Epidemiological trends of spine trauma: an Australian level 1 trauma centre study

Odontoid Fracture as Proximal Junctional Failure in Patients With Multilevel Spine Fusions

STUDY DESIGN

Retrospective study.

OBJECTIVE

Proximal junctional failure (PJF) commonly occurs as a recognized potential outcome of fusion surgery. Here we describe a unique series of patients with multilevel spine fusion including the cervical spine, who developed PJF as an odontoid fracture.

METHODS

We performed a single site retrospective review of patients with prior fusion that included a cervical component, who presented with an odontoid fracture between 2012 and 2019. Radiographic measurements included C2-C7 SVA, C2-C7 lordosis, T1 slope, Occiput-C2 angle, proximal junctional kyphosis, and cervical mismatch. Associated fractures, medical comorbidities, and treatments were determined via chart review after IRB approval.

RESULTS

Nine patients met inclusion criteria. 5 reported trauma with subsequent onset of pain. All patients sustained a Type II odontoid fracture. 5 with associated C1/Jefferson fractures. In all patients, pre-injury Occiput-C2 angle was outside normative range; C2-C7 SVA was greater than 4 cm in 6 patients; T1-slope minus cervical lordosis was greater than 18.5 degrees in 6 patients. 7 patients were treated operatively with extension of fusion to C1 and 2 patients declined operative treatment.

CONCLUSION

In this series of 9 patients with multilevel fusion with type II odontoid fractures, all patients demonstrated abnormal pre-fracture sagittal alignment parameters and a greater than normal association of C1 fractures was noted. Further study is needed to establish the role of poor sagittal alignment with compensatory occiput-C2 angulation as a predisposing factor for odontoid fracture as a proximal junctional failure mechanism.

Minimally Invasive Versus Open Surgery for the Treatment of Types B and C Thoracolumbar Injuries: A PRISMA Systematic Review

BACKGROUND

Thoracic and lumbar spine injuries may require surgical management, particularly AO Spine types B and C injuries. Open reduction and fixation using pedicle screws, with or without fusion and/or decompression, is the gold standard surgical treatment for unstable injuries. Recent advances in instrumentation design have resulted in less-invasive surgeries. However, the literature is sparse about the effectiveness of these procedures for types B and C injuries. The objective is to compare the outcomes of conventional open surgery versus minimally invasive spine surgery (MISS) for the treatment of AO Spine types B and C thoracolumbar injuries.

METHODS

A systematic review of published literature in PubMed, Web of Science, and Scopus was performed to identify studies comparing outcomes achieved with open versus minimally invasive surgery in AO Spine types B and C thoracolumbar injury patients. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used.

RESULTS

Five retrospective case-control studies and 3 prospective studies met selection criteria. In general, most of the studies demonstrated that minimally invasive spine surgery is feasible for types B and C injuries, and associated with potential advantages like reduced blood loss, postoperative pain, and muscle injury, and shorter hospital stays. However, no differences were detected in major outcomes, like neurological status or disability.

CONCLUSIONS

Published literature currently suggests that minimally invasive spine surgery is a valid alternative for treating types B and C thoracolumbar injuries. However, further comparative prospective randomized clinical trials are necessary to establish the superiority of one approach over the other.

LEVEL OF EVIDENCE

3.

The Changing Etiology and Epidemiology of Traumatic Spinal Injury: A Population-Based Study

OBJECTIVE

No previous large population-based studies of traumatic spinal injury (TSI) rates, trends, and patterns exist. We aimed to fill this knowledge gap on TSI epidemiology using a population-based study of 13 million people.

METHODS

This is a descriptive cross-sectional cohort study that analyzes a national, mandatory reporting database for all emergency departments and ambulatory care centers in Ontario over 15 years. Demographics of TSI, trends in the TSI rate, etiology, transfer, disposition, comorbidities, and associated traumatic brain injury or spinal cord injury were analyzed.

