Thoracolumbar vertebral fractures in Sweden: an analysis of 13,496 patients admitted to hospital. Eur J Epidemiol. 2010;25:431-437. [PMID: 20449637 PMCID: PMC2896644 DOI: 10.1007/s10654-010-9461-5]

Older patients with vertebral and pelvic fractures: Study protocol of a clinical cohort

BACKGROUND

Vertebral and pelvic fractures are associated with a significant burden of negative health and psychosocial outcomes. The number of vertebral and pelvic fractures is increasing in an aging society. Vertebral and pelvic fractures are increasingly significant injuries for individuals and society. However, few epidemiological studies have examined the clinical course of vertebral and pelvic fractures. This is the protocol for a study that observes patients who have been admitted to the hospital with an incident vertebral or pelvic fracture for a period of 12 months.

METHODS

The observational cohort study is conducted at three study sites in Germany. Patients affected by vertebral or pelvic fractures are recruited within the first few days of hospital admission. Data collection takes place at four-time points: baseline, before discharge, after 4 months, and after 12 months after admission to the hospital. Particular emphasis is laid on the assessment of the fall mechanisms, physical function, physical activity, life space, mobility, treatment approach, and quality of life. The hospital stay involves the collection of biomaterials (blood and urine).

DISCUSSION

The study aims to enhance understanding of the clinical progression and outcomes in patients with fractures in the vertebrae or pelvis.

Thoracolumbar fracture and spinal cord injury in blunt trauma: a systematic review, meta-analysis, and meta-regression

Thoracolumbar (TL) fractures are among the most common vertebral fractures. These patients have high morbidity and mortality due to injury mechanisms and associated injuries. Spinal cord injury (SCI) is a prevalent complication of spinal fractures of the thoracolumbar region.

AIM

To determine the pooled rate of thoracolumbar fractures and SCI in blunt trauma patients.

METHODS

A systematic review and meta-analysis of observational studies were performed. The search was conducted in the PubMed, Scopus, Web of Science, and Embase databases. The authors screened and selected studies based on predefined inclusion and exclusion criteria. Studies were then evaluated for risk of bias using the JBI checklist. The pooled event rate and 95% confidence intervals (CI) were calculated using random effects models. Subgroup and meta-regression analyses were performed to explore sources of heterogeneity.

RESULTS

Twenty-one studies fulfilled the selection criteria. The pooled rate of TL fractures was 8.08% (CI = 6.18-10.50%), with high heterogeneity (I2 = 99.98%, P < 0.001). Thoracic and lumbar fractures accounted for 45.23% and 59.01% of the TL fractures, respectively. Meta-regression revealed that the midpoint of the study period was a significant moderator. The pooled event rate of SCI among TL fracture patients was 15.81% (CI = 11.11 to 22.01%) with high heterogeneity (I2 = 98.31%, P < 0.001). The country of study was identified as a source of heterogeneity through subgroup analysis, and studies from the United States reported higher rates of SCI. Meta-regression revealed that the critical appraisal score was negatively associated with event rate.

CONCLUSION

Our study evaluated the rate of TL fractures in multiple countries at different time points. We observed an increase in the rate of TL fractures over time. SCI results also seemed to vary based on the country of the original study.

Clinical outcome after dorso-ventral stabilization of the thoracolumbar and lumbar spine with vertebral body replacement and dorsal stabilization

PURPOSE

Surgical stabilization of the spine by vertebral body replacement (VBR) is used for spinal disorders such as traumatic fractures to provide an anatomical re-adjustment of the spine to prevent late detrimental effects and pain [1-4]. This study addresses the clinical outcome after a ventral intervention with VBR and bisegmental fusion.

METHODS

The study includes 76 patients (mean age: 59.34 ± 15.97; 34 females and 42 males) with fractures in the lower thoracic and lumbar spine. They were selected from patients of our hospital who received an anterolateral VBR surgery on the corresponding lower spine region over a nine-year period. Only patients were examined with X-rays and complete follow-up records. Exclusion criteria were changes due to degeneration and pathological fractures. Patients were divided into two groups, the thoracotomy group (Th10-L1) and the lumbotomy group (L2-5), respectively. Minimum one year after surgery, patients were asked about their well-being using a precasted questionnaire.

RESULTS

No significant differences with respect to the subjective impression of the patients concerning their back pain, spinal functional impairment, their general functional status and their quality of life impairment. Unfortunately, however, only a rather modest but significant increase of the post-surgical life quality was reported.

CONCLUSIONS

Patients who underwent VBR in the lower thoracic or lumbar spine show modest long-term well-being. The results suggest that injuries to the lower thoracic or lumbar spine requiring vertebral body replacement should be classified as severe injuries since they adversely affect the patients' long-term well-being.

TRIAL REGISTRATION

Study of clinical outcome of patients after vertebral body replacement of the ventral thoracal and lumbal spine, DRKS00031452. Registered 10th March 2023 - Prospectively registered. Trial registration number DRKS00031452.

In-hospital mortality trends after surgery for traumatic thoracolumbar injury: A national inpatient sample database study

Introduction

Given the increasing incidence of traumatic thoracolumbar injuries in recent years, studies have sought to investigate potential risk factors for outcomes in these patients.

Research question

The aim of this study was to investigate trends and risk factors for in-hospital mortality after fusion for traumatic thoracolumbar injury.

Materials and methods

Patients undergoing thoracolumbar fusion after traumatic injury were queried from the National Inpatient Sample (NIS) from 2012 to 2017. Analysis was performed to identify risk factors for inpatient mortality after surgery.

Results

Patients in 2017 were on average older (51.0 vs. 48.5, P = 0.004), had more admitting diagnoses (15.5 vs. 10.7, p < 0.001), were less likely to be White (75.8% vs. 81.2%, p = 0.006), were from a ZIP code with a higher median income quartile (Quartile 1: 31.4% vs. 28.6%, p = 0.011), and were more likely to have Medicare as a primary payer (22.9% vs. 30.1%, p < 0.001). Bivariate analysis of demographics and surgical characteristics demonstrated that patients in the in-hospital mortality group (n = 90) were older (70.2 vs. 49.6, p < 0.001), more likely to be male (74.4% vs. 62.8%, p = 0.031), had a great number of admitted diagnoses (21.3 vs. 12.7, p < 0.001), and were more likely to be insured by Medicare (70.0% vs. 27.0%, p < 0.001). Multivariate regression analysis found age (OR 1.06, p < 0.001) and Black race (OR 3.71, p = 0.007) were independently associated with in-hospital mortality.

Conclusion

Our study of nationwide, traumatic thoracolumbar fusion procedures from 2012 to 2017 in the NIS database found older, black patients were at increased risk for in-hospital mortality after surgery.

Introduction to Osteoporosis, Osteomalacia, and Fragility Fractures

Background

Osteoporosis is a disease of the bones leading to decreased bone mineral density, leading to fragility fractures. This article is an overview of osteoporosis, osteomalacia and fragility fractures and serves as an introductory article for this special issue on osteoporosis.

Methods

This is a short, comprehensive account of the given conditions with concepts and a review from the recent literature. The authors provide relevant references from the literature in the bibliography. The sections herein have also been deliberated in the meetings of experts of osteoporosis.

Results

An overview of osteoporosis, osteomalacia and fragility fractures is provided, including definitions and summaries of aetiology, pathophysiology, diagnosis, prevention, and management. A detailed account of some of these topics will be provided in subsequent chapters.

Conclusion

Osteoporosis is a silent disease with the potential to cause significant morbidity and mortality if not detected early. It is important to differentiate from and diagnose associated osteomalacia to provide accurate therapy. It is also important to identify the type of fragility fractures and initiate treatment for bone strengthening to prevent subsequent fractures.

