Multiple-level noncontiguous spinal fractures

A system of predictive scores to evaluate the risk of multilevel noncontiguous spinal fractures in patients with traumatic cervical spine injury

PURPOSE

To develop a predictive scoring system to identify traumatic cervical spine injury patients at a high risk of having multilevel noncontiguous spinal fractures.

METHODS

This 12-year retrospective observational cohort study included 588 traumatic cervical spine-injured patients. Patients were categorized into two groups: patients with multilevel noncontiguous spinal fractures and patients without this remote injury. Potential risk factors were examined using multivariable analysis to derive a predictive risk score from independent predictors. Results are presented as odds ratio with a 95% confidence interval (95% CI). The accuracy of the calculated predicted score was demonstrated by the area under the receiver operating characteristic curve (AuROC).

RESULTS

The incidence of noncontiguous fracture among the patients was 17% (100 of 588). The independent risk factors associated with multilevel noncontiguous spinal fractures were motor weakness, intracranial injury, intrathoracic injury, and intraabdominal injury. The AuROC of the prediction score was 0.74 (95% CI 0.69, 0.80). The patients were classified into three groups, low-risk group (score< 1), moderate-risk group (score 1-2.5), and high-risk group (score≥ 3), based on the predicted risk of multilevel noncontiguous spinal fractures.

CONCLUSIONS

This tool can potentially help preventing the missed diagnosis of cervical spine injuries with multilevel noncontiguous spinal fractures. CT scans or MRI of the entire spine to investigate remote multilevel noncontiguous spinal fractures may have a role in cervical spine-injured patients who have at least one of the independent risk factors and are strongly suggested for patients with scores in the high-risk group.

Clinical Features and Treatment Outcomes of Acute Multiple Thoracic and Lumbar Spinal Fractures : A Comparison of Continuous and Noncontinuous Fractures

Objective

The treatment of multiple thoracolumbar spine fractures according to fracture continuity has rarely been reported. Herein we evaluate the clinical features and outcomes of multiple thoracolumbar fractures depending on continuous or noncontinuous status.

Methods

From January 2010 to January 2016, 48 patients with acute thoracic and lumbar multiple fractures who underwent posterior fusion surgery were evaluated. Patients were divided into two groups (group A : continuous; group B : noncontinuous). We investigated the causes of the injuries, the locations of the injuries, the range of fusion levels, and the functional outcomes based on the patients’ general characteristics.

Results

A total of 48 patients were enrolled (group A : 25 patients; group B : 23 patients). Both groups had similar pre-surgical clinical and radiologic features. The fusion level included three segments (group A : 4; group B : 5) or four segments (group A : 19; group B : 5). Group B required more instrumented segments than did group A. Group A scored 23.5 and group B scored 33.4 on the Korean Oswestry Disability Index (KODI) at the time of last follow-up. In both groups, longer fusion was associated with worse KODI score.

Conclusion

In this study, due to the assumption of similar initial clinical and radiologic features in both group, the mechanism of multiple fractures is presumed to be the same between continuous and noncontinuous fractures. The noncontinuous fracture group had worse KODI scores in long-term follow-up, thought to be due to long fusion level. Therefore, we recommend minimizing the number of segments that are fused in multiple thoracolumbar and lumbar fractures when decompression is not necessary.

Concomitant cervical fractures without neurological symptoms: a case report

BACKGROUND

Non-contiguous spinal fractures are rare and most frequently occur in a fall from a height, or high energy trauma such as a road traffic accident (Reid, J Trauma 27:980-986, 1987). Cervical spine fractures tend to occur at two levels, one-third of injuries occur at the level of C2, and one-half of injuries occur at the level of C6 or at C7 (Wittenberg, Spine 27:254-257, 2002). The most devastating and fatal cervical spine injuries occur in upper cervical levels, either at craniocervical junction C1 or C2.

CASE REPORT

The case we present is of a young man involved in a road traffic accident in Ireland who had a concomitant non-displaced C2 vertebral body fracture and a C6-C7 fracture dislocation. The patient had no neurological symptoms.

CONCLUSION

Following concurrent ACDF at C6/7 and peg screw fixation of C2 through the same incision the patient made a full recovery.

Multilevel Noncontiguous Spinal Fractures: Surgical Approach towards Clinical Characteristics

Study Design

The study retrospectively investigated 15 cases with multilevel noncontiguous spinal fractures (MNSF).

