Classification of thoracolumbar fractures and dislocations

Retroperitoneal arterial bleeding caused by an undisplaced conservatively treated hyperextension injury of the lumbar spine - A case report

Background

Hyperextension fractures of the thoracolumbar spine are commonly seen in ankylotic disorders due to the rigidity of the spine. The known complications include instability, neurological deficits and posttraumatic deformity but there is no report of a hemodynamic relevant arterial bleeding in undisplaced hyperextension fractures. An arterial bleeding poses a life-threatening complication and may be difficult to recognize in an ambulatory or clinical setting.

Case presentation

A 78-year-old male was brought to the emergency department after suffering a domestic fall with incapacitating lower back pain. X-rays and a CT scan revealed an undisplaced L2 hyperextension fracture which was treated conservatively. 9 days after admission, the patient complained about unprecedented abdominal pain with a CT scan disclosing a 12 × 9 × 20 cm retroperitoneal hematoma on grounds of an active arterial bleeding from a branch of the L2 lumbar artery. Subsequently, access via lumbotomy, evacuation of the hematoma and insertion of a hemostatic agent was performed. The therapy concept of the L2 fracture remained conservatively.

Conclusions

A secondary, retroperitoneal arterial bleeding after a conservatively treated undisplaced hyperextension fracture of the lumbar spine is a rare and severe complication that has not been described in literature yet and may be difficult to recognize. An early CT scan is recommended in case of a sudden onset of abdominal pain in these fractures to fasten treatment and hence decrease morbidity and mortality. Thus, this case report contributes to the awareness of this complication in a spine fracture type with increasing incidence and clinical relevance.

Posterior unilateral small fenestration of lamina combined with a custom-made Y-shaped fracture reduction device for the treatment of severe thoracolumbar burst fracture: a prospective comparative study

BACKGROUND

The purpose was to evaluate the clinical effect of a custom-made Y-shaped fracture fragment reduction device and to assist in posterior unilateral small fenestration of lamina to reduce the fracture fragments.

METHODS

In this study, 40 patients were assigned to one of two groups: the traditional reduction device group (TRG) or the Y-shaped reduction device group (YRG). All patients underwent posterior unilateral small fenestration of the lamina and direct decompression through the spinal canal. And the operation time (OT), intraoperative bleeding (IB), preoperative, postoperative, and final follow-up data on the spinal stenosis rate (SSR), Cobb angle, the anterior compression ratio of injured vertebrae (ACRIV), and ASIA neurological function grade were compared between the two groups.

RESULT

There were no complications, including vascular and nerve injury, serious postoperative infection, internal fixation fracture, or loosening, for any of the patients. And the average follow-up time of the two groups was 14.2 months, the average operation time of the TRG was 236.6 min, and the average intraoperative blood loss was 357.20 ml. Moreover, the average operation time of the YRG was 190.6 min, and the average intraoperative blood loss was 241.5 ml. There were significant differences between the two groups in terms of operation duration and intraoperative blood loss. The YRG's was lower than that of the TRG. Besides, there was no difference in SSR, Cobb angle, ACRIV, or neurological recovery between the two groups before or immediately after the operation or at the last follow-up.

CONCLUSION

The Y-shaped fracture reduction device can reduce the fracture fragments and the OT and IB stably; it also has satisfactory postoperative curative effects and clinical utility.

Automatic detection of spinal injuries under dynamic compressive loading using high-speed cine-radiography

Every year, new cases of individuals suffering from traumatic spinal injuries are detected. Advances in numerical models have allowed for the understanding of the damage caused by trauma and its impact on the patient's life. However, the kinematics and dynamics of vertebral fracture formation from its point of origin to the speed of propulsion of the fragments remain unknown. This is mainly due to the lack of data that essentially includes high-speed videos, load and displacement measurements during experimental tests reproducing spinal traumatic loading conditions. This lack of data can be addressed by the analysis of X-Ray images of animal specimens acquired during the traumatic spinal injury formation process. Thus, the purpose of this study was to develop an approach to automatically detect and track in vitro vertebral fractures using high-speed cine-radiography imaging. Four segments of porcine thoracolumbar vertebrae were dynamically compressed using a servo-hydraulic test bench. The compression process was filmed with a custom high-speed cine-radiography device, and the imaging parameters were optimized based on the physical properties of vertebrae. This paper demonstrates the feasibility of using high-speed cine-radiography imaging in this way, combined with an image processing pipeline to allow automatic documentation of the fracture's appearance and its evolution in the vertebra over time.Clinical Relevance- The proposed method will provide helpful information for proper handling of traumatic spinal injuries.

Indirect Spinal Canal Decompression Using Ligamentotaxis Compared With Direct Posterior Canal Decompression in Thoracolumbar Burst Fractures: A Prospective Randomized Study

Background

There is still no standard of care to manage thoracolumbar burst fractures. With all the recent advances, posterior approaches are still one of the mainstays of treatment. On the other hand, while spinal canal decompression in neurological impaired patients is an important goal of treatment, its technique remains controversial.This study compared the effects of direct laminectomy decompression against ligamentotaxis/indirect canal decompression on neurological and radiographic improvements.

Methods

A prospective double-blind randomized clinical trial was conducted on 60 thoracolumbar burst-fracture patients meeting our inclusion and exclusion criteria. They were randomized into 2 treatment arms: (1) direct decompression using laminectomy and (2) indirect decompression using ligamentotaxis/distraction. Each patient was observed for 6 months, and their neurological and radiographical data were collected prospectively. Statistical analysis was done by the Student t test, Friedman test, Mann Whitney-U test, Wilcoxon ranked test, and 1-way analysis of variance.

Results

Among 60 patients enrolled in our study, each treatment arm had an improvement in Frankel scores but there was no difference between the groups at any given time. After 6 months of surgery, local sagittal kyphosis improved in both groups (from 32.2 to 7.43 and 29.93 to 8.77 for the indirect and direct groups, respectively), as well as anterior vertebral height ratio (from 57.73 to 70.7 and 62.17 to 66.27 for the indirect and direct group, respectively) and posterior vertebral height ratio (from 61.17 to 74.87 and 64 to 67.5 for the indirect and direct group, respectively). For between-group comparisons after 6 months, there was a significant difference only for posterior vertebral height ratio (P = 0.040).

Conclusion

Posterior approaches with ligamentotaxis have shown to be safe and may present the same outcome as direct decompression techniques using wide laminectomy.

Comparison Between Surgical and Conservative Treatment for AOSpine Type A3 and A4 Thoracolumbar Fractures without Neurological Deficit: Prospective Observational Cohort Study

Objective  To compare the clinical results between conservative (CS) and surgical treatment (CXS) of A3 and A4 fractures without neurological deficit.

Methods  Prospective observational study of patients with thoracolumbar fractures type A3 and A4. These patients were separated between the surgical and conservative groups, and evaluated sequentially through the numeric rating scale (NRS), Roland-Morris disability questionnaire (RMDQ), EuroQol-5D (EQ-5D) quality of life questionnaire, and Denis work scale (DWS) up to 2.5 years of follow-up.

Results  Both groups showed significant improvement, with no statistical difference in pain questionnaires (NRS: CXS 2.4 ± 2.6; CS 3.5 ± 2.6; p  > 0.05), functionality (RMDQ: CS 7 ± 6.4; CXS 5.5 ± 5.2; p  > 0.05), quality of life (EQ-5D), and return to work (DWS).

Conclusion  Both treatments are viable options with equivalent clinical results. There is a tendency toward better results in the surgical treatment of A4 fractures.

Application of supervised machine learning algorithms to predict the risk of hidden blood loss during the perioperative period in thoracolumbar burst fracture patients complicated with neurological compromise

Background

Machine learning (ML) is a type of artificial intelligence (AI) and has been utilized in clinical research and practice to construct high-performing prediction models. Hidden blood loss (HBL) is prevalent during the perioperative period of spinal treatment and might result in a poor prognosis. The aim of this study was to develop a ML-based model for identifying perioperative HBL-related risk factors in patients with thoracolumbar burst fracture (TBF).

Methods

In this study, single-central TBF patients were chosen. The medical information on patients, including clinical characteristics, laboratory indicators, and surgery-related parameters, was extracted. After comparing various ML model algorithms, we selected the best model with high performance. The model was validated using the internal validation set before performing recursive feature elimination (RFE) to determine the importance of HBL-related risk factors. The area under the receiver operating characteristic (AUC) curve, accuracy (ACC), sensitivity, and specificity were reported as critical model measures for evaluating predictive performance.

