Surgery in vertebral fracture: epidemiology and functional and radiological results in a prospective series of 518 patients at 1 year's follow-up

Do the management and functional outcomes of the surgically treated spinal fractures change in suicidal jumpers?

PURPOSE

The aim of the study was to determine the effect of trauma etiology on the management, functional outcomes and psychiatric characteristics of suicide jumpers and patients who accidentally fall from height.

METHODS

89 patients (48 accidental falls and 41 suicidal jumpers) who had undergone spinal surgery were included in the study. The patients were evaluated clinically and radiologically. Visual Analog Scale (VAS), Roland Morris Disability Questionnaire (RMDQ) and McGill Pain Questionnaire (MPQ) were performed for functional evaluation. BECK hopelessness scale (BHS), BECK depression inventory (BDI), and SF-36 scales were used for the psychiatric evaluation. All outcomes were compared between suicidal jumpers and accidental falls.

RESULTS

The RMDQ and ODI questionnaires stated a higher disability in the suicide jump group (p = 0.001 and p = 0.029, respectively). However, the VAS and MPQ questionnaires did not differ in significance between groups (p = 0.182 and p = 0.306, respectively). The SF-36 scale showed that physical function, role emotional, vitality and mental health subdomains were worse in the suicide jump group (p = 0.001, p = 0.029, p = 0.014 and p = 0.030, respectively). BDI scores were significantly higher in the suicide jump group while no difference was observed between the groups in terms of BSH (p = 0.017 and p = 0.940, respectively).

CONCLUSION

Psychiatric disorders are more common in patients in the suicidal jumpers. The presence of underlying psychiatric problems adversely affects the postoperative functional outcomes of patients with surgically treated spinal fractures. A multidisciplinary approach together with raising awareness in this way can improve the clinical outcomes after orthopedic treatment, even if there is physical disability.

Spine injuries among severely injured trauma patients: A retrospective single-center cohort study

BACKGROUNDS AND AIMS

We aimed to determine the incidence and severity of spine injuries among severely injured trauma patients (Injury Severity Score (ISS)/New Injury Severity Score (NISS) > 15) treated in a single tertiary trauma center over 15 years. We also wanted to compare the demographics between patients with and without spine injuries and to determine the mortality of spine-injury patients.

METHODS

Data from the years 2006-2020 from the Helsinki Trauma Registry (HTR), a local trauma registry of the trauma unit of the Helsinki University Hospital (HUH), were reviewed. We divided patients into two groups, namely those with traumatic spine injury (TSI) and those without traumatic spine injury (N-TSI). TSI patients were further subdivided into groups according to the level of injury (cervical, thoracolumbar, or multilevel) and the presence of neurological symptoms.

RESULTS

We included 2529 patients: 1336 (53%) had a TSI and 1193 (47%) had N-TSI. TSI patients were injured more frequently by a high-fall mechanism (37% vs 21%, p < 0.001). Among TSI patients, 38% of high-fall injuries were self-inflicted. High falls, young age, and female gender were overrepresented in spine-injury patients with a self-inflicted injury mechanism. Cervical spine-injury patients were mostly elderly persons injured by a low-energy mechanism.

CONCLUSIONS

Unlike other severely injured trauma patients, severely injured trauma patients with spine injuries are more frequently injured by a high-fall mechanism and self-injury.

Venous thromboembolism prophylaxis and mortality in patients with spinal fractures in ICUs

BACKGROUND

Spinal fracture is a common traumatic condition in orthopaedics, accounting for 5%-6% of total body fractures, and is a high-risk factor for venous thromboembolism (VTE), which seriously affects patient prognosis.

AIM

The aim of this study was to determine the impact of VTE prophylaxis on the prognosis of patients with spinal fractures in intensive care units (ICUs) and to provide a scientific basis for clinical treatment and nursing.

DESIGN

A retrospective study of patients with spinal fractures from the multicenter eICU Collaborative Research Database.

METHOD

The outcomes of this study were ICU mortality and in-hospital mortality. Patients were divided into the VTE prophylaxis (VP) and no VTE prophylaxis (NVP) groups according to whether they had undergone VTE prophylaxis during their ICU admission. The association between groups and outcomes were analysed using Kaplan-Meier (KM) survival curve, log-rank test and the Cox proportional-hazards regression model.

RESULTS

This study included 1146 patients with spinal fractures: 330 in the VP group and 816 in the NVP group. KM survival curves and log-rank tests revealed that both ICU and in-hospital survival probabilities in the VP group were significantly higher than in the NVP group. After the Cox model was adjusted for all covariates, the hazard ratio for ICU mortality in the VP group was 0.38 (0.19-0.75); the corresponding value for in-hospital mortality in the VP group was 0.38 (0.21-0.68).

CONCLUSIONS

VTE prophylaxis is associated with reduced ICU and in-hospital mortality in patients with spinal fractures in ICUs. More research is necessary to further define specific strategies and optimal timing for VTE prophylaxis.