RESULTS

There were 167,357 TSI-related emergency department visits resulting in 70,684 hospitalizations and 376 deaths. The overall rate of TSI significantly increased from 66.94 to 118.61 per 100,000. Female patients had greater rates of TSI. Older patients had greater rates of TSI, especially related to falls. Fall was found to be the commonest mechanism of TSI, whereas motor vehicle collisions scaled down to the third commonest mechanism of TSI. Sport-related TSI had the greatest percentage of increase in the rate over all mechanisms (221%, P < 0.001). TSI with associated traumatic brain injury comprised 6% of the cohort but had the greatest percentage increase (91%) in the rate compared to all other TSI forms.

CONCLUSIONS

The rate of TSI continues to rise in Ontario as the population ages. The rise is primarily attributed to a shift in the epidemiology and etiology of TSI from a younger male population toward an older female population, with falls as the primary injury mechanism. Establishing preventive measures to address this shift is essential.

Correlation of Anterior Interbody Graft Choice With Patient-Reported Outcomes in Cervical Spine Trauma

STUDY DESIGN

Ambispective observational cohort study.

OBJECTIVES

Synthetic graft usage avoids morbidity associated with harvest and reduces operative time. This study aims to evaluate outcomes of anterior cervical stabilization surgery using a synthetic cage in comparison with iliac crest bone graft (ICBG) following cervical spine trauma.

METHODS

An ambispective review was conducted on patients from the Alfred Trauma Registry. Consecutive patients treated at a level 1 trauma center, aged 18 years and older who were treated with standalone anterior cervical stabilization following spine trauma (2011-2016) were included in the study. Primary outcome measures were patient overall satisfaction, Neck Disability Index (NDI), neck pain 10-point visual analogue scale (VAS-neck) and arm pain 10-point visual analogue scale (VAS-arm). Secondary outcome measures were radiographic evidence of fusion and rate of revision surgery. All patients had follow-up for at least 1 year.

RESULTS

Between 2011 and 2016, 114 traumatic disc levels in 104 patients were treated. ICBG was used in 32% and polyetheretherketone (PEEK) cage in 68% of the patients. Both groups had similar demographic metrics. There was no significant difference in primary outcome measures between the graft types: (1) patient satisfaction (P = .15), (2) NDI (P = .11), (3) VAS-neck (P = .13), and (4) VAS-arm (P = .20). Radiology based fusion assessment 6 months postsurgery did not show statistical significance (P = .10). The rates of revision surgery were similar.

CONCLUSIONS

This study showed no significant difference in patient-reported outcome measures when comparing the usage of PEEK cage and ICBG in anterior stand alone cervical spine stabilization. Level 1 evidence studies are required to further investigate this finding.

[To fix the unstable region of sagittal injured unit symmetrically with pedicle screws combined with bone graft fusion for treating thoracolumbar fractures]

Objective

To discuss the security and effectiveness of fixing the unstable region of sagittal injured unit symmetrically with pedicle screws combined with bone graft fusion for treating thoracolumbar fractures.

Methods

A series of 65 patients with a single level thoracolumbar fracture between November 2011 and November 2015 were included in the study. There were 41 males and 24 females with an average age of 36.7 years (range, 23-60 years). The fracture segments included T ₇ 1 case, T ₉ in 2 cases, T ₁₀ in 4 cases, T ₁₁ in 8 cases, T ₁₂ in 14 cases, L ₁ in 19 cases, L ₂ in 13 cases, L ₃ in 3 cases, and L ₄ in 1 case. According to AO classification, there were 34 cases classified as type A, 27 cases type B, and 4 cases type C. The neurological function was evaluated by American Spinal Injury Association (ASIA) grade score, there were 1 case at grade A, 2 cases grade B, 6 cases grade C, 15 cases grade D, and 41 cases grade E. The thoracolumbar injury severity score (TLICS) was 4 in 9 cases, 5 in 29 cases, 6-8 in 23 cases, 9-10 in 4 cases. The time form injury to operation was 2-12 days (mean, 5.3 days). The fractured vertebra, along with the superior and inferior discs were defined as a injured unit and divided into three parts on the sagittal position: region Ⅰ mainly including the superior disc, cephalic 1/3 of injured vertebra, and posterior ligamentous complex as to oppose; region Ⅱ mainly including the middle 1/3 of injured vertebra, pedicles, lamina, spinous process, and supraspinal ligament; region Ⅲ mainly including the inferior disc, caudal 1/3 of injured vertebra, and posterior ligamentous complex as to oppose. The unstable region was defined as the key injured region of the vertebra. Pedicle screws were fixed symmetrically and correspondingly with bone grafting to treat thoracolumbar fractures. The neurological status, ratio of anterior body height, and sagittal Cobb angle were collected at preoperation, immediate after operation, and last follow-up to evaluate surgical and clinical outcomes.

