff. Very friendly office and I'm glad to be a patient here.
Camaris A
20:01 28 Apr 22
Amazing team!! Very caring, profesional, and friendly!! Dr. Kevin Kuo, you are the best, very passionate, caring, and helping thank you for getting me better and being so kind to me! Elizabeth you the best thank you for you help always and you big smile and positive actitud❤️🙏🏼
breidy valerio
19:01 22 Apr 22
The staff is truly exceptional, they make you feel comfortable and welcomed. The doctors are amazing,always professional, compassionate and great listeners.
Elizabeth Collado
03:25 09 Apr 22
What a great place! The place is clean and organized.The staff is wonderful. Setting up physical therapy is right there as well.I'm so glad I found this place.
Donna Anne
22:45 05 Apr 22
This was my 1st time breaking something in my 27 years on this planet. I was recommended here by a friend Dr. Vashka helped me from day 1 and still continues to check in on me and my healing ankle. Would highly recommend
tyron davis
16:06 01 Apr 22
Brand new office, same great doctors! Rooms are clean, plenty of parking, physical therapy attached, Dr. Karkare and his staff are awesome. Thank you!
Emily B
02:49 24 Mar 22
Dr.VAksha is the best, I love the way he treats me as his patient, he is caring,understanding and very attentive to my needs
Mirna Caballero
14:53 03 Mar 22
Great staff. Dr. Vaksha is awesome and takes the time to listen to his patients. He is very compassionate. I would highly recommend this office.
Bebe Doyle
01:24 23 Feb 22
After suffering from a severe ankle injury Dr. V was able to help me heal and return back to work completely to a job where I stand for 12 hours a day. The office is very clean and I appreciated the reminders of my appointments via phone call and through text. The patient portal made it easy for me to access all my documents including work notes. The office staff is wonderful and Rebecca was able to schedule me with a busy schedule and awesome at answering all of my questions including referring me to a great physical therapy office. I highly recommend this office to anyone who’s looking for knowledgeable and kind orthopedic office.
Elizabeth Birchwell
21:31 28 Jan 21
The staff here are great, I was seen at the time of my appointment and was well taken care of!
Shaun Berry
18:14 07 Jan 21
They are an excellent practice. The front and back office people are amazing and so helpful. Rebecca is such a kind and understanding person. I had an issue with paperwork and she cleared it right up. Dr. Karkare is very knowledgeable, helpful, and caring.
Matt S.
19:31 18 Nov 20
Rebecca K. - What a true burst of sunshine. Very friendly and definitely an asset to the practice!
Laura Aston
18:17 17 Nov 20
Great experience, the Doctor is nice but the staff is incredible. I worked with Linda, who was profession and assisted me beyond what any person has done at other practices. Complete Ortho should be complimented for having such a person on their staff.I highly recommend this place!!!
Joe Allen
17:26 17 Nov 20
Linda and Becca they are so good ever time I come they are very nice I would tell everyone I no to come to this office..
Barbara Victor
16:45 17 Nov 20
I was rear ended in an auto accident , Dr Vashka was recommended by a friend of mine .I was experiencing Back , neck , and shoulder pain . After a thorough examination and given exercises to do at home , I am feeling much better , and I ended up avoiding surgery . The staff at Complete Ortho is extremely attentive and show great care when making an appointment and are very friendly and i never waited more than 5 minutes for my appointment . So I would strongly recommend Complete Orthopedics for any aches and pains that one might be experiencing.....
Bill Becht
04:44 17 Nov 20
It was the afternoon of Friday Sept. 24. We were in Pt. Jefferson and my wife, Mary Ann, broke her hip. We went to Mather Hospital and it was determined that she would have to have an operation to have it repaired. This would be her third time under the knife in the past year. It just so happened that we were very fortunate enough to have Dr. Karkare, who was on standby, perform the surgery. He put in a rod and two screws in her hip. She spent a few days in the hospital and then went to Gurwin rehabilitee for another few weeks.It has now been almost six weeks and we both worked the election the other day. If it wasn’t for Dr. Karkare’s expertise she never would have been able to work. She is able to walk with a walker and is doing physical therapy three times a week.We can not thank the doctor enough for the compassion and dedication that he puts into his work. It allows Mary Ann do the things that she likes to do, even on a limited basis for a while. I know that with her will, perseverance and the great work that the surgeon performed she will be back on her feet in no time.Sincerely:John V. PlumpEast Northport, NY 11731
Jack Harris
14:36 06 Nov 20
In the year of 2018 I was referred to Dr. Karkare because I was experiencing severe knee joint pain. After exhausting physical therapy and trying to labor through the pain, I had to make a quality of life decision. Total knee replacement was the only viable option. Dr. Karkare made my decision easy as he walked me through the whole process from surgery to recovery.On 12/13/19 ( Friday the 13th) I enter Lenox Hill Hospital in great hands. From the time I entered Dr. Karkare’s office for the first time until now, his staff has been amazing. Andrea the medical coordinator walked me through all the paper work and necessary preparations for the surgery. Courtesy and kind would be an understatement. Dr. Karkare went over and beyond from the wellness checks and phone calls all to assure me that I was important to him. This was the right decision no pain and no limp. Complete Orthopedics should be your choice!
Kenneth Randolph
22:18 25 Sep 20
Dr. Vadshka has a great bedside manner. He really takes his time and explains treatment options.
T Lee
12:33 09 Sep 20
I suffered with pain in both knees for years. My orthopedic doctor kept recommending knee replacement . I fought it for years, as I was just afraid. When I had no choice and could barely walk , it was recommended I see Dr. Karkare. We set up a consultation and my wife and I left his office feeling totally confident and comfortable with moving ahead with the surgery. He explained everything to us, and the office staff set everything up for us and made the process easy. So about one month after our initial meeting I had the first knee done. I was up walking mere hours after the surgery, and on the workout machines the next morning. I went home two days after the surgery, and yes walked my daughter down the aisle at her wedding only one week after the surgery without even a cane! Three months later I had the other knee done and went home the very next day. Dr. Karkare put my fears to rest . I would highly recommend him. His expertise gave me my life back. Thank you Dr. Karkare.SincerelyVito Congro
Ethel Congo
23:58 12 Aug 20
Dr Rhodin really cares for his patients. When I see him he makes sure to review my progress in detail.
Micki Cahill
15:03 08 Feb 20
My mom had a total hip replacement by dr karkare. He is the BEST orthopedic doctor.Her incision is almost invisable.She is going back for her other hip next week. The office staff is the best, love Andrea.You wont find a better doctor.
Ryan
21:06 13 Jul 18
There is no better Orthopedic doctor you will find. Broke my ankle three places on a Saturday. Called Dr. Karkare. He had is team ready at the hospital and operated on me within 6 hours after my injury. Now After 3 months of great care by him and his staff, I am walking to normalcy.
Spacecom Tel
04:13 23 Mar 18
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My name is Dr. Suhirad Khokhar, and am an orthopaedic surgeon. I completed my MBBS (Bachelor of Medicine & Bachelor of Surgery) at Govt. Medical College, Patiala, India.

I specialize in musculoskeletal disorders and their management, and have personally approved of and written this content.

My profile page has all of my educational information, work experience, and all the pages on this site that I've contributed to.