Results

In this study, 62 (38.5%) of the 161 TBF patients were positive for HBL. There was a significant statistical difference in age, body mass index (BMI), diabetes, hypertension, Beta (percentage of vertebral restoration), duration of operation, and other pre-operative laboratory indicators between the HBL-positive and HBL-negative groups. Nine ML-based models were built and validated, with the Random Forest model having the greatest AUC in both the training set (0.905) and internal validation set (0.864). Furthermore, following RFE, age, duration of operation, Beta, pre-operative fibrinogen (Fib), and activated partial thromboplastin time (APTT) were identified as the five main important risk factors in patients with TBF during the perioperative period.

Conclusion

In this study, we built and validated ML algorithms for an individualized prediction of HBL-related risk factors in the perioperative period of TBF. The importance of HBL-related risk factors could be determined, which contributes to clinicians' decision-making and improves perioperative management.

Retrospective analysis of reasons and revision strategy for failed thoracolumbar fracture surgery by posterior approach: a series of 31 cases

OBJECTIVES

This study aimed to analyze the reasons for failed thoracolumbar fracture treated with posterior surgical approaches and to discuss the revision strategies for the surgical treatment.

METHODS

We retrospectively studied the patients that received failed thoracolumbar fracture (T11-L2) treatment with posterior approach and underwent revision surgery in our spine department from March 2010 to December 2020.

RESULTS

A total of 31 patients were included in this study. There were 4 (12.9%) cases of A3, 2 (6.5%) cases of B1, 5 (16.1%) cases of B2, 7 (22.6%) cases of B3, and 13 (41.9%) cases of C, according to the AO classification for thoracolumbar injuries. For load sharing classification, 26 (83.9%) cases ≥7, and 5 (16.1%) cases < 7. Regarding to the reasons for surgery failure, 26 cases (83.9%) were due to fracture of the internal fixation (pedicle screw or connecting rod) and kyphosis, 3 cases (9.7%) were due to misplacement of the posterior pedicle screw, 1 case (3.2%) was due to incomplete posterior decompression, and 1 case (3.2%) was due to scoliosis after the removal of the internal fixation. The revision surgery methods included: 2 cases (6.5%) with anterior approach, 17 cases (54.8%) with posterior approach, and 12 cases (38.7%) with posterior and anterior approach. All the patients were followed-up for 12-24 months after the revision surgery, and successful bony fusion with no internal fixation failure was observed. The kyphosis angle improved significantly after the revision surgery in 26 patients at the last follow-up, and the final correction rate was 91.8%. Frankel grading system, visual analog scale (VAS), Oswestry Disability Index (ODI) showed significant improvement at the last follow-up.

CONCLUSIONS

Types B and C of thoracolumbar fracture, load sharing classification ≥7, and the posterior approach could lead to a high failure rate. Fracture of the internal fixation was the main reason for surgery failure. Performing the posterior approach is inappropriate for every thoracolumbar fracture. Reasonable revision surgery can achieve good results for posterior surgery failure in most cases.

Surgical Considerations to Improve Recovery in Acute Spinal Cord Injury

Acute traumatic spinal cord injury (SCI) can be a devastating and costly event for individuals, their families, and the health system as a whole. Prognosis is heavily dependent on the physical extent of the injury and the severity of neurological dysfunction. If not treated urgently, individuals can suffer exacerbated secondary injury cascades that may increase tissue injury and limit recovery. Initial recognition and rapid treatment of acute SCI are vital to limiting secondary injury, reducing morbidity, and providing the best chance of functional recovery. This article aims to review the pathophysiology of SCI and the most up-to-date management of the acute traumatic SCI, specifically examining the modern approaches to surgical treatments along with the ethical limitations of research in this field.

Development and validation of a nomogram for prediction of the risk of positive hidden blood loss in the perioperative period of single-level thoracolumbar burst fracture

BACKGROUND

This study aimed to develop and validate an individualized nomogram to predict the risk of positive hidden blood loss (HBL) in patients with single-level thoracolumbar burst fracture (TBF) during the perioperative period.

METHODS

We conducted a retrospective investigation including 150 consecutive patients with TBL, and the corresponding patient data was extracted from March 2013 to March 2019. The independent risk factors for positive HBL were screened using univariate and multivariate logistic regression analyses. According to published literature and clinical experience, a series of variables were selected to develop a nomogram prediction model for positive HBL. The area under the receiver operating characteristic curves (AUC), C-index, calibration plot, and decision curve analysis (DCA) were used to evaluate the performance of the prediction model. Bootstrapping validation was performed to evaluate the performance of the model.

RESULTS

Among the 150 consecutive patients, 62 patients were positive for HBL (38.0%). The multivariate logistic regression analysis showed that the six risk factors of age, length of surgical incision, duration of operation, percentage of vertebral height restoration (P1%), preoperative total cholesterol, and preoperative fibrinogen were independent risk factors of positive HBL. The C-index was 0.831 (95% CI 0.740-0.889) and 0.845 in bootstrapping validation, respectively. The calibration curve showed that the predicted probability of the model was consistent with the actual probability. Decision curve analysis (DCA) showed that the nomogram had clinical utility.

CONCLUSION

Overall, we explored the relationship between the positive HBL requirement and predictors. The individualized prediction model for patients with single-level TBF can accurately assess the risk of positive HBL and facilitate clinical decision making. However, external validation will be needed in the future.

Lag-Screw Osteosynthesis in Thoracolumbar Pincer Fractures

STUDY DESIGN

Biomechanical.

OBJECTIVE

This study evaluates the biomechanical properties of lag-screws used in vertebral pincer fractures at the thoracolumbar junction.

METHODS

Pincer fractures were created in 18 bisegmental human specimens. The specimens were assigned to three groups depending on their treatment perspective, either bolted, with the thread positioned in the cortical or cancellous bone, or control. The specimens were mounted in a servo-hydraulic testing machine and loaded with a 500 N follower load. They were consecutively tested in 3 different conditions: intact, fractured, and bolted/control. For each condition 10 cycles in extension/flexion, torsion, and lateral bending were applied. After each tested condition, a computed tomography (CT) scan was performed. Finally, an extension/flexion fatigue loading was applied to all specimens.

RESULTS

Biomechanical results revealed a nonsignificant increase in stiffness in extension/flexion of the fractured specimens compared with the intact ones. For lateral bending and torsion, the stiffness was significantly lower. Compared with the fractured specimens, no changes in stiffness due to bolting were discovered. CT scans showed an increasing fracture gap during axial loading both in extension/flexion, torsion, and lateral bending in the control specimens. In bolted specimens, the anterior fragment was approximated, and the fracture gap nullified. This refers to both the cortical and the cancellous thread positions.

CONCLUSION

The results of this study concerning the effect of lag-screws on pincer fractures appear promising. Though there was little effect on stiffness, CT scans reveal a bony contact in the bolted specimens, which is a requirement for bony healing.

Outcomes of Thoracolumbar Fracture-Dislocation Managed by Short-Segment and Long-Segment Posterior Fixation: A Single-Center Retrospective Study

BACKGROUND

Long-segment posterior fixation has been used as a mainstay treatment of spine fracture-dislocations. Studies using short-segment posterior fixation in cases of thoracolumbar fracture-dislocation are limited. We describe our experience of 26 patients with thoracolumbar fracture-dislocation treated by short-segment or long-segment posterior spinal fixation and fusion.

METHODS

This is a single-center retrospective study of 26 patients with thoracolumbar fracture-dislocation treated by long-segment (group 1, n = 12) and short-segment posterior instrumentation (group 2, n = 14). Clinical (visual analog scale [VAS], Oswestry Disability Index [ODI]), neurological (American Spinal Injury Association [ASIA] scale), radiological (kyphotic angle, translational percentage, and displacement angle), and surgical (blood loss, operative time) outcomes and complications were recorded with each method. The mean follow-up period was 8.64 months (6-20 months).

RESULTS

The mean duration of surgery was 3.92 ± 0.67 hours in group 1 and 3.21 ± 0.54 hours in group 2, and mean blood loss was 583.33 ± 111.5 mL and 478.6 ±112.2 mL in groups 1 and 2, respectively (P < .05). There was no radiologically visible pseudarthrosis, implant failure, or screw breakage in either group at follow up with no statistically significant difference between the 2 groups with regard to the radiological outcome (P > .05). Two patients in group 1 and 6 patients in group 2 improved after surgery at least 1 ASIA grade. VAS and ODI improved in both groups at the final follow up.

CONCLUSIONS

Short-segment fixation can be used for treating fracture-dislocation patients, as it results in less blood loss, decreased intraoperative time, and saves fusion segments with similar radiological and clinical outcomes as long-segment fixation.

LEVEL OF EVIDENCE

3.

Effect of manual reduction and indirect decompression on thoracolumbar burst fracture: a comparison study

OBJECTIVE

To evaluate the effect of manual reduction and indirect decompression on thoracolumbar burst fracture.