RELEVANCE TO CLINICAL PRACTICE

This study provides the basis that VTE prophylaxis may be associated with improved prognosis in patients with spinal fractures in ICUs. In clinical practice, an appropriate modality should be selected for VTE prophylaxis in such patients.

Traumatic spine injuries in Eastern India: A retrospective observational study

Background:

Trauma is the leading cause of hospitalization globally, and trauma-induced spinal injuries can be devastating and permanent. The objective of this study was to describe the pattern, association, and outcome in patients with traumatic spine injury (TSI).

Methods:

A retrospective cross-sectional study was undertaken on patients with TSI who presented to the trauma and emergency department of a level 1 trauma center in eastern India between August 15, 2018, and August 14, 2019, by including 103 patients. Information pertaining to demography, mode of injury (MOI), fracture morphology, neurological grading, and associated spinal or other regional injuries was obtained. Correlation among injury severity score (ISS), neurological damage as per American Spinal Injury Association (ASIA), and morphological patterns was determined.

Results:

The median age was 39 years, and the gender ratio was 5.87:1. Fall from height (43.7%) was the most common MOI. The median ISS was 21, and the percentage of patients with polytrauma was 73% (ISS > 15). The cervical region (n = 30) was the most common site of injury, and multiple vertebral involvement (n = 32) was more common than isolated involvement. Type A pattern (53.4%) was the predominant type, followed by types C and B (29.1% and 15.5%, respectively) for primary spine injury, and type A was the predominant type for secondary spinal injury. Severe neurological damage (ASIA A-C) was noticed in 69 patients. The correlation between ISS and ASIA scores (Spearman's ρ = 0.561, P < 0.001) and between morphology type and ASIA score (Pearson's χ ²= 69.7, P < 0.001) was statistically significant. In total, 53 patients were managed surgically and 24 patients were managed by conservative measures.

Conclusion:

Our study found a predominantly younger population, multilevel involvement, significant neurological damage, multiple associated injuries, and higher ISS among the patients of TSI. The pattern in eastern India is different from previous reports from other parts of the country.

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.

Surgical management of spine injuries in severe polytrauma patients: a retrospective study

Background: Optimal surgical management of spinal injuries as part of life-threatening multiple traumas remains challenging. We provide insights into the surgical management of spinal injuries in polytrauma patients. Methods: All patients from our polytrauma care network who both met at least one positive Vittel criteria and an injury severity score (ISS) >15 at admission and who underwent surgery for a spinal injury were included retrospectively. Demographic data, clinical data demonstrating the severity of the trauma and imaging defining the spinal and extraspinal number and types of injuries were collected.Results: Between January 2012 and December 2016, 302 (22.2%) patients suffered from spinal injury (143 total injuries) and 83 (6.1%) met the inclusion criteria. Mean ISS was 36.2 (16-75). Only 48 (33.6%) injuries led to neurological impairment involving the thoracic (n = 23, 16.1%) and lower cervical (n = 15, 10.5%) spine. The most frequent association of injuries involved the thoracic spine (n = 42). 106 spinal surgeries were performed. The 3-month mortality rate was 2.4%.Conclusions: We present data collected on admission and in the early postoperative period referring to injury severity, the priority of injuries, and development of multi-organ failure. We revealed trends to guide the surgical support of spinal lesions in polytrauma patients.

Risk of aortic dissection, congestive heart failure, pneumonia and acute respiratory distress syndrome in patients with clinical vertebral fracture: a nationwide population-based cohort study in Taiwan

OBJECTIVE

Studies on the association between clinical vertebral fractures (CVFs) and the subsequent risk of cardiopulmonary diseases, including aortic dissection (AD), congestive heart failure (CHF), pneumonia and acute respiratory distress syndrome (ARDS) are scarce. Therefore, we used the National Health Insurance Research Database to investigate whether patients with CVF have a heightened risk of subsequent AD, CHF, pneumonia and ARDS.

DESIGN

The National Health Insurance Research Database was used to investigate whether patients with CVFs have an increased risk of subsequent AD, CHF, pneumonia and ARDS.

PARTICIPANTS

This cohort study comprised patients aged ≥18 years with a diagnosis of CVF and were hospitalised at any point during 2000-2010 (n=1 08 935). Each CVF patient was frequency-matched to a no-CVF hospitalised patients based on age, sex, index year and comorbidities (n=1 08 935). The Cox proportional hazard regressions model was used to estimate the adjusted effect of CVF on AD, CHF, pneumonia and ARDS risk.

RESULTS

The overall incidence of AD, CHF, pneumonia and ARDS was higher in the CVF group than in the no-CVF group (4.85 vs 3.99, 119.1 vs 89.6, 283.3 vs 183.5 and 9.18 vs 4.18/10 000 person-years, respectively). After adjustment for age, sex, comorbidities and Charlson comorbidity index score, patients with CVF had a 1.23-fold higher risk of AD (95% CI=1.03-1.45), 1.35-fold higher risk of CHF (95% CI=1.30-1.40), 1.57-fold higher risk of pneumonia (95% CI=1.54-1.61) and 2.21-fold higher risk of ARDS (95% CI=1.91-2.57) than did those without CVF. Patients with cervical CVF and SCI were more likely to develop pneumonia and ARDS.