Mortality After Hip and Spine Fractures in Patients With End-Stage Kidney Disease: A Systematic Review and Meta-Analysis

Fractures represent a major cause of disability in the elderly, and patients with fractures exhibit a higher mortality rate than those without. Fractures are also an important health problem among patients with end-stage kidney disease (ESKD) requiring hemodialysis, peritoneal dialysis, or kidney transplantation. To the best of our knowledge, no study in the literature has yet quantitatively summarized the mortality rates, and a summary of evidence on post-hip and spine fracture mortality in patients with ESKD is lacking. The purpose of this study is to quantitatively evaluate the mortality rate, one-year mortality rate, and five-year mortality rate after hip and spine fractures in patients with ESKD receiving kidney replacement therapy. The MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and ClinicalTrials.gov databases were comprehensively searched for reports on mortality rate and time-period mortality in patients with ESKD after hip or spine fractures up to June 2022. Prospective and retrospective cohort studies, as well as case series involving four or more patients, were included. Pooled mortality rate, one-year rate, and five-year mortality rate with 95% confidence intervals (CIs) were examined using a random-effects model. The risk of bias was assessed using the Joanna Briggs Institute (JBI) Prevalence Critical Appraisal Tool. Additionally, heterogeneity between studies was evaluated. A total of 26 studies were included in this meta-analysis. The one-year and five-year mortality rates after hip and spine fractures were 215.35-774.0 per 1,000 person-year and 148-194.1 per 1,000 person-year, respectively. After hip fractures, the one-year mortality rate was 27% (95% CI: 18-38%, I2 = 98%), whereas the five-year mortality rate was 56% (95% CI: 41-71%, I2 = 99%). After spine fractures, the one-year mortality rate was 10% (95% CI: 4-17%, I2 = 70%), whereas the five-year mortality rate was 48.3%. The post-fracture mortality rate was high in patients with ESKD, particularly within one year after the occurrence of fractures. Additionally, the five-year mortality rate after hip femoral or spine fractures was high at approximately 50%.

Incidence and cost of vertebral fracture in urban China: a 5-year population-based cohort study

BACKGROUND

Osteoporotic vertebral fractures cause pain and disability, which result in a heavy socioeconomic burden. However, the incidence and cost of vertebral fractures in China are unknown. We aimed to assess the incidence and cost of clinically recognized vertebral fractures among people aged 50 years and older in China from 2013 to 2017.

MATERIALS AND METHODS

This population-based cohort study was conducted by using Urban Employee Basic Medical Insurance (UEBMI) and Urban Resident Basic Medical Insurance (URBMI) data in China from 2013 to 2017, which covered more than 95% of the Chinese population in urban areas. Vertebral fractures were identified by the primary diagnosis (i.e. International Classification of Diseases code or text of diagnosis) in UEBMI and URBMI. The incidence and medical cost of these clinically recognized vertebral fractures in urban China were calculated.

RESULTS

A total of 271 981 vertebral fractures (186 428, 68.5% females and 85 553, 31.5% males) were identified, with a mean age of 70.26 years. The incidence of vertebral fractures among patients aged 50 years and over in China increased ~1.79-fold during the 5 years, from 85.21 per 100 000 person-years in 2013 to 152.13 per 100 000 person-years in 2017. Medical costs for vertebral fractures increased from US$92.74 million in 2013 to US$505.3 million in 2017. Annual costs per vertebral fracture case increased from US$3.54 thousand in 2013 to US$5.35 thousand in 2017.

CONCLUSION

The dramatic increase in the incidence and cost of clinically recognized vertebral fractures among patients aged 50 and over in urban China implies that more attention should be given to the management of osteoporosis to prevent osteoporotic fractures.

Bracing and taping interventions for individuals with vertebral fragility fractures: a systematic review of randomized controlled trials with GRADE assessment

This systematic review analyzes the effects of bracing and taping after osteoporotic vertebral fractures. Spinal orthose may have positive effects on pain, but the evidence is of very low certainty. Clinical judgment is recommended when prescribing spinal orthoses.

PURPOSE

To examine the effects of bracing and taping interventions on pain, physical functioning, health-related quality of life, back extensor strength, kyphosis curvature, and adverse events in individuals with vertebral fragility fractures.

METHODS

Four databases were searched from inception up to January 2022. We included randomized controlled trials testing the effect of bracing or taping interventions compared with a non-intervention control in adults ≥ 45 years with vertebral fragility fractures. Narrative syntheses were presented for all the outcomes. We assessed the risk of bias using the Cochrane Risk of Bias Assessment Tool and the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation.

RESULTS

Three studies were included. Soft bracing interventions exhibited inconsistent effects on pain. One study showed no difference between groups, and another study should a decrease in pain in the soft bracing group compared to the control group. Rigid bracing interventions did not have a significant change in pain between the control and intervention groups. One study demonstrated a decrease in pain at rest (VAS: - 10.8 ± 19.3) and during movement (VAS: - 20.9 ± 29.8) after a taping intervention. The other outcomes were not consistent across studies.

CONCLUSIONS

Spinal orthoses may improve pain in people with vertebral fractures; however, we cannot draw definitive conclusions on the efficacy or harms of bracing or taping due to the very low certainty evidence and the small number of studies. Effects on other outcomes are uncertain.

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.

High exposure to perfluoroalkyl substances in drinking water is associated with increased risk of osteoporotic fractures - A cohort study from Ronneby, Sweden

BACKGROUND

Perfluoroalkyl substances (PFAS) have been reported to be related to decreased bone mineral density, but the relationship with osteoporosis and fractures is less studied. This study aimed to investigate the risks of osteoporotic fractures in a Swedish population with long-term exposure to PFAS through drinking water.

METHODS

The Ronneby Register Cohort, including 61,504 individuals who had ever lived in Ronneby during 1985-2013, was used. Exposure to PFAS was assessed according to the yearly residential address with or without highly contaminated water supply and was categorized as 'never-high' and 'ever-high' exposure. The 'ever-high' exposure was further divided into 'early-high' and 'late-high' depending on if the exposure was before or after 2005. Inpatient and outpatient hospital diagnoses of fractures were retrieved from the National Patient Register. Major osteoporotic fractures (MOF, i.e., hip, vertebrae, proximal humerus and distal forearm fractures), and hip fractures were considered as the primary outcomes. Cox proportional hazard models with time-varying exposure were used to estimate the hazard ratios (HRs). Stratified analyses were performed in each sex and age group (<50 yrs and ≥ 50 yrs).

RESULTS

Elevated risks of MOF (HR 1.11, 95% CI 1.03-1.19) and hip fractures (1.12, 1.00-1.24) were observed when comparing 'ever-high' to 'never-high' exposure. The HRs were even higher for 'late-high' exposure (MOF: 1.29, 1.16-1.44; hip fractures: 1.22, 1.01-1.47). Further adjustment for highest achieved education slightly attenuated the estimates. Individuals above 50 years old showed even higher HR estimates. Similar patterns were found for all fractures.

CONCLUSION

Our results provide further evidence supporting the adverse effects of PFAS on osteoporosis. A better understanding of dose-response relationships as a basis for risk assessment is warranted.

Analysis of lumbar vertebrae fractures among inpatients in a primary hospital: A 10-year epidemiological study

BACKGROUND

To analyze the epidemiological characteristics and changing trends of lumbar fractures in Xingtai Orthopedic Hospital in the past 10 years, and to improve the prevention and treatment of lumbar fractures.

METHODS

Using the hospital information system, data on patients with lumbar fractures in our hospital from 2009 to 2018 were collected regarding their age, gender, fracture time, injury mechanism, and the type of fracture. The epidemiological characteristics and trends of lumbar fractures for the period were summarized and analyzed.

RESULTS

The age of male patients with a high incidence of lumbar fractures was 61 to 70 years, followed by 51 to 60 years. The age of female patients with the highest incidence rate was 61 to 70 years, followed by 51 to 60 years (19.22%). Lumbar fractures in group A were predominantly of men. The majority of lumbar fractures in group B were of women. In group A, the incidence rate was higher in young men (21-50 years) than in women and higher in women >51 years. Most of the affected individuals were women. In group B, there were more middle-aged and young men (21-50 years) than women; however, there were more women than men aged ≥51 years. Car accident injury was the main cause of fractures, but in group B women, low-energy injuries were the main cause of fractures. The periods of high incidence in groups A and B were 4 to 6 years and 7 to 9 years, respectively. The number of injuries in group A was the highest and burst fracture was the main fracture type. In group B, the number of fall injuries was the highest, followed by car accident injuries, and compression fracture was the main fracture type.

CONCLUSION

The number of lumbar fractures in women caused by low-energy injuries showed an increasing trend. The type of compression fracture increased, which might be related to osteoporosis caused by the decrease in the estrogen level after menopause.

