Measurement of kyphosis and vertebral body height loss in traumatic spine fractures: an international study

Predictive factors associated with the onset of Kummell's disease

BACKGROUND CONTEXT

Kummell's disease (KD) is a long-term complication of vertebral compression fractures, resulting in vertebral collapse and kyphosis. Despite its clinical significance, the underlying mechanisms remain poorly understood.

PURPOSE

To identify the predictive factors for the onset of KD and provide clinical insights for early screening and intervention in KD patients.

DESIGN

Retrospective study.

PATIENT SAMPLES

A total of 170 patients were included, comprising 66 with KD and 104 with old compression fractures.

OUTCOME MEASURES

Relevant clinical and imaging data were collected retrospectively. Spinal imaging indicators were also assessed.

METHODS

We analyzed clinical data from patients admitted from May 2021 to April 2024 for vertebral compression fractures. Sixty-six diagnosed with KD based on clinical and imaging criteria were identified as the case group. The control group consisted of 104 patients with vertebral compression fractures who underwent conservative treatment and showed no signs of KD upon reexamination one year later. The clinical data included gender, age, bone mineral density (BMD), history of long-term smoking, alcohol abuse, hypertension, diabetes, coronary heart disease, osteoporosis, glucocorticoid use, previous vertebral compression fracture segment and vertebral compression ratio, Cobb angle, vertebral fracture morphology and disc degeneration grade. Independent predictive factors for KD were determined using multivariate binary logistic regression. Receiver operator characteristic (ROC) analysis and Kaplan-Meier plot were used to assess the diagnostic efficiency of parameters for predicting the occurrence of KD.

RESULTS

T-tests and Chi-square tests identified significant differences between groups in age, BMD, alcohol abuse, history of hypertension, history of diabetes, history of osteoporosis, history of glucocorticoid use, vertebral compression segment, Cobb angle, vertebral compression ratio, vertebral compression morphology, and disc degeneration grade between the two groups. Binary logistic regression revealed six independent predictors of KD: age, BMD, history of osteoporosis, vertebral compression rate, vertebral compression morphology, and disc degeneration grade. ROC demonstrated that age ≥ 70.5, BMD (T-score) ≤ - 3.65 and a vertebral compression ratio ≥ 29.9% were strongly correlated with KD (P < 0.001). Kaplan-Meier plot showed that most cases of KD occurred within one year after initial vertebral compression fractures, with significant differences in KD incidence observed across different disc degeneration grades (Log-rank test, P < 0.001).

CONCLUSIONS

The risk of developing KD is heightened in patients with the following predictive factors are present: (1) Age ≥ 70.5 years; (2) BMD (T-score) ≤ - 3.65; (3) History of osteoporosis; (4) Vertebral compression ratio ≥ 29.9%; (5) Wedge-shaped vertebral compression morphology; and (6) Grade III or higher disc degeneration. Early screening and regular follow-up of high-risk patients are recommended for timely preventive interventions.

Redefining physiological whole-body alignment according to pelvic incidence: normative values and prediction models

BACKGROUND CONTEXT

Spinopelvic alignment assessment needs to account for pelvic incidence (PI).

PURPOSE

This study aimed at providing normative values for commonly used parameters in whole-body alignment analysis based on PI.

DESIGN

Multicentric prospective study.

PATIENT SAMPLE

This study included healthy volunteers with full-body biplanar radiograph in free-standing position.

OUTCOME MEASURES

All radiographic data were collected from 3D reconstructions: Sagittal vertical axis (SVA), T1 pelvic angle (TPA), spino-sacral angle (SSA), sagittal odontoid-hip axis angle (ODHA), pelvic parameters, sacro-femoral angle (SFA), knee flexion angle (KFA), ankle flexion angle (AA), Pelvic shift (PSh), lumbar lordosis (LL), thoracic kyphosis (TK) and cervical lordosis (CL).

METHODS

Population was divided into five groups according to PI. Normative values were described for each group. Linear regressions including age and PI provided prediction formulas for PT, TPA, SSA and SFA.

RESULTS

642 subjects were included. Mean age was 37.7 ± 16.3 years (range: 18-90). Mean PI in the cohort was 49.3 ± 9.5°. LL, PT, SFA, SSA and TPA correlated with PI and age. ODHA, TK, CL and the other lower limb parameters were not associated with PI. All normative values across PI groups are provided for segmental, regional and global alignment parameters. Prediction formulas were: PT=-12.7 + 0.38*PI + 0.14*Age, TPA=-16.9 + 0.34*PI + 0.15*Age, SSA = 109.8 + 0.58*PI-0.19*Age, and SFA = 173 + 0.39*PI + 0.11*Age.

CONCLUSIONS

SSA, PT, TPA and SFA must be assessed according to patient's PI. This study provides normative values for each PI group, and predictive formulas taking age and PI into account. PI cannot be used to define thoracic and cervical curvatures.

LEVEL OF EVIDENCE

II.

Variation in lumbar regional kyphosis between supine and standing positions. Implications for spinal fracture management

PURPOSE

The variation of lumbar lordosis between standing and supine position is poorly explored in literature. This study sought to analyze variation of lumbar regional angulations (RA) in healthy volunteers between standing and supine positions, according to pelvic incidence (PI).

METHODS

This study included 171 patients who had an abdominal CT-scan in supine position and 879 healthy volunteers with full-body stereoradiographs. The two populations were matched using a propensity score including age, PI, and sex. PI and RAs for all vertebrae from T12 to L5 (measured between the overlying vertebra's upper endplate of and the underlying vertebra's lower endplate) were assessed. Studied parameters were compared between Supine and Standing groups in the whole cohort and in every PI group. Multivariate analysis was performed to ascertain the effect of position change.

RESULTS

The analysis was performed on 314 subjects (157 matched in each group). In the overall cohort, all RAs from L1 to L4 were more lordotic in the Standing group, ranging from 3 to 8° difference (all p < 0.001), while T12 and L5 RAs were comparable in both groups (p = 0.55 and 0.49, respectively). Multivariate analysis confirmed the significant associations between subject's position and all RAs except for L5 and T12. RA variation between positions occurred at more vertebral levels and tended to be greater in higher PI groups.

CONCLUSION

RA values in the lumbar spine are more lordotic in standing position than supine, except for T12 and L5. These results help estimate RA in Standing position in patients with lumbar fractures.

LEVEL OF EVIDENCE

IV.

Twenty year outcomes following short-segment posterior instrumentation and fusion for thoracolumbar burst fractures: A retrospective observational study

This study reviews the long-term efficacy of short-segment posterior instrumentation and fusion (SSPIF) in treating thoracolumbar burst fractures. Authors retrospectively reviewed the radiographic results of single-level thoracolumbar burst fractures treated by SSPIF. Vertebral body height and wedge angles were measured on the preoperative, postoperative, and follow-up radiographic images. The degree of pain and work ability was measured using the Denis scale. The analysis consisted of 12 patients with a mean age of 39.7 years (range 21-60) and a mean follow-up of 225.6 ± 20.3 months. There were significant differences among the wedge angles at preoperative and other periods of time, but there was no significant difference between the early postoperative and all other time periods afterwards (P < .001, P = .567, P = .937, P = .879). SSPIF effectively restored the anterior and middle vertebral body height and wedge angle deformities, and the improvement was maintained for almost 20 years after the surgery. Therefore, SSPIF is a safe and effective modality of treatment for thoracolumbar burst fractures.