Purpose

To clarify the evaluation of true diagnosis and to plane the surgical treatment.

Overview of Literature

MNSF are defined as fractures of the vertebral column at more than one level. High-energy injuries caused MNSF, with an incidence ranging from 1.6% to 16.7%. MNSF may be misdiagnosed due to lack of detailed neurological and radiological examinations.

Methods

Patients with metabolic, rheumatologic diseases and neoplasms were excluded. Despite the presence of a spinal fracture associated clearly with the clinical picture, all patients were scanned within spinal column by direct X-rays, computed tomography and magnetic resonance imaging. When there were ≥5 intact vertebrae between two fractured vertebral segments, each fracture region was managed with a separated stabilization. In cases with ≤4 intact segments between two fractured levels, both fractures were fixed with the same rod and screw system.

Results

There were 32 vertebra fractures in 15 patients. Eleven (73.3%) patients were male and age ranged from 20 to 64 years (35.9±13.7 years). Eleven cases were the American Spinal Injury Association (ASIA) E, 3 were ASIA A, and one was ASIA D. Ten of the 15 (66.7%) patients returned to previous social status without additional deficit or morbidity. The remaining 5 (33.3%) patients had mild or moderate improvement after surgery.

Conclusions

The spinal column should always be scanned to rule out a secondary or tertiary vertebra fracture in vertebral fractures associated with high-energy trauma. In MNSF, each fracture should be separately evaluated for decision of surgery and planned approach needs particular care. In MNSF with ≤4 intact vertebra in between, stabilization of one segment should prompt the involvement of the secondary fracture into the system.

Pediatric noncontiguous spinal injuries: the 15-year experience at a level 1 trauma center

STUDY DESIGN

Retrospective review.

OBJECTIVE

To determine the incidence and clinical characteristics of noncontiguous spinal injuries (NCSI) in a pediatric population. The secondary objective is to identify high-risk patients requiring further imaging to rule out NCSI.

SUMMARY OF BACKGROUND DATA

NCSI can add significant complexity to the diagnosis, management, and outcome of children. There is very little in the pediatric literature examining the nature, associated risk factors, management, and outcomes of NCSI.

METHODS

All children up to 18 years of age with a spinal injury, as defined by International Classification of Diseases, Ninth Revision codes, at one pediatric trauma hospital were included (n = 211). Data for patient demographics, mechanism of injury, spinal levels involved, extent of neurological injury and recovery, associated injuries, medical complications, treatment, and outcome were recorded.

RESULTS

Twenty-five (11.8%) of 211 patients had NCSI, with a median age of 13.0 years (interquartile range = 8-15). The most common pattern of injury was a double thoracic noncontiguous injury. Sixteen percent of the cases of NCSI were initially missed, with no clinical deterioration due to missed diagnosis. Associated injuries occurred in 44% of patients with NCSI. Twenty-four percent of patients with multiple NCSI had a neurological injury compared with 9.7% in patients with single-level or contiguous injuries (P = 0.046).

CONCLUSION

There is a high incidence of children with multiple NCSI who are more likely to experience neurological injuries compared with patients with single-level or contiguous spinal injuries. Patients with a single-level spinal injury on existing imaging with an associated neurological injury should undergo at least plain films of the entire spine to exclude noncontiguous injuries. In patients without neurological injury and a single spinal fracture, radiography showing at least 4 levels above and below the fracture should be performed. All children with spinal injury should have associated injuries carefully excluded.

Factors that predict poor outcomes in patients with traumatic vertebral body fractures

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

To identify factors that predict poor patient-reported outcomes in patients with traumatic vertebral body fracture(s) of the thoracic and/or lumbar spine without neurological deficit.

SUMMARY OF BACKGROUND DATA

There is a paucity of information on factors that predict poor patient-reported outcomes in patients with traumatic vertebral body fracture(s) of the thoracic and/or lumbar spine without neurological deficit.

METHODS

Patients were identified from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). VOTOR includes all patients with orthopaedic trauma admitted to the two adult Level 1 trauma centres in Victoria, Australia. Patient-reported outcomes and data on possible predictive factors, including demographic details, injury-related and treatment-based factors, were obtained from the VOTOR database. Patient-reported outcomes were measured at 12 months post-injury using the 12-Item Short-Form Health Survey (SF-12), a Numerical Rating Scale (NRS) for pain, global outcome questions and data was collected on return to work or study. For the identification of predictive factors, univariate analyses of outcome vs. each predictor were carried out first, followed by logistic multiple regression.