Results

All patients accepted operation safely and were followed up 12-24 months (mean, 17.3 months). Cerebrospinal fluid leakage occurred in 3 patients, and cured by symptomatic treatment. There was no complications such as loosening, displacement, and breakage of internal fixator. Bony fusion was achieved in all patients at 10-13 months (mean, 11.4 months) after operation. At last follow-up, according to ASIA grading, 1 case was grade A, 1 grade B, 3 grade C, 9 grade D, and 51 grade E, showing significant difference when compared with preoperative data ( Z=-2.963, P=0.014). The ratio of anterior body height at preoperation, immediate after operation, and last follow-up were 53.2%±6.8%, 91.3%±8.3%, 89.5%±6.6% respectively; and the sagittal Cobb angle were (16.3±8.1), (2.6±7.5), (3.2±6.8)° respectively. The ratio of anterior body height and the sagittal Cobb angle at immediate after operation and at last follow-up were significantly improved when compared with preoperative values ( P<0.05), but no significant difference was found between at immediate after operation and at last follow-up ( P>0.05).

Conclusion

It is safe and reliable to treat thoracolumbar fractures under the principle of fixing the unstable region of injured unit symmetrically with pedicle screws combined with bone grafting.

AIS scores in spine and spinal cord trauma: Epidemiological considerations

BACKGROUND

The Abbreviated Injury Scale (AIS) is an internationally accepted coding system created by the Association for the Advancement of Automotive Medicine, utilized to code traumatic injuries as a function of severity, the latter often defined as mortality risk. Periodic reassessment of that risk is prudent, in light of advances in health care and relationship of nonanatomic factors to death.

OBJECTIVE

The objective of this study was to reevaluate the risk of death associated with spine fractures with and without neurologic deficit, age factors associated with it, and the impact of hospital coding on the accuracy of these efforts.

METHODS

Medical records and imaging of patients treated at a level 1 trauma center from 2014 through 2016 with discharge International Classification of Diseases, 10th revision (ICD-10) diagnoses of spinal trauma and spinal cord injury (SCI) were reviewed. Data were collected on demographics, complications, neurologic status, and outcomes.

RESULTS

Three hundred seventy patients met the criteria for inclusion in this effort. Errors in ICD-10 discharge codes were seen in 45% of the cases, both false positive and negative. One hundred thirty-four patients, with a mean age of 45, were admitted with neurologic deficit. There were 8 SCI-related deaths; 2 were postoperative out of 110 undergoing surgical treatment. All deaths in this group were in patients with upper level SCI, with a mean age of 68. Ten patients had spontaneous neurologic improvement within 24 h. One hundred nineteen patients without deficit had AIS 2 scored fractures; there was one postoperative death out of 47 patients undergoing surgical treatment. One hundred seventeen patients without deficit suffered AIS 3 fractures; 66 underwent surgery without any deaths. There was one nonoperative death. Age and high quadriplegia were the only factors associated with mortality.

CONCLUSIONS

Mortality risk in patients with deficit was associated more with age at injury than extent of anatomic injury. Spine trauma without neurologic deficit is benign in younger populations and AIS scores could be age adjusted. Mortality risk is higher in high cervical injuries with neurologic deficit and in the elderly. An incidental finding is that demographic studies based solely on discharge ICD coding may contain errors and should be considered critically.