Incidence and Epidemiology of Thoracolumbar Spine Fractures: WFNS Spine Committee Recommendations

This review aims to search the epidemiology and incidence rates of thoracolumbar spine fractures. A systematic review of the literature of the last 10 years gave 586 results with “incidence,” and 387 results with “epidemiology,” of which 39 papers were analyzed. The review results were discussed and voted in 2 consensus meetings of the WFNS (World Federation of Neurosurgical Societies) Spine Committee. Out of 39 studies, 15 studies have focused on thoracolumbar trauma, remaining 24 studies have looked at all spine trauma. Most were retrospective in nature; few were prospective and multicenter. Some studies have focused on specific injuries. The annual incidence of TL fractures is about 30/100,000 inhabitants including osteoporotic fractures. There is a trend to increase the fractures in elderly population especially in developed countries, while an increase of motor vehicle accidents in developing countries. The mortality rate among male elderly patients is relatively high. The incidence of thoracolumbar spine fractures is increasing because of low-velocity falls in the elderly population. The main reasons are falls and traffic accidents. Learning the regional differences and some special forms of trauma such as extreme sports, war, and gunshot injuries will help the prevention of the thoracolumbar spine fractures.

Long-term Quality of Life after Fusion of the Ventral Thoracic and Lumbar Spine

BACKGROUND

 Cage implantations and autologous pelvic bone grafts are common surgical procedures to fuse the spine in cases of spinal disorders such as traumatic fractures or degenerative diseases. These surgical methods are designed to stably readjust the spine and to prevent late detrimental effects such as pain or increasing kyphosis. Benefits of these surgical interventions have been evaluated, but the long-term well-being of patients after the respective treatments has not yet been examined. This study was designed to evaluate the clinical outcome for patients who received iliac crest or cage implantations.

MATERIAL AND METHODS

 Forty-six patients with traumatic fractures after they obtained an anterior fusion in the thoracic or lumbar spine (12 cages; mean age: 54.08 years; 34 pelvic bone grafts; mean age: 42.18 years) were asked to participate in the survey using a precast questionnaire according the Visual Analog Scale (VAS) Spine Score. Twenty-nine of them provided the data requested.

RESULTS

 Evaluation of the VAS scores of the patients, reporting at least 1 year after the surgery, revealed that cage implantations led to significantly better results with respect to all aspects of their daily life such as pain sensing, capability to undertake physical activities and exercise as compared with patients with autologous pelvic bone graft. Patients with autologous pelvic bone graft treatment reported a particularly poor overall satisfaction level concerning their long-term well-being.

CONCLUSIONS

 Patients with cage implantation reported a higher degree of long-term well-being. The data provide evidence for a positive impact on the postsurgery quality of life after cage implantation.

Fragility Fractures: Risk Factors and Management in the Elderly

Given the progressive ageing of Western populations, the fragility fractures market has a growing socioeconomic impact. Fragility fractures are common in the elderly, negatively impacting their quality of life, limiting autonomy, increasing disability, and decreasing life expectancy. Different causes contribute to the development of a fractures in frail individuals. Among all, targeting fragile patients before the development of a fracture may represent the greatest challenge, and current diagnostic tools suffer from limitations. This study summarizes the current evidence on the management of fragility fractures, discussing risk factors, prevention, diagnosis, and actual limitations of the clinical therapeutic options, putting forward new ideas for further scientific investigation.

The Clinical Effect of Manual Reduction Combined with Internal Fixation Through Wiltse Paraspinal Approach in the Treatment of Thoracolumbar Fracture

Objective

To evaluate the clinical outcome of manual reduction combined with pedicle fixation through Wiltse paraspinal approach (WPA) in the treatment of thoracolumbar fractures.

Methods

From May 2017 to May 2019, 48 thoracolumbar fractures patients without neurological symptoms were enrolled in this study. Forty‐eight patients were randomly divided into two groups based on the different surgical treatment. Group 1 was manual reduction combined with pedicle screw fixation through Wiltse paraspinal approach treatment group. Group 2 was pedicle screw fixation through traditional posterior approach treatment group. The operation time (OT), intraoperative blood loss (BL), postoperative drainage (PD), time of brace (TB) and the cobb angle recovery of the injured kyphosis in the prone position were obtained and compared between the two groups, respectively. Comparison of cobb angle changes, serum creatine kinase (CK) level, pain visual analogue score (VAS), Oswestry disability index (ODI), and multifidus cross‐sectional (MCS) area changes were achieved between the two groups, respectively.

Results

Forty‐eight patients were enrolled in this study and each group had 24 patients. There was no significant difference between the two groups in patient's age, height, weight, and body mass index (BMI). There were 20 males and four females in group 1. The mean age, height, weight, and BMI of patients were 61.99 ± 11.00 years (range, 42–75 years), 175.21 ± 4.49 cm, 76.71 ± 4.87 kg, and 24.98 ± 1.03 kg/m² in group 1, respectively. Group 2 had 18 males and six females, and the mean age, height, weight, and BMI of patients were 57.95 ± 9.22 years (range, 44–77 years), 176.37 ± 4.56 cm, 77.42 ± 4.61 kg, and 24.87 ± 1.10 kg/m² in group 2, respectively. The mean bleeding volume of group 1 was significantly less than group 2 (64.13 ± 9.77 ml and 152.13 ± 10.73 ml, respectively) (P < 0.05). The mean operation time, postoperative drainage, and time of brace were 62.95 ± 9.80 min, 66.25 ± 12.75 ml, and 3.62 ± 0.97 days in group 1, respectively, and they were significantly better than those of group 2 (69.29 ± 6.82min, 162.96 ± 14.55ml and 7.88 ± 1.94 days, respectively) (P < 0.05). The mean multifidus cross‐sectional area was significantly smaller than per‐operation after surgery in two groups (P < 0.05). The mean creatine kinase of group 1 was 403.13 ± 39.78 U/L and 292.12 ± 45.81 U/L at 1 and 3 days after surgery, respectively, which was significantly smaller than those in group 2 (654.25 ± 53.13 U/L and 467.67 ± 44.25 U/L, respectively) (P < 0.05). The Oswestry disability index of group 1 were significantly better than those in group 2 especially at 1 month and final follow‐up after surgery (P < 0.05). Moreover, group 1 also had better outcomes in postoperative Cobb angle change than those in group 2, with significant difference on intra‐operation, 1 day and 1 month post‐operation (P < 0.05).

Conclusion

In short, this operation is suitable for thoracolumbar fractures without neurologic symptoms. Preoperative manual reduction had advantages of restoring the height of injured vertebrae. Wiltse intermuscular approach can reduce intraoperative blood loss, shorten operation time, and reduce paraspinal muscle damage. Using the traditional posterior approach, it is easy for surgeons to grasp this technique and it should be recommended as conforming with the minimally invasive approach of recent years.

The Role of Fall Biomechanics in the Cause and Prevention of Bone Fractures in Older Adults

PURPOSE OF REVIEW

Adults over age 65 experience the highest rates of bone fracture, and 90% of fractures in older adults are caused by falls from standing height or lower. Advances in fracture prevention rely on our ability to prevent falls, reduce the severity of falls, and enhance the resistance of bone to trauma. To help guide these efforts, we need improved understanding on the types of falls that cause fractures.

RECENT FINDINGS

In this review, we describe recent evidence on how the mechanics of falls in older adults influence the risk for fractures to the hip, wrist, vertebrae, and humerus. We discuss how fracture risk depends on fall height, fall direction, and landing configuration. We also review the benefits of exercise, wearable protective gear, and environmental modifications in preventing fractures in older adults. Our findings highlight promising new directions in fracture prevention, and the need for collaboration between the bone and falls research communities to implement proven strategies and generate new solutions.

Cage or Pelvic Graft-Study on Bony Fusion of the Ventral Thoracic and Lumbar Spine in Traumatic Vertebral Fractures

Background and Objectives: Stabilization of the spine by cage implantation or autologous pelvic bone graft are surgical methods for the treatment of traumatic spine fractures. These methods serve to stably re-adjust the spine and to prevent late detrimental effects such as pain or increasing kyphosis. They both involve ventral interventions using interbody fusion to replace the intervertebral disc space between the vertebral bodies either by cages or autologous pelvic bone grafts. We examined which of these methods serves the patients better in terms of bone fusion and the long-term clinical outcome. Materials and Methods: Forty-six patients with traumatic fractures (12 cages; mean age: 54.08/34 pelvic bone grafts; mean age: 42.18) who received an anterior fusion in the thoracic or lumbar spine were included in the study. Postoperative X-ray images were evaluated, and fusion of the stabilized segment was inspected by two experienced spine surgeons. The time to discharge from hospital and gender differences were evaluated. Results: There was a significant difference of the bone fusion rate of patients with autologous pelvic bone grafts in favor of cage implantation (p = 0.0216). Also, the stationary phase of patients who received cage implantations was clearly shorter (17.50 days vs. 23.85 days; p = 0.0089). In addition, we observed a significant gender difference with respect to the bony fusion rate in favor of females treated with cage implantations (p < 0.0001). Conclusions: Cage implantations after spinal fractures result in better bony fusion rates as compared to autologous pelvic bone grafts and a shorter stay of the patients in the hospital. Thus, we conclude that cage implantations rather than autologous pelvic bone grafts should be the preferred surgical treatment for stabilizing the spine after fracture.