RESULTS

344 patients were eligible for the study and data were obtained for 264 (76.7%) patients at 12 months follow-up. Patients reported ongoing pain at 12 months post-injury (moderate-severe: 33.5%), disability (70.1%) and inability to return to work or study (23.3%). A number of demographic, injury-related and treatment-based factors were identified as being predictive of poor patient-reported outcomes. Patients who had associated radius fracture(s) were more likely to have moderate to severe disability (odds ratio (OR)=3.85, 95% confidence interval=1.30-11.39), a poorer physical health status (OR=3.73, 1.37-10.12) and moderate to severe pain (OR=3.23, 1.22-8.56) at 12 months post-injury than patients without radius fracture. Patients who did not receive compensation for work-related or road traffic-related injuries were less likely to report moderate to severe pain (OR=0.45, 0.23-0.90) or have a poorer mental health status (OR=0.17, 0.04-0.70) at 12 months post-injury than those who received compensation.

CONCLUSIONS

The prognostic factors identified in this study may assist clinicians in the identification of patients requiring more intensive follow-up or additional rehabilitation to ultimately improve patient care.

The treatment for multilevel noncontiguous spinal fractures

We report the outcome of 30 patients with multilevel noncontiguous spinal fractures treated between 2000 and 2005. Ten cases were treated conservatively (group A), eight cases were operated on at only one level (group B), and 12 cases were treated surgically at both levels (group C). All cases were followed up for 14-60 months (mean 32 months). Initial mobilisation with a wheelchair or crutches in group A was 9.2 +/- 1.1 weeks, which was significantly longer than groups B and C with 6.8+/-0.7 weeks and 3.1 +/- 0.4 weeks, respectively. Operative time and blood loss in group C were significantly more than group B. The neurological deficit improved in six cases in group A (60%), six in group B (75%) and eight in group C (80%). Correction of kyphotic deformity was significantly superior in groups C and B at the operated level, and increasing deformity occurred in groups A and B at the non-operated level. From the results we believe that three treatment strategies were suitable for multilevel noncontiguous spinal fractures, and individualised treatment should be used in these patients. In the patients treated surgically, the clinical and radiographic outcomes are much better.

Multiple level noncontiguous fractures of the spine

From 1970 to 2000, 81 patients with noncontiguous fractures of the spine were evaluated. Of these 81 patients, 36 had a neurologic deficit. Sixty-six patients with stable injuries were treated conservatively, whereas 15 patients with unstable injuries required surgical stabilization. There was no neurologic deterioration either in the patients who had surgical stabilization or in the patients who were treated conservatively. Thirteen patients with an A score on the American Spinal Injury Association neurologic impairment scale did not improve and had a high mortality rate (61.5%). Although multiple level noncontiguous fractures of the spine are uncommon, they constitute a threat to neurologic function, and therefore warrant radiographic evaluation of the entire spine with multiple injuries.

Noncontiguous unstable spine fractures

STUDY DESIGN

Evaluation of 1054 patient charts and 100 random roentgenogram charts as well as clinical investigation of 39 patients.

OBJECTIVES

Noncontiguous unstable spine fractures are rare, easy overlooked, and difficult to treat. The purpose of the study was to evaluate the delay in diagnosis and clinical and radiologic outcome of these fractures.

SUMMARY OF BACKGROUND DATA

Noncontiguous spine fractures are reported in about 1.6-16.7% in the literature. In most of the studies stable fractures, which did not need any special treatment, were also included. Therefore, in this study only unstable fractures requiring treatment were reinvestigated.

METHODS

A total of 1054 patients with fractures of the spine were treated over a period of 14 years in the spinal cord injury unit and retrospectively reviewed; 141 (13.4%) of the patients had multiple fractures, but only 39 (3.7%) had a noncontiguous spine fracture, most frequently from a fall or jump from a greater height, or traffic accidents.