METHODS

Sixty patients with thoracolumbar burst fracture who were hospitalized from January 2018 to October 2019 were selected and divided into an experimental group (33 cases) and control group (27 cases) according to different treatment methods. The experimental group was treated with manual reduction and indirect decompression, while the control group was not treated with manual reduction. The operation time and intraoperative blood loss were recorded. VAS score was used to evaluate the improvement of pain. The anterior height of the injured vertebra, wedge angle of the injured vertebral body, and encroachment ratio of the injured vertebral canal were used to evaluate the spinal canal decompression and fracture reduction. JOA score was used to evaluate the improvement of spinal function.

RESULTS

There was no significant difference in operation time and intraoperative blood loss between the two groups. Compared with the control group, the VAS score and the wedge angle of the injured vertebral body of the experimental group 3 days after the operation and the last follow-up were significantly lower than that of the control group, and the difference was statistically significant. The ratio of the anterior height of the injured vertebra of the experimental group 3 days after the operation and the last follow-up was significantly higher than that of the control group, and the difference was statistically significant. The difference of the encroachment ratio of the injured vertebral canal between preoperation and 3 days after operation was significantly higher than that of the control group, and the difference was statistically significant. The bladder function of JOA 3 days after the operation of the experimental group was significantly higher than that of the control group, and the difference was statistically significant. And the rest aspect of JOA on 3 days after the operation and last follow-up of the experimental group has no significant difference compared with the control group.

CONCLUSION

Manipulative reduction and indirect decompression can obtain a better clinical effect in the treatment of thoracolumbar burst fractures.

Analysis of intervertebral discs adjacent to thoracolumbar A3 fractures treated by percutaneous instrumentation and kyphoplasty

INTRODUCTION

Percutaneous instrumentation and kyphoplasty can be used to treat A3 fractures at T12-L1. However, the effect on adjacent intervertebral discs remains controversial. The purpose of this retrospective study was to analyze the degeneration of the discs adjacent to the fracture and to determine its relationship with age, vertebral body deformity and clinical scores.

MATERIALS AND METHODS

Twenty-nine patients (11 females, 18 males; average age 47 years, 27-63 years) were examined at 2.2 years' follow-up (2.0-2.5). Radiographic measurements were taken preoperatively, postoperatively, at follow-up: regional and local kyphosis, sagittal index, vertebral body compression ratio, and disc height index. The Pfirrmann grade was determined on an MRI taken at the final assessment. Clinical scores were the pain level (VAS), EQ-5D-3L, and ODI. The relationships between Pfirrmann grades, age and radiographic parameters were analyzed.

RESULTS

Local kyphosis decreased from 12.4° to 7.3° postoperatively (p<0.0001), increased to 8.4° after instrumentation removal (p=0.139) and remained stable at the last follow-up (p=0.891). The sagittal index decreased from 12.3° to 7.3° postoperatively (p<0.0001) increased to 8.3° before the instrumentation was removed (p=0.764) and increased to 10.6° (p<0.05) at the last follow-up. The vertebral body compression ratio decreased from 23% to 14% postoperatively (p<0.0001) and remained stable at 17% at the last follow-up (p=0.310). The cranial disc height index was 32% preoperatively, 31% postoperatively (p=0.073), 29% at 1year (p=0.650), and decreased again to 23% at 2 years (p<0.0001). There was a significant relationship between disc degeneration and age (p=0.015), local kyphosis (p=0.008) and vertebral body compression ratio (p=0.002). The disc adjacent to the fracture was more likely to have a higher Pfirrmann grade than the control disc above it (OR=269.5). At the final assessment, the average pain level was 2.3, the EQ-5D-3L was 0.862, and the ODI was 11.8%. There was no significant relationship between the Pfirrmann grades and the clinical scores.

CONCLUSION

The risk for cranial disc degeneration after percutaneous instrumentation and kyphoplasty of A3 fractures is low. The height of the cranial disc decreased after the instrumentation was removed. The risk for disc degeneration is related to age and vertebral body deformity. Disc degeneration does not appear to impact quality of life.

Necessity of Direct Decompression for Thoracolumbar Junction Burst Fractures with Neurological Compromise

BACKGROUND

Surgical management of burst fractures is controversial, with many different operative options. From a posterior approach, decompression of the spinal cord can be performed through both indirect and direct methods, the former relying on ligamentotaxis. It is unclear whether indirect decompression with ligamentotaxis is as effective as direct decompression.

METHODS

Prospective, randomized controlled data were retrospectively analyzed to include only burst fractures of the thoracolumbar junction. Patients were treated with either direct decompression, involving wide posterior decompression in addition to operative stabilization, or indirect decompression, where decompression was performed solely through ligamentotaxis. Patients were followed up at 6 months with clinical assessment and imaging. Additional clinical assessment was performed at 1 year. For all analyses, P < 0.05 was significant.

RESULTS

The study included 46 patients, with 18 patients in the direct decompression subgroup and 28 patients in the indirect decompression subgroup. The average age of the full cohort was 35.1 ± 13.1 years (range, 16-60 years). Most patients had L1 fractures (21/46; 46%), with an AOSpine classification type A4 fracture morphology (17/46; 37%), and were American Spinal Injury Association grade B (18/46; 39%). Both treatments resulted in similar increases in canal diameter and decreases in dural sac compromise (P > 0.5) at 6-month follow-up. Both treatments resulted in similar grades of neurological improvement (P = 0.575) at 1 year.

CONCLUSIONS

There were no significant differences in clinical and imaging outcomes when comparing direct decompression with ligamentotaxis. Ligamentotaxis alone may be effective in carefully selected cases.

Thoracolumbar fracture classification: evolution, merits, demerits, updates, and concept of stability

Thoracolumbar fracture classification system is required to facilitate effective communication between spine surgeons, to guide treatment, and to help predict the prognosis. An ideal classification system should be simple, comprehensive, reliable, and reproducible with predictive outcomes. Unfortunately, most of the existing classifications have certain merits and demerits and they failed to fulfill the above criteria; some are oversimplified while others are too inclusive and complex for routine use. Given the scenario where none of the classifications is accepted worldwide, it is imperative to understand the evolution of thoracolumbar injury classification. The authors concisely review the subject from its inception in the year 1929 to the present day.

Thoracic hyperextension injury with opening wedge distraction fracture in DISH -consideration of surgical strategy based on intraoperative pathological findings

Diffuse idiopathic skeletal hyperostosis (DISH) is a well-recognized disease characterized by calcifications and ossifications of the entheses mainly in the spine. Patients with DISH are prone to sustaining spinal injuries even after minor trauma because of the long-lever arm mechanism induced by any type of force acting on the rigid yet brittle spine. The number of cases of trauma in DISH-affected spines is predicted to increase during the coming decades because of an increase in DISH-related comorbidities. Generally, posterior fixation with spinal instrumentation spanning three levels above and below the injured site is regarded as a standard treatment for hyperextension fractures of the thoracolumbar spine in patients with DISH. However, no consensus has been reached regarding whether additional anterior fixation is needed for hyperextension injuries with remarkable vertebral body wedge. We experienced one case of hyperextension injury at the thoracic level in patient with DISH. A remarkable remodeling phenomenon in the fractured vertebral body was intraoperatively noticed, which was pathologically confirmed. This is the first report to have confirmed pathologically new bone formation in the anterior column wedge despite the fact that only 1 month had passed since the first injury. Although whether additional anterior fixation is needed for hyperextension injuries with remarkable vertebral body wedge is controversial, this report supports that posterior fixation alone might be an adequate treatment.

Surgical treatment of traumatic thoracolumbar fractures: a retrospective review of 101 cases

PURPOSE

To evaluate the outcomes of vertebral stabilisation after acute traumatic thoracolumbar fractures, correlating the outcome with patient clinical data, type and location of fracture, presence of neurological damage, timing of surgical intervention and number of instrumented levels. The results have been evaluated also through the AO classification and AOSIS score.

METHODS

Retrospective analysis of 101 patients with traumatic thoracolumbar injuries from T3 to L5 operated 2011-2016 by posterior or antero-posterior fixation. The demographic data, trauma dynamics, number and type of fractures, associated lesions, timing of surgery, hospital stay, AOSIS score, RKA, SF-36 and ODI scores, pre- and post-operative neurological condition (ASIA grade), possible complications and re-interventions were evaluated for each patient.