Incidence and risk factors of subsequent vertebral fracture following percutaneous vertebral augmentation in postmenopausal women

PURPOSE

Subsequent vertebral fracture (SVF) is a severe advent event of percutaneous vertebral augmentation (PVA). However, the incidence and risk factors of SVF following PVA for OVCF in postmenopausal women remain unclear. This research aims to investigative the incidence and risk factors of SVF after PVA for OVCF in postmenopausal women.

METHODS

Women who underwent initial PVA for OVCF between August 2019 and December 2021 were reviewed. Univariate logistic regression analysis was performed to identify possible risk factors of SVF, and independent risk factors were determined by multivariate logistic regression.

RESULTS

A total of 682 women after menopause were enrolled in the study. Of these women, 100 cases had an SVF after PVA, with the incidence of 14.66%. Univariate logistic regression analysis demonstrated that age (p = 0.001), body mass index (BMI) (p < 0.001), steroid use (p = 0.008), history of previous vertebral fracture (p < 0.001), multiple vertebral fracture (p = 0.033), postoperative wedge angle (p = 0.003), and HU value (p < 0.001) were significantly correlated with SVF following PVA. Furthermore, BMI (OR [95%CI] = 0.892 [0.825 - 0.965]; p = 0.004), steroid use (OR [95%CI] = 3.029 [1.211 - 7.574]; p = 0.018), history of previous vertebral fracture (OR [95%CI] = 1.898 [1.148 - 3.139]; p = 0.013), postoperative wedge angle (OR [95%CI] = 1.036 [1.004 - 1.070]; p = 0.028), and HU value (OR [95%CI] = 0.980 [0.971 - 0.990]; p < 0.001) were identified as independent risk factors of SVF after PVA by multivariate logistic regression analysis.

CONCLUSIONS

The incidence of SVF following PVA for OVCF in postmenopausal women was 14.66%. BMI, steroid use, history of previous vertebral fracture, postoperative wedge angle, and HU value were independent risk factors of SVF after PVA for OVCF in postmenopausal women.

Deep Learning-Assisted Quantitative Measurement of Thoracolumbar Fracture Features on Lateral Radiographs

OBJECTIVE

This study aimed to develop and validate a deep learning (DL) algorithm for the quantitative measurement of thoracolumbar (TL) fracture features, and to evaluate its efficacy across varying levels of clinical expertise.

METHODS

Using the pretrained Mask Region-Based Convolutional Neural Networks model, originally developed for vertebral body segmentation and fracture detection, we fine-tuned the model and added a new module for measuring fracture metrics-compression rate (CR), Cobb angle (CA), Gardner angle (GA), and sagittal index (SI)-from lumbar spine lateral radiographs. These metrics were derived from six-point labeling by 3 radiologists, forming the ground truth (GT). Training utilized 1,000 nonfractured and 318 fractured radiographs, while validations employed 213 internal and 200 external fractured radiographs. The accuracy of the DL algorithm in quantifying fracture features was evaluated against GT using the intraclass correlation coefficient. Additionally, 4 readers with varying expertise levels, including trainees and an attending spine surgeon, performed measurements with and without DL assistance, and their results were compared to GT and the DL model.

RESULTS

The DL algorithm demonstrated good to excellent agreement with GT for CR, CA, GA, and SI in both internal (0.860, 0.944, 0.932, and 0.779, respectively) and external (0.836, 0.940, 0.916, and 0.815, respectively) validations. DL-assisted measurements significantly improved most measurement values, particularly for trainees.

CONCLUSION

The DL algorithm was validated as an accurate tool for quantifying TL fracture features using radiographs. DL-assisted measurement is expected to expedite the diagnostic process and enhance reliability, particularly benefiting less experienced clinicians.

From Radiographic Evaluation to Treatment Decisions in Neurologically Intact Patients With Thoraco-lumbar Burst Fractures

We propose that the key to improving care for these patients is to truly understand the processes that take place from the interpretation of radiographic findings, through the assessment of the severity of various injuries, to inclusion within a classification category and finally to selecting a specific treatment.

Is restoration of vertebral body height after vertebral body fractures and minimally-invasive dorsal stabilization with polyaxial pedicle screws just an illusion?

INTRODUCTION

Thoracolumbar spine fractures often require surgical treatment as they are associated with spinal instability. Optimal operative techniques and treatment are discussed controversially. Aim of our prospective cohort study was to investigate the sagittal alignment after reduction, the secondary loss of reduction and the subjective outcome as well as the causal correlation of these parameters after minimally invasive stabilization of thoracic and lumbar fractures with polyaxial pedicle screws.

MATERIALS AND METHODS

In a single-center study, a total of 78 patients with an average age of 61 ± 17 years who suffered a fracture of the thoracic or lumbar spine were included and subjected to a clinical and radiological follow-up examination after 8.5 ± 8 months. The kyphotic deformity was measured by determining the vertebral body angle, the mono- and bi-segmental wedge angle at three time points. The patients' subjective outcome was evaluated by the VAS spine score.

RESULTS

After surgical therapy, a significant reduction of the traumatic kyphotic deformity was shown with an improvement of all angles (vertebral body angle: 3.2° ± 4.4°, mono- and bi-segmental wedge angle: 3.1° ± 5.6°, 2.0° ± 6.3°). After follow-up, a significant loss of sagittal alignment was observed for all measured parameters with a loss of correction. However, no correlation between the loss of reduction and the subjective outcome regarding the VAS spine scale could be detected.

CONCLUSION

The minimally invasive dorsal stabilization of thoracic and lumbar spine fractures with polyaxial pedicle screws achieved a satisfactory reduction of the fracture-induced kyphotic deformity immediately postoperatively with a floss of reduction in the further course. However, maybe the main goal of this surgical procedure should be the prevention of a complete collapse of the vertebral body instead of a long-lasting restoration of anatomic sagittal alignment.

LEVEL OF EVIDENCE

II.