RESULTS

Thirty patients (76.9%) had all fractures diagnosed at the first examination. Nine patients (23.1%) had a delayed diagnosis of the secondary lesion, but this delay resulted in no neurologic deterioration. A total of 32 extraspinal injuries were diagnosed and treated 14 times surgically. Loss of correction was seen after surgical treatment (n = 21), and increasing deformity occurred after conservative treatment (n = 18). The neurologic deficit improved in 10 conservatively (4) and operatively (6) treated patients and deteriorated in one patient after surgery.

CONCLUSION

A delayed diagnosis of the second fracture was frequently seen without clinical consequences, and neurologic improvement occurred after conservative and operative treatment. Surgical treatment resulted in significantly earlier mobilization and less kyphotic deformity.

Four-level noncontiguous fracture of the vertebral column: a case report

The case of a patient with four-level fractures of the vertebral column, located at the cervical, thoracic, lumbar, and sacral regions, three of which were unstable, is reported. There were no injuries in the appendicular skeleton. Neurological involvement was potentially caused by multilevel compressions. This patient was treated aggressively with early surgical stabilization of all unstable levels, which facilitated early expeditious rehabilitation.

Evaluation of unstable cervical spine injury: a 6-year experience

BACKGROUND

The diagnosis of the unstable cervical spine, and its subsequent management can be difficult and a missed cervical spine injury can obviously have devastating consequences.

METHODS

This study describes a 6-year experience with these injuries and presents an algorithm for their evaluation. The case records of 100 consecutive patients who underwent an operative procedure for an unstable cervical spine injury were reviewed.

RESULTS

The population and injury characteristics were similar to that of previous studies. The process of evaluation of the spine was robust but failed to identify two unstable ligamentous injuries not detected on initial radiologic examination. Ten patients whose injuries were missed at other hospitals were identified by using this system.

CONCLUSION

A systematic, well-structured approach to the potentially injured cervical spine allows safe and effective diagnosis and management of these patients. Failure to adhere to basic principles will result in missed unstable cervical spine injuries.

Chest wall trauma

Sufficient trauma to the chest can result in injury to the bony thorax and soft tissues of the chest wall, increasing patient morbidity and mortality. Fractured ribs can lacerate the pleura, lung, or abdominal organs. Fractures to upper ribs, clavicle, and upper sternum can signal brachial plexus or vascular injury. Paradoxical movement of a flail chest can impair respiratory mechanics, promote atelectasis, and impair pulmonary drainage. Most patients with thoracic spine fracture-dislocations have complete neurologic deficits. Scapular fractures, associated with other injuries in almost all patients, are frequently overlooked on supine chest radiographs. Sternal fractures, associated with clinically silent myocardial contusion, are best visualized on chest computed tomography (CT). Severe trauma to the chest wall can be associated with large chest wall hematomas or collections of air within the chest wall that can communicate with the intrathoracic space. CT scanning can easily distinguish chest wall from parenchymal or mediastinal injury, whereas this differentiation my not be possible with chest radiography.

Human head-neck biomechanics under axial tension

A significant majority of cervical spine biomechanics studies has applied the external loading in the form of compressive force vectors. In contrast, there is a paucity of data on the tensile loading of the neck structure. These data are important as the human neck not only resists compression but also has to withstand distraction due to factors such as the anatomical characteristics and loading asymmetry. Furthermore, evidence exists implicating tensile stresses to be a mechanism of cervical spinal cord injury. Recent advancements in vehicular restraint systems such as air bags may induce tension to the neck in adverse circumstances. Consequently, this study was designed to develop experimental methodologies to determine the biomechanics of the human cervical spinal structures under distractive forces. A part-to-whole approach was used in the study. Four experimental models from 15 unembalmed human cadavers were used to demonstrate the feasibility of the methodology. Structures included isolated cervical spinal cords, intervertebral disc units, skull to T3 preparations, and intact unembalmed human cadavers. Axial tensile forces were applied, and the failure load and distraction were recorded. Stiffness and energy absorbing characteristics were computed. Maximum forces for the spinal cord specimens were the lowest (278 N +/- 90). The forces increased for the intervertebral disc (569 N +/- 54). skull to T3 (1555 N +/- 459), and intact human cadaver (3373 N +/- 464) preparations, indicating the load-carrying capacities when additional components are included to the experimental model. The experimental methodologies outlined in the present study provide a basis for further investigation into the mechanism of injury and the clinical applicability of biomechanical parameters.