RESULTS

Fractures mainly involved the region between T11 and L2. The probability of medullary involvement increases with the increase in severity of the main fracture type with no relation with the vertebral region. Type B and C fractures were common in the thoracic region and rare in the thoracolumbar junction. ODI and SF-36 scores were significantly better in patients with a lower AOSIS score, specifically in lesions classified as type A, amyelic and with no comorbidity. No difference was found in the clinical scores between thoracic, thoracolumbar and lumbar fractures, nor between male and female patients. None of the 10 patients with ASIA A lesion at presentation achieved any degree of recovery: 50% of them had a thoracic lesion. Re-intervention rate was 15%. Hospital stay was significantly higher in patients with type C fractures, and complication rate was on average 14% (7% in type A fractures, 16% in B and 25% in C).

CONCLUSIONS

This study confirmed the validity of the posterior approach in the surgical treatment of thoracolumbar fractures. Outcomes and complication risks are related to fracture severity. Surgical treatment can be recommended even with an AOSIS score of two or three. The combined antero-posterior approach could be useful in cases with LSC > 8, especially in the thoracolumbar region. The degree of neurological recovery depends on fracture type, location, ASIA score and presence of comorbidities. Early intervention in myelic patients allows for a better prognosis. Level of evidence III retrospective case series.

Minimally Invasive Decompression and Intracorporeal Bone Grafting Combined with Temporary Percutaneous Short-Segment Pedicle Screw Fixation for Treatment of Thoracolumbar Burst Fracture with Neurological Deficits

OBJECTIVE

We evaluated the clinical and radiographic outcomes of patients with thoracolumbar burst fractures and neurological deficits treated with minimally invasive decompression and intracorporeal bone grafting combined with percutaneous short-segment stabilization.

METHODS

Patients with thoracolumbar burst fractures and neurological deficits underwent minimally invasive decompression and intracorporeal bone grafting combined with percutaneous short-segment stabilization. Instrumentation was removed approximately 1 year after vertebral fracture union. The clinical and radiographic outcomes were analyzed.

RESULTS

The mean operative duration and intraoperative bleeding volume were 135 ± 63 minutes and 120 ± 200 mL, respectively. The average American Spinal Injury Association impairment scale scores had significantly improved at the final follow-up examination. The visual analog scale score had decreased from 7.8 ± 1.1 preoperatively to <2.9 ± 1.3 (P < 0.05) at 1 week postoperatively. The Oswestry disability index had decreased from 86.1 ± 8.8 preoperatively to 15.9 ± 6.4 (P < 0.05) at 1 year postoperatively. The canal stenosis index had improved from 43.4% ± 12.0% to 93.8% ± 4.8% (P < 0.05). The sagittal Cobb angle had been corrected from 17.8° ± 7.5° to 4.0° ± 1.9° (P < 0.05) and remained at 4.9° ± 2.0° (P > 0.05) at 1 year postoperatively. The sagittal index had been corrected from 16.6° ± 6.1° to 0.3° ± 4.6° (P < 0.05) and remained at 1.5° + 4.5° (P > 0.05) at 1 year postoperatively. The anterior vertebral height had increased from 49.3% ± 11.1% to 97.6% ± 6.5% (P < 0.05) and remained at 95.7% ± 6.0% (P > 0.05) at 1 year postoperatively. After implant removal, the total kyphosis correction losses were 1.5° ± 0.8° for the Cobb angle, 2.0° ± 1.1° for the sagittal index, and 3.4% ± 2.1% for the anterior vertebral height. One pullout screw and one broken rod were found in 1 patient each.

CONCLUSION

Minimally invasive decompression and intracorporeal bone grafting combined with percutaneous short-segment fixation yielded satisfactory results in decompression and immediate kyphosis correction. Additionally, this procedure resulted in maintenance of the vertebral height and prevented late correction loss after implant removal.

Evaluation of pain reduction and height restoration post vertebral augmentation using a polyether ether ketone (PEEK) polymer implant for the treatment of split (Magerl A2) vertebral fractures: a prospective, long-term, non-randomized study

OBJECTIVES

The purposes of the study were to evaluate the safety and long-term efficacy of augmented vertebroplasty using a polyether ether ketone (PEEK) implant, for the treatment of lumbar or thoracic vertebral fractures (A2 according to the Magerl's AO classification) and to analyze pain reduction, height restoration, and complications during a 2-year follow-up period.

METHODS

Prospective non-randomized evaluation was performed for 21 painful split vertebral fractures (20 patients, 14 females, 6 males; mean age 72.80 ± 10.991) treated with percutaneous vertebral augmentation using a PEEK device, under fluoroscopic guidance. Pain before the procedure and after 6, 12, and 24 months was evaluated using a numeric visual scale (NVS) questionnaire. Imaging was performed by CT and X-rays. The minimum craniocaudal diameter at the level of the fracture and the maximum craniocaudal diameter at the middle of the fractured vertebra were measured. Statistical analysis was performed to evaluate pain decrease and height restoration.

RESULTS

Successful implant positioning was achieved in all cases. No major clinical complications were observed. Comparing the mean pain scores at baseline (8.69 ± 1.138) and the first day after the treatment (1.19 ± 1.424), there was a decrease of 7.50 NVS units (p < 0.001). Minimum and maximum vertebral body heights were increased after the procedure 56.58% and 13.7% respectively (p < 0.001). Both pain relief and height restoration remained statistically significant (p < 0.001) during the follow-up period.

CONCLUSION

A2 Magerl thoracic or lumbar fractures could be successfully treated with PEEK implant-assisted vertebral augmentation. Randomized studies with larger sample sizes should be done to confirm the effectiveness of the technique.

KEY POINTS

• Vertebral augmentation using a PEEK implant for the treatment of A2 Magerl lumbar or thoracic vertebral fractures seems to be effective both in terms of pain reduction and height restoration. • Effects on pain reduction and height restoration have a long-term duration. • The technique seems to be safe for the treatment of A2 Magerl fractures, without major complications in our study group.

Treatment of a High-risk Thoracolumbar Compression Fracture Using Bilateral Expandable Titanium SpineJack Implants

In this case, an 80-year-old active patient developed an acute osteoporotic fracture after a fall at L1 above a previous interlaminar implant at L4-5 for stenosis with neurogenic claudication. Radiologic studies found both intra-discal and intra-vertebral vacuum clefts that are highly correlated with instability and progressive kyphosis. Long-term experience with kyphoplasty has shown that acute and subacute fractures can often be re-expanded; however, over three months to one year, the correction is frequently lost and the vertebral height continues to decrease leading to increased risk of both continued deformity and especially adjacent level fractures. The use of newly available titanium intra-vertebral implants combined with bone cement restores and maintains vertebral height and correction of deformities. Long-term studies also demonstrate a reduced risk of adjacent level fractures compared to balloon kyphoplasty. Using vertebral body implants that remain in place within the fractured vertebral body the initial height correction can be better maintained leading to less adjacent level fractures.

Can an unipedicular approach replace bipedicular percutaneous vertebroplasty for osteoporotic vertebral compression fracture?

OBJECTIVE

To compare outcomes of unipedicular versus bipedicular approach for percutaneous vertebroplasty for the treatment of thoracolumbar acute osteoporotic vertebral compression fracture (AOVCF).

METHOD

From November 2014 to September 2015, 382 patients with AOVCF were randomly assigned to the unipedicular and bipedicular groups. Clinical outcomes and complications were compared.

RESULTS

Both groups were comparable with respect to bone cement leakage and adjacent vertebral fractures (P> 0.05). Although the bipedicular approach was found to be superior in terms of reduction of kyphosis and loss of reduction, frequency of x-ray fluoroscopy, VAS and ODI scores, the volume of cement injected and operating time, the between-group differences were not statistically significant (P> 0.05). Nerve root stimulation was more frequent in the unipedicular group (P< 0.05).

CONCLUSIONS

The clinical and radiological outcomes of both procedures were comparable. The unipedicular approach was associated with more nerve root stimulation.

Instability and impending instability in patients with vertebral metastatic disease

Metastatic disease commonly involves the spine with an increasing incidence due to a worldwide rise of cancer incidence and a longer survival of patients with osseous metastases. Metastases compromise the mechanical integrity of the vertebra and make it susceptible to fracture. Patients with pathological vertebral fracture often become symptomatic, with mechanical pain generally due to intervertebral instability, and may develop spinal cord compression and neurological deficits. Advances in imaging, radiotherapy, as well as in spinal surgery techniques, have allowed the evolution from conventional palliative external beam radiotherapy to modern stereotactic radiosurgery and from traditional open surgery to less-invasive, and sometimes prophylactic stabilization surgical treatments. It is therefore clear that fracture risk prediction, and maintenance or restoration of intervertebral stability, are important objectives in the management of these patients. Correlation between imaging findings and clinical manifestations is crucial, and a common knowledge base for treatment team members rather than a compartmentalized view is very important. This article reviews the literature on the imaging and clinical diagnosis of intervertebral instability and impending instability in the setting of spine metastatic disease, including the spinal instability neoplastic score, which is a reliable tool for diagnosing unstable or potentially unstable metastatic spinal lesions, and on the different elements considered for treatment.