Minimally Invasive Spine Surgery versus Open Posterior Instrumentation Surgery for Unstable Thoracolumbar Burst Fracture

Study Design

Retrospective study.

Purpose

To compare the clinical and radiological results of minimally invasive spine surgery (MISS) and open posterior instrumentation surgery for the treatment of unstable burst fractures.

Overview of Literature

MISS has exhibited postoperative outcomes similar to those obtained using open posterior instrumentation in various spine diseases. There remains no consensus regarding the use of MISS in the treatment of unstable burst fracture.

Methods

We enrolled 40 patients who underwent either MISS (M group, 20 patients) or open posterior instrumentation surgery (O group, 20 patients) for the treatment of traumatic unstable burst fractures. Clinical outcomes were evaluated based on postoperative back pain, operation time, blood loss, hospital stay duration, and perioperative complications. For radiologic evaluation, preoperative magnetic resonance imaging and plain radiography were performed before and after the surgery to evaluate the changes in the kyphotic angle and fracture union.

Results

The change in the kyphotic angle was −8.2°±5.8° in the M group and −8.0°±7.8° in the O group. No significant difference was noted in terms of the change in the kyphotic angle (p=0.94, t-test) after 12 months of surgery. The Visual Analog Scale score was 1.5±0.7 points in the M group, while it was 5.2±1.4 points in the O group. In the M group, back pain has significantly decreased (p<0.01, t-test). The estimated blood loss was 195.5 mL in the M group and 1,077.5 mL in the O group; the operation time was significantly decreased in the O group from 290.7 to 120.7 minutes in the M group (p<0.05, t-test) (p=0.36, t-test). The average duration of hospital stay was 36.0 days in the M group and 41.9 days in the O group (p=0.36, t-test).

Conclusions

For the treatment of unstable burst fractures, MISS showed significant differences in terms of postoperative back pain, operation time, and blood loss as compared to open posterior instrumentation surgery.

SPLIT-TYPE FRACTURES OF THE SPINE: A NEW MINIMALLY INVASIVE PERCUTANEOUS TECHNIQUE

ABSTRACT Objective: This research presents a biomechanical analysis performed in the lumbar spine of a porcine animal model, considering a minimally invasive technique for the treatment of split fractures. Methods: Porcine spines were used to perform compression tests, considering three different approaches. Three groups were defined in order to verify and validate the proposed technique: a control group (1); spines with split fractures (2); and a treatment group (3). For the first group (control), spines were axially compressed until any kind of fracture occurred, in order to verify the strength of the structure. In the second group, split fractures were created to obtain the mechanical failure pattern of the model. In the third group, the split fractures were submitted to the proposed treatment, to verify the resistance achieved. The three groups were compared by means of axial compression tests. Statistical analysis was performed by ANOVA. Results: The control group (intact spine) and the treated split fracture group presented similar results (p>0.05), differing from the results for the untreated split fracture group (p<0.05). Conclusions: The tests performed in order to determine the behavior and strength of the lumbar spine when subjected to axial compression provided positive data for the development of a minimally invasive technique capable of restoring split fractures of the spine. Level of evidence III; Experimental research.

Incidence of Traumatic Spinal Fractures in the Netherlands: Analysis of a Nationwide Database

STUDY DESIGN

Retrospective database study based on prospectively collected data.

OBJECTIVE

The aim of this study was to describe the current incidence and epidemiology of traumatic spinal fractures in the Netherlands SUMMARY OF BACKGROUND DATA.: Traumatic spinal fractures may lead to severe disability and have considerable consequences on healthcare capacity and costs. Several studies have reported a large and increasing share of fractures in elderly. Currently, a reliable, detailed, and up to date incidence of these injuries in the Netherlands is lacking. These numbers could aid in the composition of preventative measures.

METHODS

All patients from 2010 to 2017 that were admitted with a spinal fracture were included. Patients were selected based on Abbreviated Injury Scores (AIS) codes. Collected data consisted of patient- and injury characteristics, afflicted spine-region, associated injury, referral- and discharge location, and geographic region of admittance.

RESULTS

Overall, 29,637 patients were included in this study. The incidence of spinal fractures increased from 2010 to 2017 (from 21.5 to 24.0 per 100,000 inhabitants). Most patients were injured by a (low-energy) fall from the same level followed by (high-energy) traffic accidents. Elderly patients (≥65 years of age) made up 42% of all patients. The proportion of elderly increased significantly faster over the years compared to younger patients. More than half of polytrauma (injury severity score ≥16) patients had fractures in multiple spine regions. 5,5% of all patients suffered spinal cord injury (SCI), most often associated with cervical fractures in polytrauma patients. Regional differences were found mainly in presentation through referral and low- and high-energy falls.

CONCLUSION

The incidence of patients with spinal fractures increased and elderly made up a large part. Preventative measures could be regional dependent and should focus on low-energy falls, traffic accidents, and bicycle accidents in specific. In polytraumatized patients there should be special attention for any additional spine fractures and SCI.

LEVEL OF EVIDENCE

3.

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

BACKGROUND

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

HYPOTHESIS

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

MATERIAL AND METHODS

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

RESULTS

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

DISCUSSION

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

LEVEL OF EVIDENCE

IV, retrospective cohort study.

Incidence of Spine Fracture Hospitalization and Surgery in Finland in 1998-2017

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim of this study was to assess the incidence and trends of the spine fracture hospitalization and surgery in Finland in 1998-2017.

SUMMARY OF BACKGROUND DATA

Traumatic spine fractures are rare, yet they are known to cause significant long-term disability and therefore social, functional, and financial burden. The incidence of spine fractures and related mortality has been suggested to have declined during recent years. However, there are no population-based studies investigating the incidence of surgical treatment of spine fractures.

METHODS

The data for this study was obtained from the Finnish nationwide National Hospital Discharge Register. The study population covered all patients 20 years of age or over in Finland during a 20-year period from January 1, 1998 to December 31, 2017.

RESULTS

A total of 54,612 patients were hospitalized for a spine fracture in Finland in 1998-2017, and 7138 (13%) of the patients underwent surgery. The annual population-based incidence of spine fracture hospitalization increased 57% during the 20-year period, from 57 per 100,000 person-years to 89 per 100,000 person-years. In addition, the incidence of spine fracture surgery increased 65%, from 5.3 per 100,000 person-years to 8.8 per 100,000 person-years. The incidence of cervical spine fracture surgery tripled, and thoracic spine surgery doubled from 1998 to 2017, while incidence of lumbar fracture surgery declined by 13%. Among patients 60 years of age or older, the incidence of cervical spine fracture surgery increased 400%.

CONCLUSION

Incidences of cervical, thoracic, and lumbar fracture hospitalizations increased constantly in Finland during 1998-2017. Accordingly, incidence of cervical and thoracic spine fracture surgery increased rapidly, whereas the incidence of lumbar fracture surgery even decreased, during this 20-year period.

LEVEL OF EVIDENCE

3.

Extremity fractures in patients presenting with traumatic spinal fractures and spinal cord injury

Clinical features of extremity fractures (EFs) in patients presenting with traumatic spinal fractures (TSFs) and spinal cord injury (SCI) have not been investigated. To investigate the clinical features and risk factors for EFs in patients presenting with TSFs and SCI.Data from 1392 patients presenting with TSFs and SCI in our hospitals between 2001 and 2010 were retrospectively reviewed, among which 165 patients (129 males and 36 females, 37.5 ± 10.6 years old) presented with EFs. The clinical features of EFs have been investigated.The frequencies of upper limb fractures were significantly higher in the motor vehicle collisions (MVCs) group than in the high-fall group (P = .012) and the struck-by-object group (P = .002). The frequencies of lower limb fractures were significantly higher in the struck-by-object group (P = .019) and the high-fall group (P = .011) than the MVCs group. Univariate logistic regression analysis show that being in the 19 to 39 age group (P = .001), having a lumbar spinal fracture (P < .001) and experiencing a high fall (P < .001) were risk factors for EFs. Multivariate logistic regression analysis showed that we should focus on the factors that having a lumbar spinal fracture and experiencing a high fall.High fall and MVCs were the most common aetiologies for EFs. Having a lumbar spinal fracture and experiencing a high fall were significant risk factors for EFs. We should make early diagnoses and initiate timely treatment according to different patterns of extremity fractures in patients with TSFs and SCI.