Radiological Factors Associated with Bisphosphonate Treatment Failure and Their Impact on Fracture Healing in Postmenopausal Women with Osteoporotic Vertebral Fractures

(1) Background: Bisphosphonate treatment failure is one of the most difficult clinical problems for patients with osteoporosis. This study aimed to analyze the incidence of bisphosphonate treatment failure, associated radiological factors, and effect of fracture healing in postmenopausal women with osteoporotic vertebral fractures (OVFs). (2) Methods: A total of 300 postmenopausal patients with OVFs who were prescribed bisphosphonate were retrospectively analyzed and divided into two groups according to the treatment response: response (n = 116) and non-response (n = 184) groups. The radiological factors and the morphological patterns of OVFs were included in this study. (3) Results: The initial BMD values of the spine and femur in the non-response group were significantly lower than those in the response group (all Ps < 0.001). The initial BMD value of the spine (odd ratio = 1.962) and the fracture risk assessment tool (FRAX) hip (odd ratio = 1.32) showed statistical significance in logistic regression analysis, respectively (all Ps < 0.001). (4) Conclusions: The bisphosphonate non-responder group showed a greater decrease in BMD over time than the responder group. The initial BMD value of the spine and the FRAX hip could be considered radiological factors influencing bisphosphonate non-response in the postmenopausal patients with OVFs. The failure of bisphosphonate treatment for osteoporosis has a possible negative on the fracture healing process in OVFs.

Sagittal correction after short percutaneous fixation for thoracolumbar compression fractures: comparison of the combination of SpineJack® kyphoplasty and fractured vertebra screw fixation

PURPOSE

The aim of this study was to compare two percutaneous pedicle fixations for the treatment of thoracolumbar fractures: one associating a jack kyphoplasty (SpineCut) and the other using intermediate screws (Trident).

METHODS

All adult patients treated for single-level Magerl/AO type A thoracolumbar traumatic fractures in four orthopaedic departments, with SpineCut or Trident, with a one year minimum follow-up, were retrospectively included. Neurological disorders and osteoporotic fractures were not included. The following data were collected: age, sex, Magerl/AO type, type of surgery, and complications. Radiological parameters were analyzed on pre-operative CT scan, and on standing X-rays before discharge, at three months and one year post-operative: vertebral wedge angle (VWA), regional kyphosis angle (RKA), and traumatic regional angulation (TRA: difference between RKA and physiological values for each vertebra).

RESULTS

Eighty patients were included, with 42 patients in SpineCut group and 38 in Trident group. Mean age was 41 ± 15.7 years. TRA correction did not differ between the groups: respectively 11.2 ± 8.1° in SpineCut versus 10.2 ± 9.1° in Trident group (p = 0.52). TRA loss of correction between early post-operative and three months was statistically higher in Trident group: -4 ± 5.1° versus -1.5 ± 3.8° (p = 0.03). After 3 months, TRA correction loss was comparable between the groups. Multivariate analysis demonstrated that pre-operative VWA was the only factor significantly associated with early TRA correction loss (p = 0.01). VWA correction and loss of correction did not differ significantly between the groups. No complications were observed.

CONCLUSION

Percutaneous pedicle fixations of traumatic thoracolumbar fractures associating jack kyphoplasty and intermediate screws are both safe and efficient techniques.

Efficacy of a novel percutaneous pedicle screw fixation and vertebral reconstruction versus the traditional open pedicle screw fixation in the treatment of single-level thoracolumbar fracture without neurologic deficit

Objective

The aim of this study was to compare the efficacy and safety of a novel percutaneous pedicle screw fixation and vertebral reconstruction (PPSR) vs. that of open pedicle screw fixation (OPSF) in the treatment of thoracolumbar fractures.

Methods

This retrospective study enrolled 153 patients who underwent PPSR and 176 patients who received OPSF. Periprocedural characteristics, radiographic parameters, and clinical outcomes were compared between the two groups.

Results

The operation duration was 93.843 ± 20.611 in PPSR group and 109.432 ± 11.903 in OPSF group; blood loss was 131.118 ± 23.673 in PPSR group and 442.163 ± 149.701 in OPSF group, incision length was 7.280 ± 1.289 in PPSR group and 14.527 ± 2.893 in OPSF group, postoperative stay was 8.732 ± 1.864 in PPSR group and 15.102 ± 2.117 in OPSF group, and total hospitalization costs were 59027.196 ± 8687.447 in PPSR group and 73144.432 ± 11747.567 in OPSF group. These results indicated that these parameters were significantly lower in PPSR compared with those in OPSF group. No significant difference was observed in the incidence of complications between the two groups. The radiographic parameters including height of the anterior vertebra, Cobb angle, and vertebral wedge angle were better in PPSR group than in OPSF group. Recovery rate of AVH was 0.449 ± 0.079 in PPSR group and 0.279 ± 0.088 in OPSF group. Analysis of clinical results revealed that during postoperative period, the VAS and ODI scores in PPSR group were lower than those in OPSF group.

Conclusions

Collectively, these results indicated that PPSR more effectively restored the height of anterior vertebra and alleviated local kyphosis compared with OPSF. Moreover, the VAS and ODI scores in PPSR group were better than those of OPSF group.

Percutaneous pedicle screw fixation without arthrodesis of 368 thoracolumbar fractures: long-term clinical and radiological outcomes in a single institution

PURPOSE

Traumatic thoracolumbar (TL) fractures are the most common vertebral fractures. Although a consensus on the preferred treatment is missing, percutaneous pedicle screw fixation (PPSF) has been progressively accepted as treatment option, since it is related to lower soft tissues surgical-injury and perioperative complications rate. This study aims to evaluate the long-term clinical-radiological outcomes after PPSF for TL fractures at a single tertiary academic hospital.

METHODS

This is a retrospective cohort study. Back pain was obtained at preoperative, postoperative and final follow-up using Visual Analog Scale. Patient-reported outcomes, the Oswestry Disability Index and the 36-Item Short Form, were obtained to asses disability during follow-up. Radiological measures included Cobb angle, mid-sagittal index, sagittal index (SI) and vertebral body height loss. A multivariate regression analysis on preoperative radiological features was performed to investigate independent risk factors for implant failure.

RESULTS

A total of 296 patients with 368 TL fractures met inclusion criteria. Mean follow-up was 124.3 months. The clinical and radiological parameters significantly improved from preoperative to last follow-up measurements. The multivariate analysis showed that Cobb angle (OR = 1.3, p < 0.001), SI (OR = 1.5, p < 0.001) and number of fractures (OR = 1.1, p = 0.05), were independent risk factors for implant failure. The overall complication rate was 5.1%, while the reoperation rate for implant failure was 3.4%.

CONCLUSIONS

In our case series, PPSF for TL injuries demonstrated good long-term clinical-radiological outcomes, along with low complication and reoperation rates. Accordingly, PPSF could be considered as a valuable treatment option for neurologically intact patients with TL fractures. Additionally, in this cohort, number of fractures ≥ 2, Cobb angle ≥ 15° and sagittal index ≥ 21° were independent risk factors for implant failure.