Usefulness of antero-posterior radiograph and variability of management in non-major thoracolumbar injuries: a single centre pilot study and review of literature

Background

Most adult trauma protocols suggest that where there has been a dangerous mechanism of injury or the patient exhibits abnormal physiology, CT scan is the primary radiological investigation. Other patients who may have suffered thoraco-lumbar (T-L) trauma initially have antero-posterior (AP) and lateral plain X-rays performed. Our clinical experience suggests AP views are not particularly useful in the management of these relatively low-velocity injuries. This is the first study intended to determine the contribution made by AP X-rays in these cases.

Methods

Adults with a history of T-L trauma referred to our tertiary spinal service over 20 weeks were reviewed. Those with a CT scan performed prior to X-rays were excluded. Four spine surgeons and four neuroradiologists were independently shown lateral X-rays along with the clinical details and asked to provide a management plan. Then they were shown the AP X-rays and asked if they would like to change their advice.

Results

Fifty-two patients were identified. Thirty-four sets of supine and 40 sets of erect X-rays were included (four people only had lateral X-rays performed), yielding 1152 film views. Average patient age was 58.3 years with 30 (58%) males. Forty-five (87%) were AO type A (compression-type) fractures. Seven (13%) had been erroneously referred with a diagnosis of acute fracture, which on review was not considered to be the case. Fifty-four percent of fractures were between T11 and L2. Forty-six percent appeared osteoporotic.

In no instance did evaluation of the AP X-ray change the management plan which had been suggested following the evaluation of the lateral X-ray alone. However, there was significant variation in advice on further management between consultants.

Conclusions

Our results suggest AP X-rays do not contribute to the management of low-velocity thoraco-lumbar traumas. Larger studies are required to support these findings, but there appears to be a potential to reduce both cost and radiation exposure. More importantly, it demonstrates there is large variability in the management of such patients due to the lack of evidence-based protocols.

Risk Factor of Failed Reduction of Posterior Ligamentatoxis Reduction Instrumentation in Managing Thoracolumbar Burst Fractures: A Retrospective Study

OBJECTIVE

To determine whether radiographic findings associated with thoracolumbar burst fractures could be predictors of failure of short-segment posterior instrumentation with insertion screw at the fracture level (SSPI-f).

METHODS

Seventy-five patients with thoracolumbar burst fracture surgically treated by SSPI-f were enrolled in the study and divided into 2 groups: a reduction group (n = 46) and a failed-reduction group (n = 29). Radiographic data including local kyphosis, Cobb angle, anterior vertebral height, posterior vertebral height (PVH), anterior/posterior vertebral height ratio, interpedicle distance (IPD), bony compress area, bony fracture area, and compress-fracture area of the fractured vertebra and clinical data including age and neurologic function were also analyzed. t test, Pearson χ² test, and binary logistic regression were performed to compare the values.

RESULTS

The PVH in the failed-reduction group was smaller than that of the reduction group (83.5% ± 7.2% and 89.1% ± 5.4%, respectively) (P = 0.001). The IPD differed between the reduction and failed-reduction group (18.0% ± 4.1% and 25.8% ± 7.1%, respectively) (P < 0.001). There was a statistical difference between the 2 groups in delayed time before surgery (P = 0.008). There was a significant difference of bony fracture area and compress-fracture area of the fractured vertebra between the failed-reduction and reduction group (both P < 0.001). Binary logistic regression showed that IPD was a risk factor of reduction failure of SSPI-f (P = 0.001).

CONCLUSIONS

These results showed that increased IPD was a risk factor of failed-reduction of SSPI-f in managing thoracolumbar burst fractures, particularly for patients with neurologic deficit, whereas local kyphosis, Cobb angle, anterior vertebral height, PVH, anterior/posterior vertebral height ratio, bony compress area, bony fracture area, and compress-fracture area of the fractured vertebra were not.

Biomechanical tolerance of whole lumbar spines in straightened posture subjected to axial acceleration

Quantification of biomechanical tolerance is necessary for injury prediction and protection of vehicular occupants. This study experimentally quantified lumbar spine axial tolerance during accelerative environments simulating a variety of military and civilian scenarios. Intact human lumbar spines (T12-L5) were dynamically loaded using a custom-built drop tower. Twenty-three specimens were tested at sub-failure and failure levels consisting of peak axial forces between 2.6 and 7.9 kN and corresponding peak accelerations between 7 and 57 g. Military aircraft ejection and helicopter crashes fall within these high axial acceleration ranges. Testing was stopped following injury detection. Both peak force and acceleration were significant (p < 0.0001) injury predictors. Injury probability curves using parametric survival analysis were created for peak acceleration and peak force. Fifty-percent probability of injury (95%CI) for force and acceleration were 4.5 (3.9-5.2 kN), and 16 (13-19 g). A majority of injuries affected the L1 spinal level. Peak axial forces and accelerations were greater for specimens that sustained multiple injuries or injuries at L2-L5 spinal levels. In general, force-based tolerance was consistent with previous shorter-segment lumbar spine testing (3-5 vertebrae), although studies incorporating isolated vertebral bodies reported higher tolerance attributable to a different injury mechanism involving structural failure of the cortical shell. This study identified novel outcomes with regard to injury patterns, wherein more violent exposures produced more injuries in the caudal lumbar spine. This caudal migration was likely attributable to increased injury tolerance at lower lumbar spinal levels and a faster inertial mass recruitment process for high rate load application. Published 2017. This article is a U.S. Government work and is in the public domain in the USA. J Orthop Res 36:1747-1756, 2018.

Posterior Distraction and Instrumentation Cannot Always Reduce Displaced and Rotated Posterosuperior Fracture Fragments in Thoracolumbar Burst Fracture

STUDY DESIGN

A retrospective clinical study.

OBJECTIVE

To determine the imaging features that can be used to predict failure of reduction of a retropulsed fracture fragment by posterior ligamentotaxis in thoracolumbar burst fractures.

SUMMARY OF BACKGROUND DATA

Posterior instrumentation and distraction with ligamentotaxis has been successfully used to shift retropulsed fragments anteriorly in thoracolumbar burst fractures. However, posterior longitudinal ligament rupture can lead to treatment failure. The exact preoperative radiographical parameters associated with failure of reduction remain unknown.

MATERIALS AND METHODS

A total of 85 patients who suffered from thoracolumbar burst fractures with significant retropulsion of fragments into the spinal canal, as confirmed by preoperative computed tomography and followed by postoperative computed tomography, were retrospectively analyzed. Seventy-three patients (85.9%) in whom the fragments were reduced by ligamentotaxis were included in the reduced group. In 12 patients (14.1%), the fracture fragment in the spinal canal was not reduced, and these patients were included in the nonreduced group. Neurologic status was classified according to the scoring system of the American Spinal Injury Association (ASIA). The displaced distance and rotation angle of the fracture fragment were measured at the fractured segment.

RESULTS

Preoperatively,the average displacement distances into the spinal canal of rotated posterosuperior fragments was 0.53 cm in the reduced group and 0.94 cm in the nonreduced group (P=0.002). The average rotation angles of the fracture fragments were 43.2 degrees in the reduced group and 61.7 degrees in the nonreduced group (P=0.012). "Double cortical surfaces" of the fragment were observed in the nonreduced patients. Neurological function was evaluated and recorded at the 2-year follow-up examination. There was no significant difference in the ASIA recovery grade between the 2 groups (P=0.668).

CONCLUSIONS

Displaced and rotated posterosuperior fracture fragments in thoracolumbar burst fracture cannot always be reduced by posterior ligamentotaxis. The 2 criteria for treatment failure that were most consistently present in our series were a displacement distance greater than 0.85 cm and a rotation angle greater than 55 degrees.

Treatment of Lumbar Split Fracture-Dislocation With Short-Segment or Long-Segment Posterior Fixation and Anterior Fusion

STUDY DESIGN

Retrospective analysis of 16 patients.

SUMMARY OF BACKGROUND DATA

The lumbar split fracture-dislocation is a rare but severe injury, which is type C1.2.1 fracture in the Association for the Study of Internal Fixation spine fracture classification. The axial compressive and torsional force shattered the vertebral body into 2 halves and displaced them rotationally. This kind of fracture is so highly unstable that the treatment is very challenging.

PURPOSE

The purpose of this study was to report and compare on clinical outcome and complications of patients with lumbar split fracture-dislocation which had been treated either short-segment or long-segment posterior fixation and anterior fusion.