Intelligently Taking Out Universal Screws and Nail Caps After Spine Internal Fixation

The purpose of this study was to present a surgical technique for taking out universal screw and nail caps which were difficult to removed. We used a variety of industrial hex wrenches, dental drills, and other equipment to take out internal hex nuts with different specifications (32 pieces) and universal screws (15 pieces) in 28 patients. A total of 32 nuts were taken out, 3 of which were polished by the industrial drill. A total of 17 were spun by hand, 2 were spun by locking pliers, 10 were turned by “I” type screwdriver, and 3 were turned by bone blade. A total of 15 screws were taken out, 9 of which were removed with a wrench and the other 6 by means of locking pliers after re‐fixing with a truncated titanium rod. The novel technique is simple and provides a solution following failure of a supporting device.

NUMERICAL ANALYSIS OF SHORT AND LONG INSTRUMENTATION IN THE TREATMENT OF THORACOLUMBAR FRACTURES CONSIDERING THE LIGAMENTOUS PORTION

ABSTRACT Objective: This study aims to numerically evaluate the surgical treatment of thoracolumbar fractures, comparing the strengths between the long and short fixations using the pedicle of the fractured vertebra, taking into account the supraspinous, intertransverse, and anterior longitudinal ligaments. Methods: A numerical analysis of the techniques of long and short fixation of a thoracolumbar spine fracture was performed using computed tomography images that were converted into three-dimensional models and analyzed through the ANSYS program. The two types of treatments were analyzed considering the tensions generated in the immediate postoperative period, when the fracture has not yet been consolidated. The anterior, posterior, supraspinal and intertransverse longitudinal ligaments were added, in addition to considering different vertebral geometries. Results: Taking into account that the maximum tensile stress of the material used in the metal implant, in the case of titanium, was 960 MPa, the highest tension found in the analysis of the short instrumentation was 346.83 MPa, reaching only 36.13% of the load the material supports, being, therefore, within a safety limit. The analysis performed in the spine with long instrumentation showed the highest tension value of 229.22 MPa. Conclusions: Considering the values found and the resistance of the synthesis material used, the short and long fixation can be considered in the treatment of thoracolumbar fractures with similarity and a good safety coefficient. Level of Evidence III; Case-Control.

Epidemiology of Spinal Fractures in a Level One Trauma Center in the Netherlands: A 10 Years Review

STUDY DESIGN

Retrospective epidemiological study.

OBJECTIVE

To describe the epidemiology of spinal fractures over a 10 years period in a level one trauma center in the Netherlands.

SUMMARY OF BACKGROUND DATA

Spinal fractures may have large socioeconomic consequences. The prevalence and outcomes likely change over the years owing to improved traffic safety, increasing population age and improved medical treatment. This is the first study to address the epidemiology of spinal fractures over a large period in the Netherlands.

METHODS

All patients with a cervical, thoracic, or lumbar spine fracture admitted to a level one trauma center from 2007 to 2016 were prospective registered and retrospectively analyzed. In addition to patient, accident, and associated injury characteristics, radiological and surgery data were obtained from the hospital's Electronic Patient File system.

RESULTS

Between 2007 and 2016, 1479 patients with a total of 3029 spinal fractures were admitted. Approximately 40.8% were female and 59.2% were male, with a mean age of 52.0 years; 4.9% of fractures occurred at a juvenile age (0-18 years) and 63.6% at the age of 19 to 64 years. Most fractures occurred in the thoracic spine, followed by the lumbar and cervical spine. The most common cause of injury was a fall from height, followed by traffic accidents. Spinal cord injury occurred in 8.5% and associated injuries were reported in 73% of the patients. Sixteen percent of the admitted patients were treated operatively. Over time, there was a larger increase in amount of spine fractures in elderly (≥ 65 years) compared with younger people.

CONCLUSION

The total amount of spine fractures per year increased over time. In addition, there was a larger increase in amount of spine fractures in patients over 65 years of age compared with younger patients. Despite this increase, a considerable amount of spine fractures still occur in the age-group of 19 to 64 years. Most fractures were located in the thoracic spine. This study might stimulate development of policy on precautionary actions to prevent spine fractures.

LEVEL OF EVIDENCE

4.

Inter- and intra-rater reliability of vertebral fracture classifications in the Swedish fracture register

AIM

To investigate the inter- and intra-rater reliability of the vertebral fracture classifications used in the Swedish fracture register.

METHODS

Radiological images of consecutive patients with cervical spine fractures (n = 50) were classified by 5 raters with different experience levels at two occasions. An identical process was performed with thoracolumbar fractures (n = 50). Cohen’s kappa was used to calculate the inter- and intra-rater reliability.

RESULTS

The mean kappa coefficient for inter-rater reliability ranged between 0.54 and 0.79 for the cervical fracture classifications, between 0.51 and 0.72 for the thoracolumbar classifications (overall and for different sub classifications), and between 0.65 and 0.77 for the presence or absence of signs of ankylosing disorder in the fracture area. The mean kappa coefficient for intra-rater reliability ranged between 0.58 and 0.80 for the cervical fracture classifications, between 0.46 and 0.68 for the thoracolumbar fracture classifications (overall and for different sub classifications) and between 0.79 and 0.81 for the presence or absence of signs of ankylosing disorder in the fracture area.

CONCLUSION

The classifications used in the Swedish fracture register for vertebral fractures have an acceptable inter- and intra-rater reliability with a moderate strength of agreement.

Epidemiology of vertebral fractures in pediatric and adolescent patients

Spinal injuries in children and adolescents are rare injuries, but consequences for the growing skeleton can be devastating. Knowledge of accident causes, clinical symptoms and diagnostics should be part of every trauma department treating these patients. We retrospectively analyzed patients with radiographically proven vertebral fractures of the spine. After clinical examination and tentative diagnosis the fractures and injuries were proven with conventional X-ray, computed tomography (CT) scans or magnetic resonance imaging (MRI). The study included 890 fractures in 546 patients with an average age of 12.8±6.2 (6.6-19.4) years. Females had an average age of 13.7±6.3 (7.4-20.0) years, whereas males were on average 12.0 (6.0-18.0) years old. Fall from height (58%) was the main cause of accident and the most common region of fracture was the thoracolumbar spine with a shift towards the thoracic spine the more fractures occurred. Merely 3.7% of all patients required operative treatment. If a vertebral fracture is found in children and adolescents, it is highly recommended to exclude synchronous additional spine fractures in other levels; prevention should concentrate on fall and traffic accidents.

Malunion of post-traumatic thoracolumbar fractures

Thoracolumbar malunion is the result of loss of correction, insufficient correction or even no correction (both in the frontal and sagittal planes) of a thoracolumbar fracture. The main causes are incorrect assessment of the fracture's complexity (burst fracture), its potential progression to kyphosis and associated disc or ligament damage. It can also be the result of a poorly conducted initial treatment. The types of malunion have changed over the years because of the introduction of vertebroplasty and kyphoplasty. The malunion can be well tolerated if there is only a moderate deformity. However, the functional and pain-related limitations can be severe with large deformities. Functional limitation is mainly related to sagittal imbalance, but also to sequelae associated with the injury in various ways (non-union, disc degeneration, spinal cord compression, syringomyelia, etc.). The deformity and its consequences are evaluated globally using full-body standing radiographs (EOS), CT scan and MRI. Comparison of MRI images taken in a lying position to weight bearing views or even dynamic ones is an additional means to evaluate whether the lesions are reducible. Differences in spine morphology and compensatory mechanisms to combat the sagittal imbalance induced by the deformity must also be analyzed. These provide more complete information about the consequences of the malunion and help to establish the best corrective strategy. These compensatory mechanisms consist of accentuation of lumbar lordosis along with reduction of thoracic kyphosis. As a last resort, the pelvis and femur contribute to this compensation when there is a large deformity or a stiff spine due to preexisting osteoarthritis. Treatment strategies are fairly well standardized. When the deformity is reducible, a two-stage surgery is indicated. When the deformity is not reducible, posterior transpedicular closed wedge osteotomy is the gold standard. Nevertheless, the best way to treat thoracolumbar malunion is to prevent it.