A comprehensive classification of thoracic and lumbar injuries

In view of the current level of knowledge and the numerous treatment possibilities, none of the existing classification systems of thoracic and lumbar injuries is completely satisfactory. As a result of more than a decade of consideration of the subject matter and a review of 1445 consecutive thoracolumbar injuries, a comprehensive classification of thoracic and lumbar injuries is proposed. The classification is primarily based on pathomorphological criteria. Categories are established according to the main mechanism of injury, pathomorphological uniformity, and in consideration of prognostic aspects regarding healing potential. The classification reflects a progressive scale of morphological damage by which the degree of instability is determined. The severity of the injury in terms of instability is expressed by its ranking within the classification system. A simple grid, the 3-3-3 scheme of the AO fracture classification, was used in grouping the injuries. This grid consists of three types: A, B, and C. Every type has three groups, each of which contains three subgroups with specifications. The types have a fundamental injury pattern which is determined by the three most important mechanisms acting on the spine: compression, distraction, and axial torque. Type A (vertebral body compression) focuses on injury patterns of the vertebral body. Type B injuries (anterior and posterior element injuries with distraction) are characterized by transverse disruption either anteriorly or posteriorly. Type C lesions (anterior and posterior element injuries with rotation) describe injury patterns resulting from axial torque. The latter are most often superimposed on either type A or type B lesions. Morphological criteria are predominantly used for further subdivision of the injuries. Severity progresses from type A through type C as well as within the types, groups, and further subdivisions. The 1445 cases were analyzed with regard to the level of the main injury, the frequency of types and groups, and the incidence of neurological deficit. Most injuries occurred around the thoracolumbar junction. The upper and lower end of the thoracolumbar spine and the T10 level were most infrequently injured. Type A fractures were found in 66.1%, type B in 14.5%, and type C in 19.4% of the cases. Stable type A1 fractures accounted for 34.7% of the total. Some injury patterns are typical for certain sections of the thoracolumbar spine and others for age groups. The neurological deficit, ranging from complete paraplegia to a single root lesion, was evaluated in 1212 cases.(ABSTRACT TRUNCATED AT 400 WORDS)

Bone mass measurement: prediction of risk

Accurate assessment of individual fracture risk requires measurement of bone mass (density). Another strong risk factor for identifying women or men who will develop fractures in the near future is the presence of previous (spine and nonspine) fractures. However, the occurrence of a low-trauma fracture almost anywhere in the skeleton is indicative of a more advanced stage of disease and is associated with a substantial, further increase in fracture risk, independent of bone mass. Thus, prevention of the first fracture should receive priority. In a clinical setting, initial assessment of bone mass can be combined with other, known risk factors and projected over the patient's remaining life expectancy, to estimate future, cumulative fracture probability. Estimates such as "remaining lifetime fracture probability" can also approximate the impact and cost-effectiveness of treatment, allowing for more objective and rational therapeutic planning for individual patients.

Bone mass and beyond: risk factors for fractures

Numerous prospective studies have demonstrated a strong relationship between bone mass and fracture risk. The fact that the bone mass distributions of fracture and nonfracture cases overlap does not necessarily indicate a shortcoming of bone mass, but might instead be due to the sporadic nature of falls and the influence of other fracture risk factors. The recent finding that prevalent fractures are strong predictors of fracture risk, independent of bone mass, suggests (but does not prove) that there may be other, potentially measurable fracture risk factors that complement, and act independently of, bone mass. This paper reviews possible mechanisms by which prevalent fractures might serve as etiologic risk factors, or as surrogate indicators of other risk factors. Potential risk factors other than bone mass and prevalent fractures are also considered. Whether or not etiologic fracture risk factors other than bone mass can be identified, it appears that treatments that influence bone will be most effective if begun early, before bone strength becomes impaired and fractures begin to occur.

Unilateral facet dislocations and fracture-dislocations of the cervical spine: a review

Unilateral facet dislocations or fracture-dislocations of the cervical spine constitute an important subgroup of cervical spine injuries. According to the literature, the diagnosis of this entity is often missed and the treatment is controversial. On the basis of our patient review, we conclude that operative intervention appears superior to nonoperative treatment of these injuries. Nonoperative management is often fraught with inability to obtain and maintain anatomic reduction and, in addition, late pain and instability frequently ensue. Alternatively, operative intervention provides the greatest probability for achieving and maintaining anatomic reduction and appears to eliminate chances of late symptoms.