MATERIALS AND METHODS

A total of 16 patients with acute, split fracture-dislocation of the lumbar spine from March 2000 to May 2009 in our department were recruited. Seven patients (group I) treated by long-segment posterior fixation (2 levels above and 2 below the fracture) and anterior corpectomy and strut grafting. With the improvement of surgical technique and instrument, 9 patients after August 2004 were treated by short-segment posterior fixation (1 level above and 1 below, and included the fractured vertebrae itself) and anterior discectomy and strut grafting. The intraoperative blood loss, operation time, complications of operation, time to achieve bony fusion, Frankel scale, Oswestry Disability index, and Visual Analogue Pain Scale the Cobb angle were collected and compared.

RESULTS

The mean follow-up was 33.4 months for group I and 36.2 months for group II. The operation time was 457.1 minutes in group I which was significantly longer than 240.0 minutes in group II. The total blood loss was for group I was 2001.4 mL (range, 1580-2500 mL) and for group II was 730.6 mL (range, 430-950 mL). There was no neurological deterioration after surgery in both group and no difference in neurological outcome between the 2 groups. The loss of correction in Cobb angle averaged at the final evaluation was 2 and 5 degrees for groups I and II, respectively. There was no radiologically visible pseudarthrosis. The postoperative Visual Analogue Pain Scale score was 3.3 and 2.7 for groups I and II, respectively. In the SF-36 survey, after surgery the domains Role physical and Bodily pain improved significantly only in group B (P<0.05 and P=0.06, respectively). Time to achieve bony fusion in group I was 7.9 months which was significantly longer than 3.8 months in group II. Complications included 3 urinary infections, 1 decubitus ulcer, and 1 superficial infection that were cured by antibiotics. Screw breakage was found in 1 patient in the group II.

CONCLUSIONS

The lumbar sagittal split fracture-dislocation is a rare but severe injury, which can be treated either with short-segment or long-segment posterior fixation and anterior fusion. The short construct with pedicle screws in the fractured vertebrae followed by the maneuver of rod derotation can obtain anatomic reduction, restoration of 3-column alignment, and decompress the affected neural elements by restoration of the normal canal dimension. It may be a better therapeutic option for the highly unstable lumbar fracture of C1.2.1.

Update on traumatic acute spinal cord injury. Part 2

The aim of treatment in acute traumatic spinal cord injury is to preserve residual neurologic function, avoid secondary injury, and restore spinal alignment and stability. In this second part of the review, we describe the management of spinal cord injury focusing on issues related to short-term respiratory management, where the preservation of diaphragmatic function is a priority, with prediction of the duration of mechanical ventilation and the need for tracheostomy. Surgical assessment of spinal injuries based on updated criteria is discussed, taking into account that although the type of intervention depends on the surgical team, nowadays treatment should afford early spinal decompression and stabilization. Within a comprehensive strategy in spinal cord injury, it is essential to identify and properly treat patient anxiety and pain associated to spinal cord injury, as well as to prevent and ensure the early diagnosis of complications secondary to spinal cord injury (thromboembolic disease, gastrointestinal and urinary disorders, pressure ulcers).

Evaluation of the safety and reliability of the newly-proposed AO spine injury classification system

OBJECTIVE

To evaluate the safety and reliability of the new AO Classification, a recent classification system for Thoraco-Lumbar Spine Trauma (TLST).

DESIGN

Retrospective study.

METHODS

We applied the new AO system in patients with TLST treated according to the TLICS. Two researchers classified injuries independently. Eight weeks later, the classification was repeated for intra and inter-observer agreement evaluation. To evaluate safety, we correlated the treatment performed based on the TLICS with the newer AO classification obtained.

RESULTS

Fifty-four patients were included in this study, with a mean follow-up of 363.8 days. Twenty-three neurologically intact patients were initially treated conservatively. Their mean TLICS was 1.78 (1-4 points). Four patients underwent late surgery. Thirty-one patients were treated surgically. Their average TLICS was 7.22 points (4-10 points). Agreements in the four independent evaluations according to AO groups and subgroups were of 64.8% (35/54) and 55.5% (30/54) respectively. Kappa index for groups A, B and C was 0.75, 0.7 and 0.85 respectively. Kappa index for subgroups ranged from 0.16 to 0.85. Regarding safety, thirty (57.6%) patients with total subgroups agreement were analyzed. All patients with fracture in groups B and C underwent surgical treatment and patients in group A received surgery according to neurological status or failure of conservative treatment.

CONCLUSION

The newer AO spine classification demonstrated good reliability at the level of groups. Subgroups demonstrated worse and varying reliability. Although the safety analysis was limited due to the low level of total concordance among all evaluations, patients from group A can be treated conservatively or surgically, whereas those from groups B and C are treated surgically.

RELIABILITY OF THE AO CLASSIFICATION OF THORACOLUMBAR FRACTURES COMPARED TO TLICS AND MAGERL

ABSTRACT Objective: To test the reliability of the new AO/2013 classification compared with AO/Magerl and TLICS. Methods: Four spine surgeons retrospectively and blindly evaluated imaging and clinical data from 98 patients with thoracolumbar fractures. Results: Using the Kappa coefficient, we obtained the best reproducibility for the AO/2013 classification compared to the other two, represented by Kappa coefficient of 0.690. We could also obtain, with good reproducibility among the evaluators (Kappa 0.690), the most common subtypes of AO/2013 classification with indication for surgery. Conclusion: We believe that the new AO/2013 classification has proven to be a good communication tool among spine surgeons with good reproducibility, but more studies should be conducted in several centers in order to be consolidated and so that the prognosis between the types of injury is better understood.

Reliability and reproducibility analysis of the AOSpine thoracolumbar spine injury classification system by Chinese spinal surgeons

PURPOSE

The objective of this study was to analyze the interobserver reliability and intraobserver reproducibility of the new AOSpine thoracolumbar spine injury classification system in young Chinese orthopedic surgeons with different levels of experience in spinal trauma. Previous reports suggest that the new AOSpine thoracolumbar spine injury classification system demonstrates acceptable interobserver reliability and intraobserver reproducibility. However, there are few studies in Asia, especially in China.

METHODS

The AOSpine thoracolumbar spine injury classification system was applied to 109 patients with acute, traumatic thoracolumbar spinal injuries by two groups of spinal surgeons with different levels of clinical experience. The Kappa coefficient was used to determine interobserver reliability and intraobserver reproducibility.

RESULTS

The overall Kappa coefficient for all cases was 0.362, which represents fair reliability. The Kappa statistic was 0.385 for A-type injuries and 0.292 for B-type injuries, which represents fair reliability, and 0.552 for C-type injuries, which represents moderate reliability. The Kappa coefficient for intraobserver reproducibility was 0.442 for A-type injuries, 0.485 for B-type injuries, and 0.412 for C-type injuries. These values represent moderate reproducibility for all injury types. The raters in Group A provided significantly better interobserver reliability than Group B (P < 0.05). There were no between-group differences in intraobserver reproducibility.

CONCLUSIONS

This study suggests that the new AO spine injury classification system may be applied in day-to-day clinical practice in China following extensive training of healthcare providers. Further prospective studies in different healthcare providers and clinical settings are essential for validation of this classification system and to assess its utility.

Floating lumbar spine: proposed mechanism with review of literature

Hyperextension injuries of lumbar spine resulting in lumbosacral dislocation are a rare entity. We report a case of a 60-year-old male who presented to us in outpatient department with history of trivial fall from bicycle with fracture through the pedicles extending from L2 to L5 with lumbosacral dislocation with free floating posterior elements with intact neurology. This is the first case report of 4 level extension compression injury with lumbosacral dislocation leading to floating lumbar spine to the best of author's knowledge. Treatment consists of reduction of the lumbosacral dislocation first and fusion of the disc space followed by reduction of the other fractures proximally. These injuries may present with a trivial trauma in spondylotic spine in elderly patients. MRI and CT scan should be done early to identify it, reduce and fix it, as in many cases with trivial trauma there may be no neural deficit.

Hemoptysis as the Presenting Clinical Sign of a T8-T9 Spine Fracture with Diffuse Idiopathic Skeletal Hyperostosis Changes

Diffuse idiopathic skeletal hyperostosis (DISH) is a noninflammatory degenerative disease that affects multiple spine levels and, in combination with osteoporosis, makes vertebrae more prone to fractures, especially in elderly people. We describe a rare case of thoracic fracture in an ankylosed spine in which hemoptysis was the only clinical sign. The patient (age in the early 80s) presented with chest pain and a cough associated with hemoptysis. The patient had no complaints of back pain and no neurological symptoms. Computed tomography (CT) angiography of the chest revealed changes consistent with DISH, with fractures at the T8 and T9 vertebra as well as lung hemorrhage or contusion in the right lung base. CT and magnetic resonance imaging of the thoracic spine showed similar findings, with a recent T8-T9 fracture and DISH changes. The patient underwent percutaneous pedicle screw fixation from T7 to T11 and remained neurologically intact with an uneventful postoperative course.