Traumatic Spinal Injuries in Northern Finland

STUDY DESIGN

A retrospective epidemiological study.

OBJECTIVE

To reveal incidence and epidemiological features of traumatic spinal injuries (TSI) in Northern Finland.

SUMMARY OF BACKGROUND DATA

In Finland the annual incidence of traumatic spine fractures requiring inpatient care has been found to be 27/100,000, while international incidences have varied across the range of 16-64/100,000. More specific epidemiological data from Finland is not available. Internationally, the most common mechanisms of injury are road traffic as well as low and high falls. Associated injuries occur in 30% to 55% of cases.

METHODS

The study sample included patients with traumatic spinal injury admitted to Oulu University Hospital (OYS) with injury between the January 1, 2007 and December 31, 2011. Patient information was collected from the hospital care register, including all inpatient and outpatient visits and surgical procedures. Traumatic spinal column and spinal cord injuries were identified using International Classification of Diseases 10th revision or Nordic Classification of Surgical Procedures codes and all patient records were manually reviewed.

RESULTS

Nine hundred seventy-one patients met the criteria for TSI. The mean annual incidence of hospitalized traumatic spinal injuries was 26/100,000 in the whole of Northern Finland and 35/100,000 in the OYS main responsibility area. The most frequent etiology of TSI was low falls, which accounted for 35.8% of the injuries, followed by road traffic and high falls. Lumbar spine was the most common site of the fracture. Spinal surgery was performed in 376 (38.7%) cases. Three hundred eight patients (31.7%) suffered from associated injuries, 101 (10.4%) had a spinal cord injury, and 71 (7.3%) a brain injury.

CONCLUSION

Low falls in elderly and road traffic injuries in younger age groups were the most common etiology of traumatic spinal injuries in Northern Finland and should be given more attention in primary prevention.

LEVEL OF EVIDENCE

3.

Fragility Fractures & Their Impact on Older People

Osteoporotic fractures, in particular hip and vertebral, are a major health burden worldwide. The majority of these fractures occur in the elderly population, resulting in one of the most important causes of mortality and disability in older ages. Their cost for societies is enormous and is forecast to steadily increase over the coming decades globally. Low bone mineral density (BMD) remains a key preventable risk factor for fractures. Screening and treatment of individuals with high risk of fracture is cost-effective. Predictive tools including clinical risk factors, minimisation of falls risk and public authorities' support to create Fracture Liaison Services are paramount strategies.

Thoracolumbar fractures without neurological impairment: A review of diagnosis and treatment

An appropriate protocol and unified management of thoracolumbar fractures without neurological impairment has not been well defined.

This review attempts to elucidate some controversies regarding diagnostic tools, the ability to define the most appropriate treatment of classification systems and the evidence for conservative and surgical methods based on the recent literature.

Cite this article: Vilà-Canet G, García de Frutos A, Covaro A, Ubierna MT, Caceres E. Thoracolumbar fractures without neurological impairment: a review of diagnosis and treatment. EFORT Open Rev 2016;1:332-338. DOI: 10.1302/2058-5241.1.000029

Worldwide prevalence and incidence of osteoporotic vertebral fractures

We investigated the prevalence and incidence of vertebral fractures worldwide. We used a systematic Medline search current to 2015 and updated as per authors' libraries. A total of 62 articles of fair to good quality and comparable methods for vertebral fracture identification were considered. The prevalence of morphometric vertebral fractures in European women is highest in Scandinavia (26%) and lowest in Eastern Europe (18%). Prevalence rates in North America (NA) for White women ≥50 are 20-24%, with a White/Black ratio of 1.6. Rates in women ≥50 years in Latin America are overall lower than Europe and NA (11-19%). In Asia, rates in women above ≥65 are highest in Japan (24%), lowest in Indonesia (9%), and in the Middle East, Lebanon, rates are 20%. The highest-lowest ratio between countries, within and across continents, varied from 1.4-2.6. Incidence data is less abundant and more heterogeneous. Age-standardized rates in studies combining hospitalized and ambulatory vertebral fractures are highest in South Korea, USA, and Hong Kong and lowest in the UK. Neither a North-South gradient nor a relation to urbanization is evident. Conversely, the incidence of hospitalized vertebral fractures in European patients ≥50 shows a North-South gradient with 3-3.7-fold variability. In the USA, rates in Whites are approximately 4-fold higher than in Blacks. Vertebral fractures variation worldwide is lower than observed with hip fractures, and some of highest rates are unexpectedly from Asia. Better quality representative studies are needed. We investigate the occurrence of vertebral fractures, worldwide, using published data current until the present. Worldwide, the variation in vertebral fractures is lower than observed for hip fractures. Some of the highest rates are from North America and unexpectedly Asia. The highest-lowest ratio between countries, within and across continents, varied from 1.4-2.6. Better quality representative data is needed.

Morbidity and Mortality Associated with Surgery of Traumatic C2 Fractures in Octogenarians

BACKGROUND: Management of axis fractures in the elderly remains controversial. As the US population increasingly lives past 80 years, published C2 fracture morbidity/mortality profiles in younger cohorts (55+) have become less applicable to octogenarians.

OBJECTIVE: To report associations between surgery and mortality, hospital length of stay and discharge disposition in octogenarians with traumatic C2 fractures.

METHODS: Retrospective cohort study of 3847 patients age ≥ 80 years representing 17 702 incidents nationwide, divided into surgery/nonsurgery cohorts, using the National Sample Program of the National Trauma Data Bank from 2003 to 2012. Inpatient complications, mortality, length of stay, and discharge disposition are characterized; multivariable regression was utilized to determine associations between surgery and outcomes.

Institutional Review Board (IRB): The National Sample Program dataset from the National Trauma Data Bank is fully deidentified and does not contain Health Insurance Portability and Accountability Act identifiers; therefore, this study is exempt from IRB review at the University of California, San Francisco.

RESULTS: Incidence of surgery was 10.3%. Surgery was associated with increased pneumonia, acute respiratory distress syndrome, and decubitus ulcer risks (P &lt; .001). Inpatient mortality was 12.8% (nonsurgery—13.0%; surgery—10.3%; P = .120). Length of stay was 8.31 ± 9.32 days (nonsurgery 7.78 ± 9.21; surgery 12.86 ± 9.07; P &lt; .001) and showed an adjusted mean increase of 5.68 days with surgery (95% confidence interval [4.74-6.61]). Of patients surviving to discharge, 26% returned home (nonsurgery—26.8%; surgery—18.8%; P = .001); surgery patients were less likely to return home (odds ratio 0.59 [0.44-0.78]).

CONCLUSION: The present study confirms that surgery of traumatic C2 fractures in octogenarians does not significantly affect inpatient mortality and increases discharge to institutionalized care. Patients undergoing surgery are more likely to require longer hospitalization and suffer increased medical complications during their stay. Given the retrospective nature of this study, it is unclear whether these conclusions reflect differences in injury severity between surgery cohorts. This question may be considered in a future prospective study.

Incidence and pattern of traumatic spinal fractures and associated spinal cord injury resulting from motor vehicle collisions in China over 11 years: An observational study

To investigate the incidence and pattern of traumatic spinal fractures (TSFs) and associated spinal cord injury (SCI) resulting from motor vehicle collisions (MVCs).This was a cross-sectional study. We retrospectively reviewed 698 patients with TSFs resulting from MVCs admitted to our university-affiliated hospitals from 2001 to 2011. The incidence and pattern were summarized with respect to different age groups, fracture levels, and the role of patients.There were 464 males (66.5%) and 234 females (33.5%) aged 40.5 ± 13.8 years old. The most common roles of patients in MVCs were car drivers (189, 27.1%), pedestrians hurt by a car (155, 22.2%), and car passengers (145, 20.8%). The most common fracture levels were L1 (n = 198, 19.2%) and T12 (n = 116, 11.3%), followed by C2 (n = 86, 8.3%). A total of 298 (42.7%) patients suffered a spinal cord injury. The frequencies of SCIs decreased from 53.1% to 24.6% with increasing age. The patients in the 20 to 39 age group (45.3% of all patients) had the largest sex ratio (2.4) and highest frequency of complete SCIs (19.3%) and complications (3.2%). Motorcycle drivers had the youngest mean age (35.7 ± 10.2), largest sex ratio (10.4), and highest frequency of SCIs (56.0%) and complications (4.4%). Motorcycle passengers had the highest frequency of complete SCI (22.7%) and ASOIs (45.5%) and the largest mean injury severity scoring (ISS) (18.9 ± 9.6). The most common fracture levels of motorcycle drivers were C3-C7, while that of others were T11-L2.The most common role of patients who sustained TSFs were car drivers who were 20 to 39 years old. Motorcycle drivers had the highest frequency of SCIs and complications. Motorcycle passengers had the highest frequency of complete SCIs and ASOIs and the largest ISS. Therefore, we should pay more attention to MVC patients, especially car drivers and motorcycle drivers and passengers.