C2 Fracture Subtypes, Incidence, and Treatment Allocation Change with Age: A Retrospective Cohort Study of 233 Consecutive Cases

The currently available data on the distribution of C2 fracture subtypes is sparse. This study was designed to identify the proportions of the second cervical vertebra (C2) fracture subtypes and to present age and gender specific incidences of subgroups. A dataset of all patients treated between 2002 and 2014 for C2 fractures was extracted from the regional hospital information system. C2 fractures were classified into odontoid fractures types 1, 2, and 3, Hangman's fractures types 1, 2, and 3, and atypical C2 fractures. 233 patients (female 51%, age 72 ± 19 years) were treated for a C2 fracture. Odontoid fractures were found in 183 patients, of which 2 were type 1, 127 type 2, and 54 type 3, while 26 of C2 fractures were Hangman's fractures and 24 were atypical C2 fractures. In the geriatric subgroup 89% of all C2 fractures were odontoid, of which 71% were type 2 and 29% type 3. There was an increasing incidence of odontoid fractures types 2 and 3 from 2002 to 2014. 40% of C2 fractures were treated surgically. This study presents reliable subset proportions of C2 fractures in a prospectively collected regional cohort. Knowledge of these proportions facilitates future epidemiological studies of C2 fractures.

What is the purpose of log roll examination in the unconscious adult trauma patient during trauma reception?

BACKGROUND

During assessment after injury, the log roll examination, in particular palpation of the thoracolumbar spine, has low sensitivity for detecting spinal injury. The manoeuvre itself requires a pause during trauma resuscitation. The aim of this study was to assess the utility of the log roll examination in unconscious trauma patients for the diagnosis of soft tissue and thoracolumbar spine injuries.

METHODS

A retrospective cohort study was undertaken, reviewing the cases of unconscious (Glasgow Coma Scale (GCS) <9) and/or intubated major trauma (Injury Severity Scale (ISS) >12, abbreviated injury scale 2008) patients from the Alfred Trauma Registry, over a 2-year period from January 2011 to December 2012. Log roll examination findings, as documented in the medical record, were compared with CT reports. Out of the 624 screened records, 222 (35.6%) were excluded as the log roll or CT/MRI had not been performed.

RESULTS

There were a total of 2028 major trauma presentations to the Alfred Hospital Emergency and Trauma Centre during the study period. Excluded cases comprised 147 patients who did not have a documented log roll, and 75 patients who did not have a CT or MRI. Of the 402 cases that met inclusion criteria, 35.3% had a thoracolumbar fracture, and the sensitivity of log roll examination was found to be 27.5%, with a specificity of 91%. The negative likelihood ratio for abnormalities on log roll was low (0.8).

CONCLUSIONS

Examination of the back in unconscious trauma patients could be limited to visual inspection only to allow identification of penetrating wounds and other soft tissue injuries (including of the posterior scalp) and removal of foreign bodies, in patients planned for CT scans. The low sensitivity and poor negative likelihood ratio suggest that a normal log roll examination does not accurately predict the absence of bony injury to the thoracolumbar spine.

Epidemiology of spinal injuries in the United Arab Emirates

Aim

To assess the risk factors, mechanism of injury, and clinical outcome of hospitalized patients with spinal injuries in order to recommend preventive measures.

Methods

Patients with spinal injuries admitted to Al Ain Hospital, United Arab Emirates (UAE) for more than 24 h or who died after arrival to the hospital were studied over 3 years. Demography, location and time of injury, affected body regions, hospital and ICU stay, and outcome were analyzed.

Results

239 patients were studied, 90 % were males, and 84 % were in the productive years of 25–54. Majority were from the Indian subcontinent (56 %). Road was the most common location for spinal injury (47 %), followed by work (39 %). The most common mechanism of injury was traffic collisions (48 %) followed by fall from height (39 %) and fall from the same level (9 %). UAE nationals were often injured at road and home compared with non-UAE nationals, who were more injured at work (p < 0.0001). Patients falling from the same level were older (p = 0.001) and predominantly females (p < 0.0001) when compared with other mechanisms. Spinal fractures were more common in the lumbar region (57 %). Eleven patients (5 %) sustained paraplegia and five (4 %) patients died.

Interpretation

Traffic injuries and falls were the leading causes for spinal injuries in the UAE. Expatriate males are at high risk for fall from height, UAE national males for traffic injuries and females for falls at the same level at homes. Prevention should focus on traffic and home injuries for UAE nationals and occupational safety for expatriate workers.