Complete Fracture-Dislocation of the Thoracolumbar Spine with No Critical Neurological Deficit: A Case Report

Fractures at the thoracolumbar junction are the most common spinal column fractures. Among type C fractures in the Arbeitsgemeinschaft für Osteosynthesefragen Spine Classification, cases with complete fracture-dislocations of the spinal column often result in a critical neurological deficit despite surgical treatment. We present a case of an 18-year-old man who had a complete fracture-dislocation of the T12 vertebral body and multiple injuries following high-energy trauma but no critical neurological deficits. Because of active bleeding in the left thoracic cavity, the patient underwent open reduction of the T12 vertebral body and anterior spinal fusion of the T11-L1 vertebral bodies via an anterior approach between the T9 and T10 ribs within 24 h of the accident. Four months postoperatively, the patient could ambulate independently, with a slight disturbance of light touch. At 6 months postoperatively, plain computed tomography scans showed bony union of the T12 vertebral body. We postulated two reasons for the absence of critical neurological dysfunction: (1) spontaneous spinal canal sparing because of the fracture of the right superior articular process in the L1 vertebral body and (2) fracture morphology, that is, a rotational fracture with mild to moderately strong shearing stress to the dura mater.

Do thoraco-lumbar spinal injuries classification systems exhibit lower inter- and intra-observer agreement than other fractures classifications?: A comparison using fractures of the trochanteric area of the proximal femur as contrast model

INTRODUCTION

It has been postulated that the complex patterns of spinal injuries have prevented adequate agreement using thoraco-lumbar spinal injuries (TLSI) classifications; however, limb fracture classifications have also shown variable agreements. This study compared agreement using two TLSI classifications with agreement using two classifications of fractures of the trochanteric area of the proximal femur (FTAPF).

MATERIAL AND METHODS

Six evaluators classified the radiographs and computed tomography scans of 70 patients with acute TLSI using the Denis and the new AO Spine thoraco-lumbar injury classifications. Additionally, six evaluators classified the radiographs of 70 patients with FTAPF using the Tronzo and the AO schemes. Six weeks later, all cases were presented in a random sequence for repeat assessment. The Kappa coefficient (κ) was used to determine agreement.

RESULTS

Inter-observer agreement: For TLSI, using the AOSpine classification, the mean κ was 0.62 (0.57-0.66) considering fracture types, and 0.55 (0.52-0.57) considering sub-types; using the Denis classification, κ was 0.62 (0.59-0.65). For FTAPF, with the AO scheme, the mean κ was 0.58 (0.54-0.63) considering fracture types and 0.31 (0.28-0.33) considering sub-types; for the Tronzo classification, κ was 0.54 (0.50-0.57). Intra-observer agreement: For TLSI, using the AOSpine scheme, the mean κ was 0.77 (0.72-0.83) considering fracture types, and 0.71 (0.67-0.76) considering sub-types; for the Denis classification, κ was 0.76 (0.71-0.81). For FTAPF, with the AO scheme, the mean κ was 0.75 (0.69-0.81) considering fracture types and 0.45 (0.39-0.51) considering sub-types; for the Tronzo classification, κ was 0.64 (0.58-0.70).

CONCLUSION

Using the main types of AO classifications, inter- and intra-observer agreement of TLSI were comparable to agreement evaluating FTAPF; including sub-types, inter- and intra-observer agreement evaluating TLSI were significantly better than assessing FTAPF. Inter- and intra-observer agreements using the Denis classification were also significantly better than agreement using the Tronzo scheme.

Recovery after fracture dislocation of L3/L4 ASIA B: Case report

In fracture dislocations of the lumbar region, two anatomical facts can help preserve neurological damage in patients, when compared with trauma in the cervical or thoracic region. Firstly, the spinal cord in adults extends only to the lower edge of the first lumbar vertebra, and secondly, the large vertebral space in this region gives ample space for the roots of the cauda equine. As a result, the nerve injury may be minimal, because the nerve roots in this region are accommodated in a larger area, with less content and space. This study presents the case of a 48-year-old male, a construction worker, who suffered a fall from a height of approximately 15 meters, directly hitting the lumbar region against a beam, and presenting pain and inability to move the legs. The patient was brought to the emergency room 1 hour after the accident, clinically assessed, submitted to x-rays and a CT scan, and diagnosed as having an ASIA B L3-L4 fracture dislocation. Three hours after the accident, reduction was performed via posterior transpedicular fixation. One week later, an anterior approach was performed. The patient progressed to ASIA C 24 hours after the first surgery. Three months later, the patient was functional with ASIA D and good sphincter control. The author's purpose is to show the results obtained by an intervention in the initial hours of the trauma, which helped promote the evolution from a nonfunctional injury to a functional one, with near-total recovery.

The role of emergency radiology in spinal trauma

Spinal trauma is very frequent injury with different severity and prognosis varying from asymptomatic condition to temporary neurological dysfunction, focal deficit or fatal event. The major causes of spinal trauma are high- and low-energy fall, traffic accident, sport and blunt impact. The radiologist has a role of great responsibility to establish the presence or absence of lesions, to define the characteristics, to assess the prognostic influence and therefore treatment. Imaging has an important role in the management of spinal trauma. The aim of this paper was to describe: incidence and type of vertebral fracture; imaging indication and guidelines for cervical trauma; imaging indication and guidelines for thoracolumbar trauma; multidetector CT indication for trauma spine; MRI indication and protocol for trauma spine.

Percutaneous pedicle screw fixation for an unstable thoracic spine fracture after a traumatic degloving injury

Unstable spinal fractures require urgent surgical intervention to relieve compression of the spinal cord, correct spinal deformity, stabilise the spine and prevent further neurological injury. We report the case of a young man with a thoracic chance fracture in the setting of a devastating degloving injury, whose fracture was stabilised using minimally invasive, percutaneous pedicle screw fixation. We discuss the advantages of using a minimally invasive technique for spinal fixation and its role in the treatment of complicated, multisystem trauma patients.

Is there a regional difference in morphology interpretation of A3 and A4 fractures among different cultures?

OBJECT The aim of this study was to determine if the ability of a surgeon to correctly classify A3 (burst fractures with a single endplate involved) and A4 (burst fractures with both endplates involved) fractures is affected by either the region or the experience of the surgeon. METHODS A survey was sent to 100 AOSpine members from all 6 AO regions of the world (North America, South America, Europe, Africa, Asia, and the Middle East) who had no prior knowledge of the new AOSpine Thoracolumbar Spine Injury Classification System. Respondents were asked to classify 25 cases, including 6 thoracolumbar burst fractures (A3 or A4). This study focuses on the effect of region and experience on surgeons' ability to properly classify these 2 controversial fracture variants. RESULTS All 100 surveyed surgeons completed the survey, and no significant regional (p > 0.50) or experiential (p > 0.21) variability in the ability to correctly classify burst fractures was identified; however, surgeons from all regions and with all levels of experience were more likely to correctly classify A3 fractures than A4 fractures (p < 0.01). Further analysis demonstrated that no region predisposed surgeons to increasing their assessment of severity of burst fractures. CONCLUSIONS A3 and A4 fractures are the most difficult 2 fractures to correctly classify, but this is not affected by the region or experience of the surgeon; therefore, regional variations in the treatment of thoracolumbar burst fractures (A3 and A4) is not due to differing radiographic interpretation of the fractures.

A Worldwide Analysis of the Reliability and Perceived Importance of an Injury to the Posterior Ligamentous Complex in AO Type A Fractures

Study Design Survey of spine surgeons. Objective To determine the reliability with which international spine surgeons identify a posterior ligamentous complex (PLC) injury in a patient with a compression-type vertebral body fracture (type A). Methods A survey was sent to all AOSpine members from the six AO regions of the world. The survey consisted of 10 cases of type A fractures (2 subtype A1, 2 subtype A2, 3 subtype A3, and 3 subtype A4 fractures) with appropriate imaging (plain radiographs, computed tomography, and/or magnetic resonance imaging), and the respondent was asked to identify fractures with a PLC disruption, as well as to indicate if the integrity of the PLC would affect their treatment recommendation. Results Five hundred twenty-nine spine surgeons from all six AO regions of the world completed the survey. The overall interobserver reliability in determining the integrity of the PLC was slight (kappa = 0.11). No substantial regional or experiential difference was identified in determining PLC integrity or its absence; however, a regional difference was identified (p < 0.001) in how PLC integrity influenced the treatment of type A fractures. Conclusion The results of this survey indicate that there is only slight international reliability in determining the integrity of the PLC in type A fractures. Although the biomechanical importance of the PLC is not in doubt, the inability to reliably determine the integrity of the PLC may limit the utility of the M1 modifier in the AOSpine Thoracolumbar Spine Injury Classification System.