EVALUATION OF KYPHOSIS MEASUREMENT IN THORACOLUMBAR SPINE FRACTURES

ABSTRACT Objectives: Evaluate the reliability and reproducibility of the kyphosis measurement in thoracolumbar spine traumatic fractures by different assessment methods in different types of fractures. Methods: Fifteen fractures of the thoracolumbar spine, previously classified into types A, B, and C according to Magerl’s classification, were evaluated. The value of kyphosis was measured using five different methods: (1) Cobb angle; (2) Gardner’s method; (3) back wall method; (4) angle of adjacent endplates; and (5) wedge angle. The measurements were performed by five independent observers and repeated five times with a minimum interval of two weeks between each evaluation. Results: Intraobserver reliability was excellent among the five observers, evidencing good reproducibility of the methods. The five methods used also showed great intraobserver reliability in the global analysis, with methods one and four being more consistent. Conclusion: Although there is no universal agreement on measuring kyphosis in thoracolumbar fractures, our study concluded that method 1 (Cobb angle) and method 4 (adjacent endplate angle) presented the best interobserver reliabilities. Furthermore, the use of digitized radiographs and a simple computer program allowed the performance of highly reliable and reproducible measurements by all methods, given the high intraobserver reliability. Level of Evidence II; Comparative study.

Implant removal after short percutaneous pedicle fixation associated with SpineJack® kyphoplasty: is correction sustained?

PURPOSE

This study objective was to evaluate sagittal correction loss after instrumentation removal in patients treated for thoracic or lumbar compression fractures treated with SpineJack^® kyphoplasty associated with short percutaneous pedicle screw fixation.

METHODS

This retrospective multicenter study was carried out in three major French trauma centers. All patients with a single type A thoracic or lumbar fracture, treated by the studied technique between 2017 and 2020, have been included. Demographic data, fracture type, removal procedure achievement and term were collected. Radiological parameters were measured at five timepoints: pre-operative, intra-operative, immediate post-operative, early post-operative (< 3 months) and at follow-up (1 year). Vertebral wedge angle (angle between the two endplates of the fractured vertebra) and traumatic regional angulation (TRA-calculated by subtracting regional kyphosis from the physiological reference values).

RESULTS

150 patients were included. Mean age was 48.6 ± 17.8 years. Average follow-up was 14.4 ± 3 months. 82 patients had secondary instrumentation removal. Mean time to removal was 6.4 ± 2.4 months. TRA correction loss between immediate post-operative and last follow-up was greater in removal group: 5.1 ± 5.6° versus 2.7 ± 4.7° (p = 0.01). Material was removed earlier in younger patients (p = 0.002). TRA correction loss was similar in the early and late removal groups (p = 0.83). Multivariate analysis identified only Magerl/AO A3 fractures as risk factor for loss of TRA correction (p = 0.007).

CONCLUSION

Instrumentation removal was associated with good radiological outcomes with a non-significant loss of vertebral wedge angle and tolerable loss of traumatic regional angulation (+ 2.4° compared to the no-removal group), even if performed early.

The Value of Dynamic Fracture Mobility in Determining the Optimum Operation Choice for Acute Osteoporotic Vertebral Compression Fracture

Purpose

This retrospective study aimed to verify whether the use of a balloon in balloon kyphoplasty (BKP) could offer a higher degree of vertebral height restoration and deformity correction than percutaneous vertebroplasty (PVP) after adjustment for preoperative dynamic fracture mobility. We expect that this research will help surgeons to determine the optimum operation choice (PVP or BKP) for treating osteoporotic vertebral compression fractures (OVCFs).

Patients and Methods

We evaluated retrospectively 262 patients who were treated by PVP or BKP for acute, single-level OVCF at our institution from July 2015 to July 2019. According to the presence or absence of dynamic fracture mobility, the patients were divided into two groups: mobile group and fixed group. We compared the changes in the vertebral height and kyphotic angle for PVP and BKP, respectively, within each group.

Results

In the mobile group, the anterior vertebral height restoration (BKP group, 8.73±5.27%; PVP group, 2.96±1.59%), middle vertebral height restoration (BKP group, 7.58±5.18%; PVP group, 2.74±1.24%) and kyphotic angle correction (BKP group, 4.41±4.46°; PVP group, 1.38±1.60°) due to percutaneous vertebral augmentation technique itself were more obvious in BKP group compared with PVP group (P < 0.05). The BKP group has lower incidence of bone cement leakage (BKP group, 10.17%; PVP group, 25.53%, P < 0.05). In the fixed group, differences from comparison of changes were not statistically significant between PVP and BKP (P > 0.05).

Conclusion

The use of a balloon in BKP could offer greater kyphosis correction, higher vertebral body height restoration, and lower cement leakage rate than PVP if a fractured vertebral body existed dynamic mobility. However, all these advantages of BKP over PVP are not obvious and could be overrated for a fixed fracture exhibited no mobility. BKP is recommended for a fractured vertebral body with dynamic mobility. PVP is suggested for a fixed fractured vertebral body with no mobility as it produces similar capability of vertebral height restoration, kyphosis correction, and cement leakage as BKP.

Percutaneous Cement-Augmented Screws Short Fixation for the treatment of Severe Osteoporotic Vertebral Burst Fractures

OBJECTIVE (BACKGROUND)

This study aims to evaluate the therapeutic reliability of posterior percutaneous cement-augmented screws short fixation(PASF) in patients with severe osteoporotic vertebral burst fractures(OVBFs).

METHODS

Single-level OVBFs with an anterior vertebral body height(VBH) reduction equal or superior to 60% were included. A frailty index was employed for preoperative frailty assessment. Back pain and related disability were assessed through the VAS scale and Oswestry low-back pain disability index(ODI), being administered at injury time, preoperative, postoperative, twelfth-month and last patient follow-up evaluations. The main radiological outcomes were represented by Cobb angle(CA) and anterior vertebral body compression percentage(AVBC%), being measured at injury time, preoperative, postoperative and twelfth-month examinations. Among the others, the incidence of cement leakages and hardware failures was assessed.

RESULTS

Thirty-three patients met the inclusion criteria. All patients resulted frail(76%) or semi-frail(24%). Significant VBH restoration and segmental kyphosis improvement after PASF was documented (AVBC%:-40(-43;-37) VS -67(-70;-65), P = 0.0001; CA: 10(8-12) VS 24(23-26), P = 0.0001). The mean VAS and ODI scores documented optimal and long-enduring pain relief and related disability reduction after PASF (VAS: 2(2-3) VS 8(7-8), P = 0.0001; ODI: 22(17-26) VS 64(60-69), P = 0.0001). Only one cement leakage (3%), asymptomatic, occurred. After a mean follow-up of 33 months, no early/late hardware failures were reported.

CONCLUSIONS

The clinical and radiological results of this study suggest that PASF could be a safe and effective treatment option for severe OVBFs when conservative treatments failed.

Kyphosis After Thoracolumbar Spine Fractures: WFNS Spine Committee Recommendations

Thoracolumbar fractures change the biomechanics of the spine. Load distribution causes kyphosis by the time. Treatment of posttraumatic kyphosis is still controversial. We reviewed the literature between 2010 and 2020 using a search with keywords “thoracolumbar fracture and kyphosis.” We removed osteoporotic fractures, ankylosing spondylitis fractures, non-English language papers, case reports, and low-quality case series. Up-to-date information on posttraumatic kyphosis management was reviewed to reach an agreement in a consensus meeting of the World Federation of Neurosurgical Societies (WFNS) Spine Committee. The first meeting was conducted in Peshawar in December 2019 with WFNS Spine Committee members’ presence and participation. The second meeting was a virtual meeting via the internet on June 12, 2020. We utilized the Delphi method to administer the questionnaire to preserve a high degree of validity. We summarized 42 papers on posttraumatic kyphosis. Surgical treatment of thoracolumbar kyphosis due to unstable burst fractures can be done via a posterior only approach. Less blood loss and reduced surgery time are the main advantages of posterior surgery. Kyphosis angle for surgical decision and fusion levels are controversial. However, global sagittal balance should be taken into consideration for the segment that has to be included. Adding an intermediate screw at the fractured level strengthens the construct.