CONCLUSIONS

Our study demonstrates that CVFs are associated with an increased risk of subsequent cardiopulmonary diseases. Future investigations are encouraged to delineate the mechanisms underlying this association.

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.

Epidemiology of Spinal Injury in North East India: A Retrospective Study

Aim:

To find out the epidemiology of spinal injury in North East India.

Material and Methods:

This study is a retrospective hospital-based analysis of spine injury patients admitted to Central Referral Hospital, Sikkim Manipal University from July 2013 to June 2017July 2013 to June 2017.

Results:

During the study period 57 patients with spinal injury were admitted and treated. Out of the 57 patients, 46 (81%) were male and 11 (19%) were female. The most common mode of injury was fall from height (59.64%) followed by RTA (35.08%). Most common affected age group in this study was 20-39 years followed by 50-59 years age group. Cervical spine injury was the most common (52.63%) followed by thoracic (19.29%) spine. Most common injury found was fracture dislocation of C5-C6 level. Most common associated injury is head trauma (10.52 %) followed by chest injury and 82.45% cases had no associated trauma. Average period of hospital stay was 22.83 days with maximum period of stay was 111 days. During treatment period one patient died due to respiratory complications.

Conclusion:

The epidemiology of spinal injuries in Sikkim & North Eastern India is different from rest of the India and other developing countries. In present study most common cause of spine injury was fall from height followed by motor vehicle accidents. RTA was the main cause in younger age group and fall from height was more common in elderly group.

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.

Instrumented Circumferential Fusion in Two Stages for Instable Lumbar Fracture: Long-Term Results of a Series of 74 Patients on Sagittal Balance and Functional Outcomes

OBJECTIVE

To report the radiologic and functional results of a multicenter, prospective case series of patients with comminuted lumbar fractures treated with 2-stage circumferential arthrodesis.

METHODS

A multicenter prospective case series of 74 patients with comminuted lumbar fractures was analyzed. The strategy entailed initial posterior osteosynthesis, followed by physical replacement with an expandable titanium cage filled with autologous bone via retroperitoneal lumbotomy. The mechanism of lesion formation and epidemiologic characteristics were recorded. Clinical and quality-of-life analyses (visual analog scale [VAS], Oswesty Disability Index [ODI], Short Form 12 [SF-12]) were performed over a minimum observation period of 1 year. Radiologic parameters, including deformity measurements, were recorded at each evaluation. Fusion was analyzed by means of a 1-year monitoring scan.

RESULTS

The mean patient age was 38.1 years, and median duration of follow-up was 2.1 years (interquartile range, 1.3-2.9). The distribution of fractures according to the Magerl classification scheme was as follows: A, 64.8%; B, 16.7%; C, 18.5%. At the last follow-up, fusion was considered certain in 57 cases (77%). The mean VAS score was 2.1 ± 1.3, mean ODI was 14.7 ± 8.0, mean SF-12 Physical Component Summary score was 43.2 ± 9.3, and mean SF-12 Mental Component Summary score was 50.8 ± 5.9. Correction of the regional sagittal deformity was significant during the postoperative period, with a mean increase in lordosis of 9.0° (P < 0.0001). The loss of mean correction at the last follow-up (-2.9°) was not significant.

CONCLUSIONS

Circumferential arthrodesis, including posterior osteosynthesis and physical replacement with an expandable cage and autologous graft, is applicable to the treatment of comminuted lumbar fractures. A high rate of fusion was obtained with significant and long-lasting correction of the sagittal deformity. Functional scores measured at 1 year suggest mild disability. The ODI, SF-12, and VAS scores were positively correlated with fusion at the last follow-up.

A novel approach for biomechanical spine analysis: Mechanical response of vertebral bone augmentation by kyphoplasty to stabilise thoracolumbar burst fractures

Kyphoplasty has been shown as a well-established technique for spinal injuries. This technique allows a vertebral bone augmentation with a reduction of morbidity and does not involve any adjacent segment immobilisation. There is a lack of biomechanical information resulting in major gaps of knowledge such as: the evaluation of the "quality" of stabilisation provided by kyphoplasty as a standalone procedure in case of unstable fracture. Our objective is to analyse biomechanical response of spine segments stabilised by Kyphoplasty and PMMA cement after experiencing burst fractures. Six fresh-frozen cadaveric spine specimens constituted by five vertebra (T11-L3) and four disks were tested. A specific loading setup has been developed to impose pure moments corresponding to loadings of flexion-extension, lateral bending and axial rotation. Tests were performed on each specimen in an intact state and post kyphoplasty following a burst fracture. Strain measurements and motion variations of spinal unit are measured by a 3D optical method. Strain measurements on vertebral bodies after kyphoplasty shows a great primary stabilisation. Comparisons of mobility and angles variations between the intact and post kyphoplasty states do not highlight significant difference. Percutaneous kyphoplasty offers a good primary stability in case of burst fracture. Kinematics analysis during physiological movements shows that this stabilisation solution preserve disk mobility in each adjacent spinal unit.