Compression Fractures in the Setting of Diffuse Idiopathic Skeletal Hyperostosis

Compression fractures are the most common vertebral fractures. They involve the anterior column of the spine, and are considered stable fractures due to the presence of intact posterior ligaments that aid in resisting further collapse and deformity. They are thus often managed conservatively. We describe a series of 3 cases that were initially diagnosed as compression fractures and managed conservatively. With the abundance of compression fractures and increase in preference for conservative management of compression fractures, it is of utmost importance to recognize the possibility of other spinal co-pathologies, especially that of hyperostosis of the spine, both by clinical judgment as well as radiological analysis before embarking on conservative management, should there be under-treatment and development of complications that could have otherwise been avoided, as in the cases presented in this series.

Automated Detection, Localization, and Classification of Traumatic Vertebral Body Fractures in the Thoracic and Lumbar Spine at CT

PURPOSE

To design and validate a fully automated computer system for the detection and anatomic localization of traumatic thoracic and lumbar vertebral body fractures at computed tomography (CT).

MATERIALS AND METHODS

This retrospective study was HIPAA compliant. Institutional review board approval was obtained, and informed consent was waived. CT examinations in 104 patients (mean age, 34.4 years; range, 14-88 years; 32 women, 72 men), consisting of 94 examinations with positive findings for fractures (59 with vertebral body fractures) and 10 control examinations (without vertebral fractures), were performed. There were 141 thoracic and lumbar vertebral body fractures in the case set. The locations of fractures were marked and classified by a radiologist according to Denis column involvement. The CT data set was divided into training and testing subsets (37 and 67 subsets, respectively) for analysis by means of prototype software for fully automated spinal segmentation and fracture detection. Free-response receiver operating characteristic analysis was performed.

RESULTS

Training set sensitivity for detection and localization of fractures within each vertebra was 0.82 (28 of 34 findings; 95% confidence interval [CI]: 0.68, 0.90), with a false-positive rate of 2.5 findings per patient. The sensitivity for fracture localization to the correct vertebra was 0.88 (23 of 26 findings; 95% CI: 0.72, 0.96), with a false-positive rate of 1.3. Testing set sensitivity for the detection and localization of fractures within each vertebra was 0.81 (87 of 107 findings; 95% CI: 0.75, 0.87), with a false-positive rate of 2.7. The sensitivity for fracture localization to the correct vertebra was 0.92 (55 of 60 findings; 95% CI: 0.79, 0.94), with a false-positive rate of 1.6. The most common cause of false-positive findings was nutrient foramina (106 of 272 findings [39%]).

CONCLUSION

The fully automated computer system detects and anatomically localizes vertebral body fractures in the thoracic and lumbar spine on CT images with a high sensitivity and a low false-positive rate.

Optimal timing for type C3 thoracic fractures with posterior surgical approach: a retrospective cohort study

BACKGROUND

Type C3 thoracic fracture is a severe spinal injury, but one that is clinically rare, and there are few reports pertaining to the treatment of this type of fracture. No consensus has been achieved on the proper timing of spine fracture fixation; therefore, we focused on evaluating the surgical effects using a posterior approach and determining the influence of surgical timing on surgical outcomes.

METHODS

This was a retrospective cohort study of 36 cases of type C3 thoracic fracture in patients admitted to the hospital from April 2005 to October 2012, and who were divided into two groups according to the timing of surgery: early fixation (<72 h) and late fixation (>72 h). Surgical outcomes were analyzed based on surgery duration, intraoperative blood loss, intensive care unit and hospital stay, mortality rate, and complications.

RESULTS

There were 13 patients in the early fixation group and 23 patients in the late fixation group. Patients were treated with posterior decompression, intervertebral titanium mesh support, pedicle screw fixation, and fusion. All fractures involved a single segment: T7/T8 (8 patients), T9/T10 (11 patients), and T11/T12 (17 patients). All injuries were classified as American Spinal Injury Association (ASIA) grade A. Patients underwent periodic follow-up over a period of 12-30 months (average, 22.5 months). One patient developed ascending myelitis and died of respiratory failure 1 month after early fixation, and two patients died of pulmonary infection after late fixation procedures. Other patients achieved bone fusion without improvement in ASIA grade. No statistically significant difference in parameters was observed between groups.

CONCLUSIONS

Though type C3 thoracic fracture is one of the most severe spinal injuries, complete reduction and recovery of spinal stability can be achieved using a posterior approach. As clinical outcomes in this study were similar between early and late fixation procedures, early surgical intervention may not be helpful for improving neurologic recovery in type C3 thoracic fractures.

Establishing the injury severity of thoracolumbar trauma: confirmation of the hierarchical structure of the AOSpine Thoracolumbar Spine Injury Classification System

STUDY DESIGN

Survey of spine surgeons.

OBJECTIVE

To develop a validated regional and global injury severity scoring system for thoracolumbar trauma.

SUMMARY OF BACKGROUND DATA

The AOSpine Thoracolumbar Spine Injury Classification System was recently published and combines elements of both the Magerl system and the Thoracolumbar Injury Classification System; however, the injury severity of each fracture has yet to be established.

METHODS

A survey was sent to 100 AOSpine members from all 6 AO regions of the world (North America, South America, Europe, Africa, Asia, and the Middle East). Each respondent was asked to numerically grade the severity of each variable of the AOSpine Thoracolumbar Spine Injury Classification System including the morphology, neurological grade, and patient specific modifiers. A grade of zero was considered to be not severe at all, and a grade of 100 was the most severe injury possible.

RESULTS

Seventy-four AOSpine surgeons from all 6 AO regions of the world numerically graded the severity of each variable of the AOSpine Thoracolumbar Spine Injury Classification System to establish the injury severity score. The reported fracture severity increased significantly (P < 0.0001) as the subtypes of fracture type A and type B increased, and a significant difference (P < 0.0001) in severity was established for burst fractures with involvement of 2 versus 1 endplates. Finally, no regional or experiential difference in severity or classification was identified.

CONCLUSION

Development of a globally applicable injury severity scoring system for thoracolumbar trauma is possible. This study demonstrates no regional or experiential difference in perceived severity or thoracolumbar spine trauma. The AOSpine Thoracolumbar Spine Injury Classification System provides a logical approach to assessing these injuries and enables rational strategies for treatment.

LEVEL OF EVIDENCE

4.

Hyperextension injuries of the thoracolumbar spine in diffuse idiopathic skeletal hyperostosis

STUDY DESIGN

Retrospective study of a consecutive series of patients with thoracolumbar hyperextension injuries (TLHIs) complicated by diffuse idiopathic skeletal hyperostosis (DISH) presenting to a single institution during a 9-year period.

OBJECTIVE

Assess epidemiological data, trauma mechanism, injury characteristics in hyperostotic spines, and short-term outcome.

SUMMARY OF BACKGROUND DATA

An increase in TLHIs complicated by DISH was observed. In current literature, only case reports and small case series touch this topic.

METHODS

All patients with TLHIs in the setting of DISH between January 2002 and December 2010 were reviewed retrospectively. Clinical and radiographical data during hospitalization including computed tomographic scans of all patients were analyzed as to epidemiological issues, trauma characteristics, neurological deficits, and short-term outcomes. Statistical analysis was performed to assess factors related to trauma characteristics.

RESULTS

Twenty patients with 23 TLHIs were analyzed. Twelve injuries involved the thoracic region; 1, the lumbar region; and 10, the thoracolumbar junction. A total of 85.7% of injuries were due to high-energy impact. The distribution of transdiscal and transosseous injuries was almost equal (13/10). Patients with DISH with vertebral body fractures were significantly older than those with transdiscal injuries (78.3 yr vs. 69.8 yr, P < 0.026). Post-traumatic neurological deficit was present in 22.7% patients. Neurological complications did not occur in low-energy injuries. On average, spines were posteriorly stabilized over 2.1 segments. Twenty percent of the patients died within 3 months (average age, 80.7 ± 5.1 yr, range, 76-88 yr).

CONCLUSION

To our knowledge, this is the largest series of TLHIs in DISH-altered spines in literature. The study helps to understand controversial findings in literature about morphological properties of TLHIs in DISH-affected spines. Surgeons should be aware of preexisting alterations in traumatized spines and the impact on therapeutic decisions. Because of the "aging population" and implications of metabolic diseases on an "aging spine," the incidence of TLHIs in DISH will probably rise.