Perioperative morbidity and mortality after lumbar trauma in the elderly

OBJECT Traumatic fractures of the thoracolumbar spine are common injuries, accounting for approximately 90% of all spinal trauma. Lumbar spine trauma in the elderly is a growing public health problem with relatively little evidence to guide clinical management. The authors sought to characterize the complications, morbidity, and mortality associated with surgical and nonsurgical management in elderly patients with traumatic fractures of the lumbar spine. METHODS Using the National Sample Program of the National Trauma Data Bank, the authors performed a retrospective analysis of patients ≥ 55 years of age who had traumatic fracture to the lumbar spine. This group was divided into middle-aged (55-69 years) and elderly (≥ 70 years) cohorts. Cohorts were subdivided into nonoperative, vertebroplasty or kyphoplasty, noninstrumented surgery, and instrumented surgery. Univariate and multivariable analyses were used to characterize and identify predictors of medical and surgical complications, mortality, hospital length of stay, ICU length of stay, number of days on ventilator, and hospital discharge in each subgroup. Adjusted odds ratios, mean differences, and associated 95% CIs were reported. Statistical significance was assessed at p < 0.05, and the Bonferroni correction for multiple comparisons was applied for each outcome analysis. RESULTS Between 2003 and 2012, 22,835 people met the inclusion criteria, which represents 94,103 incidents nationally. Analyses revealed a similar medical and surgical complication profile between age groups. The most prevalent medical complications were pneumonia (7.0%), acute respiratory distress syndrome (3.6%), and deep venous thrombosis (3%). Surgical site infections occurred in 6.3% of cases. Instrumented surgery was associated with the highest odds of each complication (p < 0.001). The inpatient mortality rate was 6.8% for all subjects. Multivariable analyses demonstrated that age ≥ 70 years was an independent predictor of mortality (OR 3.16, 95% CI 2.77-3.60), whereas instrumented surgery (multivariable OR 0.38, 95% CI 0.28-0.52) and vertebroplasty or kyphoplasty (OR 0.27, 95% CI 0.17-0.45) were associated with decreased odds of death. In surviving patients, both older age (OR 0.32, 95% CI 0.30-0.34) and instrumented fusion (OR 0.37, 95% CI 0.33-0.41) were associated with decreased odds of discharge to home. CONCLUSIONS The present study confirms that lumbar surgery in the elderly is associated with increased morbidity. In particular, instrumented fusion is associated with periprocedural complications, prolonged hospitalization, and a decreased likelihood of being discharged home. However, fusion surgery is also associated with reduced mortality. Age alone should not be an exclusionary factor in identifying surgical candidates for instrumented lumbar spinal fusion. Future studies are needed to confirm these findings.

Occupant and Crash Characteristics of Elderly Subjects With Thoracic and Lumbar Spine Injuries After Motor Vehicle Collisions

STUDY DESIGN

Retrospective study of a prospectively gathered database.

OBJECTIVE

To investigate the incidence and pattern of thoracic and lumbar (T and L) spine injuries among elderly subjects involved in motor vehicle collision (MVC).

SUMMARY OF BACKGROUND DATA

Adults age 65 and older currently constitute more than 16% of all licensed drivers. Despite driving less than the young, older drivers are involved in a higher proportion of crashes. Notwithstanding the safety features in modern vehicles, 15.8% to 51% of all T and L spine injuries result from MVCs.

METHODS

Crash Injury Research and Engineering Network database is a prospectively maintained, multicentered database that enrolls MVC occupants with moderate-to-severe injuries. It was queried for T and L spine injuries in subjects 65 and older. 142 Crash Injury Research and Engineering Network files for all elderly individuals were reviewed for demographic, injury, and crash data. Each occupant's T and L injury was categorized using a modified Denis classification.

RESULTS

Of 661 elderly subjects, 142 (21.48%) sustained T and L spine injuries. Of the 102 major injuries, there were 63 compression, 20 burst and 12 extension fractures. Seatbelt use predisposed elderly subjects to compression and burst fractures, whereas seatbelt and airbag use predisposed to burst fractures. Deployment of airbags without seatbelt use appeared to predispose elderly subjects to neurological injury, higher Injury Severity Score, and higher mortality. Occupants using 3-point belts who had airbags deployed during the collision had the lowest rates of fatality and neurological injury.

CONCLUSION

T and L spine injuries in the elderly are not uncommon despite restraint use. Whereas seatbelts used alone and in conjunction with airbag deployment reduced fatalities and neurological injuries in the elderly, deployment of airbags in occupants without seatbelts predisposed to more severe injury.

Numerical analysis of multi-level versus short instrumentation for the treatment of thoracolumbar fractures

PURPOSE

The research analyses the strength of metallic implants in posterior spinal instrumentation for the treatment of thoracolumbar fractures, considering extended and short fixation techniques on the immediate post-surgical load. Considering that short fixation may bring the advantage of a less invasive surgical procedure to the patient and may also result in lower costs, this evaluation becomes necessary.

METHODS

Three-dimensional modelling of the thoracolumbar spine was initially performed. CT images were captured and converted for analysis with the ANSYS program. Both treatment techniques were analysed for stresses, and strains generated in the immediate postoperative period, when the fracture is still not healed.

RESULTS

The maximum stress obtained for long fixation by the theory of Von Mises was 230 MPa, and it was located in the rod area next to the L2 vertebra. The maximum stress obtained for short fixation was 274.24 MPa, and it was located in the pedicle screw on the T12 vertebra.

CONCLUSIONS

There were no significant differences between the two techniques, since the observed stresses are well below the flow stress of the material, ensuring good safety factor (ranging from 3.5 to 4.1).

Balloon kyphoplasty and percutaneous fixation of lumbar fractures in pediatric patients

PURPOSE

Type A fractures of the spine requiring operative stabilization are rare injuries in the pediatric population. Current reports have demonstrated the safety of the combination of balloon kyphoplasty and minimal invasive management of thoraco-lumbar fractures in adults. There is no information about the efficacy of this approach in managing pediatric vertebral fractures.

METHODS

The aim of the present study was to report the outcome of a small series of children with A fractures of the lumbar spine treated with the combination of the abovementioned techniques.

RESULTS

Three male patients without neurological deficits aged 11, 12 and 14 years were treated with fractures located at L1, L1/L2 and L2/L3, respectively. In total, six kyphoplasties were performed (monolateral in 4 vertebrae, bilateral in one vertebra). Neither cases of cement leakage nor intra- or postoperative complications were noted. Minimally invasive kyphoplasty and stabilization led to a significant improvement of the sagittal index of all five treated vertebrae which could be maintained at follow-up (14, 19 and 20 months postoperatively).

CONCLUSION

This study is the first one to present an excellent outcome of children with type A fractures treated with a combination of balloon kyphoplasty and percutaneous stabilization.

Occupant and crash characteristics in thoracic and lumbar spine injuries resulting from motor vehicle collisions

BACKGROUND CONTEXT

Motor vehicle collisions (MVC) are a leading cause of thoracic and lumbar (T and L) spine injuries. Mechanisms of injury in vehicular crashes that result in thoracic and lumbar fractures and the spectrum of injury in these occupants have not been extensively studied in the literature.

PURPOSE

The objective was to investigate the patterns of T and L spine injuries after MVC; correlate these patterns with restraint use, crash characteristics, and demographic variables; and study the associations of these injuries with general injury morbidity and fatality.

STUDY DESIGN/SETTING

The study design is a retrospective study of a prospectively gathered database.

PATIENT SAMPLE

Six hundred thirty-one occupants with T and L (T1-L5) spine injuries from 4,572 occupants included in the Crash Injury Research and Engineering Network (CIREN) database between 1996 and 2011 were included in this study.

OUTCOME MEASURES

No clinical outcome measures were evaluated in this study.