The Current Status of Spinal Posttraumatic Deformity: A Systematic Review

STUDY DESIGN

Systematic Review.

OBJECTIVE

To systematically analyze the definitions and descriptions in literature of "Spinal Posttraumatic Deformity" (SPTD) in order to support the development of a uniform and comprehensive definition of clinically relevant SPTD.

METHODS

A literature search in 11 international databases was performed using "deformity" AND "posttraumatic" and its synonyms. When an original definition or a description of SPTD (Patient factors, Radiological outcomes, Patient Reported Outcome Measurements and Surgical indication) was present the article was included. The retrieved articles were assessed for methodological quality and the presented data was extracted.

RESULTS

46 articles met the inclusion criteria. "Symptomatic SPTD" was mentioned multiple times as an entity, however any description of "symptomatic SPTD" was not found. Pain was mentioned as a key factor in SPTD. Other patient related parameters were (progression of) neurological deficit, bone quality, age, comorbidities and functional disability. Various ways were used to determine the amount of deformity on radiographs. The amount of deformity ranged from not deviant for normal to >30°. Sagittal balance and spinopelvic parameters such as the Pelvic Incidence, Pelvic Tilt and Sacral Slope were taken into account and were used as surgical indicators and preoperative planning. The Visual Analog Scale for pain and the Oswestry Disability Index were used mostly to evaluate surgical intervention.

CONCLUSION

A clear-cut definition or consensus is not available in the literature about clinically relevant SPTD. Our research acts as the basis for international efforts for the development of a definition of SPTD.

Thoracolumbar Burst Fractures: A Systematic Review and Meta-Analysis Comparing Posterior-Only Instrumentation Versus Combined Anterior-Posterior Instrumentation

STUDY DESIGN

Meta-analysis.

OBJECTIVE

To compare the clinical, functional, and radiological outcomes of posterior-only versus combined anterior-posterior instrumentation in order to determine the optimal surgical intervention for thoracolumbar burst fractures.

SUMMARY OF BACKGROUND DATA

Unstable thoracolumbar burst fractures warrant surgical intervention to prevent neurological deterioration and progressive kyphosis, which can lead to significant pain and functional morbidity. The available literature remains largely inconclusive in determining the optimal instrumentation strategy.

METHODS

Electronic searches of MEDLINE (1948-May 2020), EMBASE (1947-May 2020), The Cochrane Library (1991-May 2020), and other databases were conducted. Cochrane Collaboration guidelines were used for data extraction and quality assessment. Outcomes of interest were divided into three categories: radiological (degree of postoperative kyphosis correction; loss of kyphosis correction at final follow-up), functional (visual analogue scale [VAS] pain score; Oswestry Disability Index [ODI] score), and clinical (intraoperative blood loss; length of stay [LOS]; operative time; the number and type of postoperative complications).

RESULTS

Four randomized control trials (RCTs) were retrieved, including 145 randomized participants. Seventy-three patients underwent posterior-only instrumentation and 72 underwent combined instrumentation. No significant difference was found in the degree of postoperative kyphosis correction (P = 0.39), VAS (centimeters) at final follow-up (P = 0.67), ODI at final follow-up (P = 0.89) or the number of postoperative complications between the two approaches (P = 0.49). Posterior-only instrumentation was associated with lower blood loss (P < 0.001), operative time (P < 0.001), and LOS (P = 0.01). Combined instrumentation had a lower degree of kyphosis loss at final follow-up (P = 0.001). There was heterogeneity in the duration of follow-up between the included studies (mean follow-up range 24-121 months).

CONCLUSION

The available literature remains largely inconclusive. In order to reliably inform practice in this area, there is a need for large, high-quality, multicenter RCTs with standardized reporting of outcomes, with a particular focus on outcomes relating to patient function and severe complications causing long-term morbidity.Level of Evidence: 2.

Automated Vertebral Segmentation and Measurement of Vertebral Compression Ratio Based on Deep Learning in X-Ray Images

Vertebral compression fracture is a deformity of vertebral bodies found on lateral spine images. To diagnose vertebral compression fracture, accurate measurement of vertebral compression ratio is required. Therefore, rapid and accurate segmentation of vertebra is important for measuring the vertebral compression ratio. In this study, we used 339 data of lateral thoracic and lumbar vertebra images for training and testing a deep learning model for segmentation. The result of segmentation by the model was compared with the manual measurement, which is performed by a specialist. As a result, the average sensitivity of the dataset was 0.937, specificity was 0.995, accuracy was 0.992, and dice similarity coefficient was 0.929, area under the curve of receiver operating characteristic curve was 0.987, and the precision recall curve was 0.916. The result of correlation analysis shows no statistical difference between the manually measured vertebral compression ratio and the vertebral compression ratio using the data segmented by the model in which the correlation coefficient was 0.929. In addition, the Bland–Altman plot shows good equivalence in which VCR values are in the area within average ± 1.96. In conclusion, vertebra segmentation based on deep learning is expected to be helpful for the measurement of vertebral compression ratio.

A deep learning algorithm for automated measurement of vertebral body compression from X-ray images

The vertebral compression is a significant factor for determining the prognosis of osteoporotic vertebral compression fractures and is generally measured manually by specialists. The consequent misdiagnosis or delayed diagnosis can be fatal for patients. In this study, we trained and evaluated the performance of a vertebral body segmentation model and a vertebral compression measurement model based on convolutional neural networks. For vertebral body segmentation, we used a recurrent residual U-Net model, with an average sensitivity of 0.934 (± 0.086), an average specificity of 0.997 (± 0.002), an average accuracy of 0.987 (± 0.005), and an average dice similarity coefficient of 0.923 (± 0.073). We then generated 1134 data points on the images of three vertebral bodies by labeling each segment of the segmented vertebral body. These were used in the vertebral compression measurement model based on linear regression and multi-scale residual dilated blocks. The model yielded an average mean absolute error of 2.637 (± 1.872) (%), an average mean square error of 13.985 (± 24.107) (%), and an average root mean square error of 3.739 (± 2.187) (%) in fractured vertebral body data. The proposed algorithm has significant potential for aiding the diagnosis of vertebral compression fractures.

Management of AO-type C thoracolumbar fractures during COVID-19 pandemic using distractor device: a novel technique

STUDY DESIGN

Prospective cohort study.

INTRODUCTION

Management of the severe thoracolumbar (TL) spine fracture-dislocation injuries have been further complicated by the COVID-19 pandemic. The need to optimize resources and minimize the personnel in the operating room (OR) led us to develop a novel technique to reduce TL fracture-dislocations (AO type-C) using an orthopedic distractor device (ODD).

METHODS

This prospective study was conducted at a tertiary care spine center with a study duration from March 2020 to May 2020 coinciding with the nationwide lockdown and travel restrictions imposed in view of the COVID-19 crisis. Only patients with AO type C fracture-dislocation managed using the ODD operated by a single surgeon were included in the study.

RESULTS

Of 12 cases, the most commonly affected level was D12-L1. Nine patients were American Spinal Injury Association Impairment Scale (AIS) A at presentation, two patients were AIS B, and one AIS C. The mean operative time was 125 min and mean blood loss was 454 ml. Eight patients remained AIS A, one patient improved from AIS B to C. Two patients became independent walkers, one remained AIS B. The post-operative VAS score improved to a mean value of 2.33. The improvement in kyphosis was 26.24° immediate postoperatively and maintained at 25.9°, percentage height loss reduced to 2.75% immediate postoperatively and maintained at 3.16% at 3 months follow-up.

CONCLUSIONS

Management of TL fracture-dislocations in COVID times of health care resource scarcity can be challenging. Single surgeon with ODD is a useful technique for achieving good results in these injuries.

Usefulness of Trabecular CT Attenuation Measurement of Lumbar Spine in Predicting Osteoporotic Compression Fracture: Is the L4 Trabecular Region of Interest Most Relevant?

STUDY DESIGN

Retrospective study.

OBJECTIVE

The aim of this study was to evaluate the usefulness of computed tomography (CT) attenuation in defining trabecular region-of-interest (t-ROI) at lumbar vertebral body in the assessment of osteoporotic compression fracture (OCF) compared to spinal dual x-ray absorptiometry (DXA).

SUMMARY OF BACKGROUND DATA

Even though osteoporosis was not diagnosed in the bone mineral density measurement using DXA, we often experienced cases where the screw was weakly inserted due to low bone quality during screw insertion.

METHODS

A total of 188 patients who met the inclusion criteria were enrolled. We determined best cutoff value of the simple t-ROI attenuation at the most relevant level for predicting OCF. We assessed correlations between the simple t-ROI attenuation at the most relevant level and OCF rate, and investigate the association between the number of compression fracture and simple t-ROI attenuation at the most relevant level.

RESULTS

L4 ROI attenuation is the most accurate measurement for predicting osteoporotic compression fracture with an area under the curve of 0.798. The optimal cutoff point of L4 ROI attenuation was measured at 90.5 HU with 88.8% and 60.6% sensitivity and specificity, respectively. L4 ROI attenuation was significantly correlated with the osteoporotic compression fracture rate (r = -0.545, P < 0.001). The number of compression fracture (coefficient of determination R2 = 0.286; P < 0.001) was independently correlated with L4 ROI attenuation.

CONCLUSION

Simple t-ROI computed tomography attenuation is an accurate measurement tool in predicting OCF compared to DXA T-score. The value of L4 t-ROI attenuation is the most relevant measurement for predicting osteoporotic compression fracture, is an alternative to DXA, and can predict the number and rate of compression fractures. Spine surgeons should be aware of L4 t-ROI attenuation to make successful fusion in spine surgery for elderly patients group.Level of Evidence: 3.

Natural changes of traumatic vertebral compression fractures during the first 6 months in patients visiting for disability certificates: A retrospective observational study

To identify the natural changes of traumatic vertebral compression fractures during the first six months in patients visiting for disability certificates after conservative treatment.Data of patients who visited the rehabilitation medicine department of a university hospital for disability certificates concerning traumatic vertebral compression fractures from 2015 to 2018 were reviewed. Those who visited 180 to 210 days after injuries were included, and those who received invasive procedures for compression fractures were excluded. The anterior and posterior heights, local kyphotic angle of compression fractures, and upper and lower vertebrae on initial and follow-up images were measured and compared. Compression ratio was calculated by vertebral body compression ratio and anterior vertebral body compression percentage. Thoracic and lumbar traumatic fractures were also compared.Among 110 patients, 61 patients met the criteria. After six months, the anterior height of compression fractures decreased more than 4 mm, which implies the development of new compression fractures. The compression ratio and local kyphotic angle increased significantly without affecting the upper and lower vertebrae. Thoracic and lumbar compression fractures showed similar changes.Traumatic vertebral compression fractures change significantly during the first six months. This study could warrant 6 months of waiting for issuance of disability certificates for patients with traumatic vertebral compression fractures.

Creation of a planned or central-clefted puncture combined with a second puncture during vertebroplasty to treat osteoporotic vertebral compression fractures with large clefts

BACKGROUND

Cemented vertebrae frequently re-fracture after vertebroplasty to treat osteoporotic vertebral compression fractures (OVCFs) with large clefts. We compared the efficacy of planned and central-clefted puncture, both followed by a second puncture, as treatments for OVCFs with large clefts.

METHODS

We retrospectively studied 38 patients. 18 of whom underwent planned puncture (group A) and 20 central-clefted puncture (group B). A second puncture was performed when the initially injected cement was restricted to the cleft. We recorded a visual analog scale (VAS) pain scores, vertebral kyphotic angles (KAs), and compression ratios (CRs) preoperatively and at 2 days and 6 months postoperatively. We recorded the cement dispersion patterns and complications.

RESULTS

Second punctures succeeded in 15/18 and 7/20 patients of groups A and B, respectively. At 2 days postoperatively, the VAS score, KA, and CR were significantly better than the preoperative values (P < 0.01); no significant difference was found between the two groups (P > 0.05). At the 6-month follow-up, all scores were poorer than at 2 days postoperatively (all P < 0.05), significantly more so in group B than group A (P < 0.05). Significant differences in terms of the cement dispersion patterns, and the cemented vertebral re-fracture and cement leakage rates, were observed between the two groups (all P < 0.05).

CONCLUSION

The two-puncture techniques were initially effective when treating large-clefted OVCFs. However, compared to the central-clefted puncture, the planned puncture improved the success rate of the second puncture, allowed better cement dispersion, and reduced the incidence of vertebral re-fracture during follow-up.

Postoperative Blood Loss Including Hidden Blood Loss in Early and Late Surgery Using Percutaneous Pedicle Screws for Traumatic Thoracolumbar Fracture

Introduction

Some reports revealed that hidden blood loss (HBL) during surgery for traumatic thoracolumbar fracture cannot be ignored, even when using a percutaneous approach. Using percutaneous pedicle screws (PPS) for traumatic thoracolumbar fracture, this study aimed to compare estimate blood loss (EBL), including HBL, between early and late fixation.

Methods

This investigation was a retrospective study. In the present study, data from 39 patients who underwent posterior spinal stabilization using PPS for single-level thoracolumbar fracture have been included. We divided the patients into an early group (group E) (n=20) in whom surgery was conducted within 3 days of fracture and a late group (group L) (n=19) in whom surgery was conducted more than 3 days after fracture. We evaluated hemoglobin (Hb) on the day of injury, and 1, 3 or 4, and 7 days after surgery, EBL, HBL, and transfusion requirement.

Results

Hb on day 1 (group E: 12.2±1.7 g/dL, group L: 12.3±1.6 g/dL) was significantly less than that on the injured day (group E: 14.2±1.7 g/dL, group L: 13.9±1.7 g/dL) in both groups. The values of Hb and EBL were not significantly different at any time between the two groups. HBL (group E: 487±266 mL, group L: 386±305 mL) was not significantly different between the two groups. No patients required transfusion in either group.

Conclusions

EBL in early fixation using PPS for traumatic thoracolumbar fracture is not significantly different compared with that in late surgery from days 1 to 7 postoperatively. Early fixation using PPS for traumatic thoracolumbar fracture does not result in negative outcomes any more than those in late surgery in terms of blood loss.

Management of thoracolumbar fracture in France. Analysis of practices and radiologic results of a cohort of 407 thoracolumbar fractures

BACKGROUND

Thoracolumbar fractures are a public health issue due to their severity and frequency. Management varies according to demographic, clinical and radiologic features, from non-operative treatment to extensive fusion. In the two last decades, improvements and new techniques have emerged, such as kyphoplasty and percutaneous approaches. The main goal of this study was to describe the management of thoracolumbar fractures in France in 2018.

HYPOTHESIS

The study hypothesis was that management of thoracolumbar fractures in France has progressed in recent decades.

MATERIAL AND METHODS

The files of 407 adult patients operated on between January 1, 2015 and December 31, 2016 for T4-L5 thoracolumbar fracture in 6 French teaching hospitals were retrospectively reviewed, at a mean follow-up at 10.2±8.2 [1; 42] months. Demographic, surgical and postoperative radiological data were collected. p-values<0.05 on Student test were considered significant.

RESULTS

Five hundred and thirty-one fractures were analyzed (27% of patients presented more than one fracture). Surgery consisted in internal fixation for 56% of patients, including 17% with associated kyphoplasty; 29% had fusion, and 15% stand-alone kyphoplasty. Surgery used an open posterior approach in 54% of cases, and a percutaneous approach in 46%. Initial sagittal angulation was not a significant decision criterion for screwing (p=0.8) or for a secondary anterior approach in case of fusion (p=0.6). Immediate postoperative sagittal correction was significantly better with an open than a percutaneous approach (p=0.004), but without significant difference at last follow-up (p=0.8). Correction at last follow-up was significantly better with anterior associated to posterior fusion (p=0.003).

DISCUSSION

Management of the thoracolumbar fractures has progressed in France in recent years: 46% of surgeries used a percutaneous approach, compared to 28% in 2013; 90% used a posterior approach only, compared to 83% in 2013; rates of combined approach were unchanged, at 6%. Twenty-five percent of burst fractures were treated by fusion, possibly due to lack of preoperative MRI in 79% of cases.

LEVEL OF EVIDENCE

IV, retrospective cohort study.

Reliability, validity and responsiveness of the Dutch version of the AOSpine PROST (Patient Reported Outcome Spine Trauma)

PURPOSE

To validate the Dutch version of AOSpine PROST (Patient Reported Outcome Spine Trauma).

METHODS

Patients were recruited from two level-1 trauma centers from the Netherlands. Next to the AOSpine PROST, patients also filled out SF-36 for concurrent validity. Descriptive statistics were used to analyze the characteristics. Content validity was assessed by evaluating the number of inapplicable or missing questions. Also floor and ceiling effects were analyzed. Internal consistency was assessed by calculating Cronbach's α and item-total correlation coefficients (itcc). Spearman correlation tests were performed within AOSpine PROST items and in correlation with SF-36. Test-retest reliability was analyzed using Intraclass Correlation Coefficients (ICC). Responsiveness was assessed by calculating effect sizes (ES) and standardized response mean (SRM). Factor analysis was performed to explore any dimensions within AOSpine PROST.

RESULTS

Out of 179 enrolled patients, 163 (91.1%) were included. Good results were obtained for content validity. No floor or ceiling effects were seen. Internal consistency was excellent (Cronbach's α = 0.96, itcc 0.50-0.86), with also good Spearman correlations (0.25-0.79). Compared to SF-36, the strongest correlation was seen for physical functioning (0.79; p < .001). Also test-retest reliability was excellent (ICC = 0.92). Concerning responsiveness analysis, very good results were seen with ES = 1.81 and SRM = 2.03 (p < 0.001). Factor analysis revealed two possible dimensions (Eigenvalues > 1), explaining 65.4% of variance.

CONCLUSIONS

Very satisfactory results were obtained for reliability, validity and responsiveness of the Dutch version of AOSpine PROST. Treating surgeons are encouraged to use this novel and validated tool in clinical setting and research to contribute to evidence-based and patient-centered care.

Development and reliability of the AOSpine CROST (Clinician Reported Outcome Spine Trauma): a tool to evaluate and predict outcomes from clinician's perspective

PURPOSE

To report on the development of AOSpine CROST (Clinician Reported Outcome Spine Trauma) and results of an initial reliability study.

METHODS

The AOSpine CROST was developed using an iterative approach of multiple cycles of development, review, and revision including an expert clinician panel. Subsequently, a reliability study was performed among an expert panel who were provided with 20 spine trauma cases, administered twice with 4-week interval. The results of the developmental process were analyzed using descriptive statistics, the reliability per parameter using Kappa statistics, inter-rater rater agreement using intraclass correlation coefficient (ICC), and internal consistency using Cronbach's α.

RESULTS

The AOSpine CROST was developed and consisted of 10 parameters, 2 of which are only applicable for surgically treated patents ('Wound healing' and 'Implants'). A dichotomous scoring system ('yes' or 'no' response) was incorporated to express expected problems for the short term and long term. In the reliability study, 16 (84.2%) participated in the first round and 14 (73.7%) in the second. Intra-rater reliability was fair to good for both time points (κ = 0.40-0.80 and κ = 0.31-0.67). Results of inter-rater reliability were lower (κ = 0.18-0.60 and κ = 0.16-0.46). Inter-rater agreement for total scores showed moderate results (ICC = 0.52-0.60), and the internal consistency was acceptable (α = 0.76-0.82).

CONCLUSIONS

The AOSpine CROST, an outcome tool for the surgeons, was developed using an iterative process. An initial reliability analysis showed fair to moderate results and acceptable internal consistency. Further clinical validation studies will be performed to further validate the tool.

Bisegmental posterior stabilisation of thoracolumbar fractures with polyaxial pedicle screws: Does additional balloon kyphoplasty retain vertebral height?

We retrospectively evaluated single-level compression fractures (T12-L3) scheduled for a short-segment POS (posterior-only stabilization) using polyaxial screws. Patients averaged 55.7 years (range, 19–65). Patients received either POS or, concomitantly, BK (balloon kyphoplasty) of the fractured vertebrae as well. Primary endpoint was the radiological outcome at the last radiographic follow-up prior to implant removal. POS together with BK of the fractured vertebrae resulted in a significant improvement of the local kyphosis angle and vertebral body compression rates immediately post-OP. During the further course of FU, a considerable loss of correction was observed post-OP in both groups. (Local KA: pre-OP/ post-OP/ FU: 12.6±4.8/ 3.35±4.8/ 11.6±6.0; anterior vertebral body compression%: pre-OP/post-OP/ FU: 71.94±12.3/ 94.78±19.95/ 78.17±14.74). VAS was significantly improved from 7.2±1.3 pre-OP to 2.7±1.3 (P<0.001) at FU. We found a significant restoration of the vertebral body height by BK. Nevertheless, follow-up revealed a noticeable loss of reduction. Given the fact that BK used together with polyaxial screws did not maintain intra-operative reduction, our data do not support this additional maneuver when used together with bi-segmental polyaxial pedicle screw fixation.

The Evaluation of Different Radiological Measurement Parameters of the Degree of Collapse of the Vertebral Body in Vertebral Compression Fractures

For compression fracture, vertebral body height loss (VBHL) and kyphotic angle (KA) are two important imaging parameters for determining the prognosis and appropriate treatment. This study used previous measurement methods to assess the degree of VBHL and KA, compare and examine differences between various measurement methods, and examine the correlation between relevant measurement parameters and intravertebral cleft (IVC) in the vertebral body. The radiographic images (lateral view of the T-L spine) of 18 patients with a single-level vertebral compression fracture were reviewed. We measured 9 characteristic lengths and angles on plain radiographs, including anterior vertebral height (AVH) and AVH of the adjacent upper and lower levels, middle vertebral height (MVH) and MVH of the adjacent upper and lower levels, posterior vertebral height (PVH), and vertebral body width, and assessed 6 parameters, including vertebral compression ratio (VBCR), percentage of anterior height compression (PAHC), percentage of middle height compression (PMHC), kyphotic angle (KA), calculated kyphotic angle (CKA), and IVC. The results showed that VBCR is a simple and rapid method of VBHL assessment, but it may result in an underestimation of the degree of VBHL compared to PAHC. When PMHC < 40% or kyphotic angle > 15°, the probability of IVC occurring on the vertebral body was higher which means the higher risk of vertebral body instability. The results of this study could provide a reference for surgeons when using imaging modalities to assess the degree of vertebral body collapse.

Reconstruction of vertebral body in thoracolumbar AO type A post-traumatic fractures by balloon kyphoplasty. A series of 85 patients with a long follow-up and review of literature

BACKGROUND

Traumatic fractures of the thoracolumbar spine are common injuries, accounting for approximately 90% of all spinal traumas. Optimal management of these fractures still gives rises to much debate in the literature. Currently, one of the treatment options in young patients with stable traumatic vertebral fractures is conservative treatment using braces. Kyphoplasty as a minimally invasive procedure has been shown to be effective in stabilizing vertebral body fractures, resulting in immediate pain relief and improved physical function with early return to work activity. The aim of the study is to report VAS, ODI scores, and kyphosis correction following treatment.

METHODS

This is a retrospective study to investigate the clinical and radiological results 10 years after percutaneous balloon kyphoplasty followed by cement augmentation with polymethylmethacrylate (PMMA) or calcium phosphate cements (CPC), according to age, in 85 consecutive patients affected by 91 AOSpine type A traumatic fractures of the thoracolumbar spine (A1, A2, and A3). Clinical follow-up was performed with the Visual Analogic Scale (VAS) at the preoperative visit and in the postoperative follow-up after 1 week, 1, 6, 12 months, and each year up to 10 years. Additionally, the Oswestry Disability Index (ODI) improvement was calculated as the difference between the ODI scores at the preoperative visit and at final follow-up. Finally, the Cobb angle from this cohort was assessed before surgery, immediately postoperatively, and at the end of follow-up.

RESULTS

Kyphoplasty markedly improved pain and resulted in statistically significant vertebral height restoration and normalization of morphologic shape indexes that remained stable for at least 10 years following treatment.

CONCLUSIONS

The present study showed that kyphoplasty and cement augmentation are an effective method of treatment for selected type A fractures.

Computed Tomographic Assessment of Sagittal Plane Alignment of the Thoracolumbar Junction in a Young Adult Korean Population

OBJECTIVE

The purpose of this study was to determine reference values for the sagittal plane alignment of the thoracolumbar junction (TLJ) in a young adult Korean population.

METHODS

Thoracolumbar computed tomography (CT) scans of 1000 individuals (age range, 20-39 years; 500 men and 500 women) from Hanyang University Health Care Center were reviewed. All subjects had no spinal pathology or a history of previous spinal surgery. The segmental (each level from T11 to L2) and global (T11-L1 and T11-L2) Cobb angles of the TLJ of the spine were measured in midsagittal CT scans. Moreover, comparisons between the 2 age groups (20s and 30s) and sexes were performed.

RESULTS

The segmental Cobb angles of T11, T12, L1, and L2 were 6.5° ± 3.9°, 5.5° ± 4.1°, 2.2° ± 4.7°, and -3.3° ± 5.3°, respectively. The global Cobb angles of T11-L1 and T11-L2 were 6.5° ± 5.2° and 0.5° ± 6.1°, respectively. There were no differences in the sagittal alignment between the 2 age groups. Women presented less kyphotic and more lordotic alignment in the lumbar spine (L1 and L2) than men; however, the thoracic spine (T11 and T12) alignment was not different between the 2 groups.

CONCLUSIONS

This study provides reference values with a wide physiologic range for the sagittal alignment of the TLJ of the spine in a young adult Korean population.

The Need of Validated Disease-Specific Outcome Instruments for Spine Trauma

This article focuses on patient-reported and clinician-reported outcome measures in spine trauma care. The measurement of the quality of care and functional and health-related quality of life outcomes of spine trauma patients has become increasingly important. However, no outcome instrument is specifically designed, validated, or universally adapted for this specific patient population. Issues specific to spinal trauma patients may not be adequately addressed by the instruments that are currently used in the literature and the daily clinical practice. The AOSpine Knowledge Forum Trauma initiated a project to develop and validate such instruments for spine trauma patients. To reflect the different perspectives of patients and the treating surgeons, 2 separate tools are being developed: the Patient Reported Outcome Spine Trauma (AOSpine PROST) and Clinician Reported Outcome Spine Trauma (AOSpine CROST). These tools hold promise, as useful instruments to measure the outcomes of spine trauma patients with and without neurological deficit, making it more feasible for clinical use as well. Treating surgeons around the world are encouraged to use the AOSpine PROST and AOSpine CROST in daily clinical practice and for research purposes to create and contribute to evidence-based and patient-centered care. Using the same outcome measures that are specifically developed and validated for traumatic spine injuries will allow us to compare the outcomes of various treatments in a valid and reproducible fashion. This contributes to a reduction of the ongoing controversies and providing the best treatments for our patients.