METHODS

The CIREN database includes moderate to severely injured occupants from MVC involving vehicles manufactured recently. Demographic, injury, and crash data from each patient were analyzed for correlations between patterns of T and L spine injuries, associated extraspinal injuries and overall injury severity score (ISS), type and use of seat belts, and other crash characteristics. T and L spine injuries patterns were categorized using a modified Denis' classification to include extension injuries as a separate entity.

RESULTS

T and L spine injuries were identified in 631 of 4,572 vehicle occupants, of whom 299 sustained major injuries (including 21 extension injuries) and 332 sustained minor injuries. Flexion-distraction injuries were more prevalent in children and young adults and extension injuries in older adults (mean age, 65.7 years). Occupants with extension injuries had a mean body mass index of 36.0 and a fatality rate of 23.8%, much higher than the fatality rate for the entire cohort (10.9%). The most frequent extraspinal injuries (Abbreviated Injury Scale Grade 2 or more) associated with T and L spine injuries involved the chest (seen in 65.6% of 631 occupants). In contrast to occupants with major T and L spine injuries, those with minor T and L spine injuries showed a strikingly greater association with pelvic and abdominal injuries. Occupants with minor T and L spine injuries had a higher mean ISS (27.1) than those with major T and L spine injuries (25.6). Among occupants wearing a three-point seat belt, 35.3% sustained T and L spine injuries, whereas only 11.6% of the unbelted occupants sustained T and L spine injuries. Three-point belted individuals were more likely to sustain burst fractures, whereas two-point belted occupants sustained flexion-distraction injuries most often and unbelted occupants had a predilection for fracture-dislocations of the T and L spines. Three-point seat belts were protective against neurologic injury, higher ISS, and fatality.

CONCLUSIONS

T and L spine fracture patterns are influenced by the age of occupant and type and use of seat belts. Despite a reduction in overall injury severity and mortality, seat belt use is associated with an increased incidence of T and L spine fractures. Minor T and L spine fractures were associated with an increased likelihood of pelvic and abdominal injuries and higher ISSs, demonstrating their importance in predicting overall injury severity. Extension injuries occurred in older obese individuals and were associated with a high fatality rate. Future advancements in automobile safety engineering should address the need to reduce T and L spine injuries in belted occupants.

Incidence of fractures requiring inpatient care

BACKGROUND

The overall incidence of fractures has been addressed in several studies, but there are few data on different types of fractures that require inpatient care, even though they account for considerable healthcare costs. We determined the incidence of limb and spine fractures that required hospitalization in people aged ≥ 16 years.

PATIENTS AND METHODS

We collected data on the diagnosis (ICD10 code), procedure code (NOMESCO), and 9 additional characteristics of patients admitted to the trauma ward of Central Finland Hospital between 2002 and 2008. Incidence rates were calculated for all fractures using data on the population at risk.

RESULTS AND INTERPRETATION

During the study period, 3,277 women and 2,708 men sustained 3,750 and 3,030 fractures, respectively. The incidence of all fractures was 4.9 per 10(3) person years (95% CI: 4.8-5.0). The corresponding numbers for women and men were 5.3 (5.1-5.4) and 4.5 (4.3-4.6). Fractures of the hip, ankle, wrist, spine, and proximal humerus comprised two-thirds of all fractures requiring hospitalization. The proportion of ankle fractures (17%) and wrist fractures (9%) was equal to that of hip fractures (27%). Four-fifths of the hospitalized fracture patients were operated. In individuals aged < 60 years, fractures requiring hospitalization were twice as common in men as in women. In individuals ≥ 60 years of age, the opposite was true.

Osteoporosis and fragility fractures: Vertebral fractures

The incidence of vertebral fragility fractures and deformity increase steeply with age. Every sixth woman and every twelfth man will sustain a symptomatic vertebral fracture. Vertebral fractures result in pain, functional disability and decreased quality of life, which may last for several years, and may also affect mortality. The patient with an acute fracture should be examined with radiology for diagnosis. In case of a low-energy fracture, osteoporosis should be suspected and investigated. If the pain management fails, vertebroplasty or kyphoplasty could be considered. Braces may be used, but evidence for its effect is lacking. In the rare event of neurological compromise, or unstable fractures, surgical treatment should be considered. After vertebral fragility fractures, the risk for new fractures is high and secondary preventive measures advocated. The best evidence for secondary prevention is currently on medical treatment of osteoporosis.

Advances made in the treatment of thoracolumbar fractures: current trends and future directions

Thoracolumbar fractures are common injuries after blunt trauma and are accompanied with significant morbidity, including neurologic deficit. Parallel to the evolution of initial management during the past few years, efforts have been concentrated on determining clear indications for surgical treatment, as there is no agreement over superiority of conservative or operative treatment. Various classification systems have been used for identifying those injuries requiring surgical intervention. Moreover, novel trends in surgical techniques, including minimal invasive surgery, implants and rehabilitation protocols have provided new, promising aspects regarding the treatment and outcomes of thoracolumbar fractures. The present review focuses on these recent advances.

Pedicle screw fixation for traumatic fractures of the thoracic and lumbar spine

BACKGROUND

Spine fractures are common. The treatment of traumatic fractures of the thoracic and lumbar spine remains controversial but surgery involving pedicle screw fixation has become a popular option.

OBJECTIVES

To assess the effects (benefits and harms) of pedicle screw fixation for traumatic fractures of the thoracic and lumbar spine.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2011), the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library, 2011 Issue 1), MEDLINE (1948 to March 2011), EMBASE (1980 to 2011 Week 11), the Chinese Biomedical Database (CBM Database) (1978 to March 2011), the WHO International Clinical Trials Registry Platform (March 2011), reference lists of articles and conference proceedings.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-randomised controlled trials comparing pedicle screw fixation and other methods of surgical treatment, or different methods of pedicle screw fixation, for treating traumatic fractures of the thoracic and lumbar spine.

DATA COLLECTION AND ANALYSIS

Three review authors independently performed study selection, risk of bias assessment and data extraction. Limited meta-analysis was performed.

MAIN RESULTS

Pedicle screw fixation versus other methods of surgery that do not involve pedicle screw fixation was not looked at in any of the identified trials. Studies that were identified investigated different methods of pedicle fixation.Five randomised and three quasi-randomised controlled trials were included. All were at high or unclear risk of various biases, including selection, performance and detection bias. A total of 448 patients with thoracic and lumbar spine fractures were included in the review. Participants were restricted to individuals without neurological impairment in five trials. The mean ages of study populations of the eight trials ranged from 33 to 41 years, and participants had generally experienced traumatic injury. Mean follow-up for trial participants in the eight trials ranged from 28 to 72 months.Five comparisons were tested.Two trials compared short-segment instrumentation versus long-segment instrumentation. These studies found no significant differences between the two groups in self-reported function and quality of life at final follow-up. Aside from one participant, who sustained partial neurological deterioration that was resolved by further surgery (group not known), no neurological deterioration was noted in these trials.One trial comparing short-segment instrumentation with transpedicular bone grafting versus short-segment fixation alone found no significant difference between the two groups related to patient-perceived function and pain at final follow-up. All participants had normal findings on neurological examination at final follow-up.Two trials compared posterior instrumentation with fracture level screw incorporation ('including' group) versus posterior instrumentation alone ('bridging' group). Investigators reported no differences between the two groups in patient-reported function, quality of life, or pain at final follow-up. One trial confirmed that all participants had normal findings on neurological examination at final follow-up.One trial comparing monosegmental pedicle screw instrumentation versus short-segment pedicle instrumentation found no significant differences between the two groups in Oswestry Disability Index results or in pain scores at final follow-up. No neurological deterioration was reported.Three trials compared posterior instrumentation with fusion versus posterior instrumentation without fusion. Researchers found no differences between the two groups in function and quality of life or pain. No participants showed a decline in neurological status in any of the three trials, and no significant difference was reported between groups in the numbers whose status had improved at final follow-up. Two trials stated that patients in the fusion group frequently had donor site pain. Other reported complications included deep vein thrombosis and superficial infection.

AUTHORS' CONCLUSIONS

This review included only eight small trials and five different comparisons of methods of pedicle fixation in various participants while looking at a variety of outcomes at different time points. Overall, evidence is insufficient to inform the selection of different methods of pedicle screw fixation or the combined use of fusion. However, in the absence of robust evidence to support fusion, it is important to factor the risk of long-term donor site pain related to bone harvesting into the decision of whether to use this intervention. Further research involving high-quality randomised